Eur Arch Otorhinolaryngol DOI 10.1007/s00405-014-3255-4
OTOLOGY
Determinants of non-healing ear discharge in chronic suppurative otitis media in a developing country Foster Tochukwu Orji • Benjamin O. Dike Onuoha Oji
•
Received: 1 June 2014 / Accepted: 19 August 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract The major burden of chronic suppurative otitis media (CSOM) is the embarrassing ear discharge which may last for few months to many years or even a lifetime with increasing risks of complications. We conducted this study to determine the risk factors for protracted nonhealing ear discharge among CSOM patients. We carried out a retrospective analysis of non-cholesteatomatous CSOM patients treated in a tertiary hospital in a developing country. Comparison was made between 128 patients with ear discharge persisting beyond 24 months and 58 patients whose otorrhoea resolved within 6 months in terms of socio-demographic and other potential risk factors. Major risk factors identified by logistic regression analysis were rural residence, multidrug-resistant bacteria, and bilateral CSOM (P = \0.001, 0.001, and 0.008, respectively). Others were onset of ear discharge before the age of 10 years, diabetes mellitus, persistent rhinorrhoea, home [10 miles away from hospital, and [7 persons in a family (P = 0.012, 0.041, 0.013, 0.010, and 0.043, respectively). Age, sex, nasal allergy, and self-medication were not significant risk factors for non-healing ear discharge. Protracted non-healing ear discharge still remains a prominent feature of CSOM in our experience. Rural residence,
F. T. Orji (&) Department of Otolaryngology, University of Nigeria Teaching Hospital Enugu, Enugu, Nigeria e-mail: [email protected] F. T. Orji Department of Surgery, Federal Medical Center Umuahia, Umuahia, Nigeria B. O. Dike O. Oji Department of Otolaryngology, Federal Medical Center Umuahia, Umuahia, Nigeria
multidrug resistance, bilateral CSOM, and long distance to health facilities are prime risk factors. Measures to address these risk factors to bring about a decline in the number of non-healing ear discharge among CSOM patients, especially in our rural communities, are urgently needed. Keywords Ear discharge Non-healing Chronic suppurative otitis media Risk factors
Introduction Chronic suppurative otitis media (CSOM) is a disease of mucoperiosteal lining of the middle ear cleft characterised by persistent perforation of the tympanic membrane in the presence or absence of ear discharge [1–4]. The disease often begins in early childhood, usually as acute otitis media, with potential of spilling over into adulthood, accounting for recurrent episodes of chronic ear discharge [2, 5, 6]. The major concern of most patients with CSOM is the embarrassing frequent episodes of purulent ear discharge which recurs sporadically [7]. The duration of ear discharge episode in CSOM is variable. The discharge in cholesteatomatous type often lasts for many years compared to tubotympanic, non-cholesteatomatous disease which usually lasts for few months to few years [3, 6]. But in poor resource countries, the discharge, even in safe tubotympanic type, has been observed to continue for many years with increasing risk of hearing impairment and lifethreatening infective complications [5, 7]. Although risk factors for otits media have been severally reported in both paediatric and adult series, the determinants of non-healing protracted ear discharge in CSOM patients are yet to be systematically evaluated. We conducted this study to examine the risk factors associated with protracted
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ear discharges in non-cholesteatomatous CSOM patients receiving specialist care in a low-resource country.
Table 1 Distribution of patients’ age and the age of onset of ear discharge among the target groups of chronic suppurative otitis media patients Number of patients
Methods The present study was conducted in the department of otolaryngology of Federal Medical Center Umuahia, Nigeria, in which retrospective case analysis of patients who were receiving care for chronic ear discharges during a 3-year period ending December 2012 was carried out after the necessary institutional approved was obtained. Data of consecutive patients up to 2 years of age were included if the ear discharge lasted for more than 3 months regardless of the treatment offered. Patients were excluded if clinically diagnosed with cholesteatoma or had evidence of cholesteatoma on computer tomographic imaging of the temporal bone. Those ear discharges that resulted from ear trauma were also excluded. Two hundred and fifty-one patients who met our criteria were identified. Their records were further reviewed to select the target groups depending on the duration of ear discharge, for analysis. Those selected included the group of 128 (51 %) patients whose ear discharge did not resolve after 24 months and 58 (23 %) ear discharges that resolved within 6 months. The following factors were compared between the two target groups: patient age, gender, age of onset of CSOM, bilateral/unilateral disease, multidrug resistance (defined as resistance to three or more of the following antibiotics in the antibiotic sensitivity test: amoxicillin, amoxicillin/clavulanate, gentamicin, erythromycin, ciprofloxacin, tetracycline, and chloramphenicol); rural residential, home C10 miles from health facility, self-medication practice, large family (family size of [7), coexisting diabetes mellitus, persistent rhinorrhoea (nasal discharge of up to 6 weeks), and allergic rhinitis. Statistical analysis Data were analysed with ‘Statistical Package for Social Sciences’ (SPSS), version 16.5. The association between the potential risk factors and prolonged non-healing ear discharge was studied using Chi-square test of proportions. Logistic regression test was used to model the association between significant risk factors in Chi-square test and the likelihood of prolonged chronic ear discharge separately. Statistical significance was set at P value of \0.05.
