Tag Archives: Ear

How hearing impairment is diagnosed in infant and young children?

Hearing loss can range from a mild impairment to profound loss. Conductive hearing loss is largely preventable and can be managed by medicine/surgery. Sensor neural hearing loss may need fitting with hearing aids.

Early identification of hearing loss in newborn and young children is of critical as he develops language and speech by hearing to his surroundings.

In general neonates and infants could be tested by BERA, children in the age group of 2 – 3 yrs could be screened using free – field audiometry, children above 4 yrs could be conditioned and then a audiometry can be performed to test hearing impairment.

Babies should be screened for hearing at birth especially high risk ones.

Child with mild hearing loss is generally labeled as inattentive or slow learner. Hearing should be tested as child grows at any time on slightest suspicion of hearing deficit by Parents, care givers, teachers and family doctors.

Screening for hearing has been done for many years but still does not detect hearing impairment as early as desirable. Mother’s instinct for her child is usually correct even at early age and should not be neglected.

The type of tests used to identify hearing loss depend on the age of the child, and include:

* Behavioural observation audiometry (BOA) – for babies less than seven months of age.

It consists of making noises, such as shaking a rattle close to ear, and then observing the baby’s response.

* Distraction method – it is formalized method of behavioral observation audiometry for children 7-19 months.

Infant sits on mother’s lap and one tester standing in front uses toys to raise attention. Other tester behind the child presents signals like shaking a rattle, or drum beat. First tester observes the child’s response. Response may be head turn, eye turn, frowning, sucking etc. After each response the signal intensity used to elicit a response is measured.

* Visual reinforcement orientation (VRA) – useful for children 7-30 months of age. The baby is taught to move their head towards sound by pairing it with an interesting visual stimulus, located in the direction of the speaker.  Their response to different sounds can then be measured. Test is done in sound proof room with speaker and headphone. The ears can be tested individually if the baby tolerates headphones.

* Performance audiometry test – older children are taught to respond to sounds by a performing a simple action or playing a game, such as dropping a marble when they hear the sound.

* Oto-acoustic emission – certain sounds generated by the inner ear can be recorded to check the function of the tiny hair cells in the cochlea.

* Auditory brainstem response testing – to check the electrical activity in the brain in response to a sound. Electrodes are placed on the head to measure the brain waves. It is most popular test for neonatal hearing assessment and for detection of hearing loss.

* Transtympanic Electrocochleography – to check the cochlea for signs of electrical activity in response to sound. It is better indicator of hearing threshold than any other auditory evoked response in children. An electrode is threaded through the eardrum to touch the cochlea and it requires general aneasthesia in children.

* Impedance audiometry or Tympanometry – a probe which snugly fits into the ear and air is pumped into the ear canal. Neonates and young infants may be examined so long as the probe tone is 660 Hz and not 220 Hz. Stapedius reflex are used to assess middle ear disfunction. Impedance audiometry is not an alternative to behavioral audiometry.t

** Hearing test for older children are same as for adult

How ‘otitis media with effusion’ is diagnosed?

Ear has three parts outer, middle and inner ear.

Middle ear is air filled cavity, separated from external ear by ear drum and is connected to space behind the back of nose (nasopharynx) by Eustachian tube.

Function of Eustachian tube is to drain fluid from middle ear which then can be swallowed and to provide ventilation of middle ear space.

If Eustachian tube gets blocked because of some reason middle ear air replacement fails and potential vacuum forms, this vacuum draws fluid inside the middle ear, condition known as otitis media with effusion.

Diagnsis is important specially to differentiate it (fig on right hand side) from incipient acute otits  media (fig on left side)-


incipient acute-otitis-media

1. Clinical History is important in diagnosis.

Otitis media with effusion may have no symptoms at all.

Most frequent presentation is covert and overt hearing loss which is mostly fluctuating with season and may be affected with changing position. Child may describe it as plugged ear or stuffy or wooly feeling in the ear.

Only sign by which parents come to know that the condition exists may be loud talking, not responding to verbal commands and turning up the volume of the television or music system,  sometimes it is detected on routine audiometry (test of hearing).

Hearing loss can slow up language and academic skill development; children may develop behavioral and social problems like he may appear to be distracted, or inattentive.

Infant and young children may present as delayed or defective speech development.

There may be mild earache (pain in the ear) especially with upper respiratory tract infection.

2. Otoscopy and pneumatic otoscopy:

Otoscope is an instrument to see magnified view of ear drum.

Doctor first removes any ear wax in order to visualize ear drum clearly.

