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Assessment of common otolaryngological diseases among children in rural primary schools in south eastern Nigeria
International Journal of Pediatric Otorhinolaryngology 89 (2016) 169e172
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: http://www.ijporlonline.com/
Assessment of common otolaryngological diseases among children in rural primary schools in south eastern Nigeria Onyinyechi C. Ukaegbe a, *, Nnaemeka G. Umedum b, Ethel N. Chime a, Foster T. Orji a, b a b
Otorhinolaryngology Department, Faculty of Medical Sciences, University of Nigeria, Enugu Campus, Nigeria Department of Otorhinolaryngology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 June 2016 Received in revised form 17 August 2016 Accepted 20 August 2016 Available online 24 August 2016
Objectives: Despite a global improvement in health care delivery, rural areas in developing countries still have poor access to specialist care. This study aims to assess the occurrences of ear, nose, and throat (ENT) disorders among rural primary school children in south-eastern Nigeria. Methods: Two rural primary schools were selected randomly from one of the rural regions of South Eastern State of Nigeria. All the pupils of the schools who gave consent were recruited. A structured study proforma investigating the pupils' biodata, otolaryngological symptoms, ear, nose and throat examination findings, was used to evaluate each pupil in the presence of the teachers. Results: A total of 246 children participated in the study. 145(58.9%) were males while 101(41.1%) were females with a mean age of 8.5 ± 2.4 years. The commonest symptoms reported were nasal discharge (20%) followed by nasal obstruction (11.1%), itching of the ears (11.1%) and sneezing bouts (10%), while 3.7% had subjective hearing impairment. The commonest ENT finding was cerumen auris (43%) and this was observed in 43.4% of males and 42.4% of females, 11% had abnormal tympanic membranes and 20% had grades 3/4 tonsils(Brodsky grading). Conclusion: ENT disorders are still common in children in the rural areas of developing countries. To avoid the morbidity associated with these preventable and easily manageable disorders, community health workers should be trained to manage common ENT disorders and mobile clinics with scheduled visits made available in areas where ENT services remain inaccessible. © 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: ENT diseases School children Rural arears Ear wax Hearing impairment
1. Introduction Preventable and manageable ear, nose and throat diseases are quite common in the paediatric population and may often result in disorders in hearing, olfaction, taste, feeding, breathing and swallowing [1e3]. This is often seen in situations where there is restricted access to an Otorhinolaryngologist or where the affected individual lacks the insight, knowledge or finances required in tackling their condition, a common scenario in the rural areas of developing countries [1]. Despite the improvement in health care in developing nations, the rural areas still have some problems accessing specialist health care and this is compounded by the poor state of the infrastructure which makes these areas difficult to reach by road.
* Corresponding author. E-mail addresses: [email protected], (O.C. Ukaegbe). http://dx.doi.org/10.1016/j.ijporl.2016.08.015 0165-5876/© 2016 Elsevier Ireland Ltd. All rights reserved.
[email protected]
If there is to be an improvement in the paediatric otorhinolaryngological services in the rural areas, a good knowledge of the common ear, nose and throat disorders in children within these areas is necessary. This will help in the planning of targeted community health care delivery and policy reforms. The aim of this present study was to evaluate the prevalence of common ear, nose, and throat (ENT) disorders among rural primary school children in south-eastern Nigeria. 2. Materials and methods The study was conducted over a one month period in March 2014. Ethical approval and consent were obtained from the Ministry of Education and the participating schools. Two schools located in a rural area in Nigeria were randomly selected from a total of three primary schools within that locality. The selected schools were located in a rural community within a town approximately 20 km from the state capital, with an estimated population of 238, 305 people living within an 897 km3 area.
