Children with otitis media in Greenland - A qualitative study of parental experiences.

INTRODUCTION: The Greenlandic population has one of the world's highest prevalence of otitis media (OM). Approximately 9-14% of all children suffer from OM during childhood. Due to the climate, lack of infrastructure, and minimal access to specialist services, the Greenlandic healthcare system operates under significant challenges. To support treatment implementation, we explored parental experiences of having a child with recurrent acute otitis media (rAOM) and chronic suppurative otitis media in Greenland (CSOM). METHODS: We applied a qualitative methodology with semi-structured interviews, to investigate parents' individual experiences. We included parents from six selected towns and settlements in Greenland, who were primary caregivers to minimum one child who had suffered from rAOM or CSOM. The interviews followed a semi-structured interview guide. RESULTS: Eight interviews were conducted with ten parents (nine mothers, one father) to 13 children (nine girls, four boys) aged two to 20 years (median age five years). We carried out a hermeneutic-phenomenological, Ricoeur-inspired text analysis of data. The first episode of OM was associated with uncertainty about the condition, including pain relief and treatment. However, recurrence led to symptom recognition and a changed disease perception among the parents: from being a simple case of childhood OM to a recognition of a chronic condition that might lead to delayed linguistic development and hearing impairment. CONCLUSION: Under difficult healthcare situations, parents represented a unique resource in care and treatment implementation. Parents often feel alone with the responsibility of care and had concerns for their child's hearing and language development, and they wished for their experiences and observations to be actively included in consultations.

Measurement of hearing impairment among Greenlandic school-children: association between self-reported data and clinical examinations.

BACKGROUND: Multiple ear infections is causing hearing impairment among children all over the world and the health and social consequences track into early adolescence and later in life, if not treated. The monitoring of prevalence in a population is important to assess the need for interventions in a population. METHODS: One hundred eighty  five children from 5 to 10th grade from Sisimiut town and the nearby settlements participated in a clinical examination to have ear-examination and pure tone audiometry. Participants filled out a questionnaire at home with their parents before the clinical examination, and hearing impairment was collected as individual self-reports and as audiometric measurements. RESULTS: A total of 185 children between 9 and 15 years of age (median: 11 years, IQR: 10-13) were included, 60% (n = 111) were girls. 247 (70%) of the 355 available otoscopies were clinically assessed as normal. Cohen's Kappa coefficient was 0.31. Eighteen children (10%) were found to have hearing impairment. None of the children had hearing aids. Test performance for self-reports were that sensitivity was 56% and specificity was 87%. The predictive value of a positive test was 31%, and the predictive value of a negative test was 95%. 32 children (17%) reported hearing impairment to the extent that they were not able to keep up in school, of which half reported that it had lasted for more than one year. 7 of the 32 children reporting hearing impairment (22%) reported that the extent of their hearing impairment was affecting their classroom experience so they were not able to follow. CONCLUSION: Self-reported and clinically screening for hearing impairment are two different concepts. Even though the two concepts are statistically correlated, the correlation coefficients are low. The test performance indicated that self-reported data might be measuring hearing as an experience in a social environment and not directly comparable to pure tone audiometry which examines hearing in controlled testing conditions. Since both measure hearing impairment, they supplement each other in research on impaired hearing, and the choice of measure should relate to the purpose and method of the investigation.

Stress reactions in a tertiary oto-rhino-laryngological department during the first wave of the COVID-19 pandemic in the Danish Capital region.

BACKGROUND: Health care workers (HCW) at otorhinolaryngological departments have an increased risk of contracting COVID-19, due to aerosol-inducing diagnostic and surgical procedures in the airways. The ongoing exposure to physical and psychological stressors could impact the mental health of HCW. AIM/OBJECTIVE: To investigate the impact on mental health in an otorhinolaryngological department during the COVID-19 pandemic. MATERIALS/METHOD: Cross-sectional questionnaire study, assessing symptoms of depression (PHQ-9) and anxiety (GAD-10). Physicians, nurses, and secretaries were included at a tertiary department of otorhinolaryngology in the Capital Region of Denmark during the COVID-19 lockdown in spring 2020. RESULTS: Positive screenings for stress reactions were found in 22% for depressive symptoms and 15.5% anxiety. 27% feared becoming infected, 47% feared infecting their families in relation to work. 27% felt others were distancing from them, and 38% isolated themselves from others because of their work. Women had an odds ratio of 9.18 (CI 1.49-179) for depressive stress reactions. CONCLUSION: HCW were primarily concerned with transmitting COVID-19 to their relatives. Secondarily, there was a concern about becoming infected despite feeling adequately protected by personal protective equipment. Women were at higher risk of more severe depressive symptoms when corrected for professions.

