Acta Pdiatrica ISSN 08035253

REGULAR ARTICLE

Chronic suppurative otitis media in children of Luanda, Angola

Anni Taipale (anni.taipale@fimnet.fi)1,2,3, Tuula Pelkonen2,3,4, Marko Taipale3,4, Luis Bernardino3, Heikki Peltola2,4, Anne Pitkranta1,2
1.Department of Otorhinolaryngology, Helsinki University Central Hospital, Helsinki, Finland
2.Helsinki University, Medical Faculty, Helsinki, Finland
3.Hospital Pediatrico David Bernardino, Luanda, Angola
4.Helsinki University Central Hospital, Hospital for Children and Adolescents, Helsinki, Finland

Keywords
Bacterial aetiology, Children, Developing countries,
Hearing impairment, Otitis media

ABSTRACT
Aim: Evaluation of clinical characteristics, bacteriology and hearing in paediatric

Correspondence
A Taipale, Department of Otorhinolaryngology,
Helsinki University Central Hospital, Helsinki,
Finland.
Tel: +358 44 35 19 607 |
Fax: +358 47 17 5010 |
Email: anni.taipale@fimnet.fi

Methods: Interview, clinical examination, ear-discharge culture, open air pure-tone

Received
29 November 2010; revised 14 January 2011;
accepted 21 January 2011.
DOI:10.1111/j.1651-2227.2011.02192.x

patients with and without chronic suppurative otitis media (CSOM) in Luanda, Angola.
audiometry and brainstem auditory-evoked potentials of 23 outpatients with CSOM and
23 controls in a paediatric hospital.
Results: Of the CSOM vs. control children, 35% vs. 26% had running water, 70%
vs. 70% electricity, 64% vs. 0% HIV (p < 0.0001) and 36% vs. 0% tuberculosis in history
(p = 0.002). Ten (43%) children had bilateral CSOM. The major ear-discharge pathogens
were Proteus spp. (44%) and Pseudomonas (22%). Hearing impairment of >25 dB was
present in 52% of CSOM-affected ears and bilateral hearing loss in 7 (30%) CSOM
children vs. zero control child (p = 0.009). Only one hearing-impaired childs family had
previously detected the handicap.
Conclusion: CSOM occurred in children with high co-morbidity. Persistent otorrhoea
was usually caused by Proteus spp. or Pseudomonas, and often suggestive of either HIV or
hearing impairment. In the developing countries, prompt diagnosis and treatment of CSOM
would enhance the childrens linguistic and academic development.

INTRODUCTION
Chronic suppurative otitis media (CSOM) is a chronic
infection within the middle-ear cleft and mastoid cell system, producing persistent otorrhoea through a perforated
tympanic membrane. In the developing countries, the condition often develops as acute otitis media, failing to resolve,
leads to tympanic perforation and purulent ear discharge.
In these countries, childhood CSOM, usually a localized
infection without systemic symptoms, may not be
considered a disease needing special attention. Therefore,
the incidence, characteristics and consequences of CSOM
for children in the developing countries are not well characterized.
Chronic otitis most heavily affects certain indigenous
populations, such as those living in Australia (1) and Western Pacific (2). Among these groups, as well as others, environmental factors predisposing to the disease include
crowding (36), malnutrition (2,5) and exposure to contaminated water (2). The main aerobic organisms involved

include Staphylococcus aureus, Pseudomonas and Gramnegative enteric rods (1,2,710). In the resource-poor developing countries, childhood CSOM is one of the leading
causes for acquired hearing loss, carrying potential adverse
effects on the childs linguistic development (11).
In the African countries, previous paediatric chronic
otitis data, mainly concerning school-age children, suggest that hearing loss occurs in the majority of cases.
Data from younger children are sparse (913). An earlier
report from Angola shows that chronic otitis affects a
substantial portion, up to 4.6%, of schoolchildren (10).
Our aim was to evaluate CSOM-associated morbidity,
middle-ear bacterial aetiology and the hearing status, in
comparison with disease-free controls, among children in
Luanda, Angola.

Key notes

Abbreviations
BAEP, brainstem auditory-evoked potentials; CSOM, chronic
suppurative otitis media; PTA, pure-tone audiometry; WFA,
weight-for-age.

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CSOM occurred with high co-morbidity in children of a

developing country.
Proteus spp. and Pseudomonas were the major causative agents for CSOM.
Hearing loss was common in children with CSOM,
but only one childs family had previously detected the
handicap.

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Taipale et al.

