Eur Arch Otorhinolaryngol (2006) 263: 404–408 DOI 10.1007/s00405-005-1023-1

O TO L OG Y

Refik Caylan Æ Devrim Bektas Æ Cemalettin Atalay Omer Korkmaz

Prevalence and risk factors of otitis media with effusion in Trabzon, a city in northeastern Turkey, with an emphasis on the recommendation of OME screening Received: 29 March 2005 / Accepted: 1 August 2005 / Published online: 22 November 2005 Ó Springer-Verlag 2005

Abstract This cross-sectional study was undertaken to assess the prevalence and risk factors for otitis media with effusion (OME) in Trabzon, a city in northeastern Turkey, and evaluate the need for screening for OME in the normal population. In kindergartens, daycare centers, public and private schools in the rural and central areas of Trabzon, 1,077 children aged between 5 and 12 years were examined. OME prevalence was 11.14% (120/ 1,077). Young age, attendance at kindergarten/daycare, low economical status, the mother’s working status (housewife), history of snoring and acute otitis media, antibiotic use in the previous 3 months and active upper respiratory tract infection (URTI) were found to be the risk factors for OME. A history of hearing loss reported by the parents and teachers was found significant in the diagnosis of OME despite the low predictive value. When the parents suspected that their child had experienced hearing loss (in 36 cases), they did not refer them to a healthcare facility. To conclude, the approach to OME in developing countries should be more interventional as healthcare coverage is usually low and behavioral factors such as the demand for healthcare is poor. Keywords Otitis media with effusion Æ Screening Æ Healthcare Æ Risk factors Æ Children

overwhelmingly seen in the first 15 years of life, it is generally considered to be a childhood disease. The importance of this disease for the public health comes from its tendency to follow a silent course and to harbor the potential to cause sequelae and complications such as retraction pockets, tympanosclerosis, COM and adhesive otitis media. To prevent these complications, children who have certain risk factors for OME must be identified and treated in the early phase of the disease. Although screening for OME in a specific population has the potential to decrease sequelae related to the disease, population-based screening that does not specifically address a certain high-risk group has been found to be ineffective in influencing short-term outcomes [28]. The high prevalence of the disease (rising up to 64% depending on the population, age group studied, diagnostic criteria and instruments used to detect the disease, etc. [11]) and high spontaneous resolution rates (resolution of 75–90% of the cases following AOM in 3 months [7, 22]) also complicate the problem. This study was planned to investigate the prevalence and risk factors of OME in Trabzon, a city in northeastern Turkey, which is located on the southeastern coast of the Black Sea. We also discuss the regional healthcare characteristics and behavioral attitudes towards health problems that may affect the approach to OME and make a recommendation for populationbased screening programs.

Introduction OME is one of the most commonly seen diseases of childhood. It is characterized by the collection of serous or mucous fluid behind an intact tympanic membrane cavity during an inflammatory process and the lack of acute signs and symptoms of infection. Because OME is R. Caylan (&) Æ D. Bektas Æ C. Atalay Æ O. Korkmaz Department of Otolaryngology, Black Sea Technical University School of Medicine, Trabzon, Turkey E-mail: refi[email protected] Tel.: +90-462-3775455 Fax: +90-462-3258324

Materials and methods Study design This study received an ethics review and approval from the Ethics Committee of the Medical School of Karadeniz Technical University. This cross-sectional epidemiological study was conducted in Trabzon between September 2001 and April 2002 on a total of 1,077 primary school and kindergarten children aged 5 to 12 years (567 male; 510 female). The children’s parents

