226. CCA Study Notes: Ear Disorders, Hearing Impairment, and Supporting Clients

The Big Picture

The ear helps a person hear and keep their balance. Problems with the ear range from mild hearing impairment to complete deafness.

Hearing changes often develop slowly, so a person might not notice them right away. As a CCA, you also need to know how hearing problems affect communication, safety, social life, and the way you support a client.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

Hearing Impairment Basics

The ear supports both hearing and balance. Hearing impairment ranges from slight difficulty hearing to complete deafness.

Aging and long-term exposure to loud noise are the most common causes. Other causes include accidents, illness, certain drugs or chemicals, and genetics that cause hearing impairment at birth.

Hearing impairment sometimes begins suddenly, but it usually develops gradually. It can affect one ear or both ears.

Protecting Hearing

Ear protection should be used around loud machinery, including lawn mowers.

Loud music can also damage hearing over time. Children, teenagers, and young adults who listen to music at high volume through car stereos or earphones can develop hearing impairment later.

Common Ear Disorders and Causes of Hearing Impairment

Otitis Media

Otitis media is an infection of the middle ear. It is common in infants and children and can be acute or chronic.

The Eustachian tube normally allows fresh air into the middle ear and lets fluid drain out. A cold or flu, enlarged adenoids or tonsils, or an allergy such as hay fever can block this tube and lead to otitis media.

In very young children, acute otitis media can cause:

• irritability
• poor appetite
• ear pain

These signs can be mistaken for teething or fever, so the infection can go unnoticed.

With chronic otitis media, fluid slowly collects in the middle ear. The fluid becomes thick and harder to drain.

Chronic otitis media can damage:

• the eardrum
• the ossicles, which are the bones of the middle ear that conduct sound toward the inner ear

Permanent hearing impairment can result.

Otosclerosis

Otosclerosis involves abnormal bone formation and hardening in the middle ear. It interferes with the movement of the stapes ⓘ and with the transmission of sound.

The condition develops gradually and causes progressive hearing loss. It is hereditary ⓘ and is a common cause of hearing impairment and tinnitus, which means ringing in the ear, in adults.

Surgery often restores some hearing.

Ménière’s Disease

Ménière’s disease is an inner-ear disorder involving increased fluid. The increased fluid causes pressure in the middle ear. The disorder can affect hearing and balance.

Possible effects include:

• vertigo, which means dizziness
• tinnitus
• hearing impairment
• nausea and vomiting when dizziness is severe

Usually, only one ear is affected.

Safety: A client who experiences dizziness must lie down to prevent a fall.

Presbycusis

Presbycusis is the gradual hearing impairment associated with aging. It usually begins after age 50 years.

There is no cure. Hearing aids and speech reading, also called lip reading, can help.

Temporary Hearing Impairment From Cerumen

Cerumen means ear wax. A buildup of cerumen can block the ear canal and cause temporary hearing impairment.

This problem is common in older persons. Cerumen buildup can also cause a gradual loss of balance.

A physician or nurse can remove the cerumen, which can improve both hearing and balance.

Avoid: Encourage the client to let cerumen leave the ear naturally rather than cleaning the ear canal with cotton swabs. Cotton swabs can irritate the canal, increase cerumen production, and potentially perforate ⓘ the eardrum.

Signs and Effects of Hearing Impairment

Hearing impairment does not always look obvious. A person’s behaviour or attitude can change when hearing becomes difficult.

For example, the person might not answer when someone speaks or asks a question. The person might also become angry because they believe others are not speaking loudly enough.

Family and friends might not realize hearing impairment is causing the communication problem. They can become frustrated and begin avoiding conversation with the person.

Some people deny their hearing impairment. They might not want to feel different from others or accept a change associated with aging. Some people also refuse to get or wear a hearing aid.

Signs to Notice

More obvious signs in adults and children include:

• speaking too loudly
• leaning forward to hear
• turning and cupping the unaffected ear toward the speaker
• responding inappropriately
• asking people to repeat words

Effects on the Whole Person

Hearing impairment can affect physical, emotional, social, intellectual, and spiritual health.

It can also affect speech. A person who cannot hear their own voice clearly can have difficulty with pronunciation and voice volume.

Possible speech changes include:

• slurred speech
• faulty pronunciation
• a flat tone
• dropping word endings

Some people with severe hearing impairment cannot speak.

The Canadian Hearing Society is a resource for clients, families, and support workers. It offers information, educational material, and aids for people with hearing impairment.

Aids for Hearing Impairment

Different aids help people communicate and respond to their environment. These include:

• hearing aids
• special telephone systems
• signalling devices
• service dogs

Hearing Aids

A hearing aid fits inside the ear, behind the ear, or in the ear canal. It makes sounds louder.

A hearing aid does not cure hearing impairment.

Key fact: Hearing aids make both speech and background noise louder. They make speech louder, not clearer.

Reducing background noise helps the client adjust to the hearing aid.

Handling Hearing Aids Carefully

A hearing aid can cost up to $5 000 per aid. Dropping one can damage it and create a major expense for the client or family.