CSOM in children of Luanda

CHILDREN AND METHODS

Children
The study was conducted during JanuaryJuly 2008 in the
Pediatric Hospital (Hospital Pediatrico) of Luanda, Angola.
The study protocol was approved by the hospitals ethics
committee, and informed consent was obtained from the
childrens guardians. Twenty-three consecutive outpatients
with CSOM, defined as ear discharge for at least 2 months,
were recruited. Twenty-three consecutive age- and gendermatched control children without otorrhoea were collected
among children who attended surgery consultation at the
Pediatric Hospital.
Clinical variables and microbiology
A paediatrician, two general practitioners and a nurse examined the children. The examination comprised an interview
concerning childs living conditions, vaccinations, previous
state of health, ear or hearing problems, a clinical physical
examination and ear, nose and throat status, pneumatic
otoscopy and hearing tests. HIV positivity was diagnosed by
a specific antibody-detecting test (Hexagon HIV Human,
Wiesbaden, Germany) at the hospitals HIV polyclinic.
Malnutrition was defined as weight-for-age (WFA) under
)2 SD of the mean. Children with fever, cough, tachypnoea
and crepitation during auscultation of the lungs were diagnosed with pneumonia. Ear-discharge samples were
obtained from the external auditory canal with a sterile cotton swab. Bacterial cultures were available from 18 ears. In
bilateral otorrhoea, the side with more profuse otorrhoea

was sampled. The specimens were gram-stained, cultured

under aerobic conditions, analysed and tested for antimicrobial susceptibility in the hospital laboratory according to
the norms of the National Committee for Clinical Laboratory Standards.
Hearing
Pure-tone air-conduction audiometry (PTA) was performed
without masking tones at frequencies of 125, 250, 500,
1000, 2000, 4000 and 8000 Hz (Midimate 622 Clinical Diagnostic Audiometer; Madsen Electronics, Taastrup,
Denmark) in 18 children over 5 years (8 with CSOM, 10
controls). The average hearing thresholds of 500, 1000,
2000 and 4000 Hz were counted and graded according to
WHO standards (25 dB for normal hearing, 2640 dB for
slight, 4160 dB for moderate, 6180 dB for severe and
81 dB for profound hearing loss). Brainstem auditoryevoked potentials (BAEP) were screened in the remaining
28 children (15 with CSOM, 13 controls) not capable of
performing PTA at 40, 60 and 80 dB (Bera MADSEN Octavus system v.2.001, Windows XP 2000 compatible; GN
Otometrics, Taastrup, Denmark). A response observed at
40 dB was considered normal, whereas a response at 60 dB
corresponded with moderate, 80 dB with severe and a complete lack of response with profound hearing loss.
Statistics
Data were analysed with the Statview (v.5.0.1; SAS Institute Inc., Cary, NC, USA) statistics program. The Fishers

Table 1 Background and characteristics of 23 children with chronic suppurative otitis media (CSOM) and 23 control children of Luanda
CSOM children (%)
Female
Median age in months (range)
Median size of household (range)
Total
Children
Running water at home
Electricity
Attendance at national vaccination programme
Median duration of breastfeeding, months (range)
Malaria, earlier
Tuberculosis currently or earlier
HIV positivity
Malnutrition
Acute pulmonary infection
Rhinorrhoea
Tonsils grade 2+
Cervical lymphadenopathy
Ear pain (currently or earlier)
Earlier episodes of otorrhoea
Subjective hearing impairment
Hearing impairment observed by guardian
Hearing impairment in family

11 (48)
51 (13138)
6 (311)
2 (17)
8 (35)
16 (70)
20 (87)
18 (124)
20 (87)
8 22 (36)
14 22 (64)
8 (35)
9 (39)
9 (39)
3 (13)
15 (65)
23 (100)
23 (100)
2 (9)
3 (13)
6 (26)

Control children (%)

p value

11 (48)
54 (10150)
6 (311)
3 (17)
6 (26)
16 (70)
17 (74)
18 (337)
21 (91)
0
0
2 (9)
1 (4)
5 (22)
7 20 (35)
5 (22)
3 (14)
0
0 (0)
0
8 (35)

0.96
0.58
0.75
>0.99
0.26
0.11
>0.99
0.002**
<0.0001***
0.07
0.01*
0.34
0.16
0.007**
<0.0001***
<0.0001***
0.49
0.23
0.75

During several hours 12 times daily through public electric transmission.

Clinically healthy children not tested for HIV.

In children over 6 years.

*p < 0.05, **p < 0.01, ***p < 0.001.

