Pacific Islands families study: The prevalence ofchronic middle ear disease in 2-year-old Pacificchildren living in New Zealand

J.E. Paterson a,*, S. Carter a, J. Wallace b, Z. Ahmad c,N. Garrett d, P.A. Silva e

International Journal of Pediatric Otorhinolaryngology (2006) 70, 1771—1778

www.elsevier.com/locate/ijporl

aAuckland University of Technology, New ZealandbManukau Superclinic, New ZealandcDepartment of Otolaryngology-Head and Neck Surgery-Counties Manukau Health,Manukau Superclinic, New Zealandd Faculty of Health and Environmental Science, Auckland University of Technology, New ZealandeCentre for Applied Social Science & Research, Te Wananga o Aotearoa, New Zealand

Received 27 February 2006; received in revised form 31 May 2006; accepted 1 June 2006

KEYWORDSOtitis media witheffusion;Pacific children;Middle ear disease

Summary

Objective: The aim of this study was to determine the prevalence of chronic middleear disease in 2-year-old Pacific children living in New Zealand.Methods: The data were gathered as part of the Pacific Islands Families: First TwoYears of Life (PIF) Study in which 1001 two year olds were screened using tympano-metry to identify children at risk for otitis media with effusion (OME) and otherotological disorders. Those failing the screening tests were referred to ManukauSuperclinic where they had a further tympanometry test, and if they failed this test,were followed up with a comprehensive otological examination by an otolaryngologistusing otomicroscopy and pneumatic otoscopy.Results: Bilateral otitis media with effusion (OME) was themost common abnormalitydetected (N = 102) with further cases of unilateral OME (N = 8), and unilateral OMEresolving (N = 2). Other cases of OME were associated with acute otitis media (AOM),impacted wax (N = 1), perforation (N = 1), and mild retraction (N = 2). Overall therewere 118 children with unilateral or bilateral OME. AOM of any form was seen in ninecases. Retraction of the tympanic membrane was seen in 26 cases. The populationprevalence among Pacific 2-year-old children was estimated as 25.4% for OME, 1.9%for AOM, and 26.9% for OME or AOM.

* Corresponding author at: Faculty of Health and Environmental Sciences, Auckland University of Technology, Private Bag 92006,Auckland, New Zealand. Tel.: +64 9 9179999x7324; fax: +64 9 9179877.

E-mail address: janis.paterson@aut.ac.nz (J.E. Paterson).

0165-5876/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijporl.2006.06.001

1772 J.E. Paterson et al.

Conclusions: These findings reveal that over 25% of Pacific Island 2-year-old wereaffected by OME and recommend the consideration of national screening for OME andother otological disorders at this earlier age.# 2006 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

As one of the fastest growing population subgroupsin New Zealand, the Pacific Island population (thoseresidents with a Pacific Islands heritage) form anintegral part of New Zealand society [1]. In the 2000census, over 230,000 people were of Pacific ethni-city, making up 6.5% of the New Zealand population[2]. Compared with most New Zealand children,Pacific children are at increased risk of poor healthwith a higher incidence of respiratory infections,meningococcal disease and infectious diseases suchas measles [3—5].

Otitis media with effusion (OME) is characterizedby the presence of fluid in the middle ear that mayresult in hearing loss of variable severity. OME isusually associated with a mild to moderate, fluctu-ating hearing loss [6—8]. Although moderate (about20—40 dB), it is important to note that even ahearing loss of 30 dB can mean that a normal con-versation sounds like a soft whisper. In some caseshearing loss associated with OME is as high as 50 dB[9].

OME is the most common cause of acquired con-ductive hearing loss in childhood [7]. Despite properantibiotic treatment, middle ear effusion may per-sist for weeks or months, often resulting in repeatedcourses of antibiotics, and eventually surgical inter-vention [10,11]. OME among preschool childrenaccounts for 18% of referrals to health care provi-ders [12], and the annual costs associated with thetreatment have been estimated to extend to $ 4billion annually in the United States [13].

