It is an approach Professor Kelvin Kong would like to see adopted across Australia to better address the devastatingly high rates of chronic otitis media in Aboriginal and Torres Strait Islander children.
Professor Kong, from the University of Newcastle’s School of Medicine and Public Health, says if every health professional inspected these children’s ears with an otoscope at every opportunity, there could be a significant improvement in the detection and management of otitis media.
‘The more [health professionals] look in ears, the more confident they get, and the more confident they get, the more diagnoses they make,’ says Professor Kong, who is also an otolaryngology, head and neck surgeon and hails from the Worimi people of Port Stephens. ‘It also increases community awareness of the importance of treating ear disease.’
Otitis media is the main cause of hearing loss in Aboriginal and Torres Strait Islander children, who are at risk of earlier, more severe ear disease than other children. Recurrent episodes of acute otitis media can lead to chronic suppurative otitis media (CSOM, or ‘runny ear’), which can cause permanent hearing loss.
‘The prevalence of CSOM in Aboriginal and Torres Strait Islander children declined from 24% in 2001 to 14% in 2012.’
‘This is still higher than the World Health Organization’s measure of 4% prevalence that indicates a ‘massive public health problem’.
Otitis media is a group of complex infective and inflammatory conditions affecting the middle ear with a variety of subtypes differing in presentation, associated complications and treatment. It is a preceding condition to CSOM and can be treated with myringotomy, a procedure in which a small incision is made in the child’s eardrum to drain fluid from the middle ear, and grommets (tympanostomy tubes) are usually inserted to keep the incision open.
Professor Kong’s comments come as the Australian Commission on Safety and Quality in Health Care releases its Fourth Australian Atlas of Healthcare Variation.
The Atlas examines the rate of hospitalisations for myringotomy in children aged 17 years and under, and specifically looks at the rate of the procedure among Aboriginal and Torres Strait Islander children.
The Fourth Atlas reports a 30% increase in the national myringotomy rates in Aboriginal and Torres Strait Islander children aged 17 years and younger between 2012–13 and 2017–18.
Among Aboriginal and Torres Strait Islander children aged 17 years and younger, the rate increased from 488 per 100,000 people in 2012–13 to 632 per 100,000 people in 2017–18.
Playing catch-up
While this rate of myringotomy hospitalisations is now 6% higher than the rate for non-Indigenous children, Professor Kong says it still falls far short of the rate required to address the significant burden of disease in Aboriginal and Torres Strait Islander children.
‘It’s wonderful that we are moving in the right direction,’ he says, ‘but we are still lagging behind.’
He also notes that the Atlas data does not report the age at which the children are having myringotomies. And this is crucial, he says.
‘If you address the ear disease before the age of two or three, then they are going to be able to reach the normal milestones in terms of their speech, language and development,’ Professor Kong says.
‘But if we are seeing these kids at an older age, then we are playing catch up in [all of these developmental domains]. It may make us feel good that we are getting more grommets in, but we have probably missed the boat in terms of why we are doing it.’
Significant consequences
When the window of opportunity to intervene is missed, Professor Kong says, the consequences for these children are significant and long-lasting.
‘If a child is not hearing well in their early years, then they’re not engaging as part of the family. So, first, they are missing the songlines and important interactions with grandparents and family,’ he says.
Mispronounced words may be perceived as ‘cute’, he says, rather than a sign of the speech and language development delays caused by this ‘silent disease’.
By the time children reach school age, the hearing impairment can significantly impact upon their development of play and fine motor skills, and their education. Also, Professor Kong notes, having ‘runny, smelly ears’ often affects children socially.
‘They are always playing catch up,’ Professor Kong says. ‘They don’t get the educational opportunities that they deserve, and their employment opportunities are significantly decreased.’
These social consequences come on top of medical complications such as an increased likelihood of infections, cholesteatoma (a growth in the middle ear) and hospitalisations.
Stereotypes amplify impact
Professor Kong says racial stereotyping can also increase the impact of this condition on Aboriginal and Torres Strait Islander children.
‘When they are not paying attention in class, they are often seen as the ‘naughty kids’ and put up the back of the classroom or kicked out,’ he says.
Professor Kong says this ‘blame game’ can also follow these children home, and Aboriginal and Torres Strait Islander parents may be questioned about how they are caring for their children.
‘This further alienates families and perpetuates the impoverished, negative connotation that the Aboriginal people are not looking after their kids. When, in fact, it’s purely about access to health care.’
Professor Kong says it’s important to engage with the education system to better support children with chronic otitis media.
‘Even if you can’t get medical services to these kids, then we should be making sure that there is good amplification in the classrooms so that their education is progressing while they are waiting for intervention.’
Guidelines in your pocket
An important step forward in improving the management of otitis media was the 2020 launch of the Otitis Media Guidelines App.
‘We want these guidelines to be at the fingertips of every health worker, every primary health care physician, every allied health professional who comes into contact with these kids,’ says Professor Kong, who is an author of the guidelines.
‘For far too long, it’s been seen as an issue of ear, nose and throat surgeons, which I completely disagree with. If a child has got to the stage where they have to see me, then we have missed the boat.’