Acute otitis media: Lend me your ears

MANILA, Philippines - A cute otitis media (AOM), or simply ear infection to the layman, is one of the more common childhood illnesses, usually manifesting as fever, cough and colds, with or without ear pain. “About 85 percent of children would have had at least one episode of AOM by the time they reach the age of three,” notes Dr. Lulu Bravo, vice chancellor for research and executive director of the National Institute of Health (NIH) of the University of the Philippines-Manila. “Incidence in the Asian region is 90 percent, one of the highest disease burdens in the world.”

The illness, which involves the inflammation of the middle ear area, is often misdiagnosed, mistreated or inappropriately treated. “AOM does not result in death but can lead to it,” Dr. Bravo warns.

There is only a very thin membrane between the middle ear and the brain, and an accumulation of fluids or pus in the middle ear can easily spread the infection to the brain. It can deteriorate to potentially fatal diseases such as meningitis or pneumonia.

“AOM is very common, very serious, yet very preventable,” Dr. Bravo remarks.

The first Regional Collaboration for the Prevention of Acute Otitis Media, held recently at the New World Hotel in Makati, tackled not only the medical but also the socio-economic burden and implications of AOM. For the first time, a regional conference gathered not only doctors but also representatives from other sectors such as media, parenting groups, and NGOs.

Dr. Eng Soh Ping, a consultant ENT surgeon at Mount Elizabeth Hospital, points out that otitis media is a common cause of children’s physician visits in Singapore, 75 percent of whom are two years of age or below. “When they come to see the doctor, it’s usually already in the late stage,” he observes.

The most frequent AOM complication is auditory deprivation or hearing loss, according to Dr. Kun Kiaang (Henry) Tan, clinical associate professor, senior consultant, and head of the department of otolaryngology at the KK Hospital in Singapore. This is often unrecognized and the child is thought to be simply unattentive, lazy, or even autistic. Deficiency in their verbal ability often results in a delay in the child’s schooling, which in turn could have a life-long effect.

In Malaysia, where the government gives emphasis on primary care, AOM is underdiagnosed, “since it mimics ARI or acute respiratory infection,” says Dr. Saperi Bin Sulong, associate professor in health management and health economics at the Faculty of Medicine, National University of Malaysia.

There is low awareness among parents and it is not often checked by GPs.   

The economic burden includes not only the direct cost to the patient in terms of the cost of medicines to treat the disease and even cost of transportation to go to the hospital or doctor’s clinic, but also indirect costs in terms of loss of productivity as well as intangible cost in terms of suffering and pain, which is difficult to evaluate, says Dr. Saperi. It is a burden on the family as well as a burden on healthcare resources.

An increase in the episodes of AOM results in the decrease in the quality of life, says Dr. Gretchen Navarro-Locsin, vice chair of the department of ORL-HNS and division chief of the pediatric otorhinolaryngology department at St. Luke’s Medical Center. Looking at its impact in broader terms, poor population health results in the reduction in the country’s economic growth, she observes.

While the incidence of AOM occurs across the board, certain environmental factors may be associated with AOM such as pollution and congestion. In Singapore, for example, day care centers are sometimes called “flu centers,” says Dr. Tan.

Children below three years old are more susceptible.

Anatomy is also a factor. The Eustachian tube in children is more horizontal and shorter than those of adults, creating an ideal condition for bacteria and viruses to reach the middle ear, Dr. Generoso Abes of the Philippine National Ear Institute explains. This is more so among bottle-fed babies, who are often given their milk lying down, as opposed to breastfed babies. What’s more, breastfed babies benefit from the natural antibodies found in breast milk, which is one way to protect against respiratory infections.

Since it is not uncommon, parents of very young children tend to take the symptoms of AOM for granted. Ear wax discharge, locally known as luga, is common among young children so that parents do not think anything is wrong and simply wait for it to go away. But drainage is not enough. “The problem is complacency,” shares Dr. Navarro-Locsin.

Parents need to be more vigilant and better informed. “Even mothers can recognize the symptoms by just asking a few simple questions,” says Dr. Bravo. “If the child has fever, ask if he has ear ache or pain or discharge. Mothers should not miss that out.”

Unfortunately, babies one year old and below are unable to express themselves. “Watch out for non-verbal signs that show the child is not feeling well,” says Dr. Navarro-Locsin. Is the child restless or does not eat well? Is there inconsolable crying or ear tugging?

The WHO Integrated Management of Childhood Illness (IMCI) focuses on ear infection as part of routine inspection of any child who comes to the health clinic, says Dr. Bravo. “For children below five years old, whether they come because of cough, cold, diarrhea or fever, they should be checked for malaria, measles, dengue, and ear infection. The health care workers are taught this, and every pediatrician should know this. It’s very basic.” But it’s not a simple matter of looking into the ear. They should also have the right equipment. They should know what to look for and make the correct diagnosis.

If the incidence of URTI (upper respiratory tract infection) can be cut down, the incidence of otitis media may also be cut down, Dr. Tan points out. But since the child cannot be kept inside the house all the time, prevention is the way to go. Prevention through vaccination is emphasized in Malaysia, where a health center can be found within five kilometers of every population center, says Dr. Saperi.

AOM is a vaccine-preventable disease. The Philippine Foundation for Vaccination, where Dr. Bravo is executive director, aims to protect and advocate for the promotion of vaccination as essential to disease prevention, especially among infants and children. “Prevention is a good strategy and we hope this can become a reality,” says Dr.Tan.

A landmark output of the conference was “The Manila Declaration on the Regional Advocacy for Prevention of AOM 2011.” The call to action is to promote awareness; to influence policy makers; to invest in training, research, and evaluation; to encourage early diagnosis and most importantly, prevention.

To cap the program, a young group of nine to 18-year-olds from the Link Center, all deaf, gave a moving performance, dancing to the music of It’s a Beautiful World. “We would like to create some noise and let them hear,” says Dr. Bravo. “The world is not deaf.”