1. Going Green www.arkansascsh.org.
This educational offering is joining others in an effort to save our environment by making the handouts available on our website

2. To show respect for our speakers and participants, PLEASE place your cell phone on silent or vibrate.
Should you need to answer a call, PLEASE go outside to hold your phone conversation.

3. If it is that important, please step outside!!!!
Respect the speakers and other participants around you by refraining from side bar conversations during the session.
If it is that important, please step outside!!!!

4. If it is that important, please step outside!!!!
Respect the speakers and other participants around you by refraining from side bar conversations during the session.
If it is that important, please step outside!!!!

5. The planning committee &
faculty attest that NO relevant financial, professional or
personal conflict of interest exists, nor was sponsorship of commercial support obtained,
in the preparation or presentation of this educational activity.

6. School Hearing Screening

7. It’s the Law!
Arkansas Code states that each school district shall employ a physician or nurse to make such physical examinations. The exam shall be only such as to detect contagious or infectious diseases or any defect of sight, hearing or condition that would prevent a pupil from the benefits of school work.
The only reference to a law requiring vision and hearing screening is in ACA §

8. Purpose of Hearing Screening
To screen a large number of children in a short amount of time
To separate those children likely to have hearing problems from those not likely to.
To refer those children who do not pass the screening or who are suspect for hearing problems
Even though we are moving the students thru quickly, we must have a quality screening program and must follow the protocols that have been established….

9. Importance of Hearing Screening
11-15% of school children have a hearing loss
Impaired hearing can seriously impede learning
Early identification and treatment can prevent or at least alleviate many hearing problems
Review the points above….kids can’t learn if they have a hearing or vision deficit

10. Children to Screen Grades Pre-K, K, 1, 2, 4, 6, 8 & transfer students
Special education students & teacher referrals
Recommended grades for screening although may screen any child with a suspected hearing problem or any student being referred for special ed or 504.
Students who where hearing aides can not be tested. Since this student has a chronic condition, ask parents for an annual update from the ENT. Remember these students need to have an IHP on file.

11. When to Screen NOT the first week of school
Children entering school for the first time
Have 90 days to screen
Need time to adjust to school environment
Don’t wait too long
Cold and Flu season
Need time for follow-up
Recommend screening in September
Start with older children and/or Sp. Ed. (need to screen before IEP)
Same as with vision screening
While screening is an important component of the educational program, school personnel may only see it as an interruption. Seek cooperation. Teachers appreciate knowing about planned screenings in advance so they can schedule their activities.
Seek volunteers. Screening in teams has the advantage of speed and skill. Volunteer parents can assist with escorting students, etc..
The speech-language pathologist assigned to the school is an experienced screener who may be available to help. Also there may be a local audiologist in private practice or someone in a pediatric office who could volunteer to help.

12. Ear Anatomy
The human ear is divided into the external ear, the middle ear, and the inner ear. The tympanic membrane separates the external ear from the middle ear.
Middle ear contains the three small bones: malleus, incus, stapes.
The eustachian tube connects the middle ear with the nasopharynx. It allows for equalization of middle ear pressure and for the drainage of fluids from the mucous membrane to the nasopharynx. The eustachian tubes are curved in older children and adults. In children it is about half the length of adults and is more horizontal and wider making it easier for germs to travel from the nasopharynx into the middle ear.
The inner ear contains the vestibule, the semi-circular canals, and the cochlea.
Point out cochlea….where problems can occur with ototoxic meds

13. Outer Ear
Prior to screening a student for hearing, perform a visual inspection of the outer ear.
Is there discharge, scaling, excess redness, a lesion, or a foreign body? Pull on the lobe. Is there pain? Is the ear canal so swollen that it appears closed? A medical referral is indicated for any infection of the ear canal, decreased mobility of the tympanic membrane, or perforation of the tympanic membrane.

