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Characteristics of hearing impairment in Yemeni children with chronic suppurative otitis media: A case–control study
International Journal of Pediatric Otorhinolaryngology 74 (2010) 283–286
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Characteristics of hearing impairment in Yemeni children with chronic suppurative otitis media: A case–control study Mohamed A. Elemraid a, Bernard J. Brabin a,b,c, William D. Fraser d, Gregory Harper a, Brian Faragher a, Zayed Atef e, Nasher Al-Aghbari e, Ian J. Mackenzie a,* a
WHO Collaborating Centre on Hearing Impairment, Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, UK Global Child Health Group, Emma Kinderziekenhuis, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands Department of Community Child Health, Royal Liverpool Children’s NHS Trust, Liverpool, UK d Unit of Clinical Chemistry, School of Clinical Sciences, Liverpool University, Liverpool, UK e Department of Child Health, Al-Thawra General Hospital, Sana’a, Yemen b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 October 2009 Received in revised form 2 December 2009 Accepted 2 December 2009 Available online 29 December 2009
Background: Chronic suppurative otitis media (CSOM) is a serious disorder particularly in low resource settings. It can lead to disabling hearing impairment and sometimes life-threatening infective complications. Objective: The aim of the present study was to describe the characteristics of hearing impairment associated with CSOM in Yemeni children. Methods: A case–control study of 75 children with CSOM and 74 healthy controls. Hearing was assessed by behavioural testing and audiometry. Results: Cases had lower academic performance than controls (OR 15.31, 95% CI 1.99–322.14, p < 0.001). Disabling hearing impairment >30 dB was present in 51.5% (right ear) and 66.7% (left ear) of children with CSOM. Conclusion: Disabling hearing impairment was identified as a major health problem in these Yemeni children with CSOM. There is a need for investment to reduce the burden of CSOM and its complications in these communities. Greater attention to the chronic disabling effects of CSOM in children is required in poor communities and low resource settings. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Chronic suppurative otitis media Ear disease Hearing impairment Children
1. Introduction Childhood otitis media (OM) is a potentially serious disorder, since there is a risk of permanent hearing loss [1]. It occurs in approximately 30% of children [2], and in low resource settings common complications lead to significant hearing impairment [3]. This often follows poorly managed acute OM [4], and usually has its onset in early childhood [5]. It is defined as a tympanic membrane perforation with continuous purulent otorrhoea for at least 2 weeks [6,7]. CSOM may continue for years if untreated leading to serious disabling hearing impairment and sometimes life-threatening infective complications including brain abscess or sinus thrombosis [8]. Hearing impairment has serious effects on the child’s language, cognitive, psycho-social and educational development [9–12].
The hearing loss associated with CSOM is primarily conductive, resulting from the rupture of the tympanic membrane and the consequences of chronic inflammation [13,14]. Conductive hearing loss may occur in approximately half of children with CSOM, and sensorineural hearing loss in up to one fifth [15]. There is increasing emphasis on investigating the sensorineural hearing loss complicating CSOM [13,16], as conductive hearing loss can be reduced through surgical intervention, whereas sensorineural hearing loss is permanent and is helped only by the use of hearing aids [13]. The availability and affordability of hearing aids in low resource settings are major limitations [15]. The aim of the present study was to describe the characteristics of hearing impairment associated with CSOM in Yemeni children. This is the first study reporting this disability in children from Yemen. 2. Methods 2.1. Subjects and study design
* Corresponding author at: Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L5 5QA, UK. Tel.: +44 0 151 705 3306; fax: +44 0 151 705 3329. E-mail address: [email protected] (I.J. Mackenzie). 0165-5876/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.12.004
The study was undertaken at Al-Thawra General Hospital in Sana’a, Yemen. It is located in an area with a high level of urban
284
M.A. Elemraid et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 283–286
