demographic Analysis of Adult Patients Presenting With unilateral Ear discharge at national Medical College RESEARCh

Background: Discharging ear is a common symptom among the patients presenting in ENT OPD for consultation. The commonest cause for discharging ear is chronic otitis media. Poverty, ignorance, crowded living conditions due to large families, poor sanitation, and lack of personal and environmental hygiene are some of the main factors behind the prevalence of chronic otitis media. National medical college and teaching hospital is a tertiary care center located in Birgunj metropolitan city in central Nepal. It caters to thousands of patients with discharging ear each year. Methods: This qualitative, descriptive study was carried out in department of ENT-HNS at National Medical College and Teaching Hospital located Birgunj-15, Parsa, Province no. 2 of Nepal for duration of one year from August 1, 2014 to July 30, 2015. Two hundred and five (205) adult patients with complains of unilateral          discharging ear were included in the study. Results: Mostly female patients and those in the age group of 15-30 years from Bara and Parsa districts of Nepal including the areas around the Indo-Nepal border avail the services of department of ENT-HNS of National medical college and teaching hospital. Conclusions: The delivery of ENT-HNS services to the concerned patients is insufficient and inefficient owning to various factors. The government of Nepal and India along with National medical college and teaching hospital can work together to improve the situation. Med Phoenix . Vol. 3, Issue. 1, 2018, Page: 48-51

Discharging ear is a common symptom among patients presenting to ENT OPD (Ear, Nose and Throat Out-Patient Department) for consultation.The causes are various, the most common being Chronic Otitis Media (COM).COM is defined as a chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges or otorrhoea through a tympanic membrane perforation.It is an important cause of preventable hearing loss, especially in developing countries. 2ronic otitis media is one of the commonest problems encountered by an otorhinolaryngologist in his clinical practice. 3he prevalence of COM varies around the world, affecting 30% of North America's Eskimos, 4-6% of African populations and less than 1% of individuals in the United States and United Kingdom. 4,5Poverty, ignorance, crowded living conditions due to large families, poor sanitation, and lack of personal and environmental hygiene are some of the main factors underlying the prevalence of COM. 6,7 hough, this condition doesn't seem to be common in developed countries with prevalence of less than 2%, 8 it is still a common condition to be encountered in developing nations like ours with prevalence being reported as 7.2%. 9tients diagnosed as COM, which is a major cause for ear discharge, form the bulk of those who come to ENT OPD seeking treatment.Similarly, various surgical management options like tympanoplasty, cortical mastoidectomy and modified radical mastoidectomy are among the commonest surgical procedures performed at NMCTH.Hence, it becomes important to know the population NMCTH is catering to so that special provisions could be tailor-made for dispensing of services.

METhod
This qualitative, descriptive study was carried out in department of ENT-HNS at National Medical College and Teaching Hospital located Birgunj-15, Parsa, Nepal for duration of one year from August 1, 2014 to July 30, 2015.Two hundred and five (205) adult patients with complains of unilateral discharging ear were included in the study.Those patients with previous ear surgery, traumatic perforation, bilateral ear discharge, deaf child and middle ear neoplasm were excluded from the study.Non-probability convenient sampling method was applied.Ethical approval for the study was obtained from Institutional Review Borard (IRB) of Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
The patients, suitable for the study, were first explained about the study in detail in the language that they could understand which was mostly Bhojpuri and occasionally, Hindi, Maithili and Nepali.After the explanation, they were asked to sign the consent form after going through it.Consent forms were prepared in two languages viz.English and Nepali.Consent form was read to or translated to those who were illiterates.Then, a proforma was duly filled up with all the parameters for the study.Data thus collected was entered, stored first in Microsoft Excel for convenience and then the data were exported to SPSS 20.