Results Data from 186 target groups were analysed. The 128 group ‘A’ patients had a mean age of 21.4 ± 19.1 years that
123
Percentage (%)
Age of patients at presentation, n = 186 \10 years
63
33.9
10–20 years 21–30 years
52 31
28.0 16.7
30–50 years
18
9.7
[50 years
22
11.8
Total
186
100
Age of onset of ear discharge n = 185 \1 year
37
19.9
2–5 years
47
25.3
6–10 years
15
8.1
11–20 years
30
16.1
[20 years
56
30.1
ranged from 2 to 86 years, while the mean age of the 58 group ‘B’ patients was 21.9 ± 21.7 years, with the youngest patient being 2 years and the oldest being 82 years. The difference was not significant (P = 0.382). The details of the distribution of the age as well as the age of onset of chronic ear discharge among the target groups are provided in Table 1. More than 33 % were children \10 years of age. The age at the first episode of ear discharge ranged from 6 weeks of life to 82 years with 19.9 % of the patients having their first episode before the age of 1 year. In 18 % of the patients (15 adolescents and 18 adults), their current ear discharges dated back to their early childhood. Male patients significantly outnumbered the females (P = 0.028). The duration of otorrhoea in group ‘A’ subjects ranged from 24 months to 45 years with a mean of 4.6 ± 4.8 years, while the mean duration of otorrhoea was 4.9 ± 0.9 months in group the ‘B’ and ranged from 3.5 to 6 months. The distribution of the risk factor in relation to the duration of ear discharge among the patient groups is as detailed in Table 2. Potential risk factors which had a significance of \0.05 on univariate Chi-square analysis were included in the multivariate logistic regression model to obtain the adjusted odds ratios. These included age of onset of ear discharge, ears affected, residence in rural communities, multidrug resistance, hospital distance from home, family size, coexisting diabetes mellitus, and persistent rhinorrhoea. The result of logistic regression test identified bilateral CSOM, onset of ear discharge before the age of 5 years, multidrug resistance, coexisting diabetes mellitus, and persistent rhinorrhoea as significant risk factors for nonhealing protracted ear discharge (P = 0.008, 0.012, 0,001,
Eur Arch Otorhinolaryngol Table 2 Univariate and multivariate analysis of the association of potential risk factors with the length of otorrhoea
Potential factors
Duration of otorrhoea C2 years
\6 months
Chi-square test
Logistic regression test
P value
OR (95 % CI)
P value
OR (95 % CI)
Age B10 years
44
18
0.869
1.08 (0.56–2.08)
–
–
10–20 years
35
19
0.780
0.91 (0.46–1.80)
–
–
21–30 years
21
10
0.887
0.94 (0.41–2.15)
–
–
[ 30 years
28
12
0.856
1.02 (0.81–1.29)
–
–
0.390
1.32 (0.70–2.46)
–
–
0.004
2.69 (1.39–5.23)
0.012
2.27 (1.20–4.28)
\0.001
6.23 (2.63–14.77)
0.008
3.00 (2.51–5.07)
\0.001
5.93 (2.99–11.74)
\0.001
6.02 (3.65–12.36)
0.007
2.35 (1.25–4.43)
0.010
1.79 (1.06–1.63)
0.442
1.35 (0.62–2.94)
–
–
0.295
0.68 (0.34–1.38)
–
–
0.021
1.30 (1.04–1.64)
0.013
2.35 (1.17–4.71)
0.027
2.21 (1.09–4.52)
0.043
1.74 (1.01–2.82)
0.023
4.76 (1.20–18.98)
0.041
1.67 (1.13–2.34)
0.002
2.81 (1.48–5.32)
0.001
5.66 (1.92–6.91)
Gender Male
77
31
Female
51
27
Age of onset of disease B5 years [5 years Ears involved
67
17
60
41
Biilateral
59
7
Unilateral
69
51
Rural
91
23
Urban
37
35
Area of residence
Home more than 10 miles from the hospital Yes
82
25
No
46
33
Self-medication practice Yes
39
12
No
72
30
Yes
34
20
No
78
31
Persistent rhinorrhoea Yes 72
21
Coexisting allergy
No
38
26
[7
72
22
B7
34
23
Family size
Diabetes Yes
15
3
No
21
20
Multidrug resistance OR odds ratio, 95 % CI 95 % confidence interval
Yes
83
23
No
45
35
0.041, and 0.013, respectively). Significant social risk factors included rural residence and home [10 miles away from hospital (P = \0.001 and 0.010, respectively). The family size was also significantly associated with nonhealing ear discharge (P = 0.043). In univariate analysis, bilateral disease and rural residence had the greatest odds for prolonged ear discharge (6.23 and 5.93, respectively), whereas the results of logistic regression test revealed that rural residence and multidrug resistance on antibiotic
sensitivity testing had the greatest odds of protracted nonhealing ear discharge (6.02 and 5.66, respectively).
