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A PREVALENCE STUDY OF ACUTE OTITIS MEDIA AMONG FEBRILE CHILDREN SIX MONTHS TO SIX YEARS OF AGE AT ECWA EVANGEL HOSPITAL, JOS
SUMMARY
This is a prevalence study of acute otitis media among febrile children six months to six years of age at ECWA Evangel Hospital, Jos. The study was carried out between June and August, 2005. In all sixty children within the age range specified above were studied through history and physical examination for acute otitis media and its associated factors. A subject was assessed to have acute otitis media if he or she was found to have a bulging tympanic membrane on pneumatic otoscopic examination of the tympanic membrane. Due consent was obtained before carrying out the history taking and physical examination. Data was analysed using Epi Info version 3.2 (CDC Atlanta 2000).
The prevalence of acute otitis media was found to be 18.3%. The probable associated factors included large family size, formula feeding and lower educational status of parents. Acute otitis media commonly manifested in form of sleeplessness at night, tugging at the ear or ear pain, fever and restlessness. The commonest symptom found to be associated with those that had acute otitis media was ear pain (17 of 60) out of which 9 had acute otitis media.
The signs most predictive of acute otitis media were bulging tympanic membrane in 11 subjects of the study population, (18.3% of 60) and tympanic membrane mobility abnormality 13 subjects of the study population(21.7% of 60). Ten out of the thirteen subjects had acute otitis media while all the 11 subjects that had bulging tympanic membrane had acute otitis media.
In conclusion acute otitis media was a common disease condition among febrile children in the study and hence every febrile child should be evaluated for AOM and not just treated for malaria as is commonly practiced by many physicians.
TABLE OF CONTENTS
TITLE PAGE … … … … … … … … … … … … … … … i
SUMMARY … … … … … … … … … … … … … … … .ii
DECLARATION … … … … … … … … … … … … … … … … … … … … … … ..iii
CERTIFICATION … … … … … … … … … … … … … . iv ACKNOWLEDGEMENT … … … … … … … … … … … … …v
LIST OF ABREVIATIONS … … … … … … … … … … … vi – vii
TABLE OF CONTENTS … … … … … … … … … … … …viii – ix
LIST OF TABLES … … … … … … … … … … … … … …..x
LIST OF FIGURES … … … … … … … … … … … … ….. ..xi
ABOUT THE TRAINING CENTRE … … … … … … … … …. xii – xiii
CHAPTER 1: INTRODUCTION … … … … … … … … … … .. 1- 8
CHAPTER 2: LITERATURE REVIEW … … … … … … … … … 9 – 45
2.1 Introduction … … … … … … … … … … … … … … …9
2.2 Distribution and Pattern of acute otitis media … … … … … … … …10
2.3 Definitions … … … … … … … … … … … … … … … ..16
2.4 Aetiology, Microbiology and Risk Factors … … … … … … …. … .18
2.5 Pathogenesis … … … … … … … …. … … … … … … … … … … … … … …22
2.5 Histopathology/Pathophysiology … … … … … … … … … 23
2.6 Clinical Features … … … … … … … … … … … … 25
2.7 Diagnosis … … … … … … … … … … … … … . 28
2.8 Treatment … … … … … … … … … … … … …. 31
2.9 Complications and Prognosis … … … … … … … … … . 38
2.10 Morbidity and Mortality … … … … … … … … … … . 39
2.11 Prevention … … … … … … … … … … … … … . 40 2.12 Public Health Importance and Disease Burden … … … … … ….. 41 Chapter 3: MATERIALS AND METHODS … … … … … … … … 46
3.1 Study Area … … … … … … … … … … … … …. 46
3.2 Preparation … … … … … … … … … … … … …. 47
3.3 Study Population … … … … … … … … … … … … 47
3.4 Study Design … … … … … … … … … … … … .. 48
3.5 Sample Size … … … … … … … … … … … … … 48
3.6 Data Collection … … … … … … … … … … … ….. 49
3.7 Limitations … … … … … … … … … … … … …. 49
3.8 Data Analysis … … … … … … … … … … … ……. 50
CHAPTER 4: RESULTS AND ANALYSIS … … … … … … … ….. 51
4.1 Characteristics of Subjects in the Study … … … … … … … .. 51
4.2 Other Observations Made in the Course of the Study … … … … … 66
CHAPTER 5: DISCUSSION … … … … … … … … … … …… 67
5.1 Prevalence of Acute Otitis Media among Febrile Children … … … … … … … …
-
months to Six years) … … … … … … … … … … …. 67
- Factors Associated with Acute Otitis Media … … … … … … … 71
- Interventions … … … … … … … … … … … … …. 74
CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS … … … … … 76
6.1 Conclusions & Recommendations … … … … … … … … … …76 REFERENCES … … … … … … … … … … … … … …. 78
APPENDIX A: QUESTIONNAIRE … … … … … … … … … … 86
APPENDIX B: ETHICAL APPROVAL … … … … … … … … …. 101
CHAPTER ONE
INTRODUCTION
Childhood mortality in the world is declining and has continued to be on the downward trend. This is so despite increases in population. The estimated annual number of deaths has decreased to almost a third.1This is a good and cheerful news but should not be a reason to relax or to be complacent because the above conclusion is only true when the whole world is taken into consideration.