RESulTS
The study was essentially limited to the adult age group.Table 1 shows that 125 out of 205 patients (61%) were in the age group 15-30 years.64 (31.2%) and 16 (7.8%)were from 31-45 years and 46-60 years of age group respectively.Similarly, there are more female patients compared to the males in our setup.Of 205 patients, 137 (66.8%) were females whereas only 68 (33.2%) were males.   hese results show that younger persons are more concerned about their health whereas with ageing of the population, the patients tend to live with their disease.15-30 years is the age group when people apply to join the army/police or go abroad for studies or work.Under all these circumstances, they are bound to produce certificate of medical fitness and hence, there's an increased number of patients from this age group consulting an ENT surgeon for their discharging ear.
Of 205 patients, 137 (66.8%) were females whereas only 68 (33.2%) were males.Similarly, out of 125 patients presenting in the age group of 15-30 years, 93 were females whereas only 32 are males.The reason behind seeking medical care in this age group was that the parents wanted their daughters to be perfectly well before getting them married off.In regions like this, where arranged marriages are common, any medical illness would cause embarrassment for the bride and her family.In the study by SadySalaimen da Constaet al., 51% of the patients were male.Similarly, 64.4% were male and 35.6% were females in the study carried out by Adhikariet al. 11 Likewise, in a study carried out on 46 patients by Abou-Elhamadet al. in Egypt 31 were male and 15 female. 12In another study by Mohamad Ali Damghaniet al. in Iran, 47% were male and 53% were female. 13Hence, the sex-wise distribution of patients of my study shows female patients outnumbering males by a good number.This is unlike any other study carried out across the globe where there were always more male patients compared to the females.
The results elaborate that most of the patients are from the Bara and Parsa districts of Nepal and from neighboring areas of India.These three locations combined accounted for 78.1% of the patients which is quite significant.The large number of patients from India also signifies the lack of a tertiary care center or even presence of an ENT surgeon in the Indian districts adjoining the Indo-Nepal border.There were a few patients from the far-flung areas as well viz.Morang, Lalitpur and Nawalparasi districts of Nepal.It was mostly due the fact that such patients were in the locality of the hospital mostly as students or job holders.Similarly, there were a few patients from adjoining districts viz.Rautahat, Sarlahi and Dhanusa as well.These geographical sites suggest that the catchment area of National Medical College expands over a radius of 50-60 km which is quite impressive.
Nepal is basically a Hindu country with over 90% practicing Hinduism as their religion.Only 2% of the total population of Nepal is Muslim.Yet, 22% of the patients were visiting our ENT OPD were Muslims as Bara and Parsa districts of Nepal and the adjoining areas of India have high concentration of Muslims.Non-compliance of prescription should be expected as the author observed that some patients following Islam are reluctant to instill ear drops or nasal drops or take any medicines during the daytime of the holy month of fasting.

ConCluSIon
The catchment areas of NMCTH are impoverished with crowded living conditions and poor sanitation.Similarly, there's high humidity in this region.People living out of the cities do not have a bathroom in their house and often bathe in ponds, rivers and other water bodies.All of these result in higher prevalence and persistence of ear discharge in the population here.Little can be done to alter the humidity in this area.Yet, there's a lot the government of Nepal and India can do to improve the sanitation and living condition of people living in the catchment area of this tertiary care hospital.NMCTH, though being a private institution, can mobilize outreach clinics focused especially for the rural areas so as to give a better life to those patients who are unlooked for and uncared.This, on the other hand, would help NMCTH earn public goodwill and trust.

Fig 1 :
Fig 1: Address-wise distribution of patients Mostly female patients and those in the age group of 15-30 from Bara and Parsa districts of Nepal including the areas around the Indo-Nepal border avail the services of department of ENT-HNS of NMCTH.Transportation services from the rural areas to NMCTH are not up mark.Most of the patients coming to this tertiary center are either farmers or daily wage earning laborers.They simply can't afford to lose a day of income for a consultation with an ENT surgeon and another few days if an operation is suggested.

Table 2 : distribution of Patients based on Religion
As mentioned in the results, 125 out of 205 patients (61%) were in the age group of 15-30 years while 64 patients (31.2%) and 16 (7.8%)were from 31-45 years and 46-60 years of age group respectively.The mean age was 28.96 years whereas the median was 25 and standard deviation 11.201.This was comparable to the mean age calculated by Sady Salaien da Costa et al.where it was 26.3 years.