Examination of hearing loss among school-aged children in Greenland.

BACKGROUND: The highest prevalence of chronic suppurative otitis media is seen among children in Greenland. The purpose of this study was to investigate the prevalence of hearing loss among school children in Sisimiut, the second-largest city in Greenland. MATERIAL AND METHOD: All 423 children from 5th to 10th grade from the two schools in Sisimiut and the nearby settlements were invited to participate. Participants filled out a questionnaire at home with their parents before ear-examination and audiometry. Risk factors for hearing loss and otitis media (OM) related otoscopy findings were analyzed by binomial logistic regression. RESULTS: A total of 185 children between 9 and 15 years of age (median: 11 years, IQR: 10-13) were included; 60% (n = 111) were girls. Fifty-four children (29%) were found to have hearing impairment using a PTA of 15 dB for either low or high frequencies or both as threshold. When using 25 dB as threshold, the number of children with hearing impairment was 18 (10%). None of the children had hearing aids. Of 355 otoscopies available for evaluation, the majority were normal (n = 249, 70.1%). Perforation of the tympanic membrane was found in six ears (1.7%), of which all were unilateral. Other sequelae related to OM (i.e., circular atrophy and myringosclerosis) were found in 37 ears (10.4%). Children with OM-related otoscopy findings had significantly lower hearing tresholds compared to children without. CONCLUSION: A high prevalence of untreated hearing loss was found among examined school children in Sisimiut. Children with otoscopy findings indicating prior OM had significantly lower hearing tresholds compared to children without.

The impact of the COVID-19 pandemic on mental health among healthcare workers in ear-nose-throat clinics.

INTRODUCTION: During the first wave of the COVID-19 pandemic, it was established that otorhinolaryngologists were at a high risk of contracting the infection due to examinations of the upper airways. The aim of this study was to evaluate the impact of the COVID-19 pandemic on mental health among healthcare workers (HCWs) in primary ear-nose-throat (ENT) practices. METHODS: This was a cross-sectional questionnaire study among HCWs assessing symptoms of anxiety (Generalized Anxiety Disorder, ten-item scale) and depression (Patients Health Questionnaire, nine-item scale). The survey targeted otolaryngologists and staff in primary private practices in the Capital Region of Denmark during the COVID-19 lock-down in May 2020. RESULTS: For 30% of the participants, signs were observed of depressive symptoms and 13% had signs of anxiety symptoms. Seventy percent felt sufficiently protected by their available personal protective equipment. Fifty-two percent worried about becoming infected in relation to their work and 56% feared infecting their families. CONCLUSIONS: HCWs in Danish primary ENT practices did not display extraordinary stress reactions during the first wave of the pandemic. Noticeably, participants were concerned about acquiring the infection or transmitting it to their household. FUNDING: none. TRIAL REGISTRATION: not relevant.

Lower thriving among females with hearing impairment than males - a cross-sectional study of 185 primary and secondary students in Greenland.

The prevalence of ear infections and hearing i mpairment among Greenlandic children is amajor public health problem, and studies investigating the association between hearing impairment and thriving among Greenlandic children are scarce. The aim of this study was to examine the association between hearing impairment and thriving in asample of school-children in Sisimiut, Greenland. This cross-sectional study included children from 5th to 10th grade from two schools in Sisimiut and two schools located in nearby settlements. Participants filled out aquestionnaire and underwent ear examination and audiometry. Binary logistic regression examined the associations of hearing impairment and thriving variables defined as self-rated health, headache and school satisfaction. 179 children participated from schools in Sisimiut, and 6 children were from schools in settlements. The prevalence of hearing impairment was 10% among school-children in Sisimiut. There was atendency among girls with hearing impairment to have higher odds ratios for low self-rated health, often headache and low school-satisfaction. This study indicates that girls with hearing impairment are more susceptible to low thriving compared to girls with normal hearing. Interventions targeting the thriving of hearing impairment among children in Greenland should take gender differences into account.

