Epidemiology mar 15 2017

https://emedicine.medscape.com/article/859501-
overview#a7
The larger the tympanic membrane perforation, the more likely the patient
is to develop CSOM. Some studies estimate the yearly incidence of CSOM
to be 39 cases per 100,000 persons in children and adolescents aged 15
years and younger. In Britain, 0.9% of children and 0.5% of adults have
CSOM. In Israel, only 0.039% of children are affected. [14]
Certain population subsets are at increased risk for developing CSOM. The
Native American and Eskimo populations demonstrate an increased risk of
infection. Eight percent of Native Americans and up to 12% of Eskimos are
affected by CSOM. The anatomy and function of the eustachian tube play a
significant role in this increased risk. The eustachian tube is wider and
more open in these populations than in others, thus placing them at
increased risk for nasal reflux of bacteria common to acute otitis media and
recurrent acute otitis media and leading to more frequent development of
CSOM.
Other populations at increased risk include children from Guam, Hong
Kong, South Africa, and the Solomon Islands. The prevalence of CSOM
appears to be distributed equally between males and females. Exact
prevalence in different age groups is unknown; however, some studies
estimate the yearly incidence of CSOM to be 39 cases per 100,000 in
children and adolescents aged 15 years and younger. [13]

Prevalence of Chronic Suppurative Otitis Media

(CSOM) and Associated Hearing Impairment
Among School-aged Children in Yemen
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4576383/

Chronic suppurative otitis media (CSOM) is one of the leading causes of preventable
disabling hearing impairment (DHI) in developing countries. Early detection and
management complements advances made in other survival programs, improves work
capacity, and enhances learning opportunities for school children. We aimed to determine the
prevalence of CSOM and associated DHI among school children aged six to 16 years in
Socotra Island, Yemen.

Methods
We conducted a cross-sectional community-based survey, from 20 April 2011 to 20 June
2011. The study procedures involved completing a questionnaire, an otoscopic ear
examination, an audiometric test of hearing, and tuning fork tests for the type of DHI.
Results
A total of 686 children were interviewed and examined for CSOM and associated DHI of
CSOM cases. The prevalence of CSOM was 7.4%, (95% CI 5.5–9.4). CSOM status was
significantly associated with DHI (p=0.001), but no significant associations were found
between demographic characteristics and CSOM status. Logistic regression identified four
significant independent contributing factors: history of ear discharge in the last 12 months
(odds ratio (OR) 7.8, 95% CI 3.9–15.6); swimming in local pools (OR 6.0, 95% CI 1.4–25.4);
recurrent respiratory tract infection more than three times per year (OR 5.3, 95% CI 2.5–
11.0); and overcrowding with more than three families per house (OR 4.4, 95% CI 1.7–11.5).
.

Conclusion
The burden of CSOM in the children studied indicates a high level of DHI in these
communities within Yemen. A history of ear discharge, swimming in local pools, recurrent
respiratory infections, and overcrowded housing were the strongest predictors for CSOM.
There is a need for better ear care and screening programs for early detection and
management of this disease.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4576383/

Profile of Patients with Complicated Chronic Suppurative Otitis Media in Dr. Hasan Sadikin General
Hospital Bandung, Indonesia January–December 2011

file:///C:/Users/User/Downloads/Documents/443-1871-1-PB.pdf

Background: The prevalence of chronic suppurative otitis media (CSOM) is still high in developing
countries. According to the World Health Organization (WHO), the prevalence of CSOM is 2-4%. In
1994-1996, the prevalence of CSOM in various provinces in Indonesia is diverse, with general
prevalence of 3.9%. Chronic suppurative otitis media can also lead to various complications. The
objective of this study was to determine the profiles of CSOM patients with complications in Dr
Hasan Sadikin General Hospital Bandung. Methods: Secondary data was obtained from 117 medical
records of the period January-December 2011 in Dr Hasan Sadikin General Hospital Bandung. Out of
117 medical records, 43 medical records consisted of CSOM patients who had complications. Data
of patients’demography, risk factor, chief and accompanying complaints, infected ears, pathological
findings, complications, and treatments were collected and were analyzed with frequency
distribution. Results: There was 36.75% CSOM patients with complications, 55.8% are male, 30.3%
were 30-39 years old, 62.8% level of education of patients was primary education. Ear discharge
(otorrhea) was the most common chief complaints (95.3%) and hearing loss was the most
dominated accompanying symptom (53.5%), Upper Respiratory Tract Infection (URTI) was the most
common risk factors. Most of the cases had unilateral complication (93%) and intratemporal (72%).
Both intratemporal and extratemporal was only 26% cases. Granulation tissue was the most
common intratemporal complication (32.5%). The most common procedure given was
Chronic suppurative otitis media Burden of Illness and Management Options

file:///C:/Users/User/Downloads/Documents/Chronicsuppurativeotitis_media.pdf

Definition of CSOM

Chronic suppurative otitis media (CSOM) is,for the purposes of this document,defined as a chronic
inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges or
otorrhoea through a tympanic perforation. The disease usually begins in childhood (85,114) as a
spontaneous tympanic perforation due to an acute infection of the middle ear, known as acute otitis
media (AOM), or as a sequel of less severe forms of otitis media (e.g. secretory OM)
(40,169,170).The infection may occur during the first 6 years of a child’s life,with a peak around 2
years (107). The point in time when AOM becomes CSOM is still controversial.Generally,patients
with tympanic perforations which continue to discharge mucoid material for periods of from 6
weeks (93) to 3 months,despite medical treatment, are recognized as CSOM cases. The WHO
definition requires only 2 weeks of otorrhoea (155),but otolaryngologists tend to adopt a longer
duration,e.g. more than 3 months of active disease (68). The ultimate fate of the tympanic
perforation is still largely undocumented. Thus, both the start and the end of the disease process are
difficult to define. Although healing is often observed over prolonged periods, there are more
patients who develop either recurrent bouts of otorrhoea (active CSOM) or a dry but permanent
tympanic perforation (inactive CSOM).Inactive otitis media refers to a previously discharging ear that
has apparently ceased [discharging] without probability of resumption in the near future (111); the
term is common among Asian colleagues. Often, the perforation heals imperfectly with areas of
retraction and scarring in the eardrum which do not vibrate in response to sound,as well as normal
areas. The episodes of otorrhoea are often provoked by upper respiratory infections. This is
particularly common in children. Soiling of the middle ear from swimming

