Panel 6: Otitis media and associated hearing loss among disadvantaged populations and low to middle-income countries

Global, Regional, and National Burdens of Otitis Media From 1990 to 2019: A Population Based Study

OBJECTIVES

Otitis media is one of the most important causes of hearing loss at an early age. Effective vaccination with the routine 7-valent pneumococcal conjugate vaccine (PCV-7) was introduced in 2000. It has been gradually replaced by the pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine or the higher-valent 13-valent PCV (PCV-13) since 2010. Data on the change in otitis media burden in recent years are sparse at the global, regional, and national levels.

DESIGN

The Global Burden of Disease 2019 study was used to evaluate the prevalence, incidence, mortality, disability-adjusted life year (DALY) rates, and the average annual percentage changes (AAPCs) in otitis media in geographic populations worldwide from 1990 to 2019. These global trends were further analyzed by subgroup (age, sex, and sociodemographic index [SDI]).

RESULTS

Globally, the all-age rate of prevalence (AAPC = -0.7, 95% confidence interval [CI] = -0.7 to -0.8), DALYs (AAPC = -1.0, 95% CI = -1.1 to -1.0), and mortality (AAPC = -6.8, 95% CI = -7.3 to -6.4) from otitis media decreased constantly between 1990 and 2019. The all-age rate of incidence decreased sharply between 2000 and 2009 with an AAPC of -1.2 (95% CI = -1.4 to -0.9) and continued the downward trend between 2010 and 2019 (AAPC = -0.2, 95% CI = -0.3 to -0.1). In 2019, children aged 1 to 4 years old had the highest incidence at 29,127.3 per 100,000 population, while young adults under 30 years old accounted for 91.3% of the incident cases. Individuals living in middle-SDI countries had the largest increase in the incidence of otitis media, with an AAPC of 0.3 (95% CI = 0.3 to 0.3) between 1990 and 2019. The incidence and DALYs from otitis media decreased with increasing SDI. Regionally, the largest increase in incidence was observed in high-income Asia Pacific, Eastern Europe, and Western Sub-Saharan Africa between 1990 and 2019. Nationally, the largest increase in the incidence of otitis media was observed in the Republic of Korea, with an AAPC of 0.8 (95% CI = 0.6 to 1.1) in the same time period.

CONCLUSIONS

There have been successful previous endeavors to reduce DALYs and mortality attributed to otitis media on a global scale. The worldwide incidence of otitis media experienced a sharp decline following the introduction of PCV-7 in 2000, and this downward trend persisted in subsequent years with the adoption of PCV-13/pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine. Continual epidemiological surveillance of otitis media's global trends, pathogen distribution, and resistance patterns remains imperative.

Novel ENT live telehealth and live video-otoscopy clinics in remote Australia: outcomes and comparisons to traditional clinic models

BACKGROUND

Coronavirus disease 2019 challenged the delivery of healthcare in Australia, disproportionately impacting vulnerable patients, including Aboriginal and/or Torres Strait Islander peoples and those living in remote regions. The otolaryngology service provided to remote Western Australia adapted to these barriers by altering clinical consultations to a digital model.

METHODS

A review was undertaken of patients in regional Western Australia. Demographics and clinical outcomes from 20 live telehealth clinics were retrospectively reviewed and compared to 16 face-to-face clinics.

RESULTS

The demographics of patients reviewed in both live telehealth and face-to-face clinics were similar, except for a larger proportion of Aboriginal and/or Torres Strait Islander patients utilising telehealth. The outcomes of patients reviewed through each model of care were comparable. Live video-otoscopy provided diagnostic quality images in 92 per cent of cases.

CONCLUSION

The findings of our review suggest that, despite its limitations, a large proportion of ENT patients may be safely assessed through a live telehealth model.

An Initial Validation of Community-Based Air-Conduction Audiometry in Adults With Simulated Hearing Impairment Using a New Web App, DigiBel: Validation Study

BACKGROUND

Approximately 80% of primary school children in the United States and Europe experience glue ear, which may impair hearing at a critical time for speech acquisition and social development. A web-based app, DigiBel, has been developed primarily to identify individuals with conductive hearing impairment who may benefit from the temporary use of bone-conduction assistive technology in the community.

OBJECTIVE

This preliminary study aims to determine the screening accuracy and usability of DigiBel self-assessed air-conduction (AC) pure tone audiometry in adult volunteers with simulated hearing impairment prior to formal clinical validation.

METHODS

Healthy adults, each with 1 ear plugged, underwent automated AC pure tone audiometry (reference test) and DigiBel audiometry in quiet community settings. Threshold measurements were compared across 6 tone frequencies and DigiBel test-retest reliability was calculated. The accuracy of DigiBel for detecting more than 20 dB of hearing impairment was assessed. A total of 30 adults (30 unplugged ears and 30 plugged ears) completed both audiometry tests.

