CALIDAD DE VIDA DE LAS PERSONAS CON PARÁLISIS CEREBRAL

Key concepts

Language delay may be the result of sensorineural hearing loss or caused by middle-ear disease.

 Assess development.

 Treat moderate bilateral sensorineural hearing loss with a hearing aid.

 Treat bilateral profound hearing loss by cochlear implantation.

 Children may swim with grommets in situ.

Q1: What additional features in the history would you like to elicit?

Q2: What should one look for in the examination?

Q3: What investigations would be most helpful and why?

Q4: What are the treatment options?

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Answers

CASE 1.7 – Parents are worried about a 1 year old who is not speaking.

Q1: What additional features in the history would you like to elicit?

A1

Determine whether the child is at risk of developing sensorineural hearing loss. Risks include prematurity, jaundice, hypoxia or a difficult birth, and infections either during pregnancy or post partum, e.g. measles or rubella. Ask whether the child babbled and responded to sound when younger. Also ask about the developmental milestones during the first year, and the age of sitting, crawling and use of a spoon. Sometimes language delay is the result of a general developmental delay, so is it important to exclude this.

Q2: What should one look for in the examination?

A2

Observe the child while he is sitting in the clinic and see whether he responds to sound when people move around behind him. If the child is crying the quality of the cry can also be assessed in the clinic. Examine the ears to make sure that there is no congenital cause for the hearing loss. The position of the ears on the skull may give this away. The external ear canals can be abnormal as well. Make sure that the eardrum and middle ear are normal and that there is no glue ear.

Q3: What investigations would be most helpful and why?

A3

Simple distraction testing can be carried out by trained staff in the audiology department. A tympanogram will demonstrate an effusion. A sensorineural hearing loss can be investigated by cochlear echoes and brain-stem responses. These tests require sedation but can be undertaken after a feed in some younger children.

Q4: What are the treatment options?

A4

The treatment is to identify the cause of the problem. If the child does have bilateral severe sensorineural hearing loss, it is important to provide hearing aids so that language development can occur as quickly as possible. If the child has a profound sensorineural hearing loss a cochlear implant should be considered. The earlier that surgery is undertaken the better. If surgery is undertaken before the age of 2 years, the child stands a very good chance of developing normal language.

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CASE 1.8 – A mother comes with a child of three and a half who is badly behaved and also not talking well.

Q1: What additional features in the history would you like to elicit?

A1

Ask whether language development was normal up to 2 years. Also ask whether the child has any older brothers and sisters, because language may be slower in later children. Exclude recurrent acute otitis media and discharging ears in a child of this age. There may occasionally be a sensorineural hearing loss, particularly if the child has had meningitis, so a full past history should be taken.

Q2: What should one look for in the examination?

A2

A full ENT examination should be undertaken. However, the most likely cause at this age is glue ear (otitis media with effusion).

Q3: What investigations would be most helpful and why?

A3

Children of this age may be old enough to undertake a pure-tone audiogram but may require conditioned response audiometry. Children are conditioned to remove a toy from a container when they hear a sound. Accurate thresholds can be determined well in this way at different frequencies. However, both ears are assessed together using this technique.

Language should develop normally even if one ear is deaf. Impedance audiometry will exclude glue ear.

Q4: What are the treatment options?

A4

A child with glue ear and language delay should have ventilation tubes (grommets) inserted. Behavioural problems reinforce this. It is normal practice to observe the condition to see whether it resolves over a 3-month period. As many of these children have been seen at least 2 or 3 months before their ENT clinic visit the effusion is usually previously documented.

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OSCE Counselling Cases – Answers

OSCE COUNSELLING CASE 1.7 – What would your advice be to a mother who is concerned about the education and development of this child with hearing aids?

Stress that many children who have hearing aids accept them well. Older children will use them in the classroom setting.

Explain that most children with hearing aids will be educated in a normal school with no additional support. Emphasize that special education can be provided if necessary. The hearing aid service in most areas in the UK is reasonably well developed, with teachers of deaf people entering the school to assess children with hearing aids, in order to ensure that educational needs are met. The child should fulfil his or her full potential and even go to university if desired. (The best centres have multidisciplinary teams, which incorporate teachers, social workers, the doctor and audiology support services.)

OSCE COUNSELLING CASE 1.8 – What advice would you give to a mother who is concerned about swimming and grommets?

There is much controversy about swimming and grommets. Work from Australia would suggest that the prevalence of discharge is no greater in children who swim with grommets than in those who do not. A child should not dive or jump into water. Hair washing is more risky because the soap or detergent reduces the surface tension and makes middle-ear contamination and discharge more likely. Advise parents to protect the ears in younger children and ask the child to make sure that water and soap do not run into the ear during a shower or bath.

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