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CSOM in children of Luanda

Taipale et al.

exact and Pearsons chi-square tests were used for nominal,

and MannWhitney U test was used for nominal vs. continuous variables, and p values of <0.05 were considered statistically significant.

RESULTS
Characteristics of the children
Table 1 shows the background and clinical characteristics
of the two study groups. Compared to the control children,
the children with CSOM significantly more often presented
with tuberculosis (p = 0.002), HIV (p < 0.0001), acute pulmonary infections (bronchitis and pneumonia; p = 0.01),
cervical lymphadenopathy of >1 cm (p = 0.007) and earlier
episodes of ear pain (p < 0.0001) and otorrhoea
(p < 0.0001).
Characteristics of CSOM
Of the 23 children with CSOM, 10 (43%) had bilateral disease (18 ears right, 15 left). The median duration of otorrhoea was 12 months (range: 2 months7 years). Fourteen
(61%) children were receiving antibiotic treatment, an oral
combination of sulphonamide and trimethoprim (12), local
topical gentamycin (1) and intravenous ceftriaxone and
cloxacillin (1). Six (75%) of the eight CSOM children with
tuberculosis were HIV positive. Eleven (79%) of the 14
HIV-positive CSOM children were receiving antiretroviral
treatment. One CSOM child showed delayed speech resulting from neonatal meningitis. None manifested facial nerve
dysfunction or bacterial mastoiditis.
Bacteria and antibiotic susceptibility
The typical pathogens derived from the ear-discharge samples were Proteus (44%) and Pseudomonas (22%). All successful cultures yielded one bacterial isolate (Table 2).
Among the Gram-negative bacteria, resistance occurred
against amoxicillin in 64%, amoxicillinclavulanic acid in
60% and trimethoprim-sulpha in 71%. All tested strains were
susceptible to ceftriaxone, ceftazidime and ciprofloxacin.
Otoscopy and hearing
Table 3 shows the gender, age, otoscopy and hearing thresholds of each child with CSOM. The total occurrence of
hearing loss in the CSOM group was 17 33 (52%) in the discharging ears and 3 13 (23%) in the dry ears. Seven (30%)
CSOM vs. zero control children (p = 0.009) had bilateral

Table 2 Bacteria in 18 ear-discharge cultures from children with chronic suppurative

otitis media in Luanda
Proteus vulgaris
4
Proteus mirabilis
3
Proteus
1
Pseudomonas aeruginosa
3
Pseudomonas
1
Shigella
1
Haemophilus influenzae
1
Contaminated or negative culture
4

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hearing impairment (slight 2, moderate 3 and severe 2), and

at the interview, one (14%) of these children reported poor
hearing. Regarding the possibility of ototoxicity, the bilaterally hearing-impaired children reported antiretroviral drugs
in 3, anti-tuberculotic medication in 1 and previous administration of quinine in one case. No previous cerebral infections were reported. Otoscopy of the control children
showed an intact tympanum with normal mobility in 36
(78%) ears and cerumen impaction in 10 (22%). One control child with intact tympanic membranes had slight unilateral hearing loss (average hearing threshold in PTA 26 dB).

DISCUSSION
This study suggests paediatric CSOM in Luanda occurs in
children with poor living conditions and high co-morbidity.
One-third of the patients lived in households without electricity and two-thirds without running water. One-third
appeared malnourished in terms of low WFA. Previous
studies have identified malnutrition (2,5) and exposure of
auditory canals to contaminated water (2) as risk factors for
CSOM. The proportion of malnourished children in this
study falls between the 27% among the CSOM children of
Solomon Islands (2) and 37% in Nigeria (5). In this study,
however, the control children shared the same characteristics, which may in fact be the general reality of children in
the developing countries.
The most striking feature of our studys CSOM children
was HIV positivity, found in over 60%. Even though paediatric HIV infection is known to associate with chronic otitis
(13,14), reports concerning the role of HIV among the risk
factors for CSOM in the developing countries were unavailable. Considering the recently published epidemiological
data from Angola (15), showing a markedly low HIV prevalence among the adult population (3.7%), our data suggest
HIV is real risk factor for CSOM in children of Luanda.
When encountered in health care units, children with
CSOM should always be tested for HIV positivity. Another
finding, the higher prevalence of respiratory tract infections
and tuberculosis among the CSOM children, may also
partly derive from the childrens HIV positivity,
compromising their general immunity. In our CSOM group,
female gender characterized the children with both HIV
and tuberculosis; otherwise, the disease profile in this
subgroup equalled rest of the CSOM children.
Each of our successful ear-discharge cultures yielded one
bacterial isolate, with a predominance of Proteus and Pseudomonas species. S. aureus was not detected. The majority
of the strains proved resistant against common oral antibiotics, but not resistant to third-generation cephalosporins
and ciprofloxacin. Previous CSOM reports from the developing countries described cases of varying and often
polymicrobial bacterial aetiology, mostly including Gramnegative rods and S. aureus (7,9,10,1618). In addition, previous studies from the developing countries have detected a
resistance pattern resembling ours (10,17). Given the natural resistance of gram-negative rods to the traditional oral
antibiotics, as well as the limited local availability of topical

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Taipale et al.

