National Guide

Chapter 10 | Ear health and hearing







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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    11. Chapter 10 | Ear health and hearing

Ear health and hearing

Prof Penelope Abbott, Dr Mary Belfrage 

Key messages

  • Optimising ear and hearing health and preventing hearing loss are important at all ages. Poor hearing affects language acquisition and general child development, as well as school readiness, attendance and performance.1 Hearing loss in middle age can impact employment and is linked to brain health and the development of dementia.2
  • Most hearing loss is preventable. Otitis media (OM) in childhood is the most common cause of transient, intermittent and permanent hearing loss. Other common preventable causes are noise-induced hearing loss and smoking- and chronic disease-related hearing loss.3
  • The social and cultural determinants of health are strongly linked to OM. OM is associated with inadequate overcrowded housing, nutritional deficiencies and social and economic disadvantage.3,4 The social and cultural determinants of health can also impede access to appropriate healthcare and be a significant barrier to optimal care.
  • Given the high prevalence of OM and higher rate of hearing problems in Aboriginal and Torres Strait Islander people, neonatal screening and childhood ear and hearing health checks are important. This should be linked to follow up with audiometry and proactive management as per existing clinical guidelines.4,5
  • The role of primary care in the prevention of OM is to give advice to parents about minimising respiratory infections in infants (hygiene practices), promote breastfeeding and provide advice about not smoking around children.
  • Preventing the complications of OM requires regular ear checks, appropriate medical treatment and parental education on active strategies to assist their child’s learning and education (eg speaking clearly, encouraging communication with children and reducing background noise, and notifying teachers about strategies to facilitate learning).4–6
  • Excessive noise exposure can cause hearing loss at all ages. Risk is particularly increased for young people through the use of personal listening devices and attendance at loud entertainment venues, and for adults with occupational exposure.7,8
  • Vascular risk factors and conditions (cigarette smoking, obesity, diabetes, cardiovascular risk factors) are associated with adult hearing loss, supporting the importance of optimising healthy behaviours to maintain good hearing.9
  • All attempts to improve hearing should be made to prevent or lessen other health and social problems.4 This may require hearing aids and other sound amplification and acoustic management strategies.
Type of preventive activity - Immunisation
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Children aged under 15 years Childhood vaccinations (rubella, measles, Haemophilus influenzae type b, meningococcus, varicella) As per the National Immunisation Program Schedule and state/territory schedules Strong National guidelines4,10 Routine childhood immunisations decrease the risk of acquired hearing loss

Congenital rubella is rare due to the widespread immunisation program; however, risk remains due to migration and vaccine hesitancy
Children aged 6 weeks – 18 months Pneumococcal conjugate vaccination (PCV-13 valent) At age 6 weeks, and at ages 4, 6 and 18 months, as per National Immunisation Program Schedule Strong Systematic review11
National guidelines4		 Pneumococcal vaccination is effective in preventing invasive disease and pneumonia, and this is the primary reason for vaccination

Pneumococcal vaccination does prevent pneumococcal AOM, but current evidence suggests it does not decrease all-cause AOM and more research is needed
All people aged 6 months and older Annual influenza vaccination is recommended for any person aged over 6 months who wishes to reduce the likelihood of becoming ill with influenza

Vaccination may reduce the incidence of acute OM (AOM) as a secondary complication of influenza		 Annually Strong Systematic review12
National guideline4		 Although not the primary reason for immunisation, a proportion of AOM is prevented by influenza immunisation
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All pregnant women Offer testing for rubella immunity and syphilis serology to prevent infections that may lead to congenital hearing loss Prior to conception and antenatally (refer to Chapter 5: Preconception and pregnancy care) Strong National guidelines10
Systematic review13
International guidelines14		 Education for enhanced prevention of CMV in pregnancy is also recommended (see behavioural prevention section below)
Newborn infants Ensure parents of newborn infants are aware of universal neonatal hearing screening programs in their state or territory, that their newborn has been screened for congenital hearing impairment and any recommended follow-up has occurred

Advise that at-risk children will require further periodic testing because the onset of hearing loss can be delayed or progressive in some genetic conditions		 Prior to age 1 month; if missed, prior to age 3 months

If the test is passed but the child is still at high risk, periodic tests to age 3 years		 Strong Systematic review13
National guidelines4		 Better outcomes can be achieved for children identified early through neonatal screening
Children aged 6 months – 5 years Provide regular ear health and hearing checks:
  • ask parents/ carers about:
  • their child’s ear health (recent and longer term)
  • any concerns about their child’s ear health, hearing or communication
  • review children’s development of listening and communication skills with parents/carers using appropriate checklists
  • examine the appearance of the ear canal and ear drum, and assess movement of the ear drum and middle ear using either simple otoscopy plus tympanometry or pneumatic otoscopy
  • encourage family awareness of hearing-related child developmental milestones for early detection (Box 1)
 Opportunistically and at least six monthly until the age of 4 years, and then one check at age 5 years Good practice point National guidelines4,5 Consider checklists for screening for listening and communication skills include the Parent-evaluated Listening and Understanding Measure (PLUM) and Hearing and Talking Scale (HATS) tools4

