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Audiological Finding in High-Risk Child (Meningitis)
- 1. Clinical Conference 2078 Audiology and Speech Language Pathology Unit Maharajgunj Medical Campus
- 2. A Case Study on Audiological Findings in High Risk Child Presented By: Ambrish Tiwari BASLP 3rd Year MMC, IOM
- 3. All newborn infants can be classified into 1 of 3 groups: (Prof. David Woods) 1. Well infants. 2. High-risk infants. 3. Sick infants. What is a High Risk Child?
- 4. Infants with biological or environmental risk factor that put them at increased risk for developmental disability. (M C Allen) Some Risk Factor : intraparenchymal hemorrhage, periventricular cysts, encephalomalacia, Meningitis. What is a High Risk Child?
- 5. 1. Maternal age <16 or >40 years 2. Past Medical History of mother (genetic disorder, Diabetes Mellitus, Hypertension, rheumatologic illness, Immune – Medicated Diseases, TORCH, etc) 3. Pre term (<36 weeks) or Post term (>42 Weeks) 4. Breach Delivery, 5. Meconium Aspiration, 6. Nuchal Cord 7. Cesarean Section, Forceps Delivery 8. APGAR Score <4 at 1 min. Infants regarded as high risk?
- 6. 9. Birth weight <2500 or >4000 gm (Khalid Shehzad, 2011) 10. Respiratory distress, cyanosis 11. Congenital Malformation 12. Pallor, Plethora, petechiae. 12.Infants who were sick but have now recovered (Jaundice, Meningitis, Encephalitis, measles, mumps, chicken pox, TB, etc.) Infants regarded as high risk?
- 7. An Acute inflammation of the meninges. Cased by either bacteria or virus. Injuries, cancer, certain drugs, and other types of infections also can cause meningitis What Is Meningitis?
- 9. Pathophysiology pathogen invades the CNS in the subarachnoid space This leads to activation of the immune response, resulting in lysis The presence of bacterial particles triggers a further inflammatory response across Blood Brain Barrier (BBB) Zeeshan et. al. 2018
- 10. Cont… This persistent inflammatory state leads to: decreased cerebral perfusion cerebral edema raised intracranial pressure metabolic disturbances, and vasculitis
- 11. Types of Meningitis Zawn Villines 2021 • Viral • Bacterial • Fungal • Amebic • Parasitic Infectious • Oto-toxic • Chronic Illness • Cancer Non- Infectious
- 12. Infectious Meningitis Viral Meningitis Most common Meningitis Bacterial Meningits Most serious form of meningitis Fungal Meningitis Rare Parasitic Meningits Less Common 01 03 02 04 05 Amebic Meningitis Very Rare
- 13. Clinical Manifestation Signs in Newborn High Fever with Rashes on Body Vomiting Constant Crying Excessive Sleepiness or irritability
- 14. Clinical Manifestation Signs in Newborn Poor Feeding Difficulty waking from sleep, Inactivity or sluggishness A bulge in the soft spot on top of a baby’s head. ( fontanel) Stiffness in the body and neck.
