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��ࡱ�>��	�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[�	��p�bjbj����	>�ΐΐ�m����������33333����GGG8�lG�)0����(�(�(�(�(�(�($�*��-F)u3�����)33�w)�&�&�&�T
33�(�&��(�&�&�&������w��GL#��&�(�)0�)�&�-D&��-�&�-3�&����&�����))�&����)�������������������������������������������������������������������������-����������	�:	Predictors of Non-Healing Ear Discharge in Non-cholesteatomatous Chronic Supporative Otits Media in a Developing Country

�  Foster Tochukwu Orji
Department of Otolaryngology, University of Nigeria Teaching Hospital Enugu;
Department of Surgery, Federal Medical Center Umuahia

Benjamin O. Dike
Department of Surgery, Federal Medical Center Umuahia

Onuoha Oji
Department of Surgery, Federal Medical Center Umuahia


�  Correspondence
F T Orji
Department of Otolaryngology, University of Nigeria Teaching Hospital Enugu
Tel: 2348036773342
Email: tochiorji@yahoo.com


Number of Tables = 2

Number of Figures = 1



Abstract
Objective: We conducted this study to determine the risk factors for protracted non-healing ear discharge among CSOM patients.
Materials and Methods: we carried out a retrospective analysis of non-cholesteatomatous CSOM patients treated in a tertiary hospital form a developing country. Comparison was made between 128 patients with ear discharge persisting beyond 24 months and 58 patients whose otorrhoea resolved within 6 months in terms of sociodemographic and other potential risk factors.
Results: Major risk factors identified by logistic regression analysis were rural residence,   multidrug resistant bacteria, and bilateral CSOM (P = <0.001, 0.001, and 0.008 respectively). Others were onset of ear discharge before age of 10 years, diabetes mellitus, persistent rhinorrhoea, homes > 10 miles away from hospital, and >7 persons in family (P = 0.012,  0.041, 0.013, 0.010, and 0.043 respectively). Age, sex, nasal allergy, and self medication were not significant risk factors for non-healing ear discharge.
Conclusion: Protracted non-healing ear discharge still remains a prominent feature of CSOM in our experience. Rural residence, multidrug resistance, bilateral CSOM, long distance to health facilities are prime risk factors. Measures to address these risk factors in order to bring about a decline in the number of non-healing ear discharge among CSOM patients especially in our rural communities are urgently needed.     
Keywords: Ear discharge; Non-healing; Chronic supporative otitis media; Risk factors




Introduction
Chronic Suppurative otitis media (CSOM) is a disease of mucoperiosteal lining of the middle ear cleft characterised by persistent perforation of the tympanic membrane in the presence or absence of ear discharge [1-4].The disease often begins in early childhood, usually as acute otitis media, with potential of spilling over into adulthood, accounting for recurrent episodes of chronic ear discharge [2,5,6]. The major concern of most patients with CSOM is the embarrassing frequent episodes of purulent ear discharge which recur sporadically [7]. The duration of ear discharge episode in CSOM is variable. The discharge in cholesteatomatous type often last for many years compared to tubotympanic non-cholesteatomatous disease which usually lasts for few months to few years [3,6]. But in poor resource countries, the discharge even in safe tubotympanic type has been observed to continue for many years with increasing risk of hearing impairment and life threatening infective complications [5,7].
 Although risk factors for otits media have been severally reported in both paediatric and adult series, the determinants of non-healing protracted ear discharge in CSOM patients are yet to be systematically evaluated. We conducted this study to examine the risk factors associated with protracted ear discharges in non-cholesteatomatous CSOM patients receiving specialist care in a low resource country.     
 
