Effect of living environment on ear, nose and throat diseases: a cross sectional survey in rural areas of Rohtas district in Bihar

INTRODUCTION

Ear, nose and throat (ENT) diseases are most common problems for which a person visits a doctor in developing countries like India. Although most patients manage their problems in the community by home remedies without seeking expert medical advice.¹ ENT specialists are not easily available in rural communities and those who are available do not have enough training. Also less knowledge, ignorance, poverty and traditional beliefs prevent the rural patients from attending hospital.² To overcome this hurdle and to increase the access of proper healthcare near to the doorsteps of people, health camp approach is being preferred. Interns as training medical graduates who are future doctors need to be oriented well towards common health needs of people.³

The environment affects our health in a variety of ways. The interaction between human diseases and living environment has been extensively studied. Worldwide, World Health Organization (WHO) has estimated that thirteen million deaths annually occur due to preventable environmental causes.⁴ Various respiratory infections including diseases related to ENT have been associated with different aspects of the indoor living environment.⁵

No such data about prevalence and pattern of ENT diseases in rural regions of Sasaram, Rohtas is available till now. This study aims to determine the pattern and prevalence of ENT diseases in rural areas of Sasaram, Rohats district, Bihar and to find out the effect of living environment on these diseases. The other objective of this study was to educate the people regarding various ENT diseases and methods to prevent them.

METHODS

A cross sectional study was conducted using camp approach in rural areas of Sasaram, Rohtas, Bihar from May 2017 to February 2018, for a period of ten months. The camps were organised once monthly on first Sunday of every month from 10am to 2pm. ENT specialists, including first author and interns of Community Medicine department along with second author were actively involved in conducting these camps. Also, audiologists, medico social workers, nurses and paramedical staff of Narayan Paramedical Institute and Allied Sciences were involved too.

The entire population of rural areas were covered by changing the site of camp on each visit. Inclusion criteria for the study subjects were people who had given symptom of ENT diseases and those who had given his/her consent. Exclusion criteria for the study subjects were people who had not any symptom of ENT diseases and any child less than 12 months of age.

At first, the patients were screened at primary level by interns and second author. Later they were referred to ENT experts who did a complete clinical examination and appropriate investigations depending on the merit of the presenting complaint. A free distribution of medicines was carried out after consultation. The awareness and education to the patients as well as general population was carried out by hand-out printed IEC (Information, education and communication) materials and lectures were given by experts. All the patients needing surgical interventions were referred to the hospital. Any emergency case was also referred although they were not taken for analysis.

Questionnaire method of data collection was used to know the pattern and prevalence of ENT diseases. Living environment conditions including overcrowding and inadequate cross ventilation were defined as per textbook standards.⁶ All the data were entered into Microsoft excel and analysed by SPSS version 16.0. A logistic regression analysis was conducted to determine the factors associated with ENT diseases. Odds ratios were obtained after adjustment for age, sex and other socioeconomic conditions.

RESULTS

A total of 832 patients were screened during the study period out of which 61.9% (515/832) patients were suffering from ENT disorders. The reason for such high percentage may be prior knowledge of patients about availability of ENT doctors in camps. Out of 515, 268 (52.1%) patients were male while 247 (47.9%) were females (Male: female ratio being 1.08:1). The age distributions of patients are shown in Figure 1. Most common age group affected was of 31-40 years (4^th decade). The majority of patients were suffering from ear problems (54.8%; 282/515) while nasal and throat problem was seen in 14.9% (77/515) and 30.3% (156/515) respectively (Table 1).

Table 2 depicts distribution of ENT diseases. Among the ear problems, chronic suppurative otitis media (safe type) was the commonest (41.8%; 118/282) followed by ear wax (25.2%; 71/282), otitis externa (9.6%; 27/282), acute suppurative otitis media (8.2%; 23/282), hearing loss (5.7%; 16/282), acute mastoiditis (4.3%; 12/282), otomycosis (1.8%; 5/282), foreign body (2 cases), trauma to ear (1 case) and others (7 cases). The ‘others’ category had all non-significant cases with chronic non-specific pain with normal findings and investigations. The pure tone audiometry was performed on 282 patients and hearing aid trail was given to 16 patients. The syringing of ear was done in 71 patients for wax removal.