In developing countries Infant and child mortality remain disturbingly high despite the significant decline in most parts of the developed world.2 In some countries, especially in sub-Saharan Africa of which Nigeria is a part, childhood mortality is still on the increase such that as at 1998 over 50 countries still had childhood mortality rates of over 100 per thousand live births.1 In nine countries one in every five children born alive did not survive up to the
fifth year of life.1
This trend is still the same with more recent reports. The Nigerian Demographic and Health Survey (NDHS) of 1999; showed an infant mortality rate of 75 deaths per 1000 live births and for those who were less than five years of age it was 140 deaths per 1000 live births.2 In another report for a five year period immediately preceding the 1999-2003 survey, the infant mortality rate was given as 100 deaths per 1000 live births while the over all under-five mortality rate was put as 201 deaths per 1000 live births by the 2004 National Population Commission (NPC) report.2 The level of improvement in infant and under-five mortality in Nigeria as a whole has been assessed to be significantly lower than the average of 34% for sub-Saharan Africa.2 More worrisome is the fact that in all these countries there are well articulated national health programmes aimed at decreasing childhood morbidity and mortality.1 There is a well articulated national health programme in Nigeria too.
In Nigeria there is a national health policy whose goal is to bring about a “Comprehensive health care system, based on primary health care that is promotive, protective, preventive, restorative and rehabilitative to every citizen of the country within the available resources so that individuals and communities in Nigeria are assured of productivity, social well being and enjoyment of living.3 “The health services to be based on primary health care shall include among other things; education concerning prevailing health problems, and the methods of preventing and controlling them; promotion of food supply and proper nutrition; maternal and child health including family planning; immunization against major infectious diseases, prevention and control of locally endemic and epidemic diseases and provision of essential drugs and supply”.3 As can be seen the above policy has incorporated and taken good care of the children.
Thus if the programme has been well articulated and efficiently implemented it should also bring a downward trend in childhood morbidity and mortality in Nigeria but this is not so. In spite of the above national health policy which has been in operation; childhood morbidity and mortality is still unacceptably high. Could it be that the policy has not been well implemented or could there be something else responsible?
Infectious diseases have been shown to account for over two-thirds of the 12 million annual deaths among under 5s in developing countries.4 Ear infections have been listed among the major contributors to high childhood morbidity and mortality.1 Acute respiratory tract infection which is among the 5 major child killer diseases has a very strong association with acute otitis media.5
Otitis media can be described as an all-encompassing term that describes an inflammatory process in the middle ear space. It begins in the nasopharynx and extends into the Eustachian tube and then into the middle ear mucosa. Otitis media can be divided into various categories which include: acute otitis media, acute recurrent otitis media, and otitis media with effusion, chronic otitis media with effusion and chronic suppurative otitis media. These categories
probably represent various stages along a continuum of severity.6
Acute Otitis media refers to the abrupt onset (< 48 hours) of middle ear effusion accompanied by the signs and symptoms of middle ear inflammation such as otalgia (pulling of the ear in an infant), irritability in an infant or toddler, otorrhoea and or fever; erythema of the tympanic membrane.6,7,8 Middle ear effusion is indicated by bulging of the tympanic membrane, limited or absent mobility of the tympanic membrane, air-fluid level behind the tympanic membrane and otorrhoea.7
Acute otitis media can also be defined as the presence of fluid in the middle ear in association with signs or symptoms of acute or systemic illness.9 Recurrent acute otitis media on the other hand is defined by the presence of 3 or more episodes of distinct and well-documented episodes of acute otitis media every six months or four or more episode every 12 months.9Otitis media with effusion unlike acute otitis media is the presence of middle ear effusion without the signs and symptoms of acute infection other than reduced hearing and the presence of the signs (retracted or neutral position) of a tympanic membrane under
negative pressure or no pressure and fluid in the middle ear space.10,11
Otitis media with effusion is also called “glue ear” and defined as serous or mucous but not muco-purulent fluid in the middle ear, presenting usually with hearing loss and speech problems without signs and symptoms of acute infection in children.12 Chronic suppurative otitis media occurs when there is a chronic inflammation of the middle ear persisting for at least 6 weeks and is associated with otorrhoea through a perforated tympanic membrane, an indwelling tympanostomy tube or a surgical myringotomy.13 As already mentioned above otitis media is like a spectrum of events starting from acute otitis media and progressing in severity to chronic suppurative otitis media and its sequelae. Also the rest of the spectrum can be regarded as complications of acute otitis media.
