Mayflower Medical Outreach

Strengthening hearing health and deaf education in Nicaragua

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What We Do


Mayflower Medical Outreach supports a wide variety of programs in Nicaragua. Each year a team of otolaryngologists and nurses travel to the mountain town of Jinotega to see patients and perform surgeries. This …

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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 …

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Deaf Education

Through the work of the MMO medical and audiology teams along with various Nicaraguan organizations, we became aware that there were deaf children in rural areas that were not getting access to …

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Our Mission

To Provide ENT and Audiology Services

To Provide Opportunities for Deaf Students

To Strengthen training in the fields of ENT Medicine, Audiology, and Deaf Education

~ 100% of all donations are used directly for the programs of MMO ~

Contact Us


Mayflower Medical Outreach, Inc.
P.O. Box 75449
Oklahoma City, OK 73147


Executuve Director
Mark Falk

Audiology Director
Debra Fried

Medical Director
Dr. James Saunders, MD

Deaf Education Director
Nancy Klos


Albergue Mayflower
Casa de la Mujer
Frente al comedor Chavarria
Jinotega, Nicaragua


Jinotega Contact
Monica Falk

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Otolaryngology  Program

Mayflower Medical Outreach supports a wide variety of programs in Nicaragua. Each year a team of otolaryngologists and nurses travel to the mountain town of Jinotega to see patients and perform surgeries. This is done in conjunction with a broader effort that includes construction and physician training. These trips focus on otology and otolaryngology. During these trips practicing otolaryngologists and residents from Nicaragua also joins us and learn surgical .  Their participation not only increases the manpower in the clinic, but also provides them with an excellent training opportunity. In addition, we work with Dr. Ernesto Moreno, who provides year-round otolaryngological services at Victoria  Motta Hospital in Jinotega and helps to triage consults and surgeries prior to our annual visits.

At least one trip each year is dedicated to improving otolaryngology at the Lenin Fonseca Hospital in Managua. Lenin Fonseca hospital is the site of resident specialty education and is the main tertiary referral center for otolaryngology. In Managua our efforts are mainly focused on physician and resident education. This includes staffing clinics, teaching surgical techniques, providing temporal bone dissection labs, and performing more difficult skull-base surgeries.

Last but not least, we recognize that training is of little value if the physician does not have the necessary tools and equipment. We are constantly looking for used equipment and discarded supplies that can be used at either Victoria or Lenin Fonseca Hospitals. Smaller items are hand carried with each trip and larger items, such as microscopes, are sent via shipping container. These equipment donations and our training programs have had a dramatic effect on the state of otolaryngology in Nicaragua, but there is still much work to be done.

Programs at Lenin Fonseca Hospital, Managua

Lenin Fonseca Hospital in Managua serves as the tertiary referral center for surgical patients from all over Nicaragua. The residency programs in otolaryngology, neurosurgery, general surgery, orthopedics and urology are housed at Lenin Fonseca. The otolaryngology training programs is a 4 year program and accepts 2 residents per year. There are five faculty members who support the program and all patients are seen in a single small clinic room. Although the physicians in this program have ample exposure to head and neck surgeries, limitations in surgical equipment, OR time, and lack of anesthesia supplies have lead to virtually no training in the otology and endoscopic sinus surgery. We have developed a strong working relationship with the physicians at Lenin Fonseca. With the generous donations of US companies we have been able to provide the otolaryngology program with fiber-optic nasopharyngoscopes, microscopes in the clinic and operating room, mastoid drills, a facial nerve monitor, surgical instruments, and a fully equipped audiology booth.  MMO has coordinated lecture series with the Nicaraguan Association of Otorhinolaryngology and has provided temporal bone dissection workshops at Lenin Fonseca. In addition, MMO has sponsored Nicaraguan physicians to visit and train in the US and has provided consultation and surgery for otology and pediatric patients at the Lenin Fonseca clinics. MMO physicians in Managua at the Lenin Fonseca now perform complex skull base surgeries that used to require the patient to travel to the United States.

Nicaraguan Deafness Research Project

On our first visits to Jinotega, we were prepared to see patients with chronic ear infections and conductive hearing loss. What we did not expect was the large number of patients, mostly children, with sensorineural hearing loss. This observation prompted a detailed study of the hearing loss in the region. To read more of our findings, click these links:

Hearing loss in Nicaragua

Nicaraguan findings may lead to hearing aid

An Uphill Battle

The Laryngoscope

Building Partnerships in the Americas

Hearing Loss and Heavy Metal Toxicity in a Nicaraguan Mining Community

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In Jinotega

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. ( 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 ( 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


August 2009


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)
Eye examination

Annually: Repeat audiological evaluation (as above)
Eye examination

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.

