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GROWING BURDEN OFGROWING BURDEN OF
HEARING DISABILITY INHEARING DISABILITY IN
PAKISTAN –PAKISTAN –
ITS CAUSESITS CAUSES
DR. GHULAM SAQULAINDR. GHULAM SAQULAIN
M.B.B.S., D.L.O., F.C.P.SM.B.B.S., D.L.O., F.C.P.S
Head of E.N.T DepartmentHead of E.N.T Department
Capital HospitalCapital Hospital
ISLAMABADISLAMABAD

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Never to see the face of a loved one norNever to see the face of a loved one nor
witness a summer sunset is indeed awitness a summer sunset is indeed a
handicap. But I can touch a face and feel thehandicap. But I can touch a face and feel the
warmth of the sun. But to be deprived ofwarmth of the sun. But to be deprived of
hearing the song of the first spring robin andhearing the song of the first spring robin and
the laughter of children provides me with athe laughter of children provides me with a
long and dreadful sadness_long and dreadful sadness_
Helen KellerHelen Keller
The Story of My Life, 1902The Story of My Life, 1902

4. ABSTRACABSTRAC
TT
Pakistan is an important Muslim Asian Country with anPakistan is an important Muslim Asian Country with an
area of 3,10,403 sq. miles and a population of 140area of 3,10,403 sq. miles and a population of 140
million. According to census report 1998, 9 % of totalmillion. According to census report 1998, 9 % of total
population is disabled and according to WHO survey,population is disabled and according to WHO survey,
10% of total population is suffering from one or other10% of total population is suffering from one or other
disability. Hearing impairment accounts for 9% ofdisability. Hearing impairment accounts for 9% of
disabilities.disabilities.
Based on a retrospective study of data collectedBased on a retrospective study of data collected
at National Institute for Handicapped, the articleat National Institute for Handicapped, the article
highlights the causes of increasing burden of hearinghighlights the causes of increasing burden of hearing
disability and handicap in Pakistan.disability and handicap in Pakistan.
(Key Words: Hearing Disability, Handicap)(Key Words: Hearing Disability, Handicap)

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Normal HearingNormal Hearing
Outer and middle Ear:
 Any abnormality or disease
could result in conductive
hearing loss,
Inner Ear:
 Abnormality or disease would
result in Sensory Hearing loss,
Cochlear nerve and auditory
centres:
 Abn. or disease would result
in Neural hearing loss,
INTRODUCTIO
N

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• Normal brain development in babies and young children relies onNormal brain development in babies and young children relies on
stimulation of the brain from sensory input: eyesight, hearing, taste,stimulation of the brain from sensory input: eyesight, hearing, taste,
smell and touch.smell and touch.
• Children born with a hearing impairment face great difficulty inChildren born with a hearing impairment face great difficulty in
learning to speak. During the first 4 years of life, children learn tolearning to speak. During the first 4 years of life, children learn to
mimic and recognize different sounds, respond to voices andmimic and recognize different sounds, respond to voices and
develop speech and language skills.develop speech and language skills.
• If a hearing loss remains undetected during these vital learningIf a hearing loss remains undetected during these vital learning
years, emotional and personal development is delayed, speech andyears, emotional and personal development is delayed, speech and
language are restrained, and learning disabilities may develop. Alanguage are restrained, and learning disabilities may develop. A
prolonged hearing loss, may lead to speech delays, lowerprolonged hearing loss, may lead to speech delays, lower
intelligence, and reading delays that can be permanent even afterintelligence, and reading delays that can be permanent even after
the hearing loss is corrected. Thus a hearing loss in a child aged 1-the hearing loss is corrected. Thus a hearing loss in a child aged 1-
3 years will have a far greater impact on the child than the same3 years will have a far greater impact on the child than the same
degree of hearing loss at a later age. These outcomes can bedegree of hearing loss at a later age. These outcomes can be
prevented by early diagnosis and intervention.prevented by early diagnosis and intervention.
INTRODUCTIO
N

