Hearing Loss

Why Hearing Loss Is So Important in Children

Hearing is an invisible yet defining foundation of a child’s development. Learning to speak, distinguishing between words, following what the teacher says in class, reading the tone of the person opposite in a social interaction — all of these are built upon a healthy hearing chain. This chain begins at the outer ear; sound waves travel through the ear canal to reach the eardrum, from where they are conducted to the inner ear via the middle ear ossicles, converted into a nerve impulse in the inner ear, and carried to the brain along the auditory nerve. A disruption at any of these steps presents as hearing loss.

In an adult, mild hearing loss is usually a matter of comfort that can be managed by asking the other person to repeat themselves. In a child, it is a developmental problem. For a child who is still learning to speak, even moderate hearing loss means that half of the words are learned incompletely or incorrectly. What is more, the child cannot express this deficiency by saying “I can’t hear”; they simply ask “what did you say?” often, or appear distracted in class. For this reason, the most critical decision in childhood hearing loss is early recognition.

Hearing loss falls into three main categories. Conductive loss arises when sound is blocked in the outer or middle ear (earwax, middle ear fluid, an eardrum problem); the great majority of these cases are treatable. Sensorineural loss (originating in the inner ear or nerve) results from involvement of the hair cells in the inner ear or of the auditory nerve; it is generally not reversible with medication but is managed with a hearing aid and, in selected cases, a cochlear implant. Mixed loss is the presence of both together. The correct treatment plan begins with distinguishing the type of loss.

Through the Parent’s Eyes: Which Signs Point to a Hearing Problem

In a child, hearing loss rarely begins as an obvious picture of “not hearing.” Most of the time the clues are quieter — small observations a parent may notice in daily life.

Infancy (0–2 years)

• Not startling at loud sounds, not turning towards the direction of a sound
• Babbling decreasing or disappearing around 6 months
• Simple words (mama, dada) not appearing around 12 months
• A markedly limited vocabulary at 2 years, not turning when called by name
• Responding only to high- and low-pitched sounds while missing mid-pitched speech

Preschool (2–6 years)

• Speech lagging behind that of peers
• Inability to produce certain consonants, consistent mispronunciation
• Speaking loudly, an inability to regulate the voice
• Turning the television up, turning it up again when asked
• Frequently saying “what did you say?” or “I didn’t understand”
• Not responding to things said unless looked at directly

School Age (6 years and beyond)

• Distraction in class, missing parts of lessons
• An unexpected academic decline
• Not turning when called from behind or the side
• Inability to follow speech in noisy settings (canteen, playground)
• Consistently preferring one ear when speaking on the telephone
• Social withdrawal, drifting away from peer relationships, behavioural change

None of the signs in this list makes a diagnosis of hearing loss on its own; however, when they become persistent, they are grounds for an objective hearing assessment.

Causes and Risk Factors

The causes behind hearing loss are grouped into two periods:

Congenital or arising in the newborn period:

• Genetic causes (a family history of hearing loss, syndromic conditions)
• Infections contracted in the womb (rubella, cytomegalovirus, toxoplasmosis)
• Oxygen deprivation before or during birth
• Premature birth, very low birth weight
• High bilirubin (jaundice) levels in the newborn period
• Conditions requiring neonatal intensive care, the use of ototoxic medications

Acquired after birth:

• Recurrent or chronic middle ear inflammation / middle ear fluid (the most common cause of conductive loss)
• Meningitis or severe viral infections (mumps, measles)
• Head trauma
• Exposure to high-decibel sound (particularly listening to loud music through headphones)
• The side effects of certain medications
• An earwax plug (a temporary, easily correctable cause)
• Rare familial conditions such as otosclerosis

The newborn hearing screening programme carried out in Turkey catches a significant proportion of congenital losses before discharge; however, losses that develop in later months of life, or that begin mildly and progress, may fall outside the screening programme. For this reason, parental observation retains its value even when the screening result is “pass.”

The Diagnostic Process

When hearing loss is suspected, the diagnosis is clarified through a combination of clinical examination and objective tests.

1. Detailed history: Birth history, a family history of hearing loss, illnesses experienced, medication history, the course of language and speech development, and the parent’s daily observations.
2. ENT examination: Evaluation of the ear canal, eardrum, adenoid, and the back of the nose. The most common causes of conductive loss — earwax, middle ear fluid, and adenoid enlargement — are detected at this stage.
3. Tympanometry: A painless test that measures the movement of the eardrum and shows whether there is fluid in the middle ear.
4. Otoacoustic emissions (OAE): A rapid and objective test that can assess inner ear function even in infants. This is the method used in newborn screening.
5. Behavioural audiometry and play audiometry: In children between 6 months and 5 years, hearing thresholds are determined using age-appropriate techniques (toy placement, visual reinforcement).
6. Pure-tone audiometry: The standard test, generally used in children aged 5 and over, in which hearing at different frequencies is measured through headphones.
7. Speech audiometry: Measurement of the child’s ability to understand not just sounds but words.
8. ABR (Auditory Brainstem Response): An objective measurement of the auditory signal at brainstem level, particularly in infants and in children who cannot cooperate with testing.
9. Imaging (if needed): In cases where sensorineural loss is identified, inner ear anatomy may be evaluated with MRI or CT.