RESULTS

DigiBel had 100% sensitivity (95% CI 87.23-100) and 72.73% (95% CI 54.48-86.70) specificity in detecting hearing impairment. Threshold mean bias was insignificant except at 4000 and 8000 Hz where a small but significant overestimation of threshold measurement was identified. All 24 participants completing feedback rated the DigiBel test as good or excellent and 21 (88%) participants agreed or strongly agreed that they would be able to do the test at home without help.

CONCLUSIONS

This study supports the potential use of DigiBel as a screening tool for hearing impairment. The findings will be used to improve the software further prior to undertaking a formal clinical trial of AC and bone-conduction audiometry in individuals with suspected conductive hearing impairment.

INdigenous Systems and Policies Improved and Reimagined for Ear and hearing care (INSPIRE): a multi-method study protocol

INTRODUCTION

Otitis media (middle ear disease) severity and chronicity among Aboriginal and Torres Strait Islander people, as well as gaps in socioeconomic outcomes related to hearing loss, indicates a breakdown in the current ear and hearing care system. The ear and hearing care system spans multiple sectors due to long-term impacts of otitis media and hearing loss in health, education and employment, necessitating a multi-disciplinary cross-sectorial approach to ear and hearing care. Public policies shape the current ear and hearing care system and here it is argued that a critical public policy analysis across different sectors is needed, with strong Aboriginal and Torres Strait Islander leadership and guidance. The current study aims to establish consensus-based ear and hearing care policy solutions for Aboriginal and Torres Strait Islander people in Australia.

METHODS AND ANALYSIS

This multi-method study will be guided by a Brains Trust with strong Aboriginal and Torres Strait Islander leadership. Public policies in hearing health, social services, and education will be scoped to identify policy gaps, using the World Health Organization framework. Qualitative data will be collected through a culturally specific process of yarning circles to identify policy challenges and/or limitations in enabling accessible ear and hearing care programs/services for Aboriginal and Torres Strait Islander people, using dimensions of Morestin's public policy appraisal tool as an interview guide for stakeholders. Themes from the yarning circles will be used to inform an expert Delphi process to establish consensus-based policy solutions for optimising the ear and hearing care system for Aboriginal and Torres Strait Islander people.

ETHICS AND DISSEMINATION

This study has approval from the Australian Institute of Aboriginal and Torres Strait Islander Studies Ethics Committee. Study findings will be disseminated to community through Brains Trust members and study participants, as well as through publications in peer-reviewed journals and research forum presentations.

PANEL 3: Otitis media animal models, cell culture, tissue regeneration & pathophysiology

OBJECTIVE

To review and summarize recently published key articles on the topics of animal models, cell culture studies, tissue biomedical engineering and regeneration, and new models in relation to otitis media (OM).

DATA SOURCE

Electronic databases: PubMed, National Library of Medicine, Ovid Medline.

REVIEW METHODS

Key topics were assigned to the panel participants for identification and detailed evaluation. The PubMed reviews were focused on the period from June 2019 to June 2023, in any of the objective subject(s) or keywords listed above, noting the relevant references relating to these advances with a global overview and noting areas of recommendation(s). The final manuscript was prepared with input from all panel members.

CONCLUSIONS

In conclusion, ex vivo and in vivo OM research models have seen great advancements in the past 4 years. From the usage of novel genetic and molecular tools to the refinement of in vivo inducible and spontaneous mouse models, to the introduction of a wide array of reliable middle ear epithelium (MEE) cell culture systems, the next five years are likely to experience exponential growth in OM pathophysiology discoveries. Moreover, advances in these systems will predictably facilitate rapid means for novel molecular therapeutic studies.

Knowledge and attitudes of school principals towards childhood hearing loss and hearing services: A cross-sectional survey to support the implementation of inclusive education in Samoa

Objectives

To assess the knowledge and attitudes among school principals towards childhood hearing loss and hearing services to support the implementation of inclusive education in Samoa. Educators are uniquely positioned to advocate for inclusive education in their classrooms, and may be among the first professionals to suspect hearing loss in their young students. Given the well-known impacts of childhood hearing loss on learning and development, educators therefore play a vital role in referring students for an ear and hearing health assessment.

Methods

A cross-sectional convenience sampling design and bilingual questionnaire were used (English/Samoan). School principals attending the annual conference for educators of Samoa over 4 days in June 2022 were invited to anonymously complete a 23-item questionnaire on childhood hearing loss and hearing services. Participants were required to respond to each statement with either 'yes', 'no' or 'unsure'. The questionnaire investigated general knowledge of healthy hearing and hearing loss, knowledge of causes and risk factors of hearing loss, knowledge of identification and intervention for hearing loss and the attitudes towards students with hearing loss.

