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��ࡱ�>��	�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[���0vbjbj����8�ΐΐ�5&�������������8O����BT�(�"������EBGBGBGBGBGBGB2E��G^GBQ�����GB����B�&�&�&����EB�&�EB�&�&6�=�@����� �$o���$@�>1B�B0�B�>2H%B2H8@@�2H�@|��d:�&���H���GBGBD&�����B������������������������������������������������������������������������2H�����������:	Dear Editor,
I would like to publish the following manuscript with the title: Screening for Hearing Loss among kindergarten children students.
Thank you for your kind care and cooperation.
Sincerely,
Fahd Alharbi
Dr. Fahd Alharbi, M.B.B.S , Facharzt-HNO, FEBORL-HNS 
Assistant Professor & Consultant Otolaryngology-Head & Neck Surgery
Otolaryngology-Head & Neck Surgery Department
Faculty of Medicne, Jazan University
2349-Almarjan-Industrial Zone Rd.
Unit No. 1
Jazan 82621-7413
Saudi Arabia
Tel.: 00966 543043452
E-mail:fahdalharbi3@gmail.com









Screening for Hearing Loss among kindergarten children students.

Fahd Ali Alharbi , MD1;   Mohamed Rifaat Ahmed, MD1, 2 
1 Department of Otolaryngology- Head and Neck Surgery, Faculty of Medicine, jazan University, Saudi Arabia
2 Department of  Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Suez Canal University, Egypt 

















Abstract
Introduction: Hearing loss among kindergarten children in the developing countries has been widely reported as a considerable health problem. Unfortunately, kindergarten aged children are rarely screened for hearing loss during routine clinical examination. This study was carried out to Screen the kindergarten children for any pattern of Hearing Loss.
Method :1220 kindergarten students were included to our study in jazan city , kegedom saudia . All kindergarten children were subjected to:- A structured questionnaire , Otological examination , Tuning fork tests, pure tone audiometry (PTA) , speech audiometry and tympanometry,
Results : 18 Kindergarten students had type C tympanogram , 28 Kindergarten students had type B tympanogram (otitis media with effusion) with conductive  Hearing loss , 4 kindergarten children had Chronic otitis media with conductive  Hearing loss while 6 Kindergarten students had mild sensorineural hearing loss . 
Conclusion: Regular otological examination in Kindergarten children is recommended and tympanometry as a part of the screening protocol to diagnose middle ear disease is essential. In addition, pure tone audiometry survey for early detected of hearing loss.
 
Key words 
Hearing - kindergarten










INRODUCTION
Hearing loss among kindergarten children in the developing countries has been widely reported as a considerable health problem (1), since majority of kindergarten children in such countries are based on auditory-verbal methods, hearing impairment had negative outcomes on educational performance. (2) Therefore, hearing screening at kindergarten children proposed for the early detection and rehabilitation of hearing impaired kindergarten children in the developing countries. (3)  Unfortunately, kindergarten aged children are rarely screened for hearing loss during routine clinical examination, and health authorities pay little attention to audiometric evaluation particularly in kindergarten schools. This is usually attributable to the inadequate knowledge of parents, school authorities and healthcare providers on the outcomes of hearing loss. (4)
Regarding the previously mentioned issues, it is favorable to set up a routine kindergarten school audiometry for detection of hearing impaired kindergarten children based on the World Health Organization (WHO) dentition of "disabling hearing impairment" in children under the age of 15 years described as "a permanent unaided hearing threshold level in the better ear of 31 dB or greater�. (5) This criterion, however, has some inherent limitations, For example, it excludes kindergarten children with conductive hearing loss, which is common in this age group as a result of recurrent, chronic or acute otitis media (1). It also does not recognize kindergarten children with unilateral hearing loss of any degree or those with permanent (sensorineural or mixed) hearing loss less than 31 dB. These kindergarten children face difficulties in communication caused by adverse listening conditions such as noisy classrooms. Such conditions will have negative effect on their educational state (6).
Therefore, a large number of kindergarten school children with �disabling� hearing loss are unlikely to be detected by hearing screening based on the WHO criterion alone. While kindergarten children with higher levels of  permanent and bilateral hearing loss (>40 dB) may be detected through primary parental suspicion, those with mild hearing loss (16-40 dB) are unlikely to be detected, because the condition is associated more with receptive rather than expressive linguistic skills (7). 
This study was carried out to Screen the kindergarten children for any pattern of Hearing Loss.


