Spectrum of ear, nose and throat disorders among children reporting to the out-patient department of a tertiary care center, Nepal

INTRODUCTION

ENT problems are one of the most common causes among children that warrant a visit to the doctor. Paediatric population forms a considerable proportion of the total world’s population.¹ Seasonal cough and cold, earache, sore throat are very common in children. Many of the times, the treatments for these are done at home. When the symptoms become more serious, then only the children are normally brought to the doctor. Fortunately, fatality is very low in such cases except in cases of emergencies, but complications do occur.^2,3 Ear, Nose, Throat problems are more common in children than adults. This could be due to various factors such as wider and horizontal Eustachian tube, under developed immunity, malnourishment, poor hygiene and sanitary conditions, overcrowding, lower socioeconomic status etc.⁴

The pattern of these diseases may vary from community to community or hospital to hospital based on the availability of specialist personnel or facilities for the management of such diseases which are either congenital or acquired in origin.

The objective of this study was to know the various ENT disorders among children reporting to the out-patient department of a tertiary care center and to see their associations with age and gender so that an idea of the prevalent ENT disorders can be drawn.

METHODS

A prospective cross-sectional study was conducted in the Out-Patient Department of Ear, Nose and Throat at a tertiary care center, Kathmandu, Nepal. Duration of study was one year from June 2016 to June 2017. All patients presenting with ENT problems and ranging in age-group from 0-16 yrs were included in the study with their ascent and permission of their parents. Where appropriate informed consent was taken from the patients.

Detailed history taking and clinical examinations were performed and recorded in a pre-formed proforma. Where necessary, otoscopy, rhinoscopy, throat examination, appropriate x-rays, culture sensitivity etc. were done depending on the need of the presenting complaint.

All the data were entered into Microsoft Excel format 2013 and statistical analysis was done with SPSS 20 version. Descriptive analysis was done and Chi-square test was used to see associations.

RESULTS

A total of 968 patients were examined ranging in age from 0-16 yrs during the year 2016-2017. Among them males were 633 (65.4%) and females 335 (34.6%) (Table 1). Otological disorders were the most commonly reported 482 (49.8%), followed by throat and Neck disorders 322 (33.2%) (Table 2).

Ear disorders as a whole was more common among the age-group 0-4 yrs, after that among 5-9 yrs. Throat disorders as a whole was more common among the age-group 10-16 yrs, then 5-9 yrs (Figure 1). Sixty nine and half percentage of the patients who reported during the year were from joint family (Table 1).

Similarly, when the relation of the disorders was seen with respect to gender, ear disorders as a whole was more common among males and throat disorders as a whole among females (Figure 2).

The spectrum of ENT disorders, their percentage occurrence and associations with three-age-groups of children are shown in table below (Table 2).

The most common ear disorder reported was CSOM 126 (13.0%), nose disorder was acute rhinitis 35 (3.6%) and throat disorder was tonsillitis 89 (9.2%).

Among 0-4 yrs the most common ear disorder reported was AOM 62 (19.4%), 5-9 yrs CSOM 66 (18.1%), 10-16 yrs CSOM 42(14.9%).

Similarly, the most common nose disorder among 0-4 yrs was FB nose 17(5.3%), 5-9 yrs was acute rhinitis 18 (5.0%) and 10-16 yrs was chronic sinusitis 29 (10.2%).

The most common throat disorder among 0-4 yrs was adenoid hypertrophy 42 (13.1%), 5-9 yrs was cervical lymphadenitis 31 (8.5%) and tonsillitis 30 (8.2%), 10-16 yrs chronic pharyngitis 34 (12%) after that tonsillitis 31 (10.9%) and acute pharyngitis 30 (10.6%).

