Ear Diseases in Elderly Hospital Patients in Nigeria

Hearing Impairment Overview in Africa: the Case of Cameroon

The incidence of hearing impairment (HI) is higher in low- and middle-income countries when compared to high-income countries. There is therefore a necessity to estimate the burden of this condition in developing world. The aim of our study was to use a systematic approach to provide summarized data on the prevalence, etiologies, clinical patterns and genetics of HI in Cameroon. We searched PubMed, Scopus, African Journals Online, AFROLIB and African Index Medicus to identify relevant studies on HI in Cameroon, published from inception to 31 October, 2019, with no language restrictions. Reference lists of included studies were also scrutinized, and data were summarized narratively. This study is registered with PROSPERO, number CRD42019142788. We screened 333 records, of which 17 studies were finally included in the review. The prevalence of HI in Cameroon ranges from 0.9% to 3.6% in population-based studies and increases with age. Environmental factors contribute to 52.6% to 62.2% of HI cases, with meningitis, impacted wax and age-related disorder being the most common ones. Hereditary HI comprises 0.8% to 14.8% of all cases. In 32.6% to 37% of HI cases, the origin remains unknown. Non-syndromic hearing impairment (NSHI) is the most frequent clinical entity and accounts for 86.1% to 92.5% of cases of HI of genetic origin. Waardenburg and Usher syndromes account for 50% to 57.14% and 8.9% to 42.9% of genetic syndromic cases, respectively. No pathogenic mutation was described in GJB6 gene, and the prevalence of pathogenic mutations in GJB2 gene ranged from 0% to 0.5%. The prevalence of pathogenic mutations in other known NSHI genes was <10% in Cameroonian probands. Environmental factors are the leading etiology of HI in Cameroon, and mutations in most important HI genes are infrequent in Cameroon. Whole genome sequencing therefore appears as the most effective way to identify variants associated with HI in Cameroon and sub-Saharan Africa in general.

Fokouo JV, Oluwole OG, Nguefack S, Chimusa ER, Wonkam A. Hearing Impairment Overview in Africa: the Case of Cameroon

The incidence of hearing impairment (HI) is higher in low- and middle-income countries when compared to high-income countries. There is therefore a necessity to estimate the burden of this condition in developing world. The aim of our study was to use a systematic approach to provide summarized data on the prevalence, etiologies, clinical patterns and genetics of HI in Cameroon. We searched PubMed, Scopus, African Journals Online, AFROLIB and African Index Medicus to identify relevant studies on HI in Cameroon, published from inception to 31 October, 2019, with no language restrictions. Reference lists of included studies were also scrutinized, and data were summarized narratively. This study is registered with PROSPERO, number CRD42019142788. We screened 333 records, of which 17 studies were finally included in the review. The prevalence of HI in Cameroon ranges from 0.9% to 3.6% in population-based studies and increases with age. Environmental factors contribute to 52.6% to 62.2% of HI cases, with meningitis, impacted wax and age-related disorder being the most common ones. Hereditary HI comprises 0.8% to 14.8% of all cases. In 32.6% to 37% of HI cases, the origin remains unknown. Non-syndromic hearing impairment (NSHI) is the most frequent clinical entity and accounts for 86.1% to 92.5% of cases of HI of genetic origin. Waardenburg and Usher syndromes account for 50% to 57.14% and 8.9% to 42.9% of genetic syndromic cases, respectively. No pathogenic mutation was described in GJB6 gene, and the prevalence of pathogenic mutations in GJB2 gene ranged from 0% to 0.5%. The prevalence of pathogenic mutations in other known NSHI genes was <10% in Cameroonian probands. Environmental factors are the leading etiology of HI in Cameroon, and mutations in most important HI genes are infrequent in Cameroon. Whole genome sequencing therefore appears as the most effective way to identify variants associated with HI in Cameroon and sub-Saharan Africa in general.

Diagnosis and Antibiotic Management of Otitis Media and Otitis Externa in United States Veterans

Background

Acute otitis media (AOM) and otitis media with effusion (OME) occur primarily in children, whereas acute otitis externa (AOE) occurs with similar frequency in children and adults. Data on the incidence and management of otitis in adults are limited. This study characterizes the incidence, antibiotic management, and outcomes for adults with otitis diagnoses.