Ear drum may be dull and opaque instead of usual transparent or pearly white colour. It may be pulled inside or may be bulged out. Sometimes characteristic fluid level or air-bubble may be seen.

Pneumatic otoscope has a rubber bulb attachment, air is pushed inside on pressing the bulb and reduced mobility of ear drum can be judged.

3. Use of operating microscope:

It gives more magnification and better visualization of minute details of ear drum.

4. Hearing tests:

Tuning fork tests and pure-tone audiometry may be helpful in children above 4 years and may show some conductive type of deafness.

Tympanometry is rapid and reliable even in infants.

5. Definitive and direct evidence of diseases is only when presence of fluid in the middle ear is confirmed by myringotomy.

<a href=”http://technorati.com/tag/otitis-media-with-effusion&#8221; rel=”tag”><img style=”border:0;vertical-align:middle;margin-left:.4em” src=”http://static.technorati.com/static/img/pub/icon-utag-16×13.png?tag=otitis-media-with-effusion&#8221; alt=” ” />otitis media with effusion</a>

Risk factors for development of fuid in middle ear

Certain factors predispose a child for development of fluid in the middle ear like:-

  • Allergy
  • Enrolment in day care
  • Exposure to second hand smoke
  • Bottle feeding
  • Use of pacifier
  • Lower socioeconomic group because of overcrowding and poor hygiene
  • Certain syndromes like downs, hunter and hurler’s syndrome, some kids with skull base or nasopharyngeal abnormalities like cleft palate and immunosuppressive disorders, such as HIV are more likely to develop OME.
  • Parents who smoke or pregnant woman who drink alcohol put their babies at risk.

Anatomy of human ear

Click here to see Anatomy of ear and hearing, animation on medindia.net

Ear is divided into three parts-

  • Outer ear (pinna and external auditory canal)
  • Middle ear (ear drum, ear ossicles)
  • Inner ear (cochlea,semicircular canals and vestibule)

normal ear anatomy

Outer ear protects ear drum and sends sound to the middle ear and protect ear drum. Outer 1/3rd of canal contains ceruminous glands which secret wax .

Middle ear is an air filled cavity separated from external ear by ear drum and connects to nasopharynx by Eustachian tube. Middle ear contain three small movable bones (ossicles) malleus, incus and stapes which converts sound waves into mechanical vibrations.

Inner ear contains cochlea (for hearing ) and semicircular canals & vestibule (for balance ).

Criteria for hearing screening of new born babies

First three years of life are critical for a child to develop speech and language skill. For effective language and communication skill development child need to hear normally. If any hearing impairment is there it should be managed at the earliest.

With modern technologies like Brain-stem evoked response audiometry it is possible to identify hearing-loss within days of birth.

There are certain criteria which needs to pay attention and newborn should be subjected to hearing evaluation:–

1. Parental concern about hearing levels or speech delay in their child

2. Family history of hearing loss

3. History of in-utero (cytomegalovirus, rubella or syphilis) or post natal infections (meningitis)

4. Low birth weight babies

5. Hyper Bilirubinemia

6. Cranio facial deformities or certain syndromes

7. Head injury

8. Recurrent or Persistent otitis media with effusion

9. Exposure to ototoxic drugs

E.N.T. clinic set up; Instruments and common terms

E.N.T. Specialist (oto-rhino-laryngologist):-

A doctor who specializes in diagnosing and managing diseases (by medicines or surgery) of Ear-Nose and throat.

Evaluation of the ear, nose and throat requires good source of light. Most important is, no doubt, skilled hands and experienced eyes.

Some instruments and common terms used in E.N.T. practice:

Head-mirror and bulls lamp: –

bulls-lamp Bulls lamp placed above and behind the patient’s shoulder has got a bulb and Plano-convex lens to send focused light to head mirror.

head mirror and ent-specialist1 Head mirror (I like to describe it as “naag-mani”), has special concave lens to reflect light from bull’s lamp. The examiner sees through the hole in the center of the mirror for binocular vision.


Some professionals use Head-light in place of bull’s lamp and head mirror.

Endoscopy unit:

endoscopelight source, camera and nasal endoscope are being used in a modern

ENT set-up for video demonstration of otherwise hidden- from patient’s-cavities.

Tongue depressor: –


To depress tongue and examine oral cavity.

Nasal speculum: –

thudichum nasal_speculumHelp in viewing inside of nose, procedure to inspect nasal cavity is called anterior rhinoscopy.

Laryngeal mirrors: –

il-mirror Used to examine larynx and laryngo-pharynx. Doctor will hold your tongue and will see reflection of larynx in the mirror that is why it is called indirect laryngoscopy.

