Prevalence of Ear Disease and Associated Hearing Loss Among Government Rural Primary School Students in Patiala, Punjab: A Cross Sectional Survey

Abstract

Ear disease in children are a major public health problem in developing countries and if left untreated, it may result in various social and psychological problems for affected children. Among all ear diseases, ear infections are a common but treatable cause of morbidity in children. Long term consequences of persistent severe ear infection can result in speech development disorders, poor academic and educational development and overall lower quality of life. Most of ear diseases leading to hearing loss are preventable if diagnosed and treated early. A cross sectional study was conducted in Government Rural Primary School students, 2160 students in Patiala district of Punjab state in India with aim to study the prevalence of ear disease and associated hearing loss in students and their relationship with socioeconomic status. The data was collected, compiled and analysed statistically.

Introduction

It is well accepted that children are the backbone of our society and they represent future generations. 25% of the current Indian population constitutes of children aged between 6 and 14 years. Ear disease and hearing impairment are a neglected public health problem in developing countries in the infant and adult populations. [1] Hearing loss is the most common congenital sensory birth defect, accounting for 4–6 per 1000 live births in the developing world. [2] Disabling hearing loss in children refers to hearing loss greater than 30dB in the better hearing ear. [1].

The major cause for hearing impairment is otitis media,which is second only to common cold as a cause of infection in childhood. [3].

The etiopathogenesis of otitis media are multifactorial and includes genetic, infections, allergy,environmental,social and racial factors and eustachian tube dysfunction [4].Majority of the patients with chronic ear disease came from poor communities living in subsistence agricultural or slum areas of the cities and CSOM is the commonest cause of persistent mild to moderate hearing impairment in children and young adults. [5].

According to the World Health Organization (WHO),more than two thirds of the global burden of hearing loss is found in Low and Middle Income Countries(LMICs).There are 34 million children worldwide living with hearing loss,and 60% of childhood hearing loss is known to be preventable [6].

Hearing impairment if left undiagnosed can have devastating developmental results in children. The retention rate(repeating a grade in school) among students with minimal unilateral sensorineural hearing loss(SNHL) has been estimated at 30% and 37%.

To improve this situation the Ministry of Health and Family Welfare, Government of India launched the National programme for Prevention and Control of Deafness (NPPCD) in 2008. An integral component of the NPPCD is awareness through IEC (Information,Education and Communication)activities- for early identification of hearing impaired,especially children so that timely management of such cases is possible and to remove the stigma attached to deafness [7] The recent WHO World Hearing Day campaigns promoted school based hearing screening programmes as a major public health initiative to achieve these aims [8, 9]

In view of the current status of childhood hearing loss and hearing healthcare ,school based ear examinations have been recommended as a public health measure to reduce the prevalence of ear disease and associated hearing disorders [10] The WHO Global School Health Initiative offers an attractive public health platform for routine ear health assessments. The key aim of such assessments is to facilitate medical, surgical and educational interventions for children identified with ear disease and hearing loss.

A cross sectional school based study aimed to analyse the results of prevalence of ear disease and associated hearing loss in government rural primary school students both male and female in Patiala district of state Punjab in India was conducted by Department of ENT, Government medical college and Rajindra Hospital Patiala.Data regarding the prevalence and nature of ear diseases and associated hearing loss was collected, compiled and analysed statistically using appropriate statistical tests.

Materials and Methods

The study was conducted by Department of ENT,Government Medical College and Rajindra Hospital, Patiala from April 2019 to February 2020.

Total 2160 students were examined. All the 6 blocks of district Patiala were selected for present study and and in each block 360 students from 4 schools with strength of students more than 90 were randomly selected .In each primary school 18 students from each class and total of 90 students were examined and their socioeconomic status was calculated using modified B G Prasad scale 2018.

Study Design

Cross Sectional School Based Study

Inclusion Criteria

Students whose parents/guardians gave consent to the study and previously diagnosed and/or operated cases of ear diseases and children with congenital malformations of pinna and external auditory meatus were included in the study.

Students absent on the day of examination and who did not cooperate throughout the evaluating process were excluded.

Results

In this cross-sectional study, Total 2160 students were examined .The mean age of the children was 8.01 years (SD ± 1.60) and ranged from 5 to 13 years. The most frequent group was age 7–8 years 831 (38.47%) students, whilst the least frequent group was ages 13–15 years with 96 (4.44%) students.

There were 1086 (50.28%) female students and 1074 (49.72%) male students screened during the study corresponding to a male to female ratio of approximately 1: 1.

The socioeconomic status was calculated according to modified BG Prasad scale. Majority of the cases belonged to lower class (84.95%) and lower middle class families (10.05%).

