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Prevalence of otitis media, hearing impairment and cerumen impaction among school children in rural and urban Dar es Salaam, Tanzania
International Journal of Pediatric Otorhinolaryngology
ELSEVIER
31 (1996)
29-34
Prevalence of otitis media, hearing impairment and cerumen impaction among school children in rural and urban Dar es Salaam, Tanzania B.M. Minja*, Department
of Otorhinolaryngology,
A. Machemba
Muhimbili University College Dar Es Salaam, Tanzania
of Health
Sciences,
P.O.
Box
6.5001,
Received 11 December 1995; revised 26 March 1996; accepted 31 March 1996
Abstract Eight hundred and two (802) primary school children in rural and urban Dar es Salaam, Tanzania, were examined to determine the prevalence of otitis media, hearing impairment and cerumen impaction by otoscopy and pure tone audiometry. Ear disease was found in 222 (27.7%) of the children. One hundred and twenty six (15.7%) had cerumen impaction, 70 (8.7%) had sensorineural hearing loss and 21 (2.6%) had chronic suppurative otitis media. Cerumen impaction was found in 20.45% of the rural school children and in 14.8% of the urban school children. This difference in prevalence between the two groups was not statistically significant. The prevalence of chronic suppurative otitis media (COM) was 9.44% among the rural school children and 1.30% among the urban school children, the difference being statistically significant (P < 0.001). Sensorineural hearing impairment was found in 14.1% of the rural school children and in 7.7% of the urban children, this also being statistically significant (P < 0.05). The low prevalence of chronic suppurative otitis media among the urban school children is ascribed to better medical services which facilitate early diagnosis and treatment of acute otitis media. This emphasizes the need to improve the health services in the rural areas so that acute otitis media is diagnosed and treated at the primary level of health care. This will in turn prevent hearing impairment due to chronic suppurative otitis media.
* Corresponding author. 0165-5876/96/$15.00 0 1996 Elsevier Science Ireland Ltd. All rights reserved PZI SO1 65-5876(96)01363-8
30
B.M.
Minja,
A. Machemba
/ Int. J. Pediatr.
Otorhinolaryngol.
37 (1996)
29-34
Ear disease:chronic suppurative otitis media; Hearing impairment; Cerumen impaction; School children; Dar es Salaam,Tanzania Keywords:
1. Introduction Most published data show high but variable prevalence of otitis media in Africa. The data also shows marked differences in the prevalence of chronic otitis media (COM) and secretory otitis media (SOM). In a South African study, Halama et al. [l] found a prevalence of otitis media of 8.2% among children from a black African community. In this study, COM was found in 0.7% and SOM in 3.8%. Similar trends were reported by Miller et al. [2] in a study of Nigerian children in whom the prevalence of COM was 4.1% and that of SOM was 19.4%. On the contrary, McPhersen et al. [3], in a Gambian school children study, found signs of previous middle ear infection in 15.1% and active infection in 1.3% and 3.1% with predominance of COM during different seasons. In a study done in Northern Tanzania, Bastos et al. [4] found a prevalence of COM of 1.6% among school children in urban and rural settings. In this study, there was no statistically different prevalence of COM between the urban and rural school children. However, there were significantly more children with scarred and tympanosclerotic drum membranes among the rural children when compared to that among the urban children. SOM was found in only 0.2% of the urban and rural school children respectively. This study was conducted to determine among urban and rural school children in Dar es Salaam, Tanzania: The prevalence of suppurative otitis media The prevalence of sensorinueral hearing loss The prevalence of cerumen impaction
2. Materials 2.1. Study
and methods area
Dar es Salaam is the capital and one of the twenty administrative regions of Tanzania. It is situated on the Indian Ocean coast of Tanzania mainland. There are three districts in Dar es Salaam, namely Ilala, Temeke and Kinondoni. While Hala district is wholly in the city part of Dar es Salaam, Temeke and Kinondoni districts have rural and urban settings. The population of Dar es Salaam is currently estimated to be 2 50000 people,
based on the 1988 census distributed
in both the rural and urban settings. In the
rural settings, the population density is low and the inhabitants depend largely on
subsistence farming. In the urban settings, the population
density is high and the
B.M.