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received questionnaires containing 27 questions. Information from teachers was also obtained using a different questionnaire. The children, whose parents signed informed consents, were included in the study. Out of 1,230 parents, 1,077 accepted to participate in this study (87% response rate). The children underwent an ENT examination, and those with reported otologic complaints and/or abnormal otologic examination findings (dull or retracted membrane) were further tested with tympanometry and pneumatic otoscopy. The type B tympanogram, which shows a flat, non-peaking curve with a low static compliance, was used to diagnose OME. In cases where there was a discrepancy between the tympanometric and otoscopic findings, the diagnosis was based on pneumatic otoscopy findings. The ratio of children to be studied in rural and urban areas was deducted from the population distribution of the region. A quarter of the study group was from the rural area, while the remaining 75% was selected from the central schools. Data collection The parent questionnaire included questions about the age, gender, school type, number of people in the household, presence of smoking parents, educational status of the parents, economic status and occupation of the parents, birth term and delivery type of the child, the duration of breastfeeding, previous ENT operations including adenoidectomy, tonsillectomy, myringotomy and VT insertion, otologic complaints of the child (otalgia, hearing loss and otorrhea), presence of snoring, known allergies, allergy-related complaints (sneezing, nasal discharge, nasal obstruction and itching), presence of allergy in another member of the family, presence of recurrent URTIs, nocturnal enuresis, presence of a chronic disease, any chronic drug use and antibiotic use in the previous 3 months. The teacher questionnaire included questions about the grades of the child or general degree of success if the child was in a day care center or kindergarten and the subjective opinion of the teacher on the hearing status of the children. Statistical analyses Data were analyzed using the software SPSS 10.0. The groups were tested by the chi-square test for categorical variables and t -test for continuous variables. P <0.05 was used for statistical significance.

Results Descriptive statistics for screening are presented in Table 1. Out of 1,077 children, 120 were diagnosed with OME (11.14%), of which 74 of were bilateral (61.7%)

Table 1 Distribution of the subjects according to age and gender Gender

Male (n)

Female (n)

Total (n)

Age group 5–6 7–9 10–12

567 54 326 187

510 51 288 171

1,077 105 614 358

and 46 unilateral (38.3%). Twenty-two of the unilateral cases (18.4%) were encountered in right ears, while the remaining 24 (20%) were seen in left ears. None of the children had any craniofacial anomaly affecting ET function, such as a cleft palate. No statistically significant difference was found between the prevalence of OME in rural schools (12.3%; 33 cases) and in urban schools (10.8%; 87 cases) (Table 2). Male children had significantly more OME than females (13.8 versus 8.2%). When the children were analyzed according to age groups (Table 2), group I (<6 years) and group II (7– 9 years) had significantly higher OME prevalence than group III (>10 years). There was no significant difference between the prevalence of OME in group I and II. The children were also grouped according to their school categories. The children attending daycare or kindergarten had a considerably higher prevalence rate (19%) than the children attending public schools (10.9%) and private schools (9.4%). Given the age group of the children attending daycare or kindergarten, this was an expected finding. There was no difference in the prevalence of OME between public and private school attendants. The economic status of the families, educational degree of the mother and family size also did not affect the OME prevalence in our study. However, the children of working mothers were found to have considerably lower OME prevalence than the children whose mothers were housewives (5.2 versus 11.8%). In our study, questionnaires filled in by the parents subjectively assessed the allergic status of the children. The children whose parents reported allergic symptoms in their children did not have significantly different OME rates when compared to children whose parents did not report allergic complaints in their children (9.9 versus 11.3%). Also, smoking by the parents did not affect the OME prevalence in our study. The OME prevalence of the children who had parents smoking in the home environment was 11.4%, while for the children living in smoking-free homes, it was 11.4%. Snoring appeared to be an important predictor of OME in our study. The children with reported snoring had higher OME prevalence (21%) when compared to children without snoring (9.2%). The children with antibiotic use in the previous 3 months had significantly higher OME prevalence (15.2%) than the children without antibiotic use (9.2%). The children whose parents reported a history of otalgia suggesting an AOM episode also had higher OME prevalence (19%) than the children who did not

406 Table 2 Analysis of risk factors Gender Male Female Localization Urban Rural

78/567 (13.8%) 42/510 (8.2%)

P =0.004

87/808 (10.8) 33/269 (12.3%)

P =0.498

16/105 (15.2%) 80/614 (13.0%) 24/358 (6.7%)

P =0.6451 P =0.0112 P =0.0023

Exposure to smoking Yes No Mothers’ work status

69/630 (11.0%) 51/447 (11.4%)

P =0.814

Housewife Working

114/961 (11.8%) 6/116 (5.2%)