170
O.C. Ukaegbe et al. / International Journal of Pediatric Otorhinolaryngology 89 (2016) 169e172
Most of the adults within the community were small scale farmers and petty traders. The nearest source of health care was a government sponsored health centre. Access to the community was hampered by the lack of tarred roads. There were 445 enrolled students in both schools, but 246 pupils consented to participate in the study (158 in school A and 88 in school B). The study participants were recruited from pupils whose parents or guardians had given their consent for inclusion in the study. All the pupils who consented were included in the study, Two hundred and forty six pupils participated in the study. One hundred and forty five (58.9%) were male while 101 (41.1%) were female. The age of the school children studied ranged from 4 years to 16 years with a mean age of 8.5 ± 2.4 years. Ear, nose and throat history was obtained from each participant. Where additional information was needed, the parents/guardians were contacted and interviewed in the school at a later date. Clinical examination of the ear, nose, oral cavity, oropharynx and the neck was carried out. A diagnosis of wax impaction was made if the tympanic membrane was obstructed from full view by the presence of wax [4]. Brodsky tonsil grading was used, and grade 3 and 4 were considered to be enlarged [5]. Those with minor ailments such as ear wax and rhinitis were treated, while more serious ailments were arranged for transfer to the nearby tertiary centre. All statistical comparisons were made using SPSS statistical software (version 22; IBM Corp). Chi square tests were used in computing the association between sex or school attended and the observed ear, nose and throat pathologies, while the Independent Samples t-test was used in comparing the age distribution of the participants from both schools. The significance level was set at less than 0.05. 3. Results The age and sex distribution of the 246 participants are as shown in Table 1. The commonest otological, rhinological and throat symptoms reported were itching of the ears (11%), nasal discharge (20%) and sore throat (5%) respectively (Table 2). Cerumen auris was the commonest examination finding (43%), see Table 3. On ear examination 13(5%) were noted to have abnormal tympanic membranes with 8(3%) of these diagnosed as Chronic Otitis Media, 1(0.4%) participant was observed to have House and Brackmann grade 2 facial nerve palsy while a foreign body was discovered in the ear of one other participant. None of the participants had a deformity of the pinna or the external auditory meatus. On examination of the nose, all the participants had normal nasal pyramids, 13(5.3%) had reduced nasal airflow, 33(14%) were observed to have some nasal discharge or crusts in the nasal
Table 1 Age and Sex Distribution of the Participants with respect to the schools.
Age(years)
4e8 years 9e12 years 13e16 years Total
Mean Age(±SD) Sex
School A(%)
School B(%)
Total (%)
48(30.4) 104(65.8) 6(3.8) 158(100) 9.4(±2.0)
71(80.7) 15(17) 2(2.3) 88(100) 7(±2.0)
119(48.4) 119(48.4) 8(3.2) 246(100)
92(58.2) 66(41.8) 158(100)
53(60.2) 35(39.8) 88(100)
145(59) 101(41) 246(100)
p-value
0.000 0.8
Male Female Total SD-Standard deviation.
Table 2 Symptoms reported by participants. Symptoms Ear symptoms Hearing impairment Itching Ear discharge Ear ache Nasal symptoms Nasal obstruction Nasal discharge Itching Nose bleeding Sneezing Throat symptoms Sore throat Voice changes Dysphagia Odynophagia
School A(%)
School B(%)
Total (%)
p-value
9(5.7) 18(11.4) 12(7.6) 4(2.5)
0(0) 9(10.2) 4(4.5) 2(2.3)
9(3.7) 27(11) 16(6.5) 6(2.4)
0.03 0.8 0.4 1.0
13(8.2) 18(11.4) 8(5.1) 6(3.8) 15(9.5)
14(15.9) 31(35.2) 6(6.8) 0(0) 9(10.2)
27(11) 49(19.9) 14(5.7) 6(2.4) 24(9.8)
0.07 0.000 0.6 0.09 0.9
11(7) 0(0) 0(0) 9(5.7)
