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Common Ear Conditions Underdiagnosed at Primary Level

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Common Ear Conditions Underdiagnosed at Primary Level Community Ear Hearing Volume 13 & Health Issue 17 • 2016 Otoscopic examination: bilateral impacted wax was diagnosed and removed, much to the patient's satisfaction. MADAGASCAR ANDREW SMITH Common ear conditions underdiagnosed at primary level Isaac M Macharia bout half of all causes of hearing impairment presence of normal amounts of earwax (cerumen) Professor of ENT, are preventable or can be managed at the in the external auditory canal is healthy, but earwax University of Nairobi; Aprimary healthcare level by appropriately becomes an important ear condition when it Consultant ENT Surgeon, trained workers. Many of these conditions, however, completely occludes the ear canal with consequent Kenyatta National Referral remain undiagnosed despite their high prevalence, effects on hearing. Depending on its occlusal and Teaching Hospital, due to a lack of diagnostic skills, tools and knowledge effect, impacted wax can be an important cause Nairobi, Kenya of their presenting symptoms amongst health workers. of conductive hearing loss and, as a consequence, Among the common ear conditions that are affect language and speech development in children. underdiagnosed are wax impaction, otitis media with Even for children who have already acquired effusion (OME) and foreign bodies in the ear canal. language and speech, the hearing loss caused by This situation can be reversed through training and impacted wax in both ears can have a significant provision of the necessary diagnostic tools. All three effect on academic performance. Among the elderly, conditions, particularly OME and wax impaction, reduced hearing as a result of wax impaction is can be associated with symptoms that may not likely to increase their feeling of isolation and can be significant enough to motivate patients to seek negatively affect their social interactions. help – or even be symptomless. However, these Since the occlusion of the ear canal by wax is often conditions can have a negative effect on hearing gradual, its effect on hearing may not be immediately and it is important to identify and manage them as apparent, as affected people develop coping soon as possible, because they are treatable. Primary mechanisms. In addition, the symptoms associated healthcare workers (PHWs) are in the best position with wax impaction may not be significant enough to to do so because they work within the community. warrant attendance in a health facility. Prevention of They can also train members of the community in hearing loss arising from wax impaction will therefore preventing these conditions. depend on PHWs being aware of this possibility, examining ears even when there is no complaint, and Impacted earwax taking appropriate action. Impacted earwax is most prevalent in children and PHWs should be taught good otoscopic skills: the elderly, with estimates ranging between 10 to these are essential to a proper examination of the 15% in the former and up to 30% in the later.1 The Continues overleaf ➤ Community Ear & Hearing Health Volume 13 • Issue 17 (2016) 1 Editorial ear and to a diagnosis of impacted wax. Diagnosis IN THIS ISSUE Foreign bodies in the ear needs to be followed by an intervention, the most Various types of foreign bodies, both living (such as appropriate at primary level being syringing. This 1 Common ear insects) and non-living, can be found in the ear. The conditions apparently simple procedure still has potential presence of a foreign body in the ear is not always underdiagnosed complications, so training is important to obvious, especially in children who might not report at primary level prevent potential problems. PHWs should also it. Often the foreign body is found during a routine Isaac M Macharia be taught to identify patients who may present examination of the ear or when complications contraindications to syringing and need to be 3 Otoscopy: some arising from its presence have occurred. Because a suggestions on referred to the next level of care. foreign body may occlude the ear canal, hearing loss correct technique may be one of the symptoms associated with it. Graeme Copley and Otitis media with effusion With good otoscopic skills and adequate training, Chris Prescott Otitis media with effusion (OME) is characterised PHWs should be able to identify the type of foreign body, 6 Managing cerumen by the presence of fluid in the middle ear decide whether it can be removed at primary level and at primary cavity and is another common ear condition identify the best method for removal. Good training is healthcare level underdiagnosed at the primary level. Its symptoms important, as potential complications mainly arise from Wakisa Mulwafu may be very subtle or be totally absent. The unsuccessful attempted removals. PHWs should also prevalence of OME varies in different parts of the be able to identify the situations in which they should 8 Foreign bodies in the ear canal: world, with the reported prevalence rates being immediately refer the patient and not attempt