Results

95.4% of the 109 participants agreed that healthy hearing is important, and 97.2% felt that childhood hearing loss is an important problem in Samoa. Participants agreed that hearing loss adversely impacts the interaction with peers (95.4%), listening in the classroom (94.5%), speech and language development (93.6%), classroom behaviour (88.1%) and reading skills (85.3%). 97.2% of participants felt that students with hearing loss should have the same opportunities as their normal-hearing counterparts, and 92.7% would include students with hearing loss in their classroom. 94.5% were keen to learn more about childhood hearing loss. There were no significant differences in response proportions between variable subgroups.

Conclusion

Overall, the results displayed high levels of knowledge and very positive attitudes among school principals in Samoa towards their students with hearing loss.

Vestibular migraine in low- and lower-middle-income countries: A scoping review

Background

Vestibular migraine (VM) is a common cause of dizziness that is underrecognized, underdiagnosed, and challenging to effectively treat. The prevalence, appropriate diagnostic workup, and therapies for VM in low- and lower-middle-income countries (LLMICs) remain understudied. The objective of this scoping review is to evaluate the current state of VM research in LLMICs.

Methods

PubMed, Embase, and Web of Science databases were searched to execute a scoping review of VM. Keywords "vestibular diseases" and "vertigo" were used in combination with terms referring to LLMICs as defined by the World Bank. Title and abstract screening, full-text review, and data collection were conducted by two authors independently.

Results

Twenty-six studies were included in the scoping review. Most studies were cross-sectional (57.7%) or case studies/series (23.1%) and were conducted in urban settings only (92.3%). Geographic distribution of studies was skewed, with 65.4% of articles originating from India. The prevalence of VM among clinic patients ranged from 0.3% to 33.3%. VM most frequently presented as headache, nausea and vomiting, and photophobia. Radiographic imaging, audiometry, and electronystagmography/videonystagmography were the three most commonly utilized diagnostic modalities in the dizziness workup. The most studied pharmacotherapies included calcium channel blockers, followed by beta-blockers and antiepileptics. Case studies and series discussed less common VM pharmacotherapies, such as ayurvedic medicine.

Conclusions

There is a need for more VM research in LLMICs, including innovative diagnostic approaches and therapies that can improve VM care globally. Equitable partnerships between LLMIC and high-income country researchers must expand vestibular research capacity and productivity in LLMICs.

Knowledge and attitudes of female caregivers in Samoa to childhood hearing loss and hearing services

OBJECTIVES

To assess the knowledge and attitudes of 150 female caregivers in Samoa to childhood hearing loss and hearing services, and to compare findings between urban (n = 100) and rural-dwelling (n = 50) caregivers.

METHODS

A semi-structured interview using a 26-item questionnaire was administered to participants in the Samoan language. Participants were required to respond "yes", "no", or "unsure".

RESULTS

Highest awareness of aetiology of childhood hearing loss was found for otitis media (88.7%), followed by noise exposure (64.7%) and family history (38%). Highest awareness of public health measures that may prevent/reduce otitis media was found for routine childhood immunizations (74.7%) and breast-feeding for first 6 months of life (69.3%). Overall, 40% of Samoan caregivers agreed that curses may cause childhood hearing loss. There was overwhelming support for community-based hearing services for newborns/infants (98%) and school students (97.3%).

CONCLUSIONS

There is positive support for community-based hearing health services for children among female caregivers of Samoa. There was high awareness of otitis media as a major cause of childhood hearing loss, as well as good knowledge of public health measures that reduce/minimise the risk of otitis media.

Early-life exposure to Saharan dust storms and adolescence functional disability: Evidence from Cameroon

The direct link between early-life dust storm exposure and later-in-life outcomes is not fully understood. This study examines the association of functional disability in a large sample of adolescent Cameroonians (N = 112,855) with in-utero and early childhood exposure to Saharan dust storms. Adjusting all estimations for temperature, precipitation, time and location fixed-effects, and person and family sociodemographic characteristics, we documented adverse effects on functional disability in female adolescents due to exposure to dense dust storms during the third gestation trimester and the second postnatal trimester. We also found suggestive evidence that an effect exists for the first as well as the third through fifth postnatal trimesters. In the third trimester of gestation and the second postnatal trimester, exposure to an average length dust storm with PM₁₀ levels beyond 190 μg/m³ increased the likelihood of disability among female adolescents by approximately 229 (95 % CI: 10-464) in 100,000. The size of the adverse effects for the other periods followed similar patterns. These results show the value of creating infrastructures to mitigate or adapt to the effects of dust storms. These endeavors should focus on communities and populations in and around the Sahara where international organizations can play a role. In addition, establishing health data infrastructures not only improves public health but also advances our understanding of the long-term effects of dust storms. This study demonstrates the importance of research on the long-term effects of early-life exposure to dust storms and the need for additional work on this topic.