COVID-19 infection rate among tertiary referral center otorhinolaryngology healthcare workers.

IMPORTANCE: Otorhinolaryngology is considered one of the medical specialties with a high risk for exposure to corona disease 2019 (COVID-19). Uncontrolled transmission in a hospital department poses a risk to both healthcare workers (HCWs) and patients. OBJECTIVE: To monitor SARS-CoV-2 incidence, transmission, and antibody development among HCWs to identify high risk procedures, pathways, and work areas within the department. METHODS: Prospective cohort study of HCWs using repetitive oro- and nasopharygeal swab samples, antibody tests, and self-reported symptoms questionnaires at a tertiary referral center in Copenhagen, Denmark. RESULTS: 347/361 (96%) HCWs participated. Seven (1.9%) were positive on swab tests and none had symptoms. Fifteen (4.2%) developed antibodies. Only one case of potential transmission between HCWs was identified. Infection rates were low and no procedures or areas within the department were identified as exposing HCWs to a higher risk. CONCLUSIONS AND RELEVANCE: Adherence to the surveillance program was high. The low incidence among HCW during the first wave of the COVID-19 pandemic may reflect local transmission and infection control precautions, as well as a low infectious burden in the Danish society.

The impact and prevalence of SARS-CoV-2 in patients with head and neck cancer and acute upper airway infection in a tertiary otorhinolaryngology referral center in Denmark.

PURPOSE: To determine the prevalence of SARS-CoV-2 at a Danish tertiary referral otorhinolaryngology clinic during the first wave of the COVID-19 pandemic among patients with suspected acute upper airway infection (UAI) and patients operated for head and neck cancer (HNC), respectively. To monitor changes in the number of patient encounters for acute UAI and the number of referrals for the workup of HNC. TRIAL REGISTRATION: NCT-04356560 (Clinicaltrials.gov). METHODS: Prospective enrolled case series of all patients with suspected acute UAI (n = 88) and of patients undergoing surgery for HNC (n = 96), respectively, from March 23rd to May 5th, 2020, at a public tertiary referral otorhinolaryngology clinic in Denmark. SARS-CoV-2 was diagnosed with nasopharyngeal and oropharyngeal swabbing. Patients with suspected acute UAI had symptoms and definitive diagnoses registered in a database. Trends in the number of referrals and patient encounters were retrieved from an electronic patient journal system and analyzed retrospectively. RESULTS: Eighty-eight patients with acute UAI were enrolled including 55 men and 34 women, median age of 31 years (range: 10 months to 82 years). One patient (1.1%) tested positive. Among 96 patients operated for HNC, zero tested positive. The number of referrals for HNC workup, and patient encounters for peritonsillar abscesses, decreased markedly in the first 3 weeks. CONCLUSION: The prevalence of SARS-CoV-2 during the first 6 weeks of the first wave was minimal among patients with acute UAI and zero among patients operated for HNC. The decrease in referrals for the workup of HNC may increase time to treatment initiation and patient morbidity.

Smartphone otoscopy by non-specialist health workers in rural Greenland: A cross-sectional study.

