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Hello, I'm Norman Swan.
Welcome to this program on otitis media in Indigenous children.
Middle ear infections and the hearing problems
which result in Indigenous children
are a huge issue for these kids' development and education.
In some remote communities, the rate of chronic perforation of a drum
can be over 60% with a significant unmet need for hearing aids.
Overcrowding, passive smoking, poor hygiene, poor nutrition
and limited access to evidence-based care perpetuate the problem.
Today's program is about how we can all do better
at preventing and caring for this condition and the children who have it.
You'll find a number of useful resources available
on the Rural Health Education Foundation's website, rhef.com.au.
Let me introduce our panel to you.
Andrew White is a paediatrician based at Townsville Hospital
and a senior lecturer at James Cook University's
School of Medicine. Welcome. - Hi, Norman.
David McIntosh is an ear, nose and throat surgeon
in Maroochydore in Queensland.
- Welcome, David. - Evening.
Ray Jones is a GP at Bulgarr Ngaru Aboriginal Medical Service
in Grafton, New South Wales. Welcome, Ray.
And Joe Daby is an Aboriginal health worker,
specialising in ear and eye health in the Northern Territory in Darwin.
- Welcome, Joe. And welcome to you all. - Norman.
Joe, what do you see when you get out there?
Um... A lot of *** ears.
Now I see a lot of...
Mainly with young kids, as well, and babies,
a lot of *** ears, and it's depressing
when I see kids with *** ears all the time,
and nothing getting done about it.
Yeah, we've been talking about this for years.
Is it just the same as always? What's the trend?
Yeah, it is always the same. We've just gotta keep getting to the parents
and... educating them.
What do you see when they're older, when the children are older?
Well... language and learning difficulty.
So, um... after years of *** ears, it's um... language is really down,
so they don't learn a lot.
And presumably the volume is high?
Yeah. A lot of people talk loud in communities because they can't hear.
So, you got children with language deficits,
and when they get to adulthood, that still exists, they never catch up?
Yeah. And their ears are still ***,
in the teenagers, as well. They don't seem to...
As an Aboriginal health worker, what sort of work are you doing with them?
Well, um... apart from doing school screening,
we're looking at the kids at the creches, and, um...
..trying to teach their mothers how to clean their ears with tissue spears,
and clean their ears and trying to make 'em a lot drier and heal 'em up.
Yeah. And, um... when you say screening, are you screening for otitis media?
At the school-age kids, we are, yeah.
NORMAN: Andrew, is there evidence for screening?
That's one of our questions.
We had a question from, um... Sam, an audiologist in Sydney,
asking if there was a role for screening programs.
Look, it's debatable, Norman.
I think, um... you know, it sounds good that we should screen for something
that's common, and if we can pick it up, we could do something about it.
The problem that we see sometimes in practice,
and you probably would agree, Joe, is that
there's endless screening but nothing done about it,
so, I guess, it's getting the...
And what I'd say is probably what we need for ear health
is ongoing programs rather than screening.
So, continuous surveillance and ongoing treatment programs.
NORMAN: Ray, your experience has been similar to Joe's?
Um, yes, the *** ears and poor hearing as a result,
was my experience in the early part of 2000 and 2003
till we started, um... attacking otitis media in our community
by improving the nutrition of the people
who were suffering from otitis media,
and we had dramatic improvements in those communities as a result.
So, you...? You felt that your medical treatment wasn't working?
The medical treatment had been...
We just did traditional medical treatment
which at the time, was oral antibiotics, um...
..ear toilet and maybe we... and we used drops as well,
but they were potentially odour-toxic drops -
Sofradex, I think we used.
This was before we had access to ciproxin ear drops.
And... basically... the traditional treatments, we had the same results.
We had the same audiometry...
The Royal Deaf and Blind Society
had been doing audiometry on the community at Baryulgil for many years,
and the results were the same each year - they were atrocious.
Only 40% of the kids had normal hearing at the school.
And it wasn't until we looked at what was happening
and what was causing the problem...
And we attacked it from a nutritional basis,
and we improved the nutrition of the kids in that small community...
NORMAN: By doing what?
By adding fruit and vegies to their diet on a daily basis.
And within six months, we detected a remarkable improvement
in hearing tests - audiometry - on the children.
And rates of skin infections had dropped as well,
with boils and impetigo becoming less common.
And obviously that wasn't a randomised trial?
RAY: No.
But, David, you've seen similar benefits from nutrition?
Yeah. What Ray's referring to is documented in other communities. Um...
As far back as I can recall, looking even to the 1970s
when people documented the rate of chronic disease
from an ear point of view, the rates of incidence of this
were much higher in those children with poor nutritional status.
Now, would any of our children have ears like this
if they lived in similar circumstances?
- Or is there something...? - The reality is that they would,
but we're talking about the magnitude and the numbers.
- We're talking about communities... - Nothing about Aboriginality?
It's the social circumstances in which a child is growing up that's causing it?
Well, I think the disease that we're talking about,
we notionally describe it as being at proportions of third-world status,
and that's consistent with a lot of the other social and...