poverty and at an altitude of 2200 m (7220 ft.). Cases were all children with CSOM who presented in a 3-month study period in 2007. The controls were children from the same communities who volunteered to attend the Out-patient Department. All controls had normal physical and otoscopic examination. Cases were attending the ENT/paediatric Out-patient Department or Otoscopy Clinic with a clinical diagnosis of CSOM and a history of persistent discharging ear(s) for at least 2 weeks. Two children with brain abscess secondary to CSOM presented to the hospital. One was referred and was clinically stable and was included in the study. The other child was critically unwell and died within 24 h of admission. Parents/guardians of children eligible for enrolment were given an information sheet and written informed consent was obtained. Exclusion criteria were children with immune defects or HIV/AIDS, craniofacial abnormalities, tympanoplasty, malignancy, congenital lung, heart or kidney abnormalities, acrodermatitis enteropathica, or chromosomal abnormalities. A questionnaire was used which included information on demographic and health related characteristics, medical and family history, hearing difficulties and academic achievements at school. Audiological assessment was carried out in a sound-proof cabinet available in the Audiology Clinic. For older and cooperative children, hearing thresholds were established in each ear at 0.5, 1, 2 and 4 kHz using a KAMPLEX (KS 8) diagnostic audiometer with sound-proof headphones. Measurements expressed as decibels hearing level (dB.HL) were obtained according to the guidelines of the British Society of Audiology. For children less than 4 years of age, behavioural testing was performed using low frequency voice chime bars as well as a high frequency rattle, and a warble for low and high frequencies. The measurements were expressed as freefield dBA and with headphones as dB.HL. Behavioural testing included: a distraction hearing test for children aged less than 1 year, cooperative test for children in their second year of age and performance test for children aged between 2 and 4 years. Rinne and Weber tests were performed on cooperative children to assess air and bone conduction using a tuning fork (512 Hz). Otoscopy was performed on all children. Age criteria for choice of hearing assessment were flexible depending on the child’s cooperation. This study received ethical approval from Research Ethics Committees at the Liverpool School of Tropical Medicine and AlThawra General Hospital, Yemen. 2.2. Statistical analysis Data analysis was performed using PASW Statistics 17. Differences between cases and controls were analysed using the Fisher’s exact test, Student’s unpaired t-test or Mann–Whitney’s Utest. 3. Results Fewer cases (n = 3) than controls (n = 11) had followed preparatory school education (p = 0.049). Although consanguinity was highly prevalent (>50%) there was no difference in the reported rates for cases or controls (Table 1). Overall academic achievement for cases was far worse than for controls with 43.3% of cases of poor achievers compared to 2.8% of controls (p < 0.001). Almost 90% of cases had recurrent episodes of ear discharge and two-thirds had bilateral ear involvement (Table 2). The duration of ear discharge was more than a year in two-thirds of cases, and more 5 years for a quarter of children. Both ears were involved in 70.7%. Of the 75 cases, a hearing test had been performed previously in only three children (Table 2). Table 3 summarises audiometric findings in 33 cases and 52 controls who were tested by audiometry. According to the WHO
Table 1 Demographic and social characteristics. Characteristic
Cases (n = 75)
Controls (n = 74)
p value
Age (year), median (range) Male, n (%)
5.3 (0.6–15) 41 (54.7)
8.2 (0.9–15) 42 (56.8)
Recruitment, n (%) ENT outpatient Paediatric outpatient Community
64 (85.3) 5 (6.7) 6 (8.0)
0 5 (6.8) 69 (93.2)
<0.001 – – –
Number of siblings, median (range) 1st/2nd degree consanguinity, n (%) Primary school education, n (%)
2 (0–9) 41 (54.7) 30 (40.0)
3 (0–9) 45 (60.0) 35 (47.3)
0.011 0.621 0.322
Academic level achieved, n (%) Poor Good Excellent
13 (43.3) 10 (33.3) 7 (23.3)
1 (2.8) 15 (42.9) 19 (54.3)
<0.001 <0.001 0.435 0.012
0.001 0.869
