Hearing Loss

Hearing loss can be either ‘nerve related’ hearing loss, which is relatively rare in children, or more commonly ‘conduction related’ hearing loss. Conductive hearing loss occurs when there is a problem transferring sound waves anywhere along the pathway through the outer or middle ear.

Otitis media with effusion (glue ear) is a common condition in children, especially under the age of 5. Glue ear is caused by fluid becoming trapped in the middle ear, behind the ear drum. Often glue ear will resolve on its own, especially if it developed following a cold. However glue ear can persist and cause problems with hearing, speech and infections.

Symptoms and signs of glue ear

• speech delay (particularly parts of words being missed)

• poor concentration

• not responding to being called

• television being turned up

• change in behaviour

• poor balance

• pulling at ears

Glue ear is diagnosed on the symptoms above, along with clinical examination which may confirm fluid behind the eardrum, and most importantly a hearing test. As glue ear commonly self resolves, the symptoms have to persist for more than 3 months to warrant treatment. Treatment for glue ear includes hearing aids or grommets.

Recurrent ear infections

Ear infections can either occur due to infection of the external ear canal (infront of the eardrum) or infected fluid within the middle ear (behind the ear drum).

Otitis Externa

Infections of the external ear canal (otitis externa) are often associated with swimming, trauma to the canal (such as scratching or cotton bud use) and dry skin conditions affecting the ear. Symptoms are generally pain and discharge from the ear, often at the same time. Treatment for ear canal infections includes microsuction of the ear canal and ear drop antibiotics. Infections of the ear canal are less common in children than infections of the middle ear, unless linked to the above risk factors.

Acute otitis media

Infections of the middle ear (acute otitis media) are common in children, particularly between the ages of 6 months - 4 years old. With a developing immune system, exposure to viruses via childcare, large adenoids and relatively immature Eustachian tube function (the tube that drains fluid from the middle ear), children are more prone to infections of the middle ear than adults. Symptoms and signs of acute middle ear infection can be non-specific, especially in younger children who are unable to verbalise.

Symptoms and signs of acute otitis media

• pulling at ears

• fever

• pain (can be followed by ear discharge if the ear drum bursts)

• unconsolable crying / irritability

• poor feeding

• restlessness

Acute otitis media is often caused by common viruses, but can also be bacterial. For pain, paracetamol and ibuprofen will often suffice and the infection will be self resolving. If symptoms persist, or if there is associated fever or the child is clinically unwell, then oral antibiotics are indicated. Complications of acute otitis media include mastoiditis (infection of the bone behind the ear), meningitis, facial nerve palsy and intracranial abscess. Thankfully these are all rare.

If children have more than 3 episodes of acute otitis media in 6 months, or more than 4 in one year, that is known as recurrent acute otitis media. The treatment options for recurrent acute otitis media are either to continue to treat each episode alone, or a longer course of antibiotics or grommets.

Grommets 

Grommets , or myringotomy tubes, are small plastic tubes which are placed in the ear drum.

Indications for grommets

• conductive hearing loss for greater than three months

• recurrent acute otitis media (3 episodes in 6 months / 4 episodes in 1 year)

Grommets allow fluid to drain from the middle ear and be replaced by air (which is what should occupy the middle ear space). This restores hearing and improves balance. It also reduces middle ear infections, as it prevents fluid from collecting behind the ear drum and becoming infected. Grommets are performed by making a small hole in the ear drum and inserting the plastic tube under a general anaesthetic. The procedure takes around 30 minutes, and is a day case procedure. Grommets are a temporary measure, as they often fall out between 9-18 months. The body expels the grommet, often without the patient or parent even realising. Occasionally symptoms can recur once the grommet is out.

Risks of grommet insertion

Most children recover very well from grommet insertion and have no complications. It is common to have a day or so of blood stained discharge following grommet insertion as the grommet settles into the ear drum. This typically requires no treatment. Discharge can persist or become recurrent. If this is the case, ear drop antibiotics are the treatment of choice. Very occasionally grommets are removed if there are ongoing problems.

• bleeding

• infection

• perforated ear drum (1%)

• scarring of the ear drum

Once a grommet has fallen out the ear drum closes behind it. Rarely the ear drum fails to close and this is known as a ‘perforation’. Ear drum perforations may not cause any issues and can be monitored for a period of time. If the perforation causes ongoing problem with infection, then they can be repaired.

Washing, swimming, flying

For six weeks following surgery I recommend that the ears are kept dry when washing. This can be with a large ball of cotton wool soaked in vaseline placed in the bowl of the outer ear, or with swimming ear plugs. Ideally no swimming during this time. After six weeks I am happy for children to wash and swim without water precautions. No diving under water as this increases the water pushed towards the grommet, and can cause pain and infection.

Often glue ear will cause pain when flying, with the sensation that the ear is unable to ‘pop’. Once grommets are insitu this improves and so makes flying better.