For otitis media in Australia, there’s an abundance of research and prevention activities, education, and management and treatment options. While there’s a long way to go in the fight against this pervasive condition, progress is being made. HPA examines some wins and innovations.
By the time an Australian child turns two, they’ve usually mastered a bunch of quintessential toddler milestones: wobbling into confident steps, perfecting the art of the tantrum and discovering the magic of playground slides. They’ve tasted their first choccy milk, learned to say “no” with gusto, and left a trail of half-eaten snacks throughout the house.
But there’s another milestone – far less charming – yet almost as universal. Most children will experience at least one middle ear infection, or otitis media (OM) episode, before blowing out their second birthday candles, according to the Australian Institute of Health and Welfare. And while it’s common, its impact on hearing, learning and quality of life can be anything but trivial.
One in four suffer repeat infections – recurrent or persistent OM – and for Aboriginal children, the figure increases to nearly one in two. This often results in hearing loss, requiring antibiotics and grommet surgery to insert tiny ventilation tubes and drain fluid from the eardrum. ENT surgeons perform about 35,000 grommet procedures a year in Australia to reduce risks of eardrum perforation, infection and improve hearing.
Indigenous Australian children have some of the highest rates of OM in the world, with prevalence in some remote communities reaching up to 90%. As a result, about 40% of Indigenous children aged 7–14 in remote areas have hearing loss, compared with 31% in regional areas and 23% in cities.
Overall, about 43% of First Nations people aged seven and over have hearing loss. Tragically, for some whose OM remains untreated for long periods, the damage is lifelong with permanent hearing loss requiring hearing aids, hearing implants or cochlear implants.
One organisation that’s had phenomenal success in reducing incidence and harm from OM is Earbus Foundation of Western Australia. Its model has listened to community and is based on multidisciplinary teamwork.
In 12 years, Earbus has delivered more than 100,000 occasions of care in some of the remotest communities in WA. Its staff see about 10,000 children a year.
The difference the program has made is immense. “Our stats are unbelievable,” says co-founder, audiologist Dr Lara Shur, recently nominated for an Australian of the Year Local Hero Award for her tireless work.
“Once our program starts in a community, it takes between nine and 18 months, and rates of otitis media will drop.
“Some communities have been as high as 60%, 70%, 80% but rates of chronic suppurative otitis media (CSOM) have dropped after our visits to below the World Health Organization benchmark of 4% – a rate the WHO determines is a public health emergency.”
Reduced CSOM rates
CSOM is a persistent infection of the middle ear characterised by a perforated eardrum and continuous or recurring ear discharge (otorrhoea.)
“Earbus has helped to reduce rates of otitis media in 200 communities in remote WA,” Dr Shur says. “This is evidence that our program works.”
South African-born Dr Shur previously worked at the world’s third largest hospital, Chris Hani Baragwanath Academic Hospital in Soweto where she saw many OM cases.
After migrating to Australia, she worked in several audiology clinics in Perth before joining not-for-profit children’s charity, Telethon Speech and Hearing (now TSH), where she enjoyed working with First Nations people.
There she met Mr Paul Higginbotham, former Telethon Speech and Hearing CEO and a teacher of the Deaf. The pair and nurse audiometrist Ms Dee Parker founded the not-for-profit Earbus Foundation.
Earbus staff travel in mini-buses and four-wheel drives to remote communities to check and wash ears, perform hearing tests, diagnose and treat otitis media, and educate the community about the insidious condition to reduce its incidence.
Earbus brings together experts from health, education, culture and communities.
“I’d known Dee for many years,” Dr Shur says. “She has a relationship with Aboriginal communities and people unlike anything I’ve ever seen before. The three of us sat around my kitchen table one afternoon. We’d been talking about this outreach idea and that day, we decided to do it.”
No wage for a year
None of the founders received a wage for at least the first year of the organisation.
“Our (life) partners supported us financially and were all involved in the formation of the foundation as they could see we were passionate about making a difference to children’s lives,” Dr Shur says.
“It was 2013 and there were very few services going to community.”
Higginbotham was a pioneer of the model of taking services to communities, she says, and between the three of them, they “found a solution to this problem that had persisted in Aboriginal Australia, which is how to get kids’ ears clean and get them hearing”.
