Basic ear and hearing care resource

BASIC EAR AND HEARING CARE RESOURCE

BASIC EAR AND HEARING CARE RESOURCE BASIC EAR AND HEARING CARE RESOURCE Basic ear and hearing care resource ISBN 978-92-4-000148-0 (electronic version) ISBN 978-92-4-000149-7 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Basic ear and hearing care resource. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. BASIC EAR AND HEARING CARE RESOURCE I. INTRODUCTION • Background • Purpose of this resource • How to use this resource II. HEARING LOSS AND DEAFNESS • What is hearing and hearing loss/deafness • Types of hearing loss • Causes and signs of hearing loss/deafness in children • Causes and signs of hearing loss/deafness in adults • Hearing testing III. CARE FOR PEOPLE WITH EAR DISEASES AND HEARING LOSS • How to care for discharging ears • Support for people with hearing loss • How families/carers/teachers could communicate with people with hearing loss • Hearing aids and cochlear implants • DOs and DONTs CONTENTS 5iii ACKNOWLEDGEMENTS BASIC EAR AND HEARING CARE RESOURCE Acknowledgements This document is the outcome of a consultative process led by the World Health Organization with contribution of the following World Health Organization (WHO) staff members: Shelly Chadha, Alarcos Cieza, Cherian Varughese, Maryam Mallik, Ricardo Martinez, Patanjali Dev Nayar, Karen Reyes, Emma Tebbutt, Florante Trinidad, Hala Sakr and Juan Carlos Silva. The conceptual framework and outline of the ‘Basic Ear and Hearing Care resource’ were developed in consultation with an expert group through a series of consultations organized by the World Health Organization. The initial drafting of the document was done by Mahmood Bhutta, Priyadarshni Carling and Sally Harvest. Document review and inputs were provided by: Arun Agarwal, Mazin Al Khabouri, Ned Carter, Michael Chowen, Jackie Clark, Harvey Coates, Carolina Der, Victor De Andrade, Uta Fröschl, Suneela Garg, Sally Harvest, Linda Hood, Isaac Macharia, Norberto Martinez, Amarilis Melendez, Christopher O’callaghan, Christopher Prescott, Hubert Ramos, Leela Agnes Sambantham, Diego Santana Hernandez, Andrew Smith, Paige Stringer, George Tavartkiladze, Sian Tesni, Yufeng Wang and Bu Xingkuan. The booklet and the procedures explained in it were field tested in India and Uganda with support provided by CBM India Country Office, Bengaluru; St John’s Hospital, Bengaluru and its Community Centre, Mugalur, India; Community Health Academic Department of Christian Medical College and Hospital, Vellore, India; James O’Donovan and members of ‘The Village Health Team’ of Omni Med, Uganda. Financial support for this document has been provided by CBM and the Hearing Conservation Council. iV BASIC EAR AND HEARING CARE RESOURCE 1 INTRODUCTION Background • World Health Organization estimates that there are over 460 million people in the world with disabling hearing loss. Nearly 90% of them live in low- and middle-income countries of the world. Many more people have mild hearing loss and suffer diseases of the ear. These problems can often cause life-long and sometimes life-threatening difficulties. Without suitable interventions, deaf or hard of hearing people find it difficult to communicate with others. They also have difficulty in education and in the workplace, and often they feel left out of social and family life. • • In many places there is a lack of services and trained workers to prevent and treat ear diseases and help people with hearing loss. People themselves are not well aware about the importance of hearing. There are many myths and misconceptions about ear diseases and hearing loss in the society. • • The resource focuses on community involvement and raising awareness; and will provide useful information for preventing and addressing ear diseases and hearing loss. BASIC EAR AND HEARING CARE RESOURCE 2 Purpose of this resource • The purpose of this basic ear and hearing care resource is to serve as an information resource for community level workers as well as other interested members of the community. This resource can help the community to understand common ear diseases and hearing loss. Members of the community can share information with families/people who may have hearing loss. This resource will enable people to know about the impact of unaddressed hearing loss and ear diseases. It will help the community members to suspect and deal with common ear and hearing problems. It will also educate them about possible options for diagnosing and managing these conditions. • This resource focusses on means for prevention and recognition of common ear disease and hearing loss. It also shows that, with understanding and the necessary support, people with hearing loss can play productive roles in the household, school or in the work places. The target groups for this resource includes: • Community level workers without formal training who are involved in provision of care and information to young children, older adults; people in noise workplaces • CBR (community-based rehabilitation) workers; • Parents, teachers and other members of the community that wish to know about ear and hearing care. BASIC EAR AND HEARING CARE RESOURCE 3 How to use this resource The resource can be: • Read by the individuals as an information booklet to gain knowledge or explained to them through an educational session organized by someone with specialised knowledge such as a doctor, an audiologist or a health worker who has received training on primary ear and hearing care. Instructions for readers of the resource: • Read through the booklet and make sure you understand each section. • Ask a nurse or doctor to help understand each section, if needed. • Ask guidance of a doctor or nurse to practice the practice skills mentioned in this resource. • Share information learnt with other members of your community, for example: when to suspect hearing loss; care of ears; how to take care of a hearing aid; how to instil ear drops etc • Refer to the ‘Primary ear and hearing care resource for health workers’ for further information, if needed. Instructions for trainers: When using this resource to educate others about ear and hearing care, make sure that you: • Familiarize yourself with all the sections of the resource BASIC EAR AND HEARING CARE RESOURCE 4 • Explain each section to the training participants. • Use the teaching tips to stimulate discussion with the participants. • Show participants the pictures that explain what you are teaching them. • Demonstrate the practical skills and make them practice these under your supervision. This resource forms part of a set of training resources on ear and hearing care, which includes: • Basic ear and hearing care resource. • Primary ear and hearing care resource for health workers. BASIC EAR AND HEARING CARE RESOURCE 5 HEARING LOSS AND DEAFNESS From the moment we are born we use our hearing to make sense of the world around us. It helps us connect with our families and enables us to listen, speak, and communicate our needs. As we get older, our hearing helps us to learn, work, socialize, sense potential dangers, and hear important soundslike a car horn, dog barking, someone calling your name or music playing. Being able to communicate effectively allows us to contribute to and be part of our community. What is hearing loss (HL) and deafness? Hearing loss is when a person is unable to hear as well as someone with normal hearing. Hearing loss ranges from mild to profound. It can affect one or both ears. Nearly one in sixteen people worldwide have hearing loss that impacts their daily lives. BASIC EAR AND HEARING CARE RESOURCE 6 Hearing loss grades A person with severe or profound hearing loss in both ears, is often called deaf A person with less severe hearing loss is referred to as hard of hearing. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 7 Present the scenarios to the participants. Ask them about the possible impact in these scenarios. Ask them if they have ever met or interacted with a deaf or hard of hearing person. Once you have generated some discussion about each scenario, you can explain the impact using the text provided. Teaching tip: Suhaila was born deaf, and has severe hearing loss in both ears. Since she has not had a hearing test,her parents and are unaware that she has a hearing loss. How can this test affect her life? Babies and children need to be able to hear the sounds of speech so they can develop listening and spoken language skills. All of us learn to speak based on what we hear around us. When a baby is born deaf and does not receive suitable interventions, she will not develop speech and language (including sign language skills). She will fall behind other children with good hearing. Without early diagnosis and proper rehabilitation, Suhaila will find it difficult to go to school, learn, make friends, and later in life, to get a job. What is the impact of hearing loss? BASIC EAR AND HEARING CARE RESOURCE 8 Patrick is a 6 year old studying in the second grade. Due to repeated ear infections, Patrick has a moderate hearing loss in both ears. He can hear but often misses out syllables and words. How can this affect his day to day life, at home, at school and socially? Children need good communication to learn well in school and fully grasp what is going on around them. As a result of his hearing loss, Patrick often doesn’t fully understand when his teacher says in class, especially when she faces away from him or when he sits in the back of the classroom. Sometimes he doesn’t understand the questions she asks and hence, doesn’t like to raise his hand to reply. As a result of this, the teacher feels that Patrick is not interested in his lessons and is being “difficult”. Even at home, Patrick finds it difficult to understand speech and often raises the volume of TV. His mother also thinks that Patrick is ‘difficult’ as he often doesn’t respond when she calls him. If Patrick’s ear condition is not treated, it is likely that he will lag behind academically. BASIC EAR AND HEARING CARE RESOURCE 9 Malicka is a 70-year old grandmother who lives with her family. She has hearing loss and finds it difficult to understand what her children are saying, especially when they are all speaking together or when there is music playing. How can this affect her life? Unable to understand what people are saying, Malicka starts avoiding social gatherings and prefers to stay in her room when her family is having ‘fun’. Watching TV with the family has also become difficult, as she has to raise the volume very high and others complain about it. Sometimes, the younger ones laugh when she misunderstands the question and answers incorrectly. That makes her feel hurt and lonely. Like Malicka, many older adults with hearing loss become socially isolated. Without essential support, unaddressed hearing loss can affect their mental health, causing feelings of loneliness, anxiety and depression. BASIC EAR AND HEARING CARE RESOURCE 10 The diagram above shows the parts of a ear. You can ask the participants to identify parts of their ear and reference can be made to this diagram when discussing ear conditions and hearing loss. Teaching tip: Our two ears work together to help us differentiate a variety of sounds, including loud or soft sound, and make out the direction of the source of sound. Together, our ears help us to recognise someone’s speech, in many different environments. Sound enters and travels through the three parts of our ear before the signal reaches the brain, where it is processed. We are then able to identify the sounds and understand words. The ear starts functioning even before we are born and language develops rapidly in the first few years of life. In most children that have normal hearing (and cognition), the following landmarks can be observed. How do we hear? Pinna Eardrum Middle ear Inner ear Auditory nerve BASIC EAR AND HEARING CARE RESOURCE 11 Milestones for language development Responds when called from another room. Follows longer directions, like “Put your pajamas on, brush your teeth, and then pick out a book”. Most people understand what the child says. 3 years and older Responds to her/his own name. Start speaking small words like ‘Mama’, ‘Baba’, ‘Dada’ Tries to imitate word which she/he commonly hears. 1-2 years old Baba Responds to very loud sounds. Blinks in response to a bang. Wakes up when there is a sudden noise near her/him. Quietens or smiles when the mother speaks. Birth to 3 months old Moves her/his eyes in the direction of sounds. Responds to changes in the mother’s tone of voice. Notices toys that make sounds. Pays attention to music. Coos and babbles when playing. 3-6 months old Turns and looks in the direction of sounds. Turns when someone calls her/his name. Understands words for common items and people (eg water, daddy). Starts to respond to simple words and phrases, like “No,” “Come here,” and “Want more? Babbles long strings of sounds. 6-12 months old Follows 2-part directions, like "Get the spoon and put it on the table. Understands new words quickly Puts 3 words together to talk about things. 2- 3 years old BASIC EAR AND HEARING CARE RESOURCE 12 Hearing Loss: causes, suspicion and action Many factors can affect our hearing through the course of life: It is important to note that many babies and children with hearing loss may have no obvious cause. For this reason, it is important to screen all babies for hearing loss soon after birth. Common causes of hearing loss before, during or immediately after birth include: • Hearing loss inherited directly or indirectly from parents. • Premature birth and/or low birth weight. • Birthing difficulties where the baby may suffer lack of oxygen (hypoxia). • Infections in the mother, such as rubella (german measles), syphilis, cytomegalovirus infection and toxoplasmosis during pregnancy can cause damage to the baby’s inner ear. • Use of certain medicines that damage hearing. • Jaundice, especially where it was not treated. Babies and infants Causes: Problems during pregnancy can cause problems with the growth and development of a baby’s hearing. This can cause a baby to be born with a hearing loss or develop a hearing loss soon after birth. Generate discussion by asking the participants about what they think are some common causes for hearing loss in babies, children and adults. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 13 When to suspect hearing loss in a baby? When the baby: • has any of the risk factors mentioned above. • is not responding to sounds, especially mother’s voice. • is not startled by loud sounds, eg a loud bang close to her. A mother’s story Three years ago, we were blessed with our sweet daughter, Amina. After a few months, we took her to the clinic for a checkup, and the nurse said she was healthy. At home, we noticed that if we called her name when we were standing behind her, she didn’t turn around to see who was calling her. Also, if there was a loud sound, she didn’t react. We took her back to the clinic when she was 2yrs old and explained that Amina was not responding when we talked and played with her. The nurse checked her ears and told us her ears were healthy, but suggested that Amina should be tested to see if she can hear well. She also explained that the sooner we found out if Amina had a hearing loss the better it was. We understood that it was very important to be able to communicate with our child. We took Amina to have her hearing checked and were told that Amina was deaf. They explained that Amina’s, family and friends could learn to use sign language to include our child. We also had to make sure we stood in front of Amina when we wanted to talk to her. hi!! BASIC EAR AND HEARING CARE RESOURCE 14 At first this was very upsetting but we all learned sign language and Amina became very good at ‘talking’ to us or telling us what she wanted. We hope that the teachers will also be able to learn and use sign language as Amina needs to go to school and be educated. Having a deaf child and learning about ways of including her in our everyday life showed us and our community that deaf children can do anything except hear. When our son was born last year, we were worried that he may also be deaf. The clinic tested his hearing and they told us he had some hearing and would be able to hear people talking and other sounds properly with a hearing aid. They guided us to a place where he was fitted with hearing aids. Now, we could talk and sing to him he was a happy baby. The hearing aids will also be important for him so that when he goes to school. With them, he will be able to hear the teachers and learn just like the other children. We would show the teachers how to manage his hearing aids and how to change the batteries at school. Our friends and community are very supportive and now understand how important it is to check babies, children, and even adults regularly to see if they have a problem in hearing. BASIC EAR AND HEARING CARE RESOURCE 15 Children Causes of hearing loss in children include: Wax or a foreign body (eg. beads, insects) in the ear canal: excessive amount of wax can accumulate and may cause hearing loss. A foreign body trapped in the ear canal can lead to infection. Medicines eg. certain anti-malarial drugs like Quinine, antibiotics such as gentamycin, certain anti-cancer medicines. Ear infections: commonly presenting with recurrent or persistent ear discharge. Injuries to the head or ear: can cause a hearing loss depending on the location and severity of the injury. Glue ear: fluid that remains in the middle ear after a cold or ear infection. Infections such as mumps, measles and meningitis. Loud sounds eg listening to loud music through headphones/earphones or in places such as discos; exposure to loud explosions or fireworks. BASIC EAR AND HEARING CARE RESOURCE 16 When to suspect hearing loss in a child?: • Child is not speaking or showing evidence of speech and language development at a level expected for children of their age (as shown on page 11). • Child often asks you to repeat what you say. • Child turns up the volume of the television or has trouble hearing what is being said over the phone. • Child is performing poorly at school or has behavioral problems. In many cases, this could be due to hearing loss, since the child is not hearing instructions properly and so won’t (because she can’t hear well) respond correctly. • Child has any features suggesting an ear infection, such as: - history of discharge (pus) from the ear/s, also referred to as runny ears. - complaint of pain, feeling of blockage or ringing in the ears. - fever with earache. Do not attempt to remove ear wax or foreign body at home, as this may cause’ damage to the ear. Seek help at a clinic. BASIC EAR AND HEARING CARE RESOURCE 17 If you suspect that an infant or a child may have hearing loss, make sure that you send her for a hearing test. With special equipment, hearing can be checked even on the first day of life. In babies and children up to five years of age, hearing can be checked using: • otoacoustic emission testing (OAE testing) • automated and complete auditory brainstem response testing (AABR and ABR) What to do when you suspect hearing loss in a child? Demostrate the use of the noisemaker; hand out a few noisemakers and ask participants to practice its use. Teaching tip: RIGHT EAR L R TEST > < <REVIE W In children older than five years; hearing can be tested through an audiometry test. More information about these tests is given on page 37. Where such hearing tests are not easily available, guide the parents to a health facility where her hearing can be assessed. In case you are not sure whether you should refer the child for a test, you can use a simple noisemaker to check the child’s response.You should also raise the issue with local health authorities and advocate with them to make hearing care available. BASIC EAR AND HEARING CARE RESOURCE 18 Check hearing with a ‘Noisemaker’ You can check a baby’s hearing from about nine months of age with a simple “noisemaker”. Noisemaker: you can use a rattle or make a noisemaker by putting a few grains of salt, sand or sugar in a plastic container and moving them around. The noisemaker should make a sound about as loud as a whispered voice. A few grains of salt, sand or sugar moved around (NOT shaken) on a plastic container is a good high frequency sound. If you do not have a noisemaker, try rubbing your fingers behind the baby’s ear. The baby should respond by turning in the direction of the sound. BASIC EAR AND HEARING CARE RESOURCE 19 A teacher’s story I was becoming very annoyed with Seema. She was always looking lost and sometimes she did not respond when I called her name. She looked so confused when I asked her a simple question and could not answer the questions I asked in class. At that time a health worker in our village organized an awareness session. Here she explained that hearing loss is quite common. She explained some common signs of hearing loss, like asking someone to repeat themselves or not being able to make out what is being said. She also told us about the causes which can lead to hearing loss in children and in adults. At that time. I realized that Seema’s problems might be caused by hearing loss. The next day, I asked her about her ears and some common causes of hearing loss. Seema told me that she had ear discharge off and on, since the age of 5 years. ?? BASIC EAR AND HEARING CARE RESOURCE 20 Seema told me that it was common in her community for children to have ear discharge. At times her ears ached and her mother would pour some hot oil into them. I spoke to Seema’s mother and asked her to take Seema to a doctor at the nearby health centre. At the centre, Seema underwent some tests. She and her mother were told how to care for her ears and not to instill oil into them. I made Seema sit in the front row in the classroom and made sure that she could hear clearly what was being said. Soon, Seema’s grades improved and she became more responsive. A few months later, Seema underwent an operation for her ears. Since then, she is able to hear better. Even though she is not in my class any more, I see her around. Her teacher tells me that Seema is doing well in class. I think awareness sessions such as the one organized by the health worker are very important for the community and specially teachers to know more about common issued faced by children. BASIC EAR AND HEARING CARE RESOURCE 21 What can be done if a child is diagnosed with hearing loss? Once hearing loss is identified its management, must be discussed and started at the earliest possible. Getting help as soon as possible can ensure that: • the child develops language skills, gains education, and can be socially integrated. • In a child with an ear diseases can get diagnosed and treated, so that hearing loss and other complications are avoided. Ask the participants what they know about this. Why is it important to pay attention and intervene early? What are the options for a child with hearing loss? Ask their views and the discuss the answers detailed below. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 22 Early intervention leads to better outcomes in children. For instance, infants whose hearing loss are diagnosed by 3 months after birth and intervention implemented by 6 months of age can develop speech and language similar to their peers with normal hearing. Hearing aids or cochlear implants, based on the advice of an ENT doctor or audiologist. Interventions for children with hearing loss include: Rehabilitation which can include aural rehabilitation; speech and language therapy, auditory verbal therapy, cued speech, and total communication. Learning sign language, especially where hearing devices are not preferred; are not beneficial; or are unavailable. This will ensure that the child can communicate and gain an education Families/carers and teachers Support the child in rehabilitation and use of hearing aids or cochlear implants. They learn to use sign language, if needed. Counselling and peer-group support for the child/carer/ family. BASIC EAR AND HEARING CARE RESOURCE 23 What can be done in case of ear diseases? Ask the participants about how they can suspect ear diseases. Refer to the points listed above for discussion. Teaching tip: When any person shows signs suggestive of an ear disease, should be referred to a doctor for examination and diagnosis.Treatment depend on the nature of the disease and can include: Medical treatment with oral medicines or ear drops Ear surgery Treating the ear disease early may prevent or reverse any hearing loss it caused. You can help those with ear discharge/infections by guiding them properly. Clean ears by dry mopping or wicking. This is essential and must be safely Use eardrops, if prescribed. The eardrops must be be effective. Seek and follow the advice of a doctor/ health worker Suspect ear disease in case of: • Pain in the ear • Ear discharge • Persistent heaviness in ear • Ringing in ear • Difficulty in hearing Care for discharging ears: don properly. BASIC EAR AND HEARING CARE RESOURCE 24 Dry Mopping • Only clean ears with a dry mop when the ear is discharging. • When the ear is dry it must not be cleaned with a dry mop. • A dry mop is not the same as a “cotton bud” or “q-tip”. • “Cotton buds” or “q-tips” must never be inserted into the ear as they are too big and the cotton wool is wound onto the stick too tightly. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: How to make a dry mop Materials: a thin wooden stick applicator and cotton wool Wash your hands with soap and water – air dry. Pull off a small piece of cotton wool. Gently pull it out into an oval shape. Put the tip of the stick into the center of the cotton wool. Twist the stick round and round with one hand whilst holding half of the cotton wool tightly against the stick with the thumb and index of your other hand. After completing dry mopping, wash your hand. Half of the cotton wool should extend form the end of the stick and form a fluffy, soft tip. The rolled up piece of cotton wool should be long enough so that when the soft tip is deep in the ear canal and next to the eardrum there is still some cotton wool sticking out of the ear canal. This is so that you can hold onto the cotton wool and ensure that the cotton wool comes out of the ear canal. 1. 2. 3. 4. 5. 6. 7. BASIC EAR AND HEARING CARE RESOURCE 25 How to make and use a tissue wick for mopping the ear Materials: a small piece of absorbent cotton cloth or a piece of soft, strong tissue paper – NOT flimsy toilet paper that can tear in the ear. Make all participants practice these skills under supervision. Teaching tip: 3. Place the wick into the ear canal. It will absorb any discharge or blood in the ear canal. 4. Leave it in 1. Make a wick by rolling the cloth or the tissue paper into a pointed shape. 2. Gently pull the pinna away from the head. This helps straighten the ear in the ear canal. 5. Remove the wet wick and inspect it. Is there pus on the wick? 6. Replace with a clean wick. 7. Repeat until the wick stays dry. Note: Dry mopping is recommended to clean the ear canal in the clinic. People with discharging ears could be taught dry mopping/wicking to clean the ears at home. for a minute. BASIC EAR AND HEARING CARE RESOURCE 26 Follow these steps when putting in eardrops: Demonstrate this (without actually using ear drops) and make sure the participants practice this under supervision. Teaching tip: 2. Lie the person on their side or tilt their head so that their ear is pointing upwards. 8. Keep the person on their side for 5 minutes. Wipe away any eardrops that run out of the ear when the person sits up 4. Drop 2 or 3 eardrops into the ear canal. 5. Move the pinna to make sure the eardrops go to the bottom of the ear canal. 6. Put in 2 or 3 more eardrops. 7. Pump the tragus (repeatedly push in and out). 1. Clean out the ear canal by dry mopping. 3. Gently pull the earlobe backwards and upwards to straighten the ear canal. BASIC EAR AND HEARING CARE RESOURCE 27 Adults Hearing loss can occur at any age. Common causes in adults include: Loud sounds: -Prolonged noise exposure from working in noisy places e.g factories with loud machinery, music industry, working with guns and other weapons. -Listening to loud music through headphones/earphones or in places such as discos. - Single exposures to a high intensity sound like a blast or an explosion. Do not stop the use of any medicines without consulting a doctor. If suspected that a medicine may put hearing at risk, seek the doctor’s advice. If the medicine taken is known to affect hearing, then hearing should be checked regularly. Ask the participants if they have ever had any experience with loud sounds and how that affected them. Teaching tip: Medicines that can damage hearing: certain antobiotics, antimalarials, anti- cancer medicines and injectables for drug resistant TB. Injury to the head or ears Untreated, prolonged ear infections Age-related hearing loss Our hearing may decline as we grow older. About one in three people older than 65 years have age-related hearing loss. Ear diseases indicated by recurrent or persistent ear discharge or pain. BASIC EAR AND HEARING CARE RESOURCE 28 What to do when you suspect hearing loss in an adult? Encourage the person to get his/her hearing checked. This can be done by: • A pure tone audiometry: is usually done at a clinic or other health facility. • Those adults that have a smartphone can use the free hearWHO app to screen for the haering loss. If the person has a score below 50 on the hearWHO test, he or she must definitely get a hearing test without delay. CAUTION: If an adult reports a sudden hearing loss or has a loss in just one ear, he should see a health worker as soon as possible. A person with hearing loss • Not respond when called to or may respond inappropriately. • Speak much louder than usual (this is because their own voice sounds low) • Have difficulty talking over the phone. • Become withdrawn, quiet and isolated. • Turn up the volume to hear the TV or listen to music. • Report that he can hear but cannot make out what is being said/ ‘I can hear you talking but don’t know what you’re saying’, ie sounds are muffled, or that others are mumbling. • Have unclear speech. • Have difficulty in hearing high frequency sounds like doorbells or telephone ringing. How can you suspect hearing loss in an adult? • Complain of a ringing sound in the ear (tinnitus). • Have a history of ear discharge. BASIC EAR AND HEARING CARE RESOURCE 29 John’s story John retired after working in a very noisy factory for 34 years. At home he often turned up the television volume. At times, he wouldnt hear his wife when she asked him what he would like for dinner. These changes appeared gradually. John’s wife spoke to the health worker who explained that when people work in a noisy environment and also as they become older they may not hear well. John did not know that people working in noisy factories needed to wear ear protection to prevent hearing loss. John’s wife told him what the health worker had said but he denied that he might have a hearing loss. John said the family muttered when they spoke. BASIC EAR AND HEARING CARE RESOURCE 30 After a few months, John’s wife finally persuaded him to visit the health worker who examined his ears and asked him to get his hearing tested at a nearby clinic. After the test, the audiologist explained to John that he had moderately severe hearing loss. He then explained that older people with hearing loss may hear others talking, but often they do not understand what is being said. Especially if they are in a noisy environment, people seem to mumble when they speak. John’s wife said he no longer enjoyed going out to celebrate family events because he could not hear what people were saying. John explained that he felt left out and this was making him feel very lonely. The audiologist suggested that hearing aids may help John hear what people say, but he must visit the clinic regularly after he gets the hearing aid to get its full benefit. John and his wife are managing his hearing and hearing aids with the support of the audiologist, as well as their family and friends. Their friends have learnt to talk one at a time and speak a little more slowly and clearly so that John can be included in the conversation. This has made a big difference to everyone. But mostly to John, as he is no longer avoiding family, friends and social get togethers. Now that John and his family understand the impact of hearing loss in older people, they are raising awareness in the community about the importance of checking one’s hearing. BASIC EAR AND HEARING CARE RESOURCE 31 What can be done if hearing loss or ear disease is identified in an adult? • It is important to identify what the cause of hearing loss is and address it, e.g. noise, medicines, ear diseases. • Adults with hearing loss are likely to benefit from use of devices, such as hearing aids and cochlear implants. • Adults also benefit from aural rehabilitation and support to get the maximum value from their hearing. In adults, as in case of children, it is important that hearing loss be identified as early as possible and that rehabilitation and use of devices is started without delay. BASIC EAR AND HEARING CARE RESOURCE 32 Hearing can be tested at any age. Different tests are done depending on the person’s age to identify the type and the severity of hearing loss. These include: 1. Otoacoustic emissions (OAE) or automated auditory brainstem response (AABR) tests that can be done on babies and children up to five years of age. These tests are often carried out using a handheld device, while they child is asleep. They are quick and easy to perform. When a child fails this test repeatedly (twice), s/ he be sent for an auditory brainstem response test. 2. Auditory brainstem response test (ABR): this test is usually only available at specialized centres. This test is often carried out after sedating the baby. How is hearing tested? OAE or AABR tests could be available at a health facility close to you. Find out from the health worker/doctor about the availability of such tests in your area. It is a good idea for every child to have their hearing checked soon after birth, in order to identify hearing loss early. BASIC EAR AND HEARING CARE RESOURCE 33 3. Pure Tone Audiometry: children older than five years and adults can have their hearing checked by a simple test, using the pure tone audiometry (PTA). In this test, sounds of different pitches are presented into each ear and the person is asked to respond when s/he can hear these. How is hearing tested? Children older than five years and adults: BASIC EAR AND HEARING CARE RESOURCE 34 Hearing check-ups should be routinely done for: Remember, the earlier hearing loss is detected, the sooner an intervention can be implemented. Speak to your local health worker if you feel that infant, child or adult needs a hearing test, encourage the person to get a hearing test at the earliest. • Babies • Children • Older adults • Those using ototoxic medicines • Those exposed to loud sounds BASIC EAR AND HEARING CARE RESOURCE 35 Hearing devices: What is a Hearing aid? A hearing aid is an electronic device that is worn on the ear. It helps to amplify sounds to allow a person with hearing loss to hear better. There are many different types of hearing aids and they come in various colours, sizes and shapes. A behind-the-ear hearing aid: has two parts (the hearing aid and the earmould), which are joined together by a thin, clear tube: • the hearing aid sits over and behind the ear; • the ear mould goes into the ear An in-the-ear hearing aid: is smaller and is specially shaped to fit into the person’s ear. Care of the hearing aids • Hearing aid is small and can easily be lost or damaged. • Keep hearing aid in a safe, cool place when not using it. • A hearing aid must be kept dry. If it absorbs moisture, it may not work properly. Take it off while bathing. • Every night, open the battery drawer and place the hearing aid into a sealed plastic tub, with something dry e.g. fine tissues or rice. • Make sure it is switched off when not being used, in order to save battery life. • Keep hearing aid away from water and heat e.g. a stove or flame. Ask the participants if they have ever seen anyone using a hearing aid and how they think it works. Ask them about cochlear implant. Have they ever heard of a cochlear implant. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 36 Hearing aids use batteries and these must be changed about once in 7 to 10 days, depending on how much it is worn. If the hearing aid stops working, try changing the batteries first. It is important to check the batteries in a child’s hearing aids every day. The earmould must be cleaned every day and wiped with a dry cloth. Once a week, you can remove the earmould and its tube from the hearing aid and wash in soapy water. This will make sure that any wax blocking the earmould is cleaned. Hearing aids use When wax blocks the earmould, the hearing aid can stop working. The hearing aid can make a whistling sound when it is not inserted correctly into the ear. The hearing aid itself must never get wet, or it may be damaged and stop working. Every few months, the tube that connects the earmould to the hearing aid will need replacing. The earmould itself will need to be replaced every year. This will need to be done more often in infants and children to ensure the mould fits the child’s ears, as their ears are growing. If the earmould is too small for the child, it may cause the hearing aid to whistle. How to check the battery is working: • Remove the hearing aid from the ear and take off the earmould. • Switch the hearing aid on and turn the volume control to the highest setting. • Place the hearing aid in the palm of your hand. • If there is a continuous whistling sound, it indicates the battery is working. • If there is no whistling sound, the battery should be replaced. If there is still no whistling sound after inserting a new battery, then there could be a problem with the hearing aid, you need to get it checked. KEEP HEARING AID BATTERIES AWAY FROM LITTLE CHILDREN! Children may swallow the batteries, leading to serious complications requiring surgery to remove them. BASIC EAR AND HEARING CARE RESOURCE 37 A cochlear implant is an electronic medical device for people with a severe or profound hearing loss, for whom hearing aids are not strong enough. Unlike a hearing aid, a cochlear implant converts sounds into electric signals. These signals stimulate the little hairs in the inner ear and are then carried by the hearing nerve to the brain. The brain understands these sounds or speech and so the person is able to hear better. In order to have a cochlear implant, an individual needs an operation. What is a cochlear implant? The cochlear implant has 2 parts: An external processor that sits behind the ear or on the head, and has a similar appearance to a hearing aid A second part, which is placed under the skin, behind the ear through an operation. 1 2 BASIC EAR AND HEARING CARE RESOURCE 38 Shreya’s story When Shreya was 7 months old, we celebrated the Indian festival of Diwali in the traditional way with lights, sweets and firecrackers. That was when I first noticed that Shreya was not responding to sounds as she did not startle or react, even when loud crackers were being burst. Soon after that, my husband and I took her to a doctor who sent her for hearing tests. After the tests, it became clear that Shreya was deaf. Our family had never met anyone deaf before this and we were all very worried. We felt that without hearing, Shreya would not be able to develop speech or go to school. The doctor guided us and informed us about cochlear implant and that this was a possibility for Shreya. Thanks to the government’s programme, we decided to get her implanted. At 3 years of age, Shreya started rehabilitation. BASIC EAR AND HEARING CARE RESOURCE 39 Our family had to work hard for her rehabilitation. We took her for therapy regularly and went back to see the audiologist when called. As a result, Shreya soon started to understand what was being said and slowly started speaking. We were overjoyed and continued our efforts. Now ten years old, Shreya attends the same school as her older brother and loves to study sciences. She also loves to paint and dance. But what she loves most is talking. Sometimes, she speaks so much that we have tell her to stay quiet! We now tell all our family and friends that hearing loss can be addressed. It is important that parents should take the child for assessment if they suspect a hearing loss. It is important to stay vigilant and act early. BASIC EAR AND HEARING CARE RESOURCE 40 How to speak with someone who is hard of hearing? • Speak clearly and slowly. Don’t shout! • Stand in good lighting and face the person so they can see your face when you speak • Do not exaggerate or distort lip movements as this might make it harder for the person to follow what is being said. • Try to keep background noise to a minimum, especially at school and at work, as loud background noise can make it difficult for someone with hearing loss to hear, even with a hearing aid. • If there is a hard of hearing person in a group (social, family or work) ensure people talk one at a time. This enables the hard of hearing person to be included in conversations. Supporting people with hearing loss BASIC EAR AND HEARING CARE RESOURCE 41 What can I do to support someone with a hearing loss or deafness? • Encourage them to visit a clinic and get their hearing checked. • Support them in the use of hearing aids or implants if they use these. Help them check its battery or to see if the tubing is blocked with wax.Young children and older adults may require assistance with this. • Teach children to self- advocate for their needs at home and at school. For example, encourage children to inform their teacher or parents when the hearing aid stops working, or to ask people to repeat themselves if they were unable to hear properly. • Encourage people to be open about their or their child’s hearing loss and not to hide it. • Guide parents to inform teachers at school of their Remember that with the proper care and support people with hearing loss can do everything, except hear normally. They must be included in all activities. child’s hearing loss and encourage the teacher to face the child directly as much as possible while speaking to her. • Inform parents and teachers about sign language and encourage them to learn this as a means of communication. BASIC EAR AND HEARING CARE RESOURCE 42 Preventing hearing loss Ensuring that mothers and babies receive good care before, during and after birth 60% Many cases of hearing loss can be prevented. It is estimated that in children 60% of hearing loss is due to preventable causes. Many small steps can help to prevent hearing loss such as: Vaccinating your child against rubella, measles, mumps, meningitis. 1 2 3 4 6Protecting ears from loud sounds at work and in the environment Following safe practices while listening to music over ear/headphones or in places like discos, concerts or parties. Asking your doctor if your medicine can affect your hearing and how this can be avoided Taking good care of your ears by practicing the Dos and Donts listed 5 BASIC EAR AND HEARING CARE RESOURCE 43 DOs: • Ask for a hearing screening test for your baby. • If you suspect someone has a hearing loss, refer them urgently to a health worker. This is especially important for infants and children. • Get help from a health worker or doctor in case of persistent ear-ache, ear discharge or any other problems with the ear. • See a health worker or attend a clinic to have earwax or foreign objects in the ear removed. • Assist young children and adults with the care and maintenance of their hearing aids or implants. • Go to a doctor if your child has a cold that it is not improving. • Encourage the use of hearing protection for those working in noisy place. • Encourage families and teachers of someone with hearing loss to learn sign language. • Only use medications in your ears that have been prescribed for you by the doctor. • Trust your instinct! If you suspect something is wrong with your hearing, seek help. Care of the ears: important DOs and DON’Ts BASIC EAR AND HEARING CARE RESOURCE 44 DON’Ts: • DON’T put anything in the ear. No cotton buds, clips, toothpicks, sticks or hopi candles. • DON’T ignore an ear that has any pus or fluid coming out of it. • DON’T treat any ear conditions with hot or cold oil, herba or home remedies. • DON’T swim or wash in dirty water. • DON’T listen to very loud noises or music for long periods as this can cause hearing loss. If you are ever uncertain whether an individual has a hearing loss, encourage them to seek help from their local health workers, who should be able to conduct some basic hearing tests and refer them to medical experts as required. Remember that wax is produced by the ear to protect the ear and keep it clean. Cotton buds should never be used (not even for regular cleaning), as they may push wax further into the ear and damage the ear-drum. Sometimes the cotton may remain behind as a foreign body! When listening to music over a personal device (eg MP3 player), keep the volume below 60% of máximum, take frequent breaks and limit listening time.