Prevalence of hearing loss in children living in low- and middle-income countries over the last 10 years: A systematic review

AIM

To summarize the literature on the prevalence of pediatric hearing loss in low- and middle-income countries (LMICs).

METHOD

A systematic review initially identified 2833 studies, of which 122 met the criteria for inclusion. Eighty-six of those studies included diagnoses and were included in a meta-analysis.

RESULTS

The meta-analysis indicated a 1% (95% confidence interval = 0.8-2.0) prevalence of childhood hearing loss across LMICs. There was significant heterogeneity between studies and evidence of publication bias. The prevalence of mild and moderate cases of hearing loss was higher than more severe cases and there were fewer cases of mixed hearing loss compared to conductive or sensorineural hearing loss. No differences were identified between the prevalence of unilateral versus bilateral hearing loss or hearing loss according to sex. The quality of the studies, age of participants, and location of data collection may have influenced the results. High variability in the reporting of etiology made the causes of hearing loss unclear.

INTERPRETATION

The literature indicates that 1% of children in LMICs have hearing losses. However, most studies missed children with acquired hearing loss, which may lead to under-reporting of global prevalence. This systematic review is an initial step toward developing and implementing population-appropriate treatment and prevention programs for childhood hearing loss in LMICs.

Cell division cycle 42 positively correlates with T helper 2 cytokine, effusion viscosity, and hearing loss degree in otitis media with effusion patients

OBJECTIVE

Cell division cycle 42 (CDC42) participates in the pathogenesis of some T-cell-mediated inflammatory diseases via regulating CD4⁺ T-cell differentiation and inflammation response. This study aimed to evaluate the correlation of CDC42 and T helper (Th)1/Th2 cytokines with disease risk, effusion viscosity, and hearing loss degree of otitis media with effusion (OME).

METHODS

CDC42, interleukin (IL)-4, and interferon-gamma (IFN-γ) in effusion and serum of 78 OME patients were determined by enzyme-linked immunosorbent assay. Besides, the effusion (irrigating fluid) and serum samples of 30 controls (adenoid hypertrophy patients without OME) were also obtained for CDC42, IL-4, and IFN-γ determination.

RESULTS

Effusion CDC42 and IL-4 were elevated in OME patients compared with controls (both p < 0.001). Effusion CDC42 was positively correlated with effusion IL-4 in OME patients (p = 0.004) and controls (p = 0.012) but was not related to effusion IFN-γ (both p > 0.050). Additionally, effusion CDC42 (p = 0.025) and IL-4 (p = 0.023) were increased in OME patients with mucoid effusion compared to patients with serous effusion, while effusion IFN-γ was of no difference between those patients (p = 0.215). Meanwhile, elevated effusion CDC42 (p = 0.012) and IL-4 (p = 0.033) were linked with increased hearing loss degrees, whereas effusion IFN-γ was not related to hearing loss degrees (p = 0.057). Moreover, the findings of serum CDC42, IL-4, and IFN-γ showed similar trends as effusion ones; nonetheless, their correlation with disease features was generally weaker.

CONCLUSION

OME patients present with elevated CDC42 and IL-4 levels; the latter factors are intercorrelated and positively associate with effusion viscosity and hearing loss degree.

The ECRG4 cleavage product augurin binds the endotoxin receptor and influences the innate immune response during otitis media

Otitis media (OM), the most common disease of childhood, is typically characterized by bacterial infection of the middle ear (ME). Prominent features of OM include hyperplasia of the ME mucosa, which transforms from a monolayer of simple squamous epithelium with minimal stroma into a full-thickness respiratory epithelium in 2-3 days after infection. Analysis of the murine ME transcriptome during OM showed down-regulation of the tumor suppressor gene Ecrg4 that was temporally related to mucosal hyperplasia and identified stromal cells as the primary ECRG4 source. The reduction in Ecrg4 gene expression coincided with the cleavage of ECRG4 protein to release an extracellular fragment, augurin. The duration of mucosal hyperplasia during OM was greater in Ecrg4 ^-/- mice, the number of infiltrating macrophages was enhanced, and ME infection cleared more rapidly. ECRG4-null macrophages showed increased bacterial phagocytosis. Co-immunoprecipitation identified an association of augurin with TLR4, CD14 and MD2, the components of the lipopolysaccharide (LPS) receptor. The results suggest that full-length ECRG4 is a sentinel molecule that potentially inhibits growth of the ME stroma. Processing of ECRG4 protein during inflammation, coupled with a decline in Ecrg4 gene expression, also influences the behavior of cells that do not express the gene, limiting the production of growth factors by epithelial and endothelial cells, as well as the activity of macrophages.