Methodology
This was a cross sectional study to screen hearing condition in kindergarten school children age 4-6 year old in in jazan city , kegedom saudia also to assess the patterns , the types of hearing loss and causes among the studied kindergarten children.
According to the registered data of the ministry of education  in jazan city , kegedom saudia, the total number of kindergarten schools is 34 harboring 1220 kindergarten students were included to our study.
We exclude any kindergarten child with history of otological disease, ototoxic drugs, head trauma and systemic or congenital disorder.
All kindergarten children were subjected to:- A structured questionnaire that was distributed to the parents to ascertain the medical, social and family status of the kindergarten child, Anthropometric measurements which includes height, weight, and head circumference ,  Otological examination using pneumatic otoscope ,Walch Allen,GERMANY, (to exclude local ear problem and check for drum mobility) , Tuning fork test ,512 Hz, (Weber and Rinne tests, gives idea about hearing state) , finally Basic audiomertric evaluation includes pure tone audiometry (PTA) , speech audiometry (model MAICO MA 51 ,USA) and tympanometry , GSI 39 Auto Tymp Made By: Grason-Stadler Inc.
Data Management 
Discrete variables were expressed as percentages. All statistical analyses were performed using SPSS software version13. 
Ethical consideration 
Written consents were obtained from all parents or first degree relatives before the study. The local ethics committee had approved all procedures.












Results
1220 kindergarten students were included to our study, from 2012 to 2014, with mean age 4.9 years, ranged from 4 � 6 years, 677 females represented 56.4% while 543 males represent 44.6% as seen in figure (1).
17 Kindergarten children had impacted wax need ear wash while 63 had upper respiratory tract infection were subjected for medical treatment before audiological evaluations (to treat any possibility of Eustachian tube dysfunction).
None of them had any congenital ear malformation or any history of previous ear operation.
Kindergarten students were subjected to PTA , speech audiometery in double wall soundproof room and tympanometry .
18 Kindergarten students had type C tympanogram (Eustachian tube dysfunction) either unilateral or bilateral whom received medical treatment for 14 days with repeated tympanometry which return back to normal Type A
28 Kindergarten students had type B tympanogram (otitis media with effusion) with conductive  Hearing loss in pure tone audiogram at four frequencies (500, 1000, 2000 and 4000 Hz) showed ranges from normal hearing to moderate conductive hearing loss (0�45 dB) whom received amoxicillin�clavulinic acid 90 mg/kg, oral steroids, antihistamines, nasal decongestants, and mucolytics for 4 weeks without any improvement documented by otoscopic examination and tympanometry , they were subjected for Conventional myringotomy with ventilation tube insertion with additional adenoidectomy or adenotonsillectomy according to every case presentation.
Chronic otitis media was observed in 4 children with moderate conductive hearing loss at four frequencies (500, 1000, 2000 and 4000 Hz) ranged from 40 to 55 dB with safe type and dry central perforation.
Mild sensorineural hearing loss was observed in 6 children (2 had bilateral mild SNHL while 4 had unilateral SNHL) at four frequencies (500, 1000, 2000 and 4000 Hz) ranged from 25 to 40 dB as seen in table 2 , figure 2.
All the Kindergarten students had excellent speech discrimination score (SDS) ranged from 92% to 100% at 40dBSL.