14. EXAMINATION WITH AN OTOSCOPE
Always hold the otoscope in the hand of the same side as the ear you are about to examine.
Examine the good ear first.
Be sure light is bright.
Select correct size of ear piece.
Do not insert tip too far in canal.
You will need an otoscope to visualize the tympanic membrane. The best way to become proficient with the use of an otoscope is the look at many ears.
To hold the otoscope properly, grasp the unit with at the handle with an outstretched pinkie finger. When the ear piece is inserted into the ear canal, rest the pinkie finger on the cheek of the patient. This will keep the scope from going too far into the canal, and if the patient turns his head, your hand will move with the head preventing the scope from being forced into the ear.
If the student is complaining of a problem, examine the good ear first. This has several advantages: it prevents the spread of infection, and allows you to see some normal anatomy to compare the other side with. Be sure the light is bright. Fading batteries cause a yellow glow that may dull the tympanic membrane.
Select the correct size of ear piece and do not insert the tip too far into the canal; the distal two-thirds of ear canal is sensitive.
Remember, the more normal ears you look in, the better you get at detecting abnormalities when you come across it.

15. Normal Eardrum
The tympanic membrane is normal when it appears to be pearl gray, translucent, smooth, and concave. A landmark of a normal TM is the light reflex, or cone of light. There should not be bulging, or contraction in the TM.
The ear drum is about the size of a dime. You will need to move the otoscope around in order to see all parts of the drum and ear canal as the outer ear is pulled Back and Upward. The malleus should be visible and the incus may be visible in the middle ear space. The come of light points to five o’clock in the right ear and seven o’clock in the left.
Common indicators of problems that may need referral are:
Pain and itching with a red, tender ear canal.
Cheesy material in canal, which may be pus.
Perforation (blocked feeling with drainage).
Bulging or retracted TM.
Scars on TM without any known history of cause.

16. Middle Ear Point out malleus…incus…stapes
This chain of bones conducts vibrations for the TM to the inner ear through the oval window. When the TM vibrates, it moves the malleus. The incus articulates with the malleus on one side and the stapes on the other. The footplate of the stapes attaches to the oval window to the inner ear. Muscles and ligaments hold these bones in place and allow them to move back and forth as the TM vibrates.

17. Ossicles
Note size of these bones

18. Inner Ear
The inner ear is located in the temporal bone and contains the organs of equilibrium and of hearing. Parts of the inner ear include:
The vestibule, the semi-circular canals, and the cochlea.
The vestibule contains the oval window and helps regulate balance. The semi-circular canals are fluid filled that stimulates hair cells causing nerve impulses to be transmitted to the brain so the individual senses motion.
The cochlea is also fluid- filled and as the oval window vibrates, the motion also causes the cochlea to vibrate, stimulating the organ of corti to send nerve impulses to the brain that are perceived by the brain as sound.
Note cochlea…ototoxic drugs can destroy the inner aspect…
In rare instances student can have a tear in the oval or round window….migraine type headaches…dizziness…nausea

19. Sound & Sound Measurement
SOUND: A pressure wave which consists of vibrations of molecules in an elastic medium
Frequency or Pitch:
Measured in Hertz (Hz)
Human Range is 20 to 20,000 Hz
Intensity or Loudness:
Measured in decibels (dB)
Normal conversation averages 60 dB
Puretones are sounds that are unique in the environment and are used to test ability to hear. The physical attributes are Frequency and Intensity.
Frequency is measured in Hertz. It is the Pitch, or how many times a vibration occurs per second.
Intensity is measured in Decibles. It is how LOUD a sound is in the environment. A young healthy ear can hear at 0 dB. Zero decibel is not the absence of sound.
Note wide range for frequency…
Normal conversation around 60 dB and we screen at 20 dB

20. Normal Hearing
Audiograms are grids with frequencies written across the top and decibels on the side. The decibel response for each frequency is plotted. An “X” indicates the Left ear, and an ”o” indicates the right ear.
Ranges for hearing loss have been divided as follows:
Normal hearing is -10 dB to 25 dB
Mild hearing loss is dB
Moderate is dB with Severe hearing loss at dB.
Profound hearing loss is over 90 dB.
Normal hearing ranges along 0 to 10 for most people…..0 does not mean total absence of sound….

