From per ENT to HAE: Pulling the trigger on conductive hearing loss

Team Katie, Au.D.MAC 2015

Pediatric Grand Rounds

T: 9/28/11

• 13-years-old• Passed newborn hearing screening• Normal speech and language development• No developmental delays• Using FM and strategic seating in school• Past medical history– Chronic otitis media– “several” sets of tubes placed starting at 1-year-old– Bilateral cholesteatomas removed in 5th & 6th grade

General note

• All audiograms in presentation used a conventional method of testing with good reliability

• Audiology visits always preceded ENT visits

T: 9/28/11• Audiology plan BEFORE

ENT– Retest per ENT– HAE to discuss management

options

• Medical management in office– Cerumen removed AFTER

audio

• Medical management plan– CT scan and f/u in October

• Audiology plan AFTER ENT– Retest hearing in October

coordinated with ENT visit

T: 10/26/11• Audiology plan

– HAE discussed if next round of medical management did not resolve air conduction thresholds

• ENT plan– CT scan visualized bilateral

cholesteatomas – Left tympanomastoidectomy,

left tube removal, and right tube removal scheduled 12/23/11

– Discussed T would need a second surgery for his right ear

T: 2/08/12• Audiology plan– Discussed continuing

with classroom accommodations and monitoring auditory fatigue

– Retest post next surgery

• ENT plan– Left ear reported healing

well post-operatively– Scheduled right

tympanomastoidectomy for 6/29/12

T: 5/09/12• Audiology only• Plan– Per ENT– Retest after procedure on

6/29/12

T: ENT Encounters

6/29/12• Right

tympanomastoidectomy• Right tragal cartilage

harvest• Left granulation tissue

posterior to the tube and debris in the ear canal that was removed

7/09/12• Healing well post-

operatively• Plan

– Follow-up in 4-6 months with audiogram

T: 8/22/12• Audiology plan– Discussed the importance

of reporting difficulties hearing in classroom setting

• ENT plan– Right ear

tympanomastoidectomy planned for 3/04/13

T: 4/17/13• Audiology plan– Discussed scheduling a HAE

• ENT– Referred him to another

UofM ENT for consultation

T: 4/23/13

• Hearing aid evaluation• Selected Oticon Safari

600 BTEs • Skeleton earmolds in his

high school colors• Hearing aid fitting

scheduled on 5/23/13

T: Today• Reports he benefits from hearing aids,

especially in school• Wears full time, even under football helmet• Has continued to have fluctuating conductive

hearing loss• Periods where he would only wear one hearing

aid– ear would be draining– s/p surgery

• Going to college next year out of state

Review

• Almost 20 months between first audiogram at UofM and hearing aid fitting

• 5 audiologists• Audiology

recommendations not taken into consideration by ENT

E: 09/12/11• 1 month old• Referred to ENT by plastic surgery

for debridement of EAC’s• Failed AABR bilaterally @ outside

facility• Deformed pinnae and stenosis of

both EAC’s• ABR at U of M showed

– R) moderately severe– L) mild moderate – Bone conduction: (click) 20 dB

• Flat tympanograms with small volume (1000 Hz)

General Note

• Point of Entry: Plastic Surgery ENT• Parents primary concern was the shape of the

ear• All Audiology visits preceded ENT visits (with

the exception of the first visit)

ABR Impressions and Recommendations

• It is noteworthy that the size and shape of Emma's right ear canal may have had an impact on the ABR results.

• Implications of Emma's hearing loss were discussed and her mother was actively engaged in the conversation. We discussed the importance of monitoring speech and language development.

• Follow-up with Pediatric Otolaryngology and Audiology as planned. Appropriate management will be initiated.

• Emma's mother expressed concern regarding middle ear pathology. She finished the Cipro drops treatment last week but desires to see Pediatric Otolaryngology to follow-up. She scheduled an add-on follow-up appointment for this afternoon.

E: 10/19/11 Audiology Visit• 2nd ABR

– R) moderate to severe– L) moderate– Prolonged wave V latencies with normal interpeak latencies.

Impressions:“I suspect that Emma's stenotic ear canals and otorrhea

have influenced the validity of her current and previous ABR studies. At this time, it is a challenge to reliably ascertain the degree of conductive involvement, as air conduction thresholds may be spuriously altered by inadequate transducer insertion depth.”

10/19/11 Otolaryngology Visit

• “Today's external auditory canals were full of debris bilaterally, prohibiting examination or visualization of the tympanic membrane. Mother was given directions for hydrogen peroxide and water irrigations to help debride the canals”

Hmmmm???

• Multiple factors contributing to hearing loss– Debris in canal– Size of external auditory

canals– Unknown middle ear

status re: middle ear effusions and/or ossicular abnormalities

– Low set ears????– Preauricular tag???

E: 2/15/12

E: 4/12/12

E: 5/16/12

E: 6/19/12• “Otoscopy was performed before testing commenced and

showed TM's clear to inspection bilaterally. The ABR was conducted while Emma while was in a natural sleep state. “– Right: severe– Left : Moderately severe– Masked Bone Conduction: Right * 20 dB (* patient startled

whenever stimulus was turned on)• Resumed use of ponto on soft band• Attempted use of a traditional BTE device

E: 10/18/12

• BAHA fitting• Own device• BP 100

E: 11/16/12

E: 3/14/13

E: 12/03/13

E: 1/20/14

• Hearing aid fitting• Oticon Sensei Pro BTE

for left ear

E: 6/12/14

• BAHA softband on right side

• Traditional Oticon Sensei Pro BTE on left side

• Early Intervention• Auditory Verbal Evaluation• Pre-school• Parents are still

considering genetic testing and imaging

E: 3/12/15

Discussion

• When should children with middle ear pathologies transition from “ENT patients” to “managed patients”?

• How do educate ENT’s on “interim” amplification options?