Methods

A retrospective cohort of ambulatory adult veterans who presented with acute respiratory tract infection (ARI) diagnoses at 6 VA Medical Centers during 2014-2018 was created. Then, a subcohort of patients with acute otitis diagnoses was developed. Patient visits were categorized with administrative diagnostic codes for ARI (eg, sinusitis, pharyngitis) and otitis (OME, AOM, and AOE). Incidence rates for each diagnosis were calculated. Proportions of otitis visits with antibiotic prescribing, complications, and specialty referral were summarized.

Results

Of 46 634 ARI visits, 3898 (8%) included an otitis diagnosis: OME (22%), AOM (44%), AOE (31%), and multiple otitis diagnoses (3%). Incidence rates were otitis media 4.0 (95% confidence interval [CI], 3.9-4.2) and AOE 2.0 (95% CI, 1.9-2.1) diagnoses per 1000 patient-years. By comparison, the incidence rates for pharyngitis (8.4; 95% CI, 8.2-8.6) and sinusitis (15.2; 95% CI, 14.9-15.5) were higher. Systemic antibiotics were prescribed in 75%, 63%, and 21% of AOM, OME, and AOE visits, respectively. Complications for otitis visits were low irrespective of antibiotic treatment.

Conclusions

Administrative data indicated that otitis media diagnoses in adults were half as common as acute pharyngitis, and the majority received antibiotic treatment, which may be inappropriate. Prospective studies verifying diagnostic accuracy and antibiotic appropriateness are warranted.

Ear diseases and factors associated with ear infections among the elderly attending hospital in Arar city, Northern Saudi Arabia

Background

Changes in the anatomical structures and function of the ear can result in ear diseases, and may affect all age groups including the elderly as a result of aging

Objective

To identify the frequency and types of ear diseases among the elderly attending Abdullah bin Abdul-Aziz bin Musa’ed Al Saud hospital, Arar city, in the Northern Province of KSA, and factors associated with ear infections among them.

Methods

This cross-sectional hospital based study conducted from December 2016 through May 2017 included 138 elderly participants. A questionnaire was designed for collecting data about socio-demographic variables, the frequency and types of ear diseases among participants, and factors associated with ear infections among them. Data were analyzed by SPSS version 15, using descriptive statistics and Chi-Square test.

Results

Findings showed that 49.3% of the participants were suffering from ear disease. Hearing impairment was detected in 37% of the elderly people studied. In addition, 9.4% and 2.9 % of the participants suffered from otitis media and otitis interna, respectively. None of the studied factors had a significant effect on the development and pattern of ear infection among the studied population.

Conclusion

Ear diseases were found among the participants with variable rates. More than one third of respondents suffered from hearing impairment. Ear infections were detected in lower rates. Although these problems are not life threating, they negatively impact the quality of life, and measures are needed for prevention and control.

Clinical Practice Guideline (Update): Earwax (Cerumen Impaction)

Objective

This update of the 2008 American Academy of Otolaryngology—Head and Neck Surgery Foundation cerumen impaction clinical practice guideline provides evidence-based recommendations on managing cerumen impaction. Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. Changes from the prior guideline include a consumer added to the development group; new evidence (3 guidelines, 5 systematic reviews, and 6 randomized controlled trials); enhanced information on patient education and counseling; a new algorithm to clarify action statement relationships; expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion; an enhanced external review process to include public comment and journal peer review; and 3 new key action statements on managing cerumen impaction that focus on primary prevention, contraindicated intervention, and referral and coordination of care.

Purpose

The primary purpose of this guideline is to help clinicians identify patients with cerumen impaction who may benefit from intervention and to promote evidence-based management. Another purpose of the guideline is to highlight needs and management options in special populations or in patients who have modifying factors. The guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction, and it applies to any setting in which cerumen impaction would be identified, monitored, or managed. The guideline does not apply to patients with cerumen impaction associated with the following conditions: dermatologic diseases of the ear canal; recurrent otitis externa; keratosis obturans; prior radiation therapy affecting the ear; previous tympanoplasty/myringoplasty, canal wall down mastoidectomy, or other surgery affecting the ear canal.