P =0.030

Allergic symptoms Yes No

9/91 (9.9%) 111/986 (11.3%)

P =0.691

Snoring Yes No

37/176 (21.0%) 83/901 (9.2%)

P =0.001

Age group I: 5–6 II: 7–9 III: 10–12 Schooling I: Kindergarten/daycare II: Public schools III: Private schools

12/63 (19.0%) 20/211 (9.4%) 88/803 (10.9%)

P =0.0194 P =0.055 P =0.5356

Antibiotic use in the previous 3 months Economic status of the family Low Medium High

49/354 (13.8%) 42/451 (9.3%) 29/272 (10.7%)

P =0.122

Family size 3 or less 4–5 6 or more Mother’s education Illiterate Low High school University

11/70 (15.7%) 66/639 (10.3%) 43/368 (11.7%) 12/82 (14.6%) 77/722 (10.7%) 21/176 (11.9%) 10/97 (10.3%)

Yes No

53/349 (15.2%) 67/728 (9.2%)

P =0.003

AOM history Yes No

12/63 (19.0%) 108/1014 (10.7%)

P =0.039

Yes No Breastfeeding duration

26/148 (17.6%) 94/929 (10.1%)

P =0.007

Never Less than 4 months 5–12 months More than 12 months

2/34 (5.9%) 51/393 (13.0%) 43/422 (10.2%) 24/228 (10.5%)

P =0.430

P =0.365 Active URT infection

P =0.518

Between group I and II,1 I and III2 and II and III,3 and group I and II,4 I and III5 and II and III6

Table 3 Effect of OME on school success School grades OME+ (n =108) OME (n =900)

3.53 3.72

P =0.123

have a similar anamnesis (10.7%). The presence of acute URT findings in the examination also increased OME prevalence in the study (17.6 versus 10.1%). When children were grouped according to their duration of breastfeeding, the children who were not Table 4 Importance of HL reported by parents and teachers in the diagnosis of OME

breastfed had the lowest OME, but this finding was not significant. School success of the children did not seem to be affected by the presence of OME (Table 3). Although children with OME had lower mean grades compared to normal children (3.53 versus 3.70), this difference was not significant. Parents’ awareness of the children’s hearing loss was found significant (Table 4). More than one-third of the children (14/36, 38.8% true positive) whose parents reported decreased hearing had OME, while only 10.2% (106/1,041) of the children whose parents did not report

OME percentage Parents’ report HL+ HL Teachers report

Positive predictive value of HL for OME 14/120 (11.7%)

14/36 (38.9%) 106/1,041 (10.2%)

P <0.001 9/120 (7.5%) P <0.001

HL+ HL

9/30 (%30) 111/1,047 (10.6%)

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any hearing loss were diagnosed with OME (P <0.001). However, this finding also meant that out of 120 cases of diagnosed OME, only 14 patients’ parents reported hearing loss, revealing a very poor sensitivity of 11.7%, thus decreasing the value of the parents’ referral. But the most striking finding was when the parents of 36 children who suspected HL in their children were asked if they had brought their children to a healthcare facility because of the hearing loss: the answer was negative in all cases. In our study, although not as reliable as parents, teachers also gave a significant history about the hearing loss of the children. However, out of 30 children, only 9 were found to have decreased hearing, in which the causes of HL were all OME (30% true positive, P <0.001).