FOR MORE INFORMATION PLEASE CONTACT: Department for Noncommunicable Diseases https://www.who.int/health-topics/hearing-loss World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Page 1 of 1 2/7/2020http://extranet.who.int/bpmext/includes/ePub/attachments/090000000000000000000000... ISBN 978-92-4-000148-0

BASIC EAR AND HEARING CARE RESOURCE

BASIC EAR AND HEARING CARE RESOURCE BASIC EAR AND HEARING CARE RESOURCE Basic ear and hearing care resource ISBN 978-92-4-000148-0 (electronic version) ISBN 978-92-4-000149-7 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Basic ear and hearing care resource. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. BASIC EAR AND HEARING CARE RESOURCE I. INTRODUCTION • Background • Purpose of this resource • How to use this resource II. HEARING LOSS AND DEAFNESS • What is hearing and hearing loss/deafness • Types of hearing loss • Causes and signs of hearing loss/deafness in children • Causes and signs of hearing loss/deafness in adults • Hearing testing III. CARE FOR PEOPLE WITH EAR DISEASES AND HEARING LOSS • How to care for discharging ears • Support for people with hearing loss • How families/carers/teachers could communicate with people with hearing loss • Hearing aids and cochlear implants • DOs and DONTs CONTENTS 5iii ACKNOWLEDGEMENTS BASIC EAR AND HEARING CARE RESOURCE Acknowledgements This document is the outcome of a consultative process led by the World Health Organization with contribution of the following World Health Organization (WHO) staff members: Shelly Chadha, Alarcos Cieza, Cherian Varughese, Maryam Mallik, Ricardo Martinez, Patanjali Dev Nayar, Karen Reyes, Emma Tebbutt, Florante Trinidad, Hala Sakr and Juan Carlos Silva. The conceptual framework and outline of the ‘Basic Ear and Hearing Care resource’ were developed in consultation with an expert group through a series of consultations organized by the World Health Organization. The initial drafting of the document was done by Mahmood Bhutta, Priyadarshni Carling and Sally Harvest. Document review and inputs were provided by: Arun Agarwal, Mazin Al Khabouri, Ned Carter, Michael Chowen, Jackie Clark, Harvey Coates, Carolina Der, Victor De Andrade, Uta Fröschl, Suneela Garg, Sally Harvest, Linda Hood, Isaac Macharia, Norberto Martinez, Amarilis Melendez, Christopher O’callaghan, Christopher Prescott, Hubert Ramos, Leela Agnes Sambantham, Diego Santana Hernandez, Andrew Smith, Paige Stringer, George Tavartkiladze, Sian Tesni, Yufeng Wang and Bu Xingkuan. The booklet and the procedures explained in it were field tested in India and Uganda with support provided by CBM India Country Office, Bengaluru; St John’s Hospital, Bengaluru and its Community Centre, Mugalur, India; Community Health Academic Department of Christian Medical College and Hospital, Vellore, India; James O’Donovan and members of ‘The Village Health Team’ of Omni Med, Uganda. Financial support for this document has been provided by CBM and the Hearing Conservation Council. iV BASIC EAR AND HEARING CARE RESOURCE 1 INTRODUCTION Background • World Health Organization estimates that there are over 460 million people in the world with disabling hearing loss. Nearly 90% of them live in low- and middle-income countries of the world. Many more people have mild hearing loss and suffer diseases of the ear. These problems can often cause life-long and sometimes life-threatening difficulties. Without suitable interventions, deaf or hard of hearing people find it difficult to communicate with others. They also have difficulty in education and in the workplace, and often they feel left out of social and family life. • • In many places there is a lack of services and trained workers to prevent and treat ear diseases and help people with hearing loss. People themselves are not well aware about the importance of hearing. There are many myths and misconceptions about ear diseases and hearing loss in the society. • • The resource focuses on community involvement and raising awareness; and will provide useful information for preventing and addressing ear diseases and hearing loss. BASIC EAR AND HEARING CARE RESOURCE 2 Purpose of this resource • The purpose of this basic ear and hearing care resource is to serve as an information resource for community level workers as well as other interested members of the community. This resource can help the community to understand common ear diseases and hearing loss. Members of the community can share information with families/people who may have hearing loss. This resource will enable people to know about the impact of unaddressed hearing loss and ear diseases. It will help the community members to suspect and deal with common ear and hearing problems. It will also educate them about possible options for diagnosing and managing these conditions. • This resource focusses on means for prevention and recognition of common ear disease and hearing loss. It also shows that, with understanding and the necessary support, people with hearing loss can play productive roles in the household, school or in the work places. The target groups for this resource includes: • Community level workers without formal training who are involved in provision of care and information to young children, older adults; people in noise workplaces • CBR (community-based rehabilitation) workers; • Parents, teachers and other members of the community that wish to know about ear and hearing care. BASIC EAR AND HEARING CARE RESOURCE 3 How to use this resource The resource can be: • Read by the individuals as an information booklet to gain knowledge or explained to them through an educational session organized by someone with specialised knowledge such as a doctor, an audiologist or a health worker who has received training on primary ear and hearing care. Instructions for readers of the resource: • Read through the booklet and make sure you understand each section. • Ask a nurse or doctor to help understand each section, if needed. • Ask guidance of a doctor or nurse to practice the practice skills mentioned in this resource. • Share information learnt with other members of your community, for example: when to suspect hearing loss; care of ears; how to take care of a hearing aid; how to instil ear drops etc • Refer to the ‘Primary ear and hearing care resource for health workers’ for further information, if needed. Instructions for trainers: When using this resource to educate others about ear and hearing care, make sure that you: • Familiarize yourself with all the sections of the resource BASIC EAR AND HEARING CARE RESOURCE 4 • Explain each section to the training participants. • Use the teaching tips to stimulate discussion with the participants. • Show participants the pictures that explain what you are teaching them. • Demonstrate the practical skills and make them practice these under your supervision. This resource forms part of a set of training resources on ear and hearing care, which includes: • Basic ear and hearing care resource. • Primary ear and hearing care resource for health workers. BASIC EAR AND HEARING CARE RESOURCE 5 HEARING LOSS AND DEAFNESS From the moment we are born we use our hearing to make sense of the world around us. It helps us connect with our families and enables us to listen, speak, and communicate our needs. As we get older, our hearing helps us to learn, work, socialize, sense potential dangers, and hear important soundslike a car horn, dog barking, someone calling your name or music playing. Being able to communicate effectively allows us to contribute to and be part of our community. What is hearing loss (HL) and deafness? Hearing loss is when a person is unable to hear as well as someone with normal hearing. Hearing loss ranges from mild to profound. It can affect one or both ears. Nearly one in sixteen people worldwide have hearing loss that impacts their daily lives. BASIC EAR AND HEARING CARE RESOURCE 6 Hearing loss grades A person with severe or profound hearing loss in both ears, is often called deaf A person with less severe hearing loss is referred to as hard of hearing. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 7 Present the scenarios to the participants. Ask them about the possible impact in these scenarios. Ask them if they have ever met or interacted with a deaf or hard of hearing person. Once you have generated some discussion about each scenario, you can explain the impact using the text provided. Teaching tip: Suhaila was born deaf, and has severe hearing loss in both ears. Since she has not had a hearing test,her parents and are unaware that she has a hearing loss. How can this test affect her life? Babies and children need to be able to hear the sounds of speech so they can develop listening and spoken language skills. All of us learn to speak based on what we hear around us. When a baby is born deaf and does not receive suitable interventions, she will not develop speech and language (including sign language skills). She will fall behind other children with good hearing. Without early diagnosis and proper rehabilitation, Suhaila will find it difficult to go to school, learn, make friends, and later in life, to get a job. What is the impact of hearing loss? BASIC EAR AND HEARING CARE RESOURCE 8 Patrick is a 6 year old studying in the second grade. Due to repeated ear infections, Patrick has a moderate hearing loss in both ears. He can hear but often misses out syllables and words. How can this affect his day to day life, at home, at school and socially? Children need good communication to learn well in school and fully grasp what is going on around them. As a result of his hearing loss, Patrick often doesn’t fully understand when his teacher says in class, especially when she faces away from him or when he sits in the back of the classroom. Sometimes he doesn’t understand the questions she asks and hence, doesn’t like to raise his hand to reply. As a result of this, the teacher feels that Patrick is not interested in his lessons and is being “difficult”. Even at home, Patrick finds it difficult to understand speech and often raises the volume of TV. His mother also thinks that Patrick is ‘difficult’ as he often doesn’t respond when she calls him. If Patrick’s ear condition is not treated, it is likely that he will lag behind academically. BASIC EAR AND HEARING CARE RESOURCE 9 Malicka is a 70-year old grandmother who lives with her family. She has hearing loss and finds it difficult to understand what her children are saying, especially when they are all speaking together or when there is music playing. How can this affect her life? Unable to understand what people are saying, Malicka starts avoiding social gatherings and prefers to stay in her room when her family is having ‘fun’. Watching TV with the family has also become difficult, as she has to raise the volume very high and others complain about it. Sometimes, the younger ones laugh when she misunderstands the question and answers incorrectly. That makes her feel hurt and lonely. Like Malicka, many older adults with hearing loss become socially isolated. Without essential support, unaddressed hearing loss can affect their mental health, causing feelings of loneliness, anxiety and depression. BASIC EAR AND HEARING CARE RESOURCE 10 The diagram above shows the parts of a ear. You can ask the participants to identify parts of their ear and reference can be made to this diagram when discussing ear conditions and hearing loss. Teaching tip: Our two ears work together to help us differentiate a variety of sounds, including loud or soft sound, and make out the direction of the source of sound. Together, our ears help us to recognise someone’s speech, in many different environments. Sound enters and travels through the three parts of our ear before the signal reaches the brain, where it is processed. We are then able to identify the sounds and understand words. The ear starts functioning even before we are born and language develops rapidly in the first few years of life. In most children that have normal hearing (and cognition), the following landmarks can be observed. How do we hear? Pinna Eardrum Middle ear Inner ear Auditory nerve BASIC EAR AND HEARING CARE RESOURCE 11 Milestones for language development Responds when called from another room. Follows longer directions, like “Put your pajamas on, brush your teeth, and then pick out a book”. Most people understand what the child says. 3 years and older Responds to her/his own name. Start speaking small words like ‘Mama’, ‘Baba’, ‘Dada’ Tries to imitate word which she/he commonly hears. 1-2 years old Baba Responds to very loud sounds. Blinks in response to a bang. Wakes up when there is a sudden noise near her/him. Quietens or smiles when the mother speaks. Birth to 3 months old Moves her/his eyes in the direction of sounds. Responds to changes in the mother’s tone of voice. Notices toys that make sounds. Pays attention to music. Coos and babbles when playing. 3-6 months old Turns and looks in the direction of sounds. Turns when someone calls her/his name. Understands words for common items and people (eg water, daddy). Starts to respond to simple words and phrases, like “No,” “Come here,” and “Want more? Babbles long strings of sounds. 6-12 months old Follows 2-part directions, like "Get the spoon and put it on the table. Understands new words quickly Puts 3 words together to talk about things. 2- 3 years old BASIC EAR AND HEARING CARE RESOURCE 12 Hearing Loss: causes, suspicion and action Many factors can affect our hearing through the course of life: It is important to note that many babies and children with hearing loss may have no obvious cause. For this reason, it is important to screen all babies for hearing loss soon after birth. Common causes of hearing loss before, during or immediately after birth include: • Hearing loss inherited directly or indirectly from parents. • Premature birth and/or low birth weight. • Birthing difficulties where the baby may suffer lack of oxygen (hypoxia). • Infections in the mother, such as rubella (german measles), syphilis, cytomegalovirus infection and toxoplasmosis during pregnancy can cause damage to the baby’s inner ear. • Use of certain medicines that damage hearing. • Jaundice, especially where it was not treated. Babies and infants Causes: Problems during pregnancy can cause problems with the growth and development of a baby’s hearing. This can cause a baby to be born with a hearing loss or develop a hearing loss soon after birth. Generate discussion by asking the participants about what they think are some common causes for hearing loss in babies, children and adults. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 13 When to suspect hearing loss in a baby? When the baby: • has any of the risk factors mentioned above. • is not responding to sounds, especially mother’s voice. • is not startled by loud sounds, eg a loud bang close to her. A mother’s story Three years ago, we were blessed with our sweet daughter, Amina. After a few months, we took her to the clinic for a checkup, and the nurse said she was healthy. At home, we noticed that if we called her name when we were standing behind her, she didn’t turn around to see who was calling her. Also, if there was a loud sound, she didn’t react. We took her back to the clinic when she was 2yrs old and explained that Amina was not responding when we talked and played with her. The nurse checked her ears and told us her ears were healthy, but suggested that Amina should be tested to see if she can hear well. She also explained that the sooner we found out if Amina had a hearing loss the better it was. We understood that it was very important to be able to communicate with our child. We took Amina to have her hearing checked and were told that Amina was deaf. They explained that Amina’s, family and friends could learn to use sign language to include our child. We also had to make sure we stood in front of Amina when we wanted to talk to her. hi!! BASIC EAR AND HEARING CARE RESOURCE 14 At first this was very upsetting but we all learned sign language and Amina became very good at ‘talking’ to us or telling us what she wanted. We hope that the teachers will also be able to learn and use sign language as Amina needs to go to school and be educated. Having a deaf child and learning about ways of including her in our everyday life showed us and our community that deaf children can do anything except hear. When our son was born last year, we were worried that he may also be deaf. The clinic tested his hearing and they told us he had some hearing and would be able to hear people talking and other sounds properly with a hearing aid. They guided us to a place where he was fitted with hearing aids. Now, we could talk and sing to him he was a happy baby. The hearing aids will also be important for him so that when he goes to school. With them, he will be able to hear the teachers and learn just like the other children. We would show the teachers how to manage his hearing aids and how to change the batteries at school. Our friends and community are very supportive and now understand how important it is to check babies, children, and even adults regularly to see if they have a problem in hearing. BASIC EAR AND HEARING CARE RESOURCE 15 Children Causes of hearing loss in children include: Wax or a foreign body (eg. beads, insects) in the ear canal: excessive amount of wax can accumulate and may cause hearing loss. A foreign body trapped in the ear canal can lead to infection. Medicines eg. certain anti-malarial drugs like Quinine, antibiotics such as gentamycin, certain anti-cancer medicines. Ear infections: commonly presenting with recurrent or persistent ear discharge. Injuries to the head or ear: can cause a hearing loss depending on the location and severity of the injury. Glue ear: fluid that remains in the middle ear after a cold or ear infection. Infections such as mumps, measles and meningitis. Loud sounds eg listening to loud music through headphones/earphones or in places such as discos; exposure to loud explosions or fireworks. BASIC EAR AND HEARING CARE RESOURCE 16 When to suspect hearing loss in a child?: • Child is not speaking or showing evidence of speech and language development at a level expected for children of their age (as shown on page 11). • Child often asks you to repeat what you say. • Child turns up the volume of the television or has trouble hearing what is being said over the phone. • Child is performing poorly at school or has behavioral problems. In many cases, this could be due to hearing loss, since the child is not hearing instructions properly and so won’t (because she can’t hear well) respond correctly. • Child has any features suggesting an ear infection, such as: - history of discharge (pus) from the ear/s, also referred to as runny ears. - complaint of pain, feeling of blockage or ringing in the ears. - fever with earache. Do not attempt to remove ear wax or foreign body at home, as this may cause’ damage to the ear. Seek help at a clinic. BASIC EAR AND HEARING CARE RESOURCE 17 If you suspect that an infant or a child may have hearing loss, make sure that you send her for a hearing test. With special equipment, hearing can be checked even on the first day of life. In babies and children up to five years of age, hearing can be checked using: • otoacoustic emission testing (OAE testing) • automated and complete auditory brainstem response testing (AABR and ABR) What to do when you suspect hearing loss in a child? Demostrate the use of the noisemaker; hand out a few noisemakers and ask participants to practice its use. Teaching tip: RIGHT EAR L R TEST > < <REVIE W In children older than five years; hearing can be tested through an audiometry test. More information about these tests is given on page 37. Where such hearing tests are not easily available, guide the parents to a health facility where her hearing can be assessed. In case you are not sure whether you should refer the child for a test, you can use a simple noisemaker to check the child’s response.You should also raise the issue with local health authorities and advocate with them to make hearing care available. BASIC EAR AND HEARING CARE RESOURCE 18 Check hearing with a ‘Noisemaker’ You can check a baby’s hearing from about nine months of age with a simple “noisemaker”. Noisemaker: you can use a rattle or make a noisemaker by putting a few grains of salt, sand or sugar in a plastic container and moving them around. The noisemaker should make a sound about as loud as a whispered voice. A few grains of salt, sand or sugar moved around (NOT shaken) on a plastic container is a good high frequency sound. If you do not have a noisemaker, try rubbing your fingers behind the baby’s ear. The baby should respond by turning in the direction of the sound. BASIC EAR AND HEARING CARE RESOURCE 19 A teacher’s story I was becoming very annoyed with Seema. She was always looking lost and sometimes she did not respond when I called her name. She looked so confused when I asked her a simple question and could not answer the questions I asked in class. At that time a health worker in our village organized an awareness session. Here she explained that hearing loss is quite common. She explained some common signs of hearing loss, like asking someone to repeat themselves or not being able to make out what is being said. She also told us about the causes which can lead to hearing loss in children and in adults. At that time. I realized that Seema’s problems might be caused by hearing loss. The next day, I asked her about her ears and some common causes of hearing loss. Seema told me that she had ear discharge off and on, since the age of 5 years. ?? BASIC EAR AND HEARING CARE RESOURCE 20 Seema told me that it was common in her community for children to have ear discharge. At times her ears ached and her mother would pour some hot oil into them. I spoke to Seema’s mother and asked her to take Seema to a doctor at the nearby health centre. At the centre, Seema underwent some tests. She and her mother were told how to care for her ears and not to instill oil into them. I made Seema sit in the front row in the classroom and made sure that she could hear clearly what was being said. Soon, Seema’s grades improved and she became more responsive. A few months later, Seema underwent an operation for her ears. Since then, she is able to hear better. Even though she is not in my class any more, I see her around. Her teacher tells me that Seema is doing well in class. I think awareness sessions such as the one organized by the health worker are very important for the community and specially teachers to know more about common issued faced by children. BASIC EAR AND HEARING CARE RESOURCE 21 What can be done if a child is diagnosed with hearing loss? Once hearing loss is identified its management, must be discussed and started at the earliest possible. Getting help as soon as possible can ensure that: • the child develops language skills, gains education, and can be socially integrated. • In a child with an ear diseases can get diagnosed and treated, so that hearing loss and other complications are avoided. Ask the participants what they know about this. Why is it important to pay attention and intervene early? What are the options for a child with hearing loss? Ask their views and the discuss the answers detailed below. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 22 Early intervention leads to better outcomes in children. For instance, infants whose hearing loss are diagnosed by 3 months after birth and intervention implemented by 6 months of age can develop speech and language similar to their peers with normal hearing. Hearing aids or cochlear implants, based on the advice of an ENT doctor or audiologist. Interventions for children with hearing loss include: Rehabilitation which can include aural rehabilitation; speech and language therapy, auditory verbal therapy, cued speech, and total communication. Learning sign language, especially where hearing devices are not preferred; are not beneficial; or are unavailable. This will ensure that the child can communicate and gain an education Families/carers and teachers Support the child in rehabilitation and use of hearing aids or cochlear implants. They learn to use sign language, if needed. Counselling and peer-group support for the child/carer/ family. BASIC EAR AND HEARING CARE RESOURCE 23 What can be done in case of ear diseases? Ask the participants about how they can suspect ear diseases. Refer to the points listed above for discussion. Teaching tip: When any person shows signs suggestive of an ear disease, should be referred to a doctor for examination and diagnosis.Treatment depend on the nature of the disease and can include: Medical treatment with oral medicines or ear drops Ear surgery Treating the ear disease early may prevent or reverse any hearing loss it caused. You can help those with ear discharge/infections by guiding them properly. Clean ears by dry mopping or wicking. This is essential and must be safely Use eardrops, if prescribed. The eardrops must be be effective. Seek and follow the advice of a doctor/ health worker Suspect ear disease in case of: • Pain in the ear • Ear discharge • Persistent heaviness in ear • Ringing in ear • Difficulty in hearing Care for discharging ears: don properly. BASIC EAR AND HEARING CARE RESOURCE 24 Dry Mopping • Only clean ears with a dry mop when the ear is discharging. • When the ear is dry it must not be cleaned with a dry mop. • A dry mop is not the same as a “cotton bud” or “q-tip”. • “Cotton buds” or “q-tips” must never be inserted into the ear as they are too big and the cotton wool is wound onto the stick too tightly. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: How to make a dry mop Materials: a thin wooden stick applicator and cotton wool Wash your hands with soap and water – air dry. Pull off a small piece of cotton wool. Gently pull it out into an oval shape. Put the tip of the stick into the center of the cotton wool. Twist the stick round and round with one hand whilst holding half of the cotton wool tightly against the stick with the thumb and index of your other hand. After completing dry mopping, wash your hand. Half of the cotton wool should extend form the end of the stick and form a fluffy, soft tip. The rolled up piece of cotton wool should be long enough so that when the soft tip is deep in the ear canal and next to the eardrum there is still some cotton wool sticking out of the ear canal. This is so that you can hold onto the cotton wool and ensure that the cotton wool comes out of the ear canal. 1. 2. 3. 4. 5. 6. 7. BASIC EAR AND HEARING CARE RESOURCE 25 How to make and use a tissue wick for mopping the ear Materials: a small piece of absorbent cotton cloth or a piece of soft, strong tissue paper – NOT flimsy toilet paper that can tear in the ear. Make all participants practice these skills under supervision. Teaching tip: 3. Place the wick into the ear canal. It will absorb any discharge or blood in the ear canal. 4. Leave it in 1. Make a wick by rolling the cloth or the tissue paper into a pointed shape. 2. Gently pull the pinna away from the head. This helps straighten the ear in the ear canal. 5. Remove the wet wick and inspect it. Is there pus on the wick? 6. Replace with a clean wick. 7. Repeat until the wick stays dry. Note: Dry mopping is recommended to clean the ear canal in the clinic. People with discharging ears could be taught dry mopping/wicking to clean the ears at home. for a minute. BASIC EAR AND HEARING CARE RESOURCE 26 Follow these steps when putting in eardrops: Demonstrate this (without actually using ear drops) and make sure the participants practice this under supervision. Teaching tip: 2. Lie the person on their side or tilt their head so that their ear is pointing upwards. 8. Keep the person on their side for 5 minutes. Wipe away any eardrops that run out of the ear when the person sits up 4. Drop 2 or 3 eardrops into the ear canal. 5. Move the pinna to make sure the eardrops go to the bottom of the ear canal. 6. Put in 2 or 3 more eardrops. 7. Pump the tragus (repeatedly push in and out). 1. Clean out the ear canal by dry mopping. 3. Gently pull the earlobe backwards and upwards to straighten the ear canal. BASIC EAR AND HEARING CARE RESOURCE 27 Adults Hearing loss can occur at any age. Common causes in adults include: Loud sounds: -Prolonged noise exposure from working in noisy places e.g factories with loud machinery, music industry, working with guns and other weapons. -Listening to loud music through headphones/earphones or in places such as discos. - Single exposures to a high intensity sound like a blast or an explosion. Do not stop the use of any medicines without consulting a doctor. If suspected that a medicine may put hearing at risk, seek the doctor’s advice. If the medicine taken is known to affect hearing, then hearing should be checked regularly. Ask the participants if they have ever had any experience with loud sounds and how that affected them. Teaching tip: Medicines that can damage hearing: certain antobiotics, antimalarials, anti- cancer medicines and injectables for drug resistant TB. Injury to the head or ears Untreated, prolonged ear infections Age-related hearing loss Our hearing may decline as we grow older. About one in three people older than 65 years have age-related hearing loss. Ear diseases indicated by recurrent or persistent ear discharge or pain. BASIC EAR AND HEARING CARE RESOURCE 28 What to do when you suspect hearing loss in an adult? Encourage the person to get his/her hearing checked. This can be done by: • A pure tone audiometry: is usually done at a clinic or other health facility. • Those adults that have a smartphone can use the free hearWHO app to screen for the haering loss. If the person has a score below 50 on the hearWHO test, he or she must definitely get a hearing test without delay. CAUTION: If an adult reports a sudden hearing loss or has a loss in just one ear, he should see a health worker as soon as possible. A person with hearing loss • Not respond when called to or may respond inappropriately. • Speak much louder than usual (this is because their own voice sounds low) • Have difficulty talking over the phone. • Become withdrawn, quiet and isolated. • Turn up the volume to hear the TV or listen to music. • Report that he can hear but cannot make out what is being said/ ‘I can hear you talking but don’t know what you’re saying’, ie sounds are muffled, or that others are mumbling. • Have unclear speech. • Have difficulty in hearing high frequency sounds like doorbells or telephone ringing. How can you suspect hearing loss in an adult? • Complain of a ringing sound in the ear (tinnitus). • Have a history of ear discharge. BASIC EAR AND HEARING CARE RESOURCE 29 John’s story John retired after working in a very noisy factory for 34 years. At home he often turned up the television volume. At times, he wouldnt hear his wife when she asked him what he would like for dinner. These changes appeared gradually. John’s wife spoke to the health worker who explained that when people work in a noisy environment and also as they become older they may not hear well. John did not know that people working in noisy factories needed to wear ear protection to prevent hearing loss. John’s wife told him what the health worker had said but he denied that he might have a hearing loss. John said the family muttered when they spoke. BASIC EAR AND HEARING CARE RESOURCE 30 After a few months, John’s wife finally persuaded him to visit the health worker who examined his ears and asked him to get his hearing tested at a nearby clinic. After the test, the audiologist explained to John that he had moderately severe hearing loss. He then explained that older people with hearing loss may hear others talking, but often they do not understand what is being said. Especially if they are in a noisy environment, people seem to mumble when they speak. John’s wife said he no longer enjoyed going out to celebrate family events because he could not hear what people were saying. John explained that he felt left out and this was making him feel very lonely. The audiologist suggested that hearing aids may help John hear what people say, but he must visit the clinic regularly after he gets the hearing aid to get its full benefit. John and his wife are managing his hearing and hearing aids with the support of the audiologist, as well as their family and friends. Their friends have learnt to talk one at a time and speak a little more slowly and clearly so that John can be included in the conversation. This has made a big difference to everyone. But mostly to John, as he is no longer avoiding family, friends and social get togethers. Now that John and his family understand the impact of hearing loss in older people, they are raising awareness in the community about the importance of checking one’s hearing. BASIC EAR AND HEARING CARE RESOURCE 31 What can be done if hearing loss or ear disease is identified in an adult? • It is important to identify what the cause of hearing loss is and address it, e.g. noise, medicines, ear diseases. • Adults with hearing loss are likely to benefit from use of devices, such as hearing aids and cochlear implants. • Adults also benefit from aural rehabilitation and support to get the maximum value from their hearing. In adults, as in case of children, it is important that hearing loss be identified as early as possible and that rehabilitation and use of devices is started without delay. BASIC EAR AND HEARING CARE RESOURCE 32 Hearing can be tested at any age. Different tests are done depending on the person’s age to identify the type and the severity of hearing loss. These include: 1. Otoacoustic emissions (OAE) or automated auditory brainstem response (AABR) tests that can be done on babies and children up to five years of age. These tests are often carried out using a handheld device, while they child is asleep. They are quick and easy to perform. When a child fails this test repeatedly (twice), s/ he be sent for an auditory brainstem response test. 2. Auditory brainstem response test (ABR): this test is usually only available at specialized centres. This test is often carried out after sedating the baby. How is hearing tested? OAE or AABR tests could be available at a health facility close to you. Find out from the health worker/doctor about the availability of such tests in your area. It is a good idea for every child to have their hearing checked soon after birth, in order to identify hearing loss early. BASIC EAR AND HEARING CARE RESOURCE 33 3. Pure Tone Audiometry: children older than five years and adults can have their hearing checked by a simple test, using the pure tone audiometry (PTA). In this test, sounds of different pitches are presented into each ear and the person is asked to respond when s/he can hear these. How is hearing tested? Children older than five years and adults: BASIC EAR AND HEARING CARE RESOURCE 34 Hearing check-ups should be routinely done for: Remember, the earlier hearing loss is detected, the sooner an intervention can be implemented. Speak to your local health worker if you feel that infant, child or adult needs a hearing test, encourage the person to get a hearing test at the earliest. • Babies • Children • Older adults • Those using ototoxic medicines • Those exposed to loud sounds BASIC EAR AND HEARING CARE RESOURCE 35 Hearing devices: What is a Hearing aid? A hearing aid is an electronic device that is worn on the ear. It helps to amplify sounds to allow a person with hearing loss to hear better. There are many different types of hearing aids and they come in various colours, sizes and shapes. A behind-the-ear hearing aid: has two parts (the hearing aid and the earmould), which are joined together by a thin, clear tube: • the hearing aid sits over and behind the ear; • the ear mould goes into the ear An in-the-ear hearing aid: is smaller and is specially shaped to fit into the person’s ear. Care of the hearing aids • Hearing aid is small and can easily be lost or damaged. • Keep hearing aid in a safe, cool place when not using it. • A hearing aid must be kept dry. If it absorbs moisture, it may not work properly. Take it off while bathing. • Every night, open the battery drawer and place the hearing aid into a sealed plastic tub, with something dry e.g. fine tissues or rice. • Make sure it is switched off when not being used, in order to save battery life. • Keep hearing aid away from water and heat e.g. a stove or flame. Ask the participants if they have ever seen anyone using a hearing aid and how they think it works. Ask them about cochlear implant. Have they ever heard of a cochlear implant. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 36 Hearing aids use batteries and these must be changed about once in 7 to 10 days, depending on how much it is worn. If the hearing aid stops working, try changing the batteries first. It is important to check the batteries in a child’s hearing aids every day. The earmould must be cleaned every day and wiped with a dry cloth. Once a week, you can remove the earmould and its tube from the hearing aid and wash in soapy water. This will make sure that any wax blocking the earmould is cleaned. Hearing aids use When wax blocks the earmould, the hearing aid can stop working. The hearing aid can make a whistling sound when it is not inserted correctly into the ear. The hearing aid itself must never get wet, or it may be damaged and stop working. Every few months, the tube that connects the earmould to the hearing aid will need replacing. The earmould itself will need to be replaced every year. This will need to be done more often in infants and children to ensure the mould fits the child’s ears, as their ears are growing. If the earmould is too small for the child, it may cause the hearing aid to whistle. How to check the battery is working: • Remove the hearing aid from the ear and take off the earmould. • Switch the hearing aid on and turn the volume control to the highest setting. • Place the hearing aid in the palm of your hand. • If there is a continuous whistling sound, it indicates the battery is working. • If there is no whistling sound, the battery should be replaced. If there is still no whistling sound after inserting a new battery, then there could be a problem with the hearing aid, you need to get it checked. KEEP HEARING AID BATTERIES AWAY FROM LITTLE CHILDREN! Children may swallow the batteries, leading to serious complications requiring surgery to remove them. BASIC EAR AND HEARING CARE RESOURCE 37 A cochlear implant is an electronic medical device for people with a severe or profound hearing loss, for whom hearing aids are not strong enough. Unlike a hearing aid, a cochlear implant converts sounds into electric signals. These signals stimulate the little hairs in the inner ear and are then carried by the hearing nerve to the brain. The brain understands these sounds or speech and so the person is able to hear better. In order to have a cochlear implant, an individual needs an operation. What is a cochlear implant? The cochlear implant has 2 parts: An external processor that sits behind the ear or on the head, and has a similar appearance to a hearing aid A second part, which is placed under the skin, behind the ear through an operation. 1 2 BASIC EAR AND HEARING CARE RESOURCE 38 Shreya’s story When Shreya was 7 months old, we celebrated the Indian festival of Diwali in the traditional way with lights, sweets and firecrackers. That was when I first noticed that Shreya was not responding to sounds as she did not startle or react, even when loud crackers were being burst. Soon after that, my husband and I took her to a doctor who sent her for hearing tests. After the tests, it became clear that Shreya was deaf. Our family had never met anyone deaf before this and we were all very worried. We felt that without hearing, Shreya would not be able to develop speech or go to school. The doctor guided us and informed us about cochlear implant and that this was a possibility for Shreya. Thanks to the government’s programme, we decided to get her implanted. At 3 years of age, Shreya started rehabilitation. BASIC EAR AND HEARING CARE RESOURCE 39 Our family had to work hard for her rehabilitation. We took her for therapy regularly and went back to see the audiologist when called. As a result, Shreya soon started to understand what was being said and slowly started speaking. We were overjoyed and continued our efforts. Now ten years old, Shreya attends the same school as her older brother and loves to study sciences. She also loves to paint and dance. But what she loves most is talking. Sometimes, she speaks so much that we have tell her to stay quiet! We now tell all our family and friends that hearing loss can be addressed. It is important that parents should take the child for assessment if they suspect a hearing loss. It is important to stay vigilant and act early. BASIC EAR AND HEARING CARE RESOURCE 40 How to speak with someone who is hard of hearing? • Speak clearly and slowly. Don’t shout! • Stand in good lighting and face the person so they can see your face when you speak • Do not exaggerate or distort lip movements as this might make it harder for the person to follow what is being said. • Try to keep background noise to a minimum, especially at school and at work, as loud background noise can make it difficult for someone with hearing loss to hear, even with a hearing aid. • If there is a hard of hearing person in a group (social, family or work) ensure people talk one at a time. This enables the hard of hearing person to be included in conversations. Supporting people with hearing loss BASIC EAR AND HEARING CARE RESOURCE 41 What can I do to support someone with a hearing loss or deafness? • Encourage them to visit a clinic and get their hearing checked. • Support them in the use of hearing aids or implants if they use these. Help them check its battery or to see if the tubing is blocked with wax.Young children and older adults may require assistance with this. • Teach children to self- advocate for their needs at home and at school. For example, encourage children to inform their teacher or parents when the hearing aid stops working, or to ask people to repeat themselves if they were unable to hear properly. • Encourage people to be open about their or their child’s hearing loss and not to hide it. • Guide parents to inform teachers at school of their Remember that with the proper care and support people with hearing loss can do everything, except hear normally. They must be included in all activities. child’s hearing loss and encourage the teacher to face the child directly as much as possible while speaking to her. • Inform parents and teachers about sign language and encourage them to learn this as a means of communication. BASIC EAR AND HEARING CARE RESOURCE 42 Preventing hearing loss Ensuring that mothers and babies receive good care before, during and after birth 60% Many cases of hearing loss can be prevented. It is estimated that in children 60% of hearing loss is due to preventable causes. Many small steps can help to prevent hearing loss such as: Vaccinating your child against rubella, measles, mumps, meningitis. 1 2 3 4 6Protecting ears from loud sounds at work and in the environment Following safe practices while listening to music over ear/headphones or in places like discos, concerts or parties. Asking your doctor if your medicine can affect your hearing and how this can be avoided Taking good care of your ears by practicing the Dos and Donts listed 5 BASIC EAR AND HEARING CARE RESOURCE 43 DOs: • Ask for a hearing screening test for your baby. • If you suspect someone has a hearing loss, refer them urgently to a health worker. This is especially important for infants and children. • Get help from a health worker or doctor in case of persistent ear-ache, ear discharge or any other problems with the ear. • See a health worker or attend a clinic to have earwax or foreign objects in the ear removed. • Assist young children and adults with the care and maintenance of their hearing aids or implants. • Go to a doctor if your child has a cold that it is not improving. • Encourage the use of hearing protection for those working in noisy place. • Encourage families and teachers of someone with hearing loss to learn sign language. • Only use medications in your ears that have been prescribed for you by the doctor. • Trust your instinct! If you suspect something is wrong with your hearing, seek help. Care of the ears: important DOs and DON’Ts BASIC EAR AND HEARING CARE RESOURCE 44 DON’Ts: • DON’T put anything in the ear. No cotton buds, clips, toothpicks, sticks or hopi candles. • DON’T ignore an ear that has any pus or fluid coming out of it. • DON’T treat any ear conditions with hot or cold oil, herba or home remedies. • DON’T swim or wash in dirty water. • DON’T listen to very loud noises or music for long periods as this can cause hearing loss. If you are ever uncertain whether an individual has a hearing loss, encourage them to seek help from their local health workers, who should be able to conduct some basic hearing tests and refer them to medical experts as required. Remember that wax is produced by the ear to protect the ear and keep it clean. Cotton buds should never be used (not even for regular cleaning), as they may push wax further into the ear and damage the ear-drum. Sometimes the cotton may remain behind as a foreign body! When listening to music over a personal device (eg MP3 player), keep the volume below 60% of máximum, take frequent breaks and limit listening time.