Key Action Statements

The panel made a strong recommendation that clinicians should treat, or refer to a clinician who can treat, cerumen impaction, defined as an accumulation of cerumen that is associated with symptoms, prevents needed assessment of the ear, or both. The panel made the following recommendations: (1) Clinicians should explain proper ear hygiene to prevent cerumen impaction when patients have an accumulation of cerumen. (2) Clinicians should diagnose cerumen impaction when an accumulation of cerumen, as seen on otoscopy, is associated with symptoms, prevents needed assessment of the ear, or both. (3) Clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as ≥1 of the following: anticoagulant therapy, immunocompromised state, diabetes mellitus, prior radiation therapy to the head and neck, ear canal stenosis, exostoses, and nonintact tympanic membrane. (4) Clinicians should not routinely treat cerumen in patients who are asymptomatic and whose ears can be adequately examined. (5) Clinicians should identify patients with obstructing cerumen in the ear canal who may not be able to express symptoms (young children and cognitively impaired children and adults), and they should promptly evaluate the need for intervention. (6) Clinicians should perform otoscopy to detect the presence of cerumen in patients with hearing aids during a health care encounter. (7) Clinicians should treat, or refer to a clinician who can treat, the patient with cerumen impaction with an appropriate intervention, which may include ≥1 of the following: cerumenolytic agents, irrigation, or manual removal requiring instrumentation. (8) Clinicians should recommend against ear candling for treating or preventing cerumen impaction. (9) Clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should use additional treatment. If full or partial symptoms persist despite resolution of impaction, the clinician should evaluate the patient for alternative diagnoses. (10) Finally, if initial management is unsuccessful, clinicians should refer patients with persistent cerumen impaction to clinicians who have specialized equipment and training to clean and evaluate ear canals and tympanic membranes. The panel offered the following as options: (1) Clinicians may use cerumenolytic agents (including water or saline solution) in the management of cerumen impaction. (2) Clinicians may use irrigation in the management of cerumen impaction. (3) Clinicians may use manual removal requiring instrumentation in the management of cerumen impaction. (4) Last, clinicians may educate/counsel patients with cerumen impaction or excessive cerumen regarding control measures.

Cerumen impaction: Challenges and management profile in a rural health facility

BACKGROUND

Cerumen impaction is a worldwide problem. It constitutes a significant proportion of health problems in many settings and its prevalence varies. Very few studies were done in this region with none from our center. The aim of this study is to review the challenges and management profile of cerumen impaction in a rural health facility in Nigeria.

MATERIALS AND METHODS

This was a 3-year retrospective study of all patients that were managed for cerumen impaction from June 2008 to May 2011, in the Department of Otorhinolaryngology, Federal Medical Centre, Ido-Ekiti, Nigeria.

RESULTS

A total of 239 patients, aged 3-98 years were managed for cerumen impaction. The male: female ratio was 1.6:1. The age group 1-20 years was mostly affected in 29.3%. Major complaints were hearing impairment in 120 cases. Both ears were mostly affected in 48.5% of the patients. Olive oil was a major ceruminolytic agent used in 95.4%. Ear syringing was carried out in 91.2% of cases. Major complications were bruises of external auditory canal and otalgia in 7.3% of cases each. Forty-two (17.8%) of our patients were asymptomatic, and they did not complained of ear problem. Out of those patients that were symptomatic, 44.3% had visited general medical practitioners and non-otolaryngologist, while 27.6% had self-medication or visited chemist for their ear complaints. Only 3.7% of them had been seen by ear, nose, and throat (ENT) specialist in the past.

CONCLUSION

Cerumen impaction is a common otolaryngological problem that presents to ENT surgeon, children, and elderly are more affected. Hearing impairment is the major complaint which may increase the burden of disability on society. Syringing is the most common mode of treatment of our patients. Continuing medical education, proper otological examination by the non-otolaryngologist and public health education to improve the low level of awareness on danger of self-medication is essential.

The burden of hearing loss in Kaduna, Nigeria: a 4-year study at the National Ear Care Centre

Hearing loss among people in developing countries has been recognized as a major source of disability. Many of its causes are preventable, and others are curable. We reviewed the records of 5,485 patients who had presented during a 4-year period to the National Ear Care Centre in Kaduna, Nigeria. Of these, we identified 1,435 patients-812 males and 623 females, aged 9 months to 90 years (mean: 29.2 yr)-who had been diagnosed with hearing loss (26.2%). In addition to demographic data, we compiled information on each patient's type and degree of hearing loss, the affected side, and the predisposing factors. Sex and age cross-tabulations revealed that the greatest proportion of hearing loss according to sex occurred between the ages of 11 and 20 years for males and 21 and 30 years for females. The most common type of hearing loss was sensorineural, which was seen in 78.9% of patients; conductive hearing loss was seen in 17.7% and mixed in 3.4%. More than three-quarters of hearing losses were either moderate, moderately severe, or severe. Bilateral losses were far more common than unilateral losses; among the latter, the left side was affected slightly more often than the right. Predisposing factors were not documented in the vast majority of cases (87.6%), but when they were, the most common were chronic suppurative otitis media, meningitis, febrile convulsion, measles, and trauma. We present these findings to highlight the burden of hearing loss in our part of the world.

