Treatment of otologic disease in Australian Aboriginal children

Ear, Nose & Throat Journal, Sept, 2004 by Harvey Coates

Chronic suppurative otitis media (CSOM) is a serious problem among children in Australia's Aboriginal population. Compared with white children in the urban areas of Australia, Aboriginal children develop otitis media and its complications at an earlier age and experience a higher incidence of tympanic membrane perforation and hearing loss.

Several cultural and environmental causes account for the greater threat posed by CSOM in the indigenous population: poverty, overcrowding, poor sanitation and hygiene, a lack of clean water, passive smoking, and limited access to and interest in seeking medical care.

I have been involved in several recent studies of otologic diseases in Aboriginal children, and I would like to summarize a few of them.

NACCHO CSOM study

The largest study of topical therapy in CSOM in Australia was conducted between April 1, 2001, and June 30, 2002, by the National Aboriginal Community Controlled Health Organisation (NACCHO). (1) For 3 decades, the standard antibiotic treatment for CSOM in Aboriginal children had been a combination of topical 0.5% framycetin (neomycin B), gramicidin, and dexamethasone (FGD), a preparation that is potentially ototoxic. Topical fluoroquinolones, on the other hand, have never been implicated in ototoxicity.

The NACCHO investigators compared FGD and 0.3% ciprofloxacin in a randomized, double-blind, controlled trial. Patients received 5 drops of their respective medication twice daily for 9 weeks. All patients were also treated with 0.5% povidone iodine as an ear toilet to clear otorrhea. Patients were reassessed at follow-up on days 10 and 14.

A total of 111 patients completed treatment and follow-up--55 in the ciprofloxacin group and 56 in the FGD group. The clinical cure rate among the ciprofloxacin group was significantly higher--76.4 vs. 51.8% (p = 0.009). No evidence of ciprofloxacin resistance was seen. As a result, the NACCHO investigators have urged Australian medical authorities to take steps to make ciprofloxacin more readily available as a first-line treatment in the Aboriginal population.

Kalgoorlie otitis media study

Kalgoorlie, an arid inland city in Western Australia, served as the base for a 4-year study of otitis media in 100 Aboriginal and 180 non-Aboriginal infants. (Dr. Deborah Lehmann and I served as chief investigators; the complete results have not yet been published.) All patients underwent audiometry and tympanometry as part of their examination.

We found that 53% of the Aboriginal children had developed otitis media before they had reached the age of 4 months, compared with only 24% of the non-Aboriginal children. Also, at I year of age, 20% of the Aboriginal children had a perforated tympanic membrane, compared with fewer than 2% of the others. The major risk factors associated with the development of otitis media in both groups were overcrowding, the level of maternal education, and the duration of breast-feeding.

Myringoplasty study

I was also involved in a study of the effectiveness of surgery for middle ear disease, in which we found that it improved hearing and perforation status in a significant proportion of Aboriginal children over both the short and long term. (2)

At a median postoperative follow-up of 14 months, 70% of patients had normal hearing, 72% experienced a reduction or complete closure of tympanic membrane perforations, and 53% experienced an improvement in air-bone gap of at least 10 dB.

We recommended that surgery should not be delayed, because younger children are just as likely as older children to experience a successful outcome and normal postoperative hearing; they also benefit more in terms of learning.

Swimming pool study

The Telethon Institute for Child Health Research conducted a study of the impact that the introduction of swimming pools had on the health of Aboriginal children and adolescents living in Burringurrah and Jigalong, two communities that are located in the remote areas of Western Australia. (3)

We found that children and teenagers who swam in well-maintained swimming pools rather than in natural bodies of water had a higher incidence of normal ears, fewer tympanic perforations, and better skin, eye, nose, and chest health. After authorities instituted a "no school, no pool" policy to encourage school attendance, the rate of truancy diminished significantly. In addition, the swimming pool in each of these isolated communities became the center of village life during the summer and improved the cohesiveness of the community.

References

(1.) Couzos S, Lea T, Mueller R, et al. Effectiveness of ototopical antibiotics for chronic suppurative otitis media in Aboriginal children: A community-based, multicentre, double-blind randomised controlled trial. Med J Aust 2003; 179:185-90.

(2.) Mak DB, MacKendrick A, Bulsara MK, et al. Long-term outcomes of middle-ear surgery in Aboriginal children. Med J Aust 2003;179: 324-5.

(3.) Lehmann D, Tennant MT, Silva DT, et al. Benefits of swimming pools in two remote Aboriginal communities in Western Australia: Intervention study. BMJ 2003;327(7412):415-19.