21. Speech Sounds
This is sometimes referred to as the “speech banana” because of shape
Note where the “s” “f” and “k” fall….kids with problems hearing above 40 or 50 dBs in the 4000 Hz range will not hear these sounds…

22. TYPES OF
HEARING LOSS
Hearing loss is described as conductive, sensorineural, or mixed, e.g., both a sensorineural and a conductive hearing loss.
Hearing loss can be congenital or acquired. In utero or at birth a fetus or infant can be exposed to infection (rubella, cytomeglavirus, herpes, etc.) or lack of oxygen. Hearing loss can be hereditary (ushers syndrome) or caused by trauma or by medications.

23. Conductive Hearing Loss
Absence or malformation of the pinna and/or ear canal
Atresia
Obstruction of the ear canal
Foreign object or impacted wax
Inflammation or infection in the outer or middle ear
External otitis or otitis media
Perforation of the eardrum
Otosclerosis
Malformation of the ossicles
Trauma
Disarticulation and/or fracture of the ossicles
This occurs when there is a decrease in sound transmission before the sound reaches the inner ear. These problems usually can be treated and repaired. Some common problems that can cause a conductive hearing loss include impacted ear wax, perforated ear drum, swollen adenoids blocking the eustachian tube, and otitis media.

24. Conductive Hearing Loss
This is an audiogram of someone with a conductive hearing loss.
50 dB is moderate hearing loss
60 dB is moderately severe loss

25. Sensorineural Hearing Loss
Congenital
Heredity
Infections – Maternal rubella, CMV
Ototoxic Drugs
Acquired
Infections – measles, mumps, meningitis, chicken pox
Trauma – blow to the head, noise
Sensorineural loss is result of nerve damage and is not correctable. Some examples include damage to the organ of Corti from ototoxic medications, trauma, loud noises, inherited hearing oss, or infection of the inner ear or the auditory nerve.
Diagnosis made by air conduction loss within 10 dB of bone conduction loss for one or more frequencies.

26. Sensorineural Hearing Loss
This is an audiogram of someone with a sensorineural hearing loss. Note the dip at 4000 HZ 60 dB
Remember the speech banana? These students will have a problem hearing the letters “S” and possibly the “F” and “K”.

27. Central Hearing Loss
These children will usually pass the nurse screening test
Difficulty understanding speech in noise most common symptom
Maturation a factor, usually diagnosed at age 7 or older
Normal or near-normal hearing sensitivity
ALDs and compensatory strategies often helpful
A central hearing loss is defined as an inability to understand or process spoken language in difficult listening situations or environments.
These kids pass the screening because the ear phones provide the sound directly to the ear canal.
Simple sounds such as the central heat or air conditioner can cause interference with hearing…classrooms where the teacher does not maintain strict “silence”….general classroom noises such as paper rustling, students whispering…
Auditory learning devices and auditory trainers can help these students….the teacher has a “microphone” that she speaks directly into and the student has a receiver to help cut out the interference.
Other suggestions for these students include selective seating away from auditory or visual distractions, away from windows and doors.

28. Mixed Hearing Loss
Diagnosis of mixed hearing loss is made afrer audiometric testing indicates elevated air conduction and bone conduction loss, and there is a difference between ACL and BCL greater than 10 dB.
Air conduction is the test school nurses use in the school setting. These instruments generate sounds called puretones at discrete frequencies and decible levels and earphones deliver the puretones through microphones to the ears.
A bone conduction test is where an ossilator is placed on the bony portion of the head to measure vibrations “heard” through the bone. Bone conduction tests are performed by speech-language pathologists.
Example of this loss would be a person with a congenital hearing loss with a middle ear infection.