Vestibular disorders among adults in a tertiary hospital in Lagos, Nigeria

Dizziness is not an uncommon complaint in the Otolaryngological clinics among other symptoms. To a large number of practitioners, the treatment of dizziness remains the same irrespective of the etiology, i.e., anti-vertiginous drugs. The objective of this study was to document the evaluation, causes and treatment of vestibular disorders among our patients. The design includes descriptive prospective study conducted in the Oto-rhino-laryngology and Orthopedic Clinics of Lagos University Teaching Hospital, Lagos and Nigerian Army Audiological Centre, 68 Nigerian Army Reference Hospital, Yaba, Lagos, Nigeria. Adult patients referred to the audiology clinic for dizziness had detailed history obtained by using structured questionnaire. General physical and neuro-otological examinations were done. Clinical diagnoses were made on standardized criteria. The patients had hearing evaluation, videonystagmography (VNG) evaluation using infrared videonystagmography system. X-ray of the cervical spine and computerized tomogram scan of internal auditory meatus and brain when indicated were done. A total of 102 patients were seen with age range between 21 and 90 years. Thirty patients (29.4%) recorded average duration of episode of vertiginous attacks in seconds, 69 (67.6%) recorded within minutes to hours and 3 (2.9%) with no definite pattern. Clinical signs on neuro-otological examination were elicited on 39 (38.2%) of the patients while on VNG the vestibular subtest mainly caloric test was abnormal unilaterally and bilaterally in 47 (46.1%) while with the oculomotor subtests, smooth pursuit tests were abnormal in 5 (6.9%), saccade tests were abnormal in 8 (7.8%) and OPK were abnormal in 9 (8.8%). Peripheral vestibular disorders are common of which benign paroxysmal positional vertigo (BPPV) was seen in 29 (28.4%), Meniere's disease in 22 (21.6%), recurrent vestibulopathy in 20 (19.6%), cervical vertigo in 18 (17.6%), psychogenic vertigo in 2 (2%), vestibular schwannoma, barotraumas and drug-induced vertigo in 1 (1%), respectively, central vestibular disorders of vascular origin 2 (2%), vertebrobasilar insufficiency in 1 (1%), post-traumatic vertigo in 3 (3%) and unknown in 2 (2%). In conclusion, peripheral vestibular disorders are common of which BPPV is the most prevalent. Pre-referral anti-vertiginous medication is common among general practitioners. The practising ORL/Head neck surgeon and orthopedic surgeons must be conversant with the tools of diagnosis, differential diagnosis and treatment.

Pattern of tympanic membrane perforation in ibadan: a retrospective study

BACKGROUND

Tympanic membrane perforations vary in size, shape and position. The degree of conductive deafness varies with the size and position of the tympanic membrane perforation.

OBJECTIVE

This study is to determine the pattern and causes of tympanic membrane perforation.

METHOD

Hospital based study at the ENT Clinic, UCH, Ibadan. Consecutive patients seen during the period of study with ear symptoms were interviewed and examined by ENT surgeons. This information was entered into computer and analyzed using SPSS v 11.

RESULT

Thirty-three (13.5%) of the 244 patients were found to have tympanic membrane perforation. Fifteen (45.5%) patients were new while 18 (54.5%) were follow up patients. There were 13 (39.4%) males and 20 (60.6%) females. The type of perforation seen were central 57.6%, subtotal 33.3%, total 6.1%, marginal 3.0%. The sides affected were left ear 45.5%, right ear 15.2%, and both ears 39.4%. The causes found were chronic suppurative otitis media (CSOM) 90.9%, acute suppurative otitis media (ASOM) 6.1%, and trauma to the affected ear 3.0%. CSOM was the cause of tympanic membrane perforation seen in children.

CONCLUSION

There is need for early diagnosis and treatment of all cases of tympanic membrane perforation and proper education of parents and guardians on proper method of ear care and early referral. There is also need to train all healthcare workers especially primary health care providers on how to manage these cases.