INTRODUCTION: Greenland has one of the highest prevalences of otitis media in the world. However, access to ear specialists throughout Greenland is limited and currently there are no national guidelines for treatment or prevention. Tele-otoscopy may be beneficial in optimizing diagnosis and treatment. The smartphone otoscopy device, Cupris®, has previously been validated when used by medical doctors on a population primarily consisting of adults. In this study we evaluated the usability of the Cupris® otoscope when used by local health care workers with different levels of training and education, examining children aged 1-6 years. METHODS: We conducted a cross-sectional study in three Greenlandic towns. Health care personnel were asked to perform video-otoscopy on children contacting the health clinic for any reason. The videos were sent for remote evaluation by three ear specialists who rated the videos on a five-point Likert scale and provided information on challenges with the videos. The dichotomous outcome "not useful/useful" was defined as 1-3 and 4-5 on the Likert scale, respectively. RESULTS: In total, 142 videos were recorded on 84 patients. Mean proportion of useful videos was 18.1%, with a modified Fleiss' Kappa interrater agreement coefficient of 0.67 95% CI [0.57-0.76] corresponding to substantial agreement among the three raters. CONCLUSIONS: In this study the usefulness of the Cupris® TYM otoscope did not prove to be sufficient with the presented instruction in the hands of local health care workers when examining Greenlandic children. Focus on training and education of local health personnel is crucial and warranted before advantageous implementation for non-specialist health care workers can be expected.

Recurrent otorrhea in chronic suppurative otitis media: is biofilm the missing link?

Dispersal of bacteria from a biofilm in the middle ear, serving as a bacterial reservoir, could explain the recurrent and chronic nature of chronic suppurative otitis media (CSOM). The objective of this study is to investigate if the same strains of bacteria could be detected in repeated episodes of otorrhea in CSOM. In a prospective case series at a primary healthcare clinic in Nuuk, Greenland, patients with more than 14 days of otorrhea were included consecutively. Samples for culturing and biofilm analysis were taken at enrollment and at any subsequent episode with otorrhea. Participants were treated with daily saline irrigation and Ciprofloxacin eardrops for 7-14 days. Biofilm was identified in otorrhea in 81% (17/21) of participants at enrollment. Multispecies infections dominated with Non-typeable Haemophilus Influenzae (NTHI), Staphyloccocus aureus, and anaerobes being the most frequent pathogens. After the initial treatment, 19 (90%) had dry ears. Median observation period was 140 days (range 14-280) where 13 participants had one or more recurrences. Median time to first recurrence was 60 days (range 14-197). Among the 13 with recurrence, three individuals had the same genotype of bacteria at a subsequent episode. Another two had the same phenotype (NTHI). The remaining eight had new multispecies infections. We confirmed a high rate of biofilm in CSOM. However, the clinical implication might be of minor importance when treating with irrigation and antibiotic eardrops, as recurrent episodes of otorrhea were dominated by new pathogens in each episode.

The effects of ventilation tubes versus no ventilation tubes for recurrent acute otitis media or chronic otitis media with effusion in 9 to 36 month old Greenlandic children, the SIUTIT trial: study protocol for a randomized controlled trial.

BACKGROUND: The prevalence of otitis media in Greenlandic children is one of the highest in the world. International studies have shown that otitis-prone children may benefit from tubulation of the tympanic membrane. However, it is unknown whether these results can be applied to Greenlandic children and trials on the effects of ventilation tubes in high-risk populations have, to our knowledge, never been conducted. METHODS: The trial is an investigator-initiated, multicentre, randomized, blinded superiority trial of bilateral ventilation tube insertion versus treatment as usual (no tube) in Greenlandic children aged 9-36 months with chronic otitis media with effusion or recurrent acute otitis media. With randomization stratified by otitis media subtype and trial site, a type 1 error of 5% and a power of 80%, a total of 230 participants are needed to detect a decrease of two visits to a health clinic during 2 years, which is considered the minimal clinical relevant difference. The primary outcome measure will be assessed blindly by investigating medical records. Secondary outcome measures are number of episodes of acute otitis media, quality of life, number of episodes of antibiotics administration and proportion of children with tympanic membrane perforations. DISCUSSION: This trial will provide evidence-based knowledge of the effects of ventilation tubes in children with middle ear infections from the high-risk Greenlandic population. Furthermore, this trial will improve the understanding of conducting randomized clinical trials in remote areas, where management of logistical aspects is particularly challenging. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02490332 . Registered on 14 February 2016.

Chronic suppurative otitis media, middle ear pathology and corresponding hearing loss in a cohort of Greenlandic children.