Discussion The challenges associated with CSOM include hearing loss, persistent or recurrent episodes of ear discharge, and risks of various intracranial and extracranial complications.
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But the most worrisome burden of the disease remains the social embarrassments from the recurrent ear discharges [5, 7]. The pattern of ear discharge in CSOM varies considerably between individuals and disease type. In many patients, ear discharge recurs from time to time after the initial control [1, 6, 8, 9], whereas in some, especially in tubotympanic CSOM, after the initial episode of ear discharge dry ears are achieved for a very long period of time [6]. Yet in other cases, especially in developing countries or in cholesteatomatous type, the discharge continues for many years [1, 3, 5, 7]. The risk factors for CSOM have been reported, especially from studies on paediatric populations, to include low socioeconomic status (poor housing, overcrowding, large families, poor occupational and environmental conditions), allergy/atopy, chronic rhinorrhoea, chronic nasal obstruction, previous acute or recurrent acute otitis media, secondhand smoking (in children), and indoor cooking [8–14]. The present report is an attempt to investigate the determinants of non-healing ear discharge in patients with non-cholesteatomatous CSOM. Although non-healing ear discharge was not significantly related to patient age, we found that the impact of age at onset of ear discharge was significant, as those that had their first episode of otorrhoea before the age of 5 years had more than two times greater odds of having protracted ear discharge. Early onset of otitis media has been associated with greater risk of CSOM [15]. The reason for this association is not obvious, but we noticed in our study that 35 and 52 % of the ear discharges which started before the first birthday and before the age of 5 years continued in the older age groups, respectively, thereby increasing the mean duration of ear discharge in this population. The issue of spillover of CSOM from childhood to adulthood may be related to poverty and overcrowding, which in turn influence the early onset of the disease. We discovered that 76 % of the disease spillover was noted in individuals from large families. Conversely, 69 % of CSOM before the age of 1 year were observed in patients from large families. Moreover, our study indicated that individuals from large families had more than one-anda-half times the odds of developing non-healing ear discharge. It is our impression that poverty is the underlying factor here. The competition for the very limited financial resources in these large families means that little attention is paid to the control of early childhood ear infection with the attendant risk of the disease becoming protracted. Low socioeconomic status and overcrowding have been recognised as significant risk factors for early-onset otitis media [15–17]. Significant association was also found between protracted non-healing ear discharge and chronic rhinorrhoea. We found that more than twice as many patients in the
123
group of protracted ear discharge than those in whom ear discharge resolved within 6 months had constant rhinorrhoea. The significance of constant rhinorrhoea is that retained secretions in the nasal cavity and nasopharynx form an appropriate medium for pathogenic bacteria to thrive. They subsequently ascend through the Eustachian tube to constitute a constant pool of infection in the middle ear. Similar associations between persistent rhinorrhoea/ upper respiratory tract infection and chronic otitis media have been reported, although mostly in paediatric series [8, 9, 14, 18]. To improve the chances of achieving dry ears in these patients, treatment of the underlying causes of persistent rhinorrhoea such as enlarged adenoids in children, chronic sinusitis and nasal allergy should be always be considered. The association between CSOM and allergy has been shown by some authors [9, 19] and not by others [10, 20]. Though we did not find significant association between history of allergy and protracted ear discharge with the application of the conventional P value (P = 0.05), its risk propensity for non-resolving ear discharge in CSOM patients should at least be considered since P = 0.08. There is a chance that our study missed some cases of allergy on account of missing data in view of the retrospective nature of this study. Although non-healing ear discharge was not associated with patients’ gender in this study, there were however significantly more males than females with CSOM. The apparent lower prevalence of female CSOM may be as a result of our cultural family bias towards their health. In the face of very limited family financial resources, most families would preferentially cater to the health of girls before boys, especially as it concerns illnesses that attract social stigma such as ear discharge, which are believed to drive away marriage suitors. What this means is that the female children who had acute otitis media were treated promptly, thereby possibly preventing the girls from progressing to CSOM. Dayasena et al. [1] similarly reported less number of females with CSOM compared to males. We observed that patients with bilateral CSOM had a significantly greater risk of protracted ear discharge than those with unilateral disease. The reason is not known but may not be unconnected to poorer immune status of the patients. Although the latter was not evaluated in this study, we noticed that 67 % of these patients with diabetic mellitus had bilateral disease. It is not a surprise to observe significant association between diabetes mellitus and protracted ear discharge in view of the documented role uncontrolled diabetes mellitus plays in the persistence of (ear) infections through immune depression [1, 21]. In one of the reports, 21.8 % of the 234 CSOM cases with duration of ear discharge ranging from 6 weeks to 20 years were diagnosed with diabetes mellitus [1]. However, the