Parental or teacher suspicion of hearing loss should always be investigated
Children aged under 6 years Do not use audiometry to routinely screen for ear or hearing problems in children N/A Good practice point National guidelines4,5 There is a lack of evidence to support routine audiometry screening in children for whom there are no concerns from parents/carers or healthcare providers

Audiometry is indicated when there are communication or parental concerns or signs of hearing loss

Children with episodic OM without perforation and no other concerns do not need audiometry
Children and young people aged 6-15 years Monitor for otitis media and hearing impairment by questioning, otoscopy and tympanometry Opportunistically Good practice point Single study43
National reports33,44
 		 There is a lack of evidence to support routine screening however there is some evidence of a high prevalence of hearing loss in this age group.
Adults aged 15 years and over Monitor for hearing impairment by questioning, provide advice regarding free hearing assessment and make referrals when appropriate Opportunistically Good practice point Consensus guideline9 The under-reporting of hearing impairment highlights the important role primary care has in asking after hearing loss at all ages
Adults aged over 50 years Ask about hearing difficulties Opportunistically Good practice point National guidelines15
International guidelines16		 A simple question as to whether a patient has hearing difficulties is recommended

Routine audiometry will offer a thorough assessment for those who perceive they have difficulty hearing, although is not indicated for routine screening
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Pregnant women and during the postnatal period Encourage exclusive breastfeeding in the first six months of life Opportunistically and in antenatal and postnatal checks Strong National guidelines4
Systematic review17		 Exclusive breastfeeding is associated with a decreased risk of AOM
Pregnant women and during the postnatal period Advise that risk of AOM may increase with the use of pacifiers Opportunistically and in antenatal and postnatal checks Conditional National guidelines4
Single studies18–20		 Pacifier use has been shown in population studies to be associated with an increased risk of OM
This advice may be particularly important in children who have already experienced OM or in infants over the age of 6 months
Pregnant women Advise pregnant women of the risk of cytomegalovirus (CMV) infection, particularly when exposed to young children, and emphasise the importance of handwashing and other strategies to decrease transmission of infection (Box 2) In antenatal checks Strong Systematic review21
Narrative review22		 CMV infection in pregnancy is associated with deafness and developmental delay in infants
Children aged under 6 years with persistent or recurrent OM, and children in whom there is parental and/or clinical concerns about hearing or communication Promote the use of active strategies to help communication and learning when children have hearing loss, including transient OM-associated hearing loss (Box 3) As clinically indicated Strong National guidelines4,5 Active strategies can support the development of communication skills and learning
Children aged under 6 years with persistent or recurrent OM, and children in whom there is parental and/or clinical concerns about hearing or communication Arrange audiometry As clinically indicated Strong National guidelines4,5 Conditions that require audiometry include parental concerns, recurrent AOM, persistent OME, chronic suppurative otitis media, dry perforation for more than three months and speech, language or other development not on track
Children with recurrent, persistent and chronic OM conditions Place on a review register and manage according to their OM diagnoses as recommended by the 2020 OM guidelines4 As clinically indicated Strong National guideline4 Active management and surveillance of children with recurrent and/or persistent OM can prevent or minimise hearing loss and sequelae
Children with OM with effusion (OME) Recommend nasal autoinflation (see Autoinflation for glue ear in children in Useful resources) As clinically indicated Conditional Systematic reviews4,23 An option for preventing hearing loss associated with OME in children aged 4 years and over
Adults aged over 15 years Advise that the proper use of hearing protection devices in noisy environments can prevent occupational noise-related hearing loss Opportunistically Strong Systematic review8
International report13		 Primary prevention
All parents and carers of young children Inform families about the prevention, early detection and treatment of OM in children to prevent hearing loss Opportunistically Good practice point National guideline4 Early detection and appropriate management as per the specific type of OM can prevent hearing loss
All parents and carers of young children Inform families of the importance of nose blowing, facial cleanliness and the washing and drying of hands to prevent the transmission of infectious disease that can cause OM or hearing loss As clinically indicated and opportunistically Conditional National guidelines4
Single studies24,25		 Congenital or acquired hearing loss, including due to OM, may occur through viral infections
Infants are particularly at risk
All people Promote good ear hygiene and safe practices:
  • avoid the use of cotton-tipped swabs for the ear
  • do not inserting any objects or liquids in the ear
  • avoid the use of home remedies for common ear conditions
  • seek prompt medical attention to treat ear
 Opportunistically Good practice point Expert consensus13  
All smokers Advise that tobacco smoking is a risk factor for hearing loss in adulthood, including exacerbation of noise-induced hearing loss, and support smoking cessation Opportunistically Strong Single study9 The mechanism is not fully understood, although may be related to vascular changes
All people with persistent hearing loss or recurrent OM Refer for assessment for hearing aid/remediation
Discuss strategies with patients and families to maximise hearing and communication		 As clinically indicated Good practice point Expert consensus2
Clinical guidelines4		 Remediating hearing loss is an important strategy to prevent the sequelae of hearing loss
All people Inform families of the danger of loud noise (and for prolonged periods), especially for children with a history of ear disease Opportunistic Good practice point Expert consensus8 Refer to Useful resources
All people Inform families and smokers about the need to avoid children being exposed to cigarette smoke (see Chapter 2: Healthy living and health risks, Smoking) Opportunistically Strong National guideline4 Exposure to second-hand cigarette smoke increases the risk of OM
Type of preventive activity - Medication
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Children with OM Ensure best practice management of OM, including the use of medication and other therapies as appropriate and according to guidelines As clinically indicated Good practice point National guideline4 These guidelines advise on evidence-based management of OM, including the use of medications, nasal autoinflation and tympanostomy tube insertion
All people Limit the use of medications with the potential for ototoxicity where possible As clinically indicated Good practice point Clinical guidelines13,26 Drugs commonly used in clinical practice that can be ototoxic include aminoglycoside antibiotics (including neomycin ear drops through a perforated eardrum), non-steroidal anti-inflammatory drugs and loop diuretics
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Health services and practices Promote frequent nose blowing, facial cleanliness and the washing and drying of hands in early learning and childcare centres and preschools Opportunistically where health service/practice has links Good practice point Systematic review23
Randomised controlled trial27		  
Health services and practices in settings where environmental and living conditions have a strong contribution (environmental attribution) to communicable disease transmission and other conditions, such as mental health issues Know about diseases with a high environmental attribution