grading of hearing impairment using audiometric values, disabling hearing impairment (more than 30 dB) was present in 51.5% of cases (right ear) and 66.7% (left ear). All except four younger children (all cases) passed the behavioural hearing assessment. There were 14 different approaches used for treating children with CSOM (Table 4). The combination of mopping, systemic antibiotics and ear drops was the commonest approach (24%). None of the cases had parents/guardians who were aware of the type of ear/nasal drops used for their child. 4. Discussion There is a remarkable global burden of childhood hearing impairment particularly in poor resource countries where CSOM is a recognised cause of this hearing impairment [17,18]. Early detection of CSOM and effective management of hearing impairment during the first few years of life are essential to prevent serious deficits in language and educational development [9,10,19], which can lead to impaired psycho-social development [12,20]. The finding of poorer academic performance in our cases compared to controls is consistent with previous reports from western countries of poor educational attainment in children with CSOM [9,10,12,19,20]. Lack of awareness by parents/guardians of the type of ear drops used leads to poor understanding of management. The heterogeneous approach to the management of these children indicates a lack of standardised management guidelines and probably misunderstanding amongst parents. Many children had a chronic history of ear discharge of up to 14 years duration and previously had not had a hearing test, and audiometry was performed previously in only three cases prior to their recruitment to this study. There is a need for increased active surveillance to identify hearing problems in these communities and clearer guidelines of the need for audiometry in affected children and for follow-up monitoring of their progress. WHO defines disabling hearing impairment as a permanent unaided hearing threshold in the better ear of more than 30 dB in children aged up to 15 years, or more than 40 dB in adults at frequencies of 0.5, 1, 2, and 4 kHz. This definition is commonly associated with an element of sensorineural hearing impairment [17]. In cooperative CSOM cases where audiometry assessment was performed, disabling hearing impairment was noted in approximately half and two-thirds of the right and left ears respectively, indicating the importance of conductive hearing impairment in these children. No cases used hearing aids which may relate to poor delivery, limited access to audiological services, or little awareness of health care providers and the need for early recognition and rehabilitation of hearing impairment. Their use was encouraged in the study children but hearing aids were
M.A. Elemraid et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 283–286
285
Table 2 Summary of otoscopic findings and clinical history of cases with CSOM. Finding
Unilateral CSOM, n = 22 (%)
Bilateral CSOM, n = 53 (%)
Both ears combined, n = 75, n (%; 95% CI)
Right
Left
Right
Left
Right
Left
Pus Dry perforation Inflamed Normal
7 (31.8) 1 (4.5) 1 (4.5) 13 (50.0)
10 (45.5) 2 (9.1) 1 (4.5) 9 (40.9)
35 (66.0) 18 (34.0) 0 0
39 (73.6) 14 (26.4) 0 0
42 19 1 13
49 16 1 9
Frequency First episode Recurrent
5 (22.7) 17 (77.3)
5 (9.4) 48 (90.6)
10 (13.3; 6.6–23.2) 65 (86.7; 76.8–93.4)
Duration (year)a <1 1–5 >5
1.0 [0.04–14.0] 9 (40.9) 9 (40.9) 4 (18.2)
3.0 [0.08–12.0] 12 (22.6) 25 (47.2) 16 (30.2)
2.0 (0.42–5.0) [0.04–14.0] 21 (28.0; 18.2–39.6) 34 (45.3; 33.8–57.3) 20 (26.7; 17.1–38.1)
Age 1st episodea Previous hearing test/passed
4.0 [0.25–14.0] 0/0
2.0 [0.08–8.50] 3 (5.7)/0
2.0 (0.75–5.0) [0.08–14.0] 3 (4.0; 0.8–11.2)
a
(56.0; 44.1–67.5) (25.3; 16.0–36.7) (1.3; 0.03–7.2) (17.3; 9.6–27.8)
(65.3; 53.5–76.0) (21.3; 12.7–32.3) (1.3; 0.03–7.2) (12.0; 5.6–21.6)
Median (IQR) [range].
Table 3 Audiometric averages of speech frequencies at 0.5, 1, 2 and 4 kHz. Hearing impairment (dB)
None (25 or less) Mild (26–30) Moderate (31–60) Severe (61–80) Profound (81 or more)
Cases (n = 33)
Controls (n = 52)
Right
Left
Right
Left
13 (39.4; 22.9–57.9) 3 (9.1; 1.9–24.3) 17 (51.5; 33.5–69.2) 0 0
8 2 22 0 1
51 (98.1; 87.0–99.9) 1 (1.9; 0.1–10.1) 0 0 0
48 (92.3; 81.8–97.9) 4 (7.5; 2.1–18.2) 0 0 0
(24.2; 11.1–42.3) (6.1; 0.7–20.2) (66.7; 48.2–82.0) (3.0; 0.1–15.8)
n (%; 95% CI).
expensive, and in low resource settings health systems are often unable to cope with the added morbidity due to non-fatal but disabling hearing impairment without external technical and financial support [17]. In some families it was clear that CSOM with its complications was placing an increased socio-economic burden on the household, particularly if there was more than one child with CSOM. Early intervention programs for children with hearing impairment using the family-centred approach are increasingly practiced in developed countries [21]. This approach allows families and communities to take an active role in the rehabilitation of their children and to work collaboratively with professionals in order to tailor and strengthen a programme according to individual needs [22]. The focus of these programmes is to encourage parents to play a central role in monitoring and development of their child’s language and communication skills through daily play activities [21].
