Otitis media 2009: an update

Otitis media in Australia, particularly among Indigenous children, has not received the attention that other less common but more emotive diseases attract. However, this condition, with its significant impact on hearing, language development and learning in the vulnerable early childhood years, has been commented on since early European settlement in Australia.1 The end result of recurrent acute otitis media — chronic suppurative otitis media — is uncommon in most developed countries, but Indigenous Australian children account for the highest prevalence of chronic suppurative otitis media in the world (70% in some remote communities). The World Health Organization regards a prevalence of chronic suppurative otitis media of over 4% in a defined population of children as a massive public health problem requiring urgent attention.2 John Ah Kit, Minister for Community Development from the Northern Territory, described the situation of Indigenous children as A spiral of being ill before birth, of being poorly fed in childhood, of being deaf at school. Of a life without work that would be cut short by a litany of disease and violence.3 What has happened in the 13 intervening years since the last Medical Journal of Australia supplement on otitis media was published?4 In some areas (described further in this supplement), our understanding of pathogenesis, new concepts of biofilm and intracellular infection, and the importance of nasopharyngeal carriage, we have progressed significantly. Likewise, new research — into the genetics of recurrent acute otitis media, the immunological responses of children to these infections, and the impact of antibacterial vaccines — is contributing to our knowledge about this condition. New social and medical interventions, such as the swimming pool project,5 building new housing, and the controversial Northern Territory Intervention, with new guidelines on the use of antibiotics in otitis media and its sequelae in children, have been partially successful in ameliorating the burden of otitis media in Indigenous (and non-Indigenous) children.6 Yet, in this time of financial constraint, the necessary programs to implement change in the fundamental and underlying causes of otitis media and its complications are not being provided. Chronic suppurative otitis media is a disease of poverty, and without actions to lessen overcrowding and provide appropriate housing and water supply, education of parents and adequate access to medical care, progress to improvement will be slow.7 In addition, throughout urban, rural and remote Australia, we must increase awareness about otitis media, and the ramifications of neglect of this silent epidemic, among parents, teachers, community leaders, and health workers. We must train more Aboriginal health workers specialising in ear conditions (and possibly also eye conditions and dental health), perhaps with support from ear nurse specialists (this has been very successful in the government-funded Variety Club ear buses program in New Zealand), and ensure there is an adequate workforce of audiologists, speech pathologists and teachers of the deaf to provide the necessary ancillary support services for children with impaired hearing and speech delays. The recent publication The cost burden of otitis media in Australia brings to light the pervasive nature and community costs of otitis media and its sequelae. Admission for insertion of grommets is the second major cause of surgical admission to hospital in Australia for children. Over 650 000 Australians had otitis media in 2008; 9.9% of these were Indigenous. For 2008, the estimated health system costs of otitis media range from $85.6 million to $163.2 million, and the net cost of lost wellbeing due to otitis media is estimated at between $1.05 billion and $2.6 billion.8 So where to next? Governments must advocate for otitis media prevention programs, improve living standards for socially disadvantaged families, ensure adequate medical and paramedical resources, and continue to fund basic and outcomes-based research into otitis media. As otitis media is, in part, a vaccine-preventable disease, attention to considering the newer vaccines available for invasive and otitis media infections in children for the immunisation schedule should be a priority.

Harvey L C Coates AO, MS, FRACS

Otitis media remains a major health problem in Australia, with an unacceptably great dichotomy of incidence and severity of otitis media and its complications between Indigenous and non-Indigenous Australians. Among most children with acute otitis media, infection resolves rapidly with or without antibiotics, with ongoing middle ear effusion the only sequela. Overcrowding, poor living conditions, exposure to cigarette smoke, and lack of access to medical care are all major risk factors for otitis media. Estimates of the number of cases of otitis media in 2008 vary between 992 000 and 2 430 000 Australians, with a total estimated cost of $100 – $400 million.