CSOM in children of Luanda

Table 3 Gender, age, hearing and otoscopy in 21 children with chronic suppurative otitis media in Luanda
Child

Gender, age (months)

HIV tuberculosis

Right ear (otoscopy hearing threshold dB)

Left ear (otoscopy hearing threshold dB)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

M, 95
M, 96
M, 80
F, 43
F, 138
M, 92
M, 49
F, 50
M, 94
M, 28
M, 51
F, 22
F, 24
M, 51
F, 20
F, 65
M, 61
F, 13
M, 14
M, 24
F, 37
F, 69
F, 127

))
++
+ unknown
))
))
)+
)+
)+
+)
))
)+
)+
++
Unknown +
))
++
)+
)+
))
))
++
++
++

Suppuration 48*
Suppuration 28*
Normal TM 24*
Suppuration 40
Suppuration 25*
Suppuration 45*
Suppuration 40
Suppuration 60
Suppuration 40
Middle-ear effusion 40
Suppuration 80
Suppuration 40
Suppuration 40
Suppuration 60
Suppuration 80
Suppuration 29*
Suppuration 40
Suppuration 40
Suppuration 40
Dry perforation 40
Suppuration 40
Dry perforation 31*
Retracted TM 30*

Suppuration 41*
Suppuration 24*
Suppuration 63*
Dry perforation 40
Dry perforation 28*
Suppuration 41*
Normal TM 40
CI 40
CI 40
Suppuration 60
Suppuration 80
Suppuration 40
Suppuration 40
Suppuration 60
Suppuration 80
Dry perforation 23*
Suppuration 40
CI 40
CI 40
Suppuration 40
Suppuration 40
Suppuration 41*
Suppuration 33*

*Obtained in pure-tone audiometry.

Tympanic membrane.

Cerumen impaction.

quinolones and intravenous antimicrobials, our result was

not surprising. However, our results may have been affected
by contamination from external ear regular flora, as we had
no opportunity to use sterile syringes in sampling. The prevalent role of Proteus among our CSOM children may
reflect either the unavailability of clean water, as discussed
in a report from Malawi (8), or the childrens high HIV positivity, predisposing them to infections by low-virulence bacteria. The lack of S. aureus detection remains unclear and
may, because of the relatively small sample size, even be
coincidental. We did not perform Mycobacterium culture,
so could not verify the possibility of tuberculotic otorrhoea.
In our study, 52% of the CSOM-affected ears presented
with hearing impairment. The percentage is slightly lower
than in earlier studies from Australia, Nigeria, Angola,
Kenya and Sierra Leone, exhibiting figures of 54% (1) and
5396% (5,12,1820). In the African studies, however, the
children were usually older. With age, the continuing
CSOM may cause progressive hearing loss. A fifth of our
CSOM children had at least moderate hearing loss in the
better-hearing ear, a handicap severe enough to endanger
the childs linguistic development, but only one of the seven
hearing-impaired children and his guardians had previously
paid attention to the problem. Of note, hearing tests in
younger children are difficult to conduct. We had a possibility to use BAEP, which is more appropriate than PTA for
young children.
Childhood CSOM carries an ongoing risk for serious and
potentially fatal bacterial complications, which because of

the poor availability of ear surgery in the developing countries are hardly avoidable. Therefore, higher awareness of
CSOM symptoms and risks is essential. CSOM-related
hearing loss is also a problem in developing countries with
lack of hearing aids. Recognizing the childs hearing loss is,
however, important in order to find other supportive measures before school age. The HIV positivity in this studys
CSOM children further underlines the need for early diagnosis and treatment.

ACKNOWLEDGEMENTS
We thank all the children, guardians and the personnel of
the Hospital Pediatrico David Bernardino. Special thanks
go to Elizabete Anjos and Marlene Pardal who performed
most of the diagnostic laboratory tests in Luanda. This work
was financially supported by research grants from Vaino
and Laina Kivis foundation and Ear Research Foundation.

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