Develop a safe clinical relationship in order to ask sensitively about housing and living conditions (inadequate housing facilities, access to health hardware such as working plumbing for clean drinking water and washing facilities, access to hygiene and sanitation supplies)

Know about local arrangements for environmental health referral

Offer an environmental health referral according to local arrangements, ensuring consent is obtained when a home visit is involved

Advocate with Aboriginal and Torres Strait Islander leaders for adequate housing, facilities for washing and general living conditions

Provide community-based health promotion about environmentally attributable diseases

Check local guidelines		 Opportunistically, in response to any diagnosis or condition with an environmental attribution and as part of general healthcare Good practice point
 		 International and Aboriginal and Torres Strait Islander-specific narrative reviews28,29 Household crowding and the quality of housing and environments exacerbate conditions promoting communicable disease transmission, including COVID-19, Streptococcus A infections, OM, trachoma, tuberculosis and other respiratory tract infections

Aboriginal and Torres Strait Islander peoples have long recognised the links between human health, animal health and the environment. General practitioners can better support their leadership in housing equity
Box 1. Hearing-related growth milestones in children4
Parental questionnaires can check a child’s progress through the following hearing-related growth milestones.
Warning signs that children may have hearing problems include:
  • 3–6 months: Not communicating by vocalising or eye gaze; not starting to babble
  • 9 months: Poor feeding or oral coordination; no gestures (pointing, showing, waving); no two-part babble (eg ‘gaga’)
  • 12 months: Not babbling; no babbled phrases that sound like talking
  • 20 months: Only pointing or using gestures (not speaking); no clear words; cannot understand short requests
  • 24 months: Using less than 50 words, not following simple requests; not putting words together; most of what is said is not easily understood
  • 30 months: No two-word combinations
  • 36 months: Speech difficult to understand; no simple sentences
  • 48 months: Speech difficult to understand; not following directions involving two steps
  • 60 months: Difficulty telling parent what is wrong; cannot answer questions in a simple conversation
 
Box 2. Strategies recommended by the Centers for Disease Control and Prevention to reduce the risk of cytomegalovirus infection for women who are pregnant or planning to become pregnant14
  • Thoroughly wash hands with soap and warm water after activities such as:
    • nappy changes
    • feeding or bathing a young child
    • wiping a child’s runny nose or drool
    • handling a child’s toys
  • Do not share food, drinks, eating utensils used by young children
  • Do not put a child’s dummy in your mouth
  • Do not share a toothbrush with a young child
  • Avoid contact with saliva when kissing a young child
  • Clean toys, countertops and other surfaces that come in contact with urine or saliva

See Useful resources for parent education on the prevention of CMV infection.