FOR MORE INFORMATION PLEASE CONTACT: Department for Noncommunicable Diseases https://www.who.int/health-topics/hearing-loss World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Page 1 of 1 2/7/2020http://extranet.who.int/bpmext/includes/ePub/attachments/090000000000000000000000... ISBN 978-92-4-000148-0

BASIC EAR AND HEARING CARE RESOURCE

BASIC EAR AND HEARING CARE RESOURCE BASIC EAR AND HEARING CARE RESOURCE Basic ear and hearing care resource ISBN 978-92-4-000148-0 (electronic version) ISBN 978-92-4-000149-7 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Basic ear and hearing care resource. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in Switzerland. BASIC EAR AND HEARING CARE RESOURCE I. INTRODUCTION • Background • Purpose of this resource • How to use this resource II. HEARING LOSS AND DEAFNESS • What is hearing and hearing loss/deafness • Types of hearing loss • Causes and signs of hearing loss/deafness in children • Causes and signs of hearing loss/deafness in adults • Hearing testing III. CARE FOR PEOPLE WITH EAR DISEASES AND HEARING LOSS • How to care for discharging ears • Support for people with hearing loss • How families/carers/teachers could communicate with people with hearing loss • Hearing aids and cochlear implants • DOs and DONTs CONTENTS 5iii ACKNOWLEDGEMENTS BASIC EAR AND HEARING CARE RESOURCE Acknowledgements This document is the outcome of a consultative process led by the World Health Organization with contribution of the following World Health Organization (WHO) staff members: Shelly Chadha, Alarcos Cieza, Cherian Varughese, Maryam Mallik, Ricardo Martinez, Patanjali Dev Nayar, Karen Reyes, Emma Tebbutt, Florante Trinidad, Hala Sakr and Juan Carlos Silva. The conceptual framework and outline of the ‘Basic Ear and Hearing Care resource’ were developed in consultation with an expert group through a series of consultations organized by the World Health Organization. The initial drafting of the document was done by Mahmood Bhutta, Priyadarshni Carling and Sally Harvest. Document review and inputs were provided by: Arun Agarwal, Mazin Al Khabouri, Ned Carter, Michael Chowen, Jackie Clark, Harvey Coates, Carolina Der, Victor De Andrade, Uta Fröschl, Suneela Garg, Sally Harvest, Linda Hood, Isaac Macharia, Norberto Martinez, Amarilis Melendez, Christopher O’callaghan, Christopher Prescott, Hubert Ramos, Leela Agnes Sambantham, Diego Santana Hernandez, Andrew Smith, Paige Stringer, George Tavartkiladze, Sian Tesni, Yufeng Wang and Bu Xingkuan. The booklet and the procedures explained in it were field tested in India and Uganda with support provided by CBM India Country Office, Bengaluru; St John’s Hospital, Bengaluru and its Community Centre, Mugalur, India; Community Health Academic Department of Christian Medical College and Hospital, Vellore, India; James O’Donovan and members of ‘The Village Health Team’ of Omni Med, Uganda. Financial support for this document has been provided by CBM and the Hearing Conservation Council. iV BASIC EAR AND HEARING CARE RESOURCE 1 INTRODUCTION Background • World Health Organization estimates that there are over 460 million people in the world with disabling hearing loss. Nearly 90% of them live in low- and middle-income countries of the world. Many more people have mild hearing loss and suffer diseases of the ear. These problems can often cause life-long and sometimes life-threatening difficulties. Without suitable interventions, deaf or hard of hearing people find it difficult to communicate with others. They also have difficulty in education and in the workplace, and often they feel left out of social and family life. • • In many places there is a lack of services and trained workers to prevent and treat ear diseases and help people with hearing loss. People themselves are not well aware about the importance of hearing. There are many myths and misconceptions about ear diseases and hearing loss in the society. • • The resource focuses on community involvement and raising awareness; and will provide useful information for preventing and addressing ear diseases and hearing loss. BASIC EAR AND HEARING CARE RESOURCE 2 Purpose of this resource • The purpose of this basic ear and hearing care resource is to serve as an information resource for community level workers as well as other interested members of the community. This resource can help the community to understand common ear diseases and hearing loss. Members of the community can share information with families/people who may have hearing loss. This resource will enable people to know about the impact of unaddressed hearing loss and ear diseases. It will help the community members to suspect and deal with common ear and hearing problems. It will also educate them about possible options for diagnosing and managing these conditions. • This resource focusses on means for prevention and recognition of common ear disease and hearing loss. It also shows that, with understanding and the necessary support, people with hearing loss can play productive roles in the household, school or in the work places. The target groups for this resource includes: • Community level workers without formal training who are involved in provision of care and information to young children, older adults; people in noise workplaces • CBR (community-based rehabilitation) workers; • Parents, teachers and other members of the community that wish to know about ear and hearing care. BASIC EAR AND HEARING CARE RESOURCE 3 How to use this resource The resource can be: Read by the individuals as an information booklet to gain knowledge or explained to them through an educational session organized by someone with specialised knowledge such as a doctor, an audiologist or a health worker who has received training on primary ear and hearing care. Instructions for readers of the resource: • Read through the booklet and make sure you understand each section. • Ask a nurse or doctor to help understand each section, if needed. • Ask guidance of a doctor or nurse to practice the practice skills mentioned in this resource. • Share information learnt with other members of your community, for example: when to suspect hearing loss; care of ears; how to take care of a hearing aid; how to instil ear drops etc • Refer to the ‘Primary ear and hearing care resource for health workers’ for further information, if needed. Instructions for trainers: When using this resource to educate others about ear and hearing care, make sure that you: • Familiarize yourself with all the sections of the resource BASIC EAR AND HEARING CARE RESOURCE 4 • Explain each section to the training participants. • Use the teaching tips to stimulate discussion with the participants. • Show participants the pictures that explain what you are teaching them. • Demonstrate the practical skills and make them practice these under your supervision. This resource forms part of a set of training resources on ear and hearing care, which includes: • Basic ear and hearing care resource. • Primary ear and hearing care resource for health workers. BASIC EAR AND HEARING CARE RESOURCE 5 HEARING LOSS AND DEAFNESS From the moment we are born we use our hearing to make sense of the world around us. It helps us connect with our families and enables us to listen, speak, and communicate our needs. As we get older, our hearing helps us to learn, work, socialize, sense potential dangers, and hear important soundslike a car horn, dog barking, someone calling your name or music playing. Being able to communicate effectively allows us to contribute to and be part of our community. What is hearing loss (HL) and deafness? Hearing loss is when a person is unable to hear as well as someone with normal hearing. Hearing loss ranges from mild to profound. It can affect one or both ears. Nearly one in sixteen people worldwide have hearing loss that impacts their daily lives. BASIC EAR AND HEARING CARE RESOURCE 6 Hearing loss grades A person with severe or profound hearing loss in both ears, is often called deaf A person with less severe hearing loss is referred to as hard of hearing. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 7 Present the scenarios to the participants. Ask them about the possible impact in these scenarios. Ask them if they have ever met or interacted with a deaf or hard of hearing person. Once you have generated some discussion about each scenario, you can explain the impact using the text provided. Teaching tip: Suhaila was born deaf, and has severe hearing loss in both ears. Since she has not had a hearing test,her parents and are unaware that she has a hearing loss. How can this test affect her life? Babies and children need to be able to hear the sounds of speech so they can develop listening and spoken language skills. All of us learn to speak based on what we hear around us. When a baby is born deaf and does not receive suitable interventions, she will not develop speech and language (including sign language skills). She will fall behind other children with good hearing. Without early diagnosis and proper rehabilitation, Suhaila will find it difficult to go to school, learn, make friends, and later in life, to get a job. What is the impact of hearing loss? BASIC EAR AND HEARING CARE RESOURCE 8 Patrick is a 6 year old studying in the second grade. Due to repeated ear infections, Patrick has a moderate hearing loss in both ears. He can hear but often misses out syllables and words. How can this affect his day to day life, at home, at school and socially? Children need good communication to learn well in school and fully grasp what is going on around them. As a result of his hearing loss, Patrick often doesn’t fully understand when his teacher says in class, especially when she faces away from him or when he sits in the back of the classroom. Sometimes he doesn’t understand the questions she asks and hence, doesn’t like to raise his hand to reply. As a result of this, the teacher feels that Patrick is not interested in his lessons and is being “difficult”. Even at home, Patrick finds it difficult to understand speech and often raises the volume of TV. His mother also thinks that Patrick is ‘difficult’ as he often doesn’t respond when she calls him. If Patrick’s ear condition is not treated, it is likely that he will lag behind academically. BASIC EAR AND HEARING CARE RESOURCE 9 Malicka is a 70-year old grandmother who lives with her family. She has hearing loss and finds it difficult to understand what her children are saying, especially when they are all speaking together or when there is music playing. How can this affect her life? Unable to understand what people are saying, Malicka starts avoiding social gatherings and prefers to stay in her room when her family is having ‘fun’. Watching TV with the family has also become difficult, as she has to raise the volume very high and others complain about it. Sometimes, the younger ones laugh when she misunderstands the question and answers incorrectly. That makes her feel hurt and lonely. Like Malicka, many older adults with hearing loss become socially isolated. Without essential support, unaddressed hearing loss can affect their mental health, causing feelings of loneliness, anxiety and depression. BASIC EAR AND HEARING CARE RESOURCE 10 The diagram above shows the parts of a ear. You can ask the participants to identify parts of their ear and reference can be made to this diagram when discussing ear conditions and hearing loss. Teaching tip: Our two ears work together to help us differentiate a variety of sounds, including loud or soft sound, and make out the direction of the source of sound. Together, our ears help us to recognise someone’s speech, in many different environments. Sound enters and travels through the three parts of our ear before the signal reaches the brain, where it is processed. We are then able to identify the sounds and understand words. The ear starts functioning even before we are born and language develops rapidly in the first few years of life. In most children that have normal hearing (and cognition), the following landmarks can be observed. How do we hear? Pinna Eardrum Middle ear Inner ear Auditory nerve BASIC EAR AND HEARING CARE RESOURCE 11 Milestones for language development Responds when called from another room. Follows longer directions, like “Put your pajamas on, brush your teeth, and then pick out a book”. Most people understand what the child says. 3 years and older Responds to her/his own name. Start speaking small words like ‘Mama’, ‘Baba’, ‘Dada’ Tries to imitate word which she/he commonly hears. 1-2 years old Baba Responds to very loud sounds. Blinks in response to a bang. Wakes up when there is a sudden noise near her/him. Quietens or smiles when the mother speaks. Birth to 3 months old Moves her/his eyes in the direction of sounds. Responds to changes in the mother’s tone of voice. Notices toys that make sounds. Pays attention to music. Coos and babbles when playing. 3-6 months old Turns and looks in the direction of sounds. Turns when someone calls her/his name. Understands words for common items and people (eg water, daddy). Starts to respond to simple words and phrases, like “No,” “Come here,” and “Want more? Babbles long strings of sounds. 6-12 months old Follows 2-part directions, like "Get the spoon and put it on the table. Understands new words quickly Puts 3 words together to talk about things. 2- 3 years old BASIC EAR AND HEARING CARE RESOURCE 12 Hearing Loss: causes, suspicion and action Many factors can affect our hearing through the course of life: It is important to note that many babies and children with hearing loss may have no obvious cause. For this reason, it is important to screen all babies for hearing loss soon after birth. Common causes of hearing loss before, during or immediately after birth include: • Hearing loss inherited directly or indirectly from parents. • Premature birth and/or low birth weight. • Birthing difficulties where the baby may suffer lack of oxygen (hypoxia). • Infections in the mother, such as rubella (german measles), syphilis, cytomegalovirus infection and toxoplasmosis during pregnancy can cause damage to the baby’s inner ear. • Use of certain medicines that damage hearing. • Jaundice, especially where it was not treated. Babies and infants Causes: Problems during pregnancy can cause problems with the growth and development of a baby’s hearing. This can cause a baby to be born with a hearing loss or develop a hearing loss soon after birth. Generate discussion by asking the participants about what they think are some common causes for hearing loss in babies, children and adults. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 13 When to suspect hearing loss in a baby? When the baby: • has any of the risk factors mentioned above. • is not responding to sounds, especially mother’s voice. • is not startled by loud sounds, eg a loud bang close to her. A mother’s story Three years ago, we were blessed with our sweet daughter, Amina. After a few months, we took her to the clinic for a checkup, and the nurse said she was healthy. At home, we noticed that if we called her name when we were standing behind her, she didn’t turn around to see who was calling her. Also, if there was a loud sound, she didn’t react. We took her back to the clinic when she was 2yrs old and explained that Amina was not responding when we talked and played with her. The nurse checked her ears and told us her ears were healthy, but suggested that Amina should be tested to see if she can hear well. She also explained that the sooner we found out if Amina had a hearing loss the better it was. We understood that it was very important to be able to communicate with our child. We took Amina to have her hearing checked and were told that Amina was deaf. They explained that Amina’s, family and friends could learn to use sign language to include our child. We also had to make sure we stood in front of Amina when we wanted to talk to her. hi!! BASIC EAR AND HEARING CARE RESOURCE 14 At first this was very upsetting but we all learned sign language and Amina became very good at ‘talking’ to us or telling us what she wanted. We hope that the teachers will also be able to learn and use sign language as Amina needs to go to school and be educated. Having a deaf child and learning about ways of including her in our everyday life showed us and our community that deaf children can do anything except hear. When our son was born last year, we were worried that he may also be deaf. The clinic tested his hearing and they told us he had some hearing and would be able to hear people talking and other sounds properly with a hearing aid. They guided us to a place where he was fitted with hearing aids. Now, we could talk and sing to him he was a happy baby. The hearing aids will also be important for him so that when he goes to school. With them, he will be able to hear the teachers and learn just like the other children. We would show the teachers how to manage his hearing aids and how to change the batteries at school. Our friends and community are very supportive and now understand how important it is to check babies, children, and even adults regularly to see if they have a problem in hearing. BASIC EAR AND HEARING CARE RESOURCE 15 Children Causes of hearing loss in children include: Wax or a foreign body (eg. beads, insects) in the ear canal: excessive amount of wax can accumulate and may cause hearing loss. A foreign body trapped in the ear canal can lead to infection. Medicines eg. certain anti-malarial drugs like Quinine, antibiotics such as gentamycin, certain anti-cancer medicines. Ear infections: commonly presenting with recurrent or persistent ear discharge. Injuries to the head or ear: can cause a hearing loss depending on the location and severity of the injury. Glue ear: fluid that remains in the middle ear after a cold or ear infection. Infections such as mumps, measles and meningitis. Loud sounds eg listening to loud music through headphones/earphones or in places such as discos; exposure to loud explosions or fireworks. BASIC EAR AND HEARING CARE RESOURCE 16 When to suspect hearing loss in a child?: • Child is not speaking or showing evidence of speech and language development at a level expected for children of their age (as shown on page 11). • Child often asks you to repeat what you say. • Child turns up the volume of the television or has trouble hearing what is being said over the phone. • Child is performing poorly at school or has behavioral problems. In many cases, this could be due to hearing loss, since the child is not hearing instructions properly and so won’t (because she can’t hear well) respond correctly. • Child has any features suggesting an ear infection, such as: - history of discharge (pus) from the ear/s, also referred to as runny ears. - complaint of pain, feeling of blockage or ringing in the ears. - fever with earache. Do not attempt to remove ear wax or foreign body at home, as this may cause’ damage to the ear. Seek help at a clinic. BASIC EAR AND HEARING CARE RESOURCE 17 If you suspect that an infant or a child may have hearing loss, make sure that you send her for a hearing test. With special equipment, hearing can be checked even on the first day of life. In babies and children up to five years of age, hearing can be checked using: • otoacoustic emission testing (OAE testing) • automated and complete auditory brainstem response testing (AABR and ABR) What to do when you suspect hearing loss in a child? Demostrate the use of the noisemaker; hand out a few noisemakers and ask participants to practice its use. Teaching tip: RIGHT EAR L R TEST > < <REVIE W In children older than five years; hearing can be tested through an audiometry test. More information about these tests is given on page 32. Where such hearing tests are not easily available, guide the parents to a health facility where her hearing can be assessed. In case you are not sure whether you should refer the child for a test, you can use a simple noisemaker to check the child’s response.You should also raise the issue with local health authorities and advocate with them to make hearing care available. BASIC EAR AND HEARING CARE RESOURCE 18 Check hearing with a ‘Noisemaker’ You can check a baby’s hearing from about nine months of age with a simple “noisemaker”. Noisemaker: you can use a rattle or make a noisemaker by putting a few grains of salt, sand or sugar in a plastic container and moving them around. The noisemaker should make a sound about as loud as a whispered voice. A few grains of salt, sand or sugar moved around (NOT shaken) on a plastic container is a good high frequency sound. If you do not have a noisemaker, try rubbing your fingers behind the baby’s ear. The baby should respond by turning in the direction of the sound. BASIC EAR AND HEARING CARE RESOURCE 19 A teacher’s story I was becoming very annoyed with Seema. She was always looking lost and sometimes she did not respond when I called her name. She looked so confused when I asked her a simple question and could not answer the questions I asked in class. At that time a health worker in our village organized an awareness session. Here she explained that hearing loss is quite common. She explained some common signs of hearing loss, like asking someone to repeat themselves or not being able to make out what is being said. She also told us about the causes which can lead to hearing loss in children and in adults. At that time. I realized that Seema’s problems might be caused by hearing loss. The next day, I asked her about her ears and some common causes of hearing loss. Seema told me that she had ear discharge off and on, since the age of 5 years. ?? BASIC EAR AND HEARING CARE RESOURCE 20 Seema told me that it was common in her community for children to have ear discharge. At times her ears ached and her mother would pour some hot oil into them. I spoke to Seema’s mother and asked her to take Seema to a doctor at the nearby health centre. At the centre, Seema underwent some tests. She and her mother were told how to care for her ears and not to instill oil into them. I made Seema sit in the front row in the classroom and made sure that she could hear clearly what was being said. Soon, Seema’s grades improved and she became more responsive. A few months later, Seema underwent an operation for her ears. Since then, she is able to hear better. Even though she is not in my class any more, I see her around. Her teacher tells me that Seema is doing well in class. I think awareness sessions such as the one organized by the health worker are very important for the community and specially teachers to know more about common issued faced by children. BASIC EAR AND HEARING CARE RESOURCE 21 What can be done if a child is diagnosed with hearing loss? Once hearing loss is identified its management, must be discussed and started at the earliest possible. Getting help as soon as possible can ensure that: • the child develops language skills, gains education, and can be socially integrated. • In a child with an ear diseases can get diagnosed and treated, so that hearing loss and other complications are avoided. Ask the participants what they know about this. Why is it important to pay attention and intervene early? What are the options for a child with hearing loss? Ask their views and the discuss the answers detailed below. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 22 Early intervention leads to better outcomes in children. For instance, infants whose hearing loss are diagnosed by 3 months after birth and intervention implemented by 6 months of age can develop speech and language similar to their peers with normal hearing. Hearing aids or cochlear implants, based on the advice of an ENT doctor or audiologist. Interventions for children with hearing loss include: Rehabilitation which can include aural rehabilitation; speech and language therapy, auditory verbal therapy, cued speech, and total communication. Learning sign language, especially where hearing devices are not preferred; are not beneficial; or are unavailable. This will ensure that the child can communicate and gain an education Families/carers and teachers Support the child in rehabilitation and use of hearing aids or cochlear implants. They learn to use sign language, if needed. Counselling and peer-group support for the child/carer/ family. BASIC EAR AND HEARING CARE RESOURCE 23 What can be done in case of ear diseases? Ask the participants about how they can suspect ear diseases. Refer to the points listed above for discussion. Teaching tip: When any person shows signs suggestive of an ear disease, should be referred to a doctor for examination and diagnosis.Treatment depend on the nature of the disease and can include: Medical treatment with oral medicines or ear drops Ear surgery Treating the ear disease early may prevent or reverse any hearing loss it caused. You can help those with ear discharge/infections by guiding them properly. Clean ears by dry mopping or wicking. This is essential and must be safely Use eardrops, if prescribed. The eardrops must be be effective. Seek and follow the advice of a doctor/ health worker Suspect ear disease in case of: • Pain in the ear • Ear discharge • Persistent heaviness in ear • Ringing in ear • Difficulty in hearing Care for discharging ears: don properly. BASIC EAR AND HEARING CARE RESOURCE 24 Dry Mopping • Only clean ears with a dry mop when the ear is discharging. • When the ear is dry it must not be cleaned with a dry mop. • A dry mop is not the same as a “cotton bud” or “q-tip”. • “Cotton buds” or “q-tips” must never be inserted into the ear as they are too big and the cotton wool is wound onto the stick too tightly. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: How to make a dry mop Materials: a thin wooden stick applicator and cotton wool Wash your hands with soap and water – air dry. Pull off a small piece of cotton wool. Gently pull it out into an oval shape. Put the tip of the stick into the center of the cotton wool. Twist the stick round and round with one hand whilst holding half of the cotton wool tightly against the stick with the thumb and index of your other hand. After completing dry mopping, wash your hand. Half of the cotton wool should extend form the end of the stick and form a fluffy, soft tip. The rolled up piece of cotton wool should be long enough so that when the soft tip is deep in the ear canal and next to the eardrum there is still some cotton wool sticking out of the ear canal. This is so that you can hold onto the cotton wool and ensure that the cotton wool comes out of the ear canal. 1. 2. 3. 4. 5. 6. 7. BASIC EAR AND HEARING CARE RESOURCE 25 How to make and use a tissue wick for mopping the ear Materials: a small piece of absorbent cotton cloth or a piece of soft, strong tissue paper – NOT flimsy toilet paper that can tear in the ear. Make all participants practice these skills under supervision. Teaching tip: 3. Place the wick into the ear canal. It will absorb any discharge or blood in the ear canal. 4. Leave it in 1. Make a wick by rolling the cloth or the tissue paper into a pointed shape. 2. Gently pull the pinna away from the head. This helps straighten the ear in the ear canal. 5. Remove the wet wick and inspect it. Is there pus on the wick? 6. Replace with a clean wick. 7. Repeat until the wick stays dry. Note: Dry mopping is recommended to clean the ear canal in the clinic. People with discharging ears could be taught dry mopping/wicking to clean the ears at home. for a minute. BASIC EAR AND HEARING CARE RESOURCE 26 Follow these steps when putting in eardrops: Demonstrate this (without actually using ear drops) and make sure the participants practice this under supervision. Teaching tip: 2. Lie the person on their side or tilt their head so that their ear is pointing upwards. 8. Keep the person on their side for 5 minutes. Wipe away any eardrops that run out of the ear when the person sits up 4. Drop 2 or 3 eardrops into the ear canal. 5. Move the pinna to make sure the eardrops go to the bottom of the ear canal. 6. Put in 2 or 3 more eardrops. 7. Pump the tragus (repeatedly push in and out). 1. Clean out the ear canal by dry mopping. 3. Gently pull the earlobe backwards and upwards to straighten the ear canal. BASIC EAR AND HEARING CARE RESOURCE 27 Adults Hearing loss can occur at any age. Common causes in adults include: Loud sounds: -Prolonged noise exposure from working in noisy places e.g factories with loud machinery, music industry, working with guns and other weapons. -Listening to loud music through headphones earphones or in places such as discos. -Single exposures to a high intensity sound like a blast or an explosion. Do not stop the use of any medicines without consulting a doctor. If suspected that a medicine may put hearing at risk, seek the doctor’s advice. If the medicine taken is known to affect hearing, then hearing should be checked regularly. Ask the participants if they have ever had any experience with loud sounds and how that affected them. Teaching tip: Medicines that can damage hearing: certain antobiotics, antimalarials, anti- cancer medicines and injectables for drug resistant TB. Injury to the head or ears Untreated, prolonged ear infections Age-related hearing loss Our hearing may decline as we grow older. About one in three people older than 65 years have age-related hearing loss. Ear diseases indicated by recurrent or persistent ear discharge or pain. BASIC EAR AND HEARING CARE RESOURCE 28 What to do when you suspect hearing loss in an adult? Encourage the person to get his/her hearing checked. This can be done by: • A pure tone audiometry: is usually done at a clinic or other health facility. • Those adults that have a smartphone can use the free hearWHO app to screen for the haering loss. If the person has a score below 50 on the hearWHO test, he or she must definitely get a hearing test without delay. CAUTION: If an adult reports a sudden hearing loss or has a loss in just one ear, he should see a health worker as soon as possible. A person with hearing loss • Not respond when called to or may respond inappropriately. • Speak much louder than usual (this is because their own voice sounds low) • Have difficulty talking over the phone. • Become withdrawn, quiet and isolated. • Turn up the volume to hear the TV or listen to music. • Report that he can hear but cannot make out what is being said/ ‘I can hear you talking but don’t know what you’re saying’, ie sounds are muffled, or that others are mumbling. • Have unclear speech. • Have difficulty in hearing high frequency sounds like doorbells or telephone ringing. • Complain of a ringing sound in the ear (tinnitus). • Have a history of ear discharge. How can you suspect hearing loss in an adult? BASIC EAR AND HEARING CARE RESOURCE 29 John’s story John retired after working in a very noisy factory for 34 years. At home he often turned up the television volume. At times, he wouldnt hear his wife when she asked him what he would like for dinner. These changes appeared gradually. John’s wife spoke to the health worker who explained that when people work in a noisy environment and also as they become older they may not hear well. John did not know that people working in noisy factories needed to wear ear protection to prevent hearing loss. John’s wife told him what the health worker had said but he denied that he might have a hearing loss. John said the family muttered when they spoke. BASIC EAR AND HEARING CARE RESOURCE 30 After a few months, John’s wife finally persuaded him to visit the health worker who examined his ears and asked him to get his hearing tested at a nearby clinic. After the test, the audiologist explained to John that he had moderately severe hearing loss. He then explained that older people with hearing loss may hear others talking, but often they do not understand what is being said. Especially if they are in a noisy environment, people seem to mumble when they speak. John’s wife said he no longer enjoyed going out to celebrate family events because he could not hear what people were saying. John explained that he felt left out and this was making him feel very lonely. The audiologist suggested that hearing aids may help John hear what people say, but he must visit the clinic regularly after he gets the hearing aid to get its full benefit. John and his wife are managing his hearing and hearing aids with the support of the audiologist, as well as their family and friends. Their friends have learnt to talk one at a time and speak a little more slowly and clearly so that John can be included in the conversation. This has made a big difference to everyone. But mostly to John, as he is no longer avoiding family, friends and social get togethers. Now that John and his family understand the impact of hearing loss in older people, they are raising awareness in the community about the importance of checking one’s hearing. BASIC EAR AND HEARING CARE RESOURCE 31 What can be done if hearing loss or ear disease is identified in an adult? • It is important to identify what the cause of hearing loss is and address it, e.g. noise, medicines, ear diseases. • Adults with hearing loss are likely to benefit from use of devices, such as hearing aids and cochlear implants. • Adults also benefit from aural rehabilitation and support to get the maximum value from their hearing. In adults, as in case of children, it is important that hearing loss be identified as early as possible and that rehabilitation and use of devices is started without delay. BASIC EAR AND HEARING CARE RESOURCE 32 Hearing can be tested at any age. Different tests are done depending on the person’s age to identify the type and the severity of hearing loss. These include: 1. Otoacoustic emissions (OAE) or automated auditory brainstem response (AABR) tests that can be done on babies and children up to five years of age. These tests are often carried out using a handheld device, whilvce they child is asleep. They are quick and easy to perform. When a child fails this test repeatedly (twice), s/ he be sent for an auditory brainstem response test. 2. Auditory brainstem response test (ABR): this test is usually only available at specialized centres. This test is often carried out after sedating the baby. How is hearing tested? OAE or AABR tests could be available at a health facility close to you. Find out from the health worker/doctor about the availability of such tests in your area. It is a good idea for every child to have their hearing checked soon after birth, in order to identify hearing loss early. BASIC EAR AND HEARING CARE RESOURCE 33 3. Pure Tone Audiometry: children older than five years and adults can have their hearing checked by a simple test, using the pure tone audiometry (PTA). In this test, sounds of different pitches are presented into each ear and the person is asked to respond when s/he can hear these. How is hearing tested? Children older than five years and adults: BASIC EAR AND HEARING CARE RESOURCE 34 Hearing check-ups should be routinely done for: Remember, the earlier hearing loss is detected, the sooner an intervention can be implemented. Speak to your local health worker if you feel that infant, child or adult needs a hearing test, encourage the person to get a hearing test at the earliest. • Babies • Children • Older adults • Those using ototoxic medicines • Those exposed to loud sounds BASIC EAR AND HEARING CARE RESOURCE 35 Hearing devices: What is a Hearing aid? A hearing aid is an electronic device that is worn on the ear. It helps to amplify sounds to allow a person with hearing loss to hear better. There are many different types of hearing aids and they come in various colours, sizes and shapes. A behind-the-ear hearing aid: has two parts (the hearing aid and the earmould), which are joined together by a thin, clear tube: • the hearing aid sits over and behind the ear; • the ear mould goes into the ear An in-the-ear hearing aid: is smaller and is specially shaped to fit into the person’s ear. Care of the hearing aids • Hearing aid is small and can easily be lost or damaged. • Keep hearing aid in a safe, cool place when not using it. • A hearing aid must be kept dry. If it absorbs moisture, it may not work properly. Take it off while bathing. • Every night, open the battery drawer and place the hearing aid into a sealed plastic tub, with something dry e.g. fine tissues or rice. • Make sure it is switched off when not being used, in order to save battery life. • Keep hearing aid away from water and heat e.g. a stove or flame. Ask the participants if they have ever seen anyone using a hearing aid and how they think it works. Ask them about cochlear implant. Have they ever heard of a cochlear implant. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 36 Hearing aids use batteries and these must be changed about once in 7 to 10 days, depending on how much it is worn. If the hearing aid stops working, try changing the batteries first. It is important to check the batteries in a child’s hearing aids every day. The earmould must be cleaned every day and wiped with a dry cloth. Once a week, you can remove the earmould and its tube from the hearing aid and wash in soapy water. This will make sure that any wax blocking the earmould is cleaned. Hearing aids use When wax blocks the earmould, the hearing aid can stop working. The hearing aid can make a whistling sound when it is not inserted correctly into the ear. The hearing aid itself must never get wet, or it may be damaged and stop working. Every few months, the tube that connects the earmould to the hearing aid will need replacing. The earmould itself will need to be replaced every year. This will need to be done more often in infants and children to ensure the mould fits the child’s ears, as their ears are growing. If the earmould is too small for the child, it may cause the hearing aid to whistle. How to check the battery is working: • Remove the hearing aid from the ear and take off the earmould. • Switch the hearing aid on and turn the volume control to the highest setting. • Place the hearing aid in the palm of your hand. • If there is a continuous whistling sound, it indicates the battery is working. • If there is no whistling sound, the battery should be replaced. If there is still no whistling sound after inserting a new battery, then there could be a problem with the hearing aid, you need to get it checked. KEEP HEARING AID BATTERIES AWAY FROM LITTLE CHILDREN! Children may swallow the batteries, leading to serious complications requiring surgery to remove them. BASIC EAR AND HEARING CARE RESOURCE 37 A cochlear implant is an electronic medical device for people with a severe or profound hearing loss, for whom hearing aids are not strong enough. Unlike a hearing aid, a cochlear implant converts sounds into electric signals. These signals stimulate the little hairs in the inner ear and are then carried by the hearing nerve to the brain. The brain understands these sounds or speech and so the person is able to hear better. In order to have a cochlear implant, an individual needs an operation. What is a cochlear implant? The cochlear implant has 2 parts: An external processor that sits behind the ear or on the head, and has a similar appearance to a hearing aid A second part, which is placed under the skin, behind the ear through an operation. 1 2 BASIC EAR AND HEARING CARE RESOURCE 38 Shreya’s story When Shreya was 7 months old, we celebrated the Indian festival of Diwali in the traditional way with lights, sweets and firecrackers. That was when I first noticed that Shreya was not responding to sounds as she did not startle or react, even when loud crackers were being burst. Soon after that, my husband and I took her to a doctor who sent her for hearing tests. After the tests, it became clear that Shreya was deaf. Our family had never met anyone deaf before this and we were all very worried. We felt that without hearing, Shreya would not be able to develop speech or go to school. The doctor guided us and informed us about cochlear implant and that this was a possibility for Shreya. Thanks to the government’s programme, we decided to get her implanted. At 3 years of age, Shreya started rehabilitation. BASIC EAR AND HEARING CARE RESOURCE 39 Our family had to work hard for her rehabilitation. We took her for therapy regularly and went back to see the audiologist when called. As a result, Shreya soon started to understand what was being said and slowly started speaking. We were overjoyed and continued our efforts. Now ten years old, Shreya attends the same school as her older brother and loves to study sciences. She also loves to paint and dance. But what she loves most is talking. Sometimes, she speaks so much that we have tell her to stay quiet! We now tell all our family and friends that hearing loss can be addressed. It is important that parents should take the child for assessment if they suspect a hearing loss. It is important to stay vigilant and act early. BASIC EAR AND HEARING CARE RESOURCE 40 How to speak with someone who is hard of hearing? • Speak clearly and slowly. Don’t shout! • Stand in good lighting and face the person so they can see your face when you speak • Do not exaggerate or distort lip movements as this might make it harder for the person to follow what is being said. • Try to keep background noise to a minimum, especially at school and at work, as loud background noise can make it difficult for someone with hearing loss to hear, even with a hearing aid. • If there is a hard of hearing person in a group (social, family or work) ensure people talk one at a time. This enables the hard of hearing person to be included in conversations. Supporting people with hearing loss BASIC EAR AND HEARING CARE RESOURCE 41 What can I do to support someone with a hearing loss or deafness? • Encourage them to visit a clinic and get their hearing checked. • Support them in the use of hearing aids or implants if they use these. Help them check its battery or to see if the tubing is blocked with wax.Young children and older adults may require assistance with this. • Teach children to self- advocate for their needs at home and at school. For example, encourage children to inform their teacher or parents when the hearing aid stops working, or to ask people to repeat themselves if they were unable to hear properly. • Encourage people to be open about their or their child’s hearing loss and not to hide it. • Guide parents to inform teachers at school of their Remember that with the proper care and support people with hearing loss can do everything, except hear normally. They must be included in all activities. child’s hearing loss and encourage the teacher to face the child directly as much as possible while speaking to her. • Inform parents and teachers about sign language and encourage them to learn this as a means of communication. BASIC EAR AND HEARING CARE RESOURCE 42 Preventing hearing loss Ensuring that mothers and babies receive good care before, during and after birth 60% Many cases of hearing loss can be prevented. It is estimated that in children 60% of hearing loss is due to preventable causes. Many small steps can help to prevent hearing loss such as: Vaccinating your child against rubella, measles, mumps, meningitis. 1 2 3 4 6Protecting ears from loud sounds at work and in the environment Following safe practices while listening to music over ear/headphones or in places like discos, concerts or parties. Asking your doctor if your medicine can affect your hearing and how this can be avoided Taking good care of your ears by practicing the Dos and Donts listed 5 BASIC EAR AND HEARING CARE RESOURCE 43 DOs: • Ask for a hearing screening test for your baby. • If you suspect someone has a hearing loss, refer them urgently to a health worker. This is especially important for infants and children. • Get help from a health worker or doctor in case of persistent ear-ache, ear discharge or any other problems with the ear. • See a health worker or attend a clinic to have earwax or foreign objects in the ear removed. • Assist young children and adults with the care and maintenance of their hearing aids or implants. • Go to a doctor if your child has a cold that it is not improving. • Encourage the use of hearing protection for those working in noisy place. • Encourage families and teachers of someone with hearing loss to learn sign language. • Only use medications in your ears that have been prescribed for you by the doctor. • Trust your instinct! If you suspect something is wrong with your hearing, seek help. Care of the ears: important DOs and DON’Ts BASIC EAR AND HEARING CARE RESOURCE 44 DON’Ts: • DON’T put anything in the ear. No cotton buds, clips, toothpicks, sticks or hopi candles. • DON’T ignore an ear that has any pus or fluid coming out of it. • DON’T treat any ear conditions with hot or cold oil, herba or home remedies. • DON’T swim or wash in dirty water. • DON’T listen to very loud noises or music for long periods as this can cause hearing loss. If you are ever uncertain whether an individual has a hearing loss, encourage them to seek help from their local health workers, who should be able to conduct some basic hearing tests and refer them to medical experts as required. Remember that wax is produced by the ear to protect the ear and keep it clean. Cotton buds should never be used (not even for regular cleaning), as they may push wax further into the ear and damage the ear-drum. Sometimes the cotton may remain behind as a foreign body! When listening to music over a personal device (eg MP3 player), keep the volume below 60% of máximum, take frequent breaks and limit listening time.

FOR MORE INFORMATION PLEASE CONTACT: Department for Noncommunicable Diseases https://www.who.int/health-topics/hearing-loss World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Page 1 of 1 ISBN 978-92-4-000149-7