Discussion OME is an important public health issue. It is a common ear disease of childhood second only to AOM. Many large studies have shown a high incidence of AOM, especially in young children, and the close relationship of OME with AOM [19, 23]. OME is considered a transition between acute otitis media (AOM) and chronic otitis media (COM). Despite the high frequency of the disease and the exhaustive research that has been done, the multifactorial etiology of OME is still not fully understood. Animal experiments have shown that eustachian tube dysfunction results in middle ear effusion [8]. URTI are one of the most common causes of eustachian tube dysfunction and thus OME in children [5, 25]. Mechanical obstruction of the nasopharyngeal opening of the ET by adenoid hypertrophy or craniofacial malformations that interfere with the proper ET opening by the tensor veli palatini muscle, such as cleft palate deformities and Down syndrome, also cause OME. Alho et al. reported that AOM bouts cause an 11.9-fold increase in SOM prevalence [3]. Some authors have reported various predisposing factors such as race, gender, age, allergy, season, day care attendance, reflux of gastric contents, prematurity, LBW, smoking during pregnancy, immunologic defects, etc. [21, 26, 27]. Complications of OME occur especially if the disease is not recognized at its early stage and/or treated accordingly. COM and adhesive otitis media are the major complications of OME, which usually establish in a duration measured by years. Although not proved by long-term follow-up studies, it may be speculated that at least some of these complications can be prevented if the child is offered medical attention and/or surgery (especially adenoidectomy and ventilation tube placement). In addition to the relatively insidious nature of the disease, hearing loss, which is the major symptom of OME, is usually attributed to the lack of attention by the parents, thus causing a delay in the diagnosis and treatment. The prevalence of OME in a particular region is based on various factors. Among these, the race, age

group, season when the study is conducted, climate of the region and percentage of children in the study attending day care centers are the most important risks that have been reported [6, 15, 27]. In this study, male gender, early age, the occupation of the mother, daycare/kindergarten attendance, URI and a documented AOM bout in the previous 3 months were found to be the risk factors for OME. Also, the presence of snoring and use of antibiotics in the previous 3 months were correlated with high OME rates. The economic status of the family, number in the household, educational level of the mother, location of the residence (urban versus rural), duration of breastfeeding, passive smoking and allergy were not demonstrated to be influential factors for OME (Table 5). The suspicion of poor hearing levels of the children by teachers and especially patients was found significant because approximately one third of these children were diagnosed with OME. However, they only managed to report HL in 7.5 and 11.7% of the OME cases, respectively, making the history of the parents and teachers rather unreliable in the diagnosis of OME. Epidemiological studies on OME in Turkish children generally have been performed in major cities. In these studies, the reported prevalence of OME was between 1.5 and 18.3% [4, 9, 10, 12, 13, 14, 16, 17, 18]. Except for the study of Palandoken et al., all of the studies were performed at high altitude. In a study conducted in Belgium, immigrant Turkish children had a lower incidence of OME compared with North African and Belgian native children [24]. Although OME does not seem to be correlated to the socio-economic status of the child’s family, it can be hypothesized that, in families with low socio-economic levels, despite similar OME prevalence, higher COM conversion rates are possible due to the lower access to health commodities related to the lack of social security and/or relatively poor awareness of the symptoms [6]. The occurrence of lower COM prevalence despite higher OME prevalence in developed countries supports this hypothesis. In Turkey, approximately half of the population lacks social security protection. It should also be noted that the demand for health care is another important determining factor in the genesis of the complication of a disease. This demand can be deducted Table 5 Advantages and disadvantages of OME screening in a non-high-risk population Pros Improved sequelae rates? Screening of children without healthcare coverage Screening of children of parents with low behavioral compliance (e.g., lack of applying to outpatient clinics unless an important conceived problem happens, easily getting out of monitoring programs) Cons Inaccurate treatment due to misdiagnosis or diagnosis at the resolution period Cost of screening and unnecessary treatment

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from the studies showing that in the EU, the average outpatient contacts per person per year is eight times more frequent than in Turkey [1, 2]. Although a recent OME guideline published by Aohns [20] does not recommend OME screening in healthy asymptomatic children, we suggest that the addition of pneumatic otoscopy or tympanometry in the routine examination of pediatricians might help in reducing the complications of OME, especially in a country where access to healthcare facilities is relatively limited and infrequent. We also propose that more interventional diagnostic and therapeutic algorithms should be developed in countries like Turkey, with careful consideration given not only to the healthcare coverage rate, but also to the behavioral properties of the people, such as the rate of healthcare demand and compliance with monitoring. In our study, although 36 parents suspected that their children might have HL, none of them referred their child to a doctor until they had been asked to do so. This finding made the recognition of the disease by the parent almost irrelevant and useless. To conclude, we suggest that despite the cost of screening and possibility of unnecessary treatment (inaccurate diagnosis and relatively long natural resolution period), even screening of the children without high risk factors should be considered because of the aforementioned limitations.

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