 
Box 3. Active strategies to support communication and learning when children have hearing loss, including transient otitis media-associated hearing loss4,6,30
  • Families can help communication and learning by:
    • getting their child’s attention before starting to talk
    • standing close to and facing their child as much as possible when speaking
    • speaking clearly and maintaining a normal rhythm of speech
    • encouraging a lot of talking in quiet places, storytelling, reading books and interacting with the child about their story; using the Yarning from Home resources to promote their child’s listening and talking may help.
  • For school-aged children:
    • the teacher may realise a child is having learning or behaviour problems but may not be aware that this is because of their hearing (it is important for parents to tell the teacher about their child’s hearing so that arrangements can be made in school to help)
    • the child should be able to sit near the teacher in the classroom
    • the teacher should check they have the child’s attention, allow more time, check in frequently on the child’s understanding and make sure the child is not made to feel awkward about asking for things to be repeated
    • sound amplification and better classroom acoustics may be useful.
  • Children with recurrent, persistent and chronic OM conditions should be placed on a review (recall) register and should be managed according to their diagnoses as per OM management guidelines.
  • Parents and carers of newborns and infants should be advised of the risk of early respiratory tract infections to longer-term ear health and the importance of regular ear health and hearing checks.
  • Make sure all clinical staff working with young children (Aboriginal and Torres Strait Islander health workers/health practitioners, nurses, GPs) are familiar with the strategies that support communication and learning (Box 3) and can advise parents/carers about helping children to listen and talk at home, and to use strategies that help children communicate when they have OM or hearing loss.

Clinical guidelines

  • 2020 Otitis media guidelines for Aboriginal and Torres Strait Islander children – these are available in multiple formats, including online desktop access and via an app. The app may be particularly useful for clinicians and contains extensive educational material and information to guide diagnosis and management, as well as access to the OM guidelines
  • The Royal Australian College of General Practitioners (RACGP): Autoinflation for glue ear in children 

Tools

Other resources for health professionals

Education about avoiding noise-induced hearing loss

  Parent and carer resources

  • AllPlay Learn program – a range of resources, posters, handouts and more to support the inclusion of children with disabilities and developmental challenges 

Background

Maintaining hearing health at all stages of life is important for health and wellbeing. Healthy hearing promotes communication and social connections with family and friends, increases the ability to participate in team and community activities and supports learning. Hearing loss can cause significant disability, and impaired communication can adversely affect relationships with family and friends and within workplaces. Hearing loss is associated with delayed child development, impaired speech and language development and lower educational opportunity.1,9,31 Untreated hearing loss in adults can have health, psychosocial and economic effects, including reduced quality of life, social isolation, depression and underemployment.9,32,33 Hearing loss is associated with an increased risk of poor outcomes in the elderly, including hospitalisation and dementia.2,9

Hearing impairment in Aboriginal and Torres Strait Islander people is an important and common health issue. Although the full extent of hearing impairment is not known, the rates of hearing loss are much higher than in the non-Indigenous Australian population. Self-reported rates of hearing problems/ear disease were 14% across all ages in the National Aboriginal and Torres Strait Islander health survey (2018–19).33 The health survey offered a voluntary hearing test for participants aged seven years and over, and, from 290,000 tests, 43% of people were found to have measured hearing loss, with 79% not reporting long-term hearing loss. Measured hearing loss was higher in remote areas (59%) than in non-remote areas (39%).3,33

Hearing loss has a high prevalence in incarcerated populations, particularly in Aboriginal and Torres Strait islander people.34–36 It is a risk factor for the involvement of young people in the criminal justice system, including through links to communication problems, behaviours and mental health problems.37,38 The disproportionate incarceration rate reflects a failure of prevention and early detection to protect against the negative sequelae of hearing loss. For individuals who enter the prison system with hearing loss, their condition can exacerbate the existing challenges of adjusting to the prison environment. Communication difficulties are likely to make it harder to understand instructions from staff, participate in educational or rehabilitative programs and maintain social connections, and may negatively affect mental health. It is crucial to ensure that individuals with hearing loss have equal access to communication, education, healthcare and support services to mitigate the potential negative outcomes associated with their condition. Providing appropriate services (including sound amplification and hearing aids) not only can improve the wellbeing of incarcerated individuals with hearing loss, but can also contribute to reducing recidivism rates and enhancing the overall effectiveness of the correctional system.

Optimising ear health and preventing hearing loss are important goals, as is adequately treating hearing loss to prevent its negative consequences. It is critical that clinicians and patients recognise that most hearing loss is preventable. The high rates of hearing loss in Aboriginal and Torres Strait Islander people are predominantly due to persistent OM and its consequences. OM is a common condition that generally starts in infancy or early childhood and disproportionately affects Aboriginal and Torres Strait Islander children. Much can be done to prevent hearing loss and promote healthy hearing throughout the lifespan by focusing on the primary prevention, early detection and prompt and effective management of OM.