Acute otitis media is a very common disease world wide. It’s the most common infection for which antibiotics are prescribed in the United States of America.7 In another study it was shown to be the most frequently diagnosed condition in the medical out patient.14 In Africa and Nigeria in particular the story is not different. A study carried out in Sokoto, Nigeria, showed that it was a common disease found in children, and children between 0-5 years of age accounted for 67.5% of cases of acute otitis media.15Another study showed acute otitis media to be most common during the first two years of life in Nigeria.16
Results of various studies in Nigeria suggest a rising incidence just like in other developing countries. The complications of acute otitis media are also on the increase in developing countries, while it is decreasing in developed countries as a result of emphasis on the accurate diagnosis and prompt treatment of acute otitis media with antibiotics.17 The reverse is the case in Nigeria and other developing countries where improperly treated or misdiagnosed and therefore untreated acute otitis media have led to various complications such as chronic suppurative otitis media which has been shown to be highly prevalent in Nigeria among
children.18,19
The prevalence of chronic suppurative otitis media in children seen in hospital otolaryngology clinics in Nigeria, Tanzania and Angola ranges from 7-11%.20 Another study
in Nigeria showed a CSOM prevalence of 73 per thousand pupils in a rural community.20 CSOM itself has its own complications which include meningitis, focal encephalitis and otic hydrocephalus hence it can lead to serious handicaps in terms of language skills and mental development.21 Conductive hearing loss is another effect of persisting CSOM and it has significant draw backs on learning, communication and social adjustment.21 One study showed that otitis media was the commonest cause of childhood hearing loss in developing countires.22 Impaired hearing has also been shown to be the most frequent complication of otitis media in developing countries with other complications being death or severe
disability.22
Mortality for this disease has been put at 51, 000 children younger than 5 years of age per year in developing countries.17,23 The mortality and severe disabilities associated with otitis media have been primarily related to the complications of mastoiditis or CSOM such as septic shock, brain abscess, subdural empyema, lateral sinus vein thrombosis and others already mentioned above. Other disabilities that may result from complications include spasticity, paralysis, mental retardation, cortical blindness, seizures, labrynthitis and facial nerve paralysis.8,17,24 As already mentioned these complications are due to non treatment or
inadequate treatment of acute otitis media.25,26
Acute Otitis Media has a strong association with fever. Seventy five percent of those presenting with acute otitis media do so with fever of usually less than 400C; while the remaining one quarter do not have fever at all.12,27 In our environment any child that presents with fever is assumed to have malaria until proven other wise. Acute otitis media is rarely considered as a cause of fever in the author’s environment. This was the case in one adult patient observed by the author. This patient, a 30 years old woman presented with fever, headache and was treated for malaria and subsequently resistant malaria when her fever would not resolve. While still on her quinine for resistant malaria, she developed acute suppurative otitis media and was discharging pus from her right ear and a day after she was commenced on oral amoxicillin for otitis media developed meningitis which was adjudged to have come from the acute otitis media.
The author also observed that pneumatic otoscope which is the gold standard for the diagnosis of acute otitis media was not readily available and where available was not put to use in the assessment of children with fever. This was mostly attributed to lack of necessary skill and confidence in the use of the pneumatic otoscope.This lack of pneumatic otoscopic examination of children presenting with febrile illness has made early diagnosis and prompt treatment of otitis media difficult. This is complicated by the fact that every febrile illness in the author’s environment is considered malaria first, since malaria is endemic here. This may explain why the complications of acute otitis media are on the increase in developing countries, as also being witnessed in ECWA Evangel Hospital especially since the starting of the ENT clinic and the presence of an ENT surgeon in the hospital.
All the above prompted the author to carry out this study to determine the prevalence of acute otitis media among febrile children (6 months to 6 years of age) in Evangel Hospital, Jos in order to alert physicians and family physicians in particular, of the need to pay more attention to this treatable condition and there by improve diagnostic and therapeutic approach to children with febrile illness. The aim and objectives are well explained in the next page. Studies have shown that acute otitis media presents often to family physicians who are also good at management of AOM in that they detect impending complications and therefore refer
to the otolaryngologists early.5,28,29 The associated predisposing factors will also be determined. The prevalence if significant can also serve as an advocacy tool on the public health importance of acute otitis media and the role of the community in the eradication or prevention of acute otitis media and its sequelae.
AIM AND OBJECTIVES
The aim of this study was to determine the prevalence of acute otitis media among febrile children between six months to six years of age attending ECWA Evangel Hospital Jos; and the likely associated factors with acute otitis media, in order to alert physicians of the need to pay more attention to this treatable disease and ultimately improve on their clinical and diagnostic acumen towards acute otitis media. The result can be used to sensitize family physicians on the magnitude of the problem and therefore make otoscopic examination of the febrile child a routine part of the clinical evaluation of the febrile child. In view of the above, the objectives of the study were:
- To determine the prevalence of acute otitis media among febrile children within the age group specified above in Evangel Hospital Jos.
- To determine the associated predisposing factors of otitis media among febrile children presenting to Evangel Hospital Jos.
- To advocate for a change in diagnosing attitude of physicians in Nigeria with respect to febrile children.
A PREVALENCE STUDY OF ACUTE OTITIS MEDIA AMONG FEBRILE CHILDREN SIX MONTHS TO SIX YEARS OF AGE AT ECWA EVANGEL HOSPITAL, JOS