Minja,
A. Marhemba
/ Imt. J. Pediatr.
Otorhinolaryngol.
37 (1996)
29-34
31
inhabitants earn their living from wages/salaries or business. The rural inhabitants have a lower income than the urban inhabitants. The primary schools in this study were randomly selected; one from the rural setting 35 km away from the city centre and the other one from the city centre. Both the schools are in Temeke district. 2.2. School children
The rural primary school children were aged from 5 to 20 years, with a mean of 13.9 years. There were 127 children, of whom 65 (51%) were males and 62 (49%) were females. The urban school children were aged from 5 to 19, with a mean age of 12.1 years. There were 675 children of whom 377 (56%) were males and 298 (44%) were females. All the children in each school were examined. 2.3. Examination
All the children were examined by the author (B.M) in a selected room in their respective schools. Otoscopy was done using a pneumatic otoscope or a forehead light depending on the situation. In the urban school, electricity was available. In the rural school, a petrol powered portable generator was used to generate electricity to power the forehead light. Following inspection to note any congenital anomalies, otoscopy was carried out on all the children. Cerumen was recorded only when it was impacted in the external canal. In such cases, using a forehead light, the cerumen was gently removed with a cerumen hook. Similarly, when pus discharge was found in the external canal, this was gently mopped out using cotton wool buds under direct vision. The external canals and drum membranes were inspected for exostoses, atresia, diffuse or localised external canal infection, drum membrane perforations, tympanosclerosis and evidence of middle ear effusion. The drum membrane was recorded as normal when it was noted to be greyish white in colour and the anatomical landmarks clearly visualised. All the findings were recorded on a specifically designed form. 2.4. Audiometry
In both schools, a room was selected in a quiet building for pure tone audiometry screening. A Bosch ST 10 audiometer was used for the screening procedure. The hearing threshold for air conduction (AC) was determined for the frequencies 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz. Those children who failed the screening test were eventually retested in a soundproof room at our Mulhmbili Medical Centre Clinic using a Bosch KT 10 biologically calibrated audiometer by the co-author (AM) who is an audiology assistant. AC and bone conduction (BC) thresholds at 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz and 8000 Hz were determined on all the children in this category. The averages of the AC thresholds at 500 Hz, 1000 Hz and 2000 Hz were calculated and recorded on a data collection form.
32
B.M.
Minja,
A. Machemba
/ Int. J. Pediatr.
Otorhinolaryngol.
37 (1996)
29-34
2.5. Data processing
The data collection forms for the children were analysed and the results tabulated. Statistical significance was determined using the chi-square test.
3. Results 3.1. Otoscopy
Table 1 shows the otoscopic findings in the 802 children examined. Five hundred and sixty four (81%) had normal external ears and drum membranes. Overall, 126 (15.7%) had cerumen impaction which, following removal, revealed normal drum membranes. The cerumen impaction of 20.5% among the rural school children and that of 14.8% among the urban school children was not statistically different. Active COM was found in 2.6% of all the children. The prevalences for COM of 9.5% among the rural school children and 1.3% among the urban school children were significantly statistically different (P < 0.001). There was only one child (0.15%) with SOM, a very low prevalence indeed. 3.2. Audiometry results
All the children with COM had conductive hearing loss and in none was the hearing threshold greater than 30 dB H.L. Table 2 shows the results for the 18 rural and 52 urban children with sensorineural hearing loss. The prevalence of sensorineural hearing loss is 14.1% among the
Table 1 Otoscopic findings Findings
Rural children n
Normal Cerumen COM Otitis media Foreign body SOM
Urban children o/
86 26 12 2
67.7 20.5 9.5 1.6 -
1 121
0.8 100
n
564 100 9 1 I 675
Total o/o
83.6 14.8 1.3 1.15 1.15 100
n
%
650 126 21 3 1 1 802
81.0 15.7 2.6 0.4 0.15 0.15 100
COM, chronic otitis media; SMO, secretory otitis media Rural school children have a higher prevalence of chronic otitis media than urban children (P < 0.001). The prevalence of cerumen impaction is not significantly different when the prevalence of the rural and urban school children for this condition are compared.
