|Year : 2016 | Volume
| Issue : 3 | Page : 158-162
Tympanometric assessment among a select cohort of deaf students
Iliyasu Yunusa Shuaibu1, Abdulazeez Omeiza Ahmed2, Aminu Bakari1, Mohammed Aminu Usman1
1 Department of Surgery, ENT Unit, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of ENT, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||02-Apr-2016|
|Date of Acceptance||13-Sep-2016|
|Date of Web Publication||19-Sep-2016|
Iliyasu Yunusa Shuaibu
Department of Surgery, ENT Unit, Ahmadu Bello University Teaching Hospital, Shika, Zaria
Background: Children and young adults with profound hearing impairment and/or deafness are equally at risk of developing other ear diseases such as otitis media with effusion (OME) and/or middle ear infections. Otoscopic diagnosis of middle ear effusion is often problematic, and clinicians' skills in that regard are notably variable. The objective of this study is to present the tympanometric findings among hearing-impaired students from a group of special schools for the hearing impaired in Kaduna metropolis. Participants and Methods: This was a prospective cross-sectional study conducted for 4 months between February and May, 2014. Students aged 7-18 years attending Kaduna State Special Education School for the deaf, Katsina road, and Demonstration School for the Deaf, Kawo, Kaduna, were recruited for the study. An interviewer-based questionnaire was developed to capture the student's demographic characteristics and clinical information. This was followed by ear examination and tympanometric tests. The data were analyzed using Statistical Package for the Social Sciences software, version 16. Results: A total of 294 participants were recruited into the study group, and there were 173 males (58.8%) and 121 females (41.2%). The age of the participants ranged from 7 to 18 years. The mean age of the study group was 13.6 years with a standard deviation of 3.6 years. Forty-three (14.6%) of them had dull and retracted tympanic membranes while the rest had intact shiny tympanic membrane. Tympanometric test showed that 281 participants (89.5%) had type A tympanogram while types B and C accounted for 21 (7.1%) and 9 (3.1%), respectively. Among the 43 participants with dull and retracted tympanic membrane via otoscopic examination, 13 had type A tympanogram (normal) while the rest had middle ear disorders (type B and C tympanograms). Conclusion: Middle ear diseases such as OME and eustachian tube dysfunction were found among the study population. There is a need for the provision of regular awareness lecture and periodic ear examination to prevent, detect, and treat imminent otologic diseases.
Keywords: Children, middle ear diseases, school for the hearing impaired, tympanometry
|How to cite this article:|
Shuaibu IY, Ahmed AO, Bakari A, Usman MA. Tympanometric assessment among a select cohort of deaf students. Sub-Saharan Afr J Med 2016;3:158-62
|How to cite this URL:|
Shuaibu IY, Ahmed AO, Bakari A, Usman MA. Tympanometric assessment among a select cohort of deaf students. Sub-Saharan Afr J Med [serial online] 2016 [cited 2019 Oct 17];3:158-62. Available from: http://www.ssajm.org/text.asp?2016/3/3/158/190860
| Introduction|| |
Tympanometry is a simple and objective method of assessing the eardrum with a view to providing useful information about the middle ear cavity, especially to affirm or call to question clinical diagnosis  and sometimes when specialist assessment of eardrum findings is not available. It can also help with determination of middle ear effusions (MEEs), drumhead perforations through measurements of external ear canal volume, and patency of ventilation tubes.
Due to poor health-care systems, especially hearing health care, majority of communication disorders are undetected largely in developing countries.  In these regions, children and young adults with profound hearing impairment and/or deafness are equally at risk of developing other ear diseases such as otitis media with effusion (OME) and/or middle ear infections. Otoscopic diagnosis of MEE is often problematic, and clinicians' skills in that regard are notably variable. , More so, special populations such as hearing-impaired schools are also prone to developing these middle ear problems which can be a major source of morbidity and rarely mortality in a few. 
The prevalence of otologic diseases among normal school children is 75.7%, and out of these, only 10.8% was found to have middle ear disease.  Similarly, a study conducted among the hearing-impaired children in Nigeria reported 51.4% prevalence of other otologic diseases with 18.4% having middle ear disorder.  In these studies, the diagnosis of middle ear disorders was made based on otoscopic findings. This method of diagnosis is often problematic, and clinician's skills in this regard are notably variable.  This is perhaps made more worrisome when pneumatic otoscopy is not included as it increases accuracy. Tympanometry, on the other hand, a component of aural acoustic immittance testing, is a simple, noninvasive procedure that gives objective findings reflecting middle ear status. The procedure is now widely used to assist in determining the presence or absence of OME, particularly among infants and young children.  A tympanogram is a graphical representation of acoustic impedance and air pressure of the middle ear and the mobility of tympanic membrane.  Jerger was the first person to describe the most clinically widespread approach to describing tympanograms in 1970. 
