Reducing children's hearing loss: the expertise of New Zealand ear nurse specialists--in particular their mobile community service--is arousing interest among consultants and nurses around the world.

A WARD WINNING ear nurse specialists (ENS) Barbara Middleton of Auckland and Christine Lloyd of Gisborne believe New Zealand nurses lead the world in the treatment and management of chronic ear disease.

This belief was reinforced at a recent international paediatric otorhinolaryngology (ORL-ENT) congress in England where they were the only nurses invited to attend and present a poster. Entitled "Ear Nurse Specialists--New Zealand's unique answer for the treatment of Otitis Media with Effusion--Glue ear", their poster and accompanying paper outlined their role in delivering an advanced specialised mobile service that treats and manages ear conditions in an accessible, affordable and culturally appropriate way.

"Our poster caused a lot of interest among the 500 conference attendees," explained Middleton, who is national chairperson of the 27-strong ENS group. "Many were surprised at our high level of practice and very interested in the approach our service takes. Since our return last September, we've had a lot of calls from ORLs and ear nurses overseas wanting to know more about how we operate. We're also having nurses from Australia and Singapore visiting us to find out how to set up a similar service in their countries. It's great to be able to get our message out about how to treat children's ear disease effectively, affordably and accessibly."

Middleton moved into an ENS role in 1993 after working as a district nurse in the King Country. This was shortly after Whakarongo Mai, the Maori Hearing Impairment Report, had highlighted the extent of ear problems among Maori children and the need to increase mobile clinic services in rural communities. "I set up a service in the King Country, initially as a suitcase clinic operating from railway stations, Plunket rooms or other public buildings. I would visit every area on a four-week cycle, identifying 'hot spots'. Waikato Hospital ORL consultant Malcolm Giles would hold a clinic every two months in the Te Kuiti Railway Station to see children with serious ear disease. These clinics are now held monthly in the Te Kuiti and Taumaranui Hospitals.

"Eventually I graduated to a caravan fitted out as an ear clinic, and finally to a mobile clinic designed from scratch. At that stage, there were 24 ENS in the North Island, offering a range of services including otoscopy, tympanometry, aural hygiene and treatment for ear disease, especially glue ear. We worked closely with GPs, schools and other agencies along with independent Maori providers who would identify at-risk children and refer them to our service."

There are now 27 ENS, most working in community settings, and 17 mobile clinics, all based in the North Island. Six ENS work in hospital outpatient clinics where they deal with more complex ear disease. The ENS service is free, bridging primary and secondary health care.

Much of Middleton's training came from direct experience on the job and mentoring by ENS Margaret Couillault from Waitemata District Health Board (DHB). Couillault had been trained by prominent Auckland ORL surgeon Patrick Eisdell-Moore, who believed nurses could play a key role in microscopy techniques and aural toileting. An ENS course has been for malised for the last ten years and is now delivered through Waitemata DHB's ORL. department. Couillault is the national coordinator. It takes three years for an ear nurse to achieve specialist status.

For the last three years, Middleton has worked from the Waitemata DHB's outpatients department alongside the ORL consultants. Her colleague Christine Lloyd has a similar position at Tairawhiti DHB. Both work autonomously and across the age span, running their own clinics, referring patients for grommet insertion as needed, and monitoring their care in the community following surgery. They also advise GPs and other health professionals about how to manage ear conditions.

According to Lloyd, the causes of Otitis Media with Effusion (glue ear) are many and complex. One of the major factors are children's smaller air waves and Estachian tubes, which can be easily blocked through mucous discharge due to chronically runny noses or enlarged adenoids. There is also a higher incidence of glue ear among preschoolers, with those from lower socio-economic groups particularly prone to the disease. "Poorly heated houses, inadequate diets and being exposed to smoky environments compound the problems. Much ENS work revolves around parent education and simple techniques like nose blowing."

Both Lloyd and Middleton gain enormous satisfaction from their work, particularly seeing children catch up developmentally once they can hear properly. They are also able to identify associated health problems and refer onto specialist services or GPs when needed. "Having an ear disease can make people very isolated," said Lloyd. "It's great to help people clear their conditions, thus improving the quality of their lives."

Middleton and Lloyd were recently awarded the Auckland Hearing Association's Noel Roydhouse Memorial Award for their efforts in promoting their role at last year's congress.