A Step towards Achieving Sustainable Otologic Surgery in Low-Resource Settings: A Cost Comparison between Shipping an Otologic versus Microscopic Surgical Setup

Background: The advancement of otologic surgery in low-resource settings has been limited by the cost and transport of surgical equipment. This study compared the transportation costs of an otologic microscopic surgical setup (MSS) versus an endoscopic surgical setup (ESS) in low- and low to middle-income countries (LMICs) for surgical teaching. Methods: Dimensions of microscopes, endoscopes and associated surgical instruments were used to calculate shipping costs from Minneapolis, MN, USA to Kenya, Haiti and Sri Lanka. Results: The average cost of internationally shipping the ESS is less than the MSS in Kenya (ESS: USD 1344.03; MSS: USD 20,947.00; p = 0.370), Haiti (ESS: USD 549.11; MSS: USD 1679.00; p < 0.05) and Sri Lanka (ESS: USD 945.38; MSS: USD 8490.57; p = 0.377). Freight shipping was required for the MSS while the ESS can be packed into an international checked bag for USD 35.00 USD. Discussion: The ESS has fewer logistical barriers than the MSS, making the endoscope a feasible option for surgical teaching in LMICs.

HB-EGF Plays a Pivotal Role in Mucosal Hyperplasia During Otitis Media Induced by a Viral Analog

Otitis media (OM), the most common childhood illness, can be caused by bacterial and/or viral infection. Hyperplasia of the middle ear (ME) mucosa is an important component of OM that contributes to its deleterious sequelae. Our previous research revealed that ME mucosal hyperplasia in bacterially induced OM was associated with expression of the heparin-binding epidermal growth factor (HB-EGF) gene, and that HB-EGF induced the proliferation of ME mucosal explants in culture. We used single-cell RNA-Seq to identify ME cells that express Hbegf and related genes involved in mediating responses to this factor. To determine the degree to which a viral infection might induce mucosal hyperplasia, and to assess the role of HB-EGF in hyperplasia in vivo, we used, Poly(I:C) to simulate a ME viral infection, Western blotting to confirm ME protein expression, and a specific inhibitor to block the effects of HB-EGF during OM. Genes for HB-EGF and its receptor were expressed in the ME primarily by epithelial, stromal and endothelial cells. Poly(I:C) induced prominent ME mucosal hyperplasia, peaking two days after ME injection. Immunostaining revealed that cleavage of proHB-EGF into its soluble form (sHB-EGF) was strongly induced in response to Poly(I:C). Inhibition of the sHB-EGF receptor dramatically reduced the hyperplastic response of the mucosa. The results demonstrate that a synthetic analog of viral double-stranded RNA interaction can induce OM including a strong proliferative response of the ME mucosa, independent of bacteria. They also indicate that HB-EGF is the dominant growth factor responsible for ME mucosal hyperplasia in vivo.

A transcytotic transport mechanism across the tympanic membrane

Drug treatments for middle ear diseases are currently delivered systemically, or locally after opening the impermeable tympanic membrane (TM). We previously used bacteriophage display to discover novel peptides that are actively transported across the intact TM, with a variety of transport rates. Peptide structures were analyzed for evidence regarding the mechanism for this unexpected transport, which was then tested by the application of chemical inhibitors. Primary sequences indicated that trans-TM peptides share one of two amino acid motifs. Secondary structures revealed that linear configurations associate with higher transport rates than coiled structures. Tertiary analysis indicated that the shared sequence motifs are prominently displayed at the free ends of rapidly transported peptide phage. The shared motifs were evaluated for similarity to known motifs. The highest probability matches were for protein motifs involved in transmembrane transport and exosomes. Overall, structural findings suggest that the shared motifs represent binding sequences. They also implicate transcytosis, a polarized cell transport mechanism consisting of endocytosis, transcellular transport, and exocytosis. Inhibitor studies indicated that macropinocytosis, retrograde transport through Golgi and exocytosis participate in transport across the TM, consistent with transcytosis. This process can be harnessed to noninvasively deliver therapeutics to the middle ear.