So, what are the risk factors for chronic oti...?
What is...? Let's just get down to it.
What is the pathology we're talking about here?
So, we're talking about an infectious process.
We're talking about an infectious process
where there may be acute exacerbations that come and go,
but we're really talking about a community or situation where it comes
and it doesn't go,
and it may manifest itself as recurrent infections
where they improve to some degree,
but never quite get better - fluid remains
or they perforate and discharge, and they continue to discharge.
- In terms of what perpetuates... - Is that discharge...
..if you culture it, there's an organism in it?
It's a little bit complicated when you start looking into the science,
but as a general comment to keep things simple, the answer's usually 'Yes'.
We're dealing with a type of pathophysiology
which is referred to as biofilms, which is a conference in itself.
But it explains why a lot of traditional treatments don't work.
Because essentially, the surface lining of the Audicles or what have you
are lined by a biofilm of organisms...?
The biofilm is relatively resistant
to standard antibiotics for various reasons.
NORMAN: Almost like the ear becomes a foreign object to the body?
Um... Well, it just becomes a breeding ground essentially.
And the risk factors, Andrew?
Um... Risk factors are... Aboriginality, but not genetics as far as we know.
It's social conditions, so it's overcrowding,
it's contact with lots of other children.
Lots of other children who've got... If you swab their fingers,
they've got the organisms that cause otitis media.
Um... breastfeeding's protective, so bottle-feeding is a risk factor.
Um... exposure to cigarette smoke or to any smoke is a risk factor.
Undernutrition, I'm sure is a risk factor.
Um... And recurrent...
You know, what tends to happen is -
and the studies in the Northern Territory show that...
..that all kids get ear infections,
but the Indigenous kids from the remote communities
were colonised with the bacteria much, much earlier
and had repeated infections, leading to chronic or damage to the ear.
So, the assumption here, Joe, presumably
is that 100% of the kids have the problem in some communities?
- Yeah. Yeah, because... - So, it's the rare child who doesn't?
Yeah.
Has anybody worked out what the threshold is,
where there's no turning back?
The point where you really must intervene if you want
to have a normal developmentary trajectory here,
you know, the kid to do well in life
without hearing damage which damages their development?
Is there a point where you say, 'This is where we gotta get in'?
Maybe. Menzies proved that three weeks from birth are when the problems start,
so maybe we need look at it from the... NORMAN: ..get go.
..straight away from then, and then start looking at it.
What I normally say with the health workers out in the community is,
'Start looking early. We want to try and catch 'em before it gets any further.
So, if you've got a little chest cold, then make sure you fix that up,
'cause if you don't, that'll work its way up
into the Eustachian tube and get infected.
NORMAN: Andrew, developmental trajectory,
what's the no-turning-back time?
That's a hard question, but...
NORMAN: 'Cause you'd never want to give up.
Exactly. I mean, if you intervene at any stage, then the trajectory...
Like, if you've got a child who's five and they're not hearing well
and you intervene with hearing aids, their learning will develop further,
but obviously, that child would've been better
if the intervention happened when they were three,
and perhaps even better if it happened when they were two or one.
David, is it medically preventable?
Are the sort of things that doctors and Aboriginal health workers do
gonna make a difference when the risk factors and the environment
to which they're going to return are the causative factors?
Well, I think that's in the background of the problem,
and I don't think that's an excuse not to try,
but it's actually probably more of an incentive to do so
and address the other factors at the same time.
And Ray, there's guidelines now from OATSIH...
Yeah, there's guidelines for the treatment of middle ear infections
and, um... and *** ears and chronic suppurative otitis media.
NORMAN: And has that changed how you practise?
Um, the guidelines? Well, we use those, um... traditional treatments.
We find the ciproxin ear drops have been a marvellous adjunct
to treating suppurative otitis media.
And I've... amoxil... amoxicillin as a...
..for treatment of acute otitis media is a good regimen for seven to ten days
in a dose of 50mg per kilo - I think that's the recommended dosage.
But, um... when you're seeing this happening in families,
and if you follow up families,
you see patterns of it happening in particular families,
and you see the most socially disadvantaged families
where there's overcrowding and, um...
..basically, then there could be poor hygiene
and poor eating patterns in the family.
Then we've included where I work... where we actually prescribe nutrition -
we prescribe fruit and vegies to those families.
NORMAN: We'll come back to that again later.
Let's take some case studies and follow these through,
and pick up some key information about the guidelines
and the evidence-based way of treating these children as we go through.
Lucy's our first case. She's two months old.
She comes to see you, Ray, with her mum
for her immunisations and well-baby check.
She's a bit distressed on examination,
so you look inside her ears and this is what you see.
RAY: She's got inflammation and swelling of the tympanic membrane.
So, she's got acute otitis media
and she's got this at the age of two months
which is very young to see acute otitis media. I mean...
NORMAN: But, Joe, you were saying you see it commonly in babies?
JOE: Yeah, bulging ears, I do see 'em often, yeah.
So, what are you gonna do for this baby?