Kelvin Kong BSc, MB BS, FRACS · Harvey L C Coates AO, MS, FRACS

Otitis media typically presents as either acute otitis media (AOM), with symptoms including fever, otalgia, otorrhoea or irritability and short duration; or as otitis media with effusion (OME), which is often asymptomatic and characterised by accumulation of fluid in the middle ear. Diagnostic certainty of otitis media is challenging, given the young age of patients and variability of symptoms. Otitis media predominantly occurs as coincident to viral upper respiratory tract infections and/or bacterial infections. Common viruses that cause upper respiratory tract infection are frequently associated with AOM and new-onset OME. These include respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza and coronavirus. Predominant bacteria that cause otitis media are Streptococcus pneumoniae, Moraxella catarrhalis, and non-typeable Haemophilus influenzae. Antibiotic therapy does not significantly benefit most patients with AOM, but long-term prophylactic antibiotic therapy can reduce the risk of otitis media recurrence among children at high risk. In Australia, 84% of AOM is treated with antibiotic therapy, which contributes to development of antibiotic resistance. Vaccine development is a key future direction for reducing the world burden of otitis media, but requires polymicrobial formulation and ongoing monitoring and modification to ensure sustained reduction in disease burden.

Helen M Massa PhD · Allan W Cripps PhD · Deborah Lehmann MB BS, MSc

Otitis media is a common childhood illness associated with hearing loss, social disadvantage and medical costs. Prevalence and severity are high among Indigenous children. Respiratory bacterial and viral pathogens ascend the eustachian tube from the nasopharynx to the middle ear, causing inflammation, fluid accumulation, and bulging of the tympanic membrane, with or without pain. Among Australian Indigenous children, ear disease commences earlier in life, and involves multiple strains of bacterial pathogens at high density that persist longer. Persistent nasal discharge, overcrowded living conditions (particularly exposure to many children) and poor facilities for washing children perpetuate a vicious cycle of transmission and infection. Risk factors include environmental tobacco smoke, season, lack of breastfeeding, younger age and immature immune system, and possibly genetic factors. The innate immune system is a critical first response to infection, particularly as passive maternal antibodies decline and during the maturation of the infant adaptive immune response. The relative contributions of innate factors to protection from otitis media are currently not well understood. A diversity of antibodies that target strain-specific and conserved antigens are generated in response to natural exposure to otitis media pathogens (or to vaccines). Deficiencies in these antibodies may explain susceptibility to recurrent infections. Incremental contributions from all these elements are likely to be important in otitis media susceptibility versus protection. Effective medical and social strategies to prevent early age of onset are urgently needed.

Selma P Wiertsema PhD · Amanda J Leach PhD

Acute otitis media (AOM) is diagnosed on the basis of acute onset of pain and fever; a red, bulging tympanic membrane; and middle ear effusion. AOM is managed with analgesia (paracetamol or non-steroidal anti-inflammatory drugs). Antibiotic therapy is minimally effective for most patients; it is most effective for children < 2 years with bilateral otitis media and for children with discharging ears. National guidelines recommend antibiotic therapy for Indigenous children with AOM. Evidence for corticosteroids, topical analgesia and xylitol are scant. Otitis media with effusion (OME) is diagnosed as the presence of middle ear effusion (type B tympanogram or immobile tympanic membrane on pneumatic otoscopy) without AOM criteria. Well children with OME with no speech and language delays can be observed for the first 3 months; perform audiological evaluation and refer to an ear, nose and throat (ENT) specialist if they have bilateral hearing impairment > 30 dB or persistent effusion. Children with effusions persisting longer than 3 months can benefit from a 2–4-week course of amoxycillin. Chronic suppurative otitis media is a chronic discharge through a tympanic membrane perforation. It is managed with regular ear cleaning (dry mopping or povidone–iodine [Betadine] washouts) until discharge resolves; topical ear drops (eg, ciprofloxacin); audiological evaluation; and ENT review.

Hasantha Gunasekera DCH, FRACP, MIPH(Hons) · Tony E O’Connor AFRCSI, FRCS(ORL-HNS) · Shyan Vijayasekaran MB BS, FRACS · Christopher B Del Mar MD, FRACGP