Follow your supervisor’s instructions for hearing-aid care.

Report: Tell your supervisor if a hearing aid is missing or damaged.

Make sure the client’s name appears on both the hearing aid and its container.

Modern Hearing-Aid Features

Most modern hearing aids support links to smartphones that transmit conversations through the hearing aids.

Other devices connect a television directly to hearing aids. Some hearing aids also use rechargeable batteries that recharge in a case without removing the batteries.

Regular Hearing-Aid Care

Regular care includes several checks.

Storage and Damage Checks

• Store hearing aids somewhere safe, dry, and cool.
• Check for cracks, broken parts, blocked openings, and moisture droplets.
• Handle the hearing aid carefully to prevent damage.

Battery Care

Check that the battery works. One method involves turning on the hearing aid, holding it in your cupped hand, and listening for a whistle.

Some hearing aids turn on or off when the battery chamber opens.

Check batteries regularly so they do not unexpectedly lose power.

• Discard dead batteries appropriately.
• Switch off the battery when the hearing aid is not being used.
• Remove the battery when the hearing aid will not be used for a long time.
• Clean battery contacts regularly with a cotton swab.
• Check that battery contacts are not bent.

Cleaning the Hearing Aid

The type of hearing aid determines its daily care.

Follow the care plan: The care plan tells you what care the hearing aid needs and which tools to use.

Some hearing aids must not be washed. Others need washing each time they come out of the ear.

Hearing aids that sit inside the ear can collect cerumen. Remove cerumen from the hearing aid to prevent temporary malfunction or permanent damage. Change filters often enough to prevent buildup of cerumen or dirt.

Hearing aids worn around the ear can become clogged when hair products are used while the client is wearing them.

If you cannot fully clean the hearing aid, the supervisor or client might need help from a hearing professional.

Protecting the Hearing Aid From Moisture and Sprays

Unless the manufacturer ⓘ permits it, the client should not wear a hearing aid while:

• showering
• swimming
• using a hair dryer

The client should also avoid hair spray and other sprays while wearing the device.

Cerumen in the Ear Is Different From Cerumen on the Hearing Aid

Cerumen buildup inside the ear can prevent sound from travelling from the hearing aid into the middle ear.

Safety: The client should never remove cerumen from the ear because this can damage the ear. The client’s doctor should be contacted to have the ear canals cleaned.

Troubleshooting a Hearing Aid

These are possible remedies for common hearing-aid problems. Follow your supervisor’s instructions and the care plan for the hearing-aid care you provide.

The Hearing Aid Is Not Working

Possible causes and responses include:

• Not switched on: Move the MTO switch to M.
• Weak or dead battery: Replace the battery.
• Battery inserted with reversed polarity: Insert the battery correctly.
• Blocked ear mould: Clean the ear mould.
• Receiver opening blocked with cerumen: Clean the receiver opening.
• Volume too low: Increase the volume.

The Hearing Aid Whistles

Possible causes and responses include:

• Hearing aid not seated properly: Insert it correctly.
• Volume too high: Reduce the volume.
• Too much cerumen in the ear: A doctor, or a nurse acting on a doctor’s order, removes the cerumen.
• Loose ear mould: A new ear mould requires an appointment with a hearing-aid dispenser.
• Internal feedback: The hearing aid needs factory repair.

The Volume Comes and Goes

Possible causes and responses include:

• Weak battery: Replace the battery.
• Poor battery contact: Clean the contacts.
• Intermittent on switch: Clean the switch.
• Moisture: Blow moisture out of the ear mould.
• Damaged internal parts: The device needs factory repair.

The Sound Is Too Quiet or Distorted

Possible causes and responses include:

• Volume too low: Increase the volume.
• Weak battery: Replace the battery.
• Loose ear mould: A new ear mould requires an appointment with a hearing-aid dispenser.
• Blocked ear mould: Clean the ear mould.
• Too much cerumen in the ear: A doctor, or a nurse acting on a doctor’s order, removes the cerumen.
• Change in hearing: The possible remedy is an appointment for a hearing test.

Cochlear Implants

A cochlear implant is a medical device that improves hearing for people with significant hearing impairment who do not benefit from regular hearing aids.

It has two main parts:

1. An implant placed inside the inner ear during surgery.
2. A sound processor worn behind the ear.

How a Cochlear Implant Works

The process follows this order:

1. The sound processor picks up and filters sounds.
2. The processor changes those sounds into digital information and sends the information to the internal implant.
3. The implant changes the digital information into electrical signals and sends them to electrodes inside the cochlea.
4. The electrodes stimulate the hearing nerve. This bypasses the damaged cells causing the hearing impairment and allows the brain to hear sound.

