“Just” an Ear Infection?!? Addressing Hearing Loss in the Pacific Islands Is First and Foremost About Managing Ear Disease

As I celebrate the 10-year anniversary of my first research journal publication “Overview of a public health approach to pediatric hearing impairment in the Pacific Islands”, ¹ I am struck again by the on-going challenge of communicating to colleagues from high-income nations that addressing childhood hearing loss in the Pacific Islands is first and foremost about managing ear disease. Provision of hearing aids for children with hearing impairment is of course desirable, however I often find myself pointing out that hearing aids are redundant if the child has passed away from complications of ear disease. I am not alone in advocating that Chronic Suppurative Otitis Media (CSOM) should be recognized by the World Health Organization as a Neglected Tropical Disease. ²

My professional journey as an Australian audiologist is an atypical one in that I have made the Pacific Islands my home. With additional qualifications in public health and international development, I could not ignore the reality of the context in which I found myself, and had to recreate my identity as an audiologist based on practicality and relevance. After 15 years of working in the Pacific Islands, my priority continues to be collaboration with the local ENT Clinic in the early identification and management of otitis media – an approach that should reduce the prevalence of life-threatening complications from poorly managed otitis media, as well as address any secondary hearing loss due to ear disease.^3,4

I am currently based in Samoa, and my ENT colleagues are passionate about community-based ear and hearing health screening for children. They have witnessed too many children die from avoidable otitis media in advanced stages of disease: mastoiditis that did not respond to treatment due to anti-microbial resistance, brain abscesses secondary to poorly managed chronic suppurative otitis media, parental preference for traditional medicine over admission to the intensive care unit. The reasons for the high prevalence of advanced ear disease are many and varied, and extend well beyond the social determinants of health framework. Therein also lies the challenge and complexity of addressing hearing health in the Pacific Islands from clinical, public health, research, and international development practitioner perspectives. ⁵

As Samoa and other Pacific Island countries collaborate with international development partners in the provision of hearing aid devices for children with hearing loss, these projects must not overlook the major public health issue of childhood ear disease. School-based hearing screening is certain to identify a significant proportion of children with hearing loss secondary to ear conditions requiring medical intervention, and previous work has determined CSOM to be a significant burden of disease among primary school-aged children in both Samoa and the Solomon Islands.^3,4 Should hearing aid devices be provided under these projects for children with bilateral tympanic membrane perforations (inactive CSOM), on-going collaboration with ENT review will be vital. In addition to the well-known increased risk of occluding cerumen and otitis externa, my clinical experience in the Pacific Islands suggests that the provision of hearing aids in tropical climates may be a risk factor for recurrent infection among people with dry tympanic membrane perforations who were previously medically cleared for hearing aids (ie., reduced ventilation from occluding earmould creates hot and humid ear canal environment that encourages microbial proliferation). Hearing aid service delivery must therefore collaborate closely with medical care, and include regular ENT review and counselling of hearing device maintenance and hygiene.

My clinical experience in the Pacific Islands has also shown that poorly managed CSOM in childhood will inevitably have consequences well into adulthood. This has been well-documented in the literature, ⁶ and was especially evident to me clinically when I triaged adult patients in preparation for a hearing aid donation program visit in 2023 – only 52% of patients presented with routine symmetrical sensorineural hearing loss consistent with presbycusis, while 33.5% were complex asymmetrical mixed/sensorineural hearing losses bilaterally, and 7% were suitable for monoaural fitting only. ⁷ My ENT colleagues were invaluable in ensuring that all patients were medically managed to ensure suitability for hearing aid fitting by the visiting audiology team, including management of CSOM and investigation of sensorineural asymmetries as warranted. ⁸

Global audiology as a specialist field has evolved over the past twenty years since I graduated as an audiologist. Innovation is a key feature of the research literature as audiology researchers pioneer alternative options to addressing hearing health in countries where ear and hearing health professionals are scarce. The potential of artificial intelligence in settings such as the Pacific Islands for the diagnosis and management of otitis media may become a reality for community screening by village health workers. ⁹ From my perspective, audiology has always been a technology-based profession, and tools that assist in the early identification and management of ear disease are worth investigating.