2(2.3) 0(0) 1(1.1) 1(1.1)
13(5.3) 0(0) 1(0.4) 10(4.1)
0.14 0.4 0.1
cavities while one of the participants had nasal septal deviation. The oral cavity examination showed that 62(25%) of the participants had poor oro-dental hygiene. Tonsillar enlargement was observed in 20% of the participants (Brodsky 3/4 staging). Fifty one participants (20.7%) had palpable cervical nodes at levels 1(13.8%), II (6.5%) and III(0.4%). Subjective hearing impairment, nasal discharge and nasal obstruction were higher in males while sneezing bouts, itching of the ears and nose, ear discharge, otalgia, nose bleeds, sore throat and odynophagia were reported more in females (Fig. 1). Analysis of the symptoms showed that there was no significant difference in most of the symptoms as reported by both sexes (p > 0.05), except in sneezing bouts where the frequency was significantly higher in females (p ¼ 0.000). A greater percentage of males had cerumen auris (ear wax), purulent ear discharge, tympanic membrane perforation and poor oral hygiene while a greater proportion of females had enlarged tonsils (Brodsky grade 3/4). There was no significant difference in the examination findings reported in both sexes (p > 0.05), See Fig. 1. The mean age of the participants from School A was 9.4 ± 2.0 years while that of School B was 7 ± 2.0 years. Children in School B were significantly younger (p ¼ 0.000), but there was no significant difference in the sex distribution (p ¼ 0.8). Participants from School A had significantly higher levels of subjective hearing impairment, while nasal discharge was significantly higher amongst participants from School B (p < 0.05), see Tables 2 and 3. 4. Discussion Children in rural areas of developing countries are likely to harbour common undiagnosed ear, nose and throat disorders, due to lack of access to primary health care, with attendant unfortunate associated morbidities. Wax impaction was the commonest ear finding, and this was present in almost half of the study participants. A number of similar studies from developing countries have also reported wax impaction as the commonest ear finding [1,6e11]. Our study provides additional evidence that wax impaction remains a problem in rural areas of developing countries. However few studies have reported a higher prevalence of chronic otitis media [12]. The high prevalence of wax impaction within these school children is worrisome as this has been linked to hearing impairment and poor school performance [6,11]. This potential morbidity could easily be resolved by ear syringing if they had access to proper health services. The community receives her health care from a government sponsored,
O.C. Ukaegbe et al. / International Journal of Pediatric Otorhinolaryngology 89 (2016) 169e172
171
Table 3 Examination findings.
Ear Findings PINNA EAM
Findings
School A(%)
School B(%)
Total(%)
p-value
Abnormal pinna
2(1.3)
0(0)
2(0.8)
0.5 0.08
Wax Otomycosis Purulent discharge Foreign body
60(38) 4(2.5) 3(1.9) 1(0.6)
47(53.4) 2(2.3) 4(4.5) 2(2.3)
107(43.5) 6(2.4) 7(2.8) 1(0.4)
Perforated TM TM retraction Dull TM Facial nerve palsy
3(1.9) 1(0.6) 5(3.2) 1(0.6)
4(4.5) 0(0) 0(0) 0(0)
7(2.8) 1(0.4) 5(2) 1(0.4)
1.0
Reduced/absent airflow Nasal discharge/crusts Septal deviation Engorged turbinates
8(5.1) 15(9.5) 1(0.6) 30(19)
5(5.7) 18(20.4) 0(0) 20(22.7)
13(5.3) 33(13.4) 1(0.4) 50(20.3)
0.8 0.04 1.0 0.5
Poor oral hygiene Ulcers Palpable cervical nodes
64(40.6) 1(0.6) 34(21.5)
27(30.7) 0(0) 17(19.3)
91(37) 1(0.4) 51(20.7)
Grade 1 tonsils Grade 2 tonsils Grade 3 tonsils Kissing tonsils
18(11.4) 109(69) 30(19) 1(0.6)
8(9.1) 61(69.3) 19(21.6) 0(0)
26(10.6) 170(69.1) 49(19.9) 1(0.4)
TM
0.3
Facial Nerve Nasal Findings Airflow Cavity Septum Turbinate Throat Findings Oral hygiene
Neck Oropharynx
0.02
0.4 0.6
EAM-External auditory meatus, TM-Tympanic membrane.
