Overview of Child Otological Care at the Reference Health Center of Commune V, Bamako ()
1. Introduction
Ear pathologies were estimated at 66.4% of our consultations [1] . Some of its symptoms or functional sequelae such as deafness can constitute a disability at all ages [2] [3] . This handicap is serious in children and much more in toddlers who have not yet acquired oral language [2] . The Malian population is characterized by its youth. Children aged 0 - 15 years were assessed and represented 50.1% of the population [4] .
In a context of underdevelopment and under-medicalization in a country at war for the past 10 years, the priorities are multiple. Taking care of children’s otological problems in Mali can naturally take a back seat. They are often overlooked by inattentive parents because they may be invisible. In order to tackle this scourge head-on, awareness-raising by all means remains essential. Few studies have been conducted globally on these pathologies in children in health structures in Mali. The few publications deal with specific problems such as deafness among others [5] .
2. Objective
The objective of this work was to determine the epidemiological, clinical and therapeutic profile of otological pathologies in children.
3. Methodology
The Ear Nose and Throat and Head and Neck Surgery (ENT-HNS) unit of the Commune V Reference Health Center (CSRéf CV) served as the framework for our study.
The Reference Health Centers (CSRéf) is the second level of the health pyramid of Mali (directly after the community level). Their vocation is essentially dedicated to the mother and the child (Maternity) health care. To avoid many patients going to first referral hospitals due to the absence of intermediate structures in Bamako, specialized units have been gradually created within CSRéf. Bamako has six CSRéfs distributed in each municipality.
This was a prospective descriptive study conducted at the ENT unit of the Reference Health Center (CSréf) of Commune V of the District of Bamako. Patient recruitment has taken place for one month from March 1 to March 31, 2022 in an ordinary outpatient setting. Follow-up was provided until May 30, 2022. We included all new patients from 0 to 15 years who suffered from an ear condition. Furthermore, patients admitted to another department requesting an ENT opinion and patients lost to follow-up were not included. The variables to be studied were the elements of the interview, the results of the physical examination, functional exploration and imaging if necessary, the diagnosis, the treatment and the follow-up parameters. A systematic appointment was given to each patient depending on the case from 24 hours to one week.
These data were collected on an individual survey form, from the medical file and the consultation register. They were entered and analyzed using SPSS® 22.0 software.
4. Results
4.1. Epidemiological Data
4.1.1. Frequencies
We identified 184 children suffering from otological conditions out of a total of 559 patients (276 children “49.4%” and 283 adults “50.6%)” consulted during the month of March, i.e. a hospital prevalence of 32.9%. Thus, the prevalence of otological pathologies in pediatric population was 66.7%.
4.1.2. Sex
Boys represented 56.5% (104 cases) and girls 43.5% (80 cases). The sex ratio was 1.3.
4.1.3. Age
Children under three years of age accounted for 41.3% (Table 1).
The mean age was 4 years and 5 months with a standard deviation of 4 years. The extreme ages were 2 months and 14 years.
4.2. Clinical Study and Explorations
Otalgia was present in 41.3% of patients, rhinorrhea in 57.6% and otorrhea in 35.3% (Table 2).
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Table 1. Distribution of patients according to age group.
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Table 2. Distribution of the study population according to reasons for consultation.
The onset of the disease did not exceed 24 hours in 27.7% of cases. Self-medication was done in 27.7% of patients before the consultation. Recurrent nasopharyngitis was found in 89.1% of patients. One 4-year-old child (0.5%) had asthma in the study. Overbreathing and overuse of incense were found in 84.2% and 66.3% of patients, respectively. The other environmental factors responsible for the severity or recurrence of nasopharyngitis are listed in Table 3.
Children were correctly vaccinated in 92.9% of the cases. Childcare was provided by mothers in 46.7% (86 cases). They were kept in the public child care in 13%. Other family members and housekeepers performed this role in the rest of the cases (40.2%). Breastfeeding was mixed before six months in 63.4% of the 71 children who were not yet weaned during the study period.
The concept of consanguinity of parents was found in 30.4% of patients. Otoscopy was normal in one patient (0.5%) and pathological in 183 patients (99.5%).
Auditory Steady State Response (ASSR) and impedancemetry were performed in three patients. They were two cases of severe (80 dB) bilateral pre-lingual hearing loss and one case of moderate (50 dB) bilateral symmetrical conductive hearing loss with normal post-lingual otoscopy. The case of moderate deafness had been evolving spontaneously for a year. The child was 13 years old. A case of severe deafness (3 years) was associated with cerebral palsy (CMI) followed in Pediatrics and Functional Rehabilitation. The other case of severe deafness was 27 months old. He was from 2nd degree consanguineous parents and had a prelingual deaf older brother.
There was a decrease in compliance of both tympanic membranes in all three patients. The stapedial reflex was present in two cases and absent in the other case (IMC). The temporal bone tomodensitometry could not be performed in all three cases.