OME is a middle ear disease characterized by the presence of serous or mucoid effusion in the middle ear with intact tympanic membrane and without any signs of acute infection. , It is the most common cause of conductive hearing loss in children.  The etiology of chronic serous otitis media is varied and includes adenoid hypertrophy, infection (viral or bacterial), allergy, environment, and social factors.  OME can be associated with discomfort and a feeling of fullness in the ear. Otoscopic findings in OME are mainly different combination of retraction in the pars tensa and variation in its color which can be more yellow, more bluer, or just clear fluid levels or air bubbles may also be found. 
There is currently a paucity of studies regarding tympanometric measures among vulnerable groups/institutionalized hearing impaired in Nigeria. For the researcher/clinician, the findings from this study will provide a basis for current evidence for the entire spectrum of possible tympanogram types among hearing-impaired persons in our society.
This study, therefore, aims to present the tympanometric findings among hearing-impaired students from a group of special schools for the hearing impaired in Kaduna metropolis.
| Participants and methods|| |
This was a cross-sectional study performed in two schools; a "special education school for the deaf" and "Demonstration School for the Deaf" both in Kaduna metropolis. Children from different parts of the state and neighboring states were enrolled in these schools. The study was conducted over 4 months between February and May, 2014. Ethical approval was obtained from Kaduna State Ministry of Health Research Ethical Review Committee and also from the school authorities as well as the parent-teachers Association.
Two hundred and ninety-four children, aged 7-18 years, were recruited for the study. This was arrived at using Fisher's formula (n = Z2 pq/d 2 ). Using a stratified random sampling technique, a proportional to the sample units was used to allocate the participants to be recruited.
All children 7-18 years of age attending schools for the hearing impaired in Kaduna whose parents/school guardian consented to the study were included in this study.
Students who refused to give consent or cooperate as well as mentally retarded children were excluded from this study.
An interviewer-based questionnaire was developed to capture the student's demographic characteristic such as age and sex. Clinical information included ear pain, aural fullness, tinnitus, and deep-seated headache. Subsequently, ear examination consisting of inspection of the auricle and external auditory canal of both ears was done, and this was followed immediately by otoscopy to visualize the inner aspects of the external canal and tympanic membrane. Students with intact but thickened, dull/opalescent drumheads or drumheads with increased vascularity with or without fluid levels were tentatively labeled as OME, and then later subjected to pneumatic otoscopy and tympanometry for confirmation.
Otoscopic examination was conducted for all children by the investigators using ADC 5210 standard 2.5V otoscope. After that, obstructing cerumen was removed by using a probe or via syringing; these participants were subsequently tested 2 days afterward.
Participants were duly instructed about the test procedure and warned not to move unnecessarily during testing and to avoid speaking or swallowing after the probe-tip has been fitted. Tympanometric testing was then conducted using a probe frequency of 226 Hz and a clean suitably sized probe-tip, with a Class 2 MAICO tympanometer Saizufer, Germany (according to BS EN 60645-5: 2005).
For each participant, the ear canal was straightened by pulling gently on the pinna upward and backward while inserting the probe with rotatory movements. Tracking was commenced at 200daPa. Calibration was checked daily throughout the study, while the performance of the instrument was also checked frequently on an ear with normal characteristics. Participants with congenital ear malformations were, however, excluded from the study.
Data obtained were analyzed using the Statistical Package for Social Sciences (SPSS) software, version 16 (SPPS Inc., Chicago, Illinois, USA). Qualitative data were summarized using frequencies and percentages. Furthermore, statistical tools of mean, standard deviation (SD), Chi-square test, and Fisher's exact test were also used. P ≤0.05 was considered statistically significant.
| Results|| |
Two hundred and ninety-four participants were recruited into the study group, and there were 173 males (58.8%) and 121 females (41.2%) with a M: F ratio of 1.4:1. The age of the participants ranged from 7 to 18 years, and the mean age of the study group was 13.6 years with a SD of ± 3.6.