Clinical practice guideline: cerumen impaction

OBJECTIVE

This guideline provides evidence-based recommendations on managing cerumen impaction, defined as an accumulation of cerumen that causes symptoms, prevents assessment of the ear, or both. We recognize that the term "impaction" suggests that the ear canal is completely obstructed with cerumen and that our definition of cerumen impaction does not require a complete obstruction. However, cerumen impaction is the preferred term since it is consistently used in clinical practice and in the published literature to describe symptomatic cerumen or cerumen that prevents assessment of the ear. This guideline is intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction.

PURPOSE

The primary purpose of this guideline is to improve diagnostic accuracy for cerumen impaction, promote appropriate intervention in patients with cerumen impaction, highlight the need for evaluation and intervention in special populations, promote appropriate therapeutic options with outcomes assessment, and improve counseling and education for prevention of cerumen impaction. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of audiology, family medicine, geriatrics, internal medicine, nursing, otolaryngology-head and neck surgery, and pediatrics.

RESULTS

The panel made a strong recommendation that 1) clinicians should treat cerumen impaction that causes symptoms expressed by the patient or prevents clinical examination when warranted. The panel made recommendations that 1) clinicians should diagnose cerumen impaction when an accumulation of cerumen is associated with symptoms, or prevents needed assessment of the ear (the external auditory canal or tympanic membrane), or both; 2) clinicians should assess the patient with cerumen impaction by history and/or physical examination for factors that modify management, such as one or more of the following: nonintact tympanic membrane, ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state, or anticoagulant therapy; 3) the clinician should examine patients with hearing aids for the presence of cerumen impaction during a healthcare encounter (examination more frequently than every three months, however, is not deemed necessary); 4) clinicians should treat the patient with cerumen impaction with an appropriate intervention, which may include one or more of the following: cerumenolytic agents, irrigation, or manual removal other than irrigation; and 5) clinicians should assess patients at the conclusion of in-office treatment of cerumen impaction and document the resolution of impaction. If the impaction is not resolved, the clinician should prescribe additional treatment. If full or partial symptoms persist despite resolution of impaction, alternative diagnoses should be considered. The panel offered as an option that 1) clinicians may observe patients with nonimpacted cerumen that is asymptomatic and does not prevent the clinician from adequately assessing the patient when an evaluation is needed; 2) clinicians may distinguish and promptly evaluate the need for intervention in the patient who may not be able to express symptoms but presents with cerumen obstructing the ear canal; 3) the clinician may treat the patient with cerumen impaction with cerumenolytic agents, irrigation, or manual removal other than irrigation; and 4) clinicians may educate/counsel patients with cerumen impaction/excessive cerumen regarding control measures.

DISCLAIMER

This clinical practice guideline is not intended as a sole source of guidance in managing cerumen impaction. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Otitis media as a cause of significant hearing loss among Nigerians

Mild or worse hearing loss, defined as pure tone average >25 decibel, is seen commonly with preventable etiologies.

SETTINGS

A tertiary care, urban referral hospital.

METHODS

Retrospective analysis of prospectively collected data of individuals attending the hearing loss clinic of National Hospital, Abuja, between May 2005 and April 2007. Data matching the diagnosis of acute otitis media (AOM), otitis media with effusion (OME) and chronic suppurative otitis media (CSOM) were extracted from the database and analyzed.

RESULT

A total of 298 cases with primary presenting complaints of hard of hearing were seen. A total of 77 cases had hearing loss due to otitis media. 44 (57.1%) had OME, 26 (33.8%) had CSOM, while 7 (9.1%) had AOM. The observed distribution of the OME was left OME (18.1%, n=14), right OME (9.1%, n=7) and bilateral OME (29.9%, n=23), while the CSOM is distributed into left CSOM (15.5%, n=12), bilateral CSOM (11.7%, n=9) and right CSOM (6.4%, n=5), and AOM is distributed into right AOM (2.6%, n=2), left AOM (3.9%, n=3), and bilateral AOM (2.6%, n=2). The mean pure tone averages for the three groups are AOM (30.5dB), OME (41.5dB) and CSOM (56.9dB).

CONCLUSION

Otitis media is an important cause of preventable hearing loss in developing countries, and the predominance of unilateral otitis media in the left ear observed in this study deserves further studies.