International consensus (ICON) on management of otitis media with effusion in children

The impact of new evidence on regional variation in paediatric tonsillectomy and adenoidectomy: a historical review

BACKGROUND

Tonsillectomy and adenoidectomy have been among the most commonly performed procedures in children for approximately 100 years. These procedures were the first for which unwarranted regional variation was discovered, in 1938. Indications for these procedures have become stricter over time, which might have reduced regional practice variation.

METHODS

This paper presents a historical review on practice variation in paediatric tonsillectomy and adenoidectomy rates. Data on publication year, region, level of variation, methodology and outcomes were collected.

RESULTS

Twenty-one articles on practice variation in paediatric tonsil surgery were included, with data from 12 different countries. Significant variation was found throughout the years, although a greater than 10-fold variation was observed only in the earliest publications.

CONCLUSION

No evidence has yet been found that better indications for tonsillectomy and adenoidectomy have reduced practice variation. International efforts are needed to reconsider why we are still unable to tackle this variation.

Bidirectional association between asthma and otitis media in children

BACKGROUND

This study explored the reciprocal association between otitis media and asthma in children.

METHODS

The 2002-2013 Korean Health Insurance Review and Assessment Service-National Sample Cohort participants < 15 years old were used. In study I, 14,665 asthma patients from 2002 through 2005 were selected. The asthma patients were matched 1:1 with the control I group, and the occurrence of otitis media was followed until 2013. In study II, 27,043 otitis media patients from 2002 through 2005 were selected. The otitis media patients were matched 1:1 with the control II group, and the occurrence of asthma was followed until 2013. Stratified Cox proportional hazard models were used to analyze the hazard ratio (HRs) of asthma for otitis media (study I) and otitis media for asthma (study II).

RESULTS

The HR for otitis media was 1.46 in asthma patients (95% confidence interval [CI] = 1.40-1.52, P < 0.001). The HR for asthma was 1.43 in otitis media patients (95% confidence interval [CI] = 1.36-1.50, P < 0.001).

CONCLUSION

Asthma and otitis media have a bidirectional association in children.

Effect of Balloon Eustachian Tuboplasty in Adults That Only Have Symptoms of Chronic Eustachian Tube Dysfunction, With a 1-Year Follow-Up: Prospective Clinical Trial

OBJECTIVES

Balloon eustachian tuboplasty (BET) is a promising therapeutic option for eustachian tube (ET) dysfunction. However, data are lacking on the effect of BET in adults with symptoms of chronic ET dysfunction but without a contributing pathology. This study investigated the effect of BET in adult patients with only symptoms of chronic ET dysfunction.

METHODS

This prospective clinical trial included adult patients with aerated physiological middle ears and symptoms of ET dysfunction for more than 6 months. Compliance with follow-up was 93.3%. We evaluated the effects of BET with tympanometry, assessment of the Valsalva or Toynbee maneuver with tympanometry verification, a Eustachian Tube Dysfunction Questionnaire (ETDQ-7), and pure-tone audiometry. Data were recorded 1 day before surgery and 2, 6, and 12 months after BET. Therapy was considered successful when the patient exhibited a newly acquired ability to perform the Valsalva or Toynbee maneuver or when the ETDQ-7 score improved by 20% or more.

RESULTS

We included 14 ears in the analysis. After 2, 6, and 12 months, therapy was successful, according to the ETDQ-7, in 11/14 (78.6%; 95% CI: 48.8-94.3), 13/14 (92.9%; 95% CI: 64.2-99.6), and 12/14 (85.7%; 95% CI: 56.2-97.5) ears, respectively. These results were statistically significant. The ETDQ-7 scores also significantly decreased at 2, 6, and 12 months after the BET, when any change was observed. All patients experienced improvement. Only 1 patient reported temporary deterioration after 2 months. Treatment was more frequently successful in patients without nasal polyps or pollinosis.