- 16. Complications Subdural Effusion Focal Neurological Deficit Seizures Short Term Dunbar et. al.,2018
- 17. Complications Hearing Loss Cognitive Impairment Seizures and Epilepsy Hydrocephalus Learning Disability Long Term
- 18. Spread of infection to cochlea Results in severe labyrinthitis Leads to Blood- labyrinth barrier breakage. Destruction of inner ear cells, Outer hair cells Scala Vestibuli. May also cause inflammation of auditory nerve in some cases. Ultimately meningitis associated hearing loss Hearing Loss in Meningitis Kutz et. al, 2006
- 19. Loss of hair cells leads to mild to moderate hearing loss Hearing loss starts at early stage of meningitis If not treated leads to profound Hearing loss High Risk of Ossification of Cochlea Can leave the person with tinnitus. Continued… Bartling et. al 2010
- 20. Risk Factor Skipping Vaccination Age ( More common under age of 5) Gender (Male> Female) Compromised immune system Low Birth Weight Premature Child Previous infectious disease in mother or child Nesami et.al 2015 Krebs.et.al 2007 ,
- 21. Epidemiology Most common in children younger than 1 year old. The incidence and severity decreases with age Most common in dry and cold area. Spread mainly by droplet infection. The portal of entry is through nasopharynx. Ghia, Rambhad 2021
- 22. No startle response (Birth to 4 Months) Reduced or no response to other voice such as cooing, calming etc Delayed babbling May not localize sound Less Vocabulary Unable to follow Commands Misarticulation Joy Victory, 2021 ASHA Harada et,al 2009 Auditory behavior in child with Meningitis
- 23. Learning Difficulty Behavioural Issues (irritability, Temper tantrum,) Sleep Disorder Partial or complete loss of vision. Poor Feeding Poor Motor Movement and control Jennifer Berry 2018 Non Auditory behaviour in child with Meningitis
- 24. Etiology Bacteria • Escherichia coli (or E. coli) • Listeria monocytogenes • Streptococcus pneumoniae • Neisseria meningitides • H. influenzae • syphilis • tuberculosis (TB) Virus Others • polioviruses • mumps (paramyxovirus) • herpes simplex virus (HSV) • Borrelia burgdorferi (Lyme disease) • fungi such as candida, aspergillus, or cryptococcus neoformans
- 26. Meningitis VS Encephalitis inflammation of protective layers of tissue/membranes covering the brain. acute inflammation of the brain parenchyma bacteria, virus, and fungi viral agents. exist only as a single form primary or secondary types Symptoms : sudden fever, severe headache, nausea, vomiting, double vision, photophobia, and stiff neck Symptoms: Moderate to severe fever, seizures, behavioural changes, disorientation and related neurological signs Diagnosis by spinal tap, blood culture. Might need neuroimaging technique
- 27. Diagnosis
- 29. Non-Audiological Assessment Pathological Assessment Lumber Puncture (Spinal Tap) Radiological Assessment Ophthalmic Assessment Speech and Language Assessment
- 31. Clinical Presentation Of Meningitis (Literature Review) • Rinne - +ve • Weber : Lateralized to better ear. Tuning Fork Test • Normal TM, EAC, Pinna Otoscopy examination
- 32. • Hearing threshold normal (60-75%) • OR ranges from Mild to moderate/ severe (20-30%). Or profound. • Mainly high frequency sensorial hearing loss. (Rodenburg et.al, 2018:Zainel et.al 2021) PTA • Delayed response even in normal hearing • May be Unable to localize sound • No startle response. • (Wilson, Richardson 1991) BOA
- 33. • Normal Tympanometry Parameters • 30% abnormal middle ear pressure (>-100mmhg> • 7% had reduced compliance on drum. • (Jaffery et.al 1977) • Abnormal tympanogram is associated with increased risk and mortality acc to (gwer et.al 2013) Tympanometry • Normal, partially present or absent or elevated acoustic reflex for both ipsilateral and contralateral stimulation. • (Jaffery et.al 1977) Reflexometry
- 34. • Normal (68-75%) Or Abnormal (20-30%) • Prolonged Latency of wave V, • Elevated Threshold for wave I or Normal. • unilateral or bilateral absence response • prolonged inter-wave interval of Wave III and Wave V. • Amplitude ratio(V/I) is reduced. • Reversion of wave formed on changing polarity can be seen in some cases. • (Vienny et.al 2012), Karpinen et.al 2018, kalita et.al 2001) ABR • Dysfunctioning of Outer hair cells of affected cochlea • TEOAE or DPOAE usually absent in affected ear. • Can be present when damage Cochlear damage is not present. • ( Richardson et.al 1998) OAE
- 35. • Poor SRT and SIS Speech Audiometry • Purulent Labyrinthitis Bilaterally • Hematogenous spread of the disease. • Destruction of stria Vasularis • Massive hemorrhage within the cochlear duct • Degeneration of organ of corti, cochlear nerve fibers. • Kuan et.al 2007, Igarashi et.al 1974 Temporal Bone Finding
- 37. Treatment Stages • Intravenous antibiotics • corticosteroids • Cephalosporins (Claforan) and Rocephin (ceftriaxone). • Aminoglycoside (gentamicin) Pharmacological treatment • Stem Cell Therapy Surgical Treatment