There are other preventable causes of hearing loss that are important in primary care. Epidemiological studies have found strong associations between hearing loss in adults and cigarette smoking, obesity, diabetes and other risk factors for cardiovascular disease.39,40 The causation is unclear, but it appears that vascular changes may contribute, further suggesting some age-related hearing loss may be preventable and the progression of hearing loss decreased.9 Hearing loss in mid-life is recognised as a risk factor for dementia, and older people with hearing loss have higher rates of hospitalisation, death, falls, frailty and depression even when known risks for these conditions are considered.2,9,41

This topic focuses on the prevention of hearing loss, including OM. In this edition of the National Guide we have also provided new guidance on other preventable causes of hearing loss in adults, including noise-induced hearing loss. 

Hearing loss and hearing impairment

There are different types of hearing loss, the two main types being conductive and sensorineural hearing loss. Conductive hearing loss is caused by impairment of the outer or middle ear, which prevents the transmission of sound to the inner ear. The most common causes are impacted wax, OM and otosclerosis (where the bones in the middle ear can become fixed in place). Sensorineural loss relates to dysfunction in the cochlea or nervous auditory apparatus. If hearing loss has both conductive and sensorineural components, it is referred to as mixed. Hearing loss can range in severity and be temporary or permanent.9

Hearing loss is based on an average of the hearing threshold at several frequencies and is graded as mild, moderate, severe and profound according to the degree of deviation from normal hearing thresholds as tested by audiometry (Table 1). Hearing impairment is categorised by the degree of disability associated with hearing loss in each ear or in the better ear.4

Self-reported hearing loss can be unreliable, so diagnosis must be made after audiological testing.42 However, hearing tests have limitations and can underestimate the problems caused by hearing loss. For example, OM can cause hearing loss that varies over time, so average hearing levels based on a single assessment may provide an underestimate.4 Furthermore, OM has a substantial effect on hearing for frequencies outside those routinely tested. Finally, a hearing test does not account for the effect of age of onset, duration of hearing loss, language spoken, processing ability and environmental factors.

Disabling hearing loss is defined as greater than 40 dB in the better-hearing ear in adults and greater than 30 dB in the better-hearing ear in children.4 However, even at lesser degrees of loss, both adults and children can experience problems in daily life. Unilateral hearing loss can still cause problems, including in language development.43 Furthermore, hearing loss can cause disability even if it is present for relatively short periods of time, such as when a child has recurrent OM during crucial periods of development and learning (first and early years of life).

Table 1. Grades of hearing loss in children4
Grade Corresponding audiometric ISO value (in the better ear) Performance
None or slight 20 dB or lower No or very slight hearing problems
Able to hear whispers
Mild 21–31 dB Not able to hear and repeat words spoken in normal voice at a distance greater than 1 m
ModerateA 31–60 dB Not able to hear and repeat words spoken in a raised voice at a distance greater than 1 m
Severe 61–80 dB Not able to hear most words when shouted into the better ear
Profound 81 dB or greater Unable to hear or understand even a shouted voice
ADisabling hearing loss refers to hearing loss greater than 40 dB in the better-hearing ear in adults and greater than 30 dB in the better-hearing ear in children.

Causes of hearing loss across the lifespan

There are multiple causes of hearing loss, both preventable and unpreventable (Figure 1). Notable causes of preventable hearing loss are discussed in more detail below.

 

Figure 1. Causes of hearing loss over the lifespan

Note, causes shown in italics are considered preventable.

Reproduced from AIHW with permission.44 

Otitis media

The most common cause of preventable hearing loss in Aboriginal and Torres Strait Islander people is OM, which usually starts in infancy and childhood.3 OM is inflammation and infection of the middle ear space. The most common types are acute OM (AOM), in which there is fluid in the middle ear plus symptoms and/or signs of acute infection, and OM with effusion (OME), where there is fluid in the middle ear but no acute infection present4 (Box 4). All forms of OM cause conductive hearing loss that may fluctuate according to the health of the middle ear.