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• Hearing Impairment is thus a major cause of disability andHearing Impairment is thus a major cause of disability and
handicap in developing countries. One of the main deficiencies inhandicap in developing countries. One of the main deficiencies in
the field is the absence of authentic epidemiological data in thethe field is the absence of authentic epidemiological data in the
developing countries, so much so that no concensus has beendeveloping countries, so much so that no concensus has been
reached regarding the etiology, prevention, treatment andreached regarding the etiology, prevention, treatment and
rehabilitative strategies.rehabilitative strategies.
• The data on the global magnitude of the problem is scarce, recentThe data on the global magnitude of the problem is scarce, recent
data relates that there are around 300 million people with disablingdata relates that there are around 300 million people with disabling
Hearing Impairment in the world R-1, compared to previousHearing Impairment in the world R-1, compared to previous
estimates of 100 to 120 million. However a matter of seriousestimates of 100 to 120 million. However a matter of serious
concern is that it continues to affect a vast population of developingconcern is that it continues to affect a vast population of developing
world especially children, where the problem is on the rise.world especially children, where the problem is on the rise.
INTRODUCTIO
N

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• Detection of Hearing impairment and pathologies before they resultDetection of Hearing impairment and pathologies before they result
in hearing disability and social handicap and rectify them at grassin hearing disability and social handicap and rectify them at grass
root level is essential for developing countries like Pakistan, withroot level is essential for developing countries like Pakistan, with
limited resources.limited resources.
• The processes by which Hearing impairment and pathologiesThe processes by which Hearing impairment and pathologies
ultimately result in development of Hearing Disability and Handicapultimately result in development of Hearing Disability and Handicap11
..
Relates to wide range of pathologiesRelates to wide range of pathologies 22
.The processes may be.The processes may be
influenced by a number of factors :influenced by a number of factors :
Late DetectionLate Detection
Poor Service IntegrationPoor Service Integration
InfectionsInfections
Genetic predispositionGenetic predisposition
Pre maturityPre maturity
TraumaTrauma
Birth HypoxiaBirth Hypoxia
ToxicityToxicity
ConvulsionsConvulsions

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METHODSMETHODS
• A Retrospective analysis of data collected at the E.N.TA Retrospective analysis of data collected at the E.N.T
Department, National Institute for Handicapped wasDepartment, National Institute for Handicapped was
performed.performed.
• The study included all cases of Hearing Impairment/ Disability/The study included all cases of Hearing Impairment/ Disability/
Handicap who visited the department from 1Handicap who visited the department from 1stst
.January 1998 to.January 1998 to
1212thth
Dec. 2000.Dec. 2000.
• Cases of senile deafness (Presbycusis were excluded fromCases of senile deafness (Presbycusis were excluded from
the study).the study).
• Total number of cases included in the study was five hundredTotal number of cases included in the study was five hundred
thirty seven (n = 537). These were cases who presented atthirty seven (n = 537). These were cases who presented at
NIHd with Hearing or other impairment or disability and wereNIHd with Hearing or other impairment or disability and were
subjected to E.N.T examination and audiological testing.subjected to E.N.T examination and audiological testing.

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• Audiological testing was performed by a qualifiedAudiological testing was performed by a qualified
audiologist, using Siemen’s Diagnostic Audiometer withaudiologist, using Siemen’s Diagnostic Audiometer with
facility of Free Field testing as well.facility of Free Field testing as well.
• In few cases BERA was obtained.In few cases BERA was obtained.
• Tympanometry was essentially performed in cases withTympanometry was essentially performed in cases with
suspected middle ear problems like OME.suspected middle ear problems like OME.
METHODMETHOD
SS

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RESULTRESULT
SS
• Retrospective analysis of data of 537 hearing impairedRetrospective analysis of data of 537 hearing impaired
patients including 327 males and 210 femalespatients including 327 males and 210 females
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Percentage
Males Females
Gender
Percentage Distribution of Gender of Patients

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First presentation of patients includedFirst presentation of patients included
in the studyin the study
0 50 100 150 200 250 300 350
Speech
Impaired/Handicap
Multiple
Impairments/Handicap
Hearing Impaired
alone
No. of Cases
No. of Cases
340 Patients presented with Hearing and Speech Impairment, while
29 showed multiple handicaps. Only 168 cases cases with HI alone.