I would... Initially, I would treat the middle ear infection
with probably amoxicillin in the appropriate dosage for 10 or 14 days.
I'd try to take a history from the mother
on what are the risk factors in that family.
And there's lots of risk factors, you know -
overcrowding, smoking, poor nutrition.
For the family, you know? And I'd like to intervene.
If there is significant risk factors in that family,
then I would put up my hand and say, 'Look, this family needs some support',
and the child obviously needs intensive follow-up
otherwise this child is gonna end up with chronic suppurative otitis media
and very bad hearing within the next couple of years.
We've had a question from a general practitioner in South Australia
asking, 'Andrew, what evidence is there in a baby like this
for prolonged antibiotics?'
I don't know that there's a lot of evidence in a case like this,
but certainly if this child was getting recurrent episodes of otitis media,
then there's evidence that prolonged antibiotics will reduce...
NORMAN: Is that in the guideline? - It is in the guideline.
Or it will be, if it isn't.
NORMAN: David, what's your view on long-term antibiotics?
I think we're dealing with a high-risk population,
and we need to be mindful of course, of antibiotic use in general.
But we're not talking about in general -
we're talking about a very specific problem here -
so anything that you can do to suppress infection...
But you've got to do it in conjunction with everything else
that both Joe and Ray are talking about.
NORMAN: Joe, is it easy to convince a mother that this is serious?
Um... No, it's not,
'cause she's got other issues as well - other health problems -
so it's just a matter of, you know, trying to sit down and explain to her
that the baby's not gonna learn anything while they got ear problems like this.
So, you know, it takes a long time
trying to get the message through with her,
'cause of other things happening as well.
NORMAN: Andrew, what were you gonna say?
I was gonna say in the guidelines is if you look at that ear in another week,
and the ear is still... and the child still has acute otitis media,
the guidelines say to continue with antibiotics
or to increase the dose of antibiotics to 90mg per kilogram per day.
So, Ray, we've got some slides showing the results of your work.
Now, obviously, in a two-month-old, you'll encourage breastfeeding -
you're not gonna encourage getting stuck into fruit and vegetables -
but show us some of the impressive results you got
by feeding your community with supplementary feeding.
Well... initially, when we started...
When I used to go
to this community at Baryulgil
when I started visiting there in 2000,
they had surround sound at the school
and the teachers had microphones,
and they had loud speakers on the walls
as the kids couldn't hear the teachers.
The blue graph - the blue column -
shows that at the beginning of our...
..when we started our nutrition program,
only 40% of the kids had normal hearing.
And, um... And basically, there was
about 30% who had moderate hearing loss,
and there was about 10%
who had moderate to severe hearing loss.
And then there was mild hearing loss.
So, the hearing loss was, you know...
..more than half the kids were
significantly hearing-impaired.
Um.. So, we did basic...
Because our traditional treatments
were failing, we did some basic pathology on all the kids.
We did blood tests on all the kids, and we found that every kid there
had low vitamin C levels - out of the normal range.
They also had... About 80% had iron deficiency.
These are the things that you commonly see in impoverished communities
all around the world.
I mean, I've heard of... It's been documented in Indigenous communities
in Canada and North America many years ago.
And... so, we targeted nutrition.
Initially, we tried vitamin supplements,
but the kids didn't like them, it was ineffective,
so then we just, um... started feeding the kids fruit at school every day.
We'd take up a box of fruit once a fortnight when we did our clinics
at the school, and we'd leave it at the school
and the teachers would feed the children fruit on a daily basis.
And within about three to six months,
we started to notice that the children's hearing was improving,
and they were getting fewer skin infections.
And if we can go back to that slide...
After about six months we got it to 50%
of the children having normal hearing
and by the year 2006,
we had over 80% of the children
having normal hearing at that school.
And they disbanded the surround sound
system - they didn't need it anymore.
This was a very small community,
and it was easy to study
and it was easy to implement changes,
so we could document changes, but as a result of that small study,
we then introduced this program into the other communities
that we service of Grafton, Maclean and Yamba.
And... we changed the program a little bit
in that we just targeted families that had problems, and now we do that.
We target families that have got health problems -
either ear infections or skin infections or boils or whatever.
Well, basically, infectious illnesses.
And we... If there's overcrowding in that family, and they're from...
Uh... if there's overcrowding in the household -
where sometimes we get up to 15 people in a three-bedroom house -
then we'll... we subsidise their fruit and vegetables
to the tune of 40 bucks a week.
They pay $5 a week, we pay $35
and we give 'em a box of fruit and vegies, that family.
And we make it conditional, we make a contract with them.
They come in and have a health check twice a year,
they get their audiometry done -
all the children have health checks, audiometry and blood tests.
And... we've been doing that now for seven years,
and we've expanded it to...
It's been so successful, we've run it...
We've got funding to run it in Coffs Harbour
and down at Bowraville now, which have both got significant...
Anecdotally, is it having an impact on hearing?
RAY: Hearing is good in our communities now.
Hearing is good in our communities.
Most... Because we do audiometry on all the children on the program,
and most of the children have good hearing now.