Eur Arch Otorhinolaryngol
numbers of available blood sugar test results in this series were too few for any reasonable conclusion to be drawn. Multidrug resistance to common affordable antibiotics was highly associated with non-resolving protracted ear discharge. We observed that 86.4 % of the multidrugresistant organisms were Pseudomonas aeruginosa and Staphylococcus aureus which is in agreement with the report of Perveen et al. [22]. The risk factors for multidrug resistance have been documented as improper and indiscriminate use of antibiotics, tobacco smoking, male gender, young age, day-care attendance, and immunodeficiency [22, 23]. Injudicious use of antibiotics is a very common practice in developing countries such as ours in which regulation of antibiotic dispensation is nothing to write home about. The practice of drug dispensation by quack patent drug dealers further compounds the issue. A number of our patients preferred patronizing these quacks to seeing qualified medical doctors, which was also a similar experience in Bangladesh [17]. These folks easily walk across to drugstores and ask for drugs to be ‘mixed’ for their ear discharge as much as their meagre pockets could afford. The drug ‘mixtures’ often contain ill-informed much lower doses of the common antibiotics such as amoxicillin, tetracycline, and sometimes ciprofloxacin. It is only after several such visits to these quacks, patent drug dealers who even go by the title of ‘doctor’, that our patients eventually turn up at the clinics when their discharge persists. This could explain the high rate of multidrug resistance in our study. The significant association of protracted episodes of nonhealing ear discharge with patients living in home more than 10 miles from health facilities probably reflects the difficulty in accessing proper health care. Most of these patients were rural dwellers whose communities were at greater distances away from the urban city centre where the comprehensive health facility was located. Issue of difficult access to health facilities had been reported as a risk factor for CSOM in low-resource settings [24]. The odds of developing protracted non-healing ear discharge was greatest in rural dwellers. This is in agreement with other reported works that documented greater odds of developing CSOM among rural dwellers [4, 8, 10, 17]. In our study, rural patients constituted 77 and 71 % of those with ear discharge that lasted for [10 years and [5 years, respectively. Their average duration of ear discharge was 4.22 ± 5.71 years. In these rural communities, the combination of poverty, ignorance and lack of access to health facility conspire to deny most dwellers the needed health care. Even where rural health centres are available, they are often poorly manned by non-doctor medical personnel. It is pertinent to call for the provision of properly manned health centres within the neighbourhood of the rural communities
so as to at least mitigate the problem of access. This we hope will lead to a decline in the number of non-healing ear discharges among CSOM patients in rural areas. Conflict of interest
None declared.
References 1. Dayasena RP, Dayasiri MBKC, Jayasuriya C et al (2011) Aetiological agents in chronic suppurative otitis media in Sri Lanka. Australas Med J 4:101–104 2. Meyerhoff WL (1988) Pathology of chronic suppurative otitis media. Ann Otol Rhinol Laryngol 97:21–24 3. Madana J, Yolmo D, Kalaiarasi R et al (2011) Microbiological profile with antibiotic sensitivity pattern of cholesteatomatous chronic suppurative otitis media among children. Int J Pediatr Otorhinolaryngol 75:1104–1108 4. Ologe FE, Nwawolo CC (2003) Chronic suppurative otitis media in school pupils in Nigeria. East Afr Med J 80:130–134 5. Okafor BC (1984) The chronic discharging ear in Nigeria. J Laryngol Otol 98:113–119 6. Jensen RG, Homoe P, Anderson M et al (2011) Long-term follow-up of chronic suppurative otitis media in a high-risk children cohort. Int J Pediatr Otorhinolaryngol 75:948–954 7. Orji FT (2013) A survey of the burden of management of chronic suppurative otitis media in a developing country. Ann Med Health Sci Res 3:598–601 8. Sophia A, Isaac R, Rebekah G et al (2010) Risk factors for otitis media among preschool, rural Indian children. Int J Pediatr Otorhinolaryngol 74:677–683 9. Zhang Y, Xu M, Zhang J et al (2014) Risk factors for chronic and recurrent otitis media—a meta-analysis. PLoS One 9:e86397. doi:10.1371/journal.pone.0086397 10. Lasisi AO, Olaniyan FA, Muibi SA et al (2007) Clinical and demographic risk factors associated with chronic suppurative otitis media. Inter J Pediatr Otorhinolaryngol 71:1549–1554 11. Kum-Nji P, Meloy L, Herrod HG (2006) Environmental tobacco smoke exposure: prevalence and mechanisms of causation of infections in children. Pediatrics 117:1745–1754 12. Daly KA, Pirie PL, Rhodes KL et al (2007) Early otitis media among Minnesota American Indians: the Little Ears Study. Am J Public Health 97:317–322 13. Fliss DM, Lieberman SA, Dagan R (1991) Chronic suppurative otitis media without cholesteatoma in children in Southern Israel: incidence and risk factors. Pediatr Infect Dis J 10:895–899 14. van der Veen EL, Schilder AGM, van Heerbeek N et al (2006) Predictors of chronic suppurative otitis media in children. Arch Otolaryngol Head Neck Surg 132:1115–1118 15. Lasisi AO, Olayemi O, Irabor AE (2008) Early onset otitis media: risk factors and effects on the outcome of chronic suppurative otitis media. Eur Arch Otorhinolaryngol 265:765–768 16. Auinger P, Lanphear BP, Kalkwarf HJ et al (2003) Trends in otitis media among children in the United States. Pediatrics 112:514–520 17. Shaheen M, Raquib A, Ahmad SM (2012) Chronic suppurative otitis media and its association with socio-econonic factors among rural primary school children of Bangladesh. Indian J Otolaryngol Head Neck Surg 64:36–41 18. Leach AJ, Boswell JB, Asche V et al (1994) Bacterial colonization of the nasopharynx predicts very early onset and persistence of otitis media in Australian aboriginal infants. Pediatr Infect Dis 13:983–989