- 38. Treatment Stages • Exercise to strengthen all limbs and trunk • Exercise to improve balance and coordination • Exercise to increase sensation and joint position • Stretches to maintain range of movement. Physiotherapy Treatment • Prescriptive glasses for restoring lost vision • Medicine like dexamethasone, acetaxolamide, etc are used to restore vision. Opthalmological Treatment
- 39. • Appropriate amplification device • Cochlear Implant • Assistive Listening Device Audiological Rehabilitation • Auditory verbal therapy • Speech and Language Therapy • language stimulation. Speech Rehabilitation
- 40. Prognosis
- 42. My Case Hearing Loss due to meningitis
- 43. Case History
- 44. Case History
- 45. Case History
- 46. Case History
- 47. Case History Before Meningitis First word was achieved at 10 month. Was active and curious Normal Motor Milestone development After Meningitis Delayed speech and language development Inactive and lethargic after infection. Slight Delay in Motor Milestone
- 48. Family History No history of hearing loss or Delayed Speech and Language in family. Mother-No any specific history Father-No any specific history
- 49. ENT-HEAD AND NECK EXAMINATION Bilateral pinna symmetrical normal in position ,size, shape and color. No sinus/fistula. External auditory canal- Bilateral normal. Tympanic membrane-within normal limit No sign of middle ear fluid.
- 50. Oro-Motor Function Normal facial characteristics (symmetry , size, expression. Symmetrical Eye, normal eye gaze. Normal tongue size, range of motion and voluntary sequence of tongue movement. Normal Palate and teeth Normal lips function.(smile, protrude lips) Unable to puff properly.
- 51. Audiological Test Carried • Otoscopy • Tuning Fork Test • Behavioural Observation audiometry • Speech Audiometry Behavioural Tests • Tympanometry • Reflexometry • Auditory Brainstem Response(ABR) • Transient Evoked Otoacoustic Emissions Electrophysiological Tests
- 60. Diagnosis SLD with HI RECOMMENDATION Digital Hearing Aid trial and Fitting Speech And Language Therapy Language stimulation at home Counselling and Follow Up
- 61. Speech Evaluation All subsystem of speech were evaluated informally which showed following findings: 1)RESPIRATION-No any problem found in breathing (normal inhalation and exhalation) 2)PHONATION-Normal quality with high pitch and normal loudness (perceptual evaluation) 4)RESONANCE-Slight hypernasality was perceptually analyzed.
- 62. ● Vinland Social Maturity Scale test shows the social age of 35 Months with SQ of 47. ● Seguin form board test shows average IQ with score of 95. Psychological Evaluation
- 63. Audiological Rehabilitation HEARING AID TRIAL and FITTING Digital Hearing aid trial was done in private setting.
- 64. Speech Rehabilitation Auditory Verbal Therapy Language Therapy Language Stimulation at home
- 65. It has been found that the hearing loss due to meningitis is permanent in most of the case and may affect speech and language development and other cognitive development. Hence, early diagnosis and treatment is necessary for the child suffering from meningitis or any other high risk factor. Conclusion
- 68. ● Taggart JH, Fisher JA. Meningoencephalitis complicating herpes zoster. Lancet 1938;2:944–5. Google Scholar 28. ● The high-risk infant (M C Allen Department of Pediatrics, Johns Hopkins) ● Bacterial Meningitis in Children: Neurological Complications, Associated Risk Factors, and Prevention) Abdulwahed Zainel,1 Hana Mitchell,1,2 and Manish Sadarangani1,2,* ● . (Stroke in Pediatric Bacterial Meningitis: Population-Based Epidemiology PMID: 30392967 ) Mary Dunbar 1, Hely Shah 2, Siddharth Shinde 2, Joseph Vayalumkal 3, Otto G References
- 69. Clinical Predictors for Hearing Loss in Children With Bacterial Meningitis(J. Walter Kutz, MD; Lawrence Mariano Simon, MD; Sri Kiran Chennupati, MD; et al) 1. Hearing impairment in infants after meningitis: Detection by transient evoked otoacoustic emissions*MartineFrançoisMDabLaurenceLaccourreyeMDabEsther Tran BaHuyMDabPhilippeNarcyMD 2. Repeated Audiometry After Bacterial Meningitis: Consequences for Future Management Marian B. A. Rodenburg-Vlot, Liesbet Ruytjens, Rianne Oostenbrink, and Marc P. van der Schroeff 3. Auditory brainstem responses in infants recovering from bacterial meningitis. Audiologic evaluation. Ozdamar, Kraus N ,Stein L References
Editor's Notes
- A previous head of neonatal medicine at UCT, David Woods consulted to UNICEF and the WHO,
- M C Allen Department of Pediatrics, Johns Hopkins High Risk Infant. Intraparenchymal hemorrhage (IPH) is one form of intracerebral bleeding in which there is bleeding within brain parenchyma. Encephalomalacia is the softening or loss of brain tissue after cerebral infarction, cerebral ischemia, infection, craniocerebral trauma, or other injury. The term is usually used during gross pathologic inspection to describe blurred cortical margins and decreased consistency of brain tissue after infarction.