Methods
The present study was conducted in the department of otolaryngology of a tertiary institution in which retrospective case analysis of patients who were receiving care for chronic ear discharges during a three year period ending December 2012 was carried out after the necessary institutional approved was obtained. 
Data of consecutive patients up to 2 years of age were included if the ear discharge has lasted for more than 3 months regardless of the treatment offered. Patients were excluded if diagnosed with cholesteatoma or had attic perforation. Those ear discharges that resulted from ear trauma were also excluded. Two hundred fifty one patients who met our criteria were identified. Their records were further reviewed to select the target groups depending on the duration of ear discharge, for analysis. Those selected included the group of 128 (51%) patients whose ear discharge did not resolved after 24 months, and 58 (23%) ear discharges that resolved within 6 months. 
The following factors were compared between the two target groups: patient age, gender, age of onset of CSOM, bilateral/unilateral disease, multidrug resistance (defined as resistance to 3 or more of the following antibiotics in the antibiotic sensitivity test: amoxicillin, amoxicillin/clavulanate, gentamicin, erythromycin, ciprofloxacin, tetracycline, and chloramphenical); rural residential, homes e" 10 miles from health facility, self medication practice, large family (family size of >7), coexisting diabetes mellitus, persistent rhinorrhoea (nasal discharge of up to 6 weeks), allergic rhinitis.  

Statistical Analysis
Data were analysed with  Statistical Package for Social Sciences� (SPSS), version 16.5. The association between the potential risk factors and prolonged non-healing ear discharge was studied using chi-square test of proportions. Logistic regression test was used to model the association between significant risk factors in chi-square test and the likelihood of prolonged chronic ear discharge separately. Statistical significance was set at P value of < 0.05


Results
Data from 186 target groups were analyzed. The 128 the group �A� patient had a mean age of 21.4 � 19.1 years and ranged from 2-86 years, while the mean age of the 58 group �B� patients was 21.9 � 21.7 years  with youngest patient being 2 years and the oldest being 82 years. The difference was not significant (P = 0.382). The details of the distribution of the age as well as the age of onset of chronic ear discharge among the target groups were provided in table 1. More than 33% were children < 10 years of age. The age at the first episode of ear discharge ranged from 6 weeks of life to 82 years with 19.9% of the patients having their first episode before the age of 1 year. In 18% of the patients (15 adolescents and 18 adults), their current ear discharges dated back to their early childhood. The Male patients significantly out-numbered the females (P = 0.028). The duration of otorrhoea in group �A� subjects ranged from 24 months to 45 years with a mean of 4.6 � 4.8 years, while the mean duration of otorrhoea was 4.9 � 0.9 months in group the �B� and ranged from 3.5 - 6 months. 
The distribution of the risk factor in relation to the duration of ear discharge among the patient groups is as detailed in table 2. Potential risk factors which had a significance of <0.05 on univariate Chi square analysis were included in the multivariate logistic regression model to obtain the adjusted odds ratios. These included age of onset of ear discharge, ears affected, residence in rural communities, multidrug resistance, hospital distance from home, family size, coexisting diabetes mellitus, and persistent rhinorrhoea.
The result of logistic regression test identified bilateral CSOM, onset of ear discharge before age of 5 years, multidrug resistance, coexisting diabetes mellitus, and persistent rhinorrhoea as significant risk factors for non-healing protracted ear discharge (P= 0.008, 0.012, 0,001, 0.041, and 0.013 respectively). Significant social risk factors included rural residence and homes > 10 miles away from hospital (P = <0.001 and 0.010 respectively). The size of the family size was not significantly. In univariate analysis, bilateral disease and rural residence had the greatest odds for prolonged ear discharge (6.23 and 5.93 respectively), whereas the results of logistic regression test revealed that rural residence and multidrug resistance on antibiotic sensitivity testing had the greatest odds of protracted non-healing ear discharge (6.02 and 5.66 respectively).


