Introduction
The reduction of avoidable hearing impairment through the integration of primary ear care into the primary healthcare system worldwide is a major focus of the World Health Organization.1 In 2004, over 275 million people globally had moderate-to-profound hearing impairment, 80 per cent of whom resided in low- and middle-income countries. In low-income countries, an important acquired cause of hearing impairment is persistent ear infection, which can lead to chronic suppurative otitis media (CSOM). In many low-income countries, especially within rural and semi-urban communities, the interplay of poverty and inadequate specialist ENT healthcare can lead to major problems in terms of the surgical management of CSOM.Reference Akinpelu, Amusa, Komolafe, Adeolu, Oladele and Ameye2 Furthermore, access to tertiary care and ear surgery clinics is limited and may not be available in more remote areas. The provision of mobile ear surgery units, which bring ear surgeons to such areas, is one solution to enable improved surgical ear care.Reference Homoe, Siim and Bretlau3
Ethiopia has about 84 million inhabitants and probably has less than 12 ENT specialists actively working in the capital Addis Ababa. This study reports on our attempts to optimise the pre-treatment process before mobile ear surgery for CSOM in Wolisso, a semi-urban community in the Oromia region, and in Attat, a rural community in the Gurage region, both in southwest Ethiopia.
Materials and methods
The study was carried out in St. Luke's Catholic Hospital, West Shoa Zone, Oromia region, and in Attat Hospital, Gurage region, in Ethiopia, between 2008 and 2010.
The travelling ear surgery team consisted of two or three experienced ear surgeons. The teams, which travelled two or three times per year to the hospitals, stayed between one and two weeks in each place, and typically visited both places consecutively. (The group of ear surgeons has since expanded such that more hospitals, other than the two mentioned, are served. For instance, Dutch ENT surgeons from the Eardrop Foundation now take an active part in the ENT service.4) The teams were supported by an Ethiopian nurse in the out-patient department of both hospitals. In Wolisso, ear surgery was performed under general anaesthesia with the help of an Ethiopian anaesthetics nurse and an operating theatre nurse. In Attat, surgery was performed under local anaesthesia and sedation with ketamine.
Some years before, the out-patient room in both hospitals had been equipped by one author (JJM) with two ENT examination units and a microscope. The operating theatres at both locations were equipped with standard ear instruments and another surgical microscope.
The major focus of the surgical charity work was to treat patients with CSOM, especially children. In order to optimise the pre-treatment process before surgery, three important steps were introduced: special training of a nurse to assist and later to maintain the out-patient department; organisation of scheduling for ear surgery and its performance; and optimisation of local treatment with ear drops prior to surgery.
Nurse training
One nurse in Wolisso and two nurses in Attat, all English-speaking, underwent special training. For instance, they took part in the general ENT lessons presented by the ENT surgeons as part of the education at St. Luke's Hospital Nursing School in Wolisso (Figure 1). In addition, the nurses were trained in: the principles of ear diseases, otoscopy, ear instruments, using microscopes for ear examinations and performing pure tone audiometry (Figures 2 and 3). Training in ear canal clearing, rinsing and regular suctioning, dry mopping, and placement of ear drops under otoscopic and microscopic control was emphasised for cases of chronic otorrhoea. It was important that the nurses could definitively identify eardrum perforations and evaluate eardrum closure after ear surgery.
Nurses in training receiving ENT education at St. Luke's Hospital Nursing School in Wolisso, Ethiopia.
Examination at the ENT out-patient department at Attat Hospital, Ethiopia. Routine examinations are combined with education for nurses in training. The trained nurse (left) is explaining an ear finding of a patient (sitting) to one of the teachers (centre) and another nurse in training (right). Published with patient's permission.
Examination at the ENT out-patient department at St. Luke's Hospital, Wolisso, Ethiopia. The specialist ENT nurse is performing pure tone audiometry. Published with patient's permission.
The nurses needed to have evaluated over 100 ear findings with correct diagnoses before they were allowed to examine ears independently. To achieve these otology skills, several sessions of ear examination of over 100 patients were performed during the first visits. The teacher and nurse sat side-by-side, and each ear was first examined by the nurse and then by the teacher.