CONCLUSIONS

Adults with only symptoms of chronic ET dysfunction benefitted more and had longer lasting results from BET, compared to patients with pathologies caused by ET dysfunction. Balloon eustachian tuboplasty could be recommended for these patients.

Otitis media with effusion in Africa-prevalence and associated factors: A systematic review and meta-analysis

OBJECTIVES

To estimate the overall and subgroup prevalence of otitis media with effusion (OME) in Africa, and identify setting-specific predictors in children and adults.

METHODS

PubMed, African Journals Online, African Index Medicus, Afrolib, SciELO, Embase, Scopus, Web of Science, The Cochrane Library, GreyLit and OpenGray were searched to identify relevant articles on OME in Africa, from inception to December 31st 2019. A random-effects model was used to pool outcome estimates.

RESULTS

Overall, 38 studies were included, with 27 in meta-analysis (40 331 participants). The overall prevalence of OME in Africa was 6% (95% CI: 5%-7%; I 2 = 97.5%, P < .001). The prevalence was 8% (95% CI: 7%-9%) in children and 2% (95% CI: 0.1%-3%) in adolescents/adults. North Africa had the highest prevalence (10%; 95% CI: 9%-13%), followed by West and Southern Africa (9%; 95% CI: 7%-10% and 9%; 95% CI: 6%-12% respectively), Central Africa (7%; 95% CI: 5%-10%) and East Africa (2%; 95% CI: 1%-3%). There was no major variability in prevalence over the last four decades. Cleft palate was the strongest predictor (OR: 5.2; 95% CI: 1.4-18.6, P = .02). Other significant associated factors were age, adenoid hypertrophy, allergic rhinitis in children, and type 2 diabetes mellitus, low CD4 count in adults.

CONCLUSION

OME prevalence was similar to that reported in other settings, notably high-income temperate countries. Health care providers should consider age, presence of cleft palate, adenoid hypertrophy and allergic rhinitis when assessing OME in children and deciding on a management plan. More research is required to confirm risk factors and evaluate treatment options.

LEVEL OF EVIDENCE

3a.

Effects of Adenoidectomy and Adenotonsillectomy on Tympanostomy Tube Reinsertion Based on Korean Population-Based National Sample Cohort Data

OBJECTIVES

We evaluated the effects of adenoidectomy and adenotonsillectomy (AT) on tympanostomy tube (TT) reinsertion using population-based retrospective cohort data to confirm the association of adenoidectomy or AT with TT reinsertion reported in several previous studies.

MATERIALS AND METHODS

This study used data from the National Health Insurance Service National Sample Cohort in Korea. We selected patients who underwent TT insertion between the ages of 0 and 9 years from 2006 to 2015. Patients were divided into the following groups: group 1, TT insertion only; group 2, TT insertion with adenoidectomy; and group 3, TT insertion with AT. The number of TT reinsertions was analyzed.

RESULTS

There were 745 patients in group 1, 115 in group 2, and 251 in group 3. There were 1,019 cases of total TT insertion and 336 of reinsertion in group 1, 169 of total TT insertion and 31 of reinsertion in group 2, and 343 of total TT insertion and 50 of reinsertion in group 3. The rates of TT reinsertion were significantly lower in groups 2 and 3 than in group 1. The risks of TT reinsertion in groups 2 and 3 were significantly lower than the risk in group 1 in both univariate and multivariate Cox regression analysis.

CONCLUSION

TT reinsertion was significantly lower in the TT insertion with adenoidectomy and TT insertion with AT groups than in the TT insertion only group. We confirmed the effects of adenoidectomy and AT on reduction of the rate of repeated TT insertion by analysis of population-based data.