5. Conclusion
Table 4 Summary of treatment approaches for cases.
Acknowledgements
Treatment
n (%; 95% CI)
Mopping + ear drops + systemic antibiotics 18 (24.0; 14.9–35.3) Mopping + ear drops 14 (18.7; 10.6–29.3) Mopping 7 (9.3; 3.8–18.3) Mopping + ear drops + systemic antibiotics + oil drops 6 (8.0; 3.0–16.6) Mopping + ear drops + systemic antibiotics + nasal drops 5 (6.7; 2.2–14.9) Mopping + systemic antibiotics 5 (6.7; 2.2–14.9) Ear drops + systemic antibiotics + nasal drops 5 (6.7; 2.2–14.9) Ear drops + systemic antibiotics 5 (6.7; 2.2–14.9) Mopping + systemic antibiotics + nasal drops 2 (2.7; 0.3–9.3) Systemic antibiotics + nasal drops 2 (2.7; 0.3–9.3) Ear drops 2 (2.7; 0.3–9.3) Mopping + ear drops + nasal drops 1 (1.3; 0.03–7.2) Nasal drops 1 (1.3; 0.03–7.2) Systemic antibiotics 1 (1.3; 0.03–7.2) No treatment (new patient with first episode of CSOM) 1 (1.3; 0.03–7.2) Total
75
This study highlights that childhood CSOM and disabling hearing impairment are substantial health problems in Yemen. There is a need for investment in reducing the burden of CSOM and its complications in these communities including: clear guidelines on management of CSOM, improvement of audiology services in particular the diagnosis and rehabilitation of disabling hearing impairment in children, and increased access to hearing aids as part of long-term management. Greater attention to the chronic disabling effects of CSOM in children is required in poor communities and low resource settings. Competing interests None.
We are grateful to Pamela Routledge, Senior Audiologist from Oldham Primary Care Trust and IJM for training MAE on behavioural hearing assessment, performing and interpreting audiometry, Rinne and Weber tests, and to Oldham Primary Care Trust for loaning the equipment for behavioural hearing assessment. Funding: This work was supported by the Liverpool School of Tropical Medicine, UK, and a Libyan Government Training Scholarship. References [1] A.J. Beswick, B. Lawley, A.P. Fraise, A.L. Pahor, N.L. Brown, Detection of Alloiococcus otitis in mixed bacterial populations from middle-ear effusions of patients with otitis media, Lancet 354 (1999) 386–389. [2] M.E. Pichichero, Recurrent and persistent otitis media, Pediatr. Infect. Dis. J. 19 (2000) 911–916.
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[3] World Health Organization, Prevention of deafness and hearing impairment, Geneva, WHO, 1986, Document A39/14. [4] M.A. Kenna, Epidemiology and natural history of chronic suppurative otitis media, Ann. Otol. Rhinol. Laryngol. 97 (1988) 8. [5] B.C. Okafor, The chronic discharging ear in Nigeria, J. Laryngol. Otol. 98 (1984) 113–119. [6] World Health Organization, Management of childhood illnesses, Geneva, WHO, 1995, WHO/CDR/95.14.A–L. [7] W.L. Meyerhoff, Pathology of chronic suppurative otitis media, Ann. Otol. Rhinol. Laryngol. 97 (1988) 21–24. [8] J. Kangsanarak, S. Fooanant, K. Ruckphaopunt, N. Navacharoen, S. Teotrakul, Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases, J. Laryngol. Otol. 107 (1993) 999–1004. [9] S. Nittrouer, L.T. Burton, The role of early language experience in the development of speech perception and phonological processing abilities: evidence from 5-yearolds with histories of otitis media with effusion and low socioeconomic status, J. Commun. Disord. 38 (2005) 29–63. [10] H. Winskel, The effects of an early history of otitis media on children’s language and literacy skill development, Br. J. Educ. Psychol. 76 (2006) 727–744. [11] F. Olatoke, F.E. Ologe, C.C. Nwawolo, M.J. Saka, The prevalence of hearing loss among school children with chronic suppurative otitis media in Nigeria, and its effect on academic performance, Ear Nose Throat J. 87 (2008) E19. [12] L. Bellussi, M. Mandala, F.M. Passali, G.C. Passali, M. Lauriello, D. Passali, Quality of life and psycho-social development in children with otitis media with effusion, Acta Otorhinolaryngol. Ital. 25 (2005) 359–364.
