Evidence-based management of otitis media in high risk populations.

This report is part of the Evidence-practice policy gap (EPPG) publication for Aboriginal and Torres Strait Islander health.

What is the gap and why is it important?

Otitis media and associated hearing impairment in Aboriginal and Torres Strait Islander children living in remote communities has been extensively studied.^1-11 Otitis media (middle ear infection) can be classified as acute OM (with or without perforation of the tympanic membrane), OM with effusion (accumulation of fluid) or chronic suppurative (discharge of puss) OM.^12,13 Aboriginal children are at greater risk of early onset of bacterial otopathogen colonisation of the nasopharynx ^1,3 which leads to persistent otitis media with effusion (OME), recurrent (or persistent) episodes of acute otitis media (AOM), progression to acute otitis media with tympanic membrane perforation (AOMwiP), and chronic suppurative otitis media (CSOM).1 Progressive and chronic OM is also possibly due to the asymptomatic presentation of acute OM.¹⁰ In the absence of pain, fever or irritability parents or clinicians may not suspected AOM, therefore infections are not diagnosed or treated and result in prolonged and progressive disease and associated disabling hearing impairment. Best practice requires that appropriate bilateral ear examinations should be made at all scheduled child health checks as well as opportunistically.^13,14 These examinations need to include both otoscopy and testing of tympanic membrane mobility in both ears. Otoscopy with a view of both tympanic membranes allows the detection of the bulging which distinguishes OME from AOM.  Tympanometry or pneumatic otoscopy allows the detection of middle ear fluid. Whilst these examinations are recommended, in practice examinations are rarely undertaken and/or poorly documented, with consequent impact on disease management and follow-up.¹⁵ 

The population prevalence of OM across jurisdictions, and in urban, rural and remote regions, is not currently known. Limited available data from small population surveillance¹⁰ or clinical audits suggest an ongoing crisis.¹¹ 

The prevalence of severe OM or “runny ears” (AOMwiP or CSOM) among young children has declined in remote communities, from around 24% in 20014 to approximately 15% in 2010.¹⁰ This was partially due to pneumococcal conjugate vaccines. However few children have bilaterally healthy ears; in 2013, surveillance of 140 one-year-old children in 15 remote NT communities found that 50% had OME, 20% AOM, 15% CSOM, and 10% had normal ears.¹⁰ A clinical audit of 2300 records from 46 primary healthcare and community clinics in Queensland (2009 to 2013) found, on average, 70% of children attending a clinic received an ear examination, of whom 45% had chronic OM.¹⁶ This is likely to be an underestimation. Ongoing care comprised follow-up examination (average of 93%), advice (85%), antibiotics prescription (89%), action plan (68%), referral to audiology (62%) and referral to an Ear, Nose and Throat specialist (ENT) (59%).¹⁶

Why is it important?

Failure to detect and treat early ear disease leads to chronic OME or CSOM.7  Both of these conditions are associated with long term disabling hearing loss. This has a negative impact on communication,¹⁷ learning, behaviour, school attendance,¹⁸ education outcomes, employment and can even be associated with incarceration.¹⁹ Gaps in Indigenous education, employment and incarceration are well described. Failure to improve clinical management of ear disease will perpetuate the long-term disadvantage associated with hearing loss. 

What does the best available evidence tell us? 

Without targeted clinical training and community awareness campaigns, the high prevalence of OM and hearing loss in Aboriginal and Torres Strait Islander children will likely continue unabated. 

The 2010 OM Guideline¹³ (revised 202014) sets out recommendations for clinical care including diagnosis, prognosis, treatment, audiological and surgical options for each form of OM. The 2020 update includes a full revision of the evidence (to March 2017) using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. “Summary of Findings” tables with effect sizes and a “what happens” explanation are accessible to 2020 OM Guideline users on line and freely downloadable OMapps.¹⁴

The best evidence from international studies (and Australian research) has been incorporated into the 2020 OM Guidelines¹⁴ from the most recent Cochrane systematic reviews.5, 20-30 There are modest benefits from antibiotic treatments for OME (Relative Risk 0.57)^14,23 and acute otitis media without perforation (AOMwoP) (RR 0.7).14,22 The benefits for the prevention of AOMwiP and CSOM are substantial (RR 0.37 and RR 0.45).^14,5 The case management described in the OM Guidelines will mean that the risk of AOMwiP progression is reduced, and that new cases of CSOM can be avoided. 

The 2020 Guideline will form the evidence base for clinical training and practice evaluation.¹⁴ An evaluation of the 2010 OM Guideline identified multi-system failures in uptake, and recommended a dual approach to training and service delivery.¹⁵ This model will be actioned for the 2020 OM Guideline and OM-app.¹⁴

What is the current practice and study? 

Most jurisdictions in Australia have formulated ear health policies based on the 2010 Guideline.  The focus has been on priority areas such as early detection and appropriate management of young children at risk of CSOM.

Current practice suggests substantial confusion among practitioners about how to diagnose and manage OM in high-risk Aboriginal and Torres Strait Islander children compared to low-risk or non-Aboriginal children.³¹ Our analysis of data on appropriate management of OM from a birth cohort to three years of age ^32,33 in four large remote communities shows that scheduled ear examinations with recommended follow-up are rarely conducted, findings are poorly documented and there is a mismatch between recommended management and practice.[unpublished data] This includes under-prescribing of antibiotics, and over-(inappropriate) referral to infrequent specialist outreach services for services that should be delivered in primary healthcare.

At the same time, there is increasing concern in Australia about over-prescribing antibiotics, and childhood OM has been identified as a key contributor to over-prescribing.³⁴

It is important that practitioners in Aboriginal Medical Services and other services with Aboriginal clients, particularly in regions with a high prevalence of bacterial OM and CSOM and relatively low incidence of self-resolving episodic OM, prescribe antibiotics for persistent OME in high-risk children, and for AOM with or without perforation, and that antibiotic treatment, particularly for AOMwiP and CSOM, is continued until resolution is achieved.¹⁴ 

What would the impact be if the proposed action was implemented? 

The proposal is to promote and evaluate the evidence based management of OM in Aboriginal and Torres Strait Islander children, through dissemination, education and training of the 2020 OM Guideline and OM-app.

The short-term impact would be increased health care provider (General Practitioner, Aboriginal Health Practitioner, Nurse Practitioner) diagnostic skills and confidence, early detection of OM, reduced progression of AOM to AOM with perforation, and reduced progression to CSOM.  This in turn will lead to fewer hearing impaired children, fewer audiology and speech pathology referrals for children with persistent hearing loss and language delay, and fewer ENT referrals for tympanoplasty (tympanic membrane repair). 

Longer term benefits of a successful primary healthcare ear health program will be improved learning, improved behaviour and school attendance, increased education and better social outcomes for future generations of Australian Aboriginal and Torres Strait Islander children.

References

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2. _{Gunasekera H, Knox S, Morris P, Britt H, McIntyre P, Craig JC. The spectrum and management of otitis media in Australian Indigenous and non-Indigenous children: a national study. PediatrInfectDisJ. 2007;26(8):689-92.}
3. _{Sun W, Jacoby P, Riley TV, Bowman J, Leach AJ, Coates H, et al. Association between early bacterial carriage and otitis media in Aboriginal and non-Aboriginal children in a semi-arid area of Western Australia: a cohort study. BMCInfectDis. 2012;12(1):366.}
4. _{Morris PS, Leach AJ, Silberberg P, Mellon G, Wilson C, Hamilton E, et al. Otitis media in young Aboriginal children from remote communities in Northern and Central Australia: a cross-sectional survey. BMCPediatr. 2005;5:27-37.}
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