- significantly higher risks of cesarean, preterm delivery, pre-eclampsia, gestational diabetes, and fetal death in utero (FDIU). What changes does a post-term newborn have? Postterm newborns often have dry, peeling, loose skin and may appear abnormally thin (emaciated), especially if the function of the placenta was severely reduced. The fingernails and toenails are long. The umbilical cord and nails may be stained green if meconium was present in the amniotic fluid. APGAR appearance pulse grmance muscle tone respiration. 012
- Low birth weight newborns present a 3-fold increased risk of acquiring meningitis when compared to those whose birth weight is > " 2500 g1. Krebs et al 2007 The baby's tiny body is not as strong and he or she may have a harder time eating, gaining weight, and fighting infection. Because they have so little body fat, low birthweight babies often have difficulty staying warm in normal temperatures. A high birth weight is associated with increased risk of type 2 diabetes and obesity., hypertension and certain risk of malignancy. Neonatal birth-weights and reference intervals in sonographically monitored normal fetuses Pallor:an unhealthy pale appearance. Plethora: red skin, abnormally high Erythrocyte Petechiae are pinpoint, round spots that appear on the skin as a result of bleeding. The bleeding causes the petechiae to appear red, brown or purple.
- Meningitis develops after the pathogen invades the CNS either though hematogenous route or by direct extension secondary to sinusitis or mastoiditis and multiplies in the subarachnoid space. The presence of pathogen in the subarachnoid space leads to activation of the immune response, resulting in lysis. The presence of bacterial particles triggers a further inflammatory response with on-going migration of neutrophils across the blood–brain barrier and continuous cytokine and chemokine release lysis the breaking down of the membrane of a cell, often by viral, enzymic, or osmotic Hearing impairment after acute bacterial meningitis in children Fatima Zeeshan,1 Attia Bari,2 Mubeen Nazar Dugal,3 and Fauzia Saeed4
- A persistent inflammatory state subsequently leads to decreased cerebral perfusion, cerebral edema, raised intracranial pressure, metabolic disturbances, and vasculitis, all contributing to neuronal injury and ischemia Cerebral perfusion pressure (CPP) is the net pressure gradient that drives oxygen delivery to cerebral tissue. It is the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP), measured in millimeters of mercury (mm Hg) Vasculitis involves inflammation of the blood vessels. Cerebral edema is also known as brain swelling. It's a life-threatening condition that causes fluid to develop in the brain. This fluid increases the pressure inside of the skull — more commonly referred to as intracranial pressure (ICP).
- Infectious meningitis occurs when a pathogen reaches the meninges. Noninfectious meningitisTrusted Source does not originate with an external pathogen or parasite. It is not contagious. Noninfectious meningitis can occur when a drug causes swelling around the brain, a chronic illness irritates the meninges, or cancer affects the brain.
- Viral meningitis typically goes away without treatment. However, some causes do need to be treated. Bacterial meningitis is contagious and caused by infection from certain bacteria. It’s fatal if left untreated. Between 5 to 40 percentTrusted Source of children and 20 to 50 percentTrusted Source of adults with this condition die. This is true even with proper treatment. The overall lethality rate is 20% even after medication People with a weakened immune system are more likely to develop fungal meningitis. This includes people with cancer or HIV. Parasitic meningitis This type of meningitis is less common than viral or bacterial meningitis, and it’s caused by parasites that are found in dirt, feces, and on some animals and food, like snails, raw fish, poultry, or produce.