Among the 77 patients of nasal symptoms, most common problem was sinusitis which was seen in 38 (49.4%) cases while allergic rhinitis was seen in 23 (29.9%) cases and nasal polyp was found in 5 (6.5%) cases. There were 4, 3 and 1 cases of epistaxis, foreign body and chronic dacryocystitis respectively. All the diseases with non-specific pain of nose & face with normal examination and investigations were kept in ‘others’ group which had 3 patients only.

In the throat problems, most common was sore throat or acute pharyngitis (42.9%; 67/156), followed by GERD (12.8%; 20/156) and tonsillitis (10.9%; 17/156). Neck swelling was seen in 16 (10.2%) cases while stomatitis was diagnosed in 15 (9.6%) cases. Also, 4 patients each had thyroid swelling and parotid swelling. The neck masses were seen in 7 patients while one mass was metastasis and other six were benign. All the diseases with non-specific pain of throat with normal examination and investigations were kept in ‘others’ group which had 6 patients. The number of patients who underwent flexible endoscopy and rigid nasopharyngoscopy was 39.

Table 3 presents the result of the multiple logistic regression analysis of living environment conditions of cases. After adjusting for type of house, separate kitchen and windows, the non-availability of cross ventilation in houses and overcrowding still appears to be the most important factor influencing Ear, nose and throat diseases.

DISCUSSION

Health status of a developing country like India should be assessed at the rural level. The current study was done to find pattern and prevalence of ENT diseases in rural areas of Sasaram, Rohtas, Bihar. Our institute, NMCH organized free health camps to cater those people residing in rural areas who rarely visit hospitals. It was an opportunity for interns of Community medicine to get training at rural field areas and learn more about ENT diseases.

The study shows that most of the patients with ENT diseases were from 4^th decade which corroborated with a study done by Singh et al.⁷ ENT problems are very much prevalent in geriatric population of India as also seen in this study.⁸ Male: female ratio of this study is 1.08:1 which could be due to male preponderance in population of India.⁹

The study shows Ear diseases to be most common in seeking medical advice. This study reveals that CSOM was most common among ear disease with a prevalence of 41.8%. Various studies in their ENT patients audits have shown CSOM to be the commonest problem. The burden of CSOM varies from place to place. Global prevalence rates estimates a range between 1% and 46%, our prevalence being on a higher side.¹⁰

Among nasal problems, allergic rhinitis was seen in 29.9% cases. Allergic rhinitis is often viewed as a trivial disease but it can significantly affect quality of life of patient. It is also closely related to asthma as 10-40% of people with rhinitis have concomitant asthma, According to WHO, the prevalence of allergic rhinitis ranges between 10% to 32% in Asia, very similar to our study.¹¹ Chronic rhinosinusitis is one the common problems encountered in ENT department. It does not affect a particular age or sex and is more common among patients with an upper respiratory tract infection.¹²

Sore throat was most commonly seen throat disease among people. In ENT practice, sore throat is one of the most common encountered diagnoses. It is also a common condition seen by general practitioners, paediatricians and internists. Majority of these cases are caused by viruses and only small amount are caused by Group A Streptococcus.¹³

In this survey, neck masses were seen in seven patients. Head and neck cancers in India are emerging as major health problem as they account for 30% and 16% of all cancers in males and females respectively. Most of them are difficult to manage, but being highly preventable, the emphasis, therefore should be on preventing the onset and detecting the disease at an early stage. So, camp approach is an important modality to detect these masses at the earliest.¹⁴

In this study it was found that overcrowding and lack of cross ventilation were important internal environmental factors influencing ENT diseases. Few studies have linked poor internal environment as a predictor of infectious diseases including CSOM. Studies have shown that there is a strong and sufficient evidence of the association between ventilation and the transmission and spread of infectious diseases. ^15-17 This study reveals a strong need for a multidisciplinary study investigating ENT diseases and impact of cross ventilation on spread of these diseases.

CONCLUSION

Health camps conducted by medical experts act as an opportunity to screen people with various ailments of ENT in community. Also, they can orient medical graduates towards health need of common people. Being a community based study, it reflects the exact magnitude and pattern of ENT diseases. It can be further used for proper planning and implementation of health programmes to tackle this public health problem.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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