Fig. 1. Symptoms and Signs with respect to sex.
poorly manned rural ‘health centre’. The nearest source of proper primary health care to the community is located about 20 km away in the city, through an untarred rural road with irregular public transportation in and out of the community. Only 5% of the participants in this study had abnormal tympanic membranes with a little more than half of these showing signs of chronic otitis media. This is comparable to the reports from other developing countries but lower that the prevalence reported by a study in western Nigeria by Olusanya et al. [1,6,9,11,13]. This may be attributed to the widespread availability of antibiotics and the low threshold of its use within these areas. It may also imply that there is some improvement in health care within these areas. However one of the participants with COM was observed to have facial nerve palsy, an indication of poor management. A significant reduction in nasal airflow was observed in 5% of the participants but a greater number of the participants reported that they were experiencing nasal obstruction and discharge. Rhinitis is commonly seen in this age group and is often from allergy or of
viral origin [14]. It is often a source of discomfort and can cause sleep disturbances. The nasal obstruction observed in some of the participants could also be as a result of enlarged adenoids [14]. Other rhinological symptoms encountered were sneezing bouts and epistaxis. A greater proportion of females had sneezing bouts than the males, with a significant difference in its prevalence between the two sexes. There is a paucity of community based studies on the prevalence of rhinitis and asthma in the paediatric age group. Most of the participants had poor oro-dental hygiene and did not practice regular brushing of the teeth. This may imply that they are unaware of the consequences of poor dental hygiene. Children in rural areas will likely benefit from school based public health education on the benefits of good oro-dental hygiene. Most of them had grade I and II tonsils, 20% of the participants however had enlarged tonsils. None had inflamed tonsils despite the fact that about 5% of them reported some dysphagia and soreness of the throat. Enlarged tonsils are often seen in patients with obstructive adenoids and suggest that these participants may have some level of sleep disordered breathing [14]. If the negative effects of sleep disordered breathing are to be avoided in these children, their guardians must be educated on the signs of sleep disordered breathing and on its complications. 5. Conclusion Treatable ear, nose and throat disorders are still common amongst children in rural areas. People in these communities will benefit from regular otorhinolaryngological examinations and otorhinolaryngological health awareness campaigns. These areas often lack specialist ENT services, therefore Community Health Officers (CHO's) and Community Health Extension Workers (CHEW's) should be trained to manage common otorhinolaryngology conditions, with a clear referral pathway for the difficult cases. Tertiary hospitals may also organise regular community
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outreaches to identify those with ear, nose and throat disorders. Conflict of interest There is no conflict of interest to declare. References [1] P. Adhikari, B. Kharel, J. Ma, D.R. Baral, T. Pandey, R. Rijal, et al., Pattern of otological diseases in school going children of kathmandu valley, Int Arch Otorhinolaryngol 12 (2008) 502e505. [2] O. Akinpelu, Y.B. Amusa, Otological diseases in nigerian children, Internet J. Otorhinolaryngology 7 (2007) 1. [3] A.J. Fasunla, M. Samdi, O.G. Nwaorgu, An audit of Ear, Nose and Throat diseases in a tertiary health institution in South-western Nigeria, Pan Afr. Med. J. (2013) 14. [4] P.S. Roland, T.L. Smith, S.R. Schwartz, R.M. Rosenfeld, B. Ballachanda, J.M. Earll, et al., Clinical practice guideline: cerumen impaction, Otolaryngol. Head. Neck Surg. 139 (2008) S1eS21. [5] L. Brodsky, L. Moore, J.F. Stanievich, A comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy, Int. J. Pediatr. Otorhi 13 (1987) 149e156.