Discussion
The challenges associated with CSOM include hearing loss, persistent or recurrent episodes of ear discharge, and risks of various intracranial and extracranial complications. But the most worrisome burden of the disease remains the social embarrassments from the recurrent ear discharges [5,7]. The pattern of ear discharge in CSOM varies considerably between individuals and disease type. In many patients, the ear discharge recurs from time to time after initial control of the discharge [1,6,8,9], whereas in some especially in tubotympanic CSOM, after the initial episode of ear discharge, dry ears are achieved for very long period of time [6]. Yet in other cases especially in developing countries or in cholesteatomatous type, the discharge continues for many years [1,3, 5,7]. The risk factors for CSOM have been reported especially from studies in pediatric population to include  low socio-economic status (poor housing, overcrowding, large families, poor occupational and environmental conditions), allergy/atopy, chronic rhinorrhoea, chronic nasal obstruction, previous acute or recurrent acute otitis media, second hand smoking (in children), and indoor cooking [8-14]. 
The present report is an attempt to investigate the determinants of non-healing ear discharge in patients with non-cholesteatomatous CSOM. 
Although non-healing ear discharge was not significantly related to patient age, we found that the impact of age at onset of ear discharge was significant, as those that had their first episode of otorrhoea before the age of 5 years had more than 2 times greater odds of having protracted ear discharge. Early onset of otitis media has been associated with greater risk of CSOM [15]. The reason for this association is not obvious but we noticed in our study that 35% and 52% of the ear discharges which started before the first birthday and before the age of 5 years continued in the older age groups respectively, thereby increasing the mean duration of ear discharge in this population. The issue of spill over of CSOM from childhood to adulthood may be related to poverty and overcrowding, which in turn influence the early onset of the disease. We discovered that 76% of the disease spill over was noted in individuals from large families. Conversely 69% of CSOM before age of one year were observed in patients from large families. Moreover, our study indicated that individuals from large families had more than one and half times the odd of developing non-healing ear discharge. It is our impression that poverty is the underlying factor here. The competition for the very limited financial resources in these large families means that little attention is paid to the control of the early childhood ear infection with attendant risk of disease prolonging. Low socio-economic status and overcrowding have been recognised as significant risk factors for early-onset otitis media [15,16, 17]. 
Significant association was also found between protracted non-healing ear discharge and chronic rhinorrhoea. We found that more than twice as many of patients in the group of protracted ear discharge than those in whom ear discharge resolved within 6 months had constant rhinorrhoea. The significance of constant rhinorrhoea is that retained secretions in the nasal cavity and nasopharynx form an appropriate medium for pathogenic bacteria to thrive. They subsequently ascend through the Eustachian tube to constitute a constant pool of infection in the middle ear. Similar associations between persistent rhinorrhoea/upper respiratory tract infection and chronic otitis media have been reported, although mostly in paediatric series [8,9,14,18]. In order to improve the chances of achieving dry ears in these patients, treatment of underlying causes of persistent rhinorrhoea such as enlarged adenoids in children, chronic sinusitis and nasal allergy should be always be considered. The association between CSOM and allergy has been shown by some authors [9,19]  and not by others [10,20]. Though we did not find significant association between history of allergy and protracted ear discharge with the application of the conventional p-value of 0.05, its risk propensity for non-resolving ear discharge in CSOM patients should at least be considered since its p-value is 0.08. There is a chance that our study missed some cases of allergy on account of missing data in view of the retrospective nature of this study. 