Out of total 2160 students,124 (5.74%) students complained of ear pain during history taking. Ear discharge was complained by 98(4.53%) and 94(4.35%) students complained of decreased hearing (Figs. 1 and 2).

Figure 1.

Malformation of Pinna

Figure 2.

Abnormalities of Eardrum

Findings of ear drum abnormalities (N = 287 = 13.28%) (Fig. 3).

Figure 3.

Association of hearing impairment and socioeconomic status

Discussion

Hearing in children is critical to speech development, communication and learning as it can have devastating developmental results in children. Screening of school children is a practical way of ensuring that children are evaluated for hearing capabilities. The results obtained from this study provided an estimate of hearing impairment and ear disease prevalence for rural primary school children of district Patiala.

External and middle ear disease were assessed among 2160 school going children aged 5–15 years, among rural primary school children of district Patiala.

In our study diseases of the external auditory canal (EAC) were the most commonly diagnosed ear diseases in 39.44%(852/2160) students. Among the EAC diseases, Wax impaction was the most common disease, our study included all cases of wax in EAC whether wax partially or completely obstructing EAC. Wax was present in 723(33.47%) students, which was unilateral in 352 and bilateral ears in 371 students.

Findings of our study were in accordance with the study conducted by Racheal Kasamba et al. [11] in 2016 which observed that in primary school children 36.8% children were diagnosed with ear diseases related to EAC and wax impaction was most common finding.

Second most common pathology of EAC was otorrhoea found in 98(4.53%) which included active (wet) CSOM 66(3.05%) and Otomycosis in 32 students. 0torrhoea prevalence in our study is lower than the study done by Biswas et al. (12.4%)⁽¹²⁾ and Morris et al. (15.0%)⁽¹³⁾ because of better healthcare facilities in rural area of Punjab.

Third most common pathology of EAC were undiagnosed foreign bodies in EAC in 27 students, all foreign bodies were found unilaterally which included wheat grains 8,plastic beads 4,dead insects 3,pencil leads 5 and paper piece in 7 students because children in rural area very often play in crop fields and food grains may get inserted in ear accidently.This finding was in accordance with S K Chadha et al. they observed that 21 children had undiagnosed foreign bodies in the ear canal,including food grains ,dead insects,stones and cotton wool balls.

In the present study during ear drum examination of 2160 students,1873(86.71%) students had normal ear drums.

Most common pathology of ear drums was Retraction in 4.07%(88/2160) students which included right eardrum retractions in 29, left ear drum retractions in 34 and both eardrum retractions in 25. The present study observed prevalence rate of retracted tympanic membranes in accordance( 4.07%) with other studies which observed prevalence of retracted TMs among children varies from 2.4 to 9.2% of ears examined by Axelsson A et al., [12] Tos M et al.[13], Eagles EL et al. [14] and Roberts J et al. [15], being more frequent in studies where otomicroscopy has been used in the examination instead of otoscope.

Second most common pathology of ear drums was Perforation found in 3.52%(76/2160).Perforations constituted 26.48% of total ear drum abnormalities, which included unilateral ear drum 60 and bilateral ear drums in 16 students. Medium sized perforations 45 involving AI + PI quadrant were more common than small sized 27 involving AI quadrant and large sized 4 perforations. No subtotal or total perforations were found. Out of 76 perforations,73 were diagnosed tubotympanic type(safe) CSOM and 3 were diagnosed atticoantral type(unsafe) CSOM. No other study has considered site and size of TM perforations in primary school going children.

Dullness of ear drum was the third most common pathology in total 63(2.92%)in which unilateral ear drum was dull in 22 students and bilateral in 40 students.Dullness was seen in cases of ETD,OME,post wax and foreign body removal.Dullness of ear drum was in accordance to the prevalence in school going children found by otoscopy has ranged from 2 to 4.7% by Eagles EL et al. [14] and Roberts J et al. [15].

Middle Ear Diseases

In our study, Rinne’s tuning fork tests were performed on all 2160 students with 256,512 and 1024 frequencies. In total 211 (9.77%) students failed Rinne’s test which included both ear failed 105(4.86%) right ear 75(3.47%) and left ear Rinne’s failed were 31(1.43%)students.

Tympanometry was done on 253 students out of which 166(65.61%) students showed type A tympanogram,27(10.67%) showed type B (suggestive of OME) and 60(23.71%) students showed type C tympanogram (suggestive of ETD). The overall prevalence of abnormal middle ear findings on examination was 8.19%(177/2160).Out of 177,most common middle ear disease was chronic suppurative otitis media(CSOM) in 76 because of better healthcare facilities in rural area of Punjab.