or bathing also leads to intermittent and unpleasant discharges.A decidedly smaller group of
patients,particularly those who have not been treated,develop life-threatening complications.

Difference between CSOM and other forms of chronic otitis media

Several systems of nomenclature have been developed to distinguish between different types of
otitis media, reflecting the lack of complete understanding of the processes responsible for the
inflammation and healing of the middle ear. For the purpose of this report, the presence of a
persistent tympanic perforation and middle ear discharge differentiates CSOM from other chronic
forms of otitis media. CSOM is also called chronic active mucosal otitis media, chronic oto-
mastoiditis, and chronic tympanomastoiditis. A subset of CSOM may have cholesteatomas or other
suppurative complications.The non-CSOM group includes such entities as chronic non-suppurative
otitis media, chronic otitis media with effusion (COME), chronic secretory otitis media,chronic
seromucous otitis media,chronic middle ear catarrh, chronic serous otitis media, chronic mucoid
otitis media, otitis media with persistent effusions,and glue ear.All these are recurrent or persistent
effusions in the middle ear behind an intact tympanic membrane in which the principal symptom, if
present at all,is deafness and not ear discharge (18,110).
Bacteriology of CSOM

CSOM can also be differentiated from AOM on bacteriological grounds.In AOM the bacteria found in
the middle ear include Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae
and Micrococcus catarrhalis. These are respiratory pathogens that may have been insufflated from
the nasopharynx into the middle ear through the Eustachian tube during bouts of upper respiratory
infections.In CSOM the bacteria may be aerobic (e.g.Pseudomonas aeruginosa,Escherichia
coli,S.aureus, Streptococcus pyogenes, Proteus mirabilis, Klebsiella species) or anaerobic (e.g.
Bacteroides, Peptostreptococcus, Proprionibacterium) (23,25,56). The bacteria are infrequently
found in the skin of the external canal, but may proliferate in the presence of trauma, inflammation,
lacerations or high humidity (111). These bacteria may then gain entry to the middle ear through a
chronic perforation (90).Among these bacteria, P. aeruginosa has been particularly blamed for the
deep-seated and progressive destruction of middle ear and mastoid structures through its toxins and
enzymes.

10

Chronic Suppurative Otitis media: Burden of illness and Management options

Histopathological features of CSOM

Otitis media presents an early acute phase, with essentially reversible mucosal and bony
pathological changes, which continues to a late chronic phase with well established,intractable
mucoperiosteal disease.The recurrent episodes of otorrhoea and mucosal changes are characterized
by osteoneogenesis, bony erosions, and osteitis that include the temporal bone and ossicles
(115).This is followed by ossicular destruction and/or ankylosis which,together with the tympanic
perforation,contribute to the hearing loss (39,135).

Effects of deafness on child development

The hearing impairment produced by otitis media affects intellectual performance, which has been
demonstrated by several studies. Long-term effects on overall intellectual, linguistic and
psychosocial development have not been consistently observed. For instance, the Guidelines Panel
of the Agency for Health Care Policy and Research,which developed clinical practice guidelines for
otitis media with effusion, found inconsistent and often conflicting effects on expressive and
receptive language,behaviour,and intelligence depending on the study design,the tests used,and the
age at which the tests were administered (132). Among infants with cleft palate, those with
unremitting chronic otitis media with effusion had pure tone thresholds 5 dB higher, as well as lower
scores in psychological, emotional and social development test results,compared with those who
underwent drainage of middle ear effusion. No such difference was found between otitis media-
prone and non-otitis media-prone Apache Indian children. CSOM produces mild to moderate
conductive hearing loss in more than 50% of cases.This results from disruption of the eardrum and
ossicles assembly (conductive hearing loss) or from hair cell damage by bacterial infection that has
penetrated the inner ear (sensory hearing loss),or both (mixed hearing loss) (28,33).Because of its
long duration and greater severity compared with acute otitis media,and because most children
need louder auditory stimuli than adults to perform optimally (129), CSOM in children is likely to
inhibit language and cognitive development. Several studies have linked persistent and significant
hearing loss from otitis media (not just CSOM) during the first two years of life with learning
disabilities and poor scholastic performance (161,162). Other studies have shown no effect (57,80).
Differences in design, measurement and testing (e.g. the duration and severity of hearing loss in
detecting otitis media), and in follow-up durations (e.g. in determining intellectual and language
delays) may account for the inconsistency of the association among them (104). Lack of access to
hearing aids aggravates the hearing disabilities. At a recent WHO meeting of experts from 15 African
countries, CSOM was considered

11

Chapter One – Global burden of disease to chronic supparative otitis media

the most common cause of persistent mild to moderate hearing impairment among children and
young people in developing countries. In Nairobi, Kenya, hearing loss was found in 64% of
schoolchildren with CSOM and in only 3.4% of children without CSOM (155).