BASIC EAR AND HEARING CARE RESOURCE

BASIC EAR AND HEARING CARE RESOURCE BASIC EAR AND HEARING CARE RESOURCE Basic ear and hearing care resource ISBN 978-92-4-000148-0 (electronic version) ISBN 978-92-4-000149-7 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Basic ear and hearing care resource. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in Switzerland. BASIC EAR AND HEARING CARE RESOURCE I. INTRODUCTION • Background • Purpose of this resource • How to use this resource II. HEARING LOSS AND DEAFNESS • What is hearing and hearing loss/deafness • Types of hearing loss • Causes and signs of hearing loss/deafness in children • Causes and signs of hearing loss/deafness in adults • Hearing testing III. CARE FOR PEOPLE WITH EAR DISEASES AND HEARING LOSS • How to care for discharging ears • Support for people with hearing loss • How families/carers/teachers could communicate with people with hearing loss • Hearing aids and cochlear implants • DOs and DONTs CONTENTS 5iii ACKNOWLEDGEMENTS BASIC EAR AND HEARING CARE RESOURCE Acknowledgements This document is the outcome of a consultative process led by the World Health Organization with contribution of the following World Health Organization (WHO) staff members: Shelly Chadha, Alarcos Cieza, Cherian Varughese, Maryam Mallik, Ricardo Martinez, Patanjali Dev Nayar, Karen Reyes, Emma Tebbutt, Florante Trinidad, Hala Sakr and Juan Carlos Silva. The conceptual framework and outline of the ‘Basic Ear and Hearing Care resource’ were developed in consultation with an expert group through a series of consultations organized by the World Health Organization. The initial drafting of the document was done by Mahmood Bhutta, Priyadarshni Carling and Sally Harvest. Document review and inputs were provided by: Arun Agarwal, Mazin Al Khabouri, Ned Carter, Michael Chowen, Jackie Clark, Harvey Coates, Carolina Der, Victor De Andrade, Uta Fröschl, Suneela Garg, Sally Harvest, Linda Hood, Isaac Macharia, Norberto Martinez, Amarilis Melendez, Christopher O’callaghan, Christopher Prescott, Hubert Ramos, Leela Agnes Sambantham, Diego Santana Hernandez, Andrew Smith, Paige Stringer, George Tavartkiladze, Sian Tesni, Yufeng Wang and Bu Xingkuan. The booklet and the procedures explained in it were field tested in India and Uganda with support provided by CBM India Country Office, Bengaluru; St John’s Hospital, Bengaluru and its Community Centre, Mugalur, India; Community Health Academic Department of Christian Medical College and Hospital, Vellore, India; James O’Donovan and members of ‘The Village Health Team’ of Omni Med, Uganda. Financial support for this document has been provided by CBM and the Hearing Conservation Council. iV BASIC EAR AND HEARING CARE RESOURCE 1 INTRODUCTION Background • World Health Organization estimates that there are over 460 million people in the world with disabling hearing loss. Nearly 90% of them live in low- and middle-income countries of the world. Many more people have mild hearing loss and suffer diseases of the ear. These problems can often cause life-long and sometimes life-threatening difficulties. Without suitable interventions, deaf or hard of hearing people find it difficult to communicate with others. They also have difficulty in education and in the workplace, and often they feel left out of social and family life. • • In many places there is a lack of services and trained workers to prevent and treat ear diseases and help people with hearing loss. People themselves are not well aware about the importance of hearing. There are many myths and misconceptions about ear diseases and hearing loss in the society. • • The resource focuses on community involvement and raising awareness; and will provide useful information for preventing and addressing ear diseases and hearing loss. BASIC EAR AND HEARING CARE RESOURCE 2 Purpose of this resource • The purpose of this basic ear and hearing care resource is to serve as an information resource for community level workers as well as other interested members of the community. This resource can help the community to understand common ear diseases and hearing loss. Members of the community can share information with families/people who may have hearing loss. This resource will enable people to know about the impact of unaddressed hearing loss and ear diseases. It will help the community members to suspect and deal with common ear and hearing problems. It will also educate them about possible options for diagnosing and managing these conditions. • This resource focusses on means for prevention and recognition of common ear disease and hearing loss. It also shows that, with understanding and the necessary support, people with hearing loss can play productive roles in the household, school or in the work places. The target groups for this resource includes: • Community level workers without formal training who are involved in provision of care and information to young children, older adults; people in noise workplaces • CBR (community-based rehabilitation) workers; • Parents, teachers and other members of the community that wish to know about ear and hearing care. BASIC EAR AND HEARING CARE RESOURCE 3 How to use this resource The resource can be: Read by the individuals as an information booklet to gain knowledge or explained to them through an educational session organized by someone with specialised knowledge such as a doctor, an audiologist or a health worker who has received training on primary ear and hearing care. Instructions for readers of the resource: • Read through the booklet and make sure you understand each section. • Ask a nurse or doctor to help understand each section, if needed. • Ask guidance of a doctor or nurse to practice the practice skills mentioned in this resource. • Share information learnt with other members of your community, for example: when to suspect hearing loss; care of ears; how to take care of a hearing aid; how to instil ear drops etc • Refer to the ‘Primary ear and hearing care resource for health workers’ for further information, if needed. Instructions for trainers: When using this resource to educate others about ear and hearing care, make sure that you: • Familiarize yourself with all the sections of the resource BASIC EAR AND HEARING CARE RESOURCE 4 • Explain each section to the training participants. • Use the teaching tips to stimulate discussion with the participants. • Show participants the pictures that explain what you are teaching them. • Demonstrate the practical skills and make them practice these under your supervision. This resource forms part of a set of training resources on ear and hearing care, which includes: • Basic ear and hearing care resource. • Primary ear and hearing care resource for health workers. BASIC EAR AND HEARING CARE RESOURCE 5 HEARING LOSS AND DEAFNESS From the moment we are born we use our hearing to make sense of the world around us. It helps us connect with our families and enables us to listen, speak, and communicate our needs. As we get older, our hearing helps us to learn, work, socialize, sense potential dangers, and hear important soundslike a car horn, dog barking, someone calling your name or music playing. Being able to communicate effectively allows us to contribute to and be part of our community. What is hearing loss (HL) and deafness? Hearing loss is when a person is unable to hear as well as someone with normal hearing. Hearing loss ranges from mild to profound. It can affect one or both ears. Nearly one in sixteen people worldwide have hearing loss that impacts their daily lives. BASIC EAR AND HEARING CARE RESOURCE 6 Hearing loss grades A person with severe or profound hearing loss in both ears, is often called deaf A person with less severe hearing loss is referred to as hard of hearing. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 7 Present the scenarios to the participants. Ask them about the possible impact in these scenarios. Ask them if they have ever met or interacted with a deaf or hard of hearing person. Once you have generated some discussion about each scenario, you can explain the impact using the text provided. Teaching tip: Suhaila was born deaf, and has severe hearing loss in both ears. Since she has not had a hearing test,her parents and are unaware that she has a hearing loss. How can this test affect her life? Babies and children need to be able to hear the sounds of speech so they can develop listening and spoken language skills. All of us learn to speak based on what we hear around us. When a baby is born deaf and does not receive suitable interventions, she will not develop speech and language (including sign language skills). She will fall behind other children with good hearing. Without early diagnosis and proper rehabilitation, Suhaila will find it difficult to go to school, learn, make friends, and later in life, to get a job. What is the impact of hearing loss? BASIC EAR AND HEARING CARE RESOURCE 8 Patrick is a 6 year old studying in the second grade. Due to repeated ear infections, Patrick has a moderate hearing loss in both ears. He can hear but often misses out syllables and words. How can this affect his day to day life, at home, at school and socially? Children need good communication to learn well in school and fully grasp what is going on around them. As a result of his hearing loss, Patrick often doesn’t fully understand when his teacher says in class, especially when she faces away from him or when he sits in the back of the classroom. Sometimes he doesn’t understand the questions she asks and hence, doesn’t like to raise his hand to reply. As a result of this, the teacher feels that Patrick is not interested in his lessons and is being “difficult”. Even at home, Patrick finds it difficult to understand speech and often raises the volume of TV. His mother also thinks that Patrick is ‘difficult’ as he often doesn’t respond when she calls him. If Patrick’s ear condition is not treated, it is likely that he will lag behind academically. BASIC EAR AND HEARING CARE RESOURCE 9 Malicka is a 70-year old grandmother who lives with her family. She has hearing loss and finds it difficult to understand what her children are saying, especially when they are all speaking together or when there is music playing. How can this affect her life? Unable to understand what people are saying, Malicka starts avoiding social gatherings and prefers to stay in her room when her family is having ‘fun’. Watching TV with the family has also become difficult, as she has to raise the volume very high and others complain about it. Sometimes, the younger ones laugh when she misunderstands the question and answers incorrectly. That makes her feel hurt and lonely. Like Malicka, many older adults with hearing loss become socially isolated. Without essential support, unaddressed hearing loss can affect their mental health, causing feelings of loneliness, anxiety and depression. BASIC EAR AND HEARING CARE RESOURCE 10 The diagram above shows the parts of a ear. You can ask the participants to identify parts of their ear and reference can be made to this diagram when discussing ear conditions and hearing loss. Teaching tip: Our two ears work together to help us differentiate a variety of sounds, including loud or soft sound, and make out the direction of the source of sound. Together, our ears help us to recognise someone’s speech, in many different environments. Sound enters and travels through the three parts of our ear before the signal reaches the brain, where it is processed. We are then able to identify the sounds and understand words. The ear starts functioning even before we are born and language develops rapidly in the first few years of life. In most children that have normal hearing (and cognition), the following landmarks can be observed. How do we hear? Pinna Eardrum Middle ear Inner ear Auditory nerve BASIC EAR AND HEARING CARE RESOURCE 11 Milestones for language development Responds when called from another room. Follows longer directions, like “Put your pajamas on, brush your teeth, and then pick out a book”. Most people understand what the child says. 3 years and older Responds to her/his own name. Start speaking small words like ‘Mama’, ‘Baba’, ‘Dada’ Tries to imitate word which she/he commonly hears. 1-2 years old Baba Responds to very loud sounds. Blinks in response to a bang. Wakes up when there is a sudden noise near her/him. Quietens or smiles when the mother speaks. Birth to 3 months old Moves her/his eyes in the direction of sounds. Responds to changes in the mother’s tone of voice. Notices toys that make sounds. Pays attention to music. Coos and babbles when playing. 3-6 months old Turns and looks in the direction of sounds. Turns when someone calls her/his name. Understands words for common items and people (eg water, daddy). Starts to respond to simple words and phrases, like “No,” “Come here,” and “Want more? Babbles long strings of sounds. 6-12 months old Follows 2-part directions, like "Get the spoon and put it on the table. Understands new words quickly Puts 3 words together to talk about things. 2- 3 years old BASIC EAR AND HEARING CARE RESOURCE 12 Hearing Loss: causes, suspicion and action Many factors can affect our hearing through the course of life: It is important to note that many babies and children with hearing loss may have no obvious cause. For this reason, it is important to screen all babies for hearing loss soon after birth. Common causes of hearing loss before, during or immediately after birth include: • Hearing loss inherited directly or indirectly from parents. • Premature birth and/or low birth weight. • Birthing difficulties where the baby may suffer lack of oxygen (hypoxia). • Infections in the mother, such as rubella (german measles), syphilis, cytomegalovirus infection and toxoplasmosis during pregnancy can cause damage to the baby’s inner ear. • Use of certain medicines that damage hearing. • Jaundice, especially where it was not treated. Babies and infants Causes: Problems during pregnancy can cause problems with the growth and development of a baby’s hearing. This can cause a baby to be born with a hearing loss or develop a hearing loss soon after birth. Generate discussion by asking the participants about what they think are some common causes for hearing loss in babies, children and adults. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 13 When to suspect hearing loss in a baby? When the baby: • has any of the risk factors mentioned above. • is not responding to sounds, especially mother’s voice. • is not startled by loud sounds, eg a loud bang close to her. A mother’s story Three years ago, we were blessed with our sweet daughter, Amina. After a few months, we took her to the clinic for a checkup, and the nurse said she was healthy. At home, we noticed that if we called her name when we were standing behind her, she didn’t turn around to see who was calling her. Also, if there was a loud sound, she didn’t react. We took her back to the clinic when she was 2yrs old and explained that Amina was not responding when we talked and played with her. The nurse checked her ears and told us her ears were healthy, but suggested that Amina should be tested to see if she can hear well. She also explained that the sooner we found out if Amina had a hearing loss the better it was. We understood that it was very important to be able to communicate with our child. We took Amina to have her hearing checked and were told that Amina was deaf. They explained that Amina’s, family and friends could learn to use sign language to include our child. We also had to make sure we stood in front of Amina when we wanted to talk to her. hi!! BASIC EAR AND HEARING CARE RESOURCE 14 At first this was very upsetting but we all learned sign language and Amina became very good at ‘talking’ to us or telling us what she wanted. We hope that the teachers will also be able to learn and use sign language as Amina needs to go to school and be educated. Having a deaf child and learning about ways of including her in our everyday life showed us and our community that deaf children can do anything except hear. When our son was born last year, we were worried that he may also be deaf. The clinic tested his hearing and they told us he had some hearing and would be able to hear people talking and other sounds properly with a hearing aid. They guided us to a place where he was fitted with hearing aids. Now, we could talk and sing to him he was a happy baby. The hearing aids will also be important for him so that when he goes to school. With them, he will be able to hear the teachers and learn just like the other children. We would show the teachers how to manage his hearing aids and how to change the batteries at school. Our friends and community are very supportive and now understand how important it is to check babies, children, and even adults regularly to see if they have a problem in hearing. BASIC EAR AND HEARING CARE RESOURCE 15 Children Causes of hearing loss in children include: Wax or a foreign body (eg. beads, insects) in the ear canal: excessive amount of wax can accumulate and may cause hearing loss. A foreign body trapped in the ear canal can lead to infection. Medicines eg. certain anti-malarial drugs like Quinine, antibiotics such as gentamycin, certain anti-cancer medicines. Ear infections: commonly presenting with recurrent or persistent ear discharge. Injuries to the head or ear: can cause a hearing loss depending on the location and severity of the injury. Glue ear: fluid that remains in the middle ear after a cold or ear infection. Infections such as mumps, measles and meningitis. Loud sounds eg listening to loud music through headphones/earphones or in places such as discos; exposure to loud explosions or fireworks. BASIC EAR AND HEARING CARE RESOURCE 16 When to suspect hearing loss in a child?: • Child is not speaking or showing evidence of speech and language development at a level expected for children of their age (as shown on page 11). • Child often asks you to repeat what you say. • Child turns up the volume of the television or has trouble hearing what is being said over the phone. • Child is performing poorly at school or has behavioral problems. In many cases, this could be due to hearing loss, since the child is not hearing instructions properly and so won’t (because she can’t hear well) respond correctly. • Child has any features suggesting an ear infection, such as: - history of discharge (pus) from the ear/s, also referred to as runny ears. - complaint of pain, feeling of blockage or ringing in the ears. - fever with earache. Do not attempt to remove ear wax or foreign body at home, as this may cause’ damage to the ear. Seek help at a clinic. BASIC EAR AND HEARING CARE RESOURCE 17 If you suspect that an infant or a child may have hearing loss, make sure that you send her for a hearing test. With special equipment, hearing can be checked even on the first day of life. In babies and children up to five years of age, hearing can be checked using: • otoacoustic emission testing (OAE testing) • automated and complete auditory brainstem response testing (AABR and ABR) What to do when you suspect hearing loss in a child? Demostrate the use of the noisemaker; hand out a few noisemakers and ask participants to practice its use. Teaching tip: RIGHT EAR L R TEST > < <REVIE W In children older than five years; hearing can be tested through an audiometry test. More information about these tests is given on page 32. Where such hearing tests are not easily available, guide the parents to a health facility where her hearing can be assessed. In case you are not sure whether you should refer the child for a test, you can use a simple noisemaker to check the child’s response.You should also raise the issue with local health authorities and advocate with them to make hearing care available. BASIC EAR AND HEARING CARE RESOURCE 18 Check hearing with a ‘Noisemaker’ You can check a baby’s hearing from about nine months of age with a simple “noisemaker”. Noisemaker: you can use a rattle or make a noisemaker by putting a few grains of salt, sand or sugar in a plastic container and moving them around. The noisemaker should make a sound about as loud as a whispered voice. A few grains of salt, sand or sugar moved around (NOT shaken) on a plastic container is a good high frequency sound. If you do not have a noisemaker, try rubbing your fingers behind the baby’s ear. The baby should respond by turning in the direction of the sound. BASIC EAR AND HEARING CARE RESOURCE 19 A teacher’s story I was becoming very annoyed with Seema. She was always looking lost and sometimes she did not respond when I called her name. She looked so confused when I asked her a simple question and could not answer the questions I asked in class. At that time a health worker in our village organized an awareness session. Here she explained that hearing loss is quite common. She explained some common signs of hearing loss, like asking someone to repeat themselves or not being able to make out what is being said. She also told us about the causes which can lead to hearing loss in children and in adults. At that time. I realized that Seema’s problems might be caused by hearing loss. The next day, I asked her about her ears and some common causes of hearing loss. Seema told me that she had ear discharge off and on, since the age of 5 years. ?? BASIC EAR AND HEARING CARE RESOURCE 20 Seema told me that it was common in her community for children to have ear discharge. At times her ears ached and her mother would pour some hot oil into them. I spoke to Seema’s mother and asked her to take Seema to a doctor at the nearby health centre. At the centre, Seema underwent some tests. She and her mother were told how to care for her ears and not to instill oil into them. I made Seema sit in the front row in the classroom and made sure that she could hear clearly what was being said. Soon, Seema’s grades improved and she became more responsive. A few months later, Seema underwent an operation for her ears. Since then, she is able to hear better. Even though she is not in my class any more, I see her around. Her teacher tells me that Seema is doing well in class. I think awareness sessions such as the one organized by the health worker are very important for the community and specially teachers to know more about common issued faced by children. BASIC EAR AND HEARING CARE RESOURCE 21 What can be done if a child is diagnosed with hearing loss? Once hearing loss is identified its management, must be discussed and started at the earliest possible. Getting help as soon as possible can ensure that: • the child develops language skills, gains education, and can be socially integrated. • In a child with an ear diseases can get diagnosed and treated, so that hearing loss and other complications are avoided. Ask the participants what they know about this. Why is it important to pay attention and intervene early? What are the options for a child with hearing loss? Ask their views and the discuss the answers detailed below. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 22 Early intervention leads to better outcomes in children. For instance, infants whose hearing loss are diagnosed by 3 months after birth and intervention implemented by 6 months of age can develop speech and language similar to their peers with normal hearing. Hearing aids or cochlear implants, based on the advice of an ENT doctor or audiologist. Interventions for children with hearing loss include: Rehabilitation which can include aural rehabilitation; speech and language therapy, auditory verbal therapy, cued speech, and total communication. Learning sign language, especially where hearing devices are not preferred; are not beneficial; or are unavailable. This will ensure that the child can communicate and gain an education Families/carers and teachers Support the child in rehabilitation and use of hearing aids or cochlear implants. They learn to use sign language, if needed. Counselling and peer-group support for the child/carer/ family. BASIC EAR AND HEARING CARE RESOURCE 23 What can be done in case of ear diseases? Ask the participants about how they can suspect ear diseases. Refer to the points listed above for discussion. Teaching tip: When any person shows signs suggestive of an ear disease, should be referred to a doctor for examination and diagnosis.Treatment depend on the nature of the disease and can include: Medical treatment with oral medicines or ear drops Ear surgery Treating the ear disease early may prevent or reverse any hearing loss it caused. You can help those with ear discharge/infections by guiding them properly. Clean ears by dry mopping or wicking. This is essential and must be safely Use eardrops, if prescribed. The eardrops must be be effective. Seek and follow the advice of a doctor/ health worker Suspect ear disease in case of: • Pain in the ear • Ear discharge • Persistent heaviness in ear • Ringing in ear • Difficulty in hearing Care for discharging ears: don properly. BASIC EAR AND HEARING CARE RESOURCE 24 Dry Mopping • Only clean ears with a dry mop when the ear is discharging. • When the ear is dry it must not be cleaned with a dry mop. • A dry mop is not the same as a “cotton bud” or “q-tip”. • “Cotton buds” or “q-tips” must never be inserted into the ear as they are too big and the cotton wool is wound onto the stick too tightly. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: How to make a dry mop Materials: a thin wooden stick applicator and cotton wool Wash your hands with soap and water – air dry. Pull off a small piece of cotton wool. Gently pull it out into an oval shape. Put the tip of the stick into the center of the cotton wool. Twist the stick round and round with one hand whilst holding half of the cotton wool tightly against the stick with the thumb and index of your other hand. After completing dry mopping, wash your hand. Half of the cotton wool should extend form the end of the stick and form a fluffy, soft tip. The rolled up piece of cotton wool should be long enough so that when the soft tip is deep in the ear canal and next to the eardrum there is still some cotton wool sticking out of the ear canal. This is so that you can hold onto the cotton wool and ensure that the cotton wool comes out of the ear canal. 1. 2. 3. 4. 5. 6. 7. BASIC EAR AND HEARING CARE RESOURCE 25 How to make and use a tissue wick for mopping the ear Materials: a small piece of absorbent cotton cloth or a piece of soft, strong tissue paper – NOT flimsy toilet paper that can tear in the ear. Make all participants practice these skills under supervision. Teaching tip: 3. Place the wick into the ear canal. It will absorb any discharge or blood in the ear canal. 4. Leave it in 1. Make a wick by rolling the cloth or the tissue paper into a pointed shape. 2. Gently pull the pinna away from the head. This helps straighten the ear in the ear canal. 5. Remove the wet wick and inspect it. Is there pus on the wick? 6. Replace with a clean wick. 7. Repeat until the wick stays dry. Note: Dry mopping is recommended to clean the ear canal in the clinic. People with discharging ears could be taught dry mopping/wicking to clean the ears at home. for a minute. BASIC EAR AND HEARING CARE RESOURCE 26 Follow these steps when putting in eardrops: Demonstrate this (without actually using ear drops) and make sure the participants practice this under supervision. Teaching tip: 2. Lie the person on their side or tilt their head so that their ear is pointing upwards. 8. Keep the person on their side for 5 minutes. Wipe away any eardrops that run out of the ear when the person sits up 4. Drop 2 or 3 eardrops into the ear canal. 5. Move the pinna to make sure the eardrops go to the bottom of the ear canal. 6. Put in 2 or 3 more eardrops. 7. Pump the tragus (repeatedly push in and out). 1. Clean out the ear canal by dry mopping. 3. Gently pull the earlobe backwards and upwards to straighten the ear canal. BASIC EAR AND HEARING CARE RESOURCE 27 Adults Hearing loss can occur at any age. Common causes in adults include: Loud sounds: -Prolonged noise exposure from working in noisy places e.g factories with loud machinery, music industry, working with guns and other weapons. -Listening to loud music through headphones earphones or in places such as discos. -Single exposures to a high intensity sound like a blast or an explosion. Do not stop the use of any medicines without consulting a doctor. If suspected that a medicine may put hearing at risk, seek the doctor’s advice. If the medicine taken is known to affect hearing, then hearing should be checked regularly. Ask the participants if they have ever had any experience with loud sounds and how that affected them. Teaching tip: Medicines that can damage hearing: certain antobiotics, antimalarials, anti- cancer medicines and injectables for drug resistant TB. Injury to the head or ears Untreated, prolonged ear infections Age-related hearing loss Our hearing may decline as we grow older. About one in three people older than 65 years have age-related hearing loss. Ear diseases indicated by recurrent or persistent ear discharge or pain. BASIC EAR AND HEARING CARE RESOURCE 28 What to do when you suspect hearing loss in an adult? Encourage the person to get his/her hearing checked. This can be done by: • A pure tone audiometry: is usually done at a clinic or other health facility. • Those adults that have a smartphone can use the free hearWHO app to screen for the haering loss. If the person has a score below 50 on the hearWHO test, he or she must definitely get a hearing test without delay. CAUTION: If an adult reports a sudden hearing loss or has a loss in just one ear, he should see a health worker as soon as possible. A person with hearing loss • Not respond when called to or may respond inappropriately. • Speak much louder than usual (this is because their own voice sounds low) • Have difficulty talking over the phone. • Become withdrawn, quiet and isolated. • Turn up the volume to hear the TV or listen to music. • Report that he can hear but cannot make out what is being said/ ‘I can hear you talking but don’t know what you’re saying’, ie sounds are muffled, or that others are mumbling. • Have unclear speech. • Have difficulty in hearing high frequency sounds like doorbells or telephone ringing. • Complain of a ringing sound in the ear (tinnitus). • Have a history of ear discharge. How can you suspect hearing loss in an adult? BASIC EAR AND HEARING CARE RESOURCE 29 John’s story John retired after working in a very noisy factory for 34 years. At home he often turned up the television volume. At times, he wouldnt hear his wife when she asked him what he would like for dinner. These changes appeared gradually. John’s wife spoke to the health worker who explained that when people work in a noisy environment and also as they become older they may not hear well. John did not know that people working in noisy factories needed to wear ear protection to prevent hearing loss. John’s wife told him what the health worker had said but he denied that he might have a hearing loss. John said the family muttered when they spoke. BASIC EAR AND HEARING CARE RESOURCE 30 After a few months, John’s wife finally persuaded him to visit the health worker who examined his ears and asked him to get his hearing tested at a nearby clinic. After the test, the audiologist explained to John that he had moderately severe hearing loss. He then explained that older people with hearing loss may hear others talking, but often they do not understand what is being said. Especially if they are in a noisy environment, people seem to mumble when they speak. John’s wife said he no longer enjoyed going out to celebrate family events because he could not hear what people were saying. John explained that he felt left out and this was making him feel very lonely. The audiologist suggested that hearing aids may help John hear what people say, but he must visit the clinic regularly after he gets the hearing aid to get its full benefit. John and his wife are managing his hearing and hearing aids with the support of the audiologist, as well as their family and friends. Their friends have learnt to talk one at a time and speak a little more slowly and clearly so that John can be included in the conversation. This has made a big difference to everyone. But mostly to John, as he is no longer avoiding family, friends and social get togethers. Now that John and his family understand the impact of hearing loss in older people, they are raising awareness in the community about the importance of checking one’s hearing. BASIC EAR AND HEARING CARE RESOURCE 31 What can be done if hearing loss or ear disease is identified in an adult? • It is important to identify what the cause of hearing loss is and address it, e.g. noise, medicines, ear diseases. • Adults with hearing loss are likely to benefit from use of devices, such as hearing aids and cochlear implants. • Adults also benefit from aural rehabilitation and support to get the maximum value from their hearing. In adults, as in case of children, it is important that hearing loss be identified as early as possible and that rehabilitation and use of devices is started without delay. BASIC EAR AND HEARING CARE RESOURCE 32 Hearing can be tested at any age. Different tests are done depending on the person’s age to identify the type and the severity of hearing loss. These include: 1. Otoacoustic emissions (OAE) or automated auditory brainstem response (AABR) tests that can be done on babies and children up to five years of age. These tests are often carried out using a handheld device, whilvce they child is asleep. They are quick and easy to perform. When a child fails this test repeatedly (twice), s/ he be sent for an auditory brainstem response test. 2. Auditory brainstem response test (ABR): this test is usually only available at specialized centres. This test is often carried out after sedating the baby. How is hearing tested? OAE or AABR tests could be available at a health facility close to you. Find out from the health worker/doctor about the availability of such tests in your area. It is a good idea for every child to have their hearing checked soon after birth, in order to identify hearing loss early. BASIC EAR AND HEARING CARE RESOURCE 33 3. Pure Tone Audiometry: children older than five years and adults can have their hearing checked by a simple test, using the pure tone audiometry (PTA). In this test, sounds of different pitches are presented into each ear and the person is asked to respond when s/he can hear these. How is hearing tested? Children older than five years and adults: BASIC EAR AND HEARING CARE RESOURCE 34 Hearing check-ups should be routinely done for: Remember, the earlier hearing loss is detected, the sooner an intervention can be implemented. Speak to your local health worker if you feel that infant, child or adult needs a hearing test, encourage the person to get a hearing test at the earliest. • Babies • Children • Older adults • Those using ototoxic medicines • Those exposed to loud sounds BASIC EAR AND HEARING CARE RESOURCE 35 Hearing devices: What is a Hearing aid? A hearing aid is an electronic device that is worn on the ear. It helps to amplify sounds to allow a person with hearing loss to hear better. There are many different types of hearing aids and they come in various colours, sizes and shapes. A behind-the-ear hearing aid: has two parts (the hearing aid and the earmould), which are joined together by a thin, clear tube: • the hearing aid sits over and behind the ear; • the ear mould goes into the ear An in-the-ear hearing aid: is smaller and is specially shaped to fit into the person’s ear. Care of the hearing aids • Hearing aid is small and can easily be lost or damaged. • Keep hearing aid in a safe, cool place when not using it. • A hearing aid must be kept dry. If it absorbs moisture, it may not work properly. Take it off while bathing. • Every night, open the battery drawer and place the hearing aid into a sealed plastic tub, with something dry e.g. fine tissues or rice. • Make sure it is switched off when not being used, in order to save battery life. • Keep hearing aid away from water and heat e.g. a stove or flame. Ask the participants if they have ever seen anyone using a hearing aid and how they think it works. Ask them about cochlear implant. Have they ever heard of a cochlear implant. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 36 Hearing aids use batteries and these must be changed about once in 7 to 10 days, depending on how much it is worn. If the hearing aid stops working, try changing the batteries first. It is important to check the batteries in a child’s hearing aids every day. The earmould must be cleaned every day and wiped with a dry cloth. Once a week, you can remove the earmould and its tube from the hearing aid and wash in soapy water. This will make sure that any wax blocking the earmould is cleaned. Hearing aids use When wax blocks the earmould, the hearing aid can stop working. The hearing aid can make a whistling sound when it is not inserted correctly into the ear. The hearing aid itself must never get wet, or it may be damaged and stop working. Every few months, the tube that connects the earmould to the hearing aid will need replacing. The earmould itself will need to be replaced every year. This will need to be done more often in infants and children to ensure the mould fits the child’s ears, as their ears are growing. If the earmould is too small for the child, it may cause the hearing aid to whistle. How to check the battery is working: • Remove the hearing aid from the ear and take off the earmould. • Switch the hearing aid on and turn the volume control to the highest setting. • Place the hearing aid in the palm of your hand. • If there is a continuous whistling sound, it indicates the battery is working. • If there is no whistling sound, the battery should be replaced. If there is still no whistling sound after inserting a new battery, then there could be a problem with the hearing aid, you need to get it checked. KEEP HEARING AID BATTERIES AWAY FROM LITTLE CHILDREN! Children may swallow the batteries, leading to serious complications requiring surgery to remove them. BASIC EAR AND HEARING CARE RESOURCE 37 A cochlear implant is an electronic medical device for people with a severe or profound hearing loss, for whom hearing aids are not strong enough. Unlike a hearing aid, a cochlear implant converts sounds into electric signals. These signals stimulate the little hairs in the inner ear and are then carried by the hearing nerve to the brain. The brain understands these sounds or speech and so the person is able to hear better. In order to have a cochlear implant, an individual needs an operation. What is a cochlear implant? The cochlear implant has 2 parts: An external processor that sits behind the ear or on the head, and has a similar appearance to a hearing aid A second part, which is placed under the skin, behind the ear through an operation. 1 2 BASIC EAR AND HEARING CARE RESOURCE 38 Shreya’s story When Shreya was 7 months old, we celebrated the Indian festival of Diwali in the traditional way with lights, sweets and firecrackers. That was when I first noticed that Shreya was not responding to sounds as she did not startle or react, even when loud crackers were being burst. Soon after that, my husband and I took her to a doctor who sent her for hearing tests. After the tests, it became clear that Shreya was deaf. Our family had never met anyone deaf before this and we were all very worried. We felt that without hearing, Shreya would not be able to develop speech or go to school. The doctor guided us and informed us about cochlear implant and that this was a possibility for Shreya. Thanks to the government’s programme, we decided to get her implanted. At 3 years of age, Shreya started rehabilitation. BASIC EAR AND HEARING CARE RESOURCE 39 Our family had to work hard for her rehabilitation. We took her for therapy regularly and went back to see the audiologist when called. As a result, Shreya soon started to understand what was being said and slowly started speaking. We were overjoyed and continued our efforts. Now ten years old, Shreya attends the same school as her older brother and loves to study sciences. She also loves to paint and dance. But what she loves most is talking. Sometimes, she speaks so much that we have tell her to stay quiet! We now tell all our family and friends that hearing loss can be addressed. It is important that parents should take the child for assessment if they suspect a hearing loss. It is important to stay vigilant and act early. BASIC EAR AND HEARING CARE RESOURCE 40 How to speak with someone who is hard of hearing? • Speak clearly and slowly. Don’t shout! • Stand in good lighting and face the person so they can see your face when you speak • Do not exaggerate or distort lip movements as this might make it harder for the person to follow what is being said. • Try to keep background noise to a minimum, especially at school and at work, as loud background noise can make it difficult for someone with hearing loss to hear, even with a hearing aid. • If there is a hard of hearing person in a group (social, family or work) ensure people talk one at a time. This enables the hard of hearing person to be included in conversations. Supporting people with hearing loss BASIC EAR AND HEARING CARE RESOURCE 41 What can I do to support someone with a hearing loss or deafness? • Encourage them to visit a clinic and get their hearing checked. • Support them in the use of hearing aids or implants if they use these. Help them check its battery or to see if the tubing is blocked with wax.Young children and older adults may require assistance with this. • Teach children to self- advocate for their needs at home and at school. For example, encourage children to inform their teacher or parents when the hearing aid stops working, or to ask people to repeat themselves if they were unable to hear properly. • Encourage people to be open about their or their child’s hearing loss and not to hide it. • Guide parents to inform teachers at school of their Remember that with the proper care and support people with hearing loss can do everything, except hear normally. They must be included in all activities. child’s hearing loss and encourage the teacher to face the child directly as much as possible while speaking to her. • Inform parents and teachers about sign language and encourage them to learn this as a means of communication. BASIC EAR AND HEARING CARE RESOURCE 42 Preventing hearing loss Ensuring that mothers and babies receive good care before, during and after birth 60% Many cases of hearing loss can be prevented. It is estimated that in children 60% of hearing loss is due to preventable causes. Many small steps can help to prevent hearing loss such as: Vaccinating your child against rubella, measles, mumps, meningitis. 1 2 3 4 6Protecting ears from loud sounds at work and in the environment Following safe practices while listening to music over ear/headphones or in places like discos, concerts or parties. Asking your doctor if your medicine can affect your hearing and how this can be avoided Taking good care of your ears by practicing the Dos and Donts listed 5 BASIC EAR AND HEARING CARE RESOURCE 43 DOs: • Ask for a hearing screening test for your baby. • If you suspect someone has a hearing loss, refer them urgently to a health worker. This is especially important for infants and children. • Get help from a health worker or doctor in case of persistent ear-ache, ear discharge or any other problems with the ear. • See a health worker or attend a clinic to have earwax or foreign objects in the ear removed. • Assist young children and adults with the care and maintenance of their hearing aids or implants. • Go to a doctor if your child has a cold that it is not improving. • Encourage the use of hearing protection for those working in noisy place. • Encourage families and teachers of someone with hearing loss to learn sign language. • Only use medications in your ears that have been prescribed for you by the doctor. • Trust your instinct! If you suspect something is wrong with your hearing, seek help. Care of the ears: important DOs and DON’Ts BASIC EAR AND HEARING CARE RESOURCE 44 DON’Ts: • DON’T put anything in the ear. No cotton buds, clips, toothpicks, sticks or hopi candles. • DON’T ignore an ear that has any pus or fluid coming out of it. • DON’T treat any ear conditions with hot or cold oil, herba or home remedies. • DON’T swim or wash in dirty water. • DON’T listen to very loud noises or music for long periods as this can cause hearing loss. If you are ever uncertain whether an individual has a hearing loss, encourage them to seek help from their local health workers, who should be able to conduct some basic hearing tests and refer them to medical experts as required. Remember that wax is produced by the ear to protect the ear and keep it clean. Cotton buds should never be used (not even for regular cleaning), as they may push wax further into the ear and damage the ear-drum. Sometimes the cotton may remain behind as a foreign body! When listening to music over a personal device (eg MP3 player), keep the volume below 60% of máximum, take frequent breaks and limit listening time.