Tympanometry is an objective measure of auralacoustic immitance of the middle ear. When fluid ispresent in the middle ear space the immitance ofthe middle ear system is altered, thus tympanome-try is an important tool for the screening of childrenfor OME. A number of studies have used tympano-metry to determine the prevalence of OME. Withinthe Dunedin Multidisciplinary Health and Develop-ment Study [14,15] approximately 18% of 5-year-oldwere found to have OME in one or both ears. Inter-national studies have shown prevalence rates thatrange between 2% and 52% [16] Within the preschooland early childhood range there is wide variation inprevalence rates with Saudi children up to 8 years ofage at 5.9% [17], Japanese children at 4 years of ageat 19.3% [18], Finish 2-year-old at 4.4% [19], Turkish

children at 5 years of age at 3.1% [20], Malaysianchildren between 5- and 6-year-old at 13.8% [21],and Danish children at 4 years of age at 9.8% [22].

Based on The Avon Longitudinal Study of Preg-nancy and Childhood in Britain, Midgeley et al. [23],reported an OME prevalence rate for 3-year-old of8.4% for right ears and 4.5% for bilateral type Btympanograms in summer, and 21.1% and 13.2%,respectively, in winter. These researchers reporteda peak prevalence of OME in the second half of thefirst year of life and confirm a seasonal variation ofOME.

A national New Zealand screening programmeshowed that the overall failure rate on tympano-metry tests for new school entrants was 7.7% and for3-year-old was 5.6%. The failure rate was highest forPacific Island and Maori children with Pacific Islandnew entrants recording a 13.9% failure rate (com-pared with Maori 13.8% and European 5.3%) andPacific Island 3-year-old recording of 10.7% (com-pared with Maori 11.1% and European 4.3%). Inaddition, the report showed that while there hasbeen significant progress towards reducing the num-ber of children failing the screening tests over thelast decade (e.g., 10.5% of new entrants failed in1991 compared with 7.8% in 1998—1999). The ethnicdifferences were still apparent despite the reduc-tion of OME [24].

OME in early childhood is of particular concerngiven the risk of hearing loss associated with chronicmiddle ear disease during the most intensive periodof language development [25,26]. Within the NewZealand context, bilateral OME has been shown tohave long-lasting consequences for language devel-opment, speech articulation, reading ability andclassroom behaviour to age 11 [6]. A number ofstudies have reported significant associationsbetween early childhood OME and attention orbehaviour problems [27—29]. In addition, otherotological sequelae due to untreated OME have beenidentified such as permanent perforation of thetympanic membrane, chronic suppurative otitismedia, cholesteotoma, and ossicular erosion thatmay result in permanent hearing loss [30].

The diagnosis and management of OME is a chal-lenging and difficult clinical problem and is a sig-nificant financial concern to the health care system[31]. National screening programmes for 2-year-oldchildren have not been recommended in New Zeal-

Pacific Islands families study 1773

and due to the lack of a consistently demonstratedassociation between OME and language outcomes[32—35].

In view of the concern over chronic middle eardisease among Pacific children and the lack of NewZealand research specific to this age group andpopulation group we included tympanometerscreening when the children were 2 years of agewith the aim of determining the prevalence ofchronic middle ear disease within the PIF cohort.

2. Methods

Data were collected as part of the Pacific IslandsFamilies: First Two Years of Life (PIF) Study. Thisstudy follows a cohort of Pacific Islands infants bornat Middlemore Hospital between 15 March and 17December 2000. All potential participants wereselected from births where the child had at leastone parent who identified as being of Pacific Islandsethnicity and also a New Zealand permanent resi-dent. Recruitment occurred through the BirthingUnit in conjunction with the Pacific Islands CulturalResource Unit that provided a daily list of PacificIslands ethnicity admissions and consent was soughtto make a home visit.

Approximately 6 weeks after the infant’s birth,interviewers of Pacific Islands ethnicity who werefluent in English and a Pacific Islands language visitedmothers in their homes. Once eligibility was estab-lished and informed consent obtained, mothers par-ticipated in 1-h interviews concerning the health anddevelopment of the child and family functioning.Thisinterviewwas conducted in thepreferred languageofthemother.With consent, home visits were repeatedat approximately 12- and 24-month postpartum.Detailed information about the cohort and proce-dures is described elsewhere [36].

2.1. Screening process

At the 24-month measurement point initial tympa-nometry screening was carried out as part of a childdevelopment assessment by trained staff within thehome setting. Those children who failed this tym-panometry test were referred to the South AucklandManukau Superclinic for a second screening testafter an 8-week interval. In the latter part of themeasurement phases, due to the large number ofreferrals, a second tympanometry test wasarranged, after an 8-week interval, to be carriedout in the home by an ear nurse. This was toeliminate children from the clinic visit if the middleear problem had spontaneously resolved. Thosechildren, as before, were referred to the clinic if

they failed this test. This second home administeredtympanometry test was done to minimize the num-ber of children who needed further assessment atthe clinic and thus relieve pressure on the medicaland administrative clinic staff.