B.M.
Minja,
A. Machemba
1 Int. J. Pediatr.
Otorhinolaryngol.
37 (1996)
33
29-34
Table 2 Sensorineural hearing loss Hearing loss dB.HL
<0.25 26-30 31-40 41-50 51-60 Total
Urban children
Rural children M
F
T
‘I/o
M
F
T
%I
2 6 1
2 I 0
4 13 1
3.1 102 0.8
9
18
14.1
0 8 12 6 0 26
0 18 22 10 1 52
0.1 2.1 2.3 3.3 0.1
9
1 10 10 4 1 26
1.1
The prevalence of sensorineural hearing loss is higher among the rural children than among the urban children, P i 0.05. Surprisingly, there is no sex preponderance in this prevalence. rural children and 7.7% among the urban children. The difference in these preva-
lences is statistically significant (P < 0.05). However, most of the rural school children (13.3%) had hearing thresholds averaging less than 30 dB which, by the recommended WHO criterion, is not significant. Insignificant loss ( < 30 dB) was found in 5.7% among the urban children; thus, whereas the prevalence of hearing loss among the rural children was high, this was of a mild nature and unlikely to interfere with learning. The reverse was true among the urban school children. 3.3. Other results
Table 3 shows the other findings in this study. Congenital in 0.3% of the children examined.
ear disease was found
4. Discussion The overall 2.6% prevalence of COM is almost double that of 1.6% reported by Table 3 Other findings during the screening (lOSj802) Diagnosis
Rural children
Urban children
Tonsillitis Epistaxis Aural fistula Goitre Microtia Pharyngitis Meatal atresia
10 7 1 1 -
15 3 4 3 2 1 1
85 10 5 3 2 2 1
10.6 1.2 0.2 0.4 0.2 0.2 0.1
Total
19
89
108
13.3
Total
Congential anomalies of the ear occur at a rate of 0.9% among the school children.
34
B.M.
Minja,
A. Machemba
1 Int. J. Pediatr.
Otorhinolaryngol.
37 (1996)
29-34
Bastos et al. [4] among primary school children in Northern Tanzania. While in the Northern Tanzania study there was no difference in prevalence of COM among the rural and urban school children, in this study significantly more rural children had COM compared to the urban children. All parameters considered, the tenable explanation for this discrepancy in the prevalence of COM among the rural and urban children in Dar es Salaam is availability of health services. The urban school children have easy access to the dispensaries, hospitals and the Muhlmbili Medical Centre with specialist otorhinolaryngological services. This facilitates early diagnosis and treatment of acute otitis media. The rural school children, although they have easy access to a dispensary, optimum facilities for diagnosis of acute otitis media are lacking. This calls for a deliberate move to improve the facilities in the rural settings with a dual objective of preventing hearing loss and deafness among the children. The prevalence of SOM in this study is 0.15%. This shows that this condition is very rare among the school children in Dar es Salaam. Bastos et al. [4] reported similar results in the Northern Tanzania study in which the prevalence of SOM was 0.5%. Among Angolan refugee camp children, the prevalence of SOM was 0.6% [5]. The prevalence of SOM in the Tanzanian and Angolan studies are very low indeed when compared to those reported from elsewhere in Africa. Miller et al. [2] reported a prevalence of 7.1% among rural Nigerian school children. Prescott et al. [6] reported a prevalence of 12% among South African school children. As would be expected, the hearing loss associated with chronic otitis media was mild among the rural children in this study. None of the children had hearing loss greater than 30 dB HL which, by WHO criteria, is insignificant. The high prevalence of sensorineural hearing loss in this study calls for further studies aimed at determining the possible etiological factors. In conclusion, chronic suppurative otitis media and sensorineural hearing loss are common among the primary school children in Dar es Salaam. Rural school children are worse affected by these conditions. It is recommended that health services in the rural areas be improved so that acute otitis media can be diagnosed and treated. This will in turn prevent COM and its attending complications among which is hearing loss and deafness.