On the diagnostic level (Table 4), otitis had represented 60.3% (111 cases). Earwax and epidermal plug accounted for 32.6%. Traumatic pathology accounted for 4.3%. Functional pathology (deafness) was 1.6%.
4.3. Treatment
Oral antibiotics and analgesics-antipyretics (Table 5) were used in 66.3% and
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Table 3. Distribution of patients according to contributing factors.
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Table 4. Distribution of patients according to diagnoses.
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Table 5. Distribution according to the pharmaceutical classes used.
73.4% of patients respectively for treatment.
The combination Amoxicillin + Clavulanic Acid was used in 46.2% of patients. Paracetamol was used in all patients who had received analgesics. The 8 cases of otitis media with effusion (4.3%) did not require drainage by a tympanostomy tubes. Medical treatment (nasopharyngeal disinfection, corticosteroids, suppression of factors favoring tubal dysfunction) alone was sufficient.
4.4. Evolution
During the follow-up, we were able to verify that 93.5% of the patients had a favorable evolution after the care within a period varying from immediately to three weeks. The two cases of severe deafness were candidates for cochlear implantation. A total of 12 patients (6.5%) were lost during follow-up, including the cases of average conductive deafness with normal otoscopy and the patient chronic otitis media with perforation.
5. Discussion
5.1. Limitations
The limitations of this study were:
• The short duration of the study that was only three months. This was motivated by an archiving problem. There are no electronic media or data server for electronic saving allowing the management of the consultation at the CSRéf. The files are drawn up on paper. The difficulties are:
- Very frequent homonyms, *Patients who do not bring old documents back often enough for a new consultation. However, we have opted for an arrangement of the files according to the date of the consultations and in alphabetical order.
- Workload: A single medical specialist with four medical assistants receiving 500 to 600 patients per month in difficult working conditions (cramped consultation and treatment rooms, dilapidated and rudimentary equipment, lack of air conditioning in a hot country en work space).
• Absence of microscope and aspiration allowing a good otoscopy. The alternative found is cotton swabs, portable otoscopes, makeshift oto-endoscopes after careful examination with a frontal mirror light.
• Absence of functional exploration. It was always performed outside, extending the circuit for patients who needed it.
• Failure to take into account cases treated in other units (Medicine, Paediatrics); the corollary of which is an underestimation of the real frequency of patients suffering from these pathologies and treated within the CSRéf.
• Lost patients: We most often assume that they have been cured or to a lesser extent that they have not been satisfied and have had to seek an alternative (conventional medicine in another structure or traditional medicine).
• The unavailability of means for bacteriological examination (no suction device allowing the trapping of pus so that it is not contaminated and the unavailability of infrastructure in the laboratory for this purpose). As a result, antibiotic therapy was probabilistic.
5.2. Epidemiological Data
5.2.1. Frequencies
Childhood otological pathologies accounted for 32.9% of our consultations. In the ENT pediatric population, the prevalence was 66.7%. Tall in Kolda (Senegal) and Ilechukwu G C in Nigeria had respectively found that otological pathology represented 33.9% and 63.3% of pediatric ENT recruitments [6] [7] .
5.2.2. Sex
ENT pediatric affected both boys and girls with a male predominance. Vodouhe in Benin had found a female predominance by studying otological pathologies in general [8] . Whereas in India and Treichville (Ivory Coast), the predominance was male respectively in the study of childhood ENT pathologies and otological pathologies [9] [10] .
5.2.3. Age
Children under three years old predominated (41.3%) in this study. The average age was 4 years and 5 months. The predominance of this age group is related to the high incidence of upper respiratory tract infections in this period. It is essentially nasopharyngitis that reaches the middle ear through the Eustachian tube [6] . Tall found an average age of 6 years [7] .
5.3. Clinical Study and Explorations
5.3.1. Examination
Otalgia was present in 41.3% of patients, rhinorrhea in 57.6% and otorrhea in 35.32%. The extremely painful nature of these pathologies may partly explain why 27.7% of patients consulted within 24 hours [11] . This pain could easily lead to self-medication, which is a real public health problem [12] [13] . In general, Paracetamol can be enough to temporarily relieve this pain [13] . This self-medication was practiced by 27.7% of our patients. This is often an altruistic desire to help and protect the child on the part of adults. The risk for antibiotics is a disturbance of the immune system and other side effects when it is not suitable and especially the emergence of resistance [12] . Ear drops pose a risk of ototoxicity and Paracetamol usage can lead hepatotoxicity [12] [13] . Do Santos had found 47.88% self-medication in his ENT patients at the Military Teaching Hospital Cotonou in Benin [12] . This self-medication could be motivated by the low-income power of the populations. Health expenditure follows a more dynamic upward trend than that of economic growth in developing countries [12] [14] . Other more affluent patients practice it for lack of time [14] . It is actually a real ignorance of the danger of this scourge [12] [13] . Otorrhea is a late sign that worries some parents while under the weight of culture, others trivialize it. Recurrent nasopharyngitis was found in 89.1% of patients. Several associated environmental factors were observed in these children as previously described by other authors. Indeed, any exogenous irritant factor (pollution, smoking) can be partly responsible for the genesis of these pathologies [15] [16] .