DISCUSSION

In this study male patients were predominant in number which is similar to the study done by Rijal AS et al.⁵ Whereas in a similar study conducted in India females were predominant.¹ Sixty nine and half percentage of the children were from joint family which supports the conclusions drawn by other studies that children living in overcrowded family are more prone to ENT disorders.^1,6

In our study otological disorders were most common 49.8%, followed by throat disorders 33.2% and nose disorders 16.9% which is similar to the findings of other studies.^5-7 The most common ear disorder reported in our study was CSOM 13.0%, nose disorder was acute rhinitis 3.6% and throat disorder was tonsillitis 9.2%. In other similar studies the most common ear disorder seen was wax impaction.^5-8 A low occurrence of wax 3.7% and high occurrence of CSOM in our study may be due to the fact that the study was conducted in a tertiary care center which is considered the ultimate referral center of Nepal, a government hospital for poor patients where patients come with complicated diseases.

CSOM is a major health problem throughout the world in developing countries including Nepal. It is the most common cause of persistent mild to moderate hearing impairement and more commonly found in children of government school and rural areas.⁷ Second most common ear disorder reported was OME 11.7% and 3^rd AOM 10.1%. Nepali et al, Acharya et al and Thakur et al have reported CSOM as second most common ear disorder, first being wax.^6-8 Whereas, Emerson et al reported AOM as most common ear problem in children.⁹ Rijal et al reported AOM as most common ear disorder after wax.⁵

Our study is different from other similar studies in that we attempted to see associations between three age-groups (0-4 yrs, 5-9 yrs, 10-16 yrs) and ENT disorders. Significant associations were found (p<0.001) (Table 2).

CSOM was significantly associated with the age-groups 5-9 yrs where as, AOM was significantly associated with 0-4 yrs. In the study conducted by Rijal et al, the three year olds had the highest number of ontological diseases (AOM most common after wax).⁵ The age of onset of AOM is indirectly proportional to the chronicity of the disease; that is, early onset of AOM predisposes to chronic otitis media.⁹ But, in our study CSOM was more common among the age-group 5-9 yrs. This may be due to one of the limitations of the study that all the patients, whether new or follow-up patients were included in the study.

AOM presents with local and systemic signs and has a rapid onset and is a leading cause of antibacterial treatment for children in developed countries. OME can occur during the resolution of AOM once the acute inflammation has resolved but bacteria may still be present, while CSOM requires ongoing inflammation of the middle ear leading to otorrhea persisting for at least four weeks and perforation of the tympanic membrane.^10,11

Acute rhinitis, the most common nose disorder reported in our study and deviated nasal septum were somewhat more common among 5-9 yrs children but, the association cannot be considered significant. Chronic sinusitis was significantly associated with 10-16 yrs. Tonsillitis, the most common throat disorder reported in our study was not significantly associated with any of the age-groups. Adenoid hypertrophy was significantly associated with 0-4 yrs. Acute pharyngitis and chronic pharyngitis were significantly associated with 10-16yrs. Nepali et al. also reported rhinitis as the most common nose disorder but, pharyngitis as the most common throat disorder among children.⁶ Similar to our study, the most common ear, nose and throat disorders in a study conducted by Kishve et al, were otitis media (18.25%), rhinitis (5.8%) and tonsillitis (11.7%) respectively.¹²

In a three years record based, retrospective, cross-sectional study of emergency cases conducted by Barman et al. ear emergencies were found to be far more common than nose and throat emergencies but, the most common ear emergencies were earache due to impacted wax, acute suppurative otitis media, foreign body ear and the trauma/injury. Chronic suppurative otitis media with complications were the least common emergency condition according to Barman’s study.¹³

The ENT diseases among the school going children can have a detrimental effect on their school performances. This was seen in a study by Egeli et al which showed that school going children with rural background have a higher incidence of ENT disorders and this had a negative effect upon their school performances when compared with children from the urban background.¹⁴

High incidence of CSOM among children was also seen in a study conducted by Varute et al, in a rural area who concluded that it may be due to low socio-economic factors, illiterate mothers, overcrowding in the family, low economic status, wrong feeding habits and since the area was rich in sugar cane, rice, paddy fields and animal danders the children also suffered from allergic rhinitis which acts as one of the risk factor for ear diseases in pediatric age group.¹⁵ Similarly, a study done in rural area of Nepal by Joshi et al also reported CSOM as the most common ear disorder and linked it to multiple social and environmental factors in a developing country, major problems being inadequate primary health care, high inadequacy of funding and trained manpower.¹⁶