Every effort was made to inform the parents ofthe significance of a failed screening test by out-lining the possible consequences of undetected OME(or ‘‘glue ear’’) for the child’s health, developmentand learning. Taxi vouchers to attend the Super-clinic were given out to enable parents to transporttheir child to the clinic without cost.

2.2. Screening measure

A Grason Stadler 1737 tympanometer with printer,as recommended by the National Audiology Centrewas used for screening. This was carried out byPacific people trained for the task by audiologistswho were part of the research team. The pass/failcriteria were results outside the following rangefor a type A tympanogram: middle ear pressure�100 to +100 daPa, static admittance 0.2—0.9 ml,equivalent ear canal volume 0.4—1.0 cm3. Thesepass/fail criteria were based on those recom-mended by the American Speech-Language Hear-ing Association [37].

2.3. Clinic process

At the clinic, all children were given a furthertympanometry test and otoscopy examination. Thiswas carried out by an audiologist who applied thesame pass/fail criteria as used previously andincluded tympanic width which is reported to makethe test more sensitive and specific to detectingmiddle ear effusion. Those who passed these clinictests had no further examinations, those who failedwere examined immediately by an otolaryngologist.Any obstructions (usually wax) in the external audi-tory canal were removed and tympanometryrepeated. The otolaryngologist carried out a micro-scopic examination plus pneumatic otoscopy. Thisincluded examination of the external auditory mea-tus, the tympanic membrane (colour of drum,retraction, microvascularisation, calcification,scaring, thickening, adhesions, perforations), thetympanic cavity (incus necrosis, choleseatoma,polyp or granulations) and mobility of the eardrum.A nose and throat examination was also carried out.Finally, a diagnosis was made for each ear and atreatment plan, if indicated, was recorded. A treat-ment was then recommended and carried out at theclinic under the supervision of one of the principalinvestigators. In cases where immediate or acuteproblems were detected, especially impacted wax,

1774 J.E. Paterson et al.

this was dealt with immediately or soon after theassessment.

3. Results

In total, 1708mothers were identified, 1657 invitedto participate, 1590 (96%) consented to a home visitand, of these, 1477 (93%) were eligible for the PIFstudy. Of those eligible, 1376 (93%) mothers givingbirth to 1398 infants, 680 (49%) female, partici-pated at the 6-week interview. Some 659 (47%)infants were classified as being Samoan, 296

Fig. 1 Screening process in the PIF OME Study. *Twenty-fiveinfections or glue ear (grommets or tubes)’’ or were found to hfurther assessed.

(21%) as Tongan, 233 (17%) as Cook Island Maori,61 (4%) as Niuean, and 149 (11%) as other PacificIslands (this include infants who were identifiedequally with two or more Pacific Island groups orwith a Pacific Island group not listed above).Mothers’ mean age was 27.9 years (standard devia-tion 6.2 years), 1107 (80%) were married or in defacto relationships and 377 (27%) gained post-school qualifications. The 24-month interview withmothers was conducted for 1161 infants; the med-ian infant age at interviewwas 24.1months and 95%of interviews were conducted with infants agedbetween 23.8 and 26.6 months.

participants were reported to have had ‘‘surgery for earave grommets at assessment. yFive participants were not

Pacific Islands families study 1775

Table 1 Otological abnormalities detected by tympa-nometry

Type of bilateral and unilateral abnormality Number

Bilateral otitis media with effusion (OME) 102Unilateral OME 8Unilateral OME/AOM 2Unilateral OME resolving 2Unilateral OME/perforation 1Unilateral OME/impacted wax 1Unilateral OME/mild retraction 2Bilateral AOM 4Unilateral AOM 2AOM and mild retraction 1Bilateral mild (or type I) retraction 21Unilateral mild (or type I) retraction 5Bilateral impacted wax 3Unilateral impacted wax 1

OME presenta, b 118AOM presenta 9

Total 155a Two participants had both OME and AOM.b Two participants with unilateral OME resolving were been

included in the OME present group.