So, anecdotally, it's good.
We've got a fellow studying it at the moment -
Dr Andrew Black who's doing his PhD thesis on this program,
so he's studying it more scientifically, rigorously.
We started it off just as a trial project,
and we expanded it because it worked.
But I think that, you know, you've got to look away from the box.
In the past we've looked at traditional, just therapeutic treatments with drugs,
and they've been largely ineffective.
And as Joe's saying, in the Northern Territory,
they have dreadful problems still.
So, Andrew, with the diagnosis, we're just saying this is on sight?
This is, you know, you see a bulging red drum - otitis media.
A retracted drum with fluid behind it - chronic serious otitis media.
- And a perforation... - Otitis media with effusion, yep.
We don't have to do anything fancy -
we don't need to needle the drum or anything like that?
That's the practical diagnosis. David, do you agree?
DAVID: Absolutely. - Very pragmatic.
Let's go onto our next case study and look at some more issues.
James is 23 months old,
and he comes to see you, Ray.
He's had a discharge
in his ear for three months
despite a course of antibiotics.
Inside his ear, this is what you see.
RAY: He's got a suppuration through his eardrum,
he's got pus in his ear canal, he's got an infection behind the eardrum
and so, I would make a diagnosis of chronic suppurative otitis media.
NORMAN: Which he's had for about three months...
ANDREW: We really to clean the ear...
RAY: We've gotta clean the ear. NORMAN: Show us how we do it, Joe.
Alright then. We're gonna, um... We normally say tissues or toilet paper,
'cause that's what's normally available there.
So, basically, just get a piece of tissue... take the...
I normally get the corner 'cause you can use the, um...
..all the others as well - same time.
So, it's just a matter of - I don't know if they can see it -
just screw it up nice and firm and tight.
And then nice and tight like that.
And then you just stick it in your ear,
leave it in your ear for a little while...
NORMAN: Don't have to wiggle it - just put it in?
Just put it in there and it'll absorb it all up,
and then you pull it out and hopefully,
the rest of the gunk that's on it will come out with it.
Then you can do it again,
but you don't want to jiggle it around too much in there
or too many cleaning, because it starts making it red and...
NORMAN: So, you've got to look after each one?
Yep. After you do the first one, pull it out, have a quick look.
If there's more pus there, put it in again.
At least you know where it is - if it's on the side...
And then put it in again and pull it out again.
NORMAN: So, after cleaning, this is what the ear looked like.
- Ray? RAY: Well, there's a large perforation
present in the eardrum, um... ..and... and you can see that now,
and basically, you've got to treat that condition,
and I guess, the treatment nowadays would be ciproxin ear drops, um...
..for a week to ten days.
And you'd have to follow that child up maybe on a daily basis,
to get the child to come in and clean the ears and put the drops in
- even supervise the putting the drops in -
'cause unless you get the pus out of the canal,
you're not gonna heal up the drum.
NORMAN: What are your tips, Joe, in this situation?
First of all, it's two drops, twice a day? How often do you put it in?
Two or three drops, twice a day.
Depends how bad... If it's bad, then, yeah.
Normally, three times a day if it's really bad -
morning, lunchtime and afternoon - but twice a day...
The third... I mean, at night, more or less when they're...
Try and do it when they're asleep, if it's a baby or a child.
Clean it all and then put the drops in.
Then they're not moving around too much on it.
And it's much easier for the mother to come in with the child to have it done -
then you know it's being done? - Yeah, yeah.
And what are your tips for actually how you put in?
The child presumably, has to be lying down?
- Just tell us how... - Put the head on its side there,
and then just pull the ear out and then put the drops in there.
NORMAN: After you've cleaned it? After you've dried it out?
Yeah, well, just after you've ear-wicked it, cleaned all the pus out there.
And then we have a look till all the pus has gone,
and then you put it on the side there, put the drops in there.
And then, um... different people do different things,
where David and me will pump it and try and push it
down into the drum there - into the Eustachian tube there
for a couple of seconds, just so it'll soak in there.
You've got a little trick for recognising that the pus is out
and you've done it effectively?
- Yeah. NORMAN: What's the trick?
Well... pumping it down into the Eustachian tube there,
and then ask them if they tasted it, and if they tasted it,
that means it went through the Eustachian tube.
Normally, the pus doesn't go back when the antibiotics has been through there.
David, if it's done properly like that,
what sort of success rates do you get, at least in this sort of episode?
One of your things to do in association with this,
is you've got to emphasise water precautions.
You're not gonna make much progress if this child is gonna jump into...
I mean, obviously not a 23-month-old, but in general.
If a child's gonna jump into the local waterhole
and introduce that water plus wash out the drops,
you won't make much progress.
So, an important part of it all is actually just water precautions.
NORMAN: What if they've introduced a swimming pool into the community?
Well, look, I think that has been a revolution in a lot of ways.
It's been a fabulous substitute for the waterhole,
and also, as long as it's maintained,
heavily chlorinated, apart from the ear side,
it's been shown to show benefits with skin-infection rates and so forth...