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Eur Arch Otorhinolaryngol 19. Lack G, Caulfield H, Penagos M (2011) The link between otitis media with effusion and allergy: a potential role for intranasal corticosteroids. Pediatr Allergy Immunol 22:258–266 20. Stahlberg MR, Ruuskanen O, Virolainen E (1996) Risk factors for recurrent otitis media. Pediatr Infect Dis J 5:30–32 21. Casquueiro J, Casquueiro J, Alves C (2012) Infections in patients with diabetes mellitus: a review of pathogenesis. Indian J Endocrinol Metab 16(Suppl 1):27–36 22. Perveen S, Naqvi SB (2013) Fatima A (2013) Antimicrobial susceptibility pattern of clinical isolates from cases of ear
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infection using amoxicilline and cefepime. Springerplus 2:288. doi:10.1186/2193-1801-2-288.eCollection 23. Klien JO (2012) Strategies for decreasing multidrug antibiotic resistance: role of ototopical agents for treatment of middle ear infections. Am J Manag Care 8(Suppl):345–352 24. Shaw JR, Todd NW, Goodwin MH et al (1981) Observations on the relation of environmental and behavioral factors to the occurrence of otitis media among Indian children. Pub Health Rep 96:342–349
OTOLOGY
Determinants of non-healing ear discharge in chronic suppurative otitis media in a developing country Foster Tochukwu Orji • Benjamin O. Dike Onuoha Oji
•
Received: 1 June 2014 / Accepted: 19 August 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract The major burden of chronic suppurative otitis media (CSOM) is the embarrassing ear discharge which may last for few months to many years or even a lifetime with increasing risks of complications. We conducted this study to determine the risk factors for protracted nonhealing ear discharge among CSOM patients. We carried out a retrospective analysis of non-cholesteatomatous CSOM patients treated in a tertiary hospital in a developing country. Comparison was made between 128 patients with ear discharge persisting beyond 24 months and 58 patients whose otorrhoea resolved within 6 months in terms of socio-demographic and other potential risk factors. Major risk factors identified by logistic regression analysis were rural residence, multidrug-resistant bacteria, and bilateral CSOM (P = \0.001, 0.001, and 0.008, respectively). Others were onset of ear discharge before the age of 10 years, diabetes mellitus, persistent rhinorrhoea, home [10 miles away from hospital, and [7 persons in a family (P = 0.012, 0.041, 0.013, 0.010, and 0.043, respectively). Age, sex, nasal allergy, and self-medication were not significant risk factors for non-healing ear discharge. Protracted non-healing ear discharge still remains a prominent feature of CSOM in our experience. Rural residence,
F. T. Orji (&) Department of Otolaryngology, University of Nigeria Teaching Hospital Enugu, Enugu, Nigeria e-mail: [email protected] F. T. Orji Department of Surgery, Federal Medical Center Umuahia, Umuahia, Nigeria B. O. Dike O. Oji Department of Otolaryngology, Federal Medical Center Umuahia, Umuahia, Nigeria
multidrug resistance, bilateral CSOM, and long distance to health facilities are prime risk factors. Measures to address these risk factors to bring about a decline in the number of non-healing ear discharge among CSOM patients, especially in our rural communities, are urgently needed. Keywords Ear discharge Non-healing Chronic suppurative otitis media Risk factors
Introduction Chronic suppurative otitis media (CSOM) is a disease of mucoperiosteal lining of the middle ear cleft characterised by persistent perforation of the tympanic membrane in the presence or absence of ear discharge [1–4]. The disease often begins in early childhood, usually as acute otitis media, with potential of spilling over into adulthood, accounting for recurrent episodes of chronic ear discharge [2, 5, 6]. The major concern of most patients with CSOM is the embarrassing frequent episodes of purulent ear discharge which recurs sporadically [7]. The duration of ear discharge episode in CSOM is variable. The discharge in cholesteatomatous type often lasts for many years compared to tubotympanic, non-cholesteatomatous disease which usually lasts for few months to few years [3, 6]. But in poor resource countries, the discharge, even in safe tubotympanic type, has been observed to continue for many years with increasing risk of hearing impairment and lifethreatening infective complications [5, 7]. Although risk factors for otits media have been severally reported in both paediatric and adult series, the determinants of non-healing protracted ear discharge in CSOM patients are yet to be systematically evaluated. We conducted this study to examine the risk factors associated with protracted
123
Eur Arch Otorhinolaryngol
ear discharges in non-cholesteatomatous CSOM patients receiving specialist care in a low-resource country.