Knowledge and Attitudes of Pacific Islander Doctors and Medical Students to Childhood Hearing Loss and Hearing Services: Results of a Structured Questionnaire Survey in SAMOA

The Pacific Islands have among the highest global rates of childhood hearing loss in the world. Given the scarcity of ENT Specialists and audiologists in the region, the role of the wider health professional community in addressing preventable childhood hearing loss is crucial. A 10-item 5-point Likert scale questionnaire was administered to medical officers and medical students in Samoa. The statements aimed to investigate knowledge and attitudes to childhood hearing loss and hearing services. Overall, 95.8% of participants selected “Disagree/Strongly Disagree” in response to the statement “Hearing loss is not that important because it does not kill.” There was good knowledge regarding early detection and intervention services for infant hearing assessments (73.6%) and amplification suitability for babies (69.4%-72.2%). Highest knowledge of causes of childhood sensorineural hearing loss was measured for neonatal meningitis/seizures (55.6%), followed by intra-uterine infections (52.8%), and aminoglycosides (52.8%). Knowledge was lowest for jaundice (33.3%) and birth asphyxia (38.9%).

Leukotriene B4 Is a Major Determinant of Leukocyte Recruitment During Otitis Media

Background

Pathogens of otitis media (OM) induce inflammatory responses in the middle ear (ME), characterized by mucosal hyperplasia, leukocyte infiltration, and inflammatory mediators, including arachidonic acid metabolites. We studied the role of the eicosanoid leukotriene B4 (LTB4) in OM.

Methods

Expression of LTB4-related genes was evaluated by gene array and single-cell RNA-Seq in MEs infected with nontypeable Haemophilus influenzae (NTHi). An inhibitor of LTB4 receptor 1 (i.e. U75302) was also used to block LTB4 responses.

Results

ME expression of LTB4-related genes was observed by gene arrays and scRNA-Seq. However, not all genes involved in LTB4 generation occurred in any one specific cell type. Moreover, LTB4 receptor inhibition significantly reduced mucosal hyperplasia and virtually eliminated leukocyte infiltration.

Conclusions

ME expression of LTB4-related genes suggest a functional role in OM disease. The fact that LTB4-generation is spread across different cell types is consistent with a transcellular pathway of eicosanoid biosynthesis involving cell-to-cell signaling as well as transfer of biosynthetic intermediates between cells. The dramatic reduction in ME leukocyte infiltration caused by U75302 indicates that LTB4 plays a major role in ME inflammatory cell recruitment, acting via the LTB4R1 receptor. Given that there are many other chemotactic factors that occur in the ME during OM, the ability of LTB4 to activate leukocytes and stimulate their extravasation may explain the effects of inhibition. Reduction in mucosal hyperplasia due to U75302 administration may be secondary to the reduction in leukocytes since LTB4R1 is not expressed by mucosal epithelial or stromal cells. The results suggest that LTB4 receptor antagonists could be useful in treating OM.

Knowledge and attitudes of schoolteachers in the Pacific Islands to childhood hearing loss and hearing services: A national survey protocol for Samoa

Objectives:

The Pacific Island region is estimated to have among the highest rates of childhood ear disease and hearing loss in the world. The adverse effects of childhood hearing loss include delayed speech/language development, learning difficulties, and reduced social-emotional well-being. Schoolteachers and early childhood educators are among the first professionals who may suspect hearing loss in their young students, and they are well-placed to initiate referrals to appropriate health services. Given the current efforts to implement Inclusive Education in the Pacific Islands, teachers are also uniquely positioned to positively influence, support, and advocate for a child with hearing loss in their classroom. There are no previous studies on this topic from the Pacific Island region.

Methods:

The study will use a national survey and convenience sampling design. Teachers attending the Annual Teachers Conference in Samoa will be invited to independently and anonymously completed a 23-item questionnaire on childhood hearing loss and hearing services. Questions are in English, with a Samoan translation provided. The participating teachers will be required to respond with “yes,” “no,” or “unsure,” and to mark their response on the questionnaire. The questions assess knowledge of biomedical etiology of hearing impairment, knowledge of the adverse impacts of hearing loss on childhood development, knowledge of hearing loss identification and intervention, and attitudes toward children with a hearing impairment.

Results:

Not applicable for a study protocol.

Conclusion:

We publish these protocols to facilitate similar studies in other low- and middle-income countries, and especially among our Pacific Island neighbors.

Development of a Risk-Factor Questionnaire for the Infant Ear and Hearing Program in Samoa

PURPOSE

Congenital hearing loss is the most common sensory disorder present at birth. While universal newborn hearing screening is the standard for most high-income countries, alternative models are under consideration for most low and middle-income countries. The Pacific Islands have among the highest rates of paediatric ear disease and deafness in the world, and an interim Infant Ear and Hearing Program is currently being developed for the Polynesian nation of Samoa. The inclusion of a routine risk-factor questionnaire for childhood deafness in the Infant Ear and Hearing Program package is a feasible alternative for well-baby clinics in Samoa.