Box 4. Types of otitis media4
  • Otitis media (OM)
    Refers to all forms of inflammation and infection of the middle ear. Active inflammation or infection is nearly always associated with a middle ear effusion (fluid in the middle ear space).
  • OM with effusion (OME)
    Presence of fluid behind the tympanic membrane (‘ear drum’) without any acute symptoms. Other terms have also been used to describe OME, including ‘glue ear’, ‘serous OM’ and ‘secretory OM’. OME may be episodic or persistent. A type B tympanogram or reduced mobility of the tympanic membrane on pneumatic otoscopy are the most reliable indicators of OME.
  • Episodic OME
    OM as defined above of duration less than three months.
  • Persistent (chronic) OM with effusion
    Presence of fluid in the middle ear for more than three months without any acute symptoms or signs of inflammation.
  • Acute otitis media (AOM)
    General term for both acute OM without perforation (hole in the tympanic membrane) and acute OM with perforation. AOM is defined as the presence of fluid behind the tympanic membrane plus at least one of the following: bulging tympanic membrane; red tympanic membrane; recent discharge of pus; fever; ear pain; or irritability. A bulging tympanic membrane, recent discharge of pus and ear pain are the most reliable indicators of AOM.
  • Recurrent AOM
    The occurrence of three or more episodes of AOM in a six-month period, or occurrence of four or more episodes in the past 12 months.
  • Chronic suppurative OM (CSOM)
    Persistent ear discharge through a perforation (hole) in the tympanic membrane lasting two weeks or more and tympanic membrane perforation large enough to allow penetration of topical antibiotics into the middle ear space (generally >2% of the pars tensa). The size of the perforation should be determined and recorded because this directs management, and the duration of discharge is often difficult to establish.
  • Tympanostomy tube otorrhoea
    Middle ear discharge (otorrhoea) through tympanostomy tubes (or ‘grommets’). This may occur early after insertion of tympanostomy tubes or may be delayed and may be chronic or recurrent.
  • Dry perforation
    Presence of a perforation (hole) in the tympanic membrane without any signs of discharge or fluid behind the tympanic membrane. Some people also refer to this as inactive CSOM.
  • Attic perforation
    This is a perforation in the superior part of the tympanic membrane. A perforation in this location may be associated with a deep retraction pocket or cholesteatoma.
  • Cholesteatoma
    Abnormal growth of skin cells in the middle ear, which continues to grow, eventually causing breakdown of surrounding structures (middle ear ossicles, facial nerve, base of skull), resulting in hearing loss, facial paralysis or intracranial complications.

OM is more common in Aboriginal and Torres Strait Islander children than in non-Indigenous Australian children.43–46 Chronic OM, including CSOM and tympanic membrane perforation, is highly prevalent in rural and remote Aboriginal communities, where only 10% of young children were found to have bilaterally normal ears in prevalence studies as recently as 2018.45 

OM is a spectrum of disease ranging from mild to severe. In its mildest forms (AOM and OME), OM is a common childhood condition in all populations, from which most children improve spontaneously.4 Children who have frequent episodes of AOM or have persistent OME are of most concern due to more frequent or longer periods of hearing loss and their higher risk of developing severe disease or complications. CSOM is a severe form of OM in which there is persistent discharge through a hole in the ear drum, which is extremely difficult to treat, can persist into adulthood and can cause long-term hearing loss.47 

Although conductive hearing loss due to OM is often regarded as a temporary condition, it will be a chronic problem in chronically diseased ears.4 Episodic OME and AOM cause a mild hearing loss during the periods when there is fluid in the middle ear space, whereas chronic OM (persistent OME and CSOM) can cause moderate hearing loss. Sensorineural hearing loss may occur secondary to long-term chronic OM. 

Transient hearing loss due to OM is important to manage and monitor actively as per clinical guidelines to make sure it resolves.4 If a child has recurrent AOM or persistent OME and is awaiting diagnostic audiology or tympanostomy tube surgery, provide education and support for parents/carers and families to adopt active strategies to help the child with language development and learning, and to decrease the disability caused by hearing loss (Box 3). 

Effective prevention, diagnosis and management of OM in infancy and childhood will reduce the prevalence of hearing loss and support childhood development and learning. OM is linked to upper respiratory tract infections, so minimising the transmission of infections in childhood is likely to decrease the risk of OM. The earlier OM occurs, the greater the likelihood of recurrent OM and complications.24 Thus, preventing respiratory tract infections in infancy is important, including through immunisation and household-level behavioural strategies (eg toddler hand and face hygiene) that minimise the transmission of infections to infants.24 Hearing loss during the critical period of sensorineural development in infancy and early childhood can affect auditory processing and communication skills that may be lifelong and difficult to correct.43,48,49 Relevant preventive strategies are discussed in the next section. Readers are also directed to the 2020 Otitis media guidelines for Aboriginal and Torres Strait Islander children4,50 for detailed information on the prevention and management of childhood OM. 