Although non-healing ear discharge was not associated with patients� gender in this study, there were however significantly more males than females with CSOM. The apparent lower prevalence of female CSOM may be as a result of our cultural family bias towards their health. In the face of very limited family financial resources, most families would preferentially carter for the health of the girls before the boys, especially as it concerns illnesses that attract social stigma such as ear discharge, which are believe to drive away marriage suitors. What this means is that the female children who had acute otitis media were treated promptly, thereby possibly preventing the girls from progressing to CSOM. Dayasena et al similarly reported less number of females with CSOM compared to males [1].
We observed that patients with bilateral CSOM had significant greater risk of protracted ear discharge than those with unilateral disease. The reason is not known but may not be unconnected to poorer immune status of the patients. Although the later was not evaluated in this study, we noticed that 67% of these patients with diabetic mellitus had bilateral disease. It is not a surprise to observe significant association between diabetes mellitus and protracted ear discharge in view of the documented role uncontrolled diabetes mellitus plays in persistence of (ear) infections through immune depression [1,21].  In one of the reports 21.8% of the 234 CSOM cases with duration of ear discharge ranging from 6 weeks to 20 years were diagnosed with diabetes mellitus [1]. However the numbers of available blood sugar test results in this series were too few for any reasonable conclusion to be drawn.  
Multidrug resistance to common affordable antibiotics was highly associated with non-resolving protracted ear discharge. We observed that 86.4% of the multidrug resistant organisms were Pseudomonas aeruginosa and Staphylococcus aureus which is in agreement with the report of Perveen et al [22]. The risk factors for multidrug resistance have been documented as improper and indiscriminate use of antibiotics, tobacco smoking, male gender, young age, day-care attendance, immunodeficiency [22,23]. Injudicious use of antibiotics is a very common practice in developing countries such as ours in which regulation of antibiotic dispensation is nothing to write home about. The practice of drug dispensation by quack patent drug dealers is further compounding the issue. A number of our patients preferred patronizing these quacks to seeing qualified medical doctors. This was a similarly experience in Bangladesh [17]. These folk easily walk across the drug stores and ask for drugs to be �mixed� for their ear discharge as much as their meagre pockets could afford. The drug �mixtures� often contain ill-informed much lower doses of the common antibiotics such as amoxicillin, tetracycline, and sometimes ciprofloxacin. It is only after several such visits to these quacks patent drug dealers who even go by the title of �doctor�, that our patients eventually turn up at the clinics when their discharge persist. This could explain the high rate of multidrug resistance in our study. In one 47 year old rural woman in our study, her present left sided ear discharge started at the age of 4 years. She presented only recently with multiple fistulas after a quack drug seller attempted multiple incisions and drainage of periaural swelling following failure of his �treatments� to resolve her ear discharge over the years (fig 1).
The significant association of protracted episodes of non-healing ear discharge with patients living in homes more than 10 miles from health facility probably reflects difficult access to proper health care. Most of these patients were rural dwellers whose communities are at greater distance away from the urban city centre where the comprehensive health facility is located. Issue of difficult access to health facilities had been reported as a risk factor for CSOM in low resource settings [24]. The odds of developing protracted non-healing ear discharge was greatest with the rural dwellers. This is in agreement with other reported works that documented greater odds of developing CSOM among rural dwellers [4,8,10,17]. In our study rural patients constituted 77% and 71% of ear discharge that lasted for >10 years and > 5 years respectively. Their average duration of ear discharge was 4.22 � 5.71 years. In these rural communities, the combination of poverty, ignorance and lack of access to health facility conspire to deny most dwellers of the needed health care. Even where rural health centres are available, they are often poorly manned by non-doctor medical personnel. It is pertinent to call for the provision of properly manned health centres within the neighbourhood of the rural communities so as to at least mitigate the problem of access. This we hope will lead to a decline in the number of non-healing ear discharge among CSOM patients in the rural areas.
Conflict of Interest
The authors declare that they have no conflict of interest 

