ASSESMENT OF HEARING IN INFANTS & CHILDREN

Click to edit Master subtitle style PRESENTED BY : DR. PRIYANJAL GAUTAM PG- 2nd Yr. (M.S. - E.N.T.) NIMS MEDICAL COLLEGE & HOSPITAL, JAIPUR

8/18/12

INTRODUCTION

In developed countries routine screening of newborn child for hearing impairment is a norm. But in developing countries, it is usually the parents who suspect hearing impairment & bring child to the physician. Early diagnosis & timely intervention gives best result in rehabilitating such children.
8/18/12

Speech & hearing are inter-related. For normal speech child must hears sounds. Later child understands the sounds of the words & intimates the words & talks.

8/18/12

CAUSES OF CONGENITAL DEAFNESS

1.

Genetic defects : affects inner ear & cause deafness.

(i) Michel aplasia : Complete failure of inner ear development. (ii) Mondini aplasia : Cochlea has 1 turns instead of 2 turns.
8/18/12

Causes of permanent childhood hearing impairment : (A) Congenital disorders: (i) Genetic- Syndromic recessive dominant Nonsyndromic Mitochondrial
8/18/12

Autosomal Autosomal X-linked

(B) Environmental causes:

(i)

Perinatal causes: Hypoxia Hyperbilirubinemia Low birth weight

(ii) Acquired disorders: Infections otitis media Meningitis

Chronic

Mumps
8/18/12

AIDS

RISK FACTORS FOR CONGENITAL HEARING LOSS

An illness/condition requiring admission of 48hrs or greater to a NICU Auditory neuropathy/dys-synchrony. Stigmata associated with a syndrome known to include a sensorineural or conductive hearing loss. Family H/O early childhood deafness.

8/18/12

TEMPORARY CHILDHOOD HEARING LOSS

Risk factors:

Otitis media with effusion (OME) Passive smoking Bottle feeding URTI Admission to NICU as a newborn Day care Siblings having had OME

8/18/12

IDENTIFICATION OF DEAFNESS IN CHILDREN

1. .

HISTORY : A thorough history taking from parents of suspected deaf child is very important. Eg. H/O Attack of Measles, Herpes, Syphilis etc. to mother during early part of pregnancy is important. Body wt. below 1.5 kg at birth, H/O drug taken during pregnancy is important.
8/18/12

2. Normal Responses of hearing children: (A) Neonatal Period- Birth to 2 months

(i)

Moros Reflex : Stimulation of the sleeping baby with a loud sound produces startle response in a normal child. Auriculo palpebral response : Stimulation of the child with loud sound produces closure of palpebral fissures in a normal hearing children.
8/18/12

(i)

NEWBORN HEARING SCREENING: Tests used for newborn hearing screening are -:

Automated otoacoustic emissions (AOAE) Transient evoked otoacoustic emissions (TEOAE) Distortion product otoacoustic emissions (DPOAE)

8/18/12

Automated otoacoustic emissions (AOAE):

These are low intensity acoustic signals emitted by mechanical contraction of outer hair cells of the cochlea either spontaneously or in response to acoustic stimulus. Otoacoustic emissions are recorded with a sensitive, low noise microphone that is placed in the sealed external ear canal.

8/18/12

8/18/12

Transient-evoked emissions (TEOAEs):

These are typically presented as an amplitude/time plot of acoustic waveform recorded from the ear canal.

TEOAEs greater than 20 db sound pressure level (SPL) can be 8/18/12

Distortion product emissions (DPOAEs):

These are generated in the cochlea in response to 2 simultaneous pure-tone stimuli. This tonal response is not present in the eliciting stimuli & therefore referred to as distortion.

8/18/12

Hearing tests in children:

(A)

Electrophysiological testing (0-6 months) Behavioural observation audiometry (0-6 month) The distraction test (6-18 months) Visual reinforcement audiometry (6-36 months)
8/18/12

(A)

(A)

(A)

VISUAL REINFORCEMENT AUDIOMETRY (VRA)

8/18/12

BERA

BERA stands for Brain Stem Evoked Response Audiometry. It is an important clinical tool & more standard parameter in the diagnosis of hearing problems.

