In 1999, MMO’s Audiology initiative was convened to provide basic audiology testing for the residents of the Department of Jinotega. At that time, testing was conducted in a quiet room with a portable audiometer, and over the years, a multi-faceted program has evolved.The lack of available audiological services and the high incidence of hearing loss in the region led us to set our goal to provide a comprehensive diagnostic and rehabilitative program.To meet this goal, an ENT and audiology suite was established in the Eye clinic adjacent to the Victoria Motta Hospital in Jinotega. A two-room sound treated booth was constructed, housing state of the art diagnostic audiological equipment which includes a diagnostic audiometer, an impendance bridge, soundfiled speakers and COR set-up and a real-ear analyzer. This equipment, obtained through donations, enables adults and children as young as six months old to be tested.
There are three annual mission trips in which audiologists from across the United States participate. Patients from Jinotega and the surrounding communities are seen in tandem with the MMO Otolaryngologists and Dr. Ernesto Moreno, a Nicaraguan Otolaryngologist who holds a permanent full-time position at the hospital and ENT clinic. The services provided are:
- comprehensive audiological evaluations (to diagnose the degree and type of hearing loss)
- hearing aid fittings (new analog programmable and digital behind the ear models)
- custom-fitted earmold (made in a lab in Managua) that is coupled to the hearing aid
- bone conduction hearing aid fittings (when a conventional hearing aid cannot be worn due to an external ear and/or ear canal deformity)
- one year supply of hearing aid batteries (which can be replenished at the ENT clinic)
- instruction concerning the use and care of the hearing aid and speechreading strategies for patients and their family members
- Supplemental written materials to augment the counseling process
MMO follows the World Health Organization Guidelines for the fitting of hearing aids, which extends to children and adults of all ages. Children are fitted with a hearing aid when they have at least a mild hearing loss in their better hearing ear and for adults, the hearing aid fitting takes place when their better hearing ear has at least a moderate loss of hearing. Those with profound hearing loss are referred for communication via sign language. (www.who.int/pbd/deafness). For those able to contribute, a very small monetary donation is requested at the time of the hearing aid fitting. It is MMO’s belief that people are empowered by ownership and will ultimately take better care of their possessions. Since a high percentage of our patients travel great distances to our clinic, every attempt is made to provide comprehensive services.
Since the program’s inception, approximately 800 hearing tests have been administered and 336 hearing aids have been dispensed. This number continues to increase each year; for example, 27 hearing aids were dispensed in 2007, 50 in 2008 and 63 in 2009.
MMO recognizes maintaining a sustainable program requires audiological testing and ancillary hearing aid services to be provided year round. To meet this need, MMO has trained and supports the position of a Nicaraguan audiometric technician, William Sirias Guerrero, who provides services in the ENT clinic. William administers diagnostic audiometric tests, takes earmold impressions for custom-made earmolds, counsels the patients on the use and care of their hearing aids, troubleshoots hearing aid problems, and replenishes hearing aid batteries. He also assists with coordinating the mission trips and maintains close communication with the MMO audiologists. William provides an invaluable service for MMO.
When children are fitted with hearing aids, they are referred for aural habilitation/rehabilitation and speech therapy services at Los Pipitos, a Nicaraguan NGO formed by parents of children with varying handicaps, including hearing impairment. Los Pipitos is a national organization, with headquarters in Managua but with branches nationwide, including Jinotega (www.lospipitos.org). It is MMO’s firm belief that fitting a hearing aid on a child must also include these services, the scope of which varies depending on the child’s age, hearing loss level, and auditory and verbal skills. MMO collaborates with Los Pipitos, both in Managua and in Jinotega.
So many Nicaraguans obtain their healthcare randomly, latching on to whatever is available at any given moment. To illustrate: a 19 year old woman from Matagalpa (one hour from Jinotega), accompanied by her mother, was seen for audiology testing at the Jinotega ENT clinic in July 2009. She communicated perfectly well by speaking yet she also used sign language. Her audiology test revealed that she had a moderate (or partial ) hearing loss. In early childhood she received a donated hearing aid from a mission trip, which enabled her to develop good spoken language skills and attend a regular classroom. When her hearing aid malfunctioned six years later and there was no replacement to be found, she could no longer manage in the regular classroom and therefore enrolled in the sign language classroom. Seven years later she learned of MMO’s presence, received a hearing aid, and was now able to return to the hearing world.
