Posts Tagged ‘medicine

From this month NHS England (briefly known as the NHS Commissioning Board) takes over responsibility for commissioning specialist services for deaf children. This includes specialist implantable devices such as cochlear implants, bone anchored hearing aids and middle ear implants etc. Bilateral cochlear implants are currently and continue to be funded in line with NICE recommedations which children have a right to access under the NHS Constitution.

This month NHS England have announced their clinical access policies for bone anchored hearing aids and active middle ear implants. These are important because they relate to services that don’t have NICE recommendations and were previously commissioned locally by Primary Care Trusts and were subject to wide variation in provision. In summary:

Bone anchored hearing aids

  • are of safe and of proven benefit
  • should be provided in a specialist centre doing at least 15 a year. The team should include an ENT surgeon, audiologist, paediatric anaesthetist and speech and language therapist.
  • for children with microtia their care must be coordinated by a multidisciplinary team that can provide appropriate hearing and reconstructive support.
  • early intervention is vital and children born deaf should be provided with a bone anchored hearing aid on a soft headband until they are old enough for surgery.
  • funding will be available for children with bilateral conductive hearing loss to have bilateral bone anchored hearing aids if multidisciplinary assessment suggests that this would provide children with the best hearing environment in the classroom situation.
  • although bone anchored hearing aids would not normally be funded for children with unilateral deafness, an ‘exceptional case’ request can be made centred on information regarding the child’s development, audiometry results and communication needs.
  • and for the first time service providers will be expected to collect and provide audit data on request.

“Documents which have informed this policy – The National Deaf Children’s Society. Quality Standards in Bone Anchored Hearing Aids for Children and Young People. 2010″

Middle Ear Implants

Middle ear implants are a relatively new technology and very few children world-wide have been fitted with them. The evidence base is therefore almost non-existent at the current time. For these reasons it was not unexpected that active middle ear implants will not be routinely commissioned and will only be used as part of a recognised and structured clinical research project. However, they will be commissioned in the following limited circumstances:

  • Bilateral sensorineural hearing loss when conventional hearing aids have been used and found to be medically unsuitable due to conditions of the external ear.
  • Mixed hearing loss when conventional hearing aids have been used and found to be medically unsuitable due to conditions of the external ear and when a bone anchored hearing aid has been implanted and been associated with medical problems of the soft tissues or loss of fixture on more than one occasion.

Three babies are born every day with a cleft lip and/or palate, and Cleft Lip and Palate Awareness Week is a chance to spread the word and educate about this condition and the great work that the Cleft Lip and Palate Association (CLAPA) do.

Did you know that children born with a cleft palate are very likely to have difficulties with their hearing?

The most common type of hearing loss in children with cleft palate or cleft lip and palate is caused by otitis media with effusion (OME), commonly known as ‘glue ear’. Glue ear is a buildup of sticky fluid in the middle ear. For the ears to work properly the middle ear needs to be kept full of air. The Eustachian tube runs between the middle ear and the back of the nose and throat area and shares many of the muscles of the palate. The Eustachian tube opens regularly during swallowing, yawning and speaking, allowing air to be exchanged. Generally in children this tube is not as vertical and wide as it is in an adult and as a result doesn’t work as well. In children with a cleft palate there are likely to be additional structural abnormalities of the Eustachian tube and the muscles may not work as well. If the Eustachian tube doesn’t open efficiently or becomes blocked, air cannot enter the middle ear. When this happens, the cells lining the middle ear produce fluid. With fluid filling the middle ear, it becomes harder for sound to pass through to the inner ear and these sounds become more muffled.

Glue ear may not cause any problems in hearing or it may cause a mild to moderate deafness (20-60 dB) in the affected ear. For most children without a cleft palate, glue ear is a temporary condition that they grow out of by around 8 years old as their Eustachian tube and other cavities grow larger. However, almost all children with a cleft palate will get glue ear before the age of one and it may persist much longer than for other children. For this reason children should be monitored closely. Depending on the child and degree of deafness caused by the glue ear several options are available.

For further information on the types and causes of hearing loss, and managing any hearing difficulties download the NDCS booklet Cleft palate and deafness; Information for families. (Log in is required but membership is free and takes just a few minutes on-line.)

Ear wax is good stuff. Really!

Wax protects the delicate skin of the ear canal, contains antibacterial agents that help prevent infection, and is sticky catching dirt and dust. The colour and consistency of wax varies greatly between people – from thin and yellow to thick and dark red. Some people make loads of wax and others hardly any. Wax is the ears self-cleaning mechanism – since it’s only made in the outer third of the ear canal (nearest the entrance) and as the skin of the ear canal grows outwards it brings the old wax and it’s collected debris with it. Clever huh?!

So you really can just leave wax alone and abide by the old saying “never put anything in your ears smaller than your elbow”. If you are regularly seeing wax this is a good sign because it means it is moving out of the ear as it should. You can then wipe it away with the corner of a flannel or similar.