BACKGROUND: Otitis media (OM) has been observed at elevated prevalence rates in Greenlandic children. OM associated hearing loss (HL) may compromise the children's linguistic skills, social development and educational achievements. OBJECTIVES: We investigated the prevalence of chronic suppurative otitis media (CSOM), otitis media with effusion (OME) and tympanic membrane sequelae of OM, and compared the corresponding hearing thresholds. METHODS: In 2010 we examined a cohort of 223 Greenlandic children aged 4-10 years by video otoscopy, tympanometry and tested hearing thresholds for the low-frequencies: 500, 1000 and 2000Hz and the high-frequencies: 4000 and 6000Hz. HL was categorized according to the worst hearing ear and was compared within the groups: CSOM, OME, tympanic membrane sequelae of OM and normal. RESULTS: Of 207 children, 5.8% had CSOM, 13.9% had OME and 55.6% had tympanic membrane sequelae of OM. The median pure tone average in low-frequencies/high-frequencies were: CSOM: 34.2/31.3dB, OME: 23.3/22.5dB, Sequelae of OM: 13.3/15dB and normal ears: 11.7/12.5dB. We found a significant difference (p<0.05) between the four groups. In 56.5% of all children a HL>15dB in any frequency was found, while 6.5% suffered from a bilateral low-frequency HL>25dB. CONCLUSION: The severity of OM significantly corresponded to increased HL. The burden of CSOM and HL remains high in young Greenlandic children. Aggressive treatment with antibiotics, improved hearing rehabilitation, sound field amplification in classrooms and otosurgical capacity should be further promoted in Greenland.

Human papillomavirus and oropharyngeal cancer in Greenland in 1994-2010.

BACKGROUND: Oropharyngeal squamous cell carcinoma (OPSCC) is associated with the sexually transmitted human papillomavirus (HPV), smoking and alcohol. In Greenland, a high rate of HPV-induced cervical cancer and venereal diseases are found, which exposes the population for high risk of HPV infection. In Greenland, only girls are included in the mandatory HPV vaccination program. OBJECTIVE: To investigate the annual incidence of OPSCC and the proportion of HPV-associated OPSCC (HPV+ OPSCC) in Greenland in 1994-2010. DESIGN: At Rigshospitalet, University of Copenhagen, we identified all Greenlandic patients diagnosed and treated for OPSCC from 1994 to 2010. Sections were cut from the patient's paraffin-embedded tissue blocks and investigated for p16 expression by immunohistochemistry. HPV analyses were performed with 2 sets of general HPV primers and 1 set of HPV16-specific primer. HPV+ OPSCC was defined as both >75% p16+ cells and PCR positive for HPV. RESULTS: Of 26 Greenlandic patients diagnosed with OPSCC, 17 were males and 9 were females. The proportion of HPV+ OPSCC in the total study period was 22%, without significant changes in the population in Greenland. We found an increase in the proportion of HPV+ OPSCC from 14% in 1994-2001 to 25% in 2002-2010 (p=0.51). Among males from 20 to 27% (p=0.63) and in females from 0 to 20% (p=0.71). The annual OPSCC incidence increased from 2.3/100,000 (CI=1.2-4.2) in 1994-2001 to 3.8/100,000 (CI=2.4-6.2) in 2002-2010: among males from 2.4/100,000 (CI=1.0-5.7) to 5.0/100,000 (CI=2.9-8.9). CONCLUSION: Even though the population is at high risk of HPV infection, the proportion of 22% HPV+ OPSCC in the total study period is low compared to Europe and the United States. This might be explained by our small study size and/or by ethnic, geographical, sexual and cultural differences. Continuing observations of the OPSCC incidence and the proportion of HPV+ OPSCC in Greenland are needed.

The risk of hearing loss in a population with a high prevalence of chronic suppurative otitis media.

