The prevalence and impact of otitis media with effusion in children admitted for adeno-tonsillectomy at Dr George Mukhari Academic Hospital, Pretoria, South Africa

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Abstract

Introduction

Otitis media with effusion (OME) is a leading cause of acquired hearing loss in children worldwide. However, previous South African studies have consistently reported the local paediatric OME prevalence to be lower than typically published in international literature. Furthermore, no South African studies have investigated OME in children with adenotonsillar hypertrophy. The objective of this study was to determine the prevalence of OME in children admitted for adeno-tonsillectomy at our institution in Pretoria, South Africa. In addition, the study sought to gauge the impact of OME on quality of life using a validated questionnaire (OM-6).

Methods

A cross-sectional, observational study was conducted between July 2015 and May 2016 at the Otorhinolaryngology outpatient department at DGMAH. he study included 109 consecutively sampled children, aged 2–12 years (mean 6.1; 49.7% female). Pneumatic otoscopy and tympanometry were performed on all participants. Adenoid hypertrophy was quantified using he adenoid-nasopharyngeal ratio (ANR) on a lateral post-nasal space radiograph (Fujioka's method). The OM-6 questionnaire was completed for each participant. Pure tone audiometry was performed for participants diagnosed with OME.

Results

The prevalence of bilateral OME was 11.9%. For unilateral OME, the prevalence was 22.9% and 16.5%, for the left and right ears, respectively (p > 0.05). The mean hearing loss (SD) was 19.8 dB (9.4). Clinically significant adenoid hypertrophy (ANR ≥ 0.71) was present in 43% of participants. There was no statistically significant (p > 0.05) correlation between the presence OME and adenoid hypertrophy. The mean total OM-6 survey score was 1.67 (SD ± 0.59) in children with OME, and 1.31 (SD ± 0.45) without OME, showing no statistically significant difference (p > 0.05). There was a significant (P < 0.05) correlation between OME and the presence of atopy.

Conclusion

Adeno-tonsillar pathology may play an aetio-pathological role in the development of OME. However, this may be due to the presence of biofilms rather than obstructive adenoid hypertrophy, given the lack of a significant (p > 0.05) correlation between adenoid hypertrophy and OME. Whilst OME was not found to impair quality of life in this population group, the validity of the OM-6 in the South African paediatric population requires further investigation.

Introduction

Otitis media with effusion (OME) refers to the accumulation of mucoid or serous fluid, within the middle ear cleft, without features of acute infection. With an estimated prevalence of 20%, it is the most common diagnosis in children after the common cold, and when persistent for ≥12 weeks (chronic OM) is a leading cause of treatable childhood deafness worldwide [[1], [2], [3]].

The pathogenesis of OME is incompletely understood; however, there is evidence to support an association between OME and adenoid hypertrophy, either due to physical obstruction of the torus tubarius by an enlarged adenoid pad, or due to the latter harbouring pathogenic biofilms [4,5]. Furthermore, several studies of OME in children with adenoid hypertrophy have shown a significantly higher prevalence than the general population [6,7]. Given this association, adjuvant adenoidectomy is frequently performed along with ventilation tube (VT) insertion in the treatment of chronic OME [1,5]. However, a recent systemic review found no benefit from tonsillectomy without adenoidectomy for the treatment of OME [8].

OME-related hearing loss may result in significant speech and language delay with impaired quality of life in childhood [9,10]. In South Africa, three large community-based screening studies (including approximately 3252 otherwise children) found a relatively low prevalence (3.4–3.8%) of OME [[11], [12], [13]]. A more recent study (2014) found a higher prevalence (16.5%); however, this was performed in a primary health care clinic, and thus selection bias may potentially explain the observed difference in prevalence between these studies [3]. However, none of these studies investigated either population-based risk factors for OME or its impact on hearing loss and quality of life [[11], [12], [13]]. Whilst a number of international studies have focused on adenoid hypertrophy as a risk factor for OME, there are no comparable South African studies [5,14,15].

The present study determined the prevalence of OME in children scheduled for adenoidectomy, with or without tonsillectomy, at the Otorhinolaryngology department of Dr George Mukhari Academic Hospital (DGMAH, Pretoria, South Africa). The impact of OME on quality of life was quantified using the OM-6 (Otitis Media-6) questionnaire; a 6-item questionnaire validated for evaluating the effects of otitis media on the quality of life in children. The questionnaire covered physical (otalgia, hearing loss, and speech impairment) and emotional (distress and activity limitations) domains of the functional health status of children, and the concerns of their caregivers [16].

Section snippets

Methods

This cross-sectional, observational study was conducted between July 2015 and May 2016 at the Otorhinolaryngology department of DGMAH. Prior institutional approval was granted for the study (Protocol No: SMUREC/M/123/2015:PG), and informed consent was obtained from the parents or legal guardians of all participants.

The study included consecutively sampled children, aged 2–12 years, with recurrent tonsillitis, obstructive sleep apnoea or chronic tonsillitis, admitted for either adenoidectomy or

Results

A total of 109 children, aged 2–12 years, were included in this study (Table 1). There were 57 males (52.3%) and 52 females (49.7%); Male to female ratio, 1.1:1. The mean (SD) ages for males and females were 5.54 (2.37), and 6.75 (2.54) years. Children were subdivided into 3 age groups, namely 2–5 years (n = 54; 49.5%), 6–9 years (n = 43; 39.4%), and 10–12 years (n = 12, 11.0%). The overall prevalence of HIV infection and atopy in the study population were 5.5% and 55.0%, respectively.

Discussion

The present study found a relatively higher prevalence of bilateral OME (11.9%) in children admitted to our institution for adenotonsillectomy when compared to previous South African screening studies of otherwise healthy children in the 1980's and 1990's in the institution's catchment area (Limpopo and Gauteng provinces), with rates of between 3.8 and 5.2% [[11], [12], [13]]. Whilst a similar screening study in 1991 of Western Cape Province grade 2 children reported an OME prevalence of 12%,

Limitations of the study

The present study has a number of limitations. Firstly, it was a descriptive prevalence study and thus constitutes level III evidence. Secondly, the use of lateral neck radiographs instead of rigid nasal endoscopy to assess adenoid hypertrophy may be criticised as being dated, given the availability of flexible nasal endoscopy for this purpose. However, given that most children at our institution have a lateral neck radiograph performed as part of the workup for suspected adenoid hypertrophy by

Conclusion

The present study suggests that adeno-tonsillar disease may play an aetio-pathological role in the development of OME, given the comparatively high OME prevalence (11.9%) found in relation to previous South African studies in children without documented adeno-tonsillar pathology. Whilst adenoid hypertrophy quantified using an ANR of ≥0.71 was not significantly correlated with the presence of OME, this may be due to deficiencies in the use of lateral neck radiographs to assess nasopharyngeal

Conflicts of interest

The authors declare that to our knowledge, there are no conflicts of interest with regard to the manuscript submitted for review/publication.

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