DESCRIPTION

The World Health Organisation advocates that all member states should implement newborn and infant hearing screening. This includes a risk-factor questionnaire developed from the joint committee on infant hearing risk-factors, as well as additional risk-factors unique to low and middle income countries. The present paper examines all known risk-factors for childhood deafness to develop an appropriate and evidence-based questionnaire for inclusion in the Samoan Child Health Book and Infant Ear and Hearing Program package.

ASSESSMENT

From a starting point of 19 risk-factors, 11 risk-factors were included with no changes; 5 risk-factors were modified to align with current health service availability in Samoa; 2 risk-factors were excluded due to cultural inappropriateness and irrelevance for Samoa; and 1 risk-factor was added for our Samoan and Pacific Island context.

CONCLUSION

There are 17 items on the final risk-factor questionnaire for childhood deafness developed for Samoa. The Infant Ear and Hearing Program package will also include ear examinations and monitoring of hearing developmental milestones. The risk-factor questionnaire will be reviewed again in 5 years' time for the next edition of the Samoan Child Health Book.

The inaugural World Report on Hearing: From barriers to a platform for change

The inaugural World Report on Hearing was recently published by the World Health Organisation, and outlines the burden of hearing loss, and strategies to overcome this through preventative and public health approaches. Here, we identify barriers to wide-scale adoption, including historic low prioritisation of hearing loss against other public health needs, a lack of a health workforce with relevant training, poor access to assistive technology, and individual and community-level stigma and misunderstanding. Overcoming these barriers will require multi-sector stakeholder collaboration, involving ear and hearing care professionals, patients, communities, industry and policymakers.

Otitis media outcomes of a combined 10-valent pneumococcal Haemophilus influenzae protein D conjugate vaccine and 13-valent pneumococcal conjugate vaccine schedule at 1-2-4-6 months: PREVIX_COMBO, a 3-arm randomised controlled trial

BACKGROUND

Aboriginal children living in Australian remote communities are at high risk of early and persistent otitis media, hearing loss, and social disadvantage. Streptococcus pneumoniae and non-typeable Haemophilus influenzae (NTHi) are the primary pathogens. We compared otitis media outcomes in infants randomised to either a combination of Synflorix™ (PHiD-CV10, with protein D of NTHi) and Prevenar13™ (PCV13, with 3, 6A, and 19A), with recommended schedules for each vaccine alone. We previously reported superior broader overall immunogenicity of the combination schedule at 7 months, and early superiority of PHiD-CV10 compared to PCV13 at 4 months.

METHODS

In an open-label superiority trial, we randomised (1:1:1) Aboriginal infants at 28 to 38 days of age, to either Prevenar13™ (P) at 2-4-6 months (_PPP), Synflorix™ (S) at 2-4-6 months (_SSS), or Synflorix™ at 1-2-4 months plus Prevenar13™ at 6 months (SSSP). Ears were assessed using tympanometry at 1 and 2 months, combined with otoscopy at 4, 6, and 7 months. A worst ear diagnosis was made for each child visit according to a severity hierarchy of normal, otitis media with effusion (OME), acute otitis media without perforation (AOMwoP), AOM with perforation (AOMwiP), and chronic suppurative otitis media (CSOM).

RESULTS

Between September 2011 and September 2017, 425 infants were allocated to _PPP(143), _SSS(141) or SSSP(141). Ear assessments were successful in 96% scheduled visits. At 7 months prevalence of any OM was 91, 86, and 90% in the _PPP, _SSS, and SSSP groups, respectively. There were no significant differences in prevalence of any form of otitis media between vaccine groups at any age. Combined group prevalence of any OM was 43, 57, 82, 87, and 89% at 1, 2, 4, 6, and 7 months of age, respectively. Of 388 infants with ear assessments at 4, 6 and 7 months, 277 (71.4%) had OM that met criteria for specialist referral; rAOM, pOME, or CSOM.

CONCLUSIONS

Despite superior broader overall immunogenicity of the combination schedule at 7 months, and early superiority of PHiD-CV10 compared to PCV13 at 4 months, there were no significant differences in prevalence of otitis media nor healthy ears throughout the first months of life.

TRIAL REGISTRATION

ACTRN12610000544077 registered 06/07/2010 and ClinicalTrials.gov NCT01174849 registered 04/08/2010.