BACKGROUND: Chronic suppurative otitis media (CSOM) affects 65-330 million people in the developing part of the world and develops in early childhood. Knowledge of the long-term effects on hearing is scarce. Hearing loss (HL) can cause reduced ability to communicate, impair language development and academic skills. OBJECTIVE: To estimate the prevalence of HL in a population with a high-risk of CSOM and to identify the risk of permanent hearing loss from CSOM. METHODS: Ten and 15 years follow-up of two Greenlandic population-based children cohorts. Participants underwent otologic examination and audiometric evaluation. HL was defined using both the American Speech-Language-Hearing Association's (ASHA) and the World Health Organizations's (WHO) definition. Risk factors for HL were analyzed, using binomial logistic regression analysis. RESULTS: A total of 438 individuals aged 11-24 years participated. Using the ASHA definition of HL the prevalence was 50% (95% CI 45.3-54.7). Using the WHO definition of HL the prevalence was 2.5% (95% CI 1.1-3.98). CSOM was the main cause of HL. Co-existing CSOM (OR 16.7, 95% CI 8.29-33.65), spontaneous healing from CSOM (OR 3.75, 95% CI 1.62-8.67), and male gender (OR 2.2, 95% CI 1.28-3.78) were associated with HL. Ninety-one percent of children with CSOM developed a permanent hearing loss >15dBHL. CONCLUSION: CSOM was strongly associated with permanent hearing loss. CSOM was the main reason for HL in this population. The WHO definition of hearing loss is likely to underestimate the burden of hearing loss among children and adolescents in developing countries with a high prevalence of CSOM.

Tobacco smoke increases the risk of otitis media among Greenlandic Inuit children while exposure to organochlorines remain insignificant.

BACKGROUND: Prenatal exposure to environmental levels of organochlorines (OCs) has been demonstrated to have immunotoxic effects in humans. We investigated the relationship between prenatal exposure to OCs and the occurrence of otitis media (OM) among Inuit children in Greenland. METHODS: We estimated the concentration of 14 PCB congeners and 11 pesticides in maternal and cord blood samples and in breast milk in a population-based cohort of 400 mother-child pairs. At follow-up, we examined the children's ears and used their medical records to assess the OM occurrence and severity. Multivariate regression analyses were used with adjustments for passive smoking, crowding, dietary habits, parent's educational level, breast feeding and the use of child-care. RESULTS: The children were 4-10 years of age at follow-up and 223 (85%) participated. We found no association between prenatal OC exposure and the development of OM. Factors associated with the child's hazard of OM during the first 4 years of life were: mother's history of OM (HR 1.70, 95% CI 1.11-2.59, p=0.01); mother's smoking habits: current (HR 2.47, 95% CI 1.45-4.21, p<0.01) and previous (HR 2.00, 95% CI 1.19-3.36, p<0.01); number of smokers in the home (HR 1.17, 95% CI 1.05-1.31, p<0.01). After adjustment mothers' smoking habits remained significant. CONCLUSION: We found no relationship between high levels of prenatal exposure of OCs and occurrence of OM. Passive smoking was found as the strongest environmental risk factor for the development of OM. Interventions to reduce passive smoke in children's environment are needed.

Long-term tympanic membrane pathology dynamics and spontaneous healing in chronic suppurative otitis media.

BACKGROUND: Children in the developing parts of the world have a high prevalence of chronic suppurative otitis media (CSOM). It is estimated that 65 to 330 million people worldwide have CSOM, yet very little is known about the natural course of the disease. The Inuit population of the Arctic regions is among those with the highest prevalences of CSOM. The aim of this study was to examine the long-term tympanic membrane changes since childhood among Inuit adolescents in Greenland and estimate the proportion of individuals affected by CSOM. METHODS: Follow-up study (2009) on a population-based cohort of 591 children originally examined during 1993 to 1994 at 3 to 8 years of age. Follow-up was attempted among 348 individuals still living in the areas. Video otoscopy and tympanometry were used. Data on otologic disease, ear surgery, and antibiotic use for otitis media were collected from medical records. RESULTS: Of 226 participants (65% of those contacted; median age, 22 years), 28 (12%) had present CSOM or had been surgically treated. Eleven were new cases of CSOM not seen between 1993 and 1994. Of those with CSOM in the initial study, 39% had healed spontaneously. The proportion of spontaneous healing was not influenced by the age at which CSOM was diagnosed in the initial study. Thirty-nine individuals (17%) had CSOM in either the initial study or at follow-up. Of these, 2 had never received antibiotic treatment for otitis media, and 15 had been treated less than 3 times. Eighty individuals (35%) at follow-up had CSOM, had undergone ear surgery, or had sequelae in the form of circular atrophy or myringosclerosis. CONCLUSIONS: The proportion of spontaneous healing and the findings of new cases show that CSOM is a dynamic disease both on the individual as well as on the population level. Every third participant at follow-up had a perforation or sequelae from recurrent or long-lasting perforations, indicating a burden of disease from otitis media larger than what can be estimated in cross-sectional studies. There is a potential for increased treatment of otitis media in this population, which requires raised awareness of the disease in the population and the creation of guidelines customized to conditions in Greenland.