Organisation of ear surgery
Two to four weeks before each ENT team visit, the consultation dates were announced at the out-patient department and circulated via word of mouth. Furthermore, selected patients, who had been pre-treated in-between two consultation dates by the specialist nurses using local ear care until a dry ear was achieved, were given appointments on the first day of the ENT team visit to plan their surgery. Based on the requirements of these selected patients and other patients visiting the out-patient department within the days that followed, a programme of ear surgery was planned for each week.
Pre-operatively, all patients were examined in the out-patient room. The patients were predominantly suffering from subtotal or total perforations. The surgeon took a short history and examined each patient, assisted by a nurse as an interpreter. All patients gave written informed consent for surgery. A tuning fork test was performed in all cases but audiometry only in some cases. Ear surgery was always performed unilaterally. The most frequently performed surgery was cartilage tympanoplasty with tragal cartilage, without ossiculoplasty. Patients with bilateral CSOM were treated in two stages and the second stage was not carried out until surgery on the first ear was deemed successful (i.e. definitive closure of the tympanic membrane). Patients were discharged the day after surgery with instructions (in Amharic language) on post-operative care. Sutures were removed after one week, in the out-patient department, by one of the specialist nurses. Further follow up was then organised.
Pre-operative ear drops
Access to and compliance using oral antibiotics was difficult to control. We therefore focused on local treatment. The assortment of ear drops available for local treatment was very limited, and consisted of chloramphenicol 1 per cent, ciprofloxacin 0.3 per cent and povidone (polyvinyl pyrrolidone) iodine 5.0 per cent.
In order to determine the optimal treatment, we collected middle-ear effusion specimens from 23 consecutive patients with CSOM in 2008 (discharge for longer than 6 months, eardrum perforation; patient age of 2–50 years, 10 female and 13 male). We used conventional sterile swabs (number 09.556.8056; Nerbe Plus, Winsen, Germany) and simple filter papers (item FT-3-101-045; Sartorius, Goettingen, Germany). The filter papers were dried at room temperature. The samples were transported at room temperature back to Germany. The analysis was performed two weeks later in the Institute of Medical Microbiology, University Hospital Jena, Germany (by MB). The swabs and filter papers were transferred to solid and liquid culture media. Bacterial and fungal isolates were identified using morphological and biochemical standard procedures.
Results
Nurse training and pre-treatment
After two years' ENT training with several intervals, the three ENT nurses were qualified to operate the two out-patient departments independently. They were able to detect eardrum perforation and to select patients with CSOM for surgery. The ENT nurses could prepare these patients optimally for surgery, by cleaning the affected ears with a suction device and by dry mopping. They could prescribe ear drops and explain their usage to patients. They organised the follow up sessions held in-between each ENT otosurgical team visit. Typically, 20–30 patients who had been prepared in this way were presented on the first day of the mobile team visit. Furthermore, the ENT nurses could remove the ear canal tamponades and the stitches at the follow-up visit one week after surgery, prescribe more ear drops if necessary and/or organise a further follow-up visit. Finally, the ENT nurses were qualified to determine the success of surgery in most cases, which was primarily reflected by definitive closure of the eardrum. For patients with other severe ENT diseases, it was recommended that they visit a hospital in Addis Ababa, or if justifiable wait to be seen by the mobile ENT team on their next visit.
Although chloramphenicol 1 per cent and polyvinyl pyrrolidone iodine 5.0 per cent were the favoured ear drops until 2008, ciprofloxacin 0.3 per cent became the local treatment of choice during the study period. The other ear drops were used if treatment with ciprofloxacin failed.
Microbiological investigations
Overall, the swabs were much more suitable for the analysis than the dried filter papers; Gram-negative bacteria were better conserved in the swabs.
Microbiological investigations of middle-ear discharge revealed that the most frequent Gram-positive pathogen was Staphylococcus aureus, which was found in eight patients (35 per cent). The most frequent Gram-negative isolates were enterobacteria and proteus species, which were found in eight patients (35 per cent) too. Polymicrobial involvement was common (18 out of 23 patients; 78 per cent), with up to 6 species present in one sample. Pseudomonas aeruginosa was found in only one case, as was Aspergillus niger (both 4 per cent). Other less pathogenic species identified were coagulase-negative staphylococci, enterococci, micrococci and corynebacteria. Anaerobic bacteria were not detected.