NORMAN: And schooling, if they're only allowed to go...
And the policy of 'no pool - no school' or 'no school - no pool', um...
..has made a difference to school attendance rates
which is another benefit of the arrangement.
If you've got a perforation and you go into the pool, what happens?
Well, the reality is that in the circumstances we're describing,
if that water's clean, probably a fair number of these kids are going to be OK.
Um...
NORMAN: But you'd prefer during this...? - But it's not the best option.
How long does it take for a perforation to heal?
A small perforation can heal in a few days,
but a large chronic perforation will take probably months, I would say.
- Would you agree, David? - Some of them can take quite a while.
NORMAN: On drops the whole time?
Well, no. I think the crucial part of the drops
really is to clear out the discharge.
When you get the ear nice and dry, nice and clean,
and the inflammation has settled down,
then you've introduced a favourable environment for healing.
And again, looking at all the other aspects - nutrition and passive smoking
and all those other factors that need to be emphasised -
if with monitoring, you're seeing a slow but sure
closure of the hole spontaneously,
the thing to do is just sit tight and hope that it will proceed to completion.
In practice, a lot of them never heal up though, don't they?
Is that because they haven't got adequate treatment or...?
Well, look, you know... not necessarily, is the short answer.
I mean, some just won't heal up, and they're the ones that you look at
surgical intervention and the like at some stage to finish the job.
But the reality...
NORMAN: Presumably, that brings its own issues?
That introduces a whole other aspect to the conversation
with respect to management of course, and there's usually a gap
in between when they get to having that decision,
and everything else has been done beforehand.
NORMAN: And they'll go back into the community
into the circumstances which caused it in the first place.
A lot of this comes back to what's going on in the community.
And, Ray, how do you deal with hearing testing
and following these children through?
We have an audiometry service attached to our AMS,
and we take it out to the communities.
We go into the schools and do primary school children, basically,
and screen them for... just screen them for their hearing
and, um... and we intervene if they've got problems.
Um... So, would...?
In this situation, we're not talking about oral antibiotics -
we're just talking about the topical treatment?
Yeah, I think with a chronic discharge over three months,
no systemic features otherwise, really, the evidence is for topical drops,
ear toilet, water precautions, um...
and the expectation over time of a spontaneous closure.
The other thing I think we should do is talk to the parent
about the child's speech development,
and particularly if there's concerns about speech development,
then that makes checking the hearing and intervening more important.
The child probably can't hear very well just based on the picture.
There's things parents can do...
People will present with speech problems.
..that childcare can do to help that child develop
despite having poorer hearing.
Joe, how assertive should the Aboriginal health worker be
with the family in this situation?
Well, they definitely should talk to the parents,
and constantly talking to 'em and saying... because...
As you know, Joe, there's talkin' and talkin'.
JOE: Yeah, I know, we're talkin'.
But lookin' at the child and seeing the child just lying there,
and not really saying a lot or making noise,
so obviously there's some sort of problem there.
So, maybe they've gotta get the point across to the parents to say that,
'This baby's not doing anything. You need to do something about their ears.'
A question from Jill, an audiologist in Queensland, is asking.
'Are there are any new initiatives
for Aboriginal health workers to help us overcome shame issues
when amplification's required, particularly in the classroom?'
This child's a little bit young for that, but, um...
..are there shame issues when amplification's required?
There's still the same shame that's there where, like, the hearing aids,
now they do it in caps - they've got their caps on with their hearing aid.
Them balaclava things, they put it on there with the hearing aids,
and they're trying to look at different ideas and different ways
of trying to get away from that, um... shame of having hearing aids in there,
'cause it's just embarrassing for them.
That's not gonna go away, so...
When do you refer to an ear, nose and throat specialist?
Um... when I can't fix their problem up,
either through the parents or through the clinic, so, yeah.
But we'll go through the clinic to do all that stuff with ENTs.
A question here, David, from Paul, an audiologist in Melbourne, asking,
'Given that general practitioners are short on the ground,
there's problems with primary health care,
what's the role for extended practice amongst audiologists
and direct referral from audiologists?'
The honest answer is I've taken this up politically,
and unfortunately, it is all political.
People will be quite familiar -
an optometrist can refer to an ophthalmologist.
An audiologist can't refer to an ENT - the middle step is the GP in between.
I really think we need to empower our audiologists and give them the privilege
of using their skills and being able to access ENT,
because quite often that intermediary step
really is a delay for what is ultimately the outcome anyway.
Let's... We've got a few more photographs of eardrums.
Let's just go through them just to remind ourselves
what various ones can look like.
- David, what's this...? DAVID: Certainly.
So, this is one of the dreaded complications of grommet insertion,
which is very topical if you're looking at surgical intervention with children
coming from remote communities.
This is a grommet - that blue structure in place -
and it's discharging, so this is not an ideal situation.
Again, needs to be managed much the same way as we were managing the discharge
associated with a chronic perforation.
So, topical drops, ear toilet, water precautions,
and this child, if they don't settle, may ultimately require
further surgical intervention to remove the grommet.