References [I] Halama, A.R., Voogt, G.R. and Musgrave, G.M. (1986) Prevalence of otitis medica in children in a black rural community in Venda, South Africa. Int. J. Ped. Otorhinolaryngol. 11, 19929. [2] Miller, S.A., Omeme, J.A., Bluestone, C.D. and Torkelson, D.W. (1983) A point prevalence of otitis media in a Nigerian village. Int. J. Ped. Otorhinolaryngol. 5, 19-29. [3] McPherson, B. and Halborow, CA. (1985) A study of deafness in West Africa: The Gambian Hearing Health Project. Int. J. Ped. Otorhinolaryngol. 10, 135. [4] Bastos, I., Mallya, J., Ingvarsson, L., Reimer, A. and Anderson, L. (1994) Middle ear disease and hearing impairment in Northen Tanzania: A prevalence study of school children in the Moshi and Monduli districts. Thesis; Graphic Systems Malmo, pp. 81-93. [5] Bastos, I., Janson, L., Lundgren, K. and Reimer, A. (1994) Chronic otitis media and hearing loss among school children in Angola: Thesis, Graphic Systems Malmo, pp. 67-77. [6] Prescott, C.A.J. and Kibel, M.A. (1991) Ear and hearing disorders in rural grade 2 (Sb.B) school children in the Western Cape. S. Afr. Med. J. 9, 90-93.
ELSEVIER
31 (1996)
29-34
Prevalence of otitis media, hearing impairment and cerumen impaction among school children in rural and urban Dar es Salaam, Tanzania B.M. Minja*, Department
of Otorhinolaryngology,
A. Machemba
Muhimbili University College Dar Es Salaam, Tanzania
of Health
Sciences,
P.O.
Box
6.5001,
Received 11 December 1995; revised 26 March 1996; accepted 31 March 1996
Abstract Eight hundred and two (802) primary school children in rural and urban Dar es Salaam, Tanzania, were examined to determine the prevalence of otitis media, hearing impairment and cerumen impaction by otoscopy and pure tone audiometry. Ear disease was found in 222 (27.7%) of the children. One hundred and twenty six (15.7%) had cerumen impaction, 70 (8.7%) had sensorineural hearing loss and 21 (2.6%) had chronic suppurative otitis media. Cerumen impaction was found in 20.45% of the rural school children and in 14.8% of the urban school children. This difference in prevalence between the two groups was not statistically significant. The prevalence of chronic suppurative otitis media (COM) was 9.44% among the rural school children and 1.30% among the urban school children, the difference being statistically significant (P < 0.001). Sensorineural hearing impairment was found in 14.1% of the rural school children and in 7.7% of the urban children, this also being statistically significant (P < 0.05). The low prevalence of chronic suppurative otitis media among the urban school children is ascribed to better medical services which facilitate early diagnosis and treatment of acute otitis media. This emphasizes the need to improve the health services in the rural areas so that acute otitis media is diagnosed and treated at the primary level of health care. This will in turn prevent hearing impairment due to chronic suppurative otitis media.
* Corresponding author. 0165-5876/96/$15.00 0 1996 Elsevier Science Ireland Ltd. All rights reserved PZI SO1 65-5876(96)01363-8
30
B.M.