 








References
1   Dayasena RP, Dayasiri MBKC, Jayasuriya C, Perera DSC  (2011) Aetiological agents in 
     chronic suppurative otitis media in Sri Lanka. Australas Med J. 4:101-4
2   Meyerhoff WL (1988) Pathology of chronic suppurative otitis media, Ann. Otol. Rhinol.
     Laryngol 97:21�24
3   Madana J, Yolmo D, Kalaiarasi R, Gopalakrishnan S, Sujatha S. (2011) Microbiological 
profile with antibiotic sensitivity pattern of cholesteatomatous chronic suppurative otitis media among children. Int J Pediatr Otorhinolaryngol 75:1104-8
4   Ologe FE, Nwawolo CC (2003) Chronic suppurative otitis media in school pupils in 
     Nigeria.East Afr Med J 80:130�4
5   Okafor BC (1984) The chronic discharging ear in Nigeria. J Laryngol. Otol. 98:113�
     119.
6   Jensen RG, Homoe P, Anderson M, Koch A (2011) Long-term follow-up of chronic 
suppurtive otitis media in a high-risk children cohort  Int J Pediatr Otorhinolaryngol 75:948�54 
7   Orji FT (2013) A survey of the burden of management of chronic suppurative otitis Media 
     in a developing country. Ann Med Health Sci Res. 3:598�601.
8   Sophia A, Isaac R, Rebekah G, Brahmadathan K, Rupa V (2010) Risk factors for otitis 
    media among preschool, rural Indian children Int J Pediatr Otorhinolaryngol. 74:677-83
9   Zhang Y, Xu M, Zhang J, Zeng L, Wang Y, Zheng Q Y (2014) Risk factors for chronic 
and recurrent otitis media-A meta-analysis PLoS ONE  9: e86397. doi:10.1371/journal.pone.0086397
10  Lasisi AO, Olaniyan FA, Muibi SA, I, Abdulwasiu K, Lasisi TJ, Imam ZO, Yekinni TO, 
Olayemi O. (2007) Clinical and demographic risk factors associated with chronic suppurative otitis media. Inter J  Pediatr Otorhinolaryngol 71: 1549-54
11  Kum-Nji P, Meloy L, Herrod HG (2006) Environmental tobacco smoke exposure:      
prevalence and mechanisms of causation of infections in children. Pediatrics 117:1745-54  
12  Daly KA, Pirie PL, Rhodes KL, Hunter LL, Davey CS. (2007) Early otitis media among
     Minnesota American Indians: the Little Ears Study. Am J Public Health 97: 317- 22.     
13  Fliss DM, Lieberman SA, Dagan R (1991) Chronic suppurative otitis media without
cholesteatoma in children in Southern Israel: incidence and risk factors, Pediatr. Infect. Dis. J.10:895-99.      
14  van der Veen EL, Schilder AGM, van Heerbeek N, Verhoeff M, Zielhuis GA, Rovers
MM (2006) Predictors of chronic suppurative otitis media in children. Arch Otolaryngol Head Neck Surg. 132:1115-18
15  Lasisi AO, Olayemi O, Irabor AE (2008) Early onset otitis media: risk factors and effects
      on the outcome of chronic suppurative otitis media. Eur Arch Otorhinolaryngol 265:765-8 16  Auinger P, Lanphear BP, Kalkwarf HJ, Kalkwarf HJ, Mansour ME (2003) Trends in 
     Otitis Media Among Children in the United States. Pediatrics 112;514-20
17  Shaheen M, Raquib A, Ahmad SM (2012) Chronic Suppurative Otitis Media and Its
Association with Socio-Econonic Factors Among Rural Primary School Children of Bangladesh. Indian J Otolaryngol Head Neck Surg 64:36�41
18  Leach AJ, Boswell JB, Asche V, Nienhuys TG, Mathews JD. (1994) Bacterial
colonization of the nasopharynx predicts very early onset and persistence of otitis media in Australian aboriginal infants, Pediatr. Infect. Dis.13:983-9
19  Lack G, Caulfield H, Penagos M (2011) The link between otitis media with effusion and 
allergy: a potential role for intranasal corticosteroids. Pediatr Allergy Immunol 22:258-66
20  Stahlberg MR, Ruuskanen O, Virolainen E (1996) Risk factors for recurrent otitis media.
      Pediatr. Infect. Dis. J. 5:30-32. 

21  Casquueiro J, Casquueiro J, Alves C (2012) Infections in patients with diabetes mellitus:
      A review of pathogenesis .Indian J Endocrinol Metab. Suppl 1:27-36.   
22  Perveen S, Naqvi SB, Fatima A (2013) Antimicrobial susceptibility pattern of clinical
isolates from cases of ear infection using amoxicilline and cefepime. Springerplus 2:288. doi: 10.1186/2193-1801-2-288.eCollection 2013
23  Klien JO (2012) Strategies for Decreasing Multidrug Antibiotic Resistance: Role of 
      ototopical agents for treatment of middle ear infections. 8 (Suppl):345-52   
24  Shaw JR, Todd NW, Goodwin MH, Feldman CM. (1981) Observations on the relation of
environmental and behavioral factors to the occurrence of otitis media among Indian children. Pub health Reports 96:342-49













Tables

Table 1: Distribution of Patients Age and the Age of Onset of Ear Discharge Among the Target Groups of Chronic Suppurative Otitis Media Patients 

                                               Number of Patients                      Percentage                 Age of patients at Presentation n = 186
< 10 years                                         63                                           33.9%
10-20 years                                       52                                           28.0%
21-30 years                                       31                                           16.7%
30-50 years                                       18                                            9.7%                                           
>50 years                                          22                                           11.8%
      Total                                           186                                          100%
Age of Onset of Ear Discharge n = 185
<1 year                                             37                                            19.9%                 
2-5 years                                          47                                             25.3%
6-10 years                                        15                                             8.1% 
11-20 years                                      30                                             16.1%
>20years                                          56                                             30.1%