CONCLUSION

Most common ENT disorders reported were ear disorders and second most common throat disorders. Most common ear disorder reported was chronic suppurative otitis media (CSOM) 126 (13.0%), nose disorder was acute rhinitis 35 (3.6%) and throat disorder was tonsillitis 89 (9.2%). Significant associations were found between disorders and age-groups. Ear disorders as a whole was more common among the age-group 0-4 yrs and among males; throat disorders among 10-16 yrs and females. CSOM was significantly associated with the age-groups 5-9 yrs whereas, AOM with 0-4 yrs. Adenoid hypertrophy was significantly associated with 0-4 yrs whereas, pharyngitis with 10-16 yrs.

Limitation

Patients were not categorized as new or follow-up patient and all were included in the study.

ACKNOWLEDGMENTS

We would like to thank all the participants.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Surapaneni H, Sisodia SS. Incidence of ear, nose and throat disorders in children: a study in a teaching hospital in Telangana. Int J Otorhinolaryngol Head Neck Surg. 2016;2(1):26-9.
2. 2. Sharma K, Bhattacharjya D, Barman H, Goswami SC. Common Ear, Nose, and Throat Problems in Pediatric Age Group Presenting to the Emergency Clinic: Prevalence and Management: A Hospital-Based Study: Indian J Clin Pract. 2014;24(8):756-60.
3. 3. Sox CM, Finkelstein JA, Yin R, Kleinman K, Lieu TA. Trends in otitis media treatment failure and relapse. Pediatrics. 2008;121(4):674-9.
4. 4. Gul AA, Ali L, Rahim E, Ahmed S. Chronic suppurative otitis media; frequency of Pseudomonas aeruginosa in patients and its sensitivity to various antibiotics. Professional Med J. 2007;14:411-5.
5. 5. Rijal AS, Joshi RR, Regmi S, Malla NS, Dhungana A, Jha AK, et al. Ear diseases in children presenting at Nepal Medical College Teaching Hospital. Nepal Med Coll J. 2011;13(3):164-8.
6. 6. Nepali R, Sigdel B. Prevalence of ENT diseases in children: Hospital Based Study. Int J Otorhinolaryngol. 2012;14(2):1-5.
7. 7. Thakur SK, Acharya R, Singh SK, Ghimire N. Ear diseases in school going children of sunsari and morang districts of Nepal. J Chitwan Med Coll. 2017;7(19):16-9.
8. 8. Acharya A, Singh MM, Shrestha A, Pokharel B. Ear Nose Throat (ENT) disorders in government schools of far-western Nepal. L M Coll J. 2013;1(2):86-8.
9. 9. Emerson LP, Job A, Abraham V. A model for provision of ENT health care service at primary and secondary hospital level in a developing country. BioMed Res Int. 2013;2013:562643.
10. 10. DeAntonio R, Yarzabal JP, Cruz JP, Schmidt JE, Kleijnen J. Epidemiology of otitis media in children from developing countries:A systematic review. Int J Pediatr Otorhinolaryngol. 2016;85:65-74.
11. 11. Adhikari P. Pattern of ear diseases in rural school children: experiences of free health camps in Nepal. Int J Pediatr Otorhinolaryngol. 2009;73(9):1278-80.
12. 12. Kishve SP, Kumar N, Kishve PS, Aarif SMM, Kalakoti P. Ear, nose and throat disorders in paediatric patients at a rural hospital in India. Australasian Med J. 2010;3(12):786-90.
13. 13. Barman D, Maridal S, Goswami S, Hembram R. Three years audit of the emergency patients in the department of ENT of a rural medical college. J Indian Med Assoc. 2012;110(6):370-4.
14. 14. Singh A, Kumar S. A survey of ear, nose and throat disorders in rural India. Indian J Otolaryngol Head Neck Surg. 2010;62(2):121-4.
15. 15. Varute VP, Varute PA. Prevalence of ear diseases in children of rural area in India. Int J Recent Trends Sci Tech. 2015;16(3):530-2.
16. 16. Joshi RR. Spectrum of Otorhinolaryngological diseases in remote rural western Nepal. Nepal Med Coll J. 2016;18(1-2):86-9.