Hope that the hole heals up, hope the infection settles down,
but then you could be back to square one,
so it's a problem fraught with issues.
NORMAN: What is the role of myringotomy and grommet insertion?
We've got to be mindful of the community...
In the non-Aboriginal community, it's controversial enough -
the suggestion is that if you actually take children...
..and a large, randomised trial's suggesting that
the outcome in the end is no different.
- Well, that is true... - Unless they're at risk.
That's the crucial bit.
The study that that comment's based on looks at about 600 children.
What's neglected is that about 5,400 children were excluded from that study
because they were at risk.
So you're dealing with a group of kids that weren't that bad to start with,
and not surprisingly, there wasn't that much difference
whether you did something or not, 'cause of where they were starting from.
The other thing that's been found though, following up in that cohort,
is that the rate of chronic ear disease down the track
is much higher in the observation group compared to the treatment group.
So, your cholesteatomas and your ossicular chain erosion and so forth,
is much more prevalent in the group that was observed
compared to the group that was treated,
even though speech outcomes and those sorts of measurements
came out much the same, so you've got to take that with a grain of salt,
but we're not talking about that in the context of Indigenous, of course.
How common is cholesteatoma in this group?
It's an interesting discussion because it's probably somewhat protective
in the fact that they have a hole.
A cholesteatoma is a variable disease for pathologists.
NORMAN: Remind us what it is. - Well, cholesteatoma
is in all essence, skin that's got into the middle ear one way or the other,
and that can be congenital in a very small number of cases -
in the majority, it's acquired.
In the majority of acquired, it's because the eardrum itself
has become retracted, formed a pocket, keratin has built up and you end up with
a build-up of keratin infection... disease progress.
And very occasionally, it can be because there's a perforation
and the skin grows through the perforation into the middle ear itself.
So, in the mainstay with our Indigenous children who have perforations,
it's protective against the retraction disease.
The problem is everything else is a problem that goes with it.
So, fortuitously, cholesteatoma doesn't seem to be...
..more prevalent in these circumstances.
But having said that, it's still an awful disease
regardless of whether you're Indigenous or not.
And the treatment?
For cholesteatoma, is surgery in the mainstay.
In the mainstay, it is surgical excision, reconstruction of the defect,
and maintenance and monitoring thereafter
for years and years to come.
NORMAN: So, very... not a complicated story.
Let's go to some of our other images here. This one, David?
DAVID: So, this is a slightly more favourable picture at the moment.
So, we've got a child with a perforation.
There is some scarring of the eardrum
which in the mainstay, is neither here nor there.
So, if this child was to attend to the clinic,
dry-eared, not discharging, this child doesn't need antibiotics,
this child doesn't need anything cleaned up.
This is the sort of child that we would want to have the hearing assessed.
We'd want to establish their hearing level to gauge
whether they're a candidate for audiological rehabilitation
whilst we're waiting for the hole to close
or then to make a decision at an appropriate time -
based on the child's age and other factors -
as to when we may entertain surgical closure,
but not letting them go deaf in the meantime.
ANDREW: What age would you do that?
DAVID: Uh... age is variable.
You can do it from five onwards, but really, um...
..probably from about aged eight onwards is probably a better option...
..just to make certain that you don't end up in a situation
where you've patched a hole
and then the middle ear disease starts up again.
NORMAN: Joe, let's have a look at this last one. It's yours.
- Not your ear but your.... JOE: Not my ear, yeah.
Um... Yeah, no, just... I like this one because it shows you...
NORMAN: I don't - I've had something to eat.
JOE: Yeah. It shows you everything in there.
And these are just one of many things that we see in there,
and it's a fly just sitting on the out of the canal there,
and there's another bug way up the back there,
but behind that other bug - if you clean all the pus and all that away -
there should be a hole there.
The fly just flew in there and got caught up
amongst all that pus and everything,
so there's a hole down the back there... NORMAN: So, how do you get the fly out?
JOE: Oh... you can... I've got tools to pull it out,
or you haven't, you can syringe it out, and then once you syringe it out...
But I got the tools to pull it all out, then dry mopping,
and then you see the tissue
and you see the hole in the back and everything.
NORMAN: Ghastly. - That's a nice, lovely photo.
David, did you want to make a comment?
I think that just reinforces really, what we're talking about.
We're living in a First World country,
and that's a picture of a child in this country.
NORMAN: It's absolutely shameful.
Let's go to our next case study.
This is Sarah, who's seven years old.
Um... she's had multiple courses
of antibiotics.
She's not going to school much at all.
Her speech and language
is below average,
and she's been referred to you, David,
following concerns from the GP.
DAVID: Um... the picture we're painting here is of a child
that's not hearing too well at school.
The concerns are what the cause of that hearing loss or otherwise may be,
and as part of audiological assessment,
it's shown a bilateral conductive hearing loss,
tympanometry's undertaken which shows flat, type B tympanograms on both sides,
then the clinical picture of the suspicion of otitis media with effusion.
Um... the clinical picture really is a child that's deaf
with a readily reversible cause,
and then it comes down again to appropriate management
depending on various circumstances.