Impact of air pollution on benign paroxysmal positional vertigo incidence: a retrospective study of the citizens of Seoul, South Korea

Benign paroxysmal positional vertigo (BPPV) is among the most common inner ear diseases. Although BPPV is one of the most common causes of dizziness, its pathogenesis remains unknown. Air pollutants might reach the middle ear through the eustachian tube and be absorbed into the inner ear through the round window membrane, increasing the risk of BPPV. We investigated the relationship between air pollution and BPPV risk. Data were extracted from the Korean Health Insurance Review and Assessment Service database, which contains health claims information of the entire South Korean population. Variables of interest included the number of patients diagnosed with BPPV in Seoul, South Korea, patients' clinical and demographic characteristics, and osteopenia status. Seoul's daily air pollution indicators, including SO2, CO, O3, NO2, PM10, and PM2.5, were obtained from the Korea Environment Corporation website. Overdispersed Poisson regression analysis was performed. In the multivariable analysis, NO2 air concentration (ppb) was associated with increased incidence of BPPV. In analysis stratified by gender, levels of NO2 were associated with increased incidence of BPPV in both men and women. In the analysis stratified by age, NO2 air concentration was associated with increased incidence of BPPV among all adults over the age of 19 years. In the analysis stratified by osteopenia status, NO2 was associated with increased incidence of BPPV in patients with and without osteopenia. Air levels of NO2 were associated with increased incidence of BPPV in the present study. This finding contributes toward a better understanding of BPPV pathogenesis and improved prevention and management of this condition.

Knowledge and attitudes of university health students in the Pacific Islands towards childhood hearing loss and hearing services: a Samoan survey study protocol

INTRODUCTION

The Pacific Islands have among the highest rates of ear disease and hearing loss in the world, especially among children. Given that Ear, Nose and Throat (ENT)/audiology specialists are limited in the region, the successful implementation of ear and hearing health services will depend on the participation and support of the wider community of health professionals. There are currently no studies from the Pacific Islands investigating the knowledge and attitudes of either health students or health professionals towards childhood hearing loss and hearing services.

METHODS AND ANALYSIS

Survey of medical and nursing students (n=370) currently enrolled at the National University of Samoa. Students will independently and anonymously complete a 10-item questionnaire. The questions assess attitudes to childhood hearing loss (two questions), knowledge of aetiology of childhood hearing loss (three questions), and knowledge of identification and interventions for children with hearing loss (five questions). Responses are based on a 5-point Likert scale (Strongly agree/Agree/Neutral/Disagree/Strongly disagree).

DISCUSSION/CONCLUSION

We publish these protocols to facilitate similar studies in other low-income and middle-income countries, and especially among our Pacific Island neighbours.

Chronic otitis media and subsequent hearing loss in children from the Himalayan region residing in Buddhist Monastic schools of Nepal

Objectives

The main objective of the study was to ascertain the prevalence of chronic otitis media and determine the corresponding hearing loss in children from Nepal’s Himalayan region now residing in Buddhist Monastic schools of Nepal.

Methods

The study was conducted among children at Buddhist monastic school in different parts of Nepal. A total of 3174 children aged between 5 and 15 years, who were originally from the Himalayan region of Nepal and were currently residing in monastic schools, were screened for ear problems and hearing loss. They were examined by otoscope to diagnose chronic otitis media. Hearing was evaluated by pure tone audiometer, and 0.5–4 kHz air conduction hearing threshold was measured and documented.

Results

Of the total of 3174 children who were screened for ear diseases and hearing loss, monks constituted 76.21% (n = 2419) and Nuns 23.78% (n = 755). Chronic otitis media was the most common otoscopic finding during the screening, and it affected a total of 344 (10.83%) children. Out of these 344, hearing loss of varying degrees was observed in 5.42% (n = 172) children.

Conclusion

There is high prevalence of chronic otitis media in children belonging to the Himalayan region of Nepal, and it is the main cause of avoidable hearing loss. Timely diagnosis and treatment of chronic otitis media could prevent unnecessary hearing loss in these children.

Hearing loss among Australian Aboriginal infants and toddlers: A systematic review

Aim

Australian Aboriginal and Torres Strait Islander children have among the highest rates of otitis media (OM) and associated conductive hearing loss in the world. OM begins early in life and is well-documented in the research literature. In contrast, audiology data for the infant and toddler age-groups are limited. This review aimed to summarise the recent literature on hearing loss among Aboriginal and Torres Strait Islander infants and toddlers.

Methods

Systematic literature review. PubMed and ScienceDirect databases were searched for relevant journal articles. Key search terms were “Aboriginal”, “children”, “hearing loss”, “otitis media”, and their relevant synonyms. Journal articles published before 2000 were excluded.

Results

Only two journal articles met review inclusion criteria. Ear disease and associated conductive hearing loss was significantly higher among Aboriginal and Torres Strait Islander than non-Aboriginal and Torres Strait Islander children. No intervention studies were found.

Conclusions

More research is needed to evaluate hearing health outcomes of medical (including surgical) and audiological interventions in this high-risk population.