Minja,
A. Machemba
/ Int. J. Pediatr.
Otorhinolaryngol.
37 (1996)
29-34
Ear disease:chronic suppurative otitis media; Hearing impairment; Cerumen impaction; School children; Dar es Salaam,Tanzania Keywords:
1. Introduction Most published data show high but variable prevalence of otitis media in Africa. The data also shows marked differences in the prevalence of chronic otitis media (COM) and secretory otitis media (SOM). In a South African study, Halama et al. [l] found a prevalence of otitis media of 8.2% among children from a black African community. In this study, COM was found in 0.7% and SOM in 3.8%. Similar trends were reported by Miller et al. [2] in a study of Nigerian children in whom the prevalence of COM was 4.1% and that of SOM was 19.4%. On the contrary, McPhersen et al. [3], in a Gambian school children study, found signs of previous middle ear infection in 15.1% and active infection in 1.3% and 3.1% with predominance of COM during different seasons. In a study done in Northern Tanzania, Bastos et al. [4] found a prevalence of COM of 1.6% among school children in urban and rural settings. In this study, there was no statistically different prevalence of COM between the urban and rural school children. However, there were significantly more children with scarred and tympanosclerotic drum membranes among the rural children when compared to that among the urban children. SOM was found in only 0.2% of the urban and rural school children respectively. This study was conducted to determine among urban and rural school children in Dar es Salaam, Tanzania: The prevalence of suppurative otitis media The prevalence of sensorinueral hearing loss The prevalence of cerumen impaction
2. Materials 2.1. Study
and methods area
Dar es Salaam is the capital and one of the twenty administrative regions of Tanzania. It is situated on the Indian Ocean coast of Tanzania mainland. There are three districts in Dar es Salaam, namely Ilala, Temeke and Kinondoni. While Hala district is wholly in the city part of Dar es Salaam, Temeke and Kinondoni districts have rural and urban settings. The population of Dar es Salaam is currently estimated to be 2 50000 people,
based on the 1988 census distributed
in both the rural and urban settings. In the
rural settings, the population density is low and the inhabitants depend largely on
subsistence farming. In the urban settings, the population
density is high and the
B.M.
Minja,
A. Marhemba
/ Imt. J. Pediatr.
Otorhinolaryngol.
37 (1996)
29-34
31
inhabitants earn their living from wages/salaries or business. The rural inhabitants have a lower income than the urban inhabitants. The primary schools in this study were randomly selected; one from the rural setting 35 km away from the city centre and the other one from the city centre. Both the schools are in Temeke district. 2.2. School children
The rural primary school children were aged from 5 to 20 years, with a mean of 13.9 years. There were 127 children, of whom 65 (51%) were males and 62 (49%) were females. The urban school children were aged from 5 to 19, with a mean age of 12.1 years. There were 675 children of whom 377 (56%) were males and 298 (44%) were females. All the children in each school were examined. 2.3. Examination
All the children were examined by the author (B.M) in a selected room in their respective schools. Otoscopy was done using a pneumatic otoscope or a forehead light depending on the situation. In the urban school, electricity was available. In the rural school, a petrol powered portable generator was used to generate electricity to power the forehead light. Following inspection to note any congenital anomalies, otoscopy was carried out on all the children. Cerumen was recorded only when it was impacted in the external canal. In such cases, using a forehead light, the cerumen was gently removed with a cerumen hook. Similarly, when pus discharge was found in the external canal, this was gently mopped out using cotton wool buds under direct vision. The external canals and drum membranes were inspected for exostoses, atresia, diffuse or localised external canal infection, drum membrane perforations, tympanosclerosis and evidence of middle ear effusion. The drum membrane was recorded as normal when it was noted to be greyish white in colour and the anatomical landmarks clearly visualised. All the findings were recorded on a specifically designed form. 2.4. Audiometry
In both schools, a room was selected in a quiet building for pure tone audiometry screening. A Bosch ST 10 audiometer was used for the screening procedure. The hearing threshold for air conduction (AC) was determined for the frequencies 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz. Those children who failed the screening test were eventually retested in a soundproof room at our Mulhmbili Medical Centre Clinic using a Bosch KT 10 biologically calibrated audiometer by the co-author (AM) who is an audiology assistant. AC and bone conduction (BC) thresholds at 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz and 8000 Hz were determined on all the children in this category. The averages of the AC thresholds at 500 Hz, 1000 Hz and 2000 Hz were calculated and recorded on a data collection form.