A compendium answering 150 questions on COVID-19 and SARS-CoV-2

In December 2019, China reported the first cases of the coronavirus disease 2019 (COVID-19). This disease, caused by the severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), has developed into a pandemic. To date, it has resulted in ~9 million confirmed cases and caused almost 500 000 related deaths worldwide. Unequivocally, the COVID-19 pandemic is the gravest health and socioeconomic crisis of our time. In this context, numerous questions have emerged in demand of basic scientific information and evidence-based medical advice on SARS-CoV-2 and COVID-19. Although the majority of the patients show a very mild, self-limiting viral respiratory disease, many clinical manifestations in severe patients are unique to COVID-19, such as severe lymphopenia and eosinopenia, extensive pneumonia, a "cytokine storm" leading to acute respiratory distress syndrome, endothelitis, thromboembolic complications, and multiorgan failure. The epidemiologic features of COVID-19 are distinctive and have changed throughout the pandemic. Vaccine and drug development studies and clinical trials are rapidly growing at an unprecedented speed. However, basic and clinical research on COVID-19-related topics should be based on more coordinated high-quality studies. This paper answers pressing questions, formulated by young clinicians and scientists, on SARS-CoV-2, COVID-19, and allergy, focusing on the following topics: virology, immunology, diagnosis, management of patients with allergic disease and asthma, treatment, clinical trials, drug discovery, vaccine development, and epidemiology. A total of 150 questions were answered by experts in the field providing a comprehensive and practical overview of COVID-19 and allergic disease.

Niche- and Gender-Dependent Immune Reactions in Relation to the Microbiota Profile in Pediatric Patients with Otitis Media with Effusion

Otitis media with effusion (OME) is a common inflammatory disease that primarily affects children. OME is defined as a chronic low-grade inflammation of the middle ear (ME), without any signs of infection and with effusion persisting in the ME for more than 3 months. The precise pathogenesis is, however, not fully understood. Here, we comprehensively characterized and compared the host immune responses (inflammatory cells and mediators) and the overall microbial community composition (microbiota) present in matched middle ear effusion (MEE) samples, external ear canal (EEC) lavages, and nasopharynx (NPH) samples from children with OME.

Otitis media with effusion (OME) is a common inflammatory disease that primarily affects children. OME is defined as a chronic low-grade inflammation of the middle ear (ME), without any signs of infection and with effusion persisting in the ME for more than 3 months. The precise pathogenesis is, however, not fully understood. Here, we comprehensively characterized and compared the host immune responses (inflammatory cells and mediators) and the overall microbial community composition (microbiota) present in matched middle ear effusion (MEE) samples, external ear canal (EEC) lavages, and nasopharynx (NPH) samples from children with OME. Female patients had significantly increased percentages of T lymphocytes and higher levels of a wide array of inflammatory mediators in their MEE compared to that of male patients, which were unrelated to microbiota composition. The relative abundances of identified microorganisms were strongly associated with their niche of origin. Furthermore, specific inflammatory mediators were highly correlated with certain bacterial species. Interestingly, some organisms displayed a niche-driven inflammation pattern in which presence of Haemophilus spp. and Corynebacterium propinquum in MEE was accompanied by proinflammatory mediators, whereas their presence in NPH was accompanied by anti-inflammatory mediators. For Turicella and Alloiococcus, we found exactly the opposite results, i.e., an anti-inflammatory profile when present in MEE, whereas their presence in the the NPH was accompanied by a proinflammatory profile. Together, our results indicate that immune responses in children with OME are highly niche- and microbiota-driven, but gender-based differences were also observed, providing novel insight into potential pathogenic mechanisms behind OME.

Allergy and Otitis Media in Clinical Practice

PURPOSE OF REVIEW

Otitis media (OM) is a disease with very high prevalence in infancy, substantial burden on healthcare resources, and relevant impact on the quality of life of families. The link between OM and allergy is controversial and still debated. However, a fundamental premise has to be placed before introducing this topic: there is the need to use clear and unambiguous terms. Literature abounds with misleading terms that significantly affect the methodology and consequently the outcomes. Moreover, it is essential to differentiate patients according to the OM type (i.e., acute OM, OM with effusion, and chronic suppurative OM), the allergic disease, and mainly the age.