Antenatal and childhood infections

Congenital infection with rubella or CMV can cause deafness and developmental delay.10,21 In Australia, infection rates with rubella remain extremely low due to widespread immunisation programs, with Australia judged to have officially eliminated rubella in 2017.51 Rubella elimination is defined as the absence of endemic rubella cases for a period of ≥12 months in the presence of adequate surveillance.52 However, the risk of congenital rubella remains, including due to migration or vaccine hesitancy. Congenital CMV infection is rare but does occur, and there is no immunisation available.53 CMV infection in pregnancy is often asymptomatic, and there is a lack of awareness of the risks of CMV during pregnancy.22 The best prevention of CMV is avoidance of maternal infection during pregnancy, including through handwashing14,22 (Box 2). Antiviral medications are used for infants with congenital CMV to improve outcomes, including hearing outcomes.53,54 

Immunisation against other infective causes of acquired hearing loss in childhood, such as meningococcal disease, pneumococcal disease, measles, mumps and varicella, are important preventive strategies.10,13 

Noise-induced hearing loss

Voluntary recreational noise exposure at unsafe levels, also known as unsafe listening practices, can decrease hearing health at all ages and the resultant rising hearing loss is considered a global threat.13 It is a particular risk in young people, including through the use of personal listening devices and attendance at loud entertainment venues.7 Recurrent or even single exposures can lead to transient or permanent hearing loss and tinnitus, and may increase the risk of age-related sensorineural hearing loss.13 Some people may be more susceptible to noise-induced hearing loss than others, including due to genetic predisposition, chronic conditions such as diabetes and exposure to cigarette smoke.9,13&

Education and the promotion of safe listening practices are critical and require more emphasis. International and national initiatives seek to promote healthy hearing and safe listening practices by providing accessible information on how to limit noise exposure to permissible levels (noise volume and exposure duration), the use of ear plugs and headphones and monitoring listening levels, such as through phone apps. This includes the World Health Organization Make Listening Safe initiative55 and Australian Government initiatives through the National Acoustic Laboratories, such as Know Your Noise and HEARsmart56 (see Useful resources). 

Occupational noise exposure is another important cause of hearing loss, the risk of which is similarly exacerbated by tobacco smoking and chronic conditions such as hypertension and diabetes.57 A 2017 Cochrane review showed evidence that stricter workplace legislation, and the proper use of hearing protection devices in noisy environments, can prevent occupational noise-related hearing loss.8 

Few studies have explored the prevalence of noise-related hearing disorders affecting Aboriginal and Torres Strait Islander peoples. Furthermore, few health professionals and families are aware that excessive exposure to loud noise over prolonged periods can damage hearing. In terms of interventions, Aboriginal and Torres Strait Islander health workers have an important role to play because they can best inform families about the dangers of too much loud noise, and of the particular dangers for children with a history of ear disease. A recent Cochrane review reported that reduced noise exposure can be achieved with the use of personal earmuffs and earplugs, with adequate instruction.8 Stricter legislation may reduce noise levels, but the effects of hearing loss prevention programs are not yet clear.8 

Hearing health and ageing

Hearing loss becomes increasingly common with age. Age-related hearing loss (presbycusis) is usually bilateral and symmetric and most pronounced at higher frequencies.9 Of the adults aged over 55 years who underwent the voluntary hearing test in the 2018–19 National Aboriginal and Torres Strait Islander health survey, 82% had hearing loss in one or both ears.3 

Degenerative effects of ageing on the auditory system are the leading cause of adult-onset hearing loss, but there are also potentially modifiable contributors to the incidence and severity of hearing loss: the accumulated effects of exposure to noise; therapeutic drugs with ototoxic side effects; and chronic conditions that can accelerate hearing loss.9 Therapeutic drugs that cause hearing loss are aminoglycoside antibiotics (including administration of neomycin through a perforated tympanic membrane), non-steroidal anti-inflammatory drugs, antineoplastic agents, quinine and loop diuretics.26,58 As noted previously, prevention and the management of risk factors and conditions that are associated with hearing loss, including cigarette smoking, obesity, diabetes and cardiovascular risk factors, may promote healthy hearing throughout the lifespan.9 

Preventing hearing loss and the management and amelioration of hearing loss are vital in older age given the evidence of a link between hearing loss and dementia, decreased wellbeing, depression and social exclusion.2,9

Immunisation

Prevention of antenatal and childhood infections through immunisation can prevent congenital and acquired hearing loss (rubella, measles, Haemophilus influenzae type b, pneumococcus, meningococcus).4 The prevention of some pneumococcal AOM through immunisation has been demonstrated, but the clinical significance of this is unclear given currently limited evidence of a beneficial effect on all-cause AOM.11 Current pneumococcal conjugate vaccines do not protect against all strains of pneumococcus and all pathogens that cause AOM.11 Influenza vaccination in children will prevent a proportion from developing OM, although this is not the primary reason for recommending vaccination.12 