[6] J. Hatcher, A. Smith, I. Mackenzie, S. Thompson, I. Bal, I. Macharia, et al., A prevalence study of ear problems in school children in Kiambu district, Kenya, Int. J. Pediatr. Otorhi 33 (1992) 197e205. [7] B. Sigdel, R. Nepali, Pattern of ear diseases among paediatric ENT patient: an experience from tertiary care centre, pokhara, Nepal, J. Nepal Paediatr. Soc. 32 (2012) 142e145. [8] B.M. Minja, A. Machemba, Prevalence of otitis media, hearing impairment and cerumen impaction among school children in rural and urban Dar es Salaam, Tanzania, Int. J. Pediatr. Otorhi 37 (1996) 29e34. [9] G. Sapra, S.P. Srivastava, A. Modwal, R. Saboo, G. Saxena, J. Gyanu, Hearing assessment of school going children of various schools in jaipur, Rajasthan. Sch. J. App Med. Sci. 3 (2015) 638e645. [10] K. Kovjiriyapan, Ear and Hearing Disorders In representative sample of gradeone school children in phayao municipality, J Health Sci 21 (2012) 2. [11] B.O. Olusanya, A.A. Okolo, G.T.A. Ijaduola, The hearing profile of Nigerian school children, Int. J. Pediatr. Otorhi 55 (2000) 173e179. [12] S.P. Kishve, N. Kumar, P.S. Kishve, S.M.M. Aarif, P. Kalakoti, Ear, Nose and Throat disorders in paediatric patients at a rural hospital in India, AMJ 3 (2010) 786e790. [13] S. Thakur, S. Singh, B. Mahato, A. Singh, D. Mahato, Pattern of otological diseases in school-going children of the sunsari district of eastern Nepal, Internet J. Otorhinolaryngology 17 (2015). [14] M. Gleeson, Scott Brown's Otorhinolaryngology Head and Neck Surgery, seventh ed., vol. 1, Hodder Arnold, Great Britain, 2008, pp. 1079e1111.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: http://www.ijporlonline.com/
Assessment of common otolaryngological diseases among children in rural primary schools in south eastern Nigeria Onyinyechi C. Ukaegbe a, *, Nnaemeka G. Umedum b, Ethel N. Chime a, Foster T. Orji a, b a b
Otorhinolaryngology Department, Faculty of Medical Sciences, University of Nigeria, Enugu Campus, Nigeria Department of Otorhinolaryngology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 June 2016 Received in revised form 17 August 2016 Accepted 20 August 2016 Available online 24 August 2016
Objectives: Despite a global improvement in health care delivery, rural areas in developing countries still have poor access to specialist care. This study aims to assess the occurrences of ear, nose, and throat (ENT) disorders among rural primary school children in south-eastern Nigeria. Methods: Two rural primary schools were selected randomly from one of the rural regions of South Eastern State of Nigeria. All the pupils of the schools who gave consent were recruited. A structured study proforma investigating the pupils' biodata, otolaryngological symptoms, ear, nose and throat examination findings, was used to evaluate each pupil in the presence of the teachers. Results: A total of 246 children participated in the study. 145(58.9%) were males while 101(41.1%) were females with a mean age of 8.5 ± 2.4 years. The commonest symptoms reported were nasal discharge (20%) followed by nasal obstruction (11.1%), itching of the ears (11.1%) and sneezing bouts (10%), while 3.7% had subjective hearing impairment. The commonest ENT finding was cerumen auris (43%) and this was observed in 43.4% of males and 42.4% of females, 11% had abnormal tympanic membranes and 20% had grades 3/4 tonsils(Brodsky grading). Conclusion: ENT disorders are still common in children in the rural areas of developing countries. To avoid the morbidity associated with these preventable and easily manageable disorders, community health workers should be trained to manage common ENT disorders and mobile clinics with scheduled visits made available in areas where ENT services remain inaccessible. © 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: ENT diseases School children Rural arears Ear wax Hearing impairment
1. Introduction Preventable and manageable ear, nose and throat diseases are quite common in the paediatric population and may often result in disorders in hearing, olfaction, taste, feeding, breathing and swallowing [1e3]. This is often seen in situations where there is restricted access to an Otorhinolaryngologist or where the affected individual lacks the insight, knowledge or finances required in tackling their condition, a common scenario in the rural areas of developing countries [1]. Despite the improvement in health care in developing nations, the rural areas still have some problems accessing specialist health care and this is compounded by the poor state of the infrastructure which makes these areas difficult to reach by road.