Video-laryngoscopy is routinely used now a days using telescope.

Postnasal mirror: -used to examine nasopharynx and posterior part of nasal cavity, a procedure called posterior rhinoscopy.

Ear-speculum: –

ear_specula Inserted into ear to see inside of ear canal and ear drum.



It is battery operated device with magnifying glass, gives magnified view of ear drum.

ear-exam1Otoscope is most essential tool in the hands of otolaryngologist; I often use it to inspect ear, nose and throat of infant, child or bed-ridden patients or places (like rural-camps) where an equipped E.N.T. set-up is not present.

Siegel’s speculum: – It helps to test mobility of ear drum, a very essential part of ear examination.

Jobson-Horne’s probe:

jobson-horn-and-probe1 I call it “chhoti jadu ki chhadi” (tiny magic-stick). On the one end of the probe cotton can be applied and used to clean ears of any discharge. Other end has got ring like structure to remove wax, dried secretion and foreign body.


hartmann-forceps161noyes-forceps141 (Tilley’s or Hartman’s) for packing or grasping.

Eustachian catheter: – To see the patency of Eustachian tube.

Suction-apparatus: – To suck out discharge or blood from ear or nose for detailed examination.

Ear microscope (operating microscope): –

ent-microscope To examine the ear drum more precisely under magnification, a procedure called Examination under microscope (EUM).

It gives the doctor the freedom to use suction and other Instruments in the ear.

Microscopy is used to clean discharge, to inspect ear drum, middle ear or any pathology before surgery, and to remove impacted wax or foreign bodies from ear.

Tunning Forks:

tunning-forkTo roughly assess degree and type of hearing impairment.

Pure tone audiometer and impedance meter:-

To test degree and type of hearing-loss.


pure tone audiometer

Pure tone audiometer and Tympanometer

General Ear-health


General care:

·     Outer ear can be wiped with a wash cloth or soft towel. If water goes in after head shower or swimming mere dabbing with towel with head turned to side, cleans water.

·     You can use ready made preparation of alcohol based to dry the ear if you are sure that you don’t have ear infection.

·     Do not put anything in the ear, remember it is not only for pins; it is for ear buds and q-tips as well, believed to be safe and made for ear-cleaning( even most intellectual people think so).

·     Ear is not a cooking-range, does not require oil, garlic and so on.





·     Ear wax is not a disease, rather a protective secretion which comes out by its own where it can be wiped out.

·     Excess wax causing obstruction is to be removed by your clinician.





·     During ascent and descent while air-travelling, swallow frequently to keep Eustachian tube open, infant can be put to bottle feeding.

·     Avoid air-travel during cold/sinusitis, but if not avoidable use nasal/oral decongestant before ascent and decent. 




Cold/sinusitis/Eustachian tube and ear:

·     Do not blow nose forcefully during cold, it forces secretion towards middle ear via Eustachian-tube.

·     Take care of upper respiratory tract infection/sinusitis to reduce risk of ear infection.

·     During infant feeding, keep his head high to avoid milk/fluid entering middle ear via Eustachian tube as infants have short and horizontal tube.




 Noise and ear:

·     Turn down volume of MP3 player/television.

·     While working in noisy area, rock concerts wear ear protection devices.




 Visit your doctor:

If you have excess itching,  pain in the ear, blocked ear, ringing in the ear, drainage from ear, impairment in hearing, dizziness, uncontrolled URI/sinusitis, visit a doctor.

How to clean the wax?

Most frequently asked question by people visiting ENT clinic is how to clean the ear and if I tell them it is not required, they will look at me puzzled and ask “then how to clean the wax?”


Wax is normal secretion by glands of skin of ear canal just as sweat produced by glands of skin. Wax is normal protective layer for the sensitive skin of ear canal. This coating helps repel water& traps dust particles & when you clean it out you make your ear more vulnerable to infection.


Usually small amount of wax is secreted which comes out by its own, a process helped by jaw movement.


Chronic cleaning of ear causes dryness leading to itching, scratching and if you are cleaning it daily you know vicious circle. Continues itching may cause damage of skin and in turn bacterial & fungal infections.
Sometimes accidentally if you dig down too deep you may hurt your ear-drum (I have seen patients having ear bleed when they were doing cleaning jobs religiously & there kids just jumped over them). You will be amazed to see the concentration focused on ear cleaning.


Excess, hard wax causing obstruction is to be removed (20% of population have tendency to accumulate wax because of anatomical reasons), but if you try this by yourself you tend to push it further inside causing impacted wax and related problems like blocked ear, ear-pain, swelling in the ear and list doesn’t end here.