- Subdural 20-39 % resolves spontaneously and rarely require intervention. A subdural effusion is a collection of cerebrospinal fluid (CSF) trapped between the surface of the brain and the outer lining of the brain (the dura matter). If this fluid becomes infected, the condition is called a subdural empyema. Focal neurological deficit refers to a set of signs and symptoms resulting from a lesion localized to a specific anatomical site in central nervous system 3–14% A seizure is a sudden, uncontrolled electrical disturbance in the brain
- Of the newborns who survive, 20 to 50% develop serious brain and nerve problems, such as an (hydrocephalus), hearing loss, and intellectual disability. Up to 30% have mild residual problems, such as learning disorders, mild hearing loss, or occasional seizures. . Around 10% of children with bacterial meningitis develop unilateral or bilateral sensorineural hearing loss [37,60]; 5% of children develop bilateral severe or profound hearing loss. (Bacterial Meningitis in Children: Neurological Complications, Associated Risk Factors, and Prevention) Abdulwahed Zainel,1 Hana Mitchell,1,2 and Manish Sadarangani1,2,* NCBI More than one-third of children with acute bacterial meningitis and clinically indicated MRI had ischemic stroke. (Stroke in Pediatric Bacterial Meningitis: Population-Based Epidemiology PMID: 30392967 ) Mary Dunbar 1, Hely Shah 2, Siddharth Shinde 2, Joseph Vayalumkal 3, Otto G Vanderkooi 4, Xing-Chang Wei 5, Adam Kirton 6
- Of the 134 children tested, 41 (30.6%) were found to have at least a unilateral mild sensorineural hearing loss during initial audiologic testing. Of the children with hearing loss, 17 (41.4%) had mild or moderate sensorineural hearing loss, and 29 (58.6%) had severe or profound sensorineural hearing loss. Nine (31.0%) of the 29 children with severe or profound sensorineural hearing loss had at least a severe bilateral hearing loss. Clinical Predictors for Hearing Loss in Children With Bacterial Meningitis J. Walter Kutz, MD; Lawrence Mariano Simon, MD; Sri Kiran Chennupati, MD; et al 2006
- This can make any existing hearing loss worse and treatment of the hearing loss more difficult or less successful, affect in cochlear implant. One scientific paper says 34% of people whose hearing loss was caused by meningitis reported ossification
- Recommended Immunization Schedule for Children Influenza Vaccine. We recommend Influenza Vaccine for people of all ages from 6 months of age. ... HPV (Human Papilloma Virus Vaccine) ... PCV (Pneumococcal Conjugate Vaccine) ... Meningitis Vaccine. ... Typhoid Vaccine. ... Varicella Vaccine (Chicken Pox Vaccine) ... Hepatitis A. ... Hepatitis B. Males are affected slightly more than females, and account for 55% of all cases, AIDS, alcoholism, diabetes, use of immunosuppressant drugs and other factors that affect your immune system also make you more susceptible to meningitis. Low birth weight newborns present a 3-fold increased risk of acquiring meningitis when compared to those whose birth weight is > " 2500 g1. Among very low birth weight neonates (<1500 g) the risk is a 10 to 17-fold higher
- Over winter many of us will unfortunately catch a cold or even the flu. By suppreas the temperature drops the bacteria are able to spread more rapidly as people spend longer periods indoors in close proximity, particularly through coughing, sneezing, and kissing.ssing our immune system, the flu may play a part in increasing our risk of getting meningitis. In dry atmospheres below 40%RH expelled droplets rapidly lose their moisture content through evaporation. As smaller droplets remain airborne for longer, this evaporation results in more droplets capable of staying airborne and increases the overall time they can float around.