“We went into some communities, and almost every child had discharge full of pus pouring from their ears,” Dr Shur recalls. “Our team had to upskill to wash ears because there was so much discharge.
“I remember saying to Paul and Dee, ‘This is what I used to see in Soweto and in the third world it’s kind of normalised, but we’re in Australia, a rich country with infrastructure – how can this be?’”
Solutions back then were mainly tertiary driven – seeing an ENT after damage to ears and hearing, she adds.
In their first year, the trio did 22 trips to areas such as Kalgoorlie and Port Hedland. They were on the road for more than five months in one car with equipment.
For four gruelling years they were on this conveyor belt of intensive work – flying in, being on the road all week, flying home, doing a week’s worth of paperwork and applying for funding (as the entire service was free for patients) ,then flying out again.
They changed things as they went along – if they saw improvements could be made, they did them. But none of it would have happened without the financial support of donors, Dr Shur says, and other incredible partners including audiologists who loaned them equipment as they had nothing when they started.
“I’d get on a plane and think, ‘I don’t know how I’m going to do it this week, I’m so tired’,” Dr Shur recalls. “But come Monday, the first child who walked into the room, we were on it – that was it; we loved seeing those kids.
“We’d regularly take a GP or nurse practitioner and antibiotics so if a child needed them, they could get them immediately.
“The kids got to know us, and we could really see the change in children and communities. In one community where we washed ears out constantly for four months, we returned a year later and were lucky if we washed out one ear.”
One GP wrote 28 scripts at a site but when she returned the next year, only wrote two.
“It’s a no brainer. If you take a doctor to a site once a month for a year, kids get better. It’s primary health care, it’s not waiting for tertiary treatment,” Dr Shur says. “The children referred to ENT are complex cases or needing surgery.”
Can’t hear, learn, earn
Dr Shur believes otitis media is pervasive because of the social determinants of health; environmental factors in many of these communities keep the pathology high.
“If we can abolish social determinants of health that we know affect children and are parts of the pathology such as poverty, lack of access to housing, water and healthcare, that is a huge part of the answer,” she says.
“We say, ‘can’t hear, can’t learn, can’t earn’. If you arrive at school and you’ve got otitis media you don’t hear the teacher, your speech and language is delayed, your literacy and numeracy isn’t what it should be.
“You don’t come out of school with a full education, so you don’t get a great job and are more likely to engage with juvenile justice. These are children, not adults, incarcerated with ear disease, and juvenile justice doesn’t allow people to come in and screen hearing.”
One study found many women screened at one of WA’s women’s prisons had ear disease or long-term ear pathology, Dr Shur says.
“Studies have also found 90% to 94% of incarcerated adults in the Northern Territory have some form of ear disease,” she says.
Primary prevention through programs such as EarBus aims to help halt these harrowing outcomes.
Earbus undertakes about 80 outreach trips a year and offers services in rural areas and Perth. It also treats adults with an 87-year-old being its oldest patient. “We don’t turn away anyone with ear troubles,” Dr Shur says.
Its permanent staff of six audiologists, five nurses, and a nurse practitioner are complemented by GP and nurse practitioner consultants who do several outreach trips annually. Local ENTs are also accessed wherever possible.
“But we’re only in WA and can’t get to some communities and towns because we don’t have enough funding,” Dr Shur says. “I don’t think a month goes by that someone doesn’t approach us and say, “I’ve seen your bus, I’ve seen your program, please come to us’.”
She believes other states would benefit from similar programs that are locally driven and have community buy-in. “You want local people to take the model and utilise it,” she says. “It is doable when we co-design with communities. They told us they wanted a regular, monthly visit, not every six months, the same people, rather than different ones every time, and they wanted all services to join up.
“They didn’t want to see one professional and wait for weeks to see another. This was across the board, whether in Esperance, the Pilbara or the Goldfields. They said, ‘make it easy for us, make us want to engage and we’ll come’.
“Families love their children; they will do the right thing if we just help them a bit.”
The deputy principal of one of the Earbus partnership schools sent Dr Shur an email stating Earbus had made a life-changing difference to the community. “She sees it on a day-to-day basis,” Dr Shur says. “It’s not just the kids who can now hear but the program’s also improved parent engagement at their school.”
