SECRETORY OTITIS MEDIA:A SCHOOL HEALTH SURVEY

v,* Sanjay Saxena,** Harshini Sharma,*** Ishwer Singh,"" Jagat Singh****

Abstract: The present study was carried out to find out prevalence of secretory otitis media in 200 school going children between the age group

of 5-7 years by impedance audiometry besides clinical evaluation. 100 children were taken from two different schools catering to higher and

tower socio-economic strata of society. The overall prevalence of secretory otitis media came out to be 20.75%. It was 28.5% in lower socio-

economic group and, I3% in the other group. This high prevalence warrants routine screening for secretory otitis media. Further impedance

audiometry was found to be very good method of screening Secretary Otitis media.

Key words: Glue ear, Impedence audiometry, Conductive deafness.

INTRODUCTION

Intact hearing is very essential for a healthy human being. Therelation between hearing loss and the impairment in the cognitive,linguistic and emotional development of children has been wellestablished.' , ' Even slight hearing loss, in the order of 10-15 dbmay be sufficient to impair speech and language acquisition ininfants and young children and may lead to a generalizededucational retardation? Children with hearing loss of more than30db are significantly retarded in vocabulary level and are placedbelow their normal grade in school.' The commonest cause ofhearing loss in children is secretory otitis media, 4 Commonlyknown as glue ear, the prevalence of which has increased in last50 years due to widespread but inadequate use of antibiotics forthe treatment of acute otitis media. The hearing loss may belatent or overt with the child rarely complaining of it.

The loss is of conductive type and is usually fluctuating inintensity. Importance must be given to indirect symptoms whichindicate a latent hearing loss, like shouting, increasing the volumeof television and not paying attention in the class. Screening forsecretory otitis media may be done using various methods. Themore widely used pure tone audiometry can easily identify theconductive hearing loss in secretory otitis media but it miserablyfails in detecting the underlying cause. Moreover it is a subjectivetest and requires active participation by the subject which maybe difficult to achieve in younger children. Microscopicexamination of the ear followed by aspiration of middle ear fluidmakes a sure shot diagnosis of secretory otitis media but it is aninvasive procedure and requires general anaesthesia, many aparents may not agree for the same.

Impedance audiometry or tympanometry is simple, quick,specific, noninvasive, reproducible and objective test making ita is reliable and almost ideal diagnostic test for diagnosis ofsecretory otitis media. Since there is paucity of data on theprevalence of secretory otitis media in the Indian subcontinent,hence a need was felt to find out the prevalence of this treatablecause of deafness.

MATERIAL AND METHODS

In the present study 200 school children in the age group of 5-7

years were screened. Half of these came from a public schoolcatering to upper middle and higher socio economic strata ofsociety (group A) and the other half came from a governmentschool catering to lower strata of the society (group B). All childrenhad intact tympanic membranes and children suffering from anyother disease causing hearing loss as well as those with nasalallergy and significant deviation of nasal septum were excludedfrom the study. A detailed ear, nose and throat examinationincluding tuning fork tests, pure tone audiometry andtympanometry was carried out in all the subjects in a soundproof room. The results were statistically analyzed using students" t " test.

OBSERVATIONS

The study included 200 children with mean age of 6.46 years.The age composition in the two groups matched except for aslightly higher percentage of older children in group B, however,the difference was statistically insignificant. The number of malesubjects were higher (68.5%) in both groups. A total of 30 childrengave positive history of hearing loss, 20 being from group B. Onexamination and Siegleization the tympanic membrane was foundretracted with decreased mobility in a total of 67 ears, 38 of thesebelonged to group A and 29 to the group B. In another 38 earsthere was no significant retraction but its mobility was restricted,25 of these belonged to group B and 13 to group A.

A total of 50 children clinically suspected of having adenoidhypertrophy were subjected to x-ray soft tissue nasopharynxlateral view which confirmed the same, 30 of these were fromgroup B and 20 from group A. Not much credence could be givento the tuning fork tests as 38% of children did not cooperate.Pure tone audiometry revealed normal hearing threshold i.e. 0-25dB air bone gap in 94% ears in group A. Another 5.5% werebetween 26-40 dB conductive hearing loss i. e. mild hearing lossand only 0.5% showed moderate hearing loss i. e. between 41-55dB. In the group B 91% ears had normal hearing. threshold. Mildhearing loss was found in 9% of the ears. When hearing loss inmales and females were compared there was no statisticallysignificant difference. In total 92.5% of the ears showed normalhearing thresholds.

250 *Associate Professor, **MS, ***MS, Senior Resident, **MS, **** Lecturer., Dept. of Otolaryngology Pt BDS PGIMS, Rohtak, Haryana, India.

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006

Secretory Otitis Media : A School Health Survey

Impedance audiometry graphs have been broadly classified byJerger6 into type A, B and C tympanograms but a simplerclassification of the graphs in peak and no peak groups achievesa diagnostic predictability of 84% which is quite reasonablekeeping in view the comparative ease with which the graphs canbe separated into two groups. All the 400 ears were subjected toimpedance audiometry and graphs were divided in peak and nopeak groups.