RECENT FINDINGS

There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. To identify allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, to suspect allergy in OM patients could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of allergy in OM. As there are conflicting findings, a possible interpretation of pathophysiological events and a pragmatic approach are proposed.

Unsolved problems and new medical approaches to otitis media

INTRODUCTION

Otitis media (OM) is a spectrum of infectious and inflammatory diseases that involve the middle ear. It includes acute otitis media (AOM), otitis media with effusion (OME) and chronic suppurative otitis media (CSOM).

AREAS COVERED

This manuscript discusses some of the emerging and unsolved problems regarding OM, and some of the newly developed prophylactic and therapeutic medical measures.

EXPERT OPINION

In recent years, considerable progress in the knowledge of OM physiopathology has been made. However, although extremely common, diseases included under OM have not been adequately studied, and many areas of development, evolution and possible treatments of these pathologies are not defined. It is necessary that these deficiencies be quickly overcome if we want to reduce the total burden of a group of diseases that still have extremely high medical, social and economic relevance.

Diseño, modelado 3D y optimización del comportamiento mecanoacústico de un nuevo tubo de ventilación transtimpánico

Introducción y Objetivos: En este trabajo mostramos un nuevo tubo de ventilación transtimpánico cuyo diseño pretende solventar los efectos indeseables aparecidos durante la inserción de tubos de ventilación actualmente comercializados; analizamos su comportamiento mecánico en un modelo 3D del oído a fin de optimizar su comportamiento acústico. Métodos: Para el diseño del tubo se empleó un software autoCAD; El comportamiento mecánico se analizó en un modelo computadorizado dinámico 3D del oído humano basado en el método de los elementos finitos (FEM). Resultados: El nuevo tubo de ventilación posee un tamaño y una masa significativamente menores a los actualmente disponibles en el mercado lo que provoca un menor interferencia en la vibración del sistema tímpano-osicular; su diseño facilita que permanezca insertado mientras las condiciones del paciente así lo aconsejen evitando su caída hacia la caja o su precoz extrusión. Conclusiones: Las ventajas teóricas biológicas y acústicas del nuevo tubo desarrollado (con menor masa y cuyo diseño evita las complicaciones de los actuales) puede abrir una nueva posibilidad de tratamiento de la otitis media seromucosa crónica.

Bacterial otitis media in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Otitis media is inflammation of the middle ear, comprising a spectrum of diseases. It is the commonest episode of infection in children, which often occurs after an acute upper respiratory tract infection. Otitis media is ranked as the second most important cause of hearing loss and the fifth global burden of disease with a higher incidence in developing worlds like Sub-Saharan Africa and South Asia. Therefore, this systematic review is aimed to quantitatively estimate the current status of bacterial otitis media, bacterial etiology and their susceptibility profile in sub-Saharan Africa.

METHODS

A literature search was conducted from major databases and indexing services including EMBASE (Ovid interface), PubMed/MEDLINE, Google Scholar, ScienceDirect, Cochrane Library, WHO African Index-Medicus and others. All studies (published and unpublished) addressing the prevalence of otitis media and clinical isolates conducted in sub-Saharan Africa were included. Format prepared in Microsoft Excel was used to extract the data and data was exported to Stata version 15 software for the analyses. Der-Simonian-Laird random-effects model at a 95% confidence level was used for pooled estimation of outcomes. The degree of heterogeneity was presented with I2 statistics. Publication bias was presented with funnel plots of standard error supplemented by Begg's and Egger's tests. The study protocol is registered on PROSPERO with reference number ID: CRD42018102485 and the published methodology is available from http://www.crd.york.ac.uk/CRD42018102485.