- Audiological Characteristics of Hearing Loss Following Meningitis
- A cerebral abscess is a pus-filled pocket of infected material in your brain. It is sometimes called a brain abscess. An abscess can cause your brain to swell, putting harmful pressure on brain tissue. Meningeal carcino It develops when cancer cells break away from the original tumor and invade the meninges, which are the protective membranes that surround the brain and spinal cord. Stroke is a medical emergency and urgent hospital transfer is vital. Hypoglycaemia, hyperglycaemia, epilepsy, multiple sclerosis, hemiplegic migraine, intracranial tumours or infection (meningitis/encephalitis/abscess) can all mimic stroke. Although acute stroke most commonly presents with hemiparesis, facial weakness and dysphasia, these symptoms can sometimes be the atypical presentations of other conditions which may be difficult to diagnose. Central nervous system (CNS) vasculitis means that blood vessel walls in the brain and spine are inflamed (swollen). This inflammation can be caused by a variety of conditions and illnesses. CNS vasculitis is serious but treatable.
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- In this cohort the incidence of hearing loss (>25 dB) was 28% (95% confidence interval 23–34%). The incidence of profound hearing loss (>80 dB) was 13% (95% confidence interval 10–18%).
- In this cohort the incidence of hearing loss (>25 dB) was 28% (95% confidence interval 23–34%). The incidence of profound hearing loss (>80 dB) was 13% (95% confidence interval 10–18%).
- Latencies and interpeak latencies were significantly prolonged among patients with BM. And the prolongation corelated with higher mortality or severe neurological sequale. (Maria et.al, prognosis value and changes of auditory brain stem response in children with BM In Angola.)
- tem cell therapy is a form of regenerative medicine designed to repair damaged cells within the body by reducing inflammation and modulating the immune system. Can stem cells bring back hearing? According to Stanford Medicine, stem cell therapy involves transplanting new stem cells into the inner ears. The delicate hairs inside our cochlea, or inner ear, help us hear. ... These transplanted stem cells can behave exactly like the inner ear hairs and help restore hearing. Stem cell therapy has the potential to treat a number of conditions, including hearing loss. Hearing aids and cochlear implants help many folks manage and cope with hearing loss. According to the National Library of Medicine, stem cell therapy could soon be another treatment for hearing loss. Stem cell therapy helps regenerate damaged parts of the ears, without the need for hearing aid devices. But there is still some way to go before stem cell treatment for hearing loss is made available to the general public. NEVER MISS A MOMENT Get Hearing Loss Help Today! CHAT NOW Advisors are waiting for your call: 855-364-8193* *WebMD may receive a fee When Will There Be Stem Cell Treatment for Hearing Loss? According to Stanford Medicine, stem cell therapy involves transplanting new stem cells into the inner ears. The delicate hairs inside our cochlea, or inner ear, help us hear. Damage to these hairs can lead to permanent hearing loss. Stem cells have the ability to function like other cells and also make new cells.These transplanted stem cells can behave exactly like the inner ear hairs and help restore hearing. The National Center for Biotechnology Information says that scientists have been successful in growing human inner ear hairs in a culture dish. But they are still working on transplanting these hair cells into human ears and getting them to restore hearing. “Unfortunately, to date, the only studies that have been done are preclinical animal studies. No human studies have been performed,” ..
- In cases of bacterial meningitis, steroids are added to the mix to reduce the chance of neurological damage and to prevent blindness and meningitis hearing loss. More recent treatments include injecting steroids directly into the inner ear to improve hearing preservation.
- Hearing aid in case of mild to moderate loss was considered 100% effective. However cases in severe to profound the effective ness of HI is highly reduced., Daniel J. DeNoon Research by Roukema et.al 2015 the out come of CI in post meninigitic infant is less predictable that the outcome in congenitally deaf child. The dept of electrode insetion can be compromised in these patients due to obliteration of cochlear lumen. In cochlear ossification, auditory brainstem implant to rehabilitate PHL was done. In 3 children. In which 11-15 out of 22 electrods were activated 1-6age group Significant speech discrimination and emhanced lip reading. Alexis bozorg 2007 Better prognosis and Speech and Langugage development in seen in most of the case of Meningitis with proper therapy.
- Prognosis of meningitis depends on the cause. Untreated bacterial meningitis has a very high death rate. Even with appropriate treatment, the death rate from bacterial meningitis is about 15-20%, with a higher death rate associated with increasing age. The type of bacteria makes a difference, with pneumococcal and Listeria meningitis associated with higher death rates than meningococcal meningitis.