FOR MORE INFORMATION PLEASE CONTACT: Department for Noncommunicable Diseases https://www.who.int/health-topics/hearing-loss World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Page 1 of 1 ISBN 978-92-4-000149-7

BASIC EAR AND HEARING CARE RESOURCE

BASIC EAR AND HEARING CARE RESOURCE BASIC EAR AND HEARING CARE RESOURCE Basic ear and hearing care resource ISBN 978-92-4-000148-0 (electronic version) ISBN 978-92-4-000149-7 (print version) © World Health Organization 2020 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Basic ear and hearing care resource. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Printed in Switzerland. BASIC EAR AND HEARING CARE RESOURCE I. INTRODUCTION • Background • Purpose of this resource • How to use this resource II. HEARING LOSS AND DEAFNESS • What is hearing and hearing loss/deafness • Types of hearing loss • Causes and signs of hearing loss/deafness in children • Causes and signs of hearing loss/deafness in adults • Hearing testing III. CARE FOR PEOPLE WITH EAR DISEASES AND HEARING LOSS • How to care for discharging ears • Support for people with hearing loss • How families/carers/teachers could communicate with people with hearing loss • Hearing aids and cochlear implants • DOs and DONTs CONTENTS 5iii ACKNOWLEDGEMENTS BASIC EAR AND HEARING CARE RESOURCE Acknowledgements This document is the outcome of a consultative process led by the World Health Organization with contribution of the following World Health Organization (WHO) staff members: Shelly Chadha, Alarcos Cieza, Cherian Varughese, Maryam Mallik, Ricardo Martinez, Patanjali Dev Nayar, Karen Reyes, Emma Tebbutt, Florante Trinidad, Hala Sakr and Juan Carlos Silva. The conceptual framework and outline of the ‘Basic Ear and Hearing Care resource’ were developed in consultation with an expert group through a series of consultations organized by the World Health Organization. The initial drafting of the document was done by Mahmood Bhutta, Priyadarshni Carling and Sally Harvest. Document review and inputs were provided by: Arun Agarwal, Mazin Al Khabouri, Ned Carter, Michael Chowen, Jackie Clark, Harvey Coates, Carolina Der, Victor De Andrade, Uta Fröschl, Suneela Garg, Sally Harvest, Linda Hood, Isaac Macharia, Norberto Martinez, Amarilis Melendez, Christopher O’callaghan, Christopher Prescott, Hubert Ramos, Leela Agnes Sambantham, Diego Santana Hernandez, Andrew Smith, Paige Stringer, George Tavartkiladze, Sian Tesni, Yufeng Wang and Bu Xingkuan. The booklet and the procedures explained in it were field tested in India and Uganda with support provided by CBM India Country Office, Bengaluru; St John’s Hospital, Bengaluru and its Community Centre, Mugalur, India; Community Health Academic Department of Christian Medical College and Hospital, Vellore, India; James O’Donovan and members of ‘The Village Health Team’ of Omni Med, Uganda. Financial support for this document has been provided by CBM and the Hearing Conservation Council. iV BASIC EAR AND HEARING CARE RESOURCE 1 INTRODUCTION Background • World Health Organization estimates that there are over 460 million people in the world with disabling hearing loss. Nearly 90% of them live in low- and middle-income countries of the world. Many more people have mild hearing loss and suffer diseases of the ear. These problems can often cause life-long and sometimes life-threatening difficulties. Without suitable interventions, deaf or hard of hearing people find it difficult to communicate with others. They also have difficulty in education and in the workplace, and often they feel left out of social and family life. • • In many places there is a lack of services and trained workers to prevent and treat ear diseases and help people with hearing loss. People themselves are not well aware about the importance of hearing. There are many myths and misconceptions about ear diseases and hearing loss in the society. • • The resource focuses on community involvement and raising awareness; and will provide useful information for preventing and addressing ear diseases and hearing loss. BASIC EAR AND HEARING CARE RESOURCE 2 Purpose of this resource • The purpose of this basic ear and hearing care resource is to serve as an information resource for community level workers as well as other interested members of the community. This resource can help the community to understand common ear diseases and hearing loss. Members of the community can share information with families/people who may have hearing loss. This resource will enable people to know about the impact of unaddressed hearing loss and ear diseases. It will help the community members to suspect and deal with common ear and hearing problems. It will also educate them about possible options for diagnosing and managing these conditions. • This resource focusses on means for prevention and recognition of common ear disease and hearing loss. It also shows that, with understanding and the necessary support, people with hearing loss can play productive roles in the household, school or in the work places. The target groups for this resource includes: • Community level workers without formal training who are involved in provision of care and information to young children, older adults; people in noise workplaces • CBR (community-based rehabilitation) workers; • Parents, teachers and other members of the community that wish to know about ear and hearing care. BASIC EAR AND HEARING CARE RESOURCE 3 How to use this resource The resource can be: Read by the individuals as an information booklet to gain knowledge or explained to them through an educational session organized by someone with specialised knowledge such as a doctor, an audiologist or a health worker who has received training on primary ear and hearing care. Instructions for readers of the resource: • Read through the booklet and make sure you understand each section. • Ask a nurse or doctor to help understand each section, if needed. • Ask guidance of a doctor or nurse to practice the practice skills mentioned in this resource. • Share information learnt with other members of your community, for example: when to suspect hearing loss; care of ears; how to take care of a hearing aid; how to instil ear drops etc • Refer to the ‘Primary ear and hearing care resource for health workers’ for further information, if needed. Instructions for trainers: When using this resource to educate others about ear and hearing care, make sure that you: • Familiarize yourself with all the sections of the resource BASIC EAR AND HEARING CARE RESOURCE 4 • Explain each section to the training participants. • Use the teaching tips to stimulate discussion with the participants. • Show participants the pictures that explain what you are teaching them. • Demonstrate the practical skills and make them practice these under your supervision. This resource forms part of a set of training resources on ear and hearing care, which includes: • Basic ear and hearing care resource. • Primary ear and hearing care resource for health workers. BASIC EAR AND HEARING CARE RESOURCE 5 HEARING LOSS AND DEAFNESS From the moment we are born we use our hearing to make sense of the world around us. It helps us connect with our families and enables us to listen, speak, and communicate our needs. As we get older, our hearing helps us to learn, work, socialize, sense potential dangers, and hear important soundslike a car horn, dog barking, someone calling your name or music playing. Being able to communicate effectively allows us to contribute to and be part of our community. What is hearing loss (HL) and deafness? Hearing loss is when a person is unable to hear as well as someone with normal hearing. Hearing loss ranges from mild to profound. It can affect one or both ears. Nearly one in sixteen people worldwide have hearing loss that impacts their daily lives. BASIC EAR AND HEARING CARE RESOURCE 6 Hearing loss grades A person with severe or profound hearing loss in both ears, is often called deaf A person with less severe hearing loss is referred to as hard of hearing. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 7 Present the scenarios to the participants. Ask them about the possible impact in these scenarios. Ask them if they have ever met or interacted with a deaf or hard of hearing person. Once you have generated some discussion about each scenario, you can explain the impact using the text provided. Teaching tip: Suhaila was born deaf, and has severe hearing loss in both ears. Since she has not had a hearing test,her parents and are unaware that she has a hearing loss. How can this test affect her life? Babies and children need to be able to hear the sounds of speech so they can develop listening and spoken language skills. All of us learn to speak based on what we hear around us. When a baby is born deaf and does not receive suitable interventions, she will not develop speech and language (including sign language skills). She will fall behind other children with good hearing. Without early diagnosis and proper rehabilitation, Suhaila will find it difficult to go to school, learn, make friends, and later in life, to get a job. What is the impact of hearing loss? BASIC EAR AND HEARING CARE RESOURCE 8 Patrick is a 6 year old studying in the second grade. Due to repeated ear infections, Patrick has a moderate hearing loss in both ears. He can hear but often misses out syllables and words. How can this affect his day to day life, at home, at school and socially? Children need good communication to learn well in school and fully grasp what is going on around them. As a result of his hearing loss, Patrick often doesn’t fully understand when his teacher says in class, especially when she faces away from him or when he sits in the back of the classroom. Sometimes he doesn’t understand the questions she asks and hence, doesn’t like to raise his hand to reply. As a result of this, the teacher feels that Patrick is not interested in his lessons and is being “difficult”. Even at home, Patrick finds it difficult to understand speech and often raises the volume of TV. His mother also thinks that Patrick is ‘difficult’ as he often doesn’t respond when she calls him. If Patrick’s ear condition is not treated, it is likely that he will lag behind academically. BASIC EAR AND HEARING CARE RESOURCE 9 Malicka is a 70-year old grandmother who lives with her family. She has hearing loss and finds it difficult to understand what her children are saying, especially when they are all speaking together or when there is music playing. How can this affect her life? Unable to understand what people are saying, Malicka starts avoiding social gatherings and prefers to stay in her room when her family is having ‘fun’. Watching TV with the family has also become difficult, as she has to raise the volume very high and others complain about it. Sometimes, the younger ones laugh when she misunderstands the question and answers incorrectly. That makes her feel hurt and lonely. Like Malicka, many older adults with hearing loss become socially isolated. Without essential support, unaddressed hearing loss can affect their mental health, causing feelings of loneliness, anxiety and depression. BASIC EAR AND HEARING CARE RESOURCE 10 The diagram above shows the parts of a ear. You can ask the participants to identify parts of their ear and reference can be made to this diagram when discussing ear conditions and hearing loss. Teaching tip: Our two ears work together to help us differentiate a variety of sounds, including loud or soft sound, and make out the direction of the source of sound. Together, our ears help us to recognise someone’s speech, in many different environments. Sound enters and travels through the three parts of our ear before the signal reaches the brain, where it is processed. We are then able to identify the sounds and understand words. The ear starts functioning even before we are born and language develops rapidly in the first few years of life. In most children that have normal hearing (and cognition), the following landmarks can be observed. How do we hear? Pinna Eardrum Middle ear Inner ear Auditory nerve BASIC EAR AND HEARING CARE RESOURCE 11 Milestones for language development Responds when called from another room. Follows longer directions, like “Put your pajamas on, brush your teeth, and then pick out a book”. Most people understand what the child says. 3 years and older Responds to her/his own name. Start speaking small words like ‘Mama’, ‘Baba’, ‘Dada’ Tries to imitate word which she/he commonly hears. 1-2 years old Baba Responds to very loud sounds. Blinks in response to a bang. Wakes up when there is a sudden noise near her/him. Quietens or smiles when the mother speaks. Birth to 3 months old Moves her/his eyes in the direction of sounds. Responds to changes in the mother’s tone of voice. Notices toys that make sounds. Pays attention to music. Coos and babbles when playing. 3-6 months old Turns and looks in the direction of sounds. Turns when someone calls her/his name. Understands words for common items and people (eg water, daddy). Starts to respond to simple words and phrases, like “No,” “Come here,” and “Want more? Babbles long strings of sounds. 6-12 months old Follows 2-part directions, like "Get the spoon and put it on the table. Understands new words quickly Puts 3 words together to talk about things. 2- 3 years old BASIC EAR AND HEARING CARE RESOURCE 12 Hearing Loss: causes, suspicion and action Many factors can affect our hearing through the course of life: It is important to note that many babies and children with hearing loss may have no obvious cause. For this reason, it is important to screen all babies for hearing loss soon after birth. Common causes of hearing loss before, during or immediately after birth include: • Hearing loss inherited directly or indirectly from parents. • Premature birth and/or low birth weight. • Birthing difficulties where the baby may suffer lack of oxygen (hypoxia). • Infections in the mother, such as rubella (german measles), syphilis, cytomegalovirus infection and toxoplasmosis during pregnancy can cause damage to the baby’s inner ear. • Use of certain medicines that damage hearing. • Jaundice, especially where it was not treated. Babies and infants Causes: Problems during pregnancy can cause problems with the growth and development of a baby’s hearing. This can cause a baby to be born with a hearing loss or develop a hearing loss soon after birth. Generate discussion by asking the participants about what they think are some common causes for hearing loss in babies, children and adults. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 13 When to suspect hearing loss in a baby? When the baby: • has any of the risk factors mentioned above. • is not responding to sounds, especially mother’s voice. • is not startled by loud sounds, eg a loud bang close to her. A mother’s story Three years ago, we were blessed with our sweet daughter, Amina. After a few months, we took her to the clinic for a checkup, and the nurse said she was healthy. At home, we noticed that if we called her name when we were standing behind her, she didn’t turn around to see who was calling her. Also, if there was a loud sound, she didn’t react. We took her back to the clinic when she was 2yrs old and explained that Amina was not responding when we talked and played with her. The nurse checked her ears and told us her ears were healthy, but suggested that Amina should be tested to see if she can hear well. She also explained that the sooner we found out if Amina had a hearing loss the better it was. We understood that it was very important to be able to communicate with our child. We took Amina to have her hearing checked and were told that Amina was deaf. They explained that Amina’s, family and friends could learn to use sign language to include our child. We also had to make sure we stood in front of Amina when we wanted to talk to her. hi!! BASIC EAR AND HEARING CARE RESOURCE 14 At first this was very upsetting but we all learned sign language and Amina became very good at ‘talking’ to us or telling us what she wanted. We hope that the teachers will also be able to learn and use sign language as Amina needs to go to school and be educated. Having a deaf child and learning about ways of including her in our everyday life showed us and our community that deaf children can do anything except hear. When our son was born last year, we were worried that he may also be deaf. The clinic tested his hearing and they told us he had some hearing and would be able to hear people talking and other sounds properly with a hearing aid. They guided us to a place where he was fitted with hearing aids. Now, we could talk and sing to him he was a happy baby. The hearing aids will also be important for him so that when he goes to school. With them, he will be able to hear the teachers and learn just like the other children. We would show the teachers how to manage his hearing aids and how to change the batteries at school. Our friends and community are very supportive and now understand how important it is to check babies, children, and even adults regularly to see if they have a problem in hearing. BASIC EAR AND HEARING CARE RESOURCE 15 Children Causes of hearing loss in children include: Wax or a foreign body (eg. beads, insects) in the ear canal: excessive amount of wax can accumulate and may cause hearing loss. A foreign body trapped in the ear canal can lead to infection. Medicines eg. certain anti-malarial drugs like Quinine, antibiotics such as gentamycin, certain anti-cancer medicines. Ear infections: commonly presenting with recurrent or persistent ear discharge. Injuries to the head or ear: can cause a hearing loss depending on the location and severity of the injury. Glue ear: fluid that remains in the middle ear after a cold or ear infection. Infections such as mumps, measles and meningitis. Loud sounds eg listening to loud music through headphones/earphones or in places such as discos; exposure to loud explosions or fireworks. BASIC EAR AND HEARING CARE RESOURCE 16 When to suspect hearing loss in a child?: • Child is not speaking or showing evidence of speech and language development at a level expected for children of their age (as shown on page 11). • Child often asks you to repeat what you say. • Child turns up the volume of the television or has trouble hearing what is being said over the phone. • Child is performing poorly at school or has behavioral problems. In many cases, this could be due to hearing loss, since the child is not hearing instructions properly and so won’t (because she can’t hear well) respond correctly. • Child has any features suggesting an ear infection, such as: - history of discharge (pus) from the ear/s, also referred to as runny ears. - complaint of pain, feeling of blockage or ringing in the ears. - fever with earache. Do not attempt to remove ear wax or foreign body at home, as this may cause’ damage to the ear. Seek help at a clinic. BASIC EAR AND HEARING CARE RESOURCE 17 If you suspect that an infant or a child may have hearing loss, make sure that you send her for a hearing test. With special equipment, hearing can be checked even on the first day of life. In babies and children up to five years of age, hearing can be checked using: • otoacoustic emission testing (OAE testing) • automated and complete auditory brainstem response testing (AABR and ABR) What to do when you suspect hearing loss in a child? Demostrate the use of the noisemaker; hand out a few noisemakers and ask participants to practice its use. Teaching tip: RIGHT EAR L R TEST > < <REVIE W In children older than five years; hearing can be tested through an audiometry test. More information about these tests is given on page 32. Where such hearing tests are not easily available, guide the parents to a health facility where her hearing can be assessed. In case you are not sure whether you should refer the child for a test, you can use a simple noisemaker to check the child’s response.You should also raise the issue with local health authorities and advocate with them to make hearing care available. BASIC EAR AND HEARING CARE RESOURCE 18 Check hearing with a ‘Noisemaker’ You can check a baby’s hearing from about nine months of age with a simple “noisemaker”. Noisemaker: you can use a rattle or make a noisemaker by putting a few grains of salt, sand or sugar in a plastic container and moving them around. The noisemaker should make a sound about as loud as a whispered voice. A few grains of salt, sand or sugar moved around (NOT shaken) on a plastic container is a good high frequency sound. If you do not have a noisemaker, try rubbing your fingers behind the baby’s ear. The baby should respond by turning in the direction of the sound. BASIC EAR AND HEARING CARE RESOURCE 19 A teacher’s story I was becoming very annoyed with Seema. She was always looking lost and sometimes she did not respond when I called her name. She looked so confused when I asked her a simple question and could not answer the questions I asked in class. At that time a health worker in our village organized an awareness session. Here she explained that hearing loss is quite common. She explained some common signs of hearing loss, like asking someone to repeat themselves or not being able to make out what is being said. She also told us about the causes which can lead to hearing loss in children and in adults. At that time. I realized that Seema’s problems might be caused by hearing loss. The next day, I asked her about her ears and some common causes of hearing loss. Seema told me that she had ear discharge off and on, since the age of 5 years. ?? BASIC EAR AND HEARING CARE RESOURCE 20 Seema told me that it was common in her community for children to have ear discharge. At times her ears ached and her mother would pour some hot oil into them. I spoke to Seema’s mother and asked her to take Seema to a doctor at the nearby health centre. At the centre, Seema underwent some tests. She and her mother were told how to care for her ears and not to instill oil into them. I made Seema sit in the front row in the classroom and made sure that she could hear clearly what was being said. Soon, Seema’s grades improved and she became more responsive. A few months later, Seema underwent an operation for her ears. Since then, she is able to hear better. Even though she is not in my class any more, I see her around. Her teacher tells me that Seema is doing well in class. I think awareness sessions such as the one organized by the health worker are very important for the community and specially teachers to know more about common issued faced by children. BASIC EAR AND HEARING CARE RESOURCE 21 What can be done if a child is diagnosed with hearing loss? Once hearing loss is identified its management, must be discussed and started at the earliest possible. Getting help as soon as possible can ensure that: • the child develops language skills, gains education, and can be socially integrated. • In a child with an ear diseases can get diagnosed and treated, so that hearing loss and other complications are avoided. Ask the participants what they know about this. Why is it important to pay attention and intervene early? What are the options for a child with hearing loss? Ask their views and the discuss the answers detailed below. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 22 Early intervention leads to better outcomes in children. For instance, infants whose hearing loss are diagnosed by 3 months after birth and intervention implemented by 6 months of age can develop speech and language similar to their peers with normal hearing. Hearing aids or cochlear implants, based on the advice of an ENT doctor or audiologist. Interventions for children with hearing loss include: Rehabilitation which can include aural rehabilitation; speech and language therapy, auditory verbal therapy, cued speech, and total communication. Learning sign language, especially where hearing devices are not preferred; are not beneficial; or are unavailable. This will ensure that the child can communicate and gain an education Families/carers and teachers Support the child in rehabilitation and use of hearing aids or cochlear implants. They learn to use sign language, if needed. Counselling and peer-group support for the child/carer/ family. BASIC EAR AND HEARING CARE RESOURCE 23 What can be done in case of ear diseases? Ask the participants about how they can suspect ear diseases. Refer to the points listed above for discussion. Teaching tip: When any person shows signs suggestive of an ear disease, should be referred to a doctor for examination and diagnosis.Treatment depend on the nature of the disease and can include: Medical treatment with oral medicines or ear drops Ear surgery Treating the ear disease early may prevent or reverse any hearing loss it caused. You can help those with ear discharge/infections by guiding them properly. Clean ears by dry mopping or wicking. This is essential and must be safely Use eardrops, if prescribed. The eardrops must be be effective. Seek and follow the advice of a doctor/ health worker Suspect ear disease in case of: • Pain in the ear • Ear discharge • Persistent heaviness in ear • Ringing in ear • Difficulty in hearing Care for discharging ears: don properly. BASIC EAR AND HEARING CARE RESOURCE 24 Dry Mopping • Only clean ears with a dry mop when the ear is discharging. • When the ear is dry it must not be cleaned with a dry mop. • A dry mop is not the same as a “cotton bud” or “q-tip”. • “Cotton buds” or “q-tips” must never be inserted into the ear as they are too big and the cotton wool is wound onto the stick too tightly. Ask the participants if they have ever experienced hearing loss or met anyone with hearing loss. Ask them to share their own experiences. Teaching tip: How to make a dry mop Materials: a thin wooden stick applicator and cotton wool Wash your hands with soap and water – air dry. Pull off a small piece of cotton wool. Gently pull it out into an oval shape. Put the tip of the stick into the center of the cotton wool. Twist the stick round and round with one hand whilst holding half of the cotton wool tightly against the stick with the thumb and index of your other hand. After completing dry mopping, wash your hand. Half of the cotton wool should extend form the end of the stick and form a fluffy, soft tip. The rolled up piece of cotton wool should be long enough so that when the soft tip is deep in the ear canal and next to the eardrum there is still some cotton wool sticking out of the ear canal. This is so that you can hold onto the cotton wool and ensure that the cotton wool comes out of the ear canal. 1. 2. 3. 4. 5. 6. 7. BASIC EAR AND HEARING CARE RESOURCE 25 How to make and use a tissue wick for mopping the ear Materials: a small piece of absorbent cotton cloth or a piece of soft, strong tissue paper – NOT flimsy toilet paper that can tear in the ear. Make all participants practice these skills under supervision. Teaching tip: 3. Place the wick into the ear canal. It will absorb any discharge or blood in the ear canal. 4. Leave it in 1. Make a wick by rolling the cloth or the tissue paper into a pointed shape. 2. Gently pull the pinna away from the head. This helps straighten the ear in the ear canal. 5. Remove the wet wick and inspect it. Is there pus on the wick? 6. Replace with a clean wick. 7. Repeat until the wick stays dry. Note: Dry mopping is recommended to clean the ear canal in the clinic. People with discharging ears could be taught dry mopping/wicking to clean the ears at home. for a minute. BASIC EAR AND HEARING CARE RESOURCE 26 Follow these steps when putting in eardrops: Demonstrate this (without actually using ear drops) and make sure the participants practice this under supervision. Teaching tip: 2. Lie the person on their side or tilt their head so that their ear is pointing upwards. 8. Keep the person on their side for 5 minutes. Wipe away any eardrops that run out of the ear when the person sits up 4. Drop 2 or 3 eardrops into the ear canal. 5. Move the pinna to make sure the eardrops go to the bottom of the ear canal. 6. Put in 2 or 3 more eardrops. 7. Pump the tragus (repeatedly push in and out). 1. Clean out the ear canal by dry mopping. 3. Gently pull the earlobe backwards and upwards to straighten the ear canal. BASIC EAR AND HEARING CARE RESOURCE 27 Adults Hearing loss can occur at any age. Common causes in adults include: Loud sounds: -Prolonged noise exposure from working in noisy places e.g factories with loud machinery, music industry, working with guns and other weapons. -Listening to loud music through headphones earphones or in places such as discos. -Single exposures to a high intensity sound like a blast or an explosion. Do not stop the use of any medicines without consulting a doctor. If suspected that a medicine may put hearing at risk, seek the doctor’s advice. If the medicine taken is known to affect hearing, then hearing should be checked regularly. Ask the participants if they have ever had any experience with loud sounds and how that affected them. Teaching tip: Medicines that can damage hearing: certain antobiotics, antimalarials, anti- cancer medicines and injectables for drug resistant TB. Injury to the head or ears Untreated, prolonged ear infections Age-related hearing loss Our hearing may decline as we grow older. About one in three people older than 65 years have age-related hearing loss. Ear diseases indicated by recurrent or persistent ear discharge or pain. BASIC EAR AND HEARING CARE RESOURCE 28 What to do when you suspect hearing loss in an adult? Encourage the person to get his/her hearing checked. This can be done by: • A pure tone audiometry: is usually done at a clinic or other health facility. • Those adults that have a smartphone can use the free hearWHO app to screen for the haering loss. If the person has a score below 50 on the hearWHO test, he or she must definitely get a hearing test without delay. CAUTION: If an adult reports a sudden hearing loss or has a loss in just one ear, he should see a health worker as soon as possible. A person with hearing loss • Not respond when called to or may respond inappropriately. • Speak much louder than usual (this is because their own voice sounds low) • Have difficulty talking over the phone. • Become withdrawn, quiet and isolated. • Turn up the volume to hear the TV or listen to music. • Report that he can hear but cannot make out what is being said/ ‘I can hear you talking but don’t know what you’re saying’, ie sounds are muffled, or that others are mumbling. • Have unclear speech. • Have difficulty in hearing high frequency sounds like doorbells or telephone ringing. • Complain of a ringing sound in the ear (tinnitus). • Have a history of ear discharge. How can you suspect hearing loss in an adult? BASIC EAR AND HEARING CARE RESOURCE 29 John’s story John retired after working in a very noisy factory for 34 years. At home he often turned up the television volume. At times, he wouldnt hear his wife when she asked him what he would like for dinner. These changes appeared gradually. John’s wife spoke to the health worker who explained that when people work in a noisy environment and also as they become older they may not hear well. John did not know that people working in noisy factories needed to wear ear protection to prevent hearing loss. John’s wife told him what the health worker had said but he denied that he might have a hearing loss. John said the family muttered when they spoke. BASIC EAR AND HEARING CARE RESOURCE 30 After a few months, John’s wife finally persuaded him to visit the health worker who examined his ears and asked him to get his hearing tested at a nearby clinic. After the test, the audiologist explained to John that he had moderately severe hearing loss. He then explained that older people with hearing loss may hear others talking, but often they do not understand what is being said. Especially if they are in a noisy environment, people seem to mumble when they speak. John’s wife said he no longer enjoyed going out to celebrate family events because he could not hear what people were saying. John explained that he felt left out and this was making him feel very lonely. The audiologist suggested that hearing aids may help John hear what people say, but he must visit the clinic regularly after he gets the hearing aid to get its full benefit. John and his wife are managing his hearing and hearing aids with the support of the audiologist, as well as their family and friends. Their friends have learnt to talk one at a time and speak a little more slowly and clearly so that John can be included in the conversation. This has made a big difference to everyone. But mostly to John, as he is no longer avoiding family, friends and social get togethers. Now that John and his family understand the impact of hearing loss in older people, they are raising awareness in the community about the importance of checking one’s hearing. BASIC EAR AND HEARING CARE RESOURCE 31 What can be done if hearing loss or ear disease is identified in an adult? • It is important to identify what the cause of hearing loss is and address it, e.g. noise, medicines, ear diseases. • Adults with hearing loss are likely to benefit from use of devices, such as hearing aids and cochlear implants. • Adults also benefit from aural rehabilitation and support to get the maximum value from their hearing. In adults, as in case of children, it is important that hearing loss be identified as early as possible and that rehabilitation and use of devices is started without delay. BASIC EAR AND HEARING CARE RESOURCE 32 Hearing can be tested at any age. Different tests are done depending on the person’s age to identify the type and the severity of hearing loss. These include: 1. Otoacoustic emissions (OAE) or automated auditory brainstem response (AABR) tests that can be done on babies and children up to five years of age. These tests are often carried out using a handheld device, whilvce they child is asleep. They are quick and easy to perform. When a child fails this test repeatedly (twice), s/ he be sent for an auditory brainstem response test. 2. Auditory brainstem response test (ABR): this test is usually only available at specialized centres. This test is often carried out after sedating the baby. How is hearing tested? OAE or AABR tests could be available at a health facility close to you. Find out from the health worker/doctor about the availability of such tests in your area. It is a good idea for every child to have their hearing checked soon after birth, in order to identify hearing loss early. BASIC EAR AND HEARING CARE RESOURCE 33 3. Pure Tone Audiometry: children older than five years and adults can have their hearing checked by a simple test, using the pure tone audiometry (PTA). In this test, sounds of different pitches are presented into each ear and the person is asked to respond when s/he can hear these. How is hearing tested? Children older than five years and adults: BASIC EAR AND HEARING CARE RESOURCE 34 Hearing check-ups should be routinely done for: Remember, the earlier hearing loss is detected, the sooner an intervention can be implemented. Speak to your local health worker if you feel that infant, child or adult needs a hearing test, encourage the person to get a hearing test at the earliest. • Babies • Children • Older adults • Those using ototoxic medicines • Those exposed to loud sounds BASIC EAR AND HEARING CARE RESOURCE 35 Hearing devices: What is a Hearing aid? A hearing aid is an electronic device that is worn on the ear. It helps to amplify sounds to allow a person with hearing loss to hear better. There are many different types of hearing aids and they come in various colours, sizes and shapes. A behind-the-ear hearing aid: has two parts (the hearing aid and the earmould), which are joined together by a thin, clear tube: • the hearing aid sits over and behind the ear; • the ear mould goes into the ear An in-the-ear hearing aid: is smaller and is specially shaped to fit into the person’s ear. Care of the hearing aids • Hearing aid is small and can easily be lost or damaged. • Keep hearing aid in a safe, cool place when not using it. • A hearing aid must be kept dry. If it absorbs moisture, it may not work properly. Take it off while bathing. • Every night, open the battery drawer and place the hearing aid into a sealed plastic tub, with something dry e.g. fine tissues or rice. • Make sure it is switched off when not being used, in order to save battery life. • Keep hearing aid away from water and heat e.g. a stove or flame. Ask the participants if they have ever seen anyone using a hearing aid and how they think it works. Ask them about cochlear implant. Have they ever heard of a cochlear implant. Teaching tip: BASIC EAR AND HEARING CARE RESOURCE 36 Hearing aids use batteries and these must be changed about once in 7 to 10 days, depending on how much it is worn. If the hearing aid stops working, try changing the batteries first. It is important to check the batteries in a child’s hearing aids every day. The earmould must be cleaned every day and wiped with a dry cloth. Once a week, you can remove the earmould and its tube from the hearing aid and wash in soapy water. This will make sure that any wax blocking the earmould is cleaned. Hearing aids use When wax blocks the earmould, the hearing aid can stop working. The hearing aid can make a whistling sound when it is not inserted correctly into the ear. The hearing aid itself must never get wet, or it may be damaged and stop working. Every few months, the tube that connects the earmould to the hearing aid will need replacing. The earmould itself will need to be replaced every year. This will need to be done more often in infants and children to ensure the mould fits the child’s ears, as their ears are growing. If the earmould is too small for the child, it may cause the hearing aid to whistle. How to check the battery is working: • Remove the hearing aid from the ear and take off the earmould. • Switch the hearing aid on and turn the volume control to the highest setting. • Place the hearing aid in the palm of your hand. • If there is a continuous whistling sound, it indicates the battery is working. • If there is no whistling sound, the battery should be replaced. If there is still no whistling sound after inserting a new battery, then there could be a problem with the hearing aid, you need to get it checked. KEEP HEARING AID BATTERIES AWAY FROM LITTLE CHILDREN! Children may swallow the batteries, leading to serious complications requiring surgery to remove them. BASIC EAR AND HEARING CARE RESOURCE 37 A cochlear implant is an electronic medical device for people with a severe or profound hearing loss, for whom hearing aids are not strong enough. Unlike a hearing aid, a cochlear implant converts sounds into electric signals. These signals stimulate the little hairs in the inner ear and are then carried by the hearing nerve to the brain. The brain understands these sounds or speech and so the person is able to hear better. In order to have a cochlear implant, an individual needs an operation. What is a cochlear implant? The cochlear implant has 2 parts: An external processor that sits behind the ear or on the head, and has a similar appearance to a hearing aid A second part, which is placed under the skin, behind the ear through an operation. 1 2 BASIC EAR AND HEARING CARE RESOURCE 38 Shreya’s story When Shreya was 7 months old, we celebrated the Indian festival of Diwali in the traditional way with lights, sweets and firecrackers. That was when I first noticed that Shreya was not responding to sounds as she did not startle or react, even when loud crackers were being burst. Soon after that, my husband and I took her to a doctor who sent her for hearing tests. After the tests, it became clear that Shreya was deaf. Our family had never met anyone deaf before this and we were all very worried. We felt that without hearing, Shreya would not be able to develop speech or go to school. The doctor guided us and informed us about cochlear implant and that this was a possibility for Shreya. Thanks to the government’s programme, we decided to get her implanted. At 3 years of age, Shreya started rehabilitation. BASIC EAR AND HEARING CARE RESOURCE 39 Our family had to work hard for her rehabilitation. We took her for therapy regularly and went back to see the audiologist when called. As a result, Shreya soon started to understand what was being said and slowly started speaking. We were overjoyed and continued our efforts. Now ten years old, Shreya attends the same school as her older brother and loves to study sciences. She also loves to paint and dance. But what she loves most is talking. Sometimes, she speaks so much that we have tell her to stay quiet! We now tell all our family and friends that hearing loss can be addressed. It is important that parents should take the child for assessment if they suspect a hearing loss. It is important to stay vigilant and act early. BASIC EAR AND HEARING CARE RESOURCE 40 How to speak with someone who is hard of hearing? • Speak clearly and slowly. Don’t shout! • Stand in good lighting and face the person so they can see your face when you speak • Do not exaggerate or distort lip movements as this might make it harder for the person to follow what is being said. • Try to keep background noise to a minimum, especially at school and at work, as loud background noise can make it difficult for someone with hearing loss to hear, even with a hearing aid. • If there is a hard of hearing person in a group (social, family or work) ensure people talk one at a time. This enables the hard of hearing person to be included in conversations. Supporting people with hearing loss BASIC EAR AND HEARING CARE RESOURCE 41 What can I do to support someone with a hearing loss or deafness? • Encourage them to visit a clinic and get their hearing checked. • Support them in the use of hearing aids or implants if they use these. Help them check its battery or to see if the tubing is blocked with wax.Young children and older adults may require assistance with this. • Teach children to self- advocate for their needs at home and at school. For example, encourage children to inform their teacher or parents when the hearing aid stops working, or to ask people to repeat themselves if they were unable to hear properly. • Encourage people to be open about their or their child’s hearing loss and not to hide it. • Guide parents to inform teachers at school of their Remember that with the proper care and support people with hearing loss can do everything, except hear normally. They must be included in all activities. child’s hearing loss and encourage the teacher to face the child directly as much as possible while speaking to her. • Inform parents and teachers about sign language and encourage them to learn this as a means of communication. BASIC EAR AND HEARING CARE RESOURCE 42 Preventing hearing loss Ensuring that mothers and babies receive good care before, during and after birth 60% Many cases of hearing loss can be prevented. It is estimated that in children 60% of hearing loss is due to preventable causes. Many small steps can help to prevent hearing loss such as: Vaccinating your child against rubella, measles, mumps, meningitis. 1 2 3 4 6Protecting ears from loud sounds at work and in the environment Following safe practices while listening to music over ear/headphones or in places like discos, concerts or parties. Asking your doctor if your medicine can affect your hearing and how this can be avoided Taking good care of your ears by practicing the Dos and Donts listed 5 BASIC EAR AND HEARING CARE RESOURCE 43 DOs: • Ask for a hearing screening test for your baby. • If you suspect someone has a hearing loss, refer them urgently to a health worker. This is especially important for infants and children. • Get help from a health worker or doctor in case of persistent ear-ache, ear discharge or any other problems with the ear. • See a health worker or attend a clinic to have earwax or foreign objects in the ear removed. • Assist young children and adults with the care and maintenance of their hearing aids or implants. • Go to a doctor if your child has a cold that it is not improving. • Encourage the use of hearing protection for those working in noisy place. • Encourage families and teachers of someone with hearing loss to learn sign language. • Only use medications in your ears that have been prescribed for you by the doctor. • Trust your instinct! If you suspect something is wrong with your hearing, seek help. Care of the ears: important DOs and DON’Ts BASIC EAR AND HEARING CARE RESOURCE 44 DON’Ts: • DON’T put anything in the ear. No cotton buds, clips, toothpicks, sticks or hopi candles. • DON’T ignore an ear that has any pus or fluid coming out of it. • DON’T treat any ear conditions with hot or cold oil, herba or home remedies. • DON’T swim or wash in dirty water. • DON’T listen to very loud noises or music for long periods as this can cause hearing loss. If you are ever uncertain whether an individual has a hearing loss, encourage them to seek help from their local health workers, who should be able to conduct some basic hearing tests and refer them to medical experts as required. Remember that wax is produced by the ear to protect the ear and keep it clean. Cotton buds should never be used (not even for regular cleaning), as they may push wax further into the ear and damage the ear-drum. Sometimes the cotton may remain behind as a foreign body! When listening to music over a personal device (eg MP3 player), keep the volume below 60% of máximum, take frequent breaks and limit listening time.

