Paediatric Hearing Loss

Red flags requiring urgent ENT review

·      Sudden onset (within the last 24 hours to 1 week)

·      associated facial nerve palsy

·      systemically unwell

·      neurological signs

·      fluctuance and extreme tenderness in mastoid process

Assessment and recognition

History

·      How long?

·      Was it sudden or gradual?

·      Does it affect their quality of life

·      Any recent trauma

·      Any other otological symptoms (otorrhea, tinnitus, otalgia, vertigo and changes to facial symmetry)

·      Relevant past medical history would include previous ear operations

·      Comorbidities including full medication history

·      Birth and immunisation history

·      Neonatal hearing screening results

Examination

·      Inspection of the ear; any post-aural bulge and redness, as well as the presence of scars and foreign body..

·      Check to see if the patient has congenital deformities of the pinna (eg. microtia) or exisiting hearing devices (eg. BAHA, cochlear implant)

·      Otoscopy to elicit any exudates, nature of ear canal lining and status of tympanic membrane (signs of cholesteatoma)

·      Cranial nerve examination most importantly CNVII

Differential diagnosis and primary care management

Hearing loss is usually associated with other otological symptoms and can be broadly divided into conductive, sensorineural or mixed patterns. For the purposes of working out a diagnosis, it may be better to divide them into acute and chronic causes.

A. Acute history (days to weeks)

Acute otitis media - This is inflammation of the middle ear mucosa and normally presents in children. There is usually an onset of pain before the exudate appears. Examination at initial stages would reveal a bulging and red TM, which can perforate to allow the pus to discharge into the external ear. This usually results in the otalgia resolving. As it is commonly viral, treatment is usually symptomatic however antibiotics (commonly amoxicillin) can be used for patients who's symptoms are not settling after 4-5 days. Secondary care involvement is required for any of the its complications

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Foreign body in ear canal - History may not always be suggestive and confirmation usually comes from examination. It is fairly difficult to remove these without a microscope in primary care hence it is better to refer this to ENT on a semi-elective basis. Urgent referrals should be made for live objects and button batteries.

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Wax impaction - a very common cause of hearing loss. Otoscopy confirms the diagnosis. Syringing is slowly falling out of favour due to the risks of causing otitis externa and tympanic membrane perforations. Get patients to use olive oil or sodium bicarbonate eardrops regularly for a week and give the patient analgesia if they have pain. If still present after that, refer to a microsuction service.

Acute otitis externa – This more commonly found in older children. There is inflammation of the ear canal lining usually brought on by exposure to water. Examination would reveal a narrow ear canal with purulent exudates. The tympanic membrane may not be visible. Treatment involves topical eardrops (eg. Gentisone HC or Sofradex) and water precautions to the ears. The offending organism is usually Pseudomonas spp. or Staphylococcus Aureus. If not settling despite a week of eardrops, refer to ENT on a semi-elective basis. 

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Sudden onset idiopathic sensorineural hearing loss – This is rare in children but cannot be missed. Examination of the ear is normal and there is a sudden hearing loss. The diagnosis should be confirmed by an audiogram on the same day as systemic steroids started within 48 hours. If there are no provisions for obtaining an audiogram in primary care, the patient should be referred to the urgent / Emergency ENT clinic.

B. Chronic 

Otitis media with effusion (OME) - Also know as glue ear, this is the commonest cause of hearing loss in children. It tends to be worse over winter. Otoscopy may reveal a retracted TM with fluid behind it although confirmation in an untrained (or even trained!) eye can be very difficult. Audiogram and tympanogram can aid in the diagnosis. The vast majority settle spontaneously and do not need any interventions. Otovent autoinflation balloons have been shown to help improve OME and are available on prescription. They are also now approved by NICE.  If not settling after 3-4 months, refer routinely to ENT service.

Chronic otitis media - this is a term that has replaced chronic suppurative otitis media. It can be broadly divided into squamous disease (cholesteatoma) or mucosal disease. Both generally present with discharging ears and hearing loss. These patients require routine ENT referrals and many of them may have already had prior otological interventions (eg. grommets or mastoid operations).

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Tympanic Membrane Perforation – This commonly occurs after an episode of acute otitis media or trauma. Patients should be advised to keep the ear dry to avoid infections. Patients should be reviewed in 6 weeks following discovery of a perforation. If it has not healed spontaneously then a routine ENT referral for consideration of surgical closure is required.

C. Lifelong

Congenital – Children undergo neonatal hearing screening soon after birth to identify congenital hearing loss. Congenital deafness can be causes by environmental or prenatal factors. If there are concerns that a child has an undiagnosed congenital hearing loss referral to local Audiology or audiovestibular medicine services is required. 

Referral pathways to ENT

a.     Immediate

·      button battery in ear canal

b.     Same day

·      all complications of acute otitis media (https://entsho.com/complications-of-otitis-externa/)

·      Sudden sensorineural hearing loss

c.     Routine

·      the vast majority of chronic causes of hearing loss that cannot be sorted in primary care

Resources

 Paediatric hearing loss overview (BMJ paper) https://www.bmj.com/content/356/bmj.j803.full

NICE Acute Otitis Media - https://cks.nice.org.uk/topics/otitis-media-acute/

NICE Otitis Media with Effusion - https://cks.nice.org.uk/topics/otitis-media-with-effusion/

NICE Chronic Otitis Media - https://cks.nice.org.uk/topics/otitis-media-chronic-suppurative/

Authors:

Elliot Heward ENT Registrar North West Deanery

Mr Ananth Vijendren, Consultant Otologist/ENT Surgeon, Lister Hospital, Stevenage