Table 1 Distribution of patients’ age and the age of onset of ear discharge among the target groups of chronic suppurative otitis media patients Number of patients
Methods The present study was conducted in the department of otolaryngology of Federal Medical Center Umuahia, Nigeria, in which retrospective case analysis of patients who were receiving care for chronic ear discharges during a 3-year period ending December 2012 was carried out after the necessary institutional approved was obtained. Data of consecutive patients up to 2 years of age were included if the ear discharge lasted for more than 3 months regardless of the treatment offered. Patients were excluded if clinically diagnosed with cholesteatoma or had evidence of cholesteatoma on computer tomographic imaging of the temporal bone. Those ear discharges that resulted from ear trauma were also excluded. Two hundred and fifty-one patients who met our criteria were identified. Their records were further reviewed to select the target groups depending on the duration of ear discharge, for analysis. Those selected included the group of 128 (51 %) patients whose ear discharge did not resolve after 24 months and 58 (23 %) ear discharges that resolved within 6 months. The following factors were compared between the two target groups: patient age, gender, age of onset of CSOM, bilateral/unilateral disease, multidrug resistance (defined as resistance to three or more of the following antibiotics in the antibiotic sensitivity test: amoxicillin, amoxicillin/clavulanate, gentamicin, erythromycin, ciprofloxacin, tetracycline, and chloramphenicol); rural residential, home C10 miles from health facility, self-medication practice, large family (family size of [7), coexisting diabetes mellitus, persistent rhinorrhoea (nasal discharge of up to 6 weeks), and allergic rhinitis. Statistical analysis Data were analysed with ‘Statistical Package for Social Sciences’ (SPSS), version 16.5. The association between the potential risk factors and prolonged non-healing ear discharge was studied using Chi-square test of proportions. Logistic regression test was used to model the association between significant risk factors in Chi-square test and the likelihood of prolonged chronic ear discharge separately. Statistical significance was set at P value of \0.05.
Results Data from 186 target groups were analysed. The 128 group ‘A’ patients had a mean age of 21.4 ± 19.1 years that
123
Percentage (%)
Age of patients at presentation, n = 186 \10 years
63
33.9
10–20 years 21–30 years
52 31
28.0 16.7
30–50 years
18
9.7
[50 years
22
11.8
Total
186
100
Age of onset of ear discharge n = 185 \1 year
37
19.9
2–5 years
47
25.3
6–10 years
15
8.1
11–20 years
30
16.1
[20 years
56
30.1
ranged from 2 to 86 years, while the mean age of the 58 group ‘B’ patients was 21.9 ± 21.7 years, with the youngest patient being 2 years and the oldest being 82 years. The difference was not significant (P = 0.382). The details of the distribution of the age as well as the age of onset of chronic ear discharge among the target groups are provided in Table 1. More than 33 % were children \10 years of age. The age at the first episode of ear discharge ranged from 6 weeks of life to 82 years with 19.9 % of the patients having their first episode before the age of 1 year. In 18 % of the patients (15 adolescents and 18 adults), their current ear discharges dated back to their early childhood. Male patients significantly outnumbered the females (P = 0.028). The duration of otorrhoea in group ‘A’ subjects ranged from 24 months to 45 years with a mean of 4.6 ± 4.8 years, while the mean duration of otorrhoea was 4.9 ± 0.9 months in group the ‘B’ and ranged from 3.5 to 6 months. The distribution of the risk factor in relation to the duration of ear discharge among the patient groups is as detailed in Table 2. Potential risk factors which had a significance of \0.05 on univariate Chi-square analysis were included in the multivariate logistic regression model to obtain the adjusted odds ratios. These included age of onset of ear discharge, ears affected, residence in rural communities, multidrug resistance, hospital distance from home, family size, coexisting diabetes mellitus, and persistent rhinorrhoea. The result of logistic regression test identified bilateral CSOM, onset of ear discharge before the age of 5 years, multidrug resistance, coexisting diabetes mellitus, and persistent rhinorrhoea as significant risk factors for nonhealing protracted ear discharge (P = 0.008, 0.012, 0,001,
Eur Arch Otorhinolaryngol Table 2 Univariate and multivariate analysis of the association of potential risk factors with the length of otorrhoea
Potential factors
Duration of otorrhoea C2 years
\6 months
Chi-square test
Logistic regression test
P value
OR (95 % CI)
P value
OR (95 % CI)
Age B10 years
44
18
0.869
1.08 (0.56–2.08)
–
–
10–20 years
35
19
0.780
0.91 (0.46–1.80)
–
–
21–30 years
21
10
0.887
0.94 (0.41–2.15)
–
–
[ 30 years
28
12
0.856
1.02 (0.81–1.29)
–
–
0.390
1.32 (0.70–2.46)
–
–
0.004
2.69 (1.39–5.23)
0.012
2.27 (1.20–4.28)
\0.001
6.23 (2.63–14.77)
0.008
3.00 (2.51–5.07)
\0.001
5.93 (2.99–11.74)
\0.001
6.02 (3.65–12.36)
0.007
2.35 (1.25–4.43)
0.010
1.79 (1.06–1.63)
0.442
1.35 (0.62–2.94)
–
–
0.295
0.68 (0.34–1.38)
–
–
0.021
1.30 (1.04–1.64)
0.013
2.35 (1.17–4.71)
