Impact of swimming on chronic suppurative otitis media in Aboriginal children: a randomised controlled trial.

OBJECTIVES: To measure the impact of 4 weeks of daily swimming on rates of ear discharge among Aboriginal children with a tympanic membrane perforation (TMP) and on the microbiology of the nasopharynx and middle ear. DESIGN, SETTING AND PARTICIPANTS: A randomised controlled trial involving 89 Aboriginal children (aged 5-12 2013s) with a TMP, conducted in two remote Northern Territory Aboriginal communities from August to December 2009. INTERVENTION: 4 school weeks of daily swimming lessons (45 minutes) in a chlorinated pool. MAIN OUTCOME MEASURES: Proportions of children with ear discharge and respiratory and opportunistic bacteria in the nasopharynx and middle ear. RESULTS: Of 89 children randomly assigned to the swimming or non-swimming groups, 58 (26/41 swimmers and 32/48 non-swimmers) had ear discharge at baseline. After 4 weeks, 24 of 41 swimmers had ear discharge compared with 32 of 48 non-swimmers (risk difference, - 8% (95% CI, - 28% to 12%). There were no statistically significant changes in the microbiology of the nasopharynx or middle ear in swimmers or non-swimmers. Streptococcus pneumoniae and non-typeable Haemophilus influenzae were the dominant organisms cultured from the nasopharynx, and H. influenzae, Staphylococcus aureus and Pseudomonas aeruginosa were the dominant organisms in the middle ear. CONCLUSIONS: Swimming lessons for Aboriginal children in remote communities should be supported, but it is unlikely that they will substantially reduce rates of chronic suppurative otitis media and associated bacteria in the nasopharynx and middle ear. However, swimming was not associated with increased risk of ear discharge and we found no reason to discourage it. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000634774.

[The microbiological structure of chronic suppurative otitis media in the Gomel region].

The objective of the present work was to study the spectrum of microbiota maintaining the inflammatory process in the cavities of the middle ear of the patients presenting with chronic suppurative otitis media (CSOM) and to estimate its susceptibility to antibiotic agents. The discharge from the ears was subjected to microbiological analysis in 138 patients with CSOM. Some of the microorganisms proved highly sensitive to antibiotic agents. The following etiologically important pathogens involved in the maintenance of the chronic pyoinflamatory process in the cavities of the middle ear were identified: bacteria, fungi, and bacterial-fungal associations that accounted for 66.3%, 6.7%, and 26.9% of all CSOM cases respectively. The former group was dominated by S.aureus (34.6%) whereas the group of non-fermentative Gram-negative species and enterobacteria comprised 16.3% and 15.4% of their total number respectively. The microbiota was shown to be highly susceptible to cephalosporins of the 1st and 2nd generations and fluoroquinolones of the 2nd generation. C. albicans proved highly sensitive to fluconazole while mycelial micromycetes responded fairly well to itracnazole and voriconazole.

Long-term follow-up of chronic suppurative otitis media in a high-risk children cohort.

OBJECTIVE: Chronic suppurative otitis media (CSOM) is the leading cause of mild to moderate hearing impairment in children worldwide and a major public health problem in many indigenous populations. There is a lack of basic epidemiological facts and knowledge on the development of CSOM, as the disease primarily affects developing countries where research capacities often are limited. The purpose of this study was to determine the long-term outcome of CSOM in a high-risk population and to identify risk factors. METHODS: Follow-up study (2008) on a population-based cohort of 465 children in Greenland, initially examined (1996-8) between the ages 0 and 4 years. Follow-up was attempted among 307 children living in the two major towns. Binomial logistic regression analysis was made to identify risk factors for developing CSOM and for maintaining disease in to adolescence (odds ratios). Log linear binomial regression was used to estimate risk ratios and absolute risks. RESULTS: At follow-up 236 participated (77% of those available). The prevalence of CSOM was 32/236 (14%) at age group 0-4 years and 21/236 (9%) at age group 11-15 years. Thirteen had disease debut after the initial study. Of those with CSOM in the initial study 24/32 (75%) healed spontaneously. Risk factors for the development of CSOM at any time in childhood was the mother's history of CSOM OR 2.55 (95% CI 1.14-5.70; p=0.02), and mothers with low levels of schooling OR 1.57 (1.03-2.40; p=0.04). Once CSOM had developed boys were more likely to have persistent disease OR 5.46 (95% CI 1.47-20.37; p=0.01). The absolute risk of CSOM if the mother had both a history of CSOM and low schooling was for boys 45.4% (95% CI 26.5-77.7) and for girls 30.7% (95% CI 17.8-53.10). The cumulative risk of CSOM was 19% at follow-up. CONCLUSIONS: Even though a large number of CSOM cases seemed to heal spontaneously, the prevalence of untreated CSOM among school-age children in Greenland remained high as new cases were found at follow-up. Increased focus on prevention and identification of children at special risk could reduce the high prevalence of CSOM.