Vaccine and Earflo
Earbus has also partnered with Griffiths University to partly fund researcher, PhD fellow Ms Ayesha Zahid, who is investigating an otitis media vaccine. “Surveillance, identification and treatment are great but if we can stop people from getting otitis media, we absolutely should,” Dr Shur says.
Earbus awarded Zayed its Professor Harvey Coates Scholarship named after its clinical patron, “an inspiring man who changed audiology and outcomes across Australia by bringing newborn hearing screening to Australia and WA”.
“Prof Coates was instrumental in bringing the idea behind the Earbus program to Australia from New Zealand,” Dr Shur says.
She predicts the Australian-made innovation, Earflo, will have a big impact on OM. “Those involved with developing it have done an amazing job,” she says “I think it’s going to change otitis media for the world. Ideally, every family would have an Earflo sippy cup; they’d start with this, and if it didn’t help, progress to a doctor and treatment.
“The cup pressurises through the nose. About 78% of kids who used it in a small Earbus trial improved from type B (OM with effusion) or C (developing infection or fluid buildup) to type A, which is normal.”
Earflo says ENT specialists and biomedical engineers developed the medical device, which is pending US Food and Drug Administration (FDA) approval. As a child drinks from the cup, its soft mask seals under the nose. Earflow senses the swallow and pushes air into their nose. This helps open the eustachian tube, and trapped fluid can flow out of the ear, relieving pressure and helping prevent hearing loss, Earflo says.
Spritz-OM
Two other Australian-developed OM innovations are Spritz-OM and Blitz-OM.
ENT surgeon Professor Shyan Vijayasekaran, who has worked at Perth Children’s Hospital for 20 years and been involved in OM research for 25 years, is involved in trialling both.
The Curtin University and University of Western Australia Clinical Professor says that, on one hand, much has changed in those two decades, but on the other, little has changed.
“Influenza vaccination in the early 2000s put a bit of a dent in rates of otitis media but only marginally because a lot of bacteria the vaccines covered were replaced by non-vaccine serotypes,” he says.
“Bacteria are smart, they’ve evolved and, like humans, they want to survive. You take one step in their direction, and they move in another. You get a vaccine which kills certain serotypes and another pops up.”
Research he has collaborated on includes studying which bacteria in the middle ear, nasopharynx and adenoids were associated with otitis media.
“We found Haemophilus influenzae was the culprit associated with the worst otitis media, and people who had it cultured from their nose or middle ear were far more likely to need a second set of grommets,” he says.
Further research showed Haemophilus hemolyticus placed on adenoid tissue in the lab displaced Haemophilus influenzae. In mice with Haemophilus influenzae-related middle ear infections, this replacement bacteria added to the nasopharynx stopped mice developing OM.
Research microbiologist Associate Professor Lea-Ann Kirkham and paediatric immunologist Professor Peter Richmond from The Kids Research Institute Australia in Perth turned this discovery into the nasal vaccine – Spritz-OM – to prevent ear infections.
It targets the major pathogen responsible for more than 50% of the 700 million annual ear infections worldwide.
“We’re now heading into Spritz-OM’s phase one clinical trials in humans,” Prof Vijayasekaran says.
Blitz-OM
Other research he’s participating in involves trialling the medicine Blitz-OM given during grommet surgery to help clear the infection and prevent the need for repeat surgery. Blitz-OM was developed by clinical research scientist Dr Ruth Thornton and her team at Wesfarmers Centre of Vaccines and Infectious Diseases at The Kids Research Institute of Australia.
One third of children require repeat ventilation tube insertion (grommets) for OM. Disease recurrence is associated with persistent middle ear bacterial biofilms – slime that protects bacteria, Prof Vijayasekaran says.
The drug dornase alfa (DNase) is used in cystic fibrosis to dissolve biofilm in the lungs and reduce thickness of secretions. In Blitz-OM, DNase is a liquid given during grommet surgery to try to disrupt biofilm in the middle ear. It breaks down biofilm, allowing antibiotics to penetrate and kill bacteria in the ear and the human immune system to attack and dissolve the bacteria.