RESULTS

A total of 33 studies with 6034 patients were included in this study. All studies have collected ear swab/discharge samples for bacterial isolation. The pooled isolation rate of bacterial agents from the CSOM subgroup was 98%, patients with otitis media subgroup 87% and pediatric otitis media 86%. A univariate meta-regression analysis indicated the type of otitis media was a possible source of heterogeneity (p-value = 0.001). The commonest isolates were P. aeruginosa (23-25%), S. aureus (18-27%), Proteus species (11-19%) and Klebsiella species. High level of resistance was observed against Ampicillin, Amoxicillin-clavulanate, Cotrimoxazole, Amoxicillin, and Cefuroxime.

CONCLUSION

The analysis revealed that bacterial pathogens like P. aeruginosa and S. aureus are majorly responsible for otitis media in sub-Saharan Africa. The isolates have a high level of resistance to commonly used drugs for the management of otitis media.

Panel 4: Recent advances in understanding the natural history of the otitis media microbiome and its response to environmental pressures

OBJECTIVE

To perform a comprehensive review of otitis media microbiome literature published between 1^st July 2015 and 30th June 2019.

DATA SOURCES

PubMed database, National Library of Medicine.

REVIEW METHODS

Key topics were assigned to each panel member for detailed review. Draft reviews were collated and circulated for discussion when the panel met at the 20th International Symposium on Recent Advances in Otitis Media in June 2019. The final draft was prepared with input from all panel members.

CONCLUSIONS

Much has been learned about the different types of bacteria (including commensals) present in the upper respiratory microbiome, but little is known about the virome and mycobiome. A small number of studies have investigated the middle ear microbiome; however, current data are often limited by small sample sizes and methodological heterogeneity between studies. Furthermore, limited reporting of sample collection methods mean that it is often difficult to determine whether bacteria detected in middle ear fluid specimens originated from the middle ear or the external auditory canal. Recent in vitro studies suggest that bacterial interactions in the nasal/nasopharyngeal microbiome may affect otitis media pathogenesis by modifying otopathogen behaviours. Impacts of environmental pressures (e.g. smoke, nutrition) and clinical interventions (e.g. vaccination, antibiotics) on the upper respiratory and middle ear microbiomes remain poorly understood as there are few data.

IMPLICATIONS FOR PRACTICE

Advances in understanding bacterial dynamics in the upper airway microbiome are driving development of microbiota-modifying therapies to prevent or treat disease (e.g. probiotics). Further advances in otitis media microbiomics will likely require technological improvements that overcome the current limitations of OMICs technologies when applied to low volume and low biomass specimens that potentially contain high numbers of host cells. Improved laboratory models are needed to elucidate mechanistic interactions among the upper respiratory and middle ear microbiomes. Minimum reporting standards are critically needed to improve inter-study comparisons and enable future meta-analyses.

Assessing the appropriateness of the management of otitis media in Australia: A population-based sample survey

AIM

Acute otitis media (AOM) is the most common infectious disease for which antibiotics are prescribed; its management is costly and has the potential to increase the antimicrobial resistance of this infection. This study measured the levels of adherence to the clinical practice guidelines (CPGs) of AOM and otitis media with effusion (OME) management in Australian children.

METHODS

We searched for national and international CPGs relating to AOM and OME in children and created 37 indicators for assessment. We reviewed medical records for adherence to these indicators in 120 locations, across one inpatient and three ambulatory health-care settings. Our review sample was obtained from three Australian states that contain 60% of the nation's children.

RESULTS

We reviewed the records of 1063 children with one or more assessments of CPG adherence for otitis media. Of 22 indicators with sufficient data, estimated adherence ranged from 7.4 to 99.1%. Overuse of treatment, particularly overprescribing of antibiotics, was more common than underuse. A frequent lack of adherence with recommended care was observed for children aged between 1 and 2 years with AOM. Adherence varied by health-care setting, with emergency departments and inpatient settings more adherent to CPGs than general practices.

CONCLUSIONS

Our assessment of a number of indicators in the common settings in which otitis media is treated found that guideline adherence varied widely between individual indicators. Internationally agreed standards for diagnosis and treatment, coupled with clinician education on the existence and content of CPGs and clinical decision support, are needed to improve the management of children presenting with AOM and OME.