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Deaf Education

Albergue Mayflower

Through the work of the MMO medical and audiology teams along with various Nicaraguan organizations, it we became aware that there were deaf children in rural areas that were not getting access to education. The remoteness of their homes made it difficult for some students to get to the local schools and the local schools in the rural areas did not provide an educational environment appropriate to teach deaf children. In addition to the children not getting an education, they were also, in most cases, not able to communicate except for the basic, informal mode of communication established within their immediate families. This very isolating factor was limiting their social and emotional development. It became apparent that a place for the rural students to live while attending an appropriate school program for the deaf students was needed. Work began renovating a suitable location in.  Working with agencies in Jintoga (Los Pipitos and Casa Materna) that have contact with these rural communities and through the medical contacts at the ENT clinic at Hospital Victoria Mota, the students were located and the families invited to send their children to the boarding school.

In 2008, MMO enrolled its first 7 students at the Albergue Mayflower. Currently, the Albergue has a capacity of 25 students, which it will reach in 2011. The compact campus is located in the northern part of the city of Jinotega in a building owned by the local Casa Materna. The main building once housed clinic and dormitory facilities for the clients of Casa Materna before relocating to another building. Much renovating has been done by MMO to create a pleasant home environment for the students.  The outside has a courtyard for basketball and other outdoor games and there is a garden/patio area for quieter outdoor time. Within the Albergue campus is a recently remodeled bakery and café, operated by a local bakery owner. As well as a community small business, the facility is a location for vocational training and the revenue contributes to the funding of Albergue programs. In addition, a computer lab and a conference room have been remodeled. These facilities also help generate income for the operations of the Albergue.
The academic school year is from February till November. During this time, the students live at the Albergue, but are able to make home visits on weekends and for holidays. Parents are welcome and encouraged to visit their students while their children reside in Jinotega.

Working with the Ministry of Education, MMO has provided enrollment for all students housed at the Albergue Mayflower in the local primary special education school, Max Senqui and at the secondary school, Jose Delores . Both are located in Jinotega. The students attend the school during the normal school hours, which is mornings – 8:00 am till 12:00 pm Monday through Friday. In the afternoon, students attend education enhancement class at the Albergue led by a team of 2 teachers, provided through MMO. The 2 teachers instruct in Nicaraguan Sign Language. In addition to academics, the students at the Albergue engage in life skills instruction, arts activities, sports, and occasional field trips. The daily operations are managed through our partnership with Casa Materna, including the employment of the supervisory and maintenance staff.

As deaf children needing access to education are located, they are encouraged and offered the opportunity to attend the Albergue. If the need for a larger program is deemed necessary to accommodate greater numbers, MMO is committed to seeking ways to expand the residential school program.


When the children first arrive at the Albergue, their educational level does not correspond with the child’s chronological age. The children have a very limited ability of communicating with others. Most have never been in an educational setting before. The living conditions from where they come are very rural and basic. Therefore, it requires much acclimating and adjustment for these students to come to the Albergue . The Albergue provides a nurturing and a language rich environment for these children to adjust and feel secure. Individual planning is required to help each student make gains and focus is given to areas where the students have the most difficulties.
An effort is continuously being made to incorporate the deaf children into the community of Jinotega and to create ties with the Nicaraguan deaf community. The children attend ANSIC (the national association of deaf people) activities whenever possible.

Deaf Education Team

At the present time there is no specific deaf education curriculum in the Nicaraguan schools. To assist the teachers at the Albergue Mayflower, various MMO team members along with outside resources, work closely with the staff at the Albergue to create the best learning environment possible for the deaf students.  Twice a year, members from the team use time spent in Nicaragua to visit deaf education programs in other parts of Nicaragua, to visit with the various programs involved with deaf children, and to interact with the staff and students at the Albergue. From home in the States, we review deaf education resources, network with other educators, and maintain communication with the staff at the Albergue Mayflower. We provide educational materials and furnishings as needed.


It is MMO’s hope that our contribution will enable more deaf students of Nicaragua to be educated and to have access to better opportunities as adults. While establishing a residential program for those deaf students who would otherwise be isolated and without a formal education is a great accomplishment, it is not the end of our vision.

It is hoped that the curriculum for deaf education will continue to develop and become universal throughout Nicaragua to benefit all deaf students. We will continue to work to improve teacher training for those entering classrooms for the deaf and to facilitate in any way that we can a way for teachers of deaf students from both private and public schools to network and share resources and ideas.

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