Table 2: Univariate and Multivariate Analysis Comparing Risk Factors between CSOM with Non-healed Otorrhoea of > 2 years and CSOM with Healed Otorrhoea within 6 Months
Independent                  Non-healed      Healed                 Chi Square test              Logistic Regression test                                      
Variables                        group              group             P value    OR  (95% CI)        P value    OR  (95% CI) 
                                           n      (%)       n     (%)                                                                                                                                    Age
    2-9 years                           44    (34.4)     19    (32.6)       0.869      1.08    (0.56-2.08)        -                 -
    10-20years                        35    (27.3)     17    (29.3)       0.780       0.91   (0.46-1.80)        -                 -
    21-30years                        21    (16.4)     10    (17.2)       0.887       0.94   (0.41-2.15)        -                 -
    >30years                           28    (21.8)     12    (20.7)       0.856       1.02   (0.81-1.29)        -                 -
Gender
    Male                                 77     (60.2)     31    (53.4)       0.390      1.32    (0.70-2.46)       -                  -
    Female                              51     (44.5)    27     (46.6) 
Age of Onset of disease
    d" 5  years                          67     (52.8)     17    (29.3)      0.004       2.69    (1.39-5.23)      0.012         2.27   (1.20-4.28)            
    > 5 years                           60     (47.2)     41    (70.7)
Ears Involved
    Biilateral                           59     (46.1)     7      (12.1)     <0.001     6.23    (2.63-14.77)     0.008        3.00    (2.51-5.07)  
    Unilateral                          69     (53.9)     51    (87.9)
Area of Residence
    Rural                                 91     (71.1)    23     (39.7)     <0.001     5.93    (2.99-11.74)    <0.001      6.02    (3.65-12.36)
    Urban                                37    (28.9)     35     (60.3)     
Homes more than 10 miles 
from hospital
    Yes                                   82     (64.1)     25     (43.1)      0.007     2.35     (1.25-4.43)       0.010       1.79     (1.06-1.63)            
    No                                    46     (35.9)     33     (56.9)                  
Self medication practice
     Yes                                  39     (35.1)     12     (28.6)      0.442     1.35     (0.62-2.94)         -                 -
     No                                   72      (64.9)    30     (71.4)
Allergic Rhinitis
     Yes                                  34      (30.4)    20     (39.2)      0.295     0.68     (0.34-1.38)         -                  -
     No                                   78      (69.6)    31     (60.8)
Persistent rhinorrhoea
     Yes                                  72      (65.5)    21     (44.7)      0.021    1.30      (1.04-1.64)       0.013       2.35      (1.17-4.71)     
     No                                   38      (34.5)    26      (55.3)     
Family size
     > 7                                   72      (67.9)    22     (48.8)      0.027     2.21     (1.09-4..52)      0.043       1.74      (1.01-2.82)    
     d" 7                                   34      (32.1)    23     (51.1)
Diabetes 
      Yes                                 15      (41.7)    3       (15.0)     ���"	Z	\	�	�	(
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njojsj�j}kl�l�lm]mum4o�o�o�p�p���������������d��$Ifgd1Lhkd,$$If�l�����&F*��������
t��0�*6��������������4�4�
lB�a��yt1L�p�pmq�q�q�q�r�r�r�s�s�sit�t�teu�u�u�vNwbwS�����I����������������������������������d��$Ifgd1L 0.023     4.76     (1.20-18.98)     0.041       1.67      (1.13-2.34)            
      No                                  21      (58.3)    20      (87.0)
Multidrug resistance
      Yes                                 83     (64.8)     23     (39.7)      0.002     2.81     (1.48-5.32)       0.001       5.66      (1.92-6.91)
       No                                 45      (35.1)    35     (60.3)


CSOM = chronic suppurative otitis media; OR = Odds Ratio; (95% CI) = 95% confidence interval;  n = number
 
Legend To The Figure
Figure 1: Complicated left chronic suppurative otitis media in a 47 year old rural woman with 43 year history of non-healing ear discharge under the care of quack drug sellers. She developed tympanocutaneous fistulas and discharging osteomyelitis of left mandible after one of the quacks attempted multiple incisions over her left periauricular swelling 15 months prior to presentation, which were preceded by a persistent polyp occluding the ear canal.   















Risk Factors Associated with Protracted Ear Discharge in Chronic Suppurative Otitis Media


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