* Corresponding author. E-mail addresses: [email protected], (O.C. Ukaegbe). http://dx.doi.org/10.1016/j.ijporl.2016.08.015 0165-5876/© 2016 Elsevier Ireland Ltd. All rights reserved.
[email protected]
If there is to be an improvement in the paediatric otorhinolaryngological services in the rural areas, a good knowledge of the common ear, nose and throat disorders in children within these areas is necessary. This will help in the planning of targeted community health care delivery and policy reforms. The aim of this present study was to evaluate the prevalence of common ear, nose, and throat (ENT) disorders among rural primary school children in south-eastern Nigeria. 2. Materials and methods The study was conducted over a one month period in March 2014. Ethical approval and consent were obtained from the Ministry of Education and the participating schools. Two schools located in a rural area in Nigeria were randomly selected from a total of three primary schools within that locality. The selected schools were located in a rural community within a town approximately 20 km from the state capital, with an estimated population of 238, 305 people living within an 897 km3 area.
170
O.C. Ukaegbe et al. / International Journal of Pediatric Otorhinolaryngology 89 (2016) 169e172
Most of the adults within the community were small scale farmers and petty traders. The nearest source of health care was a government sponsored health centre. Access to the community was hampered by the lack of tarred roads. There were 445 enrolled students in both schools, but 246 pupils consented to participate in the study (158 in school A and 88 in school B). The study participants were recruited from pupils whose parents or guardians had given their consent for inclusion in the study. All the pupils who consented were included in the study, Two hundred and forty six pupils participated in the study. One hundred and forty five (58.9%) were male while 101 (41.1%) were female. The age of the school children studied ranged from 4 years to 16 years with a mean age of 8.5 ± 2.4 years. Ear, nose and throat history was obtained from each participant. Where additional information was needed, the parents/guardians were contacted and interviewed in the school at a later date. Clinical examination of the ear, nose, oral cavity, oropharynx and the neck was carried out. A diagnosis of wax impaction was made if the tympanic membrane was obstructed from full view by the presence of wax [4]. Brodsky tonsil grading was used, and grade 3 and 4 were considered to be enlarged [5]. Those with minor ailments such as ear wax and rhinitis were treated, while more serious ailments were arranged for transfer to the nearby tertiary centre. All statistical comparisons were made using SPSS statistical software (version 22; IBM Corp). Chi square tests were used in computing the association between sex or school attended and the observed ear, nose and throat pathologies, while the Independent Samples t-test was used in comparing the age distribution of the participants from both schools. The significance level was set at less than 0.05. 3. Results The age and sex distribution of the 246 participants are as shown in Table 1. The commonest otological, rhinological and throat symptoms reported were itching of the ears (11%), nasal discharge (20%) and sore throat (5%) respectively (Table 2). Cerumen auris was the commonest examination finding (43%), see Table 3. On ear examination 13(5%) were noted to have abnormal tympanic membranes with 8(3%) of these diagnosed as Chronic Otitis Media, 1(0.4%) participant was observed to have House and Brackmann grade 2 facial nerve palsy while a foreign body was discovered in the ear of one other participant. None of the participants had a deformity of the pinna or the external auditory meatus. On examination of the nose, all the participants had normal nasal pyramids, 13(5.3%) had reduced nasal airflow, 33(14%) were observed to have some nasal discharge or crusts in the nasal
Table 1 Age and Sex Distribution of the Participants with respect to the schools.