Even most educated patients are very ignorant about ear and use anything they have in their hands to insert in the ear. Anything means anything they find which can go inside the ear- hair-pins, pen, pencil, paper, keys, and recently I removed a bulb of decoration-lights for “diwali” accidently trapped inside the ear while trying to clean it.


But really nothing is safe not even so called sterile ear-buds available at chemist shop.


Now, I hope you got the point, I usually tell my overenthusiastic patients “ear cleaning is useless job, you don’t need it if you don’t have the excess wax & you won’t be able to remove it if you have excess wax.”

And yes it becomes a habit. People will often deny this fact, very difficult at times to convince them.

Management of hearing loss; Hearing loss is more evident than Hearing-aids

Hearing loss in adult should be evaluated and managed properly taking care of emotional and social impact of condition on patient & his family. Bilateral hearing loss may affect professional life of a person. Aim is to know the treatable cause and manage effectively to prevent further loss. Sensori-neural loss which can not be cured by medicines should be started with rehabilitation by hearing-aids.

Symptoms of hearing loss:

  • Sound may be distorted, quieter and less clear
  • Patients usually have difficulty in hearing in noisy area or while in a group
  • Problem in hearing over telephone
  • Turn up volume of television/Mp3 player
  • Ask people frequently to repeat the sentence/words
  • Patients often misunderstand what others are saying
  • Patients think others are not speaking well

Evaluation of patient:

Thorough medical history(ear infection, giddiness, tinnitus, past medical illness or medication, trauma, exposure to noise-occupational or otherwise if any).

Clinical examination of Ear-Nose and Throat and patient.

Investigation-Audiometry tests to know degree and type of hearing impairment. Depending on clinical clues CT/MRI may be required.

Most common cause of hearing-impairment in adult is wax and after exclusion of wax tympanic membrane perforation is most common cause.

Management of Hearing loss

Management depends on type and cause of hearing loss; loss is of two types conductive and sensori-neural. Sometimes it may be mixed loss.

Conductive hearing loss:

When something hampering conduction of sound from your ear-canal, ear-drum and ear ossicles to reach inner ear or nerves of hearing.

Can be corrected by medicine and/or surgery, like-

  • Wax or foreign body-removal
  • Eustachian tube blockage or fluid in the middle ear -medicines or by procedure of putting small tube (grommet) in ear drum
  • Infection(otitis media)-Medicines
  • Perforation in ear drum-Surgery(Tympanoplasty)
  • Otosclerosis-stapedectomy& piston placement
  • Any cause in nose/throat is managed by medicine/surgery.

Sensorineural hearing loss:

When problem is in inner ear or nerves of hearing (same as one has weak eye-sight).


  • Age -hearing loss after age of 65
  • noise-trauma
  • Menieres disease
  • Post viral infections like mumps, measles, influenza, herpes
  • Ototoxic drugs like aminoglycoside antibiotics (neomycin, streptomycin, amikacin, gentamicin, netilmycin), Salycylates, certain diuretics, antimalarial ( quinine & chloroquine), erythromycin and cisplatinum.
  • Hereditary
  • Immune mediated
  • Endocrine& metabolic disorders
  • Vascular or neurogenic
  • tumor

Management of sensorineural hearing loss

Mostly chronic sensori-neural loss can not be cured and person is prescribed to wear hearing-aids. In bilateral severe to profound hearing loss cochlear implant (electronic device, a part is implanted under skin by surgery) may be successful.

Some treatable causes:

If it is sudden loss, spontaneous recovery may be expected assisted by steroids. Underlying etiology present in 10-15 % should be identified & treated.

Immune mediated -steroids


Ototoxicity-Medicine stopped.


Though hearing aids are not as good as normal ear but if properly met with fitting requirements it can compensate well for hearing loss.

Hearing aids should be fitted and customized to individual after thorough hearing evaluation by by E.N.T. specialist and audiologist.

Most patients are benefited but there is limitation of sound quality and back ground noise that means it works well in quiet environment but some users have trouble enjoying music and listening in a crowded room.Improving FM (frequency modulation) boosts the performance of hearing aid and hearing aids can be optimally set for music.

Quality of hearing aid is of utmost importance and it takes few days to adjust but eventually initial chaotic sound disappear and person is able to appreciate the difference. Usually patients are happy after few weeks of use often coming to tell us that it has improved their quality of life.

Sensori-neural hearing loss may be shocking news to the patient and his relatives. Good doctor-patient relationship and understanding is required to help accept the fact. Talk with your doctor, friends, family and person with same problem to support you.