The PIF Study screening process is presented inFig. 1. There were 1075 two-year-old childrenwhose mothers were interviewed at home abouttheir children’s health and development. Sixty-four children (6.0%) were not screened but 28 ofthese were referred either directly to the Super-clinic for screening or because the parentsexpressed concern about their hearing. Ten otherchildren were screened but were reported as hav-ing had ‘‘surgery for ear infections or glue ear(grommets or tubes)’’ or were found to have grom-mets at clinic assessment therefore were excludedfrom this analysis as they would automatically failthe screening test. Of the 1001 who werescreened, 755 (76.4%) failed the tympanometrytest. Tympanometry screening results in a fail ifthere is one or more of the following: (1) negativemiddle ear pressure or retracted ear drum, (2)perforated ear drum, (3) grommet in situ, (4)hypermobile ear drum due to scaring or ossiculardislocation, or (5) stiffened middle ear system.Tympanometry highlights any middle ear systemthat is not functioning normally and gives an indi-cation that further assessment is necessary. Forexample, a type B high volume tympanogram couldmean a perforation in the ear drum or a function-ing grommet. As a grommet provides a hole in theear drum, effectively the result is the same as aperforated ear drum. The screeners could notdifferentiate between the two possibilities as theydid not inspect the ear using otoscopy. Thus, it wasexpected that some children who already hadgrommets in place would fail the test.

The largest proportion of children who had failedthe initial screening were referred directly to theSuperclinic (N = 473) while a smaller number(N = 282) were followed up with a second screeningin the home. An additional four children who passedthe first screen were referred because of parentalconcern at this time. Of those who had a secondscreening test at home, approximately 8—12 weeksafter the first test, 155 (55%) passed the test and 127(45%) failed. Those who failed were referred to theSuperclinic. Of an overall total of 600 children whowere referred to the Superclinic, 279 (46.5%) actu-ally attended. Despite numerous reminders, 321(53.5%) failed to attend the clinic.

Of the 279 who attended the clinic, 105 (37.6%)children passed the tympanometer and otoscopyscreening tests and were not subjected to anyfurther examination. One hundred and sixty-five(59.1%) children were examined by the otolaryngol-ogist, however five did not return for an appoint-ment on the following day. Fourteen of thesechildren were found to be normal. This left 155who had abnormalities. Details of the otological

abnormalities detected by tympanometry are listedin Table 1.

Table 1 shows that bilateral otitis media witheffusion (OME) was the most common abnormalitydetected (N = 102) with further cases of unilateralOME (N = 8), unilateral OME associated with acuteotitis media (AOM) (N = 2), unilateral OME resolving(N = 2) unilateral OME associated with impacted wax(N = 1), unilateral OME associated with perforation(N = 1), unilateral OME associated with mild retrac-tion (N = 2). Overall there were 118 children withunilateral or bilateral OME.

Acute otitis media (AOM) was much less commonwith four bilateral cases, two unilateral cases andone associated with OME in the other ear and onewith a mild retraction in the other ear. Two furthercases were associated with AOM or OME in the otherear. Thus, AOM of any form was seen in nine cases.

Retraction of the tympanic membrane was seenin 26 cases. Twenty-one of these were bilateral andfive were unilateral. All were mild or classified astype I according to Sade’s (1979) classification [38].

Twenty-five children were reported as having had‘‘surgery for ear infections or glue ear (grommets ortubes)’’ or were found to have grommets duringtheir clinic assessment. Of these 25 children, only10 were screened, all of which failed the tympano-metry screening tests. Six of these were given a fullclinic assessment and four were found to have an earinfection or OME.

In summary, of those who attended the clinicfollowing the first home screening, 67.0% of those

1776 J.E. Paterson et al.

who failed both screens were found to have OME,3.6% were found to have AOM, and 72.5% were foundto have either OME or AOM. Of those who had asecond home screening before being invited to theclinic, 79.5% who failed three screens were found tohave OME, 2.3% were found to have AOM, and 81.8%were found to have either OME or AOM. In bothsituations only 46.5% of those referred actuallyattended the clinic for the final screening andassessment. Assuming that attendance at the clinicafter screening in the community was not related tothe presence of OME or AOM, the population pre-valence is estimated as 25.4% for OME, 1.9% forAOM, and 26.9% for OME or AOM. All children withany abnormality were followed up and offeredtreatment as appropriate.