Age(years)
4e8 years 9e12 years 13e16 years Total
Mean Age(±SD) Sex
School A(%)
School B(%)
Total (%)
48(30.4) 104(65.8) 6(3.8) 158(100) 9.4(±2.0)
71(80.7) 15(17) 2(2.3) 88(100) 7(±2.0)
119(48.4) 119(48.4) 8(3.2) 246(100)
92(58.2) 66(41.8) 158(100)
53(60.2) 35(39.8) 88(100)
145(59) 101(41) 246(100)
p-value
0.000 0.8
Male Female Total SD-Standard deviation.
Table 2 Symptoms reported by participants. Symptoms Ear symptoms Hearing impairment Itching Ear discharge Ear ache Nasal symptoms Nasal obstruction Nasal discharge Itching Nose bleeding Sneezing Throat symptoms Sore throat Voice changes Dysphagia Odynophagia
School A(%)
School B(%)
Total (%)
p-value
9(5.7) 18(11.4) 12(7.6) 4(2.5)
0(0) 9(10.2) 4(4.5) 2(2.3)
9(3.7) 27(11) 16(6.5) 6(2.4)
0.03 0.8 0.4 1.0
13(8.2) 18(11.4) 8(5.1) 6(3.8) 15(9.5)
14(15.9) 31(35.2) 6(6.8) 0(0) 9(10.2)
27(11) 49(19.9) 14(5.7) 6(2.4) 24(9.8)
0.07 0.000 0.6 0.09 0.9
11(7) 0(0) 0(0) 9(5.7)
2(2.3) 0(0) 1(1.1) 1(1.1)
13(5.3) 0(0) 1(0.4) 10(4.1)
0.14 0.4 0.1
cavities while one of the participants had nasal septal deviation. The oral cavity examination showed that 62(25%) of the participants had poor oro-dental hygiene. Tonsillar enlargement was observed in 20% of the participants (Brodsky 3/4 staging). Fifty one participants (20.7%) had palpable cervical nodes at levels 1(13.8%), II (6.5%) and III(0.4%). Subjective hearing impairment, nasal discharge and nasal obstruction were higher in males while sneezing bouts, itching of the ears and nose, ear discharge, otalgia, nose bleeds, sore throat and odynophagia were reported more in females (Fig. 1). Analysis of the symptoms showed that there was no significant difference in most of the symptoms as reported by both sexes (p > 0.05), except in sneezing bouts where the frequency was significantly higher in females (p ¼ 0.000). A greater percentage of males had cerumen auris (ear wax), purulent ear discharge, tympanic membrane perforation and poor oral hygiene while a greater proportion of females had enlarged tonsils (Brodsky grade 3/4). There was no significant difference in the examination findings reported in both sexes (p > 0.05), See Fig. 1. The mean age of the participants from School A was 9.4 ± 2.0 years while that of School B was 7 ± 2.0 years. Children in School B were significantly younger (p ¼ 0.000), but there was no significant difference in the sex distribution (p ¼ 0.8). Participants from School A had significantly higher levels of subjective hearing impairment, while nasal discharge was significantly higher amongst participants from School B (p < 0.05), see Tables 2 and 3. 4. Discussion Children in rural areas of developing countries are likely to harbour common undiagnosed ear, nose and throat disorders, due to lack of access to primary health care, with attendant unfortunate associated morbidities. Wax impaction was the commonest ear finding, and this was present in almost half of the study participants. A number of similar studies from developing countries have also reported wax impaction as the commonest ear finding [1,6e11]. Our study provides additional evidence that wax impaction remains a problem in rural areas of developing countries. However few studies have reported a higher prevalence of chronic otitis media [12]. The high prevalence of wax impaction within these school children is worrisome as this has been linked to hearing impairment and poor school performance [6,11]. This potential morbidity could easily be resolved by ear syringing if they had access to proper health services. The community receives her health care from a government sponsored,
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Table 3 Examination findings.