32
B.M.
Minja,
A. Machemba
/ Int. J. Pediatr.
Otorhinolaryngol.
37 (1996)
29-34
2.5. Data processing
The data collection forms for the children were analysed and the results tabulated. Statistical significance was determined using the chi-square test.
3. Results 3.1. Otoscopy
Table 1 shows the otoscopic findings in the 802 children examined. Five hundred and sixty four (81%) had normal external ears and drum membranes. Overall, 126 (15.7%) had cerumen impaction which, following removal, revealed normal drum membranes. The cerumen impaction of 20.5% among the rural school children and that of 14.8% among the urban school children was not statistically different. Active COM was found in 2.6% of all the children. The prevalences for COM of 9.5% among the rural school children and 1.3% among the urban school children were significantly statistically different (P < 0.001). There was only one child (0.15%) with SOM, a very low prevalence indeed. 3.2. Audiometry results
All the children with COM had conductive hearing loss and in none was the hearing threshold greater than 30 dB H.L. Table 2 shows the results for the 18 rural and 52 urban children with sensorineural hearing loss. The prevalence of sensorineural hearing loss is 14.1% among the
Table 1 Otoscopic findings Findings
Rural children n
Normal Cerumen COM Otitis media Foreign body SOM
Urban children o/
86 26 12 2
67.7 20.5 9.5 1.6 -
1 121
0.8 100
n
564 100 9 1 I 675
Total o/o
83.6 14.8 1.3 1.15 1.15 100
n
%
650 126 21 3 1 1 802
81.0 15.7 2.6 0.4 0.15 0.15 100
COM, chronic otitis media; SMO, secretory otitis media Rural school children have a higher prevalence of chronic otitis media than urban children (P < 0.001). The prevalence of cerumen impaction is not significantly different when the prevalence of the rural and urban school children for this condition are compared.
B.M.
Minja,
A. Machemba
1 Int. J. Pediatr.
Otorhinolaryngol.
37 (1996)
33
29-34
Table 2 Sensorineural hearing loss Hearing loss dB.HL
<0.25 26-30 31-40 41-50 51-60 Total
Urban children
Rural children M
F
T
‘I/o
M
F
T
%I
2 6 1
2 I 0
4 13 1
3.1 102 0.8
9
18
14.1
0 8 12 6 0 26
0 18 22 10 1 52
0.1 2.1 2.3 3.3 0.1
9
1 10 10 4 1 26
1.1
The prevalence of sensorineural hearing loss is higher among the rural children than among the urban children, P i 0.05. Surprisingly, there is no sex preponderance in this prevalence. rural children and 7.7% among the urban children. The difference in these preva-
lences is statistically significant (P < 0.05). However, most of the rural school children (13.3%) had hearing thresholds averaging less than 30 dB which, by the recommended WHO criterion, is not significant. Insignificant loss ( < 30 dB) was found in 5.7% among the urban children; thus, whereas the prevalence of hearing loss among the rural children was high, this was of a mild nature and unlikely to interfere with learning. The reverse was true among the urban school children. 3.3. Other results
Table 3 shows the other findings in this study. Congenital in 0.3% of the children examined.
ear disease was found
4. Discussion The overall 2.6% prevalence of COM is almost double that of 1.6% reported by Table 3 Other findings during the screening (lOSj802) Diagnosis
Rural children
Urban children
Tonsillitis Epistaxis Aural fistula Goitre Microtia Pharyngitis Meatal atresia
10 7 1 1 -
15 3 4 3 2 1 1
85 10 5 3 2 2 1
10.6 1.2 0.2 0.4 0.2 0.2 0.1
Total
19
89
108
13.3
Total
Congential anomalies of the ear occur at a rate of 0.9% among the school children.