“The liquid turns into a slow-release gel,” Prof Vijayasekaran says. “Our study using a single dose found the grommet extrusion rate and blockage rate was reduced in the ear of patients who had one dose (versus their other ear, the control ear).” A second study gave DNase for five days but results are not yet in. Further trials are approaching.
Other advances on the horizon include grommet guns to enable insertion under local, instead of general anaesthetic.
Perth has extensive waiting lists for grommet surgery which Prof Vijayasekaran says is due to insufficient theatre time as every speciality is competing for operating theatres. While category one surgery is always within a month and category two within three months, category three surgery waits have blown out to 12 months, he adds.
Prof Vijayasekaran says risk factors for OM include not being fully vaccinated, genetics, and daycare attendance. The ideal is smaller daycares, better ventilation, hand hygiene, and enforcing non-attendance for sick kids, but he agrees these are hard to achieve.
However, he says progress is being made.
Dr Shur adds: “There is so much hope for children, that’s the exciting part. The ideal is for Earbus not to exist, for no child to need our services because they’re all hearing well and reaching their full potential.”
Otitis media guidelines update
Work is underway on an update to otitis media guidelines which will include new treatments, says audiologist, Ms Sally-Anne Regan, Hearing Australia’s head of community services.
The Otitis Media Guidelines for Aboriginal and Torres Strait Islander Children 2020 were developed by experts in the field of ear and hearing health.
Regan says other good news includes more audiologists now have access to the portable Visually Reinforced Orientation Audiometry (VROA) hearing test that Hearing Australia and its research division, the National Acoustic Laboratories (NAL) pioneered.
Since 2019, Hearing Australia has run HAPEE (Hearing Assessment Program Early Ears) providing free services nationwide to First Nations children aged six and under.
Regan says HAPEE, which is an initiative of Hearing Australia and funded by the Australian Government, is vital, with more than 10,000 children in over 300 metropolitan, rural and remote locations accessing hearing services through the program each year. Recent analysis of its data found more than 26% of children it assessed have undiagnosed ear disease and one-in-five have undiagnosed hearing loss.
Additionally, 8% have persistent ear trouble and these are the ones who are most at risk. She says Hearing Australia works with surgeons, community controlled, and state and territory health services to develop and implement treatment pathways to minimise the time these children experience ear disease and hearing loss.
A further 35% have fluctuating ear disease where otitis media changes over time and need ongoing monitoring as they may progress to chronic disease.
“According to our data, these percentages have not shifted significantly over the past six years,” Regan says. But Hearing Australia isn’t seeing a high rate of perforations, she says, and believes this reflects a change in disease patterns from the more severe chronic suppurative otitis media – associated with perforations – to otitis media with effusion or glue ear.
“Both problems require specialist attention,” she says. “OME can be treated successfully at an early age whereas repair of perforations is not usually undertaken until the child is at school. Assuming children have access to the required ENT treatment, early identification can reduce the amount of time spent with hearing loss and its effects on development.”
Hearing Australia works with communities to design services to meet local needs. Through HAPEE, Hearing Australia’s team has supported the upskilling of more than 1,000 health workers in hearing health.
Additionally, the PLUM (parent-evaluated listening and understanding measure) tool, developed by NAL, is available to everyone. The questionnaire helps early childhood educators and health workers ask parents about their child’s listening behaviours to help identifying kids likely to have long term ear and hearing trouble. Hearing Australia can train health practitioners who wish to use the tool.
“Hearing Australia is striving to halve the rate of hearing loss in Aboriginal and Torres Strait Islander children by 2029,” Regan says. “This is an ambitious goal and one that we cannot achieve on our own. Through HAPEE, we’ve taken important first steps towards this by raising awareness of the need for early identification and treatment and by working with our many partners to streamline and strengthen referral pathways.”
The HAPEE program also integrates with Hearing Australia’s rehabilitation services, ensuring timely provision of amplification devices whenever required, Regan says.
“Reduction in the rate of chronic disorders is going to take time, but we believe that by 2029 there should be significant improvements,” she says. “We’ll continue to work closely with our many amazing partners to improve the ear and hearing health outcomes of First Nations children.”