It is an accurate measure of auditory function & measures the electrical activity in 8/18/12 auditory pathways. the

Uses of BERA :
1.

Detection of deafness in the difficult-to-test patients like infants, mentally retarded or malingering subjects. Assessment of nature of deafness whether conductive or sensory or neural. Identification of the site of lesion in retrocochlear pathologies.
8/18/12

1.

1.

Principle of BERA :
v

When a sound reaches cochlea, it is converted

into an electric impulse & passes from cochlea to auditory cortex.

8/18/12

Pathway : Sound Spiral ganglion (cochlea) Ventral & Dorsal cochlear nuclei (brainstem) Superior Olivary complex (midbrain) Lateral Lemniscus (midbrain)
8/18/12

8/18/12

BERA MACHINE

8/18/12

ELECTRODE PLACEMENTS IN BERA

1. Over the vertex or scalp (active electrode). 2. Over the mastoid or earlobe of ipsilateral ear (reference electrode). 3. Over the forehead just above the nasion
8/18/12

Sound stimulus nearly 60 dB above threshold is given to patient via headphones which deliveres a broad band click sound of 100 micro sec. (0.1 milli sec.) duration. The click sound is fed into the ear to be tested by a headphone and the contralateral ear is masked. A series of rapid sounds provide a stimulus & events are recorded during the 1st 10 milli sec. following the sound stimulus.

8/18/12

Each of these waves represents a neuroelecritical activity generated by the neural generators at some site in the auditory pathway in b/w the cochlea & the brainstem. SITE OF NEURAL

WAVE GENERATOR 1st end) 2nd 3rd 8/18/12

Cochlear Nerve (distal Cochlear Nucleus Superior Olivary

INTERPRETATION OF BERA RESPONSE :

8/18/12

A normal BERA recording has 5 prominent peaks & 2 small peaks. These peaks are BERA potentials & since they have troughs & crests, they are known as BERA waves. Each wave give information about a specific segment of the auditory pathway from the cochlea to the brainstem region.

Hence especially I, III, & V wave have to be accurately identified. 8/18/12

Wave 5th :

It is to be identified before all the other waves. It is most reliable & easily identifiable wave in BERA tracing. The hallmark of 5th wave is that there is a sharp negative deflection (downward) imediating following the peak.

8/18/12

Wave 4th :

It is identified as a peak just preceding wave 5th. So, once 5th wave is identified, it is not difficult to recognize wave 4th.

Wave 3rd :

It is the wave preceding wave 4th. So, once wave 4th has been recognized wave 3rd is identified as upward peak b/w wave 2nd & 4th at or beyond 3 milli sec. mark on the graph. 8/18/12

Wave 2nd :

It is the peak immediately preceding the wave 3rd. This wave has a latency of appox. 2 milisec. & hence it is difficult to identify. So, it should be looked for at or just beyond 2 milisec. mark on BERA graph.

8/18/12

Wave 1st :

It has to be recognized properly because it give an idea whether the stimulus has crossed over from the cochlea & the distal auditory nerve. If wave 1st is present & other waves 2nd, 3rd, 4th & 5th are absent, it suggest that the stimulus has reached the cochlea well enough but not able to proceed further. This means there is retrocochlear pathology.

8/18/12

STUDY OF WAVE MORPHOLOGY

In case of newborns the graph has 3 peaks (instead of 5 to 7 peaks in adults) & wave 2nd & 4th are absent. Moreover the graph in newborns has a larger wave 1st & much smaller wave 5th than in adults.

Note: Other pathological conditions which alters the morphology of the graph includes- Acoustic 8/18/12 neuromas, on which the time interval b/w peak

BERA GRAPH IN ACOUSTIC NEUROMA

8/18/12

BIBILOGRAPHY

1. SCOTT BROWNS 17TH EDITION, VOL - I

AUDIOVESTIBULOMETRY ANIRBAN bISWAS

8/18/12

THANK

YOU !

DR. S. P. SRIVASTAVA (Prof. & HOD) DR. AMIT MODWAL (Assoc. Prof.) DR. PRADEEP SHARMA (Assoc. Prof.) DR. RAKESH SABOO (Asst. Prof.) GURLEEN KAUR (P.G. 2nd Yr.)

DR. 8/18/12