[13] S.S. da Costa, L.P. Rosito, C. Dornelles, Sensorineural hearing loss in patients with chronic otitis media, Eur. Arch. Otorhinolaryngol. 266 (2009) 221–224. [14] A.D. Olusesi, Otitis media as a cause of significant hearing loss among Nigerians, Int. J. Pediatr. Otorhinolaryngol. 72 (2008) 787–792. [15] A.O. Lasisi, O.A. Sulaiman, O.A. Afolabi, Socio-economic status and hearing loss in chronic suppurative otitis media in Nigeria, Ann. Trop. Paediatr. 27 (2007) 291– 296. [16] A.F. de Azevedo, D.C. Pinto, N.J. de Souza, D.B. Greco, D.U. Goncalves, Sensorineural hearing loss in chronic suppurative otitis media with and without cholesteatoma, Braz. J. Otorhinolaryngol. 73 (2007) 671–674. [17] B.O. Olusanya, V.E. Newton, Global burden of childhood hearing impairment and disease control priorities for developing countries, Lancet 369 (2007) 1314–1317. [18] World Health Organization, Deafness and hearing impairment, Geneva, WHO, 2006, Fact sheet no. 300. [19] C.R. Kennedy, D.C. McCann, M.J. Campbell, C.M. Law, M. Mullee, S. Petrou, et al., Language ability after early detection of permanent childhood hearing impairment, N. Engl. J. Med. 354 (2006) 2131–2141. [20] R.J. Ruben, Redefining the survival of the fittest: communication disorders in the 21st century, Laryngoscope 110 (2000) 241–245. [21] S. Ingber, E. Dromi, Actual versus desired family-centered practice in early intervention for children with hearing loss, J. Deaf Stud. Deaf Educ. 15 (2010) 59–71. [22] S.L. McBride, M.J. Brotherson, H. Joanning, D. Whiddon, A. Demmitt, Implementation of family centered services: perceptions of families and professionals, Infants Young Child. 1 (1993) 10–21.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Characteristics of hearing impairment in Yemeni children with chronic suppurative otitis media: A case–control study Mohamed A. Elemraid a, Bernard J. Brabin a,b,c, William D. Fraser d, Gregory Harper a, Brian Faragher a, Zayed Atef e, Nasher Al-Aghbari e, Ian J. Mackenzie a,* a
WHO Collaborating Centre on Hearing Impairment, Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, UK Global Child Health Group, Emma Kinderziekenhuis, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands Department of Community Child Health, Royal Liverpool Children’s NHS Trust, Liverpool, UK d Unit of Clinical Chemistry, School of Clinical Sciences, Liverpool University, Liverpool, UK e Department of Child Health, Al-Thawra General Hospital, Sana’a, Yemen b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 October 2009 Received in revised form 2 December 2009 Accepted 2 December 2009 Available online 29 December 2009
Background: Chronic suppurative otitis media (CSOM) is a serious disorder particularly in low resource settings. It can lead to disabling hearing impairment and sometimes life-threatening infective complications. Objective: The aim of the present study was to describe the characteristics of hearing impairment associated with CSOM in Yemeni children. Methods: A case–control study of 75 children with CSOM and 74 healthy controls. Hearing was assessed by behavioural testing and audiometry. Results: Cases had lower academic performance than controls (OR 15.31, 95% CI 1.99–322.14, p < 0.001). Disabling hearing impairment >30 dB was present in 51.5% (right ear) and 66.7% (left ear) of children with CSOM. Conclusion: Disabling hearing impairment was identified as a major health problem in these Yemeni children with CSOM. There is a need for investment to reduce the burden of CSOM and its complications in these communities. Greater attention to the chronic disabling effects of CSOM in children is required in poor communities and low resource settings. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Chronic suppurative otitis media Ear disease Hearing impairment Children
1. Introduction Childhood otitis media (OM) is a potentially serious disorder, since there is a risk of permanent hearing loss [1]. It occurs in approximately 30% of children [2], and in low resource settings common complications lead to significant hearing impairment [3]. This often follows poorly managed acute OM [4], and usually has its onset in early childhood [5]. It is defined as a tympanic membrane perforation with continuous purulent otorrhoea for at least 2 weeks [6,7]. CSOM may continue for years if untreated leading to serious disabling hearing impairment and sometimes life-threatening infective complications including brain abscess or sinus thrombosis [8]. Hearing impairment has serious effects on the child’s language, cognitive, psycho-social and educational development [9–12].
