Last week I had the opportunity to evaluate a child who was having problems hearing. His mother reported the following history. John (not his real name), failed newborn hearing screening. Follow up testing indicated a mild hearing loss with middle ear fluid. He was retested several times by both the audiologist and the otolaryngologist who both told the parents that “it was only a conductive hearing loss” and that they did not need to be concerned.
Speech and language were mildly delayed. Re-evaluation continued to indicate a conductive hearing loss. Radiology did not identify anything significant. No recommendations were made re hearing. John was enrolled in speech-language therapy at age two and made progress. He entered school in kindergarten and, although everyone agreed that he was a bright little boy, he seemed to be struggling. Repeated hearing testing continued to identify a mild-moderate conductive hearing loss. Because the hearing loss was conductive, no hearing aids or classroom listening systems were recommended.
John started really struggling in school at about 3rd grade. By 4th grade teachers were describing him as “rude” and “uncooperative”. They said he just “did not pay attention.” They said he would not respond to his name being called when he was walking down the hall. The family was very frustrated. They also observed that if John was at a distance he did not respond but they felt he was not hearing. They did not feel it was a behavior issue. They had followed up on all medical recommendations but asked for another hearing test and that’s when I met the family.
Test results
John was clearly a cautious little guy who did not feel sure of himself. I asked him how he liked school. He was not overly enthusiastic. I tested him and, lo and behold, he still had a mild conductive hearing loss in the right ear and a moderate conductive hearing loss in the left ear. Speech perception under earphones was excellent (92%) in the right ear and fair (72%) in the left ear.
Soundfield functional testing
Speech perception testing was also conducted in soundfield to try and assess how John might be hearing in the classroom. Speech perception testing at a normal conversational level in quiet with no background noise was excellent (92%) but at a soft conversational level, even in quiet, testing indicated that John was beginning to struggle (80%). In competing noise John was struggling even more (68%).
What to do! what to do!
Whether or not the hearing loss is conductive, John is struggling. His speech perception can help explain why the teachers in his 4th grade class are not happy with his functioning. It helps explain why he is having academic problems and why he is missing things at home. He has had multiple ENT and audiology visits, radiology indicated an intact middle ear system. None of the physicians the family has seen have had any recommendations about improving middle ear status. But John is not hearing well.
When do we recommend technology for kids with middle ear disease?
If a child is not hearing well, and there is no medical contraindication, I think we need to move ahead with technology. If problems are limited to the classroom, an FM system may be sufficient. But John was clearly having more than a mild problem. It was affecting his learning, affecting socialization, and everyone noticed that he was struggling. I think John needs a hearing aid, at least in his poorer left ear as well as personal wearable FM for both ears. We got ENT permission for technology and moved ahead. Both John and his parents were relieved that we had an answer. John picked out the color he wanted for his hearing aid and for earmolds. He was relieved that things might get better now.
Performance with the hearing aid made a significant difference. John’s stress level was reduced. He was less stressed about school. He felt like he could understand what was happening in class most of the time. The FM made a big difference. After the teachers began to understand that John’s poor attention both in the classroom and in the hallway were not a behavior issue their attitude towards him improved. (I think it is likely they will be more likely to recognize hearing loss in the future.)
Counseling
Mom kept asking why technology was not recommended sooner and if she had missed the boat. I cannot explain why technology was not recommended sooner. I think audiologists may just assume that a conductive hearing loss is temporary and will improve with time. But in this case, it did not. Reports of performance from teachers and parents should have been a red flag to the audiologists and caused them to look a little further. Functional testing in soundfield confirmed that John was struggling. (In my view, functional testing should be routine.)
Conductive hearing loss is not to be minimized – especially in a child. By performing functional testing we can demonstrate if a child is struggling. And if a child is struggling, we are obligated to solve the problem. Sometimes we need to think out of the box.