29. Ear Abnormalities

30. Microtia and Atresia
Microtia is an unusually small auricle or external ear….
Atresia is typically congenital absence or abnormal closure of ear canal

31. Wax Impaction
The old adage to never put anything in your ear but your elbow holds true. The ear is self-cleaning. As the skin in the ear canal sheds, it propels the wax slowly to the outer surface where it tends to dry and flake off or can be wiped away. Putting an object into the ear to clean it just pushes it deeper into the ear canal and can become packed against the eardrum resulting in a loss of hearing.
Installation of softening drops may be needed to remove wax build up and restore hearing. It is wise to refer them to a physician before putting in drops to be sure the eardrum is intact. If a perforation or puncture is present and liquid is instilled, infection of the middle ear may occur.

32. External Otitis This is called “Swimmers Ear”.
Glands within the ear canal produce a layer of protective cerumen. Too little cerumen may predispose to infection, while too much cerumen may cause retention of water and debris.
This condition is most common in persons who are swimmers who have allowed contaminated water to be trapped in the external canal

33. Retracted Eardrum Due to Negative Pressure
This is called cholesteatoma.
This may form over time as a result of negative pressure in the middle ear cavity. The TM is pulled back into the head toward small bones so they appear more prominent….kind of like shrink-wrap.
As skin cells slough off into the sac that is created by the negative pressure, matter fills the sac and it destroys parts of the middle ear and mastoids. Symptoms include a loss of hearing and cheesy material may be visible in the ear. The growth is painless.

34. Middle Ear Fluid
Fluid in the middle ear is usually a result of eustachian tube dysfunction or otitis media.
Note obvious bubbles in the picture on the left
Picture on the right not so obvious….may see shadow of fluid line on diagonal

35. Acute Otitis Media
Otitis media is an inflammation of the middle ear. Also called Acute otitis media and otitis media with effusion in refferencing the different stages of the same disease. This is considered one of the most common childhood condition in the US.
Symptoms include ear pain, reduction in hearing, fever, unsteadiness, and occasional drainage.
Signs include an immobile TM, which can be dull, opaque, red, bulging, and possible pus.
Note extreme redness due to capillaries being engorged: injected
Bulging noted, no landmarks identifiable

36. Eardrum Perforation
Hole in drum easily identified….may or may not have drainage

37. PE tube
Tympanostomy is the placement of middle ear ventilation tubes or pneumatic equalizing (PE) tubes in the TM.
Tubes can be made of plastic, Teflon, or steel. The tube allows air to go into the middle ear space when the eustachian tubes are closed (usually by infection). The P.E. tubes equalize pressure and allow fluid in the middle ear to drain into the ear canal as air flows into the middle ear.
Individuals with tubes must be careful not to get water into the ear, which can cause infection. The use of P.E. tubes has almost eliminated hearing loss associated with chronic otitis media and other serious conditions like cholesteatoma.

38. USHER SYNDROME
Usher syndrome is the most common condition that involves both vision and hearing. The major symptoms of Usher syndrome are hearing loss and an eye disorder called retinitis pigmentosa which causes night blindness and a loss of peripheral vision. Many people with usher syndrome also have severe balance problems. There is currently no cure for ushers.
Usher syndrome is inherited as an autosomal recessive trait. Meaning that a person must inherit a mutated gene from each parent. Usually parents who have normal hearing and vision are unaware they even carry this gene. Recently the gene was identified in a Jewish group descending from eastern European ancestors. So now a baby that is born with impaired hearing can be tested for this gene before the vision problems appear so that treatment options may begin early so that children can prepare for new communication skills.

39. THREE TYPES OF USHER SYNDROME
HEARING
TYPE 1
Profound deafness in both ears at birth.
TYPE 2
Moderate to severe
Hearing loss from birth.
TYPE 3
Normal at birth; progressive loss in childhood or early teens.
VISION
Decreased night vision before age 10.
Decreased night vision begins in late childhood or teens.
Varies in severity; night vision problems often begin in teens.
BALANCE
Balance problems at birth. Slow to sit or walk before 18 months.
normal
Normal to near-normal, chance of later problems.
Hearing loss and retinitis pigmentosa are rarely found in combination. Most people with these two will have usher Syndrome. Early diagnosis is very important. The earlier that parents know if their child has usher syndrome, te sooner the child can begin special education training programs to manage the loss of hearing and vision.