4. Discussion

Although there has been a considerable body ofresearch addressing issues related to the prevalenceof chronic middle ear disease [16—22] there is noNew Zealand research that specifically examinesthis important health issue in Pacific 2-year-oldchildren. The main finding from the current studywas that OME was the most common otologicalproblem. Bilateral otitis media with effusion(OME) was the most common abnormality detected(N = 102) with further cases of unilateral OME(N = 8), and unilateral OME resolving (N = 2). Othercases of unilateral OME were associated with acuteotitis media (AOM), impacted wax (N = 1), perfora-tion (N = 1), and mild retraction (N = 2). Overallthere were 118 children with unilateral or bilateralOME. AOM of any form was seen in nine cases.Retraction of the tympanic membrane was seen in26 cases. The population prevalence among Pacific2-year-old children was estimated as 25.4% for OME,1.9% for AOM, and 26.9% for OME or AOM.

In comparison with other studies using tympano-metry the PIF Study prevalence estimate is substan-tially higher than the Dunedin Study (18%), theNational Screening for new Pacific Island schoolentrants (13.9%) and Pacific Island 3-year-old(10.7%) and international studies of the same agegroup. This is possibly due to the high rates ofinfectious diseases among Pacific children [3—5]and such factors as cold and damp housing and largehousehold size [39]. However the default rates infollow-up appointments must be taken into accountas this is likely to have had some impact on thesehigh prevalence rates.

There are several limitations of this study. Firstly,the initial screening would have been more preciseif another measure of the initial tympanogram had

been used to categorise the children as pass or failfor the screeners. This is called tympanic widthwhich is reported to make the test more sensitiveand specific to detecting middle ear effusion. Thismeasure was used in the clinic screening process butif it had been used within our initial home screeningprotocol it would have resulted in even more chil-dren failing the initial screening test. This couldmean that our results are underestimating theextent of the problem.

Secondly, just over half of the children referredto the Superclinic did not attend the clinic forfurther investigation and treatment. This wasdespite the reminder calls the day before, thepossibility of rescheduling to alternative clinictimes, and the provision of taxis to the clinic forthe family. The child assessors who did the initialscreening tympanometry test in the home dis-cussed the importance of OME detection and treat-ment with the mother and gave them aninformation sheet outlining OME and details ofthe Manukau Superclinic and the taxi process. Agreat deal of effort was put in to encourage atten-dance but only 53% of children who had possibleOMEwere brought to the clinic for follow-up. This isof concern given the importance of early detectionand treatment of OME but it is in line with generalattendance figures at the Manukau Superclinic. Atthat clinic the general non-attendance rates areapproximately 10—15% but these are around 14—29% for Pacific clients.

In 1995, the Public Health Commission in NewZealand recommended universal tympanometryscreening at 3 and 5 years [40]. A pilot OME screen-ing programme demonstrated that a low socioeco-nomic status population can be successfullyscreened, however it was pointed out that thereare two principal concerns that must be addressedbefore universal screening for OME is carried out.The long term benefits of screening and interven-tion for speech, language, learning and behaviourdevelopment in children needs to be more estab-lished, and a thorough cost—benefit analysis shouldbe carried out in New Zealand to justify commit-ment to resources to an OME screening programme[41].

In the South Auckland community, where themajority of the PIF Study cohort reside, ear nursespecialists (ENS) mostly work in community settingsoperating mobile ear clinics equipped to deliverotoscopic expertise to the wider community andto families who have difficulty with transport. Thisis a free service that works with other individualsand agencies (e.g., caregivers, Plunket nurses, gen-eral practitioners) to identify children with poten-tially serious middle ear disease and potential

Pacific Islands families study 1777

hearing loss at an early age. However, despite thisexcellent service to the community, the prevalenceof OME among Pacific 2-year-old in this cohort wasvery high.

Watchful waiting is a strategy used for this oftenself-limiting condition in childhood, however, thereare likely to be large number of children who slipthrough this system and remain untreated over along period. The National Vision and Hearing Screen-ing protocol in New Zealand includes a preschoolscreening using tympanometry at 3 years of age. Thecurrent findings suggest that, given the implicationsof undetected and untreated chronic middle eardisease and the high prevalence of the disease inthis 2-year-old Pacific Island cohort, the target pre-school age of 2 years for screening in New Zealandshould be reconsidered. This would allow earlieridentification and treatment and would be expectedto prevent or minimize the developmental, educa-tional, behavioural and otological consequences[6,30].

These findings, based on a robust longitudinalstudy of Pacific Island children living in New Zeal-and, reveal that over 25% of Pacific Island 2 year oldshave been affected by this disease and it is stronglyrecommended that consideration be given tonational screening for OME and other otologicaldisorders at this earlier age.

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