The hearing loss associated with CSOM is primarily conductive, resulting from the rupture of the tympanic membrane and the consequences of chronic inflammation [13,14]. Conductive hearing loss may occur in approximately half of children with CSOM, and sensorineural hearing loss in up to one fifth [15]. There is increasing emphasis on investigating the sensorineural hearing loss complicating CSOM [13,16], as conductive hearing loss can be reduced through surgical intervention, whereas sensorineural hearing loss is permanent and is helped only by the use of hearing aids [13]. The availability and affordability of hearing aids in low resource settings are major limitations [15]. The aim of the present study was to describe the characteristics of hearing impairment associated with CSOM in Yemeni children. This is the first study reporting this disability in children from Yemen. 2. Methods 2.1. Subjects and study design
* Corresponding author at: Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L5 5QA, UK. Tel.: +44 0 151 705 3306; fax: +44 0 151 705 3329. E-mail address: [email protected] (I.J. Mackenzie). 0165-5876/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.12.004
The study was undertaken at Al-Thawra General Hospital in Sana’a, Yemen. It is located in an area with a high level of urban
284
M.A. Elemraid et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 283–286
poverty and at an altitude of 2200 m (7220 ft.). Cases were all children with CSOM who presented in a 3-month study period in 2007. The controls were children from the same communities who volunteered to attend the Out-patient Department. All controls had normal physical and otoscopic examination. Cases were attending the ENT/paediatric Out-patient Department or Otoscopy Clinic with a clinical diagnosis of CSOM and a history of persistent discharging ear(s) for at least 2 weeks. Two children with brain abscess secondary to CSOM presented to the hospital. One was referred and was clinically stable and was included in the study. The other child was critically unwell and died within 24 h of admission. Parents/guardians of children eligible for enrolment were given an information sheet and written informed consent was obtained. Exclusion criteria were children with immune defects or HIV/AIDS, craniofacial abnormalities, tympanoplasty, malignancy, congenital lung, heart or kidney abnormalities, acrodermatitis enteropathica, or chromosomal abnormalities. A questionnaire was used which included information on demographic and health related characteristics, medical and family history, hearing difficulties and academic achievements at school. Audiological assessment was carried out in a sound-proof cabinet available in the Audiology Clinic. For older and cooperative children, hearing thresholds were established in each ear at 0.5, 1, 2 and 4 kHz using a KAMPLEX (KS 8) diagnostic audiometer with sound-proof headphones. Measurements expressed as decibels hearing level (dB.HL) were obtained according to the guidelines of the British Society of Audiology. For children less than 4 years of age, behavioural testing was performed using low frequency voice chime bars as well as a high frequency rattle, and a warble for low and high frequencies. The measurements were expressed as freefield dBA and with headphones as dB.HL. Behavioural testing included: a distraction hearing test for children aged less than 1 year, cooperative test for children in their second year of age and performance test for children aged between 2 and 4 years. Rinne and Weber tests were performed on cooperative children to assess air and bone conduction using a tuning fork (512 Hz). Otoscopy was performed on all children. Age criteria for choice of hearing assessment were flexible depending on the child’s cooperation. This study received ethical approval from Research Ethics Committees at the Liverpool School of Tropical Medicine and AlThawra General Hospital, Yemen. 2.2. Statistical analysis Data analysis was performed using PASW Statistics 17. Differences between cases and controls were analysed using the Fisher’s exact test, Student’s unpaired t-test or Mann–Whitney’s Utest. 3. Results Fewer cases (n = 3) than controls (n = 11) had followed preparatory school education (p = 0.049). Although consanguinity was highly prevalent (>50%) there was no difference in the reported rates for cases or controls (Table 1). Overall academic achievement for cases was far worse than for controls with 43.3% of cases of poor achievers compared to 2.8% of controls (p < 0.001). Almost 90% of cases had recurrent episodes of ear discharge and two-thirds had bilateral ear involvement (Table 2). The duration of ear discharge was more than a year in two-thirds of cases, and more 5 years for a quarter of children. Both ears were involved in 70.7%. Of the 75 cases, a hearing test had been performed previously in only three children (Table 2). Table 3 summarises audiometric findings in 33 cases and 52 controls who were tested by audiometry. According to the WHO