Adult Requirements for a Cochlear Implant

Adults must meet a minimum set of requirements:

• be 18 years of age or older
• have severe-to-profound sensorineural hearing impairment in both ears
• have little or no understanding of speech, even with well-fitted hearing aids
• communicate mainly through spoken language
• have realistic expectations
• be strongly motivated and committed to being part of the hearing world
• have no medical contraindications to the procedure

Requirements for Children

Children from 12 months to 17 years must also meet minimum requirements:

• be at least 12 months old
• have severe-to-profound sensorineural hearing impairment
• have received limited benefit from a binaural amplification trial
• have no medical contraindications to a cochlear procedure
• attend an appropriate educational program that emphasizes auditory and oral skill development when old enough
• both the child and family must have good motivation and realistic expectations about the implant

Auditory Processing Disorder

An auditory processing disorder (APD) affects the way heard information is understood.

A child or adult with APD can have normal hearing ability but experience a disconnect between hearing a sound and understanding it. The brain interprets the sound as though it is delayed or distorted.

APD can make:

• listening difficult
• learning difficult
• memorization difficult

A routine hearing test does not identify APD. Advanced testing is needed for a diagnosis.

Therapeutic approaches and support groups are available for people who believe they have APD and need help.

Technology for Hearing Assistance

Several types of technology support people with hearing impairment.

Enhanced Headphones

Enhanced headphones make people’s voices louder. Some also work for television or music.

Telephone Systems and Applications

TTYs, once called telephone teletypes, let people with hearing impairment type messages back and forth through a landline telephone system.

Other options include:

• amplified telephone handsets that make the caller’s voice louder
• extension bells that make the telephone ring louder
• Bluetooth features that stream television and cell-phone audio through newer hearing aids

Signalling Devices

Signalling devices connect to equipment such as:

• telephones
• doorbells
• smoke alarms

When the equipment makes a sound, a light flashes. Some devices also vibrate.

Email and Text Communication

Email and text messaging through computers and cell phones support communication between people with hearing impairment and people who hear.

Speaking computer software programs are another available option.

Closed Captioning

Closed captioning displays television dialogue as written words on the screen.

Since 1993, all televisions with screens larger than 33 cm (13 inches) have included built-in decoder circuitry for closed captioning.

Service Dogs

Service dogs can alert a person with hearing impairment to sounds such as:

• a ringing telephone
• a doorbell
• an alarm
• a crying baby

Supporting Clients With Hearing Impairment

Clients use different ways to manage hearing impairment.

Some wear hearing aids. Others have hearing impairment that hearing aids do not improve. Some choose not to use a hearing aid or feel unable to afford one.

Other clients use:

• sign language
• service dogs
• speech reading by watching facial expressions, gestures, and body language

A client who has gradually lost hearing might not realize how much their hearing has changed.

Communication difficulties can cause frustration and embarrassment when a client repeatedly asks others to repeat themselves. Some clients begin avoiding social situations, which increases isolation.

Safety Risks

A client with significant hearing impairment might not hear a smoke alarm, a whistling kettle, or another sound that warns of danger.

All health care team members share responsibility for keeping the client safe.

Some clients with hearing impairment also have speech or language disorders.

Get the Client’s Attention First

Before speaking:

• alert the client that you are present
• get the client’s attention
• raise your arm or hand, or lightly touch the client’s arm when needed

Avoid: Do not startle the client or approach from behind.

Make Your Face Easy to See

Use good lighting. The client might need to see your face for speech reading.

Shadows and glare can make your face harder to see.

Face the client while speaking. Stand or sit on the side of the unaffected ear.

Do not turn away, walk away, or perform another task while you are talking to the client.

Reduce Background Noise

When possible, reduce or turn off background sounds such as:

• radios
• televisions
• air conditioners
• fans

This makes communication easier when other sounds interfere.

Speak Clearly

Use a normal tone. Speak slowly and clearly.

Do not shout.

Do not cover your mouth while speaking because the client might need to watch your face.

Check Communication Aids

Make sure the client has any needed:

• hearing aids
• eyeglasses
• contact lenses

Help the client put on these aids when necessary.

Vision aids matter because a client who speech reads needs to see your face.

Adjust Your Language

State the topic clearly.

Use simple words and short sentences. Focus on important words.

Learn what works for the individual client. If the client does not understand, try expressing the message another way.

Use Other Communication Methods When Needed

Speech does not always work.

Other methods include:

• body language and other nonverbal communication
• writing key words on paper
• closed captioning for television

Ensure the client has access to closed captioning whenever they watch television.

Watch for Fatigue

Watch for signs that communication is tiring the client.

Examples include:

• drooping shoulders
• declining understanding

Avoid exhausting the client.

If you use sign language, signing for only 30 minutes at a time is recommended to avoid tiring the client.

Observe, Report, and Document Environmental Hazards

Watch for devices that depend on sound to alert the client.

Examples include:

• telephones
• alarm clocks
• doorbells
• stove timers
• kettle whistles

These devices might not be suitable for a client who cannot hear the sound.

Report: Tell your supervisor about these environmental hazards.

Document: Record your observations.

Common Mix-Ups

Wrong Idea	Better Idea
A hearing aid makes speech clearer.	A hearing aid makes speech louder, not clearer.
Cerumen should be removed from the ear with cotton swabs.	Let cerumen leave naturally. If buildup needs removal, a physician or nurse removes it.