FOR MORE INFORMATION PLEASE CONTACT: Department for Noncommunicable Diseases https://www.who.int/health-topics/hearing-loss World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Page 1 of 1 ISBN 978-92-4-000149-7

БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА

БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 4 Basic ear and hearing care resource ISBN 978-92-4-000227-2 (Версия онлайн) ISBN 978-92-4-000228-9 (Версия для печати) © Всемирная организация здравоохранения 2020 Некоторые права защищены. Настоящая публикация распространяется на условиях лицензии Creative Commons 3.0 IGO «С указанием авторства – Неком- мерческая – Распространение на тех же условиях» (CC BY-NC-SA 3.0 IGO; htttp://creativecommons.org/licenses/by-nc-a/3.0/igo). Лицензией допускается копирование, распространение и адаптация публикации в некоммерческих целях с указанием библиографической ссылки согласно нижеприведенному образцу. Никакое использование публикации не означает одобрения ВОЗ какой-либо организации, товара или услуги. Использование логотипа ВОЗ не допускается. Распространение адаптированных вариантов публикации допускается на условиях указанной или эквивалентной лицензии Creative Commons. При переводе публикации на другие языки приводится библиографическая ссылка согласно нижеприведенному образцу и следующая оговорка: «Настоящий перевод не был выполнен Всемирной организацией здравоохранения (ВОЗ). ВОЗ не несет ответственности за его содержание и точность. Аутентичным подлинным текстом является оригинальное издание на английском языке». Урегулирование споров, связанных с условиями лицензии, производится в соответствии с согласительным регламентом Всемирной организации интел- лектуальной собственности. Образец библиографической ссылки: Базовая информация о помощи при болезнях уха и слуха [Basic ear and hearing care resource]. Женева: Всемир- ная организация здравоохранения; 2020. Лицензия: CC BY-NC-SA 3.0 IGO. Данные каталогизации перед публикацией (CIP). Данные CIP доступны по ссылке: http://apps.who.int/iris/. Приобретение, авторские права и лицензирование. По вопросам приобретения публикаций ВОЗ см. http://apps.who.int/bookorders. По вопросам оформления заявок на коммерческое использование и направления запросов, касающихся права пользования и лицензирования, см. http://www.who.int/ about/licensing/. Материалы третьих сторон. Пользователь, желающий использовать в своих целях содержащиеся в настоящей публикации материалы, принадлежащие третьим сторонам, например таблицы, рисунки или изображения, должен установить, требуется ли для этого разрешение обладателя авторского права, и при необходимости получить такое разрешение. Ответственность за нарушение прав на содержащиеся в публикации материалы третьих сторон несет пользователь. Оговорки общего характера. Используемые в настоящей публикации обозначения и приводимые в ней материалы не означают выражения мнения ВОЗ относительно правового статуса любой страны, территории, города или района или их органов власти или относительно делимитации границ. Штрихпун- ктирные линии на картах обозначают приблизительные границы, которые могут быть не полностью согласованы. Упоминание определенных компаний или продукции определенных производителей не означает, что они одобрены или рекомендованы ВОЗ в отличие от аналогичных компаний или продукции, не названных в тексте. Названия патентованных изделий, исключая ошибки и пропуски в тексте, выделяются начальными прописными буквами. ВОЗ приняты все разумные меры для проверки точности информации, содержащейся в настоящей публикации. Однако данные материалы публикуются без каких-либо прямых или косвенных гарантий. Ответственность за интерпретацию и использование материалов несет пользователь. ВОЗ не несет ника- кой ответственности за ущерб, связанный с использованием материалов. Перевод на русский язык выполнен переводчиком Владимиром Изотовым, Киев, Украина. ВОЗ не несет ответственности за его содержание и точность. В случае любого несоответствия между английской и русской версией, оригинальная версия на английском языке должна приниматься в качестве обяза- тельной и подлинной. Отпечатано в Швейцарии. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Выражение признательности I. ВВЕДЕНИЕ • Исходные данные • Цель данного пособия • Как использовать данное пособие II. ПОТЕРЯ СЛУХА И ГЛУХОТА • Что такое слух и потеря слуха/глухота • Типы потери слуха • Причины и признаки потери слуха/глухоты у детей • Причины и признаки потери слуха/глухоты у взрослых • Проверка слуха III. ПОМОЩЬ ЛЮДЯМ С БОЛЕЗНЯМИ УШЕЙ И ПОТЕРЕЙ СЛУХА • Что делать при выделениях из ушей • Оказание поддержки людям с потерей слуха • Как члены семьи/опекуны/учителя могут общаться с людьми с потерей слуха • Слуховые аппараты и кохлеарные импланты • Что МОЖНО и что НЕЛЬЗЯ делать СОДЕРЖАНИЕ iii БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Выражение признательности Настоящий документ является результатом кон- сультативного процесса, проводившегося под руко- водством Всемирной организации здравоохранения при участии следующих сотрудников Всемирной ор- ганизации здравоохранения (ВОЗ): Shelly Chadha, Alarcos Cieza, Cherian Varughese, Maryam Mallik, Ricardo Martinez, Patanjali Dev Nayar, Karen Reyes, Emma Tebbutt, Florante Trinidad, Hala Sakr и Juan Carlos Silva. Концептуальная основа и общий план пособия «Ба- зовая информация о помощи при болезнях уха и слуха» были разработаны в консультации с группой экспертов в рамках серии консультаций, органи- зованных Всемирной организацией здравоохране- ния. Первоначальный вариант документа был под- готовлен следующими специалистами: Mahmood Bhutta, Priyadarshni Carling and Sally Harvest. Arun Agarwal, Mazin Al Khabouri, Ned Carter, Michael Chowen, Jackie Clark, Harvey Coates, Carolina Der, Victor De Andrade, Uta Frцschl, Suneela Garg, Sally Harvest, Linda Hood, Isaac Macharia, Norberto Martinez, Amarilis Melendez, Christopher O’callaghan, Christopher Prescott, Hubert Ramos, Leela Agnes Sambantham, Diego Santana Hernandez, Andrew Smith, Paige Stringer, George Tavartkiladze, Sian Tesni, Yufeng Wang и Bu Xingkuan провели обзор документа и предоставили некоторые материалы. Процедуры, описанные в брошюре были опробова- ны на местах в Индии и Уганде при поддержке со стороны странового отделения организации CBM Индия в г. Бангалор; больницы Св. Джона в г. Бан- галор, и ее общинного центра Мугалур, Индия; фа- культета общественного здравоохранения Христи- анского медицинского колледжа и больницы в г. Веллор, Индия; James O’Donovan и членов «Дере- венской группы здоровья» организации Omni Med, Уганда. Финансовую поддержку при подготовке данного до- кумента оказали организация CBM и Совет по защи- те слуха. iV 1БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА ВВЕДЕНИЕ Исходные данные • По оценкам ВОЗ, в мире насчитывается более 460 миллионов человек с инвалидизирующей потерей слуха. Почти 90% из них живут в странах с низким и средним уровнем дохода. Гораздо больше людей имеют легкую потерю слуха и страдают заболеваниями уха. Эти проблемы зачастую могут вызывать затруднения в течение всей жизни, а иногда и угрожать жизни. Без соответствующих вмешательств глухим или слабослышащим людям трудно общаться с другими людьми. Они также испытывают трудности в учебе и на рабочем месте, и часто чувствуют себя исключенными из социальной и семейной жизни. • • Во многих местах отсутствуют необходимые службы и не хватает обученных работников для профилактики и лечения ушных болезней и оказания помощи людям с потерей слуха. Сами люди не слишком хорошо осознают важность слуха. В обществе существует множество мифов и заблуждений о заболеваниях уха и потере слуха. • • В настоящем пособии основное внимание уделяется вовлечению общин и повышению осведомленности; в нем содержится полезная информация о профилактике и методах решения проблем, связанных с болезнями ушей и потерей слуха. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 2 Цель данного пособия • Данное пособие об основных видах помощи при болезнях уха и потере слуха станет источником информации для общинных медико-санитарных работников, а также для других заинтересованных членов сообщества. Этот ресурс может помочь населению получить представление о распространенных ушных заболеваниях и потере слуха. Члены сообщества могут обмениваться информацией с семьями/ людьми, у которых может быть потеря слуха. Этот ресурс позволит людям узнать о последствиях нелеченных болезней уха и потери слуха. Эта информация поможет членам сообщества заблаговременно заподозрить наличие распространенных проблем со слухом и ушных болезней и принять необходимые меры. Кроме того, из этого пособия они могут узнать о возможных вариантах диагностики и лечения этих заболеваний. В данном пособии основное внимание уделяется средствам профилактики и распознавания распространенных заболеваний уха и нарушений слуха. Здесь также отмечается, что при наличии понимания и необходимой поддержки люди с потерей слуха могут играть продуктивную роль в домохозяйстве, школе или на рабочем месте. Целевые группы для данного пособия: • Общинные медико-санитарные работники, не получившие официального образования, которые вовлечены в работу по оказанию услуг по уходу и предоставлению информации детям, людям старшего возраста и лицам, работающих на шумном производстве. • Работники программ РБО (реабилитации на базе общин); • Родители, учителя или другие члены общин, которые хотят узнать о методах оказания помощи при болезнях уха и потере слуха. 3БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Как использовать данное пособие Настоящее пособие • Можно прочитать как информационный буклет, чтобы приобрести знания; можно использовать в качестве учебного материала на занятиях, организованных специалистами, например, врачом, аудиологом или медицинским работником, прошедшим подготовку по оказании первичной медико- санитарной помощи при болезнях уха и слуха. Инструкции для читателей пособия: • Прочитайте этот буклет и убедитесь, что вы поняли содержание каждого раздела. • Если необходимо, попросите медсестру или врача помочь вам понять содержание разделов. • Обратитесь к врачу или медсестре за советом о том, как отработать практические навыки, описанные в этом пособии. • Поделитесь полученной информацией с другими членами вашей общины, например, расскажите, когда можно подозревать потерю слуха у кого-нибудь; как ухаживать за ушами; как обслуживать слуховой аппарат; как правильно закапывать ушные капли, и т.п. • Если необходимо получить дополнительную информацию, прочитайте пособие для медицинских работников «Оказание первичной медико-санитарной помощи при болезнях уха и слуха». Инструкции для тренеров: При использовании этого пособия для обучения других людей методам оказания помощи при болезнях уха и слуха: • Внимательно изучите все разделы данного пособия БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 4 • Объясните содержание каждого раздела участникам тренинга. • Используйте методические рекомендации, чтобы побудить участников к обсуждению. • Показывайте участникам наглядные пособия, чтобы лучше объяснить учебные темы. • Продемонстрируйте практические приемы и предложите участникам отработать их под вашим наблю- дением. • Это пособие входит в набор учебных материалов из двух частей на тему оказания медико-санитарной помощи при болезнях уха и слуха: Базовая информация о помощи при болезнях уха и слуха. • Оказание первичной медико-санитарной помощи при болезнях уха и слуха - Пособие для медицинских работников. 5БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА ПОТЕРЯ СЛУХА И ГЛУХОТА С момента рождения наш слух помогает нам понять окружающий мир. Благодаря слуху мы можем общаться членами семьи, слушать, говорить и сообщать о наших потребностях. С возрастом наш слух помогает нам учиться, работать, общаться, чувствовать потенциальную опасность и слышать важные звуки, такие как автомобильный гудок, лай собак, голос человека, который обращается к вам по имени, или музыку. Способность эффективно общаться позволяет нам вносить свой вклад в общественную жизнь и быть ее частью. Что такое потеря слуха (ПС) и глухота? При потере слуха человек не может слышать так же хорошо, как человек с нормальным слухом. Потеря слуха может быть как легкой, так и глубокой. Может быть затронуто одно или оба уха. Почти каждый шестнадцатый человек в мире страдает тугоухостью, которая влияет на их повседневную жизнь. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 6 Степени потери слуха Человека с тяжелой или глубокой потерей слуха в обоих ушах часто называют глухим. Человека с менее тяжелыми нарушениями слуха называют тугоухим. Спросите участников, испытывали ли они сами нарушения слуха или встречали ли людей с потерей слуха. Попросите их поделиться собственным опытом. Совет: 0 20 35 50 65 80 95 Аудиограмма Ти хи й зв ук Гр ом ки й зв ук Гр ом ко ст ь Нет проблем со слухом. Трудности с восприятием речи в шумных местах. Трудности с пониманием разговорной речи, особенно в шумных местах. Трудности с поддержанием разговора, особенно в шумных местах. Как правило, воспринимает громкую речь без особых трудностей. < 20 dbHL 20 < 35 dbHL 35 < 50 dbHL Большие сложности с восприятием даже громкой речи. Не разбирает речь и большинство окружающих звуков. Почти не слышит разговорную речь, может испытывать затруднения с восприятием громкой речи. Испытывает большие трудности в шумных местах; трудно поддерживать разговор. Слух в норме Слабая потеря слуха Умеренная потеря слуха Средне-тяжелая потеря слуха 50 < 65 dbHL Тяжелая потеря слуха 65 < 80 dbHL Глубокая потеря слуха 80 < 95 dbHL Полная потеря слуха/глухота 95 dbHL и больше 7БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Представьте сценарии участникам. Спросите их о возможных последствиях развития этих сценариев. Спросите их, приходилось ли им встречать глухих или слабослышащих людей или общаться с ними. После обсуждения каждого сценария можно объяснить их последствия с помощью предложенного текста. Совет: Сухайла родилась глухой и страдает тяжелой двусторонней потерей слуха. Поскольку проверку слуха она не проходила, ее родители и близкие не знают о ее проблеме со слухом. Как проверка слуха может повлиять на ее жизнь? Младенцы и дети должны уметь слышать звуки речи, чтобы развивать навыки слушания и разговорной речи. Все мы учимся говорить, основываясь на том, что мы слышим вокруг нас. Когда ребенок рождается глухим и не получает необходимой помощи, у него не развивается речь и языковые навыки (в том числе навыки языка жестов). Ребенок будет отставать от других детей с хорошим слухом. Без ранней диагностики и правильной реабилитации Сухайле будет трудно учиться в школе, овладевать знаниями, заводить друзей, а позже и устроиться на работу. Каковы последствия потери слуха? БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 8 Патрику 6 лет, он учится во втором классе. Из-за неоднократных ушных инфекций у Патрика развилась умеренная потеря слуха в обоих ушах. Он может слышать, но часто пропускает слоги и слова. Как это может повлиять на его повседневную жизнь, дома, в школе и в обществе? Дети нуждаются в хорошем общении, чтобы хорошо учиться в школе и в полной мере понимать, что происходит вокруг них. Из-за потери слуха Патрик часто не до конца понимает, что говорит его учительница в классе, особенно, когда она не смотрит на него или когда он сидит на задней парте. Иногда он не понимает, какие вопросы она задает, и поэтому не любит поднимать руку, чтобы ответить на них. В результате учительница считает, что Патрик не интересуется уроками и что он “трудный” ребенок Даже дома Патрику трудно понимать, что ему говорят, и он часто увеличивает громкость телевизора. Его мама тоже думает, что Патрик «трудный» ребенок, потому что он часто не отвечает, когда она к нему обращается. Если нарушения слуха у Патрика не лечить, у него может ухудшиться успеваемость в школе. 9БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Малика – 70-летняя бабушка, которая живет со своей семьей. Она плохо слышит, и ей трудно понимать, что ей говорят дети, особенно если все они говорят одновременно, или если играет музыка. Как это может повлиять на ее жизнь? Из-за того, что Малика не понимает, что говорят другие люди, она избегает семейных мероприятий и обычно сидит в своей комнате, пока другие «веселятся». Ей стало трудно смотреть телевизор вместе с семьей, потому что она слишком сильно увеличивает громкость, а другие на это жалуются. Иногда младшие дети смеются, когда она не понимает вопрос и отвечает невпопад. Из-за этого она обижается и чувствует себя одинокой. Так же, как и Малика, многие люди старшего возраста с нарушениями слуха оказываются в социальной изоляции. При отсутствии необходимой поддержки и лечения потеря слуха может повлиять на их психическое здоровье, вызывая чувство одиночества, тревоги и депрессии. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 10 На рисунке выше показано устройство уха. Попросите участников назвать части своих ушей, после чего можно показать им этот рисунок при обсуждении заболеваний ушей и потери слуха. Совет: Оба наших уха работают вместе, помогая различать различные звуки, в том числе громкие или тихие, и определять направление источника звука. Вместе наши уши помогают нам распознавать речь других людей в различных условиях. Звук поступает и проходит через три части нашего уха, прежде чем сигнал попадает в мозг, где он обрабатывается. Затем мы можем определить звуки и понять слова. Ухо начинает функционировать еще до нашего рождения, а язык быстро развивается в первые годы жизни. У большинства детей с нормальным слухом (и уровнем восприятия) можно наблюдать следующие этапы развития. Как устроен слух? Ушная раковина Барабанная перепонка Среднее ухо Внутреннее ухо Слуховой нерв Наружный слуховой проход 11 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Этапы языкового развития ребенка Отвечает, когда его зовут из другой комнаты. Выполняет более сложные просьбы вроде «Надень пижаму, почисти зубки, а потом возьми книжку». Большинство людей понимают, что говорит ребенок. 3 года и старше Реагирует на звук своего имени. Начинает произносить короткие слова: «Мама», «Баба», «Дада». Пытается повторять слова, которые часто слышит. 1-2 года Ба-ба Реагирует на очень громкие звуки. Моргает, услышав хлопок. Просыпается из-за неожиданного звука. Затихает или улыбается при звуках голоса матери. С рождения до 3 месяцев Следит глазами за источником звука. Реагирует на изменения в тоне голоса матери. Замечает игрушки, издающие звуки. Обращает внимание на музыку. Гулит и лепечет при ее звуках. 3-6 месяцев Поворачивается и смотрит в направлении звуков. Оборачивается, когда кто-нибудь зовет его/ее по имени. Понимает слова: названия некоторых предметов и людей (напр., вода, папа). Начинает реагировать на простые слова и фразы, напр., «Нет», «Иди сюда» и «Хочешь еще?». Произносит цепочки лепетных сегментов. 6-12 месяцев Выполняет просьбы, предполагающие 2 действия, вроде «Возьми ложку и положи на стол». Быстро понимает новые слова. Умеет складывать фразы из 3 слов, пытаясь говорить. 2 года БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 12 Потеря слуха: причины, подозрение и действия В течение жизни на состояние слуха могут подействовать различные факторы: Следует отметить, что у многих младенцев и детей потеря слуха не была обусловлена очевидными причинами. Поэтому так важно проводить скрининг слуха у всех младенцев вскоре после рождения. Основные причины потери слуха до, во время и после рождения: • Потеря слуха, унаследованная непосредственно или косвенно от родителей. • Недоношенность и/или низкая масса тела при рождении. • Сложные роды, во время которых ребенок мог пострадать от недостатка кислорода (гипоксии). • Краснуха (немецкая корь), сифилис, цитомегаловирусная инфекция, токсоплазмоз у матери во время беременности могут привести к повреждению внутреннего уха новорожденного. • Употребление некоторых лекарственных средств, которые могут вызвать повреждение слуха. • Желтуха, особенно если ее не лечили. Младенцы и дети младшего возраста Причины: Проблемы во время беременности могут вызвать проблемы со слухом ребенка. Это может привести к тому, что ребенок родится с нарушением слуха или у него разовьется потеря слуха вскоре после рождения. Инициируйте дискуссию, попросив участников назвать основные (по их мнению) причины потери слуха у младенцев, детей и взрослых. Совет: 13 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Когда можно заподозрить потерю слуха у ребенка? Если ребенок: • подвергался каким-либо из вышеперечисленных факторов риска; • не реагирует на звуки, особенно на голос матери; • не пугается громких звуков, например, громкого хлопка рядом с ним... История одной матери Три года назад Бог подарил нам нашу прекрасную дочку, Амину. Через несколько месяцев мы отвезли ее в клинику на обследо- вание, и медсестра сказала, что она здорова. Дома мы замети- ли, что если мы звали ее по имени, когда стояли позади нее, то она не поворачивалась, чтобы посмотреть, кто ее зовет. Также она не реагировала на громкие звуки. Мы снова отвезли ее в клинику, когда ей было 2 года, и объяс- нили, что Амина не реагирует, когда мы разговариваем и играем с ней. Медсестра проверила ее уши и сказала нам, что уши здо- ровы, но предложила протестировать Амину, чтобы убедиться, что она хорошо слышит. Она также объяснила, что чем раньше мы узнаем, есть ли у Амины потеря слуха, тем лучше. Мы по- няли, что очень важно иметь возможность общаться с нашим ребенком. Мы отвезли Амину на проверку слуха, и нам сказали, что Амина глухая. Нам объяснили, что Амина, наша семья и дру- зья могут научиться использовать язык жестов, чтобы вовлечь в общение нашего ребенка. Нам также сказали, что когда мы хотим поговорить с Аминой, нужно становиться к ней лицом. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 14 Поначалу это очень нас расстроило, но мы все изучили язык жестов, и Амина очень хорошо «раз- говаривала» с нами или говорила, что она хочет. Мы надеемся, что учителя также смогут выучить и использовать язык жестов, так как Амине нужно ходить в школу и получить образование. Рождение глухого ребенка и изучение способов включения его в нашу повседневную жизнь показа- ло нам окружающим, что глухие дети могут делать абсолютно всё, только не слышат. В прошлом году, когда у нас родился сын, мы беспокоились, что он тоже может быть глухим. В клинике проверили его слух, и сказали, что у него есть слух, и что с помощью слухового аппарата он сможет нор- мально слышать разговоры людей и другие звуки. Они направили нас в учреждение, где ему подобрали слуховой аппарат. Теперь, когда мы начали разговаривать с ним и петь ему, он был очень счастлив. Слухо- вой аппараты также ему понадобится, когда он пойдет в школу. С его помощью он сможет слышать учителей и учиться так же, как и другие дети. Мы покажем учителям, как обращаться со слуховым аппаратом и как менять батарейки в школе. Наши друзья и окружающие очень поддерживают нас и теперь понимают, как важно регулярно проверять слух у новорожден- ных, младенцев, детей постарше и даже взрослых, чтобы вы- явить проблемы со слухом. 15 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Дети Причины потери слуха у детей могут быть следующими: Ушная сера или посторонние предметы (напр. бусины, насекомые) в слуховом проходе: чрезмерное количество ушной серы может привести к потере слуха. Инородное тело, застрявшее в ушном проходе, может привести к инфекции. Лекарства, напр. некоторые противомалярийные препараты, такие как хинин; антибиотики, напр. гентамицин, некоторые противораковые лекарства. Ушные инфекции: часто сопровождаются рецидивирующими или постоянными выделениями из уха. Травмы головы или уха: могут привести к потере слуха в зависимости от локализации и тяжести травмы. Гнойный отит: Жидкость остается в среднем ухе после простуды или ушных инфекций. Инфекции, напр. паротит, корь и менингит. Громкие звуки, напр., прослушивание громкой музыки в наушниках или на дискотеках; громкие взрывы или фейерверки. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 16 Когда можно заподозрить потерю слуха у ребенка?: • Ребенок не говорит или у него отсутствуют признаки речевого и языкового развития на уровне, ожидаемом у детей его возраста (см. стр. 11). • Ребенок часто просит повторить то, что вы сказали. • Ребенок увеличивает громкость телевизора или плохо слышит, что ему говорят по телефону. • Ребенок плохо учится в школе или имеет проблемы с поведением. Во многих случаях это может быть обусловлено потерей слуха, поскольку ребенок недостаточно хорошо слышит вопросы и не может правильно на них ответить (просто потому, что плохо слы- шит). • У ребенка отмечались признаки ушной инфекции, например: • были выделения (гнойные) из уха или обоих ушей, которые так- же называют оторея; • были жалобы на боль, чувство заложенности или звон в ушах; • температура, сопровождаемая болью в ушах. НЕ пытайтесь удалить ушную серу или посторонний предмет из уха в домашних условиях, т.к. при этом можно повредить ухо. Обратитесь за помощью в клинику. 17 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Что делать при подозрении на потерю слуха у ребенка? Покажите, как пользоваться погремушкой; раздайте несколько погремушек участникам для тренировки. Совет: RIGHT EAR L R TEST > < <REVIE W Если вы подозреваете вероятную потерю слуха у младен- ца или ребенка, обязательно пройдите проверку слуха. При помощи специального оборудования состояние слуха можно проверить даже в первый день жизни. У младенцев и детей в возрасте до пяти лет слух можно проверить с по- мощью следующих тестов: • регистрация отоакустической эмиссии (ОАЭ тест); • проверка стволомозговых слуховых вызванных потенциалов 22 (КСВП и АСВП). Слух у детей старше пяти лет можно проверить с помо- щью аудиометрического обследования. Дополнитель- ную информацию об этом обследовании можно найти на странице ... Если такие проверки слуха у вас не проводятся, направь- те родителей в медицинское учреждение, где можно бу- дет проверить слух ребенка. Если вы не уверены, следует ли направлять ребенка на обследование, можно восполь- зоваться простой погремушкой, чтобы проверить реак- цию ребенка. Вы также должны обсудить этот вопрос с местными органами здравоохранения и объяснить им не- обходимость обеспечения услуг по охране здоровья уха и слуха. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 18 Проверьте слух с помощью погремушки Можно проверить слух ребенка примерно с девяти месяцев с помощью простой погремушки. Погремушка: Вы можете использовать обычную погремушку или сделать ее самостоятельно, для чего насыпьте несколько крупиц соли, песка или сахара в пластиковый контейнер и покачайте его. Звук погремушки должен быть не громче шепота. Если этот пластиковый контейнер с крупицами соли, песка или сахара покачать (НЕ трясти), вы получите хороший звук высокой частоты. Если у вас нет погремушки, попробуйте потереть пальцы за ухом ребенка. Ребенок должен отреагировать, повернув голову в направлении звука. 