Table 1 Demographic and social characteristics. Characteristic
Cases (n = 75)
Controls (n = 74)
p value
Age (year), median (range) Male, n (%)
5.3 (0.6–15) 41 (54.7)
8.2 (0.9–15) 42 (56.8)
Recruitment, n (%) ENT outpatient Paediatric outpatient Community
64 (85.3) 5 (6.7) 6 (8.0)
0 5 (6.8) 69 (93.2)
<0.001 – – –
Number of siblings, median (range) 1st/2nd degree consanguinity, n (%) Primary school education, n (%)
2 (0–9) 41 (54.7) 30 (40.0)
3 (0–9) 45 (60.0) 35 (47.3)
0.011 0.621 0.322
Academic level achieved, n (%) Poor Good Excellent
13 (43.3) 10 (33.3) 7 (23.3)
1 (2.8) 15 (42.9) 19 (54.3)
<0.001 <0.001 0.435 0.012
0.001 0.869
grading of hearing impairment using audiometric values, disabling hearing impairment (more than 30 dB) was present in 51.5% of cases (right ear) and 66.7% (left ear). All except four younger children (all cases) passed the behavioural hearing assessment. There were 14 different approaches used for treating children with CSOM (Table 4). The combination of mopping, systemic antibiotics and ear drops was the commonest approach (24%). None of the cases had parents/guardians who were aware of the type of ear/nasal drops used for their child. 4. Discussion There is a remarkable global burden of childhood hearing impairment particularly in poor resource countries where CSOM is a recognised cause of this hearing impairment [17,18]. Early detection of CSOM and effective management of hearing impairment during the first few years of life are essential to prevent serious deficits in language and educational development [9,10,19], which can lead to impaired psycho-social development [12,20]. The finding of poorer academic performance in our cases compared to controls is consistent with previous reports from western countries of poor educational attainment in children with CSOM [9,10,12,19,20]. Lack of awareness by parents/guardians of the type of ear drops used leads to poor understanding of management. The heterogeneous approach to the management of these children indicates a lack of standardised management guidelines and probably misunderstanding amongst parents. Many children had a chronic history of ear discharge of up to 14 years duration and previously had not had a hearing test, and audiometry was performed previously in only three cases prior to their recruitment to this study. There is a need for increased active surveillance to identify hearing problems in these communities and clearer guidelines of the need for audiometry in affected children and for follow-up monitoring of their progress. WHO defines disabling hearing impairment as a permanent unaided hearing threshold in the better ear of more than 30 dB in children aged up to 15 years, or more than 40 dB in adults at frequencies of 0.5, 1, 2, and 4 kHz. This definition is commonly associated with an element of sensorineural hearing impairment [17]. In cooperative CSOM cases where audiometry assessment was performed, disabling hearing impairment was noted in approximately half and two-thirds of the right and left ears respectively, indicating the importance of conductive hearing impairment in these children. No cases used hearing aids which may relate to poor delivery, limited access to audiological services, or little awareness of health care providers and the need for early recognition and rehabilitation of hearing impairment. Their use was encouraged in the study children but hearing aids were
M.A. Elemraid et al. / International Journal of Pediatric Otorhinolaryngology 74 (2010) 283–286
285
Table 2 Summary of otoscopic findings and clinical history of cases with CSOM. Finding
Unilateral CSOM, n = 22 (%)
Bilateral CSOM, n = 53 (%)
Both ears combined, n = 75, n (%; 95% CI)
Right
Left
Right
Left
Right
Left
Pus Dry perforation Inflamed Normal
7 (31.8) 1 (4.5) 1 (4.5) 13 (50.0)
10 (45.5) 2 (9.1) 1 (4.5) 9 (40.9)
35 (66.0) 18 (34.0) 0 0
39 (73.6) 14 (26.4) 0 0
42 19 1 13
49 16 1 9
Frequency First episode Recurrent
5 (22.7) 17 (77.3)
5 (9.4) 48 (90.6)
10 (13.3; 6.6–23.2) 65 (86.7; 76.8–93.4)
Duration (year)a <1 1–5 >5
1.0 [0.04–14.0] 9 (40.9) 9 (40.9) 4 (18.2)
3.0 [0.08–12.0] 12 (22.6) 25 (47.2) 16 (30.2)
2.0 (0.42–5.0) [0.04–14.0] 21 (28.0; 18.2–39.6) 34 (45.3; 33.8–57.3) 20 (26.7; 17.1–38.1)
Age 1st episodea Previous hearing test/passed
4.0 [0.25–14.0] 0/0
2.0 [0.08–8.50] 3 (5.7)/0
2.0 (0.75–5.0) [0.08–14.0] 3 (4.0; 0.8–11.2)
a
(56.0; 44.1–67.5) (25.3; 16.0–36.7) (1.3; 0.03–7.2) (17.3; 9.6–27.8)
(65.3; 53.5–76.0) (21.3; 12.7–32.3) (1.3; 0.03–7.2) (12.0; 5.6–21.6)
Median (IQR) [range].