We hope that our contribution will enable the residents of Nicaragua to receive audiologic care in a systematic and reliable fashion from the professionals in their own community, with ongoing support from MMO.
Read more about Hearing Screenings of School-Age Children, Albergue Mayflower Certified Audiometric Technician Training ProgramCertified Speech Therapist Training ProgramChallenges/Future Goals
AUDIOLOGICAL GUIDELINES FOR THE ALBERGUE MAYFLOWER
All children admitted to the Albergue Mayflower use Nicaraguan Sign Language (NSL) as their primary mode of communication. The children who have some residual hearing may be able to develop some listening, speaking and speechreading skills with the use of amplification in conjunction with auditory training/speech and language therapy. Listening skills may encompass the ability to hear and distinguish warning signals, environmental sounds, some vowel and consonant sounds, words and simple sentences, which may also aid in the development of some ability to lipread Spanish. These abilities may also bolster the child’s literacy skills by improving the child’s reading and writing levels. All children are unique, progressing at their own pace, and some will ultimately acquire more of these skills than others.
In addition to the use of amplification, the auditory training/speech and language therapy services which will be provided at Los Pipitos are a critical component in the development of these abilities. At this juncture, these services provided by Los Pipitos are in their nascent stage. Mayflower Medical Outreach has set a goal to strengthen these speech therapy services by initiating an academic and clinical training program. Additionally, Dr. Natalia Popova, speech therapist based in Managua, will be providing ongoing training to the staff at Los Pipitos.
As the primary caregivers of the children in the Albergue Mayflower, the house staff needs to be educated, informed and involved in all aspects of the child’s hearing care. Of equally critical importance is the notification, education and involvement of the child’s parents in this process as well. The child fitted with a hearing aid also needs to understand the rationale and, depending on their age, will be able to assume varying levels of responsibility for the care of their hearing aid. Likewise, the children not fitted with hearing aids need to understand the rationale for that decision.
Upon Admission: Audiological evaluation (audiogram, tympanogram)
Annually: Repeat audiological evaluation (as above)
Hearing Aid Fitting Protocol:
- Residual hearing better than or equal to 80dB in at least two frequencies, starting at 250 Hz
- Fitted with a monaural Behind The Ear hearing aid
- Provided with a custom-made earmold
- Children <10 years old may need a new earmold every six months
- Children > 10 years old may need a new earmold annually
- Provided with a one year supply of batteries (given to Georgina)
- Counseling, expectations and use/care explained at the time of the fitting by the MMO audiologist and William
- Hearing aid verification to assess appropriateness of the fitting when the custom-made earmold is received (soundfield testing and/or real-ear measures)
- Annual hearing aid verification (at the time of the annual audiological evaluation)
- Battery supply replenished annually
Hearing Aid Maintenance: William will provide weekly listening checks of the hearing aids and will check that the earmolds are free of cerumen. This will be conducted at the Albergue Mayflower, after school hours. This will be done in exchange for one hour per week of William’s ENT clinic time.
Los Pipitos: All children fit with a hearing aid will be referred to Los Pipitos for auditory training and speech and language therapy. A minimum of three hours per week of therapy would be appropriate.
The child should be encouraged to wear their hearing aid on a daily basis during their waking hours. However, after a six month period of consistent hearing aid use and Los Pipitos therapy services, should the child choose not to wear their hearing aid, they should not be forced to. At that time, William should be notified to determine that the issue is not one of comfort or of a modification that could be made to the hearing aid. In the absence of the aforementioned, the hearing aid should be returned to the ENT clinic.
In-service training of the Albergue Mayflower housestaff: This will be the responsibility of the Mayflower Medical Outreach audiologist and William.
Parental notification/counseling/training: This will be the responsibility of Georgina, the Mayflower Medical Outreach audiologist, William and Marwell.
Counseling the children of the Albergue Mayflower: This will be the responsibility of Georgina, the Mayflower Medical Outreach audiologist, William and Marwell.
A spreadsheet will be developed to track all of the children, their tests, their hearing aids and their follow-up.