Myringotomy and tube insertion combined with balloon eustachian tuboplasty for the treatment of otitis media with effusion in children

OBJECTIVE

This study aimed to clarify the role and safety of balloon eustachian tuboplasty (BET) in the treatment of otitis media with effusion (OME) in children.

METHODS

This retrospective study was performed between January 2017 and February 2018. The study covered 25 OME patients treated with BET combined with myringotomy and tube insertion (MTI), designated as the BET group, and 24 OME patients treated with MTI during the same period considered as the controls. In addition, all patients received adenoidectomy if found with adenoid hypertrophy. The air-bone conduction gap (ABG) and curative effect were compared between the two groups. Tubomanometry (TMM) results were recorded preoperatively to confirm existence of eustachian tube dysfunction (ETD). Otologic history and examination results of all patients were carefully recorded before the operation, at 6, 12 and 18 months postoperatively.

RESULTS

Six months after surgery, ABG difference between the two groups was less than 1 dB HL. At 12 months after the operation, ABG in the BET group was smaller than that in the control group. There was a marked ABG deterioration (from 10.1 to 15.9 dB HL) in the control group compared to that in BET. Statistically significant differences in ABG difference between the two groups were observed 18 months after surgery with cured and total effective rates of BET at 76.1 and 93.5%, respectively. In the control group, these rates were 60.9 and 89.1% respectively. No serious complications and tympanic perforations were found in all subjects.

CONCLUSION

MTI combined with BET is effective and safe in the treatment of children with OME. Compared to simple MTI, application of BET can effectively extend improvement period and increase cured rate, especially after removal of the ventilation tube. Directly benefit from the ventilation tube, the curative effect was close during the period of tube retention. Considering the sample size and follow-up time of this study, related studies targeting large cohorts are needed in the future to validate the benefits of BET in children with OME.

Bacteriology and resistance patterns of otitis media with effusion

OBJECTIVES

Following the increased use of antibiotics, the emergence of antibiotic-resistant species in pediatric patients with otitis media has become a problem in recent years. The aim of this study was to investigate change in bacterial species, antibiotic resistance, and detection rate of highly pathogenic species, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa according to the number of repeated ventilation tube insertion (VTI) procedures in pediatric patients diagnosed with otitis media with effusion (OME).

MATERIALS & METHODS

From May 2010 to June 2018, 158 patients under 17 years of age who were admitted to the outpatient clinic of Kyung Hee Medical Center and diagnosed as OME and underwent unilateral or bilateral VTI were included in this study. Bacterial cultures were performed on aseptically collected middle ear effusion (MEF) at the time of VTI and antibiotic sensitivity tests were performed on the identified bacteria.

RESULTS

Bacteria were not identified in 195 (70.1%) cultures and identified in 83 (29.9%) cultures. Coagulase-negative staphylococci (CNS) was the most frequently detected species in both the non-recurrent group and the recurrent group. MRSA detection rate was found to be significantly higher in the recurrent group than in the non-recurrent group (p = 0.029). The two groups showed no significant difference in antibiotic resistance against all antibiotics (p > 0.05).

CONCLUSION

Staphylococcus species were detected most frequently in the MEF of pediatric OME patients, and the MRSA detection rate was higher in the recurrent group than in the non-recurrent group. There was no difference in antibiotic sensitivity between the two groups against all antibiotics, but resistance to penicillin G and cefoxitin was newly appeared in patients with repeated detection of same bacterial isolates.

The Proposed Usage of Intranasal Steroids and Antihistamines for Otitis Media with Effusion

PURPOSE OF REVIEW

To examine the role of allergy medications in the treatment of otitis media with effusion (OME), focusing on use of intranasal steroids and antihistamines.