19 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Рассказ учительницы Меня стала очень сердить Сима. Она постоянно выглядела потерянной, и иногда не отвечала, когда я звала ее по имени. Она выглядела очень растерянной, когда я задавала ей простой вопрос, и не отвечала на вопросы, которые я задавала в классе. Как раз тогда медицинская работница в нашей деревне организовала информационную встречу. Там она объяснила, что потеря слуха довольно распространенная проблема. Она рассказала о некоторых распространенных признаках потери слуха, например, о том, что слабослышащие люди часто переспрашивают или не могут разобрать, о чем им говорят. Она также рассказала нам о причинах, которые могут привести к потере слуха у детей и взрослых И тогда я поняла, что проблемы Симы могут быть вызваны потерей слуха. На следующий день я спросила ее, все ли у нее в порядке с ушами и о некоторых распространенных причинах потери слуха. Сима сказала мне, что у неё были выделения из ушей, начиная с 5 лет. ?? БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 20 Сима сказала мне, что в ее общине у многих детей бывают выделения из ушей. Когда у нее болят уши, мать закапывает их горячим маслом. Я поговорила с матерью Симы и попросила ее отвезти Симу к врачу в близлежащий медицинский центр. В этом центре Сима прошла несколько обследований. Ей и ее матери рассказали, как заботиться об ушах и что не надо закапывать в них масло. Я посадила Симу на первый ряд в классе и проследила за тем, чтобы она четко слышала, что ей говорят. Вскоре оценки Симы улучшились, и она стала более активной. Через несколько месяцев Симе сделали операцию на ушах. После этого она стала лучше слышать. Хотя она больше не учится в моем классе, я ее иногда вижу. Ее учительница сказала мне, что Сима хорошо учится. Я думаю, что ознакомительные занятия, подобные тем, которые тогда провела медицинская работница, очень важны для общины и особенно для учителей, поскольку помогают им больше узнать о распространенных проблемах, с которыми сталкиваются дети. 21 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Что делать, если у ребенка диагностирована потеря слуха? При выявлении потери слуха или про- блем с ушами необходимо обсудить под- ходы к лечению и начать его как можно раньше. Своевременное оказание помо- щи позволит обеспечить следующее: • У ребенка разовьются языковые навы- ки, он получит образование и сможет интегрироваться в общество. • Заболевания ушей у ребенка будут ди- агностированы и вылечены, благодаря чему можно будет избежать потери слу- ха и других осложнений. Спросите участников, что они об этом знают. Почему важно обращать на это внимание и обеспечить раннее вмешательство? Какие есть возможности у ребенка с потерей слуха? Попросите их поделиться своим мнением и обсудить ответы, перечисленные ниже. Совет: БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 22 Раннее вмешательство помогает детям добиваться лучших результатов. Например, младенцы, у которых потеря слуха была диагностирована через 3 месяца после рождения (если вмешательство началось к 6-месячному возрасту), могут освоить речевые и языковые навыки не хуже, чем их ровесники с нормальным слухом. Слуховые аппараты или кохлеарные импланты по совету ЛОР-врача или аудиолога. Виды вмешательств для детей с потерей слуха: Реабилитация, включая сурдореабилитацию; речевую и языковую терапию, слухоречевую терапию, жестовое артикулирование и полную коммуникацию. Изучение языка жестов, особенно при нежелании использовать слуховые аппараты, их отсутствии или бесполезности. Это поможет ребенку общаться и получить образование. Семьи, опекуны, учителя помогают детям пройти курс реабилитации и использовать слуховые аппараты или кохлеарные импланты. При необходимости они изучают язык жестов. Консультирование и группы взаимной поддержки для детей, опекунов, семей. 23 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Очистите уши сухим тампоном или влажной турундой. Это необходимо делать правильно. При назначении используйте ушные капли. Капли должны действовать эффективно. Что можно сделать при ушных болезнях? Спросите участников, как заподозрить болезнь уха. Предложите обсудить перечисленные выше пункты. При появлении у человека признаков, указывающих на наличие у него ушных болезней, его следует направить к врачу для об- следования и постановки диагноза. Лечение зависит от харак- тера заболевания и может включать в себя следующее: - Прием лекарств внутрь или в форме ушных капель. - Хирургическая операция на ухе. Раннее лечение ушной болезни на ранней стадии позволит пре- дотвратить или обратить вспять вызванную ею потерю слуха. Вы можете помочь людям с выделениями из уха или ушными инфекциями, направив их к соответствующему специалисту. Обратитесь к врачу Когда можно заподозрить болезнь уха: • Боль в ухе • Выделения из уха • Постоянное чувство распирания в ухе • Звон в ушах. • Сложности со слухом Совет: Помощь при ушных выделениях: БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 24 Сухой тампон • Чистить уши можно только сухим тампоном при появлении выделений. • Если ухо сухое, его нельзя чистить сухим тампоном. • Сухой тампон – не то же самое, что «ватная палочка». • «Ватные палочки» ни в коем случае нельзя вводить глубоко в ухо, поскольку они слишком длинные, а вата намотана на палочку слишком плотно. Спросите участников, испытывали ли они сами нарушения слуха или встречали ли людей с потерей слуха. Попросите их поделиться собственным опытом. Совет: Вымойте руки с мылом и высушите на воздухе. Оторвите комочек ваты. Аккуратно придайте ему овальную форму. Поместите кончик палочки в центр ватного комочка. Поворачивайте палочку вокруг оси одной рукой, плотно прижимая вату к палочке большим и указательным пальцами другой руки. По окончании чистки уха вымойте руки. Половина комочка должна выступать над концом палочки и образовать пушистый, мягкий кончик. Скрученный комочек ваты должен быть достаточно длинным, чтобы при вводе мягкого кончика тампона в слуховой проход до барабанной перепонки остальная часть тампона находилась снаружи. Это необходимо для того, чтобы вы могли извлечь ватный тампон из слухового прохода. 1. 2. 3. 4. 5. 6. 7. Как изготовить сухой тампон Материалы: тонкая деревянная палочка и вата. 25 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 1. Сверните конусовидный жгутик из ткани или мягкой бумаги. 2. Мягко оттяните ушную раковину от головы. Это поможет расширить вход в слуховой проход. 3. Введите турунду в слуховой проход. Она впитает любые выделения или кровь в слуховом проходе. 5. Вытяните влажную турунду и изучите ее. Есть ли на ней следы гноя? 6. Введите чистую турунду. 7. Повторите несколько раз, пока турунда не будет сухой. 4. Оставьте на минуту. Как изготовить и использовать турунду из ткани для чистки ушей Материалы: кусочек хлопчатобумажной ткани (марли), впитывающей влагу, или кусочек мягкой, крепкой бумаги – НЕ рыхлой туалетной бумаги, которая может оторваться внутри уха. Предложите всем участникам отработать эти навыки под наблюдением специалиста. Примечание: Рекомендуется использовать сухую турунду для чистки слухового прохода в клинике. Людей с выделениями из ушей можно научить использовать сухие турунды для чистки ушей на дому Совет: БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 26 1. Очистите слуховой проход сухой турундой. 2. Попросите человека лечь на бок или наклонить голову, чтобы можно было закапывать ухо сверху. 3. Мягко оттяните ушную раковину назад и вверх, чтобы расширить ушной проход. 5. Потяните мочку уха, чтобы капли достигли дна ушного прохода. 4. Закапайте 2-3 капли в ушной проход. 8. Пациент должен полежать на боку 5 минут. 7. Несколько раз нажмите на козелок. 6. Закапайте еще 2-3 капли. Вытрите капли, вытекшие из уха, когда пациент сядет. Как правильно закапывать ухо. Пошаговая инструкция: Продемонстрируйте эти приемы (без использования капель) и предложите участникам отработать эти приемы под наблюдением. Совет: 27 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Взрослые Потеря слуха может произойти в любом возрасте. Ниже перечислены наиболее распространенные причины: Громкие звуки: - Длительное воздействие шума при работе в шумных местах, например, на фабриках с громким оборудованием, в музыкальной индустрии, при стрельбе из ружья и других видов оружия. - Прослушивание громкой музыки в наушниках или на дискотеках. - Однократное воздействие очень громкого звука, напр., взрыва. Не прекращайте прием лекарств без консультации с врачом. При подозрении, что лекарство может повредить слух, обратитесь за советом к врачу. Если известно, что принимаемое лекарство влияет на слух, необходимо регулярно проверять слух. Спросите участников, подвергались ли они воздействию громких звуков, и если да, как они на них повлияли. Совет: С возрастом наш слух может ухудшиться. Примерно каждый третий человек старше 65 лет страдает возрастной потерей слуха. Лекарства, которые могут повредить слух: некоторые антибиотики, противомалярий- ные препараты, противораковые лекарства и инъекционные препараты для лечения лекар- ственно-устойчивого туберкулеза. Травмы головы или ушей Нелеченные или продолжительные ушные инфекции. Возрастная потеря слуха. Ушные болезни, сопровождающиеся ре- цидивирующими или постоянными выде- лениями из уха или болью. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 28 Что делать при подозрении на потерю слуха у взрослого человека? Порекомендуйте тако- му человеку проверить слух. Это можно сде- лать следующим обра- зом: ВНИМАНИЕ! Если взрослый человек жалуется на внезапную потерю слуха на оба или одно уха, ему следует незамедлительно обратиться к врачу. Человек с потерей слуха: • Не отвечает, когда к нему обращаются, или отвечает невпопад. • Говорит громче обычного (потому что ему кажется, что его голос звучит тихо). • Испытывает затруднения при разговоре по телефону. • Становится отстраненным, тихим и оди- ноким. • Увеличивает громкость при просмотре телевизора или прослушивании музыки. • Сообщает, что может слышать, но не раз- бирает, что ему говорят («Я слышу, что вы говорите, но не понимаю, о чем»), т.е., звуки для него звучат приглушенно, как будто другие люди бормочут. • Говорит нечетко. • Не очень хорошо слышит звуки высокой Как можно заподозрить потерю слуха у взрослого человека? частоты (напр., дверной или телефонный звонок). • Жалуется на звон в ушах (тиннитус). • Переболел ушными заболеваниями с выделениями из ушей. • Тональная аудиометрия: обычно такую проверку мож- но пройти в клинике или другом медицинском учреж- дении. • При наличии смартфона можно воспользоваться при- ложением hearWHO app, чтобы пройти скрининг на потерю слуха. Если по результатам теста hearWHO человек набирает меньше 50 баллов, ему обязатель- но и без промедления следует пройти проверку слуха. 29 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА История Джона Джон ушел на пенсию после 34 лет работы на очень шумной фабрике. Дома он часто увеличивал гром- кость телевизора. Иногда он не слышал, когда его жена спрашивала его, что он хочет на ужин. Эти изменения происходили постепенно. Жена Джона поговорила с медицинским работником, который объяснил, что когда люди работают в шумной обстановке, а также с возрастом у них может ухудшиться слух. Джон не знал, что людям, работающим на шумных фабри- ках, необходимо носить средства защи- ты ушей, чтобы предотвратить потерю слуха. Жена Джона рассказала ему, что сказал медицинский работник, но он отрицал, что у него может быть потеря слуха. Джон сказал, что члены семьи не разговаривают с ним, а бормочут БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 30 Через несколько месяцев жена Джона, наконец, уговорила его обратиться к медицинскому работнику, кото- рый осмотрел его уши, и предложил ему пройти проверку слуха в ближайшей клинике. После этой проверки аудиолог объяснил Джону, что у него потеря слуха средней тяжести. Затем он объяс- нил, что пожилые люди с потерей слуха могут слышать, как говорят другие люди, но часто не понимают, о чем говорят. Особенно если они находятся в шумной обстановке, им кажется, что люди бормочут, когда говорят. Жена Джона сказала, что ему больше не нравится ходить на семейные праздники, потому что он не слышит, что говорят люди. Джон объяснил, что он чувствует себя брошенным, и из-за этого очень одиноким. Аудиолог сказал, что слуховой аппарат может помочь Джону слы- шать то, что говорят люди, но он должен регулярно посещать клинику после того, как получит слуховой аппарат, чтобы в полной мере воспользоваться его преимуществами. Джон и его жена занимаются его слухом и обслужива- ют слуховой аппарат при поддержке аудиолога, а так- же их семьи и друзей. Их друзья научились говорить по очереди и немного медленнее и разборчивее, что- бы Джон мог участвовать в разговоре. Это принесло огромную пользу всем, но в основном Джону, так как он больше не избегает семьи, друзей и встреч с дру- гими людьми. Теперь, когда Джон и его семья понимают послед- ствия потери слуха у пожилых людей, они рассказы- вают другим людям о важности проверки слуха. 31 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Что делать при обнаружении потери слуха или болезней уха у взрослых? • Важно определить причину потери слуха (напр., шум, лекарства, болезни уха) и принять меры. • Взрослым с потерей слуха могут помочь различные устройства, напр., слуховой аппарат или кохлеарные импланты. • Взрослым также может помочь сурдореабилитация и поддержка, чтобы они могли использовать свой слух в полной мере. Взрослым, так же, как и детям, важно выявить потерю слуха как можно раньше и принять меры для восстановления слуха и использовать слуховые устройства без промедления. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 32 Слух можно проверить в любом возрасте. В зависимости от возраста человека проводятся различные тесты для определения типа и степени тяжести потери слуха, например: 1. Регистрация отоакустической эмиссии (ОАЭ) или аппаратная проверка акустических стволомозговых вызванных потенциалов (АСВП) могут проводиться у младенцев и детей в возрасте до пяти лет. Эти тесты часто проводят с помощью портативного аппарата, пока ребенок спит. Тест проводится быстро и легко. Если ребенок дважды не пройдет эту проверку, его направляют на… 2. Исследование коротколатентных стволомозговых слуховых вызванных потенциалов (КСВП): этот тест обычно проводится в специализированных центрах после седации ребенка. Как проверить слух? Тесты ОАЭ или АСВП могут быть проведены в медицинском учреждении, находящемся недалеко от вас. Узнайте у врача или медработника о том, где можно пройти такие тесты в вашем районе. Желательно проверять слух каждого ребенка вскоре после рождения, чтобы выявить проблемы со слухом на раннем этапе. 33 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 3. Тональная пороговая аудиометрия: слух у детей старше пяти лет и у взрослых можно про- верить с помощью простого теста с применением метода тональной пороговой аудиометрии (ТПА). В ходе этого теста подаются звуки разных тонов в каждое ухо пациента, которого просят сообщить, когда он их услышит. Как проверить слух? Дети старше пяти лет и взрослые: БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 34 Кто должен регулярно проходить проверку слуха? Помните: чем раньше будет выявлена потеря слуха, тем раньше можно начать лечение. Обратитесь к местному медицинскому работнику, если считаете, что необходимо проверить слух у младенца, ребенка или взрослого; порекомендуйте такому человеку пройти проверку слуха в ближайшее время. • Младенцы • Дети • Люди старшего воз- раста • Люди, принимающие ототоксичные лекар- ства • Люди, подвергаю- щиеся воздействию громких звуков 35 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Слуховые аппараты: Что такое слуховой аппарат? Слуховой аппарат - это электронное устройство, которое надевается на ухо. Он помогает усилить звуки, чтобы человек с потерей слуха мог лучше слышать. Существует множество различных типов слуховых аппаратов, и они бывают разных цветов, размеров и форм. Заушный слуховой аппарат: состоит из двух частей (собственно слуховой аппарат и ушной вкладыш), которые соединены тонкой, прозрачной трубкой: • слуховой аппарат надевается за ухо; • вкладыш вставляется в ухо. Слуховой аппарат внутриушного типа: он меньше и изго- тавливается индивидуально в соответствии с формой уха. Обслуживание слуховых аппаратов • Из-за небольшого размера их легко потерять или по- вредить. • Храните слуховой аппарат в безопасном, прохладном месте, когда его не используете. • Слуховой аппарат должен быть сухим. Если он впитает влагу, он может работать некорректно. Снимайте его во время приема душа или ванны. • Каждый вечер открывайте батарейный отсек и поме- щайте слуховой аппарат в закрытый пластиковый кон- тейнер, в который следует сухие тонкие салфетки или рис. • Обязательно выключайте аппарат, когда не используе- те, чтобы продлить время работы батареи. • Избегайте воздействия на аппарат влаги или тепла (напр., от кухонной плиты или пламени). Спросите участников, встречали ли они людей, пользующихся слуховыми аппаратами, и как, по их мнению, они работают. Задайте вопрос о кохлеарных имплантах, Слышали ли они когда- нибудь о таких устройствах? Совет: БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 36 Слуховые аппараты работают от батареек, которые необходимо менять примерно раз в 7-10 дней в зависимости от того, насколько они разряжены. Если слуховой аппарат перестает работать, сначала попробуйте поменять батарейки. Рекомендуется проверять батарейки в слуховом аппарате ребенка каждый день. Ушной вкладыш необходимо чистить и протирать сухой тканью ежедневно. Раз в неделю отсоединяйте вкладыш с трубкой от слухового аппарата и промывайте теплой водой с мылом. Таким образом вы смоете ушную серу, которая может закупорить звуковое отверстие вкладыша. Использование слухового аппарата Если ушная сера закупорит звуковое отверстие вкладыша, слуховой аппарат может перестать работать. Слуховой аппарат может издавать свистящий звук, если его неправильно вставить в ухо. Сам слуховой аппарат мыть нельзя, иначе он может выйти из строя и перестанет работать. Трубку, соединяющую вкладыш и слуховой аппарат необходимо менять через несколько месяцев. Вкладыш необходимо менять раз в несколько лет. У младенцев и детей это следует делать чаще, поскольку вкладыш должен соответствовать размеру детских ушей по мере их роста. Если вкладыш слишком мал для ребенка, слуховой аппарат может издавать свистящий звук. ХРАНИТЕ БАТАРЕЙКИ СЛУХОВОГО АППАРАТА ВДАЛИ ОТ ДЕТЕЙ! Дети могут проглотить батарейки, что может привести к серьезным осложнениям и потребовать хирургической операции для их извлечения. Как проверить состояние батареи: • Снимите слуховой аппарат с уха и из- влеките вкладыш. • Включите слу- ховой аппарат и переведите ре- гулятор звука на максимум. • Положите слухо- вой аппарат на ладонь. • Если слышите постоянный свистящий звук, это значит, что батарея заряжена. • Если не слышите свистящего звука, батарею следует заменить. Если после этого звук не по- явится, это указывает на технические пробле- мы со слуховым аппаратом – его необходимо проверить. 37 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Кохлеарный имплант - это электронное медицинское устройство для людей с тяжелой или глубокой потерей слуха, для которых слуховые аппараты недостаточно эффективны. В отличие от слухового аппарата кохлеарный имплант преобразует звуки в электрические сигналы. Эти сигналы стимулируют волосковые рецепторы во внутреннем ухе и затем передаются слуховым нервом в мозг. Мозг распознает эти звуки или речь и таким образом человек лучше слышит. Для установки кохлеарного импланта требуется операция. Что такое кохлеарный имплант? 1 2 Кохлеарный имплант состоит из 2 частей: Внешний процессор, расположенный за ухом или на коже головы, - он похож на обычный слуховой аппарат. Сам имплант, хирургически вживленный под кожу голо- вы за ухом. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 38 История Шрейи Когда Шрейе было 7 месяцев, мы отмечали индийский праздник Дивали традиционным способом - с огнями, сладостями и фейерверками. Тогда я впервые заметила, что Шрейя не слышит звуки, поскольку она не пугалась и не реагировала, даже когда громко взрывались петарды. Вскоре после этого мы с мужем отвезли ее к врачу, который направил ее на проверку слуха. После тестов стало ясно, что Шрейя глухая. Наша семья никогда не сталкивалась с глухими людьми до этого, и мы все очень волновались. Мы боялись, что без слуха Шрейя не сможет научиться говорить и не пойдет в школу. Врач нам все объяснил и рассказал о кохлеарных имплантах, а также о том, что их установка возможна для Шрейи. Благодаря правительственной программе мы решили установить ей имплантат. В возрасте 3 года Шрейя начала реабилитацию. 39 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Нашей семье пришлось много работать для ее реабилита- ции. Мы регулярно возили ее на терапию и посещали ау- диолога, когда нам звонили. В результате Шрейя вскоре начала понимать, что ей говорят, и потихоньку стала гово- рить. Мы были рады и продолжили наши усилия. Сейчас, в десять лет, Шрейя учится в той же школе, что и ее старший брат, и ей нравятся естественные науки. Она также любит рисовать и танце- вать. Но что она любит больше всего - это поговорить. Иногда она говорит так много, что мы просим ее по- молчать! Теперь мы рассказываем всем нашим род- ственникам и друзьям, что проблему потери слуха можно решить. Важно, чтобы родите- ли отвезли ребенка на обследование, если у них есть подозрения о потере слуха. Важно быть бдительными и действовать на ранней стадии. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 40 Как разговаривать со слабослышащими людьми? • Говорите четко и медленно. Не кричите! • Общайтесь в хорошо освещенном месте и смотрите на со- беседника, чтобы он видел ваше лицо, когда вы говорите. • Не следует чрезмерно артикулировать, поскольку сла- бослышащему при этом будет труднее вас понимать. • Постарайтесь свести к минимуму фоновый шум, особенно в школе или на рабочем месте, поскольку громкий фо- новый шум мешает людям с потерей слуха слышать вас, даже если они используют слуховой аппарат. • Если в вашей группе (среди знакомых, в семье или на ра- боте) есть слабослышащий, старайтесь говорить по одно- му. Это поможет слабослышащему человеку участвовать в разговоре. Оказание поддержки людям с потерей слух 41 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА Что я могу сделать, чтобы поддержать человека с потерей слуха или глухотой? • Посоветуйте им обратиться в клинику для проверки слуха. • Поддержите их, если они используют слуховые аппараты или кохлеарные импланты. Помогайте проверить заряд батарейки или посмотреть, не закупорилась ли трубка ушной серой. Детям и людям старшего возраста такая помощь может понадобиться. • Научите детей рассказывать о своих потребностях дома и в школе. Например, посоветуйте детям говорить учителям или родителям, если их слуховой аппарат перестал работать, или переспрашивать, если они не расслышали сказанное. • Поощряйте людей открыто говорить о потребностях – своих или их детей – в связи с потерей слуха и не стесняться этого. • Посоветуйте родителям проинформировать школьных учителей о том, что у ребенка потеря слуха, и Помните, что при надлежащей помощи и поддержке люди с потерей слуха могут делать все – только не могут нормально слышать. Их необходимо вовлекать во все виды деятельности. попросите учителей всегда смотреть такому ребенку прямо в лицо, если они к нему обращаются. • Проинформируйте родителей и учителей о языке жестов и порекомендуйте их выучить его как средство общения. БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 42 Профилактика потери слуха Надлежащая охрана здоровья матери и ребенка до, во время, и после рождения. 60% Многие случаи потери слуха можно предупредить. По оценкам, до 60% случаев потери слуха вызваны предотвратимыми причинами. Потерю слуха можно предупредить с помощью ряда простых мер: Вакцинация детей против краснухи, кори, свинки и менингита. 1 2 3 4 6Защита ушей от громких звуков на работе и в окружающей среде Соблюдение правил безопасности при прослушивании музыки в наушниках или на дискотеках, концертах или вечеринках. Спросите вашего врача, не влияет ли ваше лекарство на слух, и если да, как этого избежать. Позаботьтесь о своих ушах, следуя правилам «Что МОЖНО и что НЕЛЬЗЯ делать». 5 43 БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА МОЖНО: • Попросите провести скрининг слуха вашего младенца. • Если подозреваете потерю слуха у кого-нибудь, срочно направьте их к медицинскому работнику. Это особенно важно для младенцев и детей. • Обратитесь к медицинскому работнику или врачу в случае постоянной ушной боли, выделений из ушей или любых других проблем с ушами. • Обратитесь к медицинскому работнику или в клинику для удаления серной пробки или инородных объектов из уха. • Помогайте детям и взрослым обслуживать их слуховые аппараты или импланты. • Обращайтесь к врачу, если у вашего ребенка не проходит простуда. • Посоветуйте людям, работающим на шумном производстве, использовать средства зашиты ушей. • Посоветуйте родственникам и учителям детей с потерей слуха изучить язык жестов. • Для лечения ушей используйте только те лекарства, которые назначил вам врач. • Верьте своему инстинкту! Если подозреваете, что с вашим слухом что-то не так, обращайтесь за помощью. Уход за ушами: что МОЖНО и что НЕЛЬЗЯ делать БАЗОВАЯ ИНФОРМАЦИЯ О ПОМОЩИ ПРИ БОЛЕЗНЯХ УХА И СЛУХА 44 НЕЛЬЗЯ: • Ничего НЕ засовывайте в ухо. Никаких ватных пало- чек, зажимов, зубочисток, палочек или ушных свечей! • Если из уха выделяется гной или жидкость, НЕ сле- дует это игнорировать. • НЕ лечите болезни ушей горячим или холодным мас- лом, травами или домашни- ми средствами. • НЕ плавайте и не мойтесь в грязной воде. • НЕ слушайте слишком громкие звуки или музыку длительное время, т.к. это может привести к потере слуха. Если вы не уверены в том, что у человека может быть потеря слуха, предложите ему обратиться за помощью к местным медицинским работникам, которые могут провести базовую проверку слуха и в случае необходимости направить такого человека к медицинскому специалисту. Помните, что ушная сера вырабатывается для защиты уха и поддержания его в чистоте. Никогда не используйте ватные палочки (даже для регулярной чистки), так как это может привести к более глубокому проникновению серы в ухо и повредить барабанную перепонку. Иногда обрывок ваты может остаться в ухе как инородное тело! При прослушивании музыки через персональное устройство (например, MP3-плеер) поддерживайте уровень громкости ниже 60% от максимального, делайте частые перерывы и ограничивайте время прослушивания.

ДЛЯ ПОЛУЧЕНИЯ ДОПОЛНИТЕЛЬНОЙ ИНФОР- МАЦИИ ПРОСЬБА ОБРАЩАТЬСЯ В Департамент по неинфекционным заболеваниям, инвалидности и предупреждению насилия и травма- тизма, Всемирная организация здравоохранения https://www.who.int/deafness/make-listening-safe/en/ Всемирная организация здравоохранения Avenue Appia 20 CH-1211 Geneva 27 Швейцария