5.3.2. Diagnoses, Treatments and Evolution
Otitis accounted for 60.3%. This observation of the predominance of infectious pathologies is in agreement with other authors findings [6] [9] [17] [18] . Acute otitis media (AOM) alone accounted for 50% of the study. It was followed by cerumen and epidermal plugs which represented 33.2% of diagnoses. These facts agree with previous studies [6] [8] [14] . Earwax plugs may be related to overuse of cotton swabs by parents or patients or may be related to excessive earwax production or particular anatomical conditions [7] [8] . The peak incidence of otitis media in children usually occurs during the first two years of life [16] . Most children have at least one episode of AOM. The incidence, estimated in a rather variable way, is maximum between 6 and 11 months. Before 3 years, more than half of children (50% to 85%) will have had an episode of AOM [19] [20] . It is due to the specific anatomical structure of the upper respiratory tract of young children and the tendency of children to spend a lot of time outdoors with mothers in our regions [16] [19] . In fact, their auditory tube is short, gaping and horizontal [19] . Fasunla in his study, had found 41% of acute otitis media in children by studying ENT pathologies. This was the most frequent ENT pathology [14] . They are favored by dysfunction of the auditory tube, inflammation or chronic obstruction of the upper airways and by the fragility of the local terrain (local immunity, allergy) [9] . The interaction between poverty and ignorance is a major factor in the development of otitis media in our countries with limited resources [6] [14] .
For treatment, nasopharyngeal disinfection and analgesics are necessary. Antibiotic treatment is necessary in the case of bacterial AOM, especially if the child is an infant and the symptoms persist and worsen. Amoxicillin + Clavulanic Acid are widely used as the first treatment intention. The evolution is most often favorable with a cure in 80% - 90% of cases [3] [19] . When poorly treated, acute otitis media can progress to recurrent otitis media with effusion, mastoiditis, labyrinthitis, meningitis, middle ear cholesteatoma, or other forms of chronic otitis media [3] [6] . We found 1 case of chronic otitis media with tympanic perforation and 4.3% of Otitis Media with Effusion (OME) which is the mother of all forms of otitis media [15] . It is recognized that OME probably affects all children at some point in their early years. Their pathogenesis involves a locoregional inflammatory state of probably multifactorial origin. Whether or not it is complicated by acute infectious accidents (realizing what we define by the acronym SIAC or secretory and/or infectious accidents of childhood); they raise the question of their place and their possible initiating role in the history and development of the various forms of chronic otitis media [21] . Ologe in Nigeria reported a prevalence of chronic otitis media among schoolchildren in a rural community at 73 per 1000 students [14] .
Otitis externa is a common infection in children 5 - 14 years old. Earwax is acidic and contains lysozyme which can inhibit bacterial growth to help protect the external ear canal. It is likely that changes in the environment (water, heat, scratching) of the canal can predispose to otitis externa. They may be related to the use of soiled ear washing instruments [22] [23] .
Traumatic pathology concerned 4.34% of children. In the ENT trauma profile presentation, Adegbiji found that 50% of these lesions involved the ear. They can be complicated by otitis [24] . Foreign bodies in the ear were relatively rare (1 case). Children are very curious, eager to explore their surroundings and probe their head and neck orifices. They constitute emergencies depending on their nature [14] [25] . These ear foreign bodies were the second most prevalent ENT condition among children in a hospital in Nigeria [14] . However, ENT foreign bodies constituted 1.42% of our consultations in a previous study. These were mainly children (72.05%). Auricular location accounted for 58.83% [25] .
Functional pathology (deafness) accounted for 1.6% (3 cases). Deafness is an important health problem in developing countries [14] [26] . When it is congenital, the impact is major on the lives of affected infants and their families. It is said that two out of three deaf people in the world live in developing countries. Reasons may include lack of appropriated programs for early diagnosis, prompt treatment, low income, poor education and poor access to great medical services [14] . Hearing rehabilitation after etiological treatment if possible is important for a better quality of life [14] [27] .
6. Conclusions
Childhood ear pathologies were dominated by otitis. Children under the age of three were the most affected. Earache, otorrhea and rhinorrhea were the main symptoms observed. When they are well treated, the evolution is most often favorable. Otherwise, they can develop into complications. Although these pathologies are not integrated into priority health policies, they can be a source of serious disability, in this case deafness. Financial constraints, ignorance and often negligence are factors that contribute to delayed diagnosis and therefore treatment. Raising awareness is essential in order to prevent and cure them. It requires massive awareness-raising among the population and political decision-makers involvement.
Improving the level of existing health infrastructure and greater accessibility to care constitute the way forward to minimizing the impact of these conditions. Universal hearing screening must be more than a reality as a prelude to a vast national program for ear health.
Funding Statement
The authors declare that they have not received any specific funding for this work.