DISCUSSION
Hearing is a critical part of a child�s social, emotional and cognitive development (3)
Hearing loss among pre school children in the developing countries has been widely reported as a considerable health problem. (4)  In addition, Hearing loss had a negative outcome on educational tasks.
Hearing screening at pre school entry has been widely developed for early detection and rehabilitation (8) The purpose of the screening program is to identify early in a child�s life any possible hearing loss that may affect their development and their overall general health. (9)
Unfortunately, pre school-aged children are not routinely screened for hearing loss in Egypt 
Children with hearing loss usually face difficulties in communication due to adverse listening conditions such as noisy classrooms that had negative effect on the educational level. (6, 10, 11) 
38 Kindergarten children was reported hearing loss from our study population represent 3.1%
28 Kindergarten children had OME with mild to moderate conductive hearing loss, 4 Kindergarten children had CSOM with moderate conductive hearing loss while 6 Kindergarten children had mild sensorineural hearing loss.
Otitis media is considered as the most common cause of Kindergarten children hearing loss in the developing countries.(12)
OME usually developed in Kindergarten children due to several factors such as: adenoid hypertrophy, poor nutritional status, poor housing conditions, and presence of viral or bacterial infection and upper respiratory allergy. (13)
Tympanometry is highly sensitive and quite expensive to diagnose OME (14) the negative effect of hearing loss on speech and language development, early detection of hearing loss is undoubtedly worthwhile. Currently, with new technology, such as
otoacoustic emission screening, initial testing can be done at an earlier age and with better reliability. (15)
Our study found that hearing loss in Kindergarten children cannot be detected during clinical examination without additional audiologic screening. In addition, OME which is the most common cause of hearing loss in this population needs suitable tympanometric evaluation. 

Conclusion
Regular otological examination in Kindergarten children is recommended and tympanometry as a part of the screening protocol to diagnose middle ear disease is essential. In addition, pure tone audiometry survey for early detected of hearing loss.
References
1-Rao RS, Subramanyam MA, Nair NS, Rajashekhar B. Hearing impairment and ear diseases among children of school entry age in rural South India. Int J Pediatr Otorhinolaryngol 
2002;64:105-110. 
2- HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=%22Williams%20C%22%5BAuthor%5D" Williams C. Adapted interactive writing instruction with kindergarten children who are deaf or hard of hearing.  HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/21644447" \o "American annals of the deaf." Am Ann Deaf. 2011 Spring;156(1):23-34.
3- McPherson BD, Holborow CA. School screening for hearing loss in developing countries. Scand Audiol Suppl 1988;28: 103-110.
4-Olusanya BO, Okolo AA, Ijaduola GT. The hearing pro�le of Nigerian school children. Int J Pediatr Otorhinolaryngol 2000;55:173-179.
5- World Health Organisation. Report of the 4th Informal Consultation on Future Program Developments for the Prevention of Deafness and Hearing Impairment, Geneva,  February 17-18, 2000. http://whqlibdoc.who.int/hq/ 
6- Teele DW, Klein JO, Chase C, Menyuk P, Rosner BA. Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years. Greater Boston Otitis Media Study Group. J Infect Dis 1990;162:685-694.
7- Thompson MD, Thompson G. Early identi�  cation of hearing loss: listen to parents. Clin Pediatr (Phila) 1991;30:77-80.
8- Swart SM, Lemmer R, Parbhoo JN, Prescott CA. A survey of ear and hearing disorders amongst a representative  sample of grade 1 schoolchildren in Swaziland. Int J Pediatr 
Otorhinolaryngol 1995;32:23-34.
9-  Mourad MI, Farghaly NF, Mohamed HG. Hearing impairment: is it a public health problem among primary school pupils in Alexandria. J Egypt Public Health Assoc 1993;68:703-726.
10- Bess FH, Dodd-Murphy J, Parker RA. Children with minimal sensorineural hearing loss: prevalence, educational performance and functional status. Ear Hear 1998;19:339-354.12 
11- Keller WD, Bundy RS. Effects of unilateral hearing loss upon educational achievement. Child Care Health Dev 1980; 6:93-100.
12- Sowemimo CO. Validation of Slosson's drawing coordination test of brain damage with Nigerian samples. B. Sc Psychology project (unpublished). Lagos: University of Lagos, 1990.
13- Joint Committee on Infant Hearing. Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics 2000;106:
798-817.
14- Saim A, Saim L, Saim S, Ruszymah BH, Sani A. Prevalence of otitis media with effusion amongst pre-school children in N���!
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Tables
Table 1: show affected Kindergarten students with different ear disorders.
Number ofPercent %wax171.4%URTI635.2%ETD181.5%OME282.3%COM40.3%SNHL60.4%
























Figures























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