In group A 87% ears and in group B 71.5% fell in the peak typei. e. an overall of 79.25% of ears were in peak group. The other20.75% ears were in the no peak group. The middle ear pressurewas noted in all the 400 ears. It ranged between - 400 to +200 ofwater. Positive middle ear pressure was found in a total of 43 earsi. e. 10.75%. Majority of ears i. e. 74.25% had middle ear pressureranging from 0 to -100mm of water. The rest i. e. 15% had middleear pressure between -100 to -400mm of water.

Mean middle ear pressure was -49.59mm of water. There wasincrease in mean middle ear pressure with increase in age. Themales were found to have a more negative mean middle earpressure (-53.28mm) as compared to females (-43.21mm).Microscopic examination was done in 83 ears (52 children) withtympanometric evidence of middle ear effusion, 73 ears (87.95%)showed microscopic evidence of middle ear effusion. The childrenwere advised only medical treatment during the survey no surgicaltreatment was carried out during the survey as consent was notforthcoming from the parents.

DISCUSSION

The age group 5-7 years of 200 children in this study constitutesthe youngest of the school going children and matches well withother studies carried out throughout the world. 8 ' 9 As ageincreases the prevalence of secretory otitis media falls, moreoverthe effect of secretory otitis media on development and scholasticachievements is maximum in this age group. Male subjectsdominated the present study (68.5%) but the prevalence ofsecretory otitis media (in one or both ears) was found to behigher in females (38.1%) as compared to males (20.4%). Europeanstudies show a higher prevalence of secretory otitis media inmales but other studies suggest no significant difference. 1 °Socioeconomic status and secretory otitis media seem to have astrong relationship.

In the present study the lower socioeconomic group showed aprevalence of 28.5% which is more than double as compared tohigher socioeconomic group (13%). This is due to high prevalenceof childhood catarrh in the former group. This differencecorrelates well with findings of Fay et al." Direct evidence orcomplaint of hearing loss was not reported by any subject but15% gave indirect evidence in form of listening to transistorsand televisions at high volume. On examination of the eardrum,67 out of the total of 400 ears were found to be retracted or haddecreased mobility. This is a mere 16.75% and is less than thetympanometric evidence of secretory otitis media i. e. 20.75%. Itis well known that effusion may also be present behind a normallooking eardrum. 12

Thus otoscopy besides being highly subjective, is lacking bothin sensitivity and specificity in detecting secretory otitis media.Pure tone audiometry (PTA) showed that 92.5% of the ears hadnormal hearing (0-25dB ) which accurately gives the degree ofhearing loss but does not give much indication as to the causeof hearing loss. PTA is a subjective test requiring activecooperation from the subject which might be difficult to obtainfrom young children, besides being time consuming and hencenot suitable as a screening device. Tympanometry was done inall 400 ears. Mean middle ear pressure was -49.59mm of water.There is wide difference of opinion regarding the negative valuebelow which middle ear pressure can be taken as abnormal.Renvalt 13 showed that pressure beyond -80mm of water may betaken as abnormal but Brooks 14 suggests that pressure upto -170mm of water is essentially normal. Bluestone 15 and Jergerbhave recommended -100mm of water to be used as borderlinebetween normal and abnormal middle ear pressure.

In the present study we had only 15% of the ears showing middleear pressure below -100mm of water. The prevalence of secretoryotitis media in the present study was 20.75%. There is a widedifference in the reported prevalence of secretory otitis media byvarious workers from different parts of the world. Brooks 8 reportsa prevalence of 50% in 5-7 year old children from UK which ismuch higher as compared to present study and may be due tothe generally cold climate of UK. The prevalence rate of secretoryotitis media in our study (20.75%) is similar to that of Lous 16 andSilvia." Tos 18 reported higher prevalence of 30% however, hestudied children in the age group of 2-4 years. Harker19 reportedprevalence of 41.3% in Alaskan children where there are extremelycold climatic conditions.

On the other hand Ogisi 20 reported a prevalence of 8% only. Inthe present study we divided the graphs into two categories i. e.one with peak formation and other without peak. The secondgroup was taken positive for secretory otitis media as a whole.When compared to the microscopic examination of the ear weobserved a diagnostic predictability of 87.95% which iscomparable with-the finding of Cantekin.' In view of the quitehigh incidence of secretory otitis media in the present study andpossibility of development of cholesteatoma in some of thesechildren it is suggested that ENT examination should be carriedout in primary schools at least once a year.

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Indian Journal of Otolaryngology And Head and Neck Surgery Vol. 58, No. 3, July-September 2006

Secretory Otitis Media : A School Health

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Address for correspondence :Dr. Harshini SharmaC/o Dr. S. P. S. Yadav9J/30 PGIMS Rohtak

Haryana, (India)

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 58, No. 3, July-September 2006