40. Second Hand Smoke

41. Secondhand Smoke More ear infections and hearing problems
More upper respiratory infections
More bronchitis and pneumonia
Higher rate of SIDS
More cases of asthma
More severe symptoms in children who already have asthma
There’s more…………….

42. Secondhand Smoke More likely to develop leukemia during childhood
Higher Cholesterol Levels in Adolescents
More likely to develop lung cancer and heart disease later in life.
And more…………..

43. Secondhand Smoke
Children living in households where more than three packs of cigarettes were smoked per day were more than four times as likely to be hospitalized for placement of ear tubes.
As you can see SHS causes many illnesses, each one could be a class in itself, but today we will focus on ear infections.
Ear Infections are one of the most common PREVENTABLE illnesses seen in children.

44. Otitis Media Middle Ear Infections
24.5 million visits to doctors’ offices yearly
Most frequently cited reason for taking child to the emergency room
Most common surgery for children is a Tympanostomy, 110,000 per year
Health care costs are reported between $3 and $5 billion/year
How big is the problem, here are a few statistics to show just how big the problem is.
Most importantly these ear infections are happening during the critical period for language development

45. Screening Procedure
Let’s go over the screening protocol

46. Audiometer Controls Power Intensity Dial Frequency Dial
Ear Selector Switch
Presentation Switch
Additional
Warble
Pulse
Masking
Power is off/on
Intensity is dB such as 20
Frequency is Hz such as 4000
Ear selector is right or left ear….may have separate switch for right and left and may be color coded red for right and blue for left just like the headphones…
Presentation switch actually delivers the tone and may also be the right/left ear selector.
Check the audiometer at the beginning of each test day to assure it is functioning correctly. Should be calibrated once a year.

47. Headphone Placement Hair behind ears. Remove large earrings
May want to remove glasses
Diaphragm over ear canal
Adjust head band for snug, even fit.
Head band on top of head preferred
Must have ear canal unobstructed.
Students may place headphones…just make sure that the diaphragm is over canal…may even put head band under chin but this is okay if diaphragm is aligned with canal…

48. Protocol Observation Pure Tone Screening Play Pure Tone Screening
Rescreening
Referral
Follow-up
Annual summary
This is the outline of protocol…we will review each…

49. Observation Look for the following:
Structural defects of the outer ear
Obvious ear canal abnormalities
Inflammation
Drainage
Foreign body/object
Eardrum perforation
Signs of possible otitis media
Observe the outer ear structures for any evidence of deformity…. Use otoscope to visualize ear canal and tympanic membrane if you have one.
Usually it is an automatic referral for the problems listed…except for impacted wax and nurse may choose to suggest otc drops for parent to try…if wax does not clear then can refer

50. Screening Protocol Observation Right Ear 1000 Hz 20 dB 2000 Hz 20 dB
Left Ear Hz 20 dB
You may choose to start with 4000 then proceed to 2000 and 1000
Must test each ear at all three dBs…begin with right and give the three tones, switch to left ear and give three tones, then return to right for last tone…give the tone for at least three seconds so that child may focus and respond
May test 4000 at 25 dB and pass
Have child respond by raising hand (don’t tell them to raise right or left specifically, just raise hand)..dropping block into bucket, etc…

51. Play Audiometry Condition with headphones off
4000 Hz
Highest level
Hold hand with toy near ear
Help drop toy until pushes against your hand
See if does on own
This is helpful with the kindergartener in teaching how to respond

52. Play Audiometry cont. Practice with headphones on
Lower level to 50 dB BEFORE headphones on
1000 Hz
Recondition if needed
Lower level to 20 dB
Follow screening protocol
Can do with entire class or one on one….teacher can do this for you with music, etc.