0.027
2.21 (1.09–4.52)
0.043
1.74 (1.01–2.82)
0.023
4.76 (1.20–18.98)
0.041
1.67 (1.13–2.34)
0.002
2.81 (1.48–5.32)
0.001
5.66 (1.92–6.91)
Gender Male
77
31
Female
51
27
Age of onset of disease B5 years [5 years Ears involved
67
17
60
41
Biilateral
59
7
Unilateral
69
51
Rural
91
23
Urban
37
35
Area of residence
Home more than 10 miles from the hospital Yes
82
25
No
46
33
Self-medication practice Yes
39
12
No
72
30
Yes
34
20
No
78
31
Persistent rhinorrhoea Yes 72
21
Coexisting allergy
No
38
26
[7
72
22
B7
34
23
Family size
Diabetes Yes
15
3
No
21
20
Multidrug resistance OR odds ratio, 95 % CI 95 % confidence interval
Yes
83
23
No
45
35
0.041, and 0.013, respectively). Significant social risk factors included rural residence and home [10 miles away from hospital (P = \0.001 and 0.010, respectively). The family size was also significantly associated with nonhealing ear discharge (P = 0.043). In univariate analysis, bilateral disease and rural residence had the greatest odds for prolonged ear discharge (6.23 and 5.93, respectively), whereas the results of logistic regression test revealed that rural residence and multidrug resistance on antibiotic
sensitivity testing had the greatest odds of protracted nonhealing ear discharge (6.02 and 5.66, respectively).
Discussion The challenges associated with CSOM include hearing loss, persistent or recurrent episodes of ear discharge, and risks of various intracranial and extracranial complications.
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Eur Arch Otorhinolaryngol
But the most worrisome burden of the disease remains the social embarrassments from the recurrent ear discharges [5, 7]. The pattern of ear discharge in CSOM varies considerably between individuals and disease type. In many patients, ear discharge recurs from time to time after the initial control [1, 6, 8, 9], whereas in some, especially in tubotympanic CSOM, after the initial episode of ear discharge dry ears are achieved for a very long period of time [6]. Yet in other cases, especially in developing countries or in cholesteatomatous type, the discharge continues for many years [1, 3, 5, 7]. The risk factors for CSOM have been reported, especially from studies on paediatric populations, to include low socioeconomic status (poor housing, overcrowding, large families, poor occupational and environmental conditions), allergy/atopy, chronic rhinorrhoea, chronic nasal obstruction, previous acute or recurrent acute otitis media, secondhand smoking (in children), and indoor cooking [8–14]. The present report is an attempt to investigate the determinants of non-healing ear discharge in patients with non-cholesteatomatous CSOM. Although non-healing ear discharge was not significantly related to patient age, we found that the impact of age at onset of ear discharge was significant, as those that had their first episode of otorrhoea before the age of 5 years had more than two times greater odds of having protracted ear discharge. Early onset of otitis media has been associated with greater risk of CSOM [15]. The reason for this association is not obvious, but we noticed in our study that 35 and 52 % of the ear discharges which started before the first birthday and before the age of 5 years continued in the older age groups, respectively, thereby increasing the mean duration of ear discharge in this population. The issue of spillover of CSOM from childhood to adulthood may be related to poverty and overcrowding, which in turn influence the early onset of the disease. We discovered that 76 % of the disease spillover was noted in individuals from large families. Conversely, 69 % of CSOM before the age of 1 year were observed in patients from large families. Moreover, our study indicated that individuals from large families had more than one-anda-half times the odds of developing non-healing ear discharge. It is our impression that poverty is the underlying factor here. The competition for the very limited financial resources in these large families means that little attention is paid to the control of early childhood ear infection with the attendant risk of the disease becoming protracted. Low socioeconomic status and overcrowding have been recognised as significant risk factors for early-onset otitis media [15–17]. Significant association was also found between protracted non-healing ear discharge and chronic rhinorrhoea. We found that more than twice as many patients in the
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group of protracted ear discharge than those in whom ear discharge resolved within 6 months had constant rhinorrhoea. The significance of constant rhinorrhoea is that retained secretions in the nasal cavity and nasopharynx form an appropriate medium for pathogenic bacteria to thrive. They subsequently ascend through the Eustachian tube to constitute a constant pool of infection in the middle ear. Similar associations between persistent rhinorrhoea/ upper respiratory tract infection and chronic otitis media have been reported, although mostly in paediatric series [8, 9, 14, 18]. To improve the chances of achieving dry ears in these patients, treatment of the underlying causes of persistent rhinorrhoea such as enlarged adenoids in children, chronic sinusitis and nasal allergy should be always be considered. The