When ear wax is a problem

For most people wax is not a problem and should be left alone. For all those who have ever been nagged about not cleaning their ears by me I can only apologise – but only about the nagging, not the message – but audiologists and ENT doctors only nag because we are the ones who regularly see the results of self-cleaning. Wax will only cause a hearing problem if it is pushed down inside the ear, blocks the ear canal completely or becomes impacted. So please never try to remove wax yourself as putting anything into the ear (such as cotton bud, hair grips, paper clips, Hopi ear candles) will push the wax deeper where it shouldn’t be, risk hearing loss and injury.

Wax and hearing aids

Wearers of hearing aids do sometimes find they have a problem with wax build-up in their ears. This is because the use of earmoulds all day every day prevents wax from leaving the ear as it would normally. A build up of wax next to the ear mould will mean the child won’t hear as well as they should with their hearing aid and can cause the hearing aid to feedback causing an annoying whistling noise. It also makes it impossible to take good impressions for new earmoulds (or at worst can cause injury to the ear if we attempt to take impressions with lots of wax present). The problem is often worse for very young children and those with very small ear canals.

From a diagnostic point of view your GP, audiologist, or ENT doctor will also need to have any build-up of wax removed to be able to get an accurate hearing test and a good look at your eardrums and find out what is happening behind the wax in your ears, particularly if there is a chance of infection. Since the majority of audiologists aren’t trained to remove wax they rely on the GP or ENT doctor having done this before referral so that the poor patient isn’t sent straight back again.

Wax removal for children

There are 3 main ways to remove wax from the ears – syringing (using water), microsuction (using a tiny hoover to suck out the wax), and by manually picking it out with a probe. Which method used will depend on the age and development of the child as well as the equipment available and skills of the professional you see. Syringing can be carried out on children as long as the child has no contraindications which includes perforation (hole) of the eardrum now or in the past, ear infection, grommets in place, history of ear surgery, or young children who are uncooperative with the procedure. This means that for many children microsuction is usually the easiest and safest method. Microsuction involves lying still on a couch and having the wax ‘hoovered’ out the the ear with a tiny sucker. It is very noisy and can be a scary experience for children who have had their hearing aids taken out and can’t be reassured verbally, so it’s important to explain it fully to the child beforehand, but it it shouldn’t be uncomfortable or painful.

Your audiologist or ENT doctor may recommend using drops for a couple of weeks before appointments to soften any wax build-up to make it easier to remove. There is no evidence that one type of drop works better than another but medicinal olive oil ear drops are very gentle and safe for all ages. Warm a couple of drops in the palm of your hand before use. Put into the child’s ear at night after their hearing aid is out for the day. Often this is easiest to do with them lying and you can alternate the side each night putting the drops into the ear facing up. Do not use any eardrops if the child has a perforated eardrum (hole in the eardrum) or has grommets in their ears without advice from an ENT doctor.

Further reading

Five of the best… eardrops Daily Mail article featuring advice from John Graham, consultant surgeon at the Royal National Throat, Nose and Ear Hospital in London

NHS Evidence Clinical Knowledge Summaries – Earwax

Best Practice Statement; Ear Care, NHS Quality Improvement Scotland, 2006

Guidance Document in Ear Care, The Primary Ear Care Centre / Action on ENT, 2008 

I wanted to share a couple of excellent articles by Dr Carol Flexer, Ph.D. on the importance of early hearing aid fitting and use, & associated development of the auditory brain…

“Hart and Risley (1999) studied children from professional families and determined that they have heard 46 million live-spoken words by age 4. This is the magnitude of practice that is critical. This speaks volumes to the fact that less than every waking hour of technology use will not cut it for children with hearing loss. Dehaene (2009) talked about the listening basis for reading, and children with hearing loss require three times the exposure to learn new words and concepts because of reduced acoustic bandwidth compared to typical hearing peers.”

The Auditory Brain: Conversations for Pediatric Audiologists (2011)

“Robbins et al. (2004) found that skills mastered as a course of normal development result in developmental synchrony. Therefore, it appears we are pre-programmed to develop specific skills during certain periods of development. If those skills can be triggered at the intended time, we will be operating under a developmental and not a remedial paradigm. That is, we will be working harmoniously within the design of the human structure.”

Neuroplasticity is greatest during the first 3 ½ years of life; the younger the infant, the greater the neuroplasticity. Rapid infant brain growth requires prompt intervention, typically including amplification and a program to promote auditory skill development. In the absence of sound, the brain re-organizes itself to receive input from other senses, primarily vision; this process is called “crossmodal re-organization” and it reduces auditory neural capacity. Early amplification or implantation stimulates a brain that has not yet been reorganized, allowing the brain to be more receptive to auditory input resulting in greater auditory capacity.”

Auditory Brain Development: The key to developing listening, language and literacy (2012)

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