53. Play audiometry to get the student used to responding

54. Using blocks

55. Using shapes

56. Re-screening
Important part of screening protocol

57. Rescreening Protocol Observation (Refer if appearance abnormal)
Right Ear Hz 20 dB
2000 Hz 20 dB
4000 Hz 20 dB
Left Ear Hz 20 dB
When performing the initial screen may make the exception for 25 dB at 4000 only
Deliver the tone and give three seconds minimum to respond…may actually do this several times…sometimes may have to turn the sound up to get student’s attention but must return to 20 to give the test….
Don’t waste time on 1000, 2000, 4000 turning the volume (dB, intensity) up until student responds---they either respond at 20 (or 25 for 4000) or they fail that tone….
Screening and rescreening are exactly the same…

58. Hearing Pass Criteria: Rescreening: Play audiometry
Observation normal—Immediate referral if not
Responds to each frequency in each ear
Same for screen and rescreen
Rescreening:
Repeat screening in 4-6 weeks
Play audiometry
Use with preschool, immature, shy, sp. ed, non–English, etc.
Overview of protocol

59. Referral Refer immediately if observation shows physical abnormality
Refer to MD if fails rescreen
May immediately refer if child does not pass and there is serious concern regarding hearing or speech/language
Refer to MD if child passes, but there is concern regarding hearing
Problems noted during observation usually are referred immediately
May refer immediately following initial screen if there is serious problem…
May occasionally refer even if child passes screen because of behavior exhibited and change in school performance, etc.
We have to refer to primary care physician….the physician can refer to audiologist or hearing specialist

60. Follow-up
Send letter
Send 2nd letter or make personal contact if needed
Have financial assistance information available
Have list of appropriate professionals available
Review information received back from examining professional
Rescreen after medical treatment
Involve sp. ed. personnel if necessary
This applies to both vision and hearing…
Initial letter sent to inform parent of failure of screening
If you have not had a response from the parent within a reasonable time (usually 6-8 weeks) then send a reminder letter…attached to copy of original referral. Personal contact with parents may be needed.
Have info available if parent needs assistance
Always review results of exam and share with teacher when appropriate
If student is treated for disease/condition, rescreen after treatment to be sure problem has been solved

61. Do’s and Don’ts ALWAYS find a quiet room; screen at 20 dB
Exception is 25 dB at 4000 only
Don’t tell to raise right or left hand
Present for at least 3 seconds
Don’t pattern
Don’t give visual cues-position audiometer controls out of view
Use pulsed tone if possible
Don’t screen ear w/known hearing loss
Find the quietest room available…helpful to avoid a room near the playground; helpful to have heat/air control so you can turn the blower off if necessary…pause screening during time when halls are full of students changing classrooms….pause when the bells ring or phone rings….
Position students: if may be helpful to face a younger student when delivering the tones….you can see their “eyes light up”; with older students it may work better to have their back to you…you don’t want the students to see you pushing the button to deliver the tone…they will respond that way….and may never hear the sound….
Students may wear only one aid so can screen the good ear….

62. Forms
Several forms to use to may paperwork simpler

63. Hearing Screening Record Sheet
This has the roster of students to be screened…simple recording of 0 for pass and X for fail…you can put comments such as impacted wax, screening deferred, parent advised, etc in the last column

64. Hearing Referral
This is the referral sent to parent/guardian to take to audiologist/physician
This is front and back form
Front has student specific info…back is the audiogram result completed by the nurse…top audiogram…student may return with a machine generated audiogram rather than the one on the bottom of the form…

65. Hearing Follow-up Record
Hearing follow up has place to document those that failed the rescreen and then what response if any from referral

66. Hearing Annual Summary
The annual summary form is the only form that will be mailed in to Paula.

67. Resources Ear and Hearing A Guide for School Nurses
National Association of School Nurses
EARS Team (Educational Audiology Resources Services)
Arkansas Children's Hospital
Educational Audiologist
Arkansas School for the Deaf
Community Health Nurse Specialist
Mary Glasscock

68. Practicum Assignment
Set up audiometers and make sure the nurse knows how to work the controls…discuss the possibility of headphone going out…can use one phone and turn from ear to ear if necessary…usually phones are specific to machine so can’t just grab headphone from another machine….may have to order replacement and reschedule screenings….