The most crucial part is getting this child hearing one way or the other.
So, she's got a significant issue. What are you gonna do for her?
We've got an issue here for many reasons.
We're laying the foundations of this girl's future life in many regards.
She's got the social aspects of it,
she's got the communication aspects of it
and she's got the education as well.
From a practical point of view, there's really three options.
Do nothing and wait for her to outgrow it.
That's not appropriate because she's already behind.
From a management point of view, you're either looking at hearing aids -
waiting for the fluid to then go away by itself -
on the proviso that you don't have anything else intervening,
such as recurrent or further infections
or damage to the drum and the concerns about cholesteatoma.
And then the third option is from a surgical point of view,
is adenoidectomy and then removing the fluid.
The question of removing the fluid
comes down to whether you put a grommet in or not,
and that again, raises a lot of issues
regarding to where these children are going back to.
You've really got to balance
all of the risks and benefits of that in conjunction.
The other thing that was referred to previously,
is the sound field systems in schools.
They work fabulously - not only for the children that are deaf,
but also for the children that aren't deaf -
because of the acoustics of classrooms in the dead zones are there.
The study's quite convincing that it's a fabulous investment to make -
not only for that child but for everyone else in the room too.
And what about instillation or you know, the nose-blowing, bubbling,
through a straw into the...? - Absolutely.
I think it's something that makes us feels good
because we're doing something,
but unfortunately, the evidence isn't there.
Um... it's anecdotal.
Any studies are pretty... low-powered, not very well designed.
RAY: What about Otovents?
Yep, the same with the Otovents. There's no evidence.
From a practical point of view, if you think about an Otovent,
which is a little balloon that you put over the nose,
you're blowing against pressure, so the theory is
you're putting pressure then through the Eustachian tube.
That'll clear the fluid from the middle ear,
but it's only going one way - into the mastoid -
it's not going back down the Eustachian tube.
Um... and then if you come back and look at these kids
5, 10, 15 minutes down the track, the fluid's back again.
So, it's not shifting things.
ENT went through the whole, uh... pneumatisation and...
..puffing air through the Eustachian tube and so forth.
Unfortunately, it doesn't work. It makes us feel good
that we're doing something, which is not to be discredited,
but the studies really aren't very good, one way or the other.
Some show a benefit, some show a detriment,
so really, you're back stuck in the middle again.
What about developmental interventions, Andrew?
I guess, the biggest thing is, you know...
if I saw this child, I might be sending her along to see an ENT specialist
but I'd also be sending her along to see Australian Hearing
to ask them about hearing aids for her.
Um, the classroom thing, I think, is really important
but it's not, you know, it's not an intervention for an individual,
it's something that, if I was working in a community,
I'd suss out whether the classrooms had sound field systems,
whether they were acoustically OK.
And if they have got sound field systems,
are the teachers actually turning them on and using them?
And I think they're fabulous
because, you know, they would help that girl
but they would also help the other kids in the classroom
who don't know they've got hearing problems.
Do you find they're not being turned on, Joe? Some people aren't using them?
Yeah, some of them don't turn it on or the battery's gone flat.
Or... things like that.
It's all plugged up and pus coming out again
and blocks it all up.
They don't get checked regular, and they should. Yeah.
So we're talking here about a condition
which just... people see so much of, they almost don't care.
Yeah.
A lot of teachers may not get well orientated
or taught about how to teach children who have hearing impairment.
What about specific interventions
apart from that, with individual children,
difficult though that might be in a remote community?
Well, if she had speech impairment,
I would send her to see a speech therapist.
So that could help with her speech development.
But they're not hanging off the trees in Katherine or Tennant Creek, are they?
You might get to see someone in Katherine
but, you know, even in remote...
I would still refer to speech therapy
because, if they get a million referrals,
you know, it may help someone to decide to appoint an extra speech therapist.
If we never refer to them, they'll never...
DAVID: The other issue, of course, is that we're talking about children
where English may not necessarily be their first language.
Although, that's their language of education.
So, that can exacerbate the situation in some regards as well.
I guess, there's other things that teachers can do too.
They can sit that child out the front,
they can give the instructions verbally and visually,
um, they can use prompts for change of activities
or change of topics.
There's things they can do.
So, Joe, do they ever...
When a child like this is 15,
do they ever, you know, get through it and out the other side?
Well, I know looking at the teenage ones now,
some of them still got *** ears,
perforations...
..and, um, what do you do then, at that age?
DAVID: You were talking about laying the foundations.
One of the scariest statistics I've seen in years gone by
is looking at Indigenous people
that are through the criminal justice system.
Particularly the ones that end up in gaol.
It's estimated that it's as high as 20% of those people
have some form of hearing loss.
Yes, in fact, there was a question from WA along those lines, yes.
DAVID: So, I mean, that's extraordinary.
You're dealing with a situation where, you know, 20% of Indigenous people,
potentially, in front of a judge, can't hear what's going on,
that had poor education,
so they have poor comprehension of what's going on,
English might not be their first language.
