Hearing Assessment for a 2-Year-Old with Recurrent Ear Infections
This child requires immediate play audiometry screening or comprehensive audiologic evaluation, given the history of 6 ear infections in the past year, which places them at high risk for acquired hearing loss. 1
Why Hearing Testing is Critical Now
- Children with repeated or chronic otitis media with effusion are at high risk of acquired hearing loss and should undergo comprehensive hearing evaluation. 1
- Temporary hearing loss has been demonstrated during episodes of acute otitis media, and chronic middle ear effusion can lead to poor school performance and behavioral problems. 1
- The frequency of ear infections (6 in one year) meets criteria for consideration of tympanostomy tubes (≥4 episodes within one year with one in the preceding 6 months), making baseline hearing assessment essential before any surgical intervention. 2, 3
Recommended Testing Approach
For this 2-year-old, play audiometry is the most appropriate age-specific hearing test:
- Children aged 2 to 4 years are screened or tested most appropriately by play audiometry, where the child is conditioned to respond to auditory stimuli through play activities (such as dropping a block when a sound is heard through earphones). 1
- Air-conduction hearing threshold levels greater than 20 dB at any frequency indicate possible hearing loss and require referral to a pediatric audiologist. 1
If play audiometry cannot be performed due to cooperation issues, referral to a pediatric audiologist for comprehensive evaluation is mandatory:
- Comprehensive audiologic evaluation should include visual response audiometry (VRA) or diagnostic auditory brainstem response (ABR) testing if behavioral testing is not feasible. 1
- Diagnostic ABR can provide frequency-specific hearing data even in uncooperative children, though sedation may be required. 1
Additional Concurrent Assessment
Tympanometry should be performed alongside hearing testing:
- Tympanometry assesses middle ear function and can identify persistent middle ear effusion, which is the most common cause of conductive hearing loss in this age group. 1
- Type B (flat) tympanograms indicate high probability of middle ear effusion or tympanic membrane perforation, both likely to cause hearing loss. 1
- A high-frequency probe tone (1000 Hz) should be used for accurate assessment in young children. 1
Clinical Decision Points
If hearing loss is documented:
- Children with bilateral OME and documented hearing loss require counseling about potential impact on speech and language development. 3
- Referral to an otolaryngologist should be made for consideration of tympanostomy tubes, especially given the frequency of infections. 2, 4
If hearing is normal but infections continue:
- Reevaluate at 3- to 6-month intervals until effusion resolves or hearing loss develops. 3
- Consider tympanostomy tubes if the child has 3 or more episodes within 6 months or 4 episodes within one year with one in the preceding 6 months. 2
Common Pitfalls to Avoid
- Do not assume hearing is normal based solely on the normal newborn screening – acquired hearing loss from recurrent otitis media is common and would not have been detected at birth. 1
- Do not rely on pneumatic otoscopy or tympanometry alone – these assess middle ear status but do not measure actual hearing ability. 1
- Do not delay hearing assessment – waiting for infections to resolve may miss critical periods for speech and language development if hearing loss is present. 1, 3