The age group with the highest number of participants was 15-18 years, accounting for 140 participants (47.6%) and the age group with the lowest number of participants was 7-10 years, accounting for 64 participants (21.8%), as shown in [Table 1].
Otoscopic examination of the participants' ears showed that 43 (14.6%) of them had dull and retracted tympanic membranes while the rest had intact shiny tympanic membrane as shown in [Table 2].
Tympanometric test showed that 281 participants (89.5%) had type A tympanogram while types B and C accounted for 21 (7.1%) and 9 (3.1%), respectively [Table 3]. Type B tympanograms were more frequently observed among the 7-10-year-old age groups. Statistical analysis showed a strong association between age groups and tympanogram types (exact test: P =0.0001).
|Table 3: Pattern of tympanometry by age group among the study population (n=294)|
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Among the 43 participants with dull and retracted tympanic membrane via otoscopic examination, 13 had type A tympanogram (normal) while the rest had middle ear disorders (types B and C tympanograms) [Table 4].
|Table 4: Cross-tabulation of tympanic membrane findings and types of tympanogram|
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| Discussion|| |
This community-based study involved 294 participants attending two major schools for the hearing impaired in Kaduna State. The mean age recorded in this study was 13.6 years, and these were predominantly male students. About 10.2% of our study population had middle ear disease although OME was the most common adjudged middle ear disease seen in 7.1% of the participants.
Hearing-impaired people like the rest of the population are prone to have common ear disorders such as ear infections and MEE.  A comprehensive examination of the ears of these students may lead to identification of conditions predisposing to or associated with preventable ear disease.
Majority of the students who attend schools for the hearing impaired have been shown to be males, and this is in line with the findings of several studies both in our environment and internationally. ,,,,, The high number of males may be due to sociocultural practices as obtainable in parts of northern Nigeria where only few girls have the privilege of acquiring Western education as most of them usually stay at home.  Similarly, it has also been reported that in developing countries, children with hearing loss and/or deafness rarely attend school. 
Majority of the participants in this study were between 15 and 18 years of age. This age group also conforms to that reported by Egeli et al.  We posit that lack of initial awareness, paucity of hearing health care personnel, and specialized centers for early screening and identification of hearing-impaired children in most of our communities may have contributed to the delay in early enrollment at this school. Consequently, it is not unusual to find a hearing-impaired child of 15 years and above attending primary education for the first time as recorded in this study.
Otoscopic examination of the study population showed that most of the participants had intact and shiny tympanic membrane. Dull and retracted tympanic membrane was observed in only 14.6% of the participants. This prevalence is corroborated by the findings of Ahmad et al.  and Elango et al. 
In our study, 30 (10.2%) students had middle ear disorder with 21 (7.1%) having a type B tympanogram. This compares favorably with the studies of Egeli et al.  and Akinpelu and Amusa.  Although our finding is lower than that reported by Naeimeh et al.  and Olusanya et al.,  this may be due to inclusion of much younger children <5 years in their studies in whom incidence of middle ear disease is usually high. OME is known to be the most common cause of hearing loss in children.  Even though it is characterized by a high rate of spontaneous recovery, it is also characterized by a high rate of recurrence as well.  OME has a resolution rate with or without medical treatment of about 22%-30%, 70%, and 90%, at 1, 2, and 3 months, respectively. 
Eustachian tube More Details plays an important role in pressure equalization and ventilation of the middle ear, mucociliary clearance of secretions from the middle ear, and protection of the middle ear from sounds, from pathogens, and secretions from the nasopharynx. 
Eustachian tube dysfunction with type C tympanogram was observed in 9 (3.1%) students in this study. This is lower than the values obtained by Egeli et al.  and Ozturk et al.  This may be due to a high incidence of respiratory tract infections found among their participants.
Inability to use a soundproof booth to conduct pure tone audiometry is a limitation as this would have helped to relate audiometric findings with tympanometric results. As with many cross-sectional studies, a cause-effect relationship cannot be established from this study as well as making room for confounding variables.
| Conclusion|| |
Middle ear diseases such as OME and eustachian tube dysfunction were found among our study population. This, however, underscores the need to provide facilities for ear examination in the schools for the hearing impaired to be run by hearing health-care professionals and/or ear, nose, and throat specialist who will ensure proper screening of new students, periodic examination of student's ears, and provision of regular awareness lectures to prevent, detect, and treat imminent otologic diseases.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]