All those events combined are really a very difficult situation
when you then look at the long-term rehabilitation of this person.
Whereas, if you got in early on in the piece,
you would hope that the outcomes would have been a lot more favourable.
So, to summarise, we're dealing here,
not just with this case, but overall,
we're dealing with getting in early -
um, if you've got a child who has got otitis media,
the first step, you want to treat it fairly aggressively, get it clear.
If there is a discharge and perforation,
you really, ideally, want direct observation of treatment.
You don't want to leave it to the parents at home.
Make sure it's dry and the child gets a decent course
of cipro drops in a clear ear.
And then...
ANDREW: If you've got the resources to do that.
Yes, but then you're really dealing with a situation
where, um, we're dealing with all the problems of Aboriginal communities
which is reducing overcrowding,
trying to get smoking rates down from 80% to 20%,
or less,
and nutrition, as you say, even though it's not a randomised trial,
what harm can we be doing by handing a box of fruit and vegetables out?
And, um... But then pursuing it, not letting this go.
That's right. Over in Western Australia,
they've put in some, you know...
Some of these therapies don't make a lot of sense, but they work.
So I think you've got to look at what works, what's working...
NORMAN: And be pragmatic, as you're saving a generation.
JOE: And all what Andrew and David
have been talking about, and with this Sarah one,
that could be the same kind of problem, as well,
where you'll probably need to try and put a grommet in
to bring the drum out, because it's retracted.
You've got hearing aids, you might need to put the hearing aids on this,
but their hearing, with that audiology not long ago,
probably in the 50 - this is probably the 50 and 60 mark -
the level of their hearing loss.
So hearing aids will probably be good for that
if you don't want to do the grommets.
You know, so their lack of education...
And we see a lot of those, retracted,
and they have a lot of problems with these things
because hearing and speech and all that stuff.
So it's exactly what Sarah has got there
but in a different way.
All the same problems what Andrew and David was talking about.
And it's ubiquitous.
And then the teachers put them up the front for learning,
the sound field and all this stuff.
NORMAN: Why are kids up the front, Joe? - So they can hear better.
'Cause when they're at the back, a lot of them sit at the back,
they can be naughty, and they can't hear anything, so they play up.
So when they're up the front, they can't play up.
Then they can see or hear what's going on.
So how many Aboriginal health workers are there in the Northern Territory,
who specialise in ear, nose and throat like you do?
Oh, there's some new ones coming on now
with some of the AGI money, the Territory funding came out of that.
So we've probably got another...
..five, five more coming up
that are out there now, yeah.
They're starting to get some more.
NORMAN: And other states? What happens in other states?
Yeah, no, I don't know what's happening.
NORMAN: Great resource if they're all like Joe.
There's very few people trained like Joe
in New South Wales that I'm aware of.
Aboriginal health workers.
We don't have any...
We don't have Joe in our community anywhere.
And we service...
NORMAN: We'll just have to call you, Joe. (Chuckles)
Need to get Joe bottled.
(Chuckles) What are your messages for people watching? Joe?
Um... I would like the parents to clean more of the babies' ears
and, um...
I suppose get the, um...
the babies or the kids to start learning early in age.
NORMAN: And throw their bloody cigarettes away.
Yeah. And try and pick up their language
and the learning and all that stuff.
NORMAN: Ray, before you give your message,
there are resources available now. EarInfoNet.
There's a new guideline coming out, manuals,
there's a fair bit coming out
that's available for GPs, Aboriginal health workers and others.
Here's the, I think, EarInfoNet there on the screen.
RAY: Yeah, there's a lot of resources around
and... um, it's a huge problem in the Indigenous community.
My message would be...
try to improve the nutrition of your communities that you service.
If you're dealing with Indigenous communities,
then that... the nutrition is a huge part
of this disease process
because the people you're dealing with
are immunocompromised
and they get infectious diseases as a result.
If you can help promote their immune system work better,
then they get less infections. NORMAN: David?
We're dealing with the foundations of children in their future development
which flows on from the individual to the family to the community.
We need to treasure what has been around for so many thousands of years
that is being lost at a rapid rate
and this is part of the problem
and we need to be addressing it as part of the solution.
NORMAN: Andrew? - I guess, my message for health workers
would be - all health staff -
would be whenever you see a young Indigenous child,
look in their ears,
ask the parents about their speech development.
If there's concerns, if you see an ear disease,
treat it aggressively and treat it early.
And the highest priority would be the youngest kids
because that's where you might have a big impact.
It's very hard to treat older kids.
Thank you all very much indeed.
A major issue which requires much more attention
from the whole community, not just the clinicians.
I hope you got a lot out of tonight's program
on otitis media in Indigenous children.
Our thanks go the Department of Health and Ageing
for making this program possible
but thanks also to you for taking the time to attend and contribute.
As always, if you're interested in obtaining more information
about the issues raised, there are a number of resources
available of the Rural Health Education Foundation's website.
That's at rhef.com.au.
Don't forget to complete and send in your evaluation forms
and to register for CPD points.
I'm Norman Swan, and I'll see you next time