Children with unilateral hearing loss are more likely to struggle in school

Children born with a complete absence of the external ear canal, even if only one ear is affected, are more likely than their peers to struggle in school, according to new research at Washington University School of Medicine in St. Louis.

Hearing amplification and corrective surgery are available for the condition, called aural atresia. But many children with single ear atresia (unilateral atresia) often are not treated, even though they have significant hearing loss in their affected ear. The assumption has been that having one good ear is adequate for children with the condition.

"Until the 1990s, any kind of hearing loss that occurred in just one ear and was present from birth was not considered a serious disability," said Judith E.C. Lieu, MD, co-author of a study that looked at the effects of aural atresia on speech development. "It was assumed that these children would adjust and develop normally. But we know now that isn't always the case."

The research is published July 18 in JAMA Otolaryngology.

Aural atresia occurs in about one of 10,000 live births. In two-thirds of cases, only one ear—more commonly the right ear—is affected. The condition is almost always accompanied by a malformed or absent external ear.

Because ears affected by atresia lack an ear canal, sound is not conducted to the inner ear, which in most cases is healthy. Children born with unilateral atresia may have completely normal hearing in their other ear. A number of surgical and amplification techniques that enable sound to reach the inner ear can restore hearing for this condition.

Many of these children, however, do not use devices that would enable hearing with both ears. "There are cost issues, comfort issues and vanity issues behind this," said Lieu. "And society has a long history of believing that one good ear is sufficient."

Lieu calls it an invisible impairment. "That is part of the problem," she said. "Because the child appears normal, it is easy to forget that they have an impairment. A child with unilateral atresia who fails to pay attention in class or keeps talking when he or she should be quiet, might be labeled a problem student when the real issue is that he or she simply does not hear the teacher.

Armed with recent studies indicating that children with unilateral hearing loss from causes other than atresia have an increased risk of speech and language delays that can affect school performance, Lieu and her colleagues at Washington University School of Medicine set out to determine if the same was true for children with aural atresia.

The investigators analyzed medical records collected by the Center for Communication Disorders at St. Louis Children's Hospital over a 35-year period to select 74 children who were seen at the clinic from the age of two to 12. "There were slightly more males and more than twice as many cases of right atresia as left atresia," said Lieu, who noted that those proportions are consistent with the general demographics of children seen for the condition. The study also included seven children with both ears affected (bilateral atresia).

Nearly all children with the condition had a moderately severe hearing loss in their affected ears. And those with atresia in only one ear had normal hearing in their other healthy ear. Of note is that all children with atresia in both ears wore two hearing aids, but fewer than 5 percent children with atresia in one ear had received a hearing aid.

As part of the study, the investigators analyzed data from speech pathologists' evaluations and from clinic notes by psychologists and nurses, and parental reports to evaluate rates of speech or language delays, prevalence of speech therapy and educational interventions.

The data showed that in children with unilateral atresia, about 40 percent required speech therapy and 25 percent experienced difficulties learning in school.

As expected, children with atresia of both ears had received speech therapy, and none of these children had any academic performance issues. "This may be because their impairment was more fully appreciated and addressed, and their learning environment was modified," said Lieu.

Compared with children who have atresia of the left ear, those with the condition on the right may be more likely to have problems learning in school. In previously published studies, nearly 35 percent of those with right unilateral hearing loss had repeated a grade, compared with fewer than seven percent of children with left unilateral hearing loss.

Based on their findings, the investigators advocate close, early and ongoing monitoring of children with unilateral aural atresia for early signs of speech or academic struggles and adoption of a low threshold for interventions.

"There are bone-anchored devices and bone-conduction hearing aids that can either restore hearing or make it significantly better," Lieu said. "Even if parents do not choose these options, or children refuse to wear them, teachers, parents and physicians should be vigilant about watching for signs of language delays and school problems and attempt to understand the root cause."


  1. Sarah K Masterson Sarah K Masterson United States says:

    Seriously? My son has complete unilateral hearing loss in his left ear. No, it is not caused by unilateral atresia. His ear is perfectly formed PHYSICALLY, it just doesn't work. Never has. Unfortunately, he wasn't diagnosed (conclusively) until he was 5. Around age 3, I started to suspect he had a problem. but since the only thing I noticed was how close he sat to the TV, I thought it was related to his eye sight! (Especially since I wear glasses.) ALL of that said, he is now 11 an HONOUR student with straight A's and a talented tackle football player. How much unilateral hearing loss effects a child has a LOT to do with the child and his or her parent(s). I make sure teachers/coaches are aware of the situation, I go to practices and games, I go up to the school...probably a lot more than my child wants! When he was younger, the school did use a FM system...most of the time. Now, in grade 6, the middle school isn't equipped with one; he knows how to compensate. He does just fine. I wish more than anything that I could fix the hearing in his bad ear. I know it would benefit him greatly, but when I talk about it with him, he says that he is FINE. That this is the way he has always heard things and he is okay with it. Isn't THAT what counts? How the kid feels about his/herself and how they function? Fixing the physical problem is great, but making the kid feel like he/she doesn't have a problem, THAT is he/she is okay should be the goal. No matter what.

    • toastie postie toastie postie United States says:

      I was born without a defective right ear. Mom didn't realize until going to wash me as a tiny baby. Right ear is slightly smaller than left. No hole on outer ear. Only learned that I didn't have an ear connection much later in life. When I was perhaps 5 or 6 my mom took me to Scottish Rite hospital for testing and a possible operation to fix the problem. Well no doctor wanted to do the operation(only found our later in adulthood why). They said, "Wait until she loses hearing in the good ear." Sounded callous at the time.

      I did have some problems, in the beginning, at school but only not hearing the teacher giving instructions. That was fixed somewhat by having me sit in one the front desks. But often, as I do now, I had to turn slightly to hear properly.

      But later in HS, I didn't let the teachers know about my problem and I was an honor student throughout my HS years.

      About 10 years ago, I finally went to an Otolaryngologist. After testing, he passed me onto another doctor(apparently he didn't want to fool with it). Again after testing, the doctor was very frank with me. After so many years I found out that I didn't have an ear canal. He would have to take skin from another part of my body to form one. There was no guarantee that it wouldn't be rejected and I would be back at zero. The chances were 1 in 100 that it might cause nerve damage. Okay. Not doing that. I'm now at the point, since hearing has lessen in good ear, that I need to look into an hearing aid.

The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News Medical.
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