removal. identification and influenced by the diagnostic criteria and the PHWs can also play a preventive role through management at research methodology (see page 10). education of caregivers and children, e.g. by telling primary level The presence of fluid in the middle ear affects them not to insert any foreign object in the ear and Diego J Santana- sound transmission, which results in hearing not to use cotton buds. Hernández loss. Most cases of OME in children will resolve 10 Identification spontaneously within three months, but it is not Conclusion of otitis media always the case. Hearing loss and the potential It is important for primary level health workers with effusion by delay in language development are the main to appreciate that, although OME, foreign bodies primary health complications of OME in children, hence the and impacted earwax may be asymptomatic, their workers importance of an early diagnosis. potential to affect hearing makes them important ear Franco Louie LB Abes and Jose M Acuin OME can occur in adults but is less common. conditions to look out for and manage appropriately. If OME is present and persistent in only one ear, The following are important to address these 12 Three common the patient should be referred to an ENT doctor three preventable and manageable conditions at conditions that to check that this is not due to the presence of a primary level and thus reduce their complications matter at primary tumour in the post-nasal space. and long-term effects: healthcare level It is important to teach PHWs the otoscopic skills necessary for the diagnosis of OME, so • Routine examination of the ears even in the that they may identify those children with absence of symptoms. long-standing unresolved OME and those with • Training of primary level health workers in otoscopic and diagnostic skills. hearing loss who will need referral for specialist Training of primary level health workers in management. They should also be taught that • syringing and removal of foreign bodies and wax. the presence of OME in adults is an indication Availability of equipment: otoscopes and simple for referral. • headlights (with regular supply of batteries), PHWs can also educate parents and teachers instruments for syringing and for the removal on the potential effects of OME on hearing and of foreign bodies. language development, as well as deliver health • Health education to ensure the active participation education messages for the prevention of OME. of community members in preventing and Preventive measures include breastfeeding, avoiding treating these conditions. exposure to tobacco smoke and avoiding bottle- or breastfeeding children while they are lying flat on 1 JF Guest et al. Impacted cerumen: composition, production, This journal is funded by CBM their backs. epidemiology and management. Q J Med 2004;97: 477– 88. Community Editor Editorial assistant please send your name, please contact Joanna Ear Hearing Volume 13 Dr Paddy Ricard Joanna Jeremy occupation, postal address, Jeremy (as above). Health Issue 17 • 2016 & phone number and email Editorial committee Design Correspondence Otoscopic examination: bilateral impacted wax address to: Joanna Jeremy, was diagnosed and removed, much to the patient's satisfaction. Dr Diego J Santana- Lance Bellers Please send all enquiries to: MADAGASCAR Community Ear and Hearing Hernández (Chair) Joanna Jeremy (for contact Printing Health, International Centre details, see left). ANDREW SMITH Dr Ian Mackenzie for Eye Health, London Common ear conditions Newman Thomson underdiagnosed at primary level Professor Valerie E Newton School of Hygiene and Copyright bout half of all causes of hearing impairment presence of normal amounts of earwax (cerumen) Isaac M Macharia Online edition Professor of ENT, are preventable or can be managed at the in the external auditory canal is healthy, but earwax University of Nairobi; Aprimary healthcare level by appropriately becomes an important ear condition when it Tropical Medicine, Keppel Consultant ENT Surgeon, trained workers. Many of these conditions, however, completely occludes the ear canal with consequent Dr Tony Sirimanna Articles may be photocopied, Kenyatta National Referral remain undiagnosed despite their high prevalence, effects on hearing. Depending on its occlusal and Teaching Hospital, due to a lack of diagnostic skills, tools and knowledge effect, impacted wax can be an important cause Nairobi, Kenya See ‘Publications’ on http:// of their presenting symptoms amongst health workers. of conductive hearing loss and, as a consequence, Among the common ear conditions that are affect language and speech development in children. Street, London WC1E 7HT, underdiagnosed are wax impaction, otitis media with Even for children who have already acquired Professor Andrew Smith reproduced or translated, effusion (OME) and foreign bodies in the ear canal. language and speech, the hearing loss caused by This situation can be reversed through training and impacted wax in both ears can have a significant disabilitycentre.lshtm.ac.uk provision of the necessary diagnostic tools. All three effect on academic performance.
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