Table 3 Audiometric averages of speech frequencies at 0.5, 1, 2 and 4 kHz. Hearing impairment (dB)
None (25 or less) Mild (26–30) Moderate (31–60) Severe (61–80) Profound (81 or more)
Cases (n = 33)
Controls (n = 52)
Right
Left
Right
Left
13 (39.4; 22.9–57.9) 3 (9.1; 1.9–24.3) 17 (51.5; 33.5–69.2) 0 0
8 2 22 0 1
51 (98.1; 87.0–99.9) 1 (1.9; 0.1–10.1) 0 0 0
48 (92.3; 81.8–97.9) 4 (7.5; 2.1–18.2) 0 0 0
(24.2; 11.1–42.3) (6.1; 0.7–20.2) (66.7; 48.2–82.0) (3.0; 0.1–15.8)
n (%; 95% CI).
expensive, and in low resource settings health systems are often unable to cope with the added morbidity due to non-fatal but disabling hearing impairment without external technical and financial support [17]. In some families it was clear that CSOM with its complications was placing an increased socio-economic burden on the household, particularly if there was more than one child with CSOM. Early intervention programs for children with hearing impairment using the family-centred approach are increasingly practiced in developed countries [21]. This approach allows families and communities to take an active role in the rehabilitation of their children and to work collaboratively with professionals in order to tailor and strengthen a programme according to individual needs [22]. The focus of these programmes is to encourage parents to play a central role in monitoring and development of their child’s language and communication skills through daily play activities [21].
5. Conclusion
Table 4 Summary of treatment approaches for cases.
Acknowledgements
Treatment
n (%; 95% CI)
Mopping + ear drops + systemic antibiotics 18 (24.0; 14.9–35.3) Mopping + ear drops 14 (18.7; 10.6–29.3) Mopping 7 (9.3; 3.8–18.3) Mopping + ear drops + systemic antibiotics + oil drops 6 (8.0; 3.0–16.6) Mopping + ear drops + systemic antibiotics + nasal drops 5 (6.7; 2.2–14.9) Mopping + systemic antibiotics 5 (6.7; 2.2–14.9) Ear drops + systemic antibiotics + nasal drops 5 (6.7; 2.2–14.9) Ear drops + systemic antibiotics 5 (6.7; 2.2–14.9) Mopping + systemic antibiotics + nasal drops 2 (2.7; 0.3–9.3) Systemic antibiotics + nasal drops 2 (2.7; 0.3–9.3) Ear drops 2 (2.7; 0.3–9.3) Mopping + ear drops + nasal drops 1 (1.3; 0.03–7.2) Nasal drops 1 (1.3; 0.03–7.2) Systemic antibiotics 1 (1.3; 0.03–7.2) No treatment (new patient with first episode of CSOM) 1 (1.3; 0.03–7.2) Total
75
This study highlights that childhood CSOM and disabling hearing impairment are substantial health problems in Yemen. There is a need for investment in reducing the burden of CSOM and its complications in these communities including: clear guidelines on management of CSOM, improvement of audiology services in particular the diagnosis and rehabilitation of disabling hearing impairment in children, and increased access to hearing aids as part of long-term management. Greater attention to the chronic disabling effects of CSOM in children is required in poor communities and low resource settings. Competing interests None.
We are grateful to Pamela Routledge, Senior Audiologist from Oldham Primary Care Trust and IJM for training MAE on behavioural hearing assessment, performing and interpreting audiometry, Rinne and Weber tests, and to Oldham Primary Care Trust for loaning the equipment for behavioural hearing assessment. Funding: This work was supported by the Liverpool School of Tropical Medicine, UK, and a Libyan Government Training Scholarship. References [1] A.J. Beswick, B. Lawley, A.P. Fraise, A.L. Pahor, N.L. Brown, Detection of Alloiococcus otitis in mixed bacterial populations from middle-ear effusions of patients with otitis media, Lancet 354 (1999) 386–389. [2] M.E. Pichichero, Recurrent and persistent otitis media, Pediatr. Infect. Dis. J. 19 (2000) 911–916.
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