Chronic suppurative otitis media in Nepal: ethnicity does not determine whether disease is associated with cholesteatoma or not.

OBJECTIVES: To determine the frequency of cholesteatoma in a population of patients with chronic suppurative otitis media, and to determine whether this frequency is affected by ethnicity. PATIENTS: The study included 6005 patients with chronic suppurative otitis media seen during the course of 30 charitable surgical 'ear camps' in Nepal. MAIN OUTCOME MEASURES: Proportion of patients with each subtype of disease, and their ethnicity. A secondary outcome measure was concordance of surname with Nepalese ethnic affiliation. RESULTS: A total of 762 patients were grouped as being of Tibeto-Mongolian origin, and 4875 as Indo-Caucasian. The rate of chronic suppurative otitis media with cholesteatoma, expressed as a proportion of the rate of all chronic suppurative otitis media subtypes, was 17.8 per cent in Tibeto-Mongolian patients and 18.6 per cent in Indo-Caucasian patients (p > 0.05). The effect of other risk factors (i.e. age, gender and geographical district) on disease distribution was also non-significant. Analysis of secondary outcome measures indicated that patients' surnames were a reliable predictor of ethnicity in this Nepalese population. CONCLUSION: There is almost complete concordance in proportions of patients with significant genetic, cultural, and even geographical heterogeneity, suggesting that, in Nepal, the aetiology of cholesteatoma owes little to these factors.

Management of children with otitis media: a survey of Australian Aboriginal Medical Service practitioners.

AIM: To determine whether Australian Aboriginal Medical Service (AMS) practitioners treat otitis media (OM) more aggressively in Aboriginal than non-Aboriginal children and the factors influencing their management decisions. METHODS: A case vignette questionnaire was sent to all AMS practitioners working in December 2006. We compared responses based on the child's Aboriginal status using chi(2) analysis. RESULTS: Questionnaires were returned from 63/87 (72%) of the AMSs by 131/238 (55%) eligible practitioners. Few practitioners (13%) reported using tympanometry or pneumatic otoscopy (9%) when examining children's ears. Practitioners were more likely to treat acute OM with antibiotics (92% vs. 49%, P < 0.01) and to treat with courses longer than 7 days (25% vs. 14%, P= 0.03) in Aboriginal than non-Aboriginal children. Most practitioners (60%) used oral antibiotics to treat chronic suppurative OM and OM with effusion in Aboriginal children (58%). Factors increasing the likelihood of antibiotic use included: the child being Aboriginal (67%), wet perforations (62%) and bulging eardrums (59%). No AMS or practitioner characteristics were significant predictors. Most practitioners (99%) were aware of Therapeutic Guidelines (Antibiotic). Only half (54%) were aware of the Australian Government guidelines for managing OM in Aboriginal and Torres Strait Islander populations and only 22% used them 'often' or 'always'. CONCLUSIONS: Australian AMS practitioners treat OM more aggressively in Aboriginal children, consistent with the Australian Government guidelines, despite half being unaware of them. Opportunities to improve management include increased use of pneumatic otoscopy and tympanometry, and decreased antibiotic usage for OM with effusion and chronic suppurative OM.

Topical ciprofloxin versus topical framycetin-gramicidin-dexamethasone in Australian aboriginal children with recently treated chronic suppurative otitis media: a randomized controlled trial.