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Distribution of patients according toDistribution of patients according to
province of originprovince of origin
NO. OF PATIENTS
N.W.F.P
A.J.K
Baluchistan
Punjab
Poor service integration was noted as services were
mainly utilized by a single province because of one
reason or the other,

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Distribution of Patients according to Age ofDistribution of Patients according to Age of
PresentationPresentation
Distribution of hearing impaired children according to age of presentation
is shows in fig., which shows that very few cases presented before three
years of age i.e., hardly 10% which was responsible for the increasing
disability.
5%
24%
23%
43%
5%
Less than 1 year
1.1 to 3 Years
3.1 to 5 Years
5.1 to 18 Years
Above 18 Years

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0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00%
Percentage
Late Presentation (After 3 Years)
Offsprings of First Cousins
Prenatal CM V
Prenatal Rubella
Prenatal Ototoxic Drug Exposure
Birth Hypoxia
Prematurity
Low Birth Weight
Forceps Delivery
Delivery via C/Section
Neonatal Jaundice
M eningitis
Typhoid
High Grade Fever
M umps
M easles
Trauma
Noise Trauma
OM E
Discharging Ears
Ototoxic drug intake
Cause/RiskFactor
Breakdown of
causes/risk factors
responsible for
increasing burden
of hearing
disability and
handicap.

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CONCLUSIOCONCLUSIO
NN
• Identification of possible causes responsible forIdentification of possible causes responsible for
increasing the hearing disability and handicap is ofincreasing the hearing disability and handicap is of
utmost importance especially for formulation ofutmost importance especially for formulation of
evaluation, treatment and rehabilitation strategies.evaluation, treatment and rehabilitation strategies.
• The Common Causes of Increasing Burden of HearingThe Common Causes of Increasing Burden of Hearing
disability and Handicap noted in this study were:disability and Handicap noted in this study were:
 Late Presentation and lack of neonatal screening.Late Presentation and lack of neonatal screening.
 ConsanguinityConsanguinity
 OMEOME

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• Most of the causes are either:Most of the causes are either:
Preventable through immunization, early diagnosisPreventable through immunization, early diagnosis
and treatment of OME and ear infections andand treatment of OME and ear infections and
avoidance of ototoxic drugs so that disease/avoidance of ototoxic drugs so that disease/
impairment do not occur.impairment do not occur.
Other pathologies/ impairments may be contained byOther pathologies/ impairments may be contained by
early diagnosis esp. neonatal screening andearly diagnosis esp. neonatal screening and
intervention at an early age to prevent developmentintervention at an early age to prevent development
of disability or handicap.of disability or handicap.
• Lack of Neonatal Screening and Late presentation ofLack of Neonatal Screening and Late presentation of
cases with hearing pathologies and impairments is thecases with hearing pathologies and impairments is the
root cause of increasing burden of hearing disability androot cause of increasing burden of hearing disability and
handicap. Not only is it resulting in delayed diagnosishandicap. Not only is it resulting in delayed diagnosis
and wastage of resources but also easily treatableand wastage of resources but also easily treatable
conditions like Otiits Media and CSOM are resulting inconditions like Otiits Media and CSOM are resulting in
hearing disability and handicap.hearing disability and handicap.

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THE LEEDS CASTLETHE LEEDS CASTLE
DECLARATIONDECLARATION
““Avoidable disability with all its consequences inAvoidable disability with all its consequences in
human suffering and economic loss need nohuman suffering and economic loss need no
longer be an inescapable part of our humanlonger be an inescapable part of our human
predicament. It’s prevention on an unprecedentedpredicament. It’s prevention on an unprecedented
scale and at an acceptable cost is one of thescale and at an acceptable cost is one of the
options which are now available to theoptions which are now available to the
international community.”international community.”

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In children 1-6 years of age, at any one point in timeIn children 1-6 years of age, at any one point in time
5-10 % of children have OME in both ears and 20% in5-10 % of children have OME in both ears and 20% in
single ear. In children with persisting OME after 7single ear. In children with persisting OME after 7
years are at very high risk of developing complicationsyears are at very high risk of developing complications
of OME and becoming handicapped.of OME and becoming handicapped.

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Several NGO’s have taken up deafness and hearingSeveral NGO’s have taken up deafness and hearing
impairment on their main agenda like Hearingimpairment on their main agenda like Hearing
International, Impact Foundation, Dewa Academy,International, Impact Foundation, Dewa Academy,
Lions Club and so many others.Lions Club and so many others.

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REFERENCESREFERENCES
World Health Forum: Prevention of deafness andWorld Health Forum: Prevention of deafness and
hearing impairment, 1993, 14,No 1, 1:12 WHOhearing impairment, 1993, 14,No 1, 1:12 WHO
Geneva.Geneva.

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