RECENT FINDINGS

There has been ongoing controversy regarding the role of allergy in the development of OME. Treatment of OME with medications commonly used for allergic symptomatology has been studied. Proposed treatment options include decongestants, mucolytics, oral steroids, topical steroids, antihistamines, and antibiotics. We begin by evaluating the proposed association between allergy and OME, and then evaluate intranasal steroids and oral antihistamine therapy in the treatment of OME. The role of the adenoid and concurrent nasal symptomatology is also addressed. The preponderance of data suggests that neither intranasal steroids nor antihistamines improve the long-term clearance of isolated OME and are therefore not recommended. However, data are notably limited with regard to improvement rates in OME in patients specifically with concurrent allergy and/or adenoid hypertrophy. Future studies of medications for OME would ideally incorporate study designs controlling for both allergic rhinitis and adenoid hypertrophy, to better understand the impact of these medications on OME in these subgroups of patients.

What's New with Tubes, Tonsils, and Adenoids?

Evidence-based recommendations are constantly being updated for various pediatric surgical procedures, including the role for tympanostomy tubes, as well as indications for adenoidectomy and tonsillectomy. With a growing body of research available on some of the most prevalent pediatric conditions, an update on the current concepts surrounding management is warranted.

Is otitis media with effusion associated with oxidative stress? Evaluation of thiol/disulfide homeostasis

BACKGROUND

We evaluated the relationship between otitis media with effusion and thiol/disulfide homeostasis using a novel marker of oxidative stress.

METHODS

The study group consisted of 30 patients (mean age 8.33 ± 3.30 years) with bilateral otitis media with effusion admitted to our hospital. The control group consisted of 35 (mean age 7.40 ± 3.97 years) age-, sex-, and body mass index-matched healthy subjects. Thiol/disulfide homeostasis was measured using a newly developed method.

RESULTS

Native and total thiol levels were lower in the study than the control group (native thiols 421.37 ± 72 μmol/L vs. 464.46 ± 46.42 μmol/L, p < 0.05; total thiols 468.42 ± 77.89 μmol/L vs. 501.32 ± 50.30 μmol/L, respectively). Disulfide levels and the disulfide/native thiol and disulfide/total thiol ratios were higher in the study group (disulfides 23.56 ± 4.68 μmol/L vs. 18.43 ± 4.94 μmol/L; disulfide/native thiol ratio 5.65 ± 1.05 vs. 3.97 ± 1.03%; disulfide/total thiol ratio 5.06 ± 0.83 vs. 3.66 ± 0.88%, respectively).

CONCLUSION

Oxidative stress may be the major cause of the increase in oxidized thiols in patients with bilateral otitis media with effusion, however, this relationship requires further investigation.

Otitis media with effusion in children: Pathophysiology, diagnosis, and treatment. A review

Otitis media with effusion (OME) is a frequent paediatric disorder. The condition is often asymptomatic, and so can easily be missed. However, OME can lead to hearing loss that impairs the child's language and behavioural development. The diagnosis is essentially clinical, and is based on otoscopy and (in some cases) tympanometry. Nasal endoscopy is only indicated in cases of unilateral OME or when obstructive adenoid hypertrophy is suspected. Otitis media with effusion is defined as the observation of middle-ear effusion at consultations three months apart. Hearing must be evaluated (using an age-appropriate audiometry technique) before and after treatment, so as not to miss another underlying cause of deafness (e.g. perception deafness). Craniofacial dysmorphism, respiratory allergy and gastro-oesophageal reflux all favour the development of OME. Although a certain number of medications (antibiotics, corticoids, antihistamines, mucokinetic agents, and nasal decongestants) can be used to treat OME, they are not reliably effective and rarely provide long-term relief. The benchmark treatment for OME is placement of tympanostomy tubes (TTs) and (in some cases) adjunct adenoidectomy. The TTs rapidly normalize hearing and effectively prevent the development of cholesteatoma in the middle ear. In contrast, TTs do not prevent progression towards tympanic atrophy or a retraction pocket. Adenoidectomy enhances the effectiveness of TTs. In children with adenoid hypertrophy, adenoidectomy is indicated before the age of 4 but can be performed later when OME is identified by nasal endoscopy. Children must be followed up until OME has disappeared completely, so that any complications are not missed.