34
B.M.
Minja,
A. Machemba
1 Int. J. Pediatr.
Otorhinolaryngol.
37 (1996)
29-34
Bastos et al. [4] among primary school children in Northern Tanzania. While in the Northern Tanzania study there was no difference in prevalence of COM among the rural and urban school children, in this study significantly more rural children had COM compared to the urban children. All parameters considered, the tenable explanation for this discrepancy in the prevalence of COM among the rural and urban children in Dar es Salaam is availability of health services. The urban school children have easy access to the dispensaries, hospitals and the Muhlmbili Medical Centre with specialist otorhinolaryngological services. This facilitates early diagnosis and treatment of acute otitis media. The rural school children, although they have easy access to a dispensary, optimum facilities for diagnosis of acute otitis media are lacking. This calls for a deliberate move to improve the facilities in the rural settings with a dual objective of preventing hearing loss and deafness among the children. The prevalence of SOM in this study is 0.15%. This shows that this condition is very rare among the school children in Dar es Salaam. Bastos et al. [4] reported similar results in the Northern Tanzania study in which the prevalence of SOM was 0.5%. Among Angolan refugee camp children, the prevalence of SOM was 0.6% [5]. The prevalence of SOM in the Tanzanian and Angolan studies are very low indeed when compared to those reported from elsewhere in Africa. Miller et al. [2] reported a prevalence of 7.1% among rural Nigerian school children. Prescott et al. [6] reported a prevalence of 12% among South African school children. As would be expected, the hearing loss associated with chronic otitis media was mild among the rural children in this study. None of the children had hearing loss greater than 30 dB HL which, by WHO criteria, is insignificant. The high prevalence of sensorineural hearing loss in this study calls for further studies aimed at determining the possible etiological factors. In conclusion, chronic suppurative otitis media and sensorineural hearing loss are common among the primary school children in Dar es Salaam. Rural school children are worse affected by these conditions. It is recommended that health services in the rural areas be improved so that acute otitis media can be diagnosed and treated. This will in turn prevent COM and its attending complications among which is hearing loss and deafness.
References [I] Halama, A.R., Voogt, G.R. and Musgrave, G.M. (1986) Prevalence of otitis medica in children in a black rural community in Venda, South Africa. Int. J. Ped. Otorhinolaryngol. 11, 19929. [2] Miller, S.A., Omeme, J.A., Bluestone, C.D. and Torkelson, D.W. (1983) A point prevalence of otitis media in a Nigerian village. Int. J. Ped. Otorhinolaryngol. 5, 19-29. [3] McPherson, B. and Halborow, CA. (1985) A study of deafness in West Africa: The Gambian Hearing Health Project. Int. J. Ped. Otorhinolaryngol. 10, 135. [4] Bastos, I., Mallya, J., Ingvarsson, L., Reimer, A. and Anderson, L. (1994) Middle ear disease and hearing impairment in Northen Tanzania: A prevalence study of school children in the Moshi and Monduli districts. Thesis; Graphic Systems Malmo, pp. 81-93. [5] Bastos, I., Janson, L., Lundgren, K. and Reimer, A. (1994) Chronic otitis media and hearing loss among school children in Angola: Thesis, Graphic Systems Malmo, pp. 67-77. [6] Prescott, C.A.J. and Kibel, M.A. (1991) Ear and hearing disorders in rural grade 2 (Sb.B) school children in the Western Cape. S. Afr. Med. J. 9, 90-93.