BACKGROUND: Chronic suppurative otitis media (CSOM) affects many children in disadvantaged populations. The most appropriate topical antibiotic treatment in children with persistent disease is unclear. METHODS: Children with CSOM despite standard topical treatment were randomized to 6-8 weeks of topical ciprofloxacin (CIP) versus topical framycetin-gramicidin-dexamethasone (FGD). Otoscopic, audiologic, and microbiologic outcomes were measured using standardized assessments and blinding. RESULTS: Ninety-seven children were randomized. Ear discharge failed to resolve at the end of therapy in 70% children regardless of allocation [risk difference = -2%; (95% CI: -20 to 16)]. Healing of the tympanic membrane occurred in one of 50 children in the CIP group and none of 47 children in the FGD group. Severity of discharge failed to improve in more than 50% children in each group, and mean hearing threshold (38 dB and 35 dB) and proportion of children with greater than 25 dB hearing loss (98% and 88%) were not significantly different between the CIP and FGD groups. Side effects were rare. CONCLUSIONS: This study showed a similarly low rate of improvement or cure in children with persistent CSOM for both CIP and FGD topical therapies. Complications and side effects were insufficient to cease therapy or inform prescribing of either therapy.

An overview of acute otitis media in Australian Aboriginal children living in remote communities.

Australian Aboriginal children experience early, persistent and severe middle ear infections. We conducted a review of the medical literature that addressed acute otitis media (AOM) in Australian Aboriginal children. Comparisons were made with the recent guidelines on the diagnosis and management of AOM prepared by the American Academies of Pediatrics and Family Physicians (AAP & AAFP 2004). Otitis media in Aboriginal children living in remote communities begins in the first 3 months of life following early bacterial colonisation. Young children with persistent signs of suppurative disease (bulging of the tympanic membrane or middle ear discharge) are probably most at risk of developing chronic suppurative otitis media.

'We are not just participants--we are in charge': the NACCHO ear trial and the process for Aboriginal community-controlled health research.

OBJECTIVE: Methodological criteria that characterise ethically sound community-based studies are often described in overviews but are rarely documented in clinical studies. Research investigating the health of Aboriginal Australians is often small-scale, descriptive and largely driven by non-Indigenous people. The 'community-controlled' model of research relating to Aboriginal peoples health is a form of 'participatory' research that shifts the balance of control towards those being researched. This paper describes the methodological issues and principles that underpin community-controlled health research; their practical application; and encourages their adoption in research involving Indigenous populations. DESIGN: Descriptive report of the methods used to conduct the landmark Aboriginal community-controlled multi-centre double-blind randomised controlled clinical ear trial investigating ototopical treatments for chronic suppurative otitis media. RESULTS: The characteristics of the community-controlled research model are illustrated under the headings of: setting the research agenda; research project planning and approval; conduct of research; and analysis, dissemination and application of findings. CONCLUSION: The 22 methodological elements which defined the community-controlled design of the ear trial may assist community groups, external research bodies and funding agencies to improve the acceptability, quality and scope of research involving Indigenous peoples. Aboriginal community-controlled organisations are well placed to lead research, which can be interventional and of a high scientific standard without compromising the values and principles of those being researched. With over 120 Aboriginal community-controlled health services (ACCHSs) across Australia, the potential exists for these services to engage in multi-centre research to realise solutions to health problems faced by Indigenous Australians.

Prevalence and natural history of otitis media with perforation in Maori school children.

New Zealand Maoris are one of five ethnic groups in developed countries known to have a high rate of ear disease, including perforation of the eardrum (CSOM). It is a strongly held belief by otolaryngologists whose practice dates back to the 1960's that the prevalence of CSOM in Maori children is gradually falling. Despite the obvious practical implications this change has not yet been documented. The aim of the study was to compare the prevalence of CSOM in two surveys conducted in 1978 and 1987 of children living in a North Island Maori community. A second aim was to examine the natural history of CSOM in these children. The raw data from the 1978 study were reviewed. Of 134 children aged 4-13, 12 had CSOM. In 1987 the same age group yielded 12 children out of 250 with CSOM. The prevalence of CSOM fell from 9 per cent to 4 per cent. The incidence of new perforations in 1987 was 1.3 per cent per child per year. It is concluded there has been a fall in the rate of CSOM, although otitis media remains a significant problem for these children. The probability of a perforation healing was influenced by whether or not the perforation had been observed before: at least 35 per cent of perforations seen for the first time healed, but none of the perforations seen on two occasions healed spontaneously. It was concluded that perforation of the eardrum can be managed conservatively at first.