The Influence of Age on the Relationship Between Allergic Rhinitis and Otitis Media

PURPOSE OF REVIEW

To examine the relationship between otitis media, allergic rhinitis, and age.

RECENT FINDINGS

Otitis media and allergic rhinitis are prevalent conditions with a controversial relationship. Some data suggest that these entities are significantly associated, either through allergic rhinitis inducing Eustachian tube dysfunction or through allergic pathophysiology simultaneously occurring intranasally and in the ear. Other studies, however, have refuted this relationship. For example, treatment with antihistamines does not reliably improve OME, making causation and association challenging to establish. Age may have an effect on the nature of the relationship between allergic rhinitis and otitis media, by impacting both the individual conditions and their association. Epidemiological, immunological, and adenoidal studies have suggested that differences occur with age, and this review encapsulates the related data and publications. We begin by evaluating how allergic rhinitis and otitis media each are affected by age, then evaluate the role that age may have in the relationship between the two conditions. Adult and pediatric literature are evaluated so as to include the full impact of age across patients' lifespan. Age induces changes in immunity, patterns of inflammation, and susceptibility to both allergic rhinitis and otitis media with effusion. Age may also be an effect modifier which impacts the nature of the relationship between these two conditions. The influence of age on the association between these highly prevalent conditions remains a topic of active study.

Evaluation of clinical approaches and physician adherence to guidelines for otitis media with effusion

OBJECTIVES

Otitis media with effusion (OME) is an important clinical entity because of its high prevalence, difficulties in diagnosis, complications and diversities in management. Herein, we aimed to evaluate current physician approaches on OME and determine clinical adherence to current guidelines.

METHODS AND MATERIALS

A total of 370 physicians [Group 1: pediatricians (n = 256, 69.2%), Group 2: otorhinolarynologists (n = 114, 30.8%)] completed a survey instrument addressing demographic data and clinical practice parameters on OME in children. We also compared clinical approaches of Group 1 and Group 2. In addition, multiple logistic regression analysis was performed to evaluate factors which may effect correct approaches.

RESULTS

The mean period of clinical experience was 9.30 ± 8.35 [median 6 (1-40)] years. A total of 311 (84%) respondents reported satisfactory level of self-confidence as regards of clinical approaches to OME. Reduced mobility of the tympanic membrane and preference of pneumatic otoscopy was signified by 107 (28.9%) and 64 (17.3%) respondents, respectively. Fifty-six (15.1%) physicians identified "watchful waiting" for 3 months for children who are not at risk while 314 (84.9%) reported preference of medications, with antibiotics the most preferred prescription (n = 223, 63%). Comparison of Group 1 and Group 2 indicated similar results except better, yet insufficient, characterization of physical examination findings of OME by Group 2 (p < 0.001, for each parameter). Group 2 preferred tympanometry more in uncertain cases (p < 0.001) and handled chronic cases better (p < 0.001). Multiple logistic regression analysis revealed lower signification of reduced mobility of the tympanic membrane for respondents who denoted depending on personal experience ([OR] = 3.077 [95% CI 1.042-9.09]) or following clinical guidelines ([OR] = 3.365 [95% CI 1.38-8.20]) rather than combining them both. Rate of antibiotic avoidance was lowest in physicians with a period of clinical experience<5 years ([OR] = 2.14 [95% CI 1.32-3.48]).

CONCLUSIONS

Despite notifying high self-confidence and adherence to current guidelines on OME, both pediatricians and otorhinolaryngologists lacked to exhibit proper approaches. Further research is warranted to evaluate the causes of poor adherence to current guidelines and bring suggestions for the maintenance of consistent and correct clinical approaches to OME.