association between CSOM and allergy has been shown by some authors [9, 19] and not by others [10, 20]. Though we did not find significant association between history of allergy and protracted ear discharge with the application of the conventional P value (P = 0.05), its risk propensity for non-resolving ear discharge in CSOM patients should at least be considered since P = 0.08. There is a chance that our study missed some cases of allergy on account of missing data in view of the retrospective nature of this study. Although non-healing ear discharge was not associated with patients’ gender in this study, there were however significantly more males than females with CSOM. The apparent lower prevalence of female CSOM may be as a result of our cultural family bias towards their health. In the face of very limited family financial resources, most families would preferentially cater to the health of girls before boys, especially as it concerns illnesses that attract social stigma such as ear discharge, which are believed to drive away marriage suitors. What this means is that the female children who had acute otitis media were treated promptly, thereby possibly preventing the girls from progressing to CSOM. Dayasena et al. [1] similarly reported less number of females with CSOM compared to males. We observed that patients with bilateral CSOM had a significantly greater risk of protracted ear discharge than those with unilateral disease. The reason is not known but may not be unconnected to poorer immune status of the patients. Although the latter was not evaluated in this study, we noticed that 67 % of these patients with diabetic mellitus had bilateral disease. It is not a surprise to observe significant association between diabetes mellitus and protracted ear discharge in view of the documented role uncontrolled diabetes mellitus plays in the persistence of (ear) infections through immune depression [1, 21]. In one of the reports, 21.8 % of the 234 CSOM cases with duration of ear discharge ranging from 6 weeks to 20 years were diagnosed with diabetes mellitus [1]. However, the
Eur Arch Otorhinolaryngol
numbers of available blood sugar test results in this series were too few for any reasonable conclusion to be drawn. Multidrug resistance to common affordable antibiotics was highly associated with non-resolving protracted ear discharge. We observed that 86.4 % of the multidrugresistant organisms were Pseudomonas aeruginosa and Staphylococcus aureus which is in agreement with the report of Perveen et al. [22]. The risk factors for multidrug resistance have been documented as improper and indiscriminate use of antibiotics, tobacco smoking, male gender, young age, day-care attendance, and immunodeficiency [22, 23]. Injudicious use of antibiotics is a very common practice in developing countries such as ours in which regulation of antibiotic dispensation is nothing to write home about. The practice of drug dispensation by quack patent drug dealers further compounds the issue. A number of our patients preferred patronizing these quacks to seeing qualified medical doctors, which was also a similar experience in Bangladesh [17]. These folks easily walk across to drugstores and ask for drugs to be ‘mixed’ for their ear discharge as much as their meagre pockets could afford. The drug ‘mixtures’ often contain ill-informed much lower doses of the common antibiotics such as amoxicillin, tetracycline, and sometimes ciprofloxacin. It is only after several such visits to these quacks, patent drug dealers who even go by the title of ‘doctor’, that our patients eventually turn up at the clinics when their discharge persists. This could explain the high rate of multidrug resistance in our study. The significant association of protracted episodes of nonhealing ear discharge with patients living in home more than 10 miles from health facilities probably reflects the difficulty in accessing proper health care. Most of these patients were rural dwellers whose communities were at greater distances away from the urban city centre where the comprehensive health facility was located. Issue of difficult access to health facilities had been reported as a risk factor for CSOM in low-resource settings [24]. The odds of developing protracted non-healing ear discharge was greatest in rural dwellers. This is in agreement with other reported works that documented greater odds of developing CSOM among rural dwellers [4, 8, 10, 17]. In our study, rural patients constituted 77 and 71 % of those with ear discharge that lasted for [10 years and [5 years, respectively. Their average duration of ear discharge was 4.22 ± 5.71 years. In these rural communities, the combination of poverty, ignorance and lack of access to health facility conspire to deny most dwellers the needed health care. Even where rural health centres are available, they are often poorly manned by non-doctor medical personnel. It is pertinent to call for the provision of properly manned health centres within the neighbourhood of the rural communities
so as to at least mitigate the problem of access. This we hope will lead to a decline in the number of non-healing ear discharges among CSOM patients in rural areas. Conflict of interest
None declared.
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