Long-term follow-up of chronic suppurative otitis media in a high-risk children cohort.

OBJECTIVE: Chronic suppurative otitis media (CSOM) is the leading cause of mild to moderate hearing impairment in children worldwide and a major public health problem in many indigenous populations. There is a lack of basic epidemiological facts and knowledge on the development of CSOM, as the disease primarily affects developing countries where research capacities often are limited. The purpose of this study was to determine the long-term outcome of CSOM in a high-risk population and to identify risk factors. METHODS: Follow-up study (2008) on a population-based cohort of 465 children in Greenland, initially examined (1996-8) between the ages 0 and 4 years. Follow-up was attempted among 307 children living in the two major towns. Binomial logistic regression analysis was made to identify risk factors for developing CSOM and for maintaining disease in to adolescence (odds ratios). Log linear binomial regression was used to estimate risk ratios and absolute risks. RESULTS: At follow-up 236 participated (77% of those available). The prevalence of CSOM was 32/236 (14%) at age group 0-4 years and 21/236 (9%) at age group 11-15 years. Thirteen had disease debut after the initial study. Of those with CSOM in the initial study 24/32 (75%) healed spontaneously. Risk factors for the development of CSOM at any time in childhood was the mother's history of CSOM OR 2.55 (95% CI 1.14-5.70; p=0.02), and mothers with low levels of schooling OR 1.57 (1.03-2.40; p=0.04). Once CSOM had developed boys were more likely to have persistent disease OR 5.46 (95% CI 1.47-20.37; p=0.01). The absolute risk of CSOM if the mother had both a history of CSOM and low schooling was for boys 45.4% (95% CI 26.5-77.7) and for girls 30.7% (95% CI 17.8-53.10). The cumulative risk of CSOM was 19% at follow-up. CONCLUSIONS: Even though a large number of CSOM cases seemed to heal spontaneously, the prevalence of untreated CSOM among school-age children in Greenland remained high as new cases were found at follow-up. Increased focus on prevention and identification of children at special risk could reduce the high prevalence of CSOM.

Survival of head and neck cancer in Greenland.

OBJECTIVES: Head and neck cancer is frequent in the Inuit population of Greenland and is characterized by a very high incidence of Epstein-Barr virus associated nasopharyngeal carcinoma (NPC). However, information on the treatment and survival of Inuit head and neck cancer patients is practically non-existent. The aim of this study, therefore, was to analyse the epidemiological pattern, time course and survival of head and neck cancer patients in Greenland. STUDY DESIGN: Retrospective register-based study. METHODS: The Danish Civil Registration System, the Danish Cancer Registry and hospital-based registries were used to identify all patients resident in Greenland diagnosed with head and neck cancer during the period 1994-2003. Data were analysed with regard to clinical characteristics, treatment delay and survival. RESULTS: A total of 125 patients were identified. The age-standardized incidence rate for all head and neck cancer cases was 28/100,000 for males and 19/100,000 for females. High incidence rates were found for NPC and oral cancers. Of all cancers, 47% were stage IV at the time of diagnosis, while 61% of all NPC's were stage IV. The median delay from date of first symptom to treatment was 248 days for all cancers. The overall crude 5-year survival rate for all sites together was 35% and for NPC 20%. CONCLUSION: Survival of head and neck cancer in Greenland is very low. Delays in treatment and inadequate follow-up on treatment complications are probable causes. The improvements in treatment for NPC and other head and neck cancer cases over the last decades are yet to be seen in this Inuit population.