The prevalence of CSOM in present study was found to be 3.52%(76/2160).Out of 76, 16 students had bilateral CSOM, 50 had unilateral CSOM. Out of 76 perforations 86.84% were found actively discharging and 13.16% were found dry and this was in accordance with study by Dr.Prakash Adhikari et al. [16]that found prevalence of CSOM 5.0%.But current study observed more active CSOM 86.84% than inactive CSOM in 13.16% students. CSOM prevalence of present study is lower than the study done by Rupa et al. (6%)⁽¹⁹⁾ and Ologe et al. [17] (6%) in rural communities of south India and Nigeria respectively.

Second most common middle ear pathology was Eustachian tube disorder(ETD) in 60(33.9%)students out of 177 students who had middle ear disease and prevalence of 2.78%(60/2160).The association between ETD, abnormal middle ear pressure and chronic otitis media is well described by Yuceturk AV et al. [20].The prevalence is lower than study of Josephine Ann Czechowicz et al. [21].where ETD was detected in 8.1%of children and was also associated with HI.

Third most common middle ear pathology was Otitis Media with Effusion (OME). It was observed in total 27 students with prevalence of 1.25% (27/2160) in which 17 students had bilateral and rest 10 had unilateral OME. The literature from other community based studies of school age children in LMICs(low middle income countries) reported OME prevalence varying between 0.5% and 19.4% as reported by Bastos et al. [22],C Lyn et al. [23] and H S Dang et al. . [24].

Hearing Impairment Prevalence

In our study PTA was done on 343 students and 142 students had some degree of hearing impairment and 201 students had normal hearing upto 25 dB. Hearing loss prevalence according to present study stands out to be 6.57%(142/2160).Out of 142 students, CHL was observed in 111(78.17%)students, mixed hearing loss in 29(20.42%) and SNHL in 2 (1.41%)students. Out of 142 total hearing impaired students,77(54.23%) had slight impairment and 65(45.77%) had moderate impairment according to WHO classification for grades of hearing impairment.

Similarly, Stevens et al. [25] observed HL prevalence in children between ages 4 and 15 years in sub sahara African region and was found to be 70.9%0.12.2%,2.4% and 0.6% for mild,moderate,moderate-severe,and severe hearing loss respectively.Our study was not in accordance with study by Racheal Kasamba et al. [11] in 2016 observed the hearing impairment prevalence of 11.5%.The proportion of children with unilateral HI was 22.4% and bilateral was present in 77.6%of children.

According to disease wise causes of hearing impairment ,CSOM was most common disease causing hearing loss in rural government primary school students. Hearing impairment was most prevalent in the age group of 7–8 years followed by age group of 9–10 years (Tables 1 and 2).

Table 1.

Prevalence of CSOM in various studies

Study	CSOM prevalence (%)
Dr Prakash Adhikari et al. in 2007 [16]	5.0
Rupa et al. in 1999 [18]	6.0
Ologe et al. in 2002 [17]	6.0
Biswas et al. in 2005 [5]	12.4
Morris et al. in 2005 [19]	15.0
Our study	3.52

Table 2.

Prevalence of Hearing Impairment in various studies

Study	HI prevalence (%)
Racheal Kasamba et al. [11] in 2020	11.5
Prasan Norman et al. [26] 2016	30.9
Mehra et al. [27] in 2009	3.1
Takuji et al. [28] in 2000	1.2
Our study	6.57

Association of CSOM and Hearing Impairment with Socioeconomic Status(SES)

Current study observed that CSOM was most prevalent in lower class and hearing impairment was also most commonly seen in lower class and p value was significant.

Our study was in accordance with study by S K Chadha et al. [29].He conducted a study in delhi in 2006 where two groups of schools within delhi were taken, Group A comprised of government schools located in slum areas with an average parental income of INR 1050 per month and group B of elite private schools with an average family income of INR 35,000 per month. Three thousand children between the ages of 5–12 years were screened.19.6% of children of group A were found to be suffering from ear diseases compared to 2.13% of group B children. Similar findings were observed in Chishimba PN that demonstrated that children residing in crowded and densly populated areas with lower socioeconomic status were more likely to have hearing impairment.

Conclusion

Our study showed that ear diseases and associated hearing loss are a major health problem among rural primary school students. Therefore, regular ENT screening of children at school level has been recommended based on this survey to ensure that children have a school life without hearing disability and preventable ear diseases.

Declarations

Conflict of interest

The authors have no conflicts of interest

Ethical Approval

Ethics Approval has been obtained from the ethics committee of Government Medical College, Patiala

Informed Consent

Informed consent has been taken from the patient for publication