In Australia, three to five children die each year because of otitis media complications, and 15 children will suffer permanent hearing loss each year as a result of otitis media. Extracranial complications occur most commonly, and include mastoiditis, cholesteatoma and otitis media with perforation. Intracranial complications are less common, and include meningitis, brain abscess and lateral sinus thrombosis. In Australia, approximately 60% of extracranial and intracranial complications of otitis media occur in children. The contrasting rates of childhood otitis media among Indigenous and non-Indigenous children have implications for the frequency and types of complications occurring in both groups. Otitis media with effusion and acute otitis media predominate among non-Indigenous children, whereas chronic suppurative otitis media (CSOM) occurs most commonly among Indigenous children. The incidence of mastoiditis in Australia is low by international standards (2/100 000 children), but cholesteatoma rates among Indigenous children in Australia are higher than previously estimated (up to 10% in CSOM). A high rate of chronic tympanic membrane perforation occurs among Indigenous children, estimated to be as high as 80%. Intracranial complications of otitis media are uncommon, but are potentially life-threatening and are more likely to occur among Indigenous than non-Indigenous children. Reduced access to medical care, lower socioeconomic status and remote living conditions mean that levels of early childhood hearing loss among Indigenous children are likely to be underestimated. This has implications for early childhood speech and language development and education.

Tony E O’Connor AFRCSI, FRCS(ORL-HNS) · Christopher F Perry MB BS, DTM · Francis J Lannigan MD, FRCS(ORL)(Ed), FRACS

Otitis media with effusion and recurrent acute otitis media are ubiquitous among Indigenous children. Otitis media causes conductive hearing loss that may persist throughout early childhood and adversely affect social interactions, language acquisition and learning. Control of otitis media usually restores hearing to adequate levels. Surgery is to be considered when otitis media has not responded to medical treatment. In non-Indigenous populations, tympanostomy tubes (“grommets”), with or without adenoidectomy, can control otitis media; how these findings relate to Indigenous Australians is not known. Tympanic membrane perforation is a frequent sequela of early childhood otitis media among Indigenous children. It occurs as early as 12 months of age and causes conductive hearing loss. Perforation is associated with recurrent aural discharge, particularly in the tropics and in desert regions. Medical and public health management is required until a child is old enough to undergo surgical closure of the perforation, usually by an age of 7–10 years. Surgical closure of the tympanic membrane stops the aural discharge and improves the hearing sufficiently to avoid the need for hearing aids in most cases. The success rate of surgery conducted in rural and remote Australia is below urban benchmarks; improving this will probably require funding for community-based follow-up.

Stephen J O’Leary BMedSc, PhD, FRACS · Ross D Triolo BSc(MedSci), MB BS

Otitis media is a common disease in childhood that can adversely affect cognitive and educational outcomes. The literature in this area is equivocal, and findings may be influenced by research design. The impact of otitis media on individual children’s development appears to depend on the inter-relationship between several factors. Children who have early-onset otitis media (under 12 months) are at high risk of developing long-term speech and language problems. Otitis media has been found to interact negatively with pre-existing cognitive or language problems. For biological or environmental reasons, some populations have a pattern of early onset, higher prevalence and episodes of longer duration; this pattern leads to a higher risk of long-term speech and language problems. These factors suggest that Indigenous children may be at higher risk of cognitive and educational sequelae than non-Indigenous children.

Corinne J Williams PhD · Ann M Jacobs BAppSc(Speech and Hearing)

Otitis media affects nearly all children worldwide. Despite an enormous amount of research, our understanding of this common condition continues to be challenged. New pathogens involved in otitis media are still being identified. The importance of interactions between viral and bacterial infection and the role of new vaccines need to be clarified. The proposal that bacteria can become more resistant to therapy through biofilm formation and intracellular infection could have important implications for treatment. The most important clinical research findings have been summarised in systematic reviews. In developed countries, research supporting “watchful waiting” of otitis media with effusion and acute otitis media have had most impact on evidence-based clinical practice guidelines. Indigenous Australian children remain at risk of more severe otitis media. Research programs targeting this population have been well supported. Unfortunately, interventions that can dramatically improve outcomes have remained elusive. For children at high risk of otitis media, health care services should concentrate on accurate diagnosis, antibiotic treatment of suppurative infections, and scheduled follow-up of affected children. Despite the lack of recent studies, strategies to minimise the impact the hearing loss associated with otitis media are important. Improvements in education, hygiene practices, and living conditions are likely to reduce the incidence and severity of otitis media. Studies of these types of interventions are needed.

Peter S Morris MB BS, FRACP, PhD · Peter Richmond MB BS, FRACP · Deborah Lehmann MB BS, MSc · Amanda J Leach MAgSci, PhD · Hasantha Gunasekera DCH, FRACP, MIPH(Hons) · Harvey L C Coates AO, MS, FRACS