Service and surgical results
In the out-patient service in Attat, 4383 patients were examined in 2008, 4460 patients in 2009 and 2446 patients in 2010. In Wolisso, 1403, 1691 and 2337 patients were treated in the out-patient department in the years 2008, 2009 and 2010, respectively. Altogether (at both places), 64 tympanoplasties were performed in 2008, 101 in 2009 and 83 in 2010. Intra-operatively, a cholesteatoma was found in only two cases. Mastoidectomy was performed in 10 cases. Compared with earlier years, the surgery rate had more than doubled. Nearly all patients appeared at the first follow-up visit to have ear tamponades and stitches removed. Longer-term follow up was possible for 59 per cent of the patients, indicating a closure rate of 72 per cent after about six months.
Discussion
Fagan recently pointed out that the majority of patients in Sub-Saharan countries do not have access to even the most basic otological surgical treatments.Reference Fagan5 According to his calculation, the ratio of ENT surgeons per 100 000 population is less than 0.025 in Ethiopia (in the UK this figure is about 1). The presented structure, which was used to maintain a regular otosurgical service in a small area of Ethiopia, represents a small but important first step. In western Nepal, a programme for community ear assistants is very successful.Reference Youngs, Weir, Tharu, Bohara and Bahadur6 Workers receive intensive training in the diagnosis of ear diseases, and they are qualified to select patients for ear surgery. The present study showed that similar skills can also be obtained by specially trained nurses. It would be suitable to tether such an education to an Ethiopian health officer programme, of which several are running countrywide.Reference Force7, Reference Manni and Lema8
Worldwide, the predominant aerobic isolates in CSOM are Staphylococcus aureus, Pseudomonas aeruginosa and proteus species (to a lesser extent).Reference Brook9 This is in accordance with a recent study from northern Ethiopia, in which Staphylococcus aureus and proteus species were important pathogens in the study region (but Pseudomonas aeruginosa only played a minor role).Reference Abera and Biadeglegne10 The method we used for the microbiological investigations was limited by the long transport time between the collection and analysis of specimens. Therefore, the detection of anaerobic pathogens that might play a role in CSOM may not have been effective.Reference Brook9 However, the bacterial spectrum identified in our cohort corresponded to the flora expected in chronically discharging wounds. Furthermore, topical pre-treatment primarily with ciprofloxacin (which was fitting to the pathogen spectrum found) was highly effective. Similar results have been reported from South Africa.Reference Loock11 Two recent Cochrane reviews have confirmed the superiority of quinolone antibiotics over other topical treatment or systemic antibiotics to clear discharge in patients with CSOM.Reference Macfadyen, Acuin and Gamble12, Reference Macfadyen, Acuin and Gamble13 However, a potential future problem with the increasing topical use of ciprofloxacin drops is antibiotic resistance.Reference Jang and Park14
• Nurses were trained to pre-treat chronic suppurative otitis media (CSOM) patients
• This aided subsequent mobile ear surgery in a Sub-Saharan African country
• Pre-treatment consisted of regular cleaning, suctioning, dry mopping under microscopic control and topical treatment with antibiotic ear drops
• Staphylococcus aureus and proteus species were the important pathogens in CSOM patients in south-west Ethiopia (Pseudomonas aeruginosa played a minor role)
• In the absence of regular follow up, cartilage tympanoplasty appears highly effective for definitive closure of eardrum perforations
Finally, we believe that the predominant use of cartilage as robust transplantation material contributed to the reasonable closure rate of about 60–70 per cent for subtotal and total perforations, comparable to the results of other mobile ear teams.Reference Snidvongs, Vatanasapt, Thanaviratananich, Pothaporn, Sannikorn and Supiyaphun15, Reference Mohamad, Khan and Hussain16 A next step will be to have audiological assessment performed in all patients prior to and after otosurgery.
Conclusion
Specialist ENT nurses, with experience in ear mopping, suctioning and the diagnostic skills to detect a CSOM, in combination with a standardised pre-treatment protocol for patients with CSOM scheduled for tympanoplasty, helped to create optimal conditions for mobile ear surgery in the south-west of Ethiopia.
Acknowledgement
Parts of the study were supported by a grant from the German Academic Exchange Service (‘DAAD’ grant number 50023054).