Screening

Screening in pregnancy for conditions that could cause congenital hearing loss and neonatal hearing screening are important strategies to prevent and detect hearing loss at birth. Universal newborn hearing screening programs operate in all Australian states and territories, and early intervention has been shown to lead to better outcomes.59 Parents/carers should ensure their child has not missed neonatal screening, and that any recommended follow-up occurs. It is also important to recognise late-onset or progressive hearing loss associated with some genetic conditions, which may be missed on the first screening, so further periodic testing is needed for high-risk children up to age three years.4 The main causes of late-onset deafness are CMV infection, genetic syndromes associated with progressive hearing loss, neurodegenerative disorders, trauma and bacterial meningitis in the neonatal period.60 

Given the high prevalence of OM in Aboriginal and Torres Strait Islander children, ear checks and hearing-related developmental checks are recommended at least six-monthly from the age of six months to four years and then at five years.4,5 Every time a child has OM, they have poorer hearing. Screening audiometry is not recommended as a routine measure, but should be undertaken if there are parent/carer or practitioner concerns or when there is a persistent or recurring middle ear condition.4 Hearing-related growth milestones in children are noted in Box 1. Six-monthly checks involve:

  • undertaking an ear examination that includes visualising the eardrum(otoscopy) and assessing mobility of the eardrum (tympanometry or pneumatic otoscopy)
  • asking parents and carers about their child’s ear health and any concerns about hearing, listening, milestones or communication skills.4,5 

The Parent-evaluated Listening and Understanding Measure (PLUM) is a hearing health screening questionnaire for Aboriginal and Torres Strait Islander children aged under six years. The Hearing and Talking Scale (HATS) was developed to identify children who may have speech communication difficulties.61,62 The PLUM and HATS checklists may assist healthcare providers and teachers to identify at-risk Aboriginal and Torres Strait islander children through parent/carer observations (see Useful resources). 

Evidence does not support screening for hearing loss in asymptomatic adults aged over 50 years, and a case-finding approach is preferred.9,15 Primary care providers should assess hearing in adult patients who perceive they have hearing loss, and should identify patients by asking a simple screening question enquiring whether they have difficulty with their hearing.16 Given the known under-reporting of hearing impairment in the Aboriginal and Torres Strait Islander population, case identification is important.63 Audiometry provides a thorough assessment for those who identify they have difficulty hearing. Hearing assessments, such as whispered voice and finger rub, are no longer recommended because results can be variable.16 

Behavioural

Behavioural strategies to decrease the risk of OM and viral infections that can lead to congenital or acquired hearing loss are recommended. These include breastfeeding, avoiding tobacco smoke exposure of children, minimising the use of pacifiers in children and avoiding transmission of upper respiratory tract infections within families through handwashing and other household hygiene strategies.4,17 

Parent/carer and healthcare provider vigilance for the detection of hearing loss in children is crucial given the high prevalence of OM in Aboriginal and Torres Strait islander children and that every time a child has OM, they have poorer hearing. Recognition will allow families and teachers to make arrangements to decrease the effect on children’s communication and learning. Primary care providers should provide parents and carers with advice on the active strategies needed (Box 3), including while children with chronic OM are on waiting lists for tympanostomy tube surgery.4,5 

Safe listening practices both for recreational noise and occupational noise are important to decrease hearing loss, including accumulated loss throughout the lifespan.7 Education in primary care, including during annual health assessments, is warranted (see Useful resources). Finally, the association between cigarette smoking, obesity, diabetes and cardiovascular risk factors in adults9 supports the importance of lifestyle behaviour strategies to also prevent hearing loss. 

Medication and other therapies

The appropriate medical management of conditions that cause hearing loss, in particular OM, is important. Detailed evidence-based guidelines for the prevention and management of OM are available in the 2020 Otitis media guidelines for Aboriginal and Torres Strait Islander children.4 This includes a summary of research into therapeutic medications and medications being investigated for possible prevention of OM. 

There is evidence that autoinflation (balloon inflation via nose blowing) may improve hearing loss associated with OME in the short to medium term and create benefits for children and parents in ear-related quality of life.23,27 

Tympanostomy tubes or grommets may be effective in decreasing recurrent AOM64 and in decreasing hearing loss associated with OME,65 and are recommended to improve hearing outcomes.4 

Environmental

The social determinants of health are strongly linked to OM. OM is associated with crowded housing conditions, nutritional deficiencies and social and economic disadvantage.3,4 Leadership, commitment and support at national, community, family and individual levels is required to decrease the burden of OM and hearing loss for Aboriginal and Torres Strait Islander people. 

Decreasing noise-induced hearing loss and the promotion of safe listening practices is vital, particularly in young people. Occupational noise exposure must also be managed safely, including through education as to what individuals can do to maximise their hearing safety56,66 (see Useful resources).

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