Ear Findings PINNA EAM
Findings
School A(%)
School B(%)
Total(%)
p-value
Abnormal pinna
2(1.3)
0(0)
2(0.8)
0.5 0.08
Wax Otomycosis Purulent discharge Foreign body
60(38) 4(2.5) 3(1.9) 1(0.6)
47(53.4) 2(2.3) 4(4.5) 2(2.3)
107(43.5) 6(2.4) 7(2.8) 1(0.4)
Perforated TM TM retraction Dull TM Facial nerve palsy
3(1.9) 1(0.6) 5(3.2) 1(0.6)
4(4.5) 0(0) 0(0) 0(0)
7(2.8) 1(0.4) 5(2) 1(0.4)
1.0
Reduced/absent airflow Nasal discharge/crusts Septal deviation Engorged turbinates
8(5.1) 15(9.5) 1(0.6) 30(19)
5(5.7) 18(20.4) 0(0) 20(22.7)
13(5.3) 33(13.4) 1(0.4) 50(20.3)
0.8 0.04 1.0 0.5
Poor oral hygiene Ulcers Palpable cervical nodes
64(40.6) 1(0.6) 34(21.5)
27(30.7) 0(0) 17(19.3)
91(37) 1(0.4) 51(20.7)
Grade 1 tonsils Grade 2 tonsils Grade 3 tonsils Kissing tonsils
18(11.4) 109(69) 30(19) 1(0.6)
8(9.1) 61(69.3) 19(21.6) 0(0)
26(10.6) 170(69.1) 49(19.9) 1(0.4)
TM
0.3
Facial Nerve Nasal Findings Airflow Cavity Septum Turbinate Throat Findings Oral hygiene
Neck Oropharynx
0.02
0.4 0.6
EAM-External auditory meatus, TM-Tympanic membrane.
Fig. 1. Symptoms and Signs with respect to sex.
poorly manned rural ‘health centre’. The nearest source of proper primary health care to the community is located about 20 km away in the city, through an untarred rural road with irregular public transportation in and out of the community. Only 5% of the participants in this study had abnormal tympanic membranes with a little more than half of these showing signs of chronic otitis media. This is comparable to the reports from other developing countries but lower that the prevalence reported by a study in western Nigeria by Olusanya et al. [1,6,9,11,13]. This may be attributed to the widespread availability of antibiotics and the low threshold of its use within these areas. It may also imply that there is some improvement in health care within these areas. However one of the participants with COM was observed to have facial nerve palsy, an indication of poor management. A significant reduction in nasal airflow was observed in 5% of the participants but a greater number of the participants reported that they were experiencing nasal obstruction and discharge. Rhinitis is commonly seen in this age group and is often from allergy or of
viral origin [14]. It is often a source of discomfort and can cause sleep disturbances. The nasal obstruction observed in some of the participants could also be as a result of enlarged adenoids [14]. Other rhinological symptoms encountered were sneezing bouts and epistaxis. A greater proportion of females had sneezing bouts than the males, with a significant difference in its prevalence between the two sexes. There is a paucity of community based studies on the prevalence of rhinitis and asthma in the paediatric age group. Most of the participants had poor oro-dental hygiene and did not practice regular brushing of the teeth. This may imply that they are unaware of the consequences of poor dental hygiene. Children in rural areas will likely benefit from school based public health education on the benefits of good oro-dental hygiene. Most of them had grade I and II tonsils, 20% of the participants however had enlarged tonsils. None had inflamed tonsils despite the fact that about 5% of them reported some dysphagia and soreness of the throat. Enlarged tonsils are often seen in patients with obstructive adenoids and suggest that these participants may have some level of sleep disordered breathing [14]. If the negative effects of sleep disordered breathing are to be avoided in these children, their guardians must be educated on the signs of sleep disordered breathing and on its complications. 5. Conclusion Treatable ear, nose and throat disorders are still common amongst children in rural areas. People in these communities will benefit from regular otorhinolaryngological examinations and otorhinolaryngological health awareness campaigns. These areas often lack specialist ENT services, therefore Community Health Officers (CHO's) and Community Health Extension Workers (CHEW's) should be trained to manage common otorhinolaryngology conditions, with a clear referral pathway for the difficult cases. Tertiary hospitals may also organise regular community
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