Not every case requires all of these tests; the right combination is planned according to the clinical picture.

Treatment Approaches

Treatment is planned according to the type, degree, and cause of the loss. The approach is not a single prescription; it is tailored to each child.

In Conductive Losses

• Earwax plug: Resolved with a simple in-office procedure; hearing often returns to normal in a single session.
• Middle ear fluid: The first step is observation and medical support for up to 3 months. In cases that persist and affect hearing, a ventilation tube is placed; if there is an underlying cause (adenoid), it is addressed in the same session. See: Pediatric Otitis Media.
• Chronic middle ear / eardrum problems: In selected cases, eardrum repair (tympanoplasty) or middle ear surgery comes onto the agenda.
• Congenital outer ear anomalies: Managed with surgical repair or special conductive devices.

In Sensorineural Losses

• Hearing aid: The most common solution in mild, moderate, and severe losses. Modern devices are small, programmable, and can be re-adjusted as the child develops. Simply fitting the device is not enough; an auditory rehabilitation programme accompanies it so that the child learns to use hearing with the device.
• Cochlear implant: Comes onto the agenda in very severe or total losses, in children who do not derive sufficient benefit from a hearing aid. It is based on the principle of directly stimulating the auditory nerve through an electrode system surgically placed in the inner ear. Implantation performed at an early age is of critical importance for speech development.
• Bone-conduction devices: Options preferred in unilateral cases and in structural anomalies of the outer and middle ear.

Accompanying Support

Whichever treatment is chosen, ancillary elements such as speech and language therapy, auditory-verbal therapy, and adjustments to the school environment (sitting at the front, the use of an FM system) are inseparable parts of the treatment if the child is to gain real benefit from a hearing aid or surgery. Communication between the ENT physician, the audiologist, the speech and language therapist, and the school is a determinant of a successful course.

The Process and Recovery

The treatment of hearing loss is not a one-off procedure; it is a follow-up process that progresses alongside a developing child.

• In conductive cases (for example, middle ear fluid or earwax), hearing usually improves markedly within days after treatment. After tube treatment, parents often notice within the first week that the child begins to respond differently to sounds.
• With hearing aid use, the first weeks are a period of adaptation. Recognising sounds anew and hearing one’s own voice differently takes the child some getting used to. Regular audiological adjustments make it possible for the programme to adapt to the child’s growing ear and changing needs.
• After a cochlear implant, the rehabilitation process lasts months; however, particularly in children implanted at an early age, language and speech development is seen to catch up largely with that of peers.
• Regular follow-up: It is important that every child diagnosed with hearing loss has their hearing re-evaluated at certain intervals, because some losses can deepen over time.

In treatments requiring anaesthesia and surgery (tube, cochlear implant, eardrum repair), paediatric anaesthesia protocols are planned to be brief and to provide rapid recovery after waking. The hardest moment a parent witnesses is the moment the child is taken to the operating theatre; being beside the child when they wake is one of the most important points of support throughout the process.

Impact on School and Development

The effect of hearing loss on a child is related less to the degree of loss than to the age at which it is recognised.

Speech and language development. The first three years of life are the period in which the foundation of language is laid. A hearing loss not detected within this window can lead to a permanent lag in vocabulary, grammar, and pronunciation. Early treatment and rehabilitation markedly increase these children’s chances of catching up with their peers.

Academic achievement. Even a mild, undetected hearing loss means that a significant part of what the teacher says in class is missed. This may mean that the child interpreted as “careless” or “lazy” is in fact unable to hear; once a diagnosis is made, a child whose academic performance and behaviour both recover markedly is a course frequently seen in ENT practice.

Social and emotional development. A child who cannot follow conversation with their peers gradually withdraws from social settings; their self-confidence is affected, and signs of isolation may develop. After treatment, these children’s re-entry into social life is often a gain as valuable as the diagnosis itself.

Behaviour. Constantly “not hearing” can leave a child tired and irritable in daily life. Some behavioural changes resolve on their own once the underlying hearing problem is addressed.

When to Consult a Paediatric ENT Physician

The following situations are grounds for a hearing assessment; none is a diagnosis in itself:

• If, despite a “pass” result on newborn hearing screening, the baby is observed not to startle at loud sounds
• A 6-month-old baby not producing babbling sounds, or producing fewer of them
• A 12-month-old child not having produced simple words such as “mama, dada”
• A 2-year-old child with a limited vocabulary who does not turn when their name is called
• A child constantly turning the television up and frequently saying “what did you say?”
• An unexpected academic decline or attention problem in class
• A history of recurrent middle ear inflammation or middle ear fluid lasting longer than 3 months
• Speaking loudly, an inability to regulate the voice
• An inability to produce certain consonants, speech development lagging behind that of peers
• Following meningitis, a severe infection, or head trauma
• A family history of hearing loss beginning in childhood
• Unilateral hearing difficulty, always holding the telephone to the same ear

Early assessment reveals that in most children the cause is easily correctable (earwax, middle ear fluid). In sensorineural losses, too, early intervention minimises the price that has to be paid for the child’s language and school development. In cases of doubt, a hearing assessment is a far safer path than a “they’ll grow out of it” approach.