Screening for otitis media with effusion in preschool children

An evidence-based patient information leaflet about otitis media with effusion

Leaflets are a useful resource for information provision. Many otolaryngology patients have poor reading skills, and may have difficulty understanding medical jargon. The aim of this project was to produce a patient information leaflet on otitis media with effusion whose content is based on the best available research evidence, and which is presented in a clear format with simple language. Patients were involved at the planning stage, and in testing the final draft. The leaflet was preferred by the majority compared to existing information material and was felt to be more informative and easier to understand. The leaflet has been given the Crystal Mark for clarity of language by the Plain English Campaign. This study shows that existing guidelines can be used to improve the quality of written information provision.

Otitis media and academic achievements

OBJECTIVE

This is a study of whether there are any long-term differences in academic achievements between children with and without observed or treated middle ear disease in a population with a stable long-standing treatment policy.

METHODS

A birth cohort of 2156 children was previously studied through a questionnaire to the parents at 4 years of age, follow-up after audiometric screening at 4, 7, 11 and 14 years of age, and study of records from all Ear, Nose and Throats departments in the area; 2095 of these still lived in the area and received academic grades on leaving the ninth year of the state school system. We have compared these grades, and the choice of high school course for children with different experiences of otitis media.

RESULTS

A history of treatment for bilateral secretory otitis media was correlated to minor group difference in the mean of grades, but not to any significant difference in the individual grades or in the choice of further studies. Having many episodes of acute otitis before the age of four was uncorrelated to lower grades and to less tendency to continue with theoretical studies.

CONCLUSIONS

No harmful effect of middle ear disease could be shown in a large sample, suggesting that Swedish children do not suffer long-term effects on learning from otitis media.

A cross-sectional study of speech- and language-abilities of children with normal hearing, mild fluctuating conductive hearing loss, or moderate to profound sensoneurinal hearing loss

A total of 1528 pre-school children (mean age 4 years and 9 months), being identified as speech or language delayed, were evaluated with respect to micro-otoscopy, nose and throat pathology, hearing function, and speech-language abilities. Subjects were classified into groups of (I) constant normal hearing, (II) fluctuating conductive hearing loss and (III) bilateral moderate to profound sensorineural hearing loss requiring hearing aids. In groups II and III, severe speech and language pathologies were found more frequently than in group I. Additionally, auditory perception skills were less in group II, even if peripheral hearing function was normalized. Group III was affected more than group II, but not significantly. The results indicate that in children having speech or language delay for severals reasons, mild fluctuating hearing loss can additionally alter language acquisition, but less than in cases of moderate or profound sensoneurinal hearing loss. The need of early detection of sensoneurinal hearing loss appears widely accepted; this study demonstrates also the necessity of early diagnosis of mild fluctuating hearing loss, especially in children with speech-language delay.

Hearing screening in Jamaica: prevalence of otitis media with effusion

Hearing screening is well established in most developed countries, and the data extensively published. However, little information has been presented by the developing, nonwhite populations. A screening study was carried out on 2202 Jamaican children aged 5 to 7 years. This involved tympanometry and pure-tone audiometry (frequencies of 0.5, 1, and 2 kHz.) Failure was considered to have occurred if a type B or C curve was obtained or if the threshold of hearing was greater than 20 dB. These children were further evaluated by a full ear, nose, and throat examination, inclusive of pneumatic otoscopy, and audiologic testing. The prevalence of hearing impairment was 4.9%. Otitis media with effusion (OME) was present in 1.9%. The prevalence of OME in Jamaica is low when compared with that of the same age-group in the developed countries.

Double-blind randomised trial of co-amoxiclav versus placebo for persistent otitis media with effusion in general practice

BACKGROUND

The treatment of persistent otitis media with effusion (OME) remains controversial, but this condition is the commonest reason for children to require ear, nose, and throat (ENT) surgery. Trials of antibiotics are inconclusive, are often weak methodologically, and have not been done in general practice. Our aim was a trial of an antibiotic for OME in such a population.

METHODS

433 children, aged 6 months to 6 years, with OME from 57 general practices entered a 3-month watchful waiting period. Of 223 (52%) with persistent bilateral OME, 162 were randomised double-blind to receive co-amoxiclav suspension (20 mg/kg amoxicillin, 5 mg/kg clavulanate potassium) or matching placebo, orally three times a day for 14 days. All cases also received xylometazoline 0.25% decongestant nosedrops thrice daily. Of the 61 not randomised, 13 children were referred to an ENT surgeon and parents refused consent in 48 cases. The main outcome measures were persistent OME in both ears and in one or both ears, as assessed clinically and by tympanometry. Analysis was by intention-to-treat.

FINDINGS

79 children in the treatment group and 70 in the placebo group were analysed for efficacy. 3 withdrew in the co-amoxiclav group (2 lost to follow-up, 1 due to side-effects); 6 withdrew in the placebo group (5 and 1, respectively). In addition, 4 tympanograms were uninterpretable in the controls. Compliance was over 90% in both groups. Persistent OME in both ears and in one or both ears were found at significantly lower rates in the co-amoxiclav group than in the controls at the 2-week follow-up: 53 vs 84% and 77 vs 93%, respectively. Odds ratios adjusted for sex, history of adenoidectomy, and upper respiratory tract infection at follow-up were 0.25 (95% CI 0.11, 0.58, p = 0.001) and 0.30 (0.10, 0.89, p = 0.03), respectively. Parents of children in the co-amoxiclav group reported significantly more side-effects than those of control children (44 vs 22%, p = 0.03). Side-effects were mostly gastrointestinal and mild.

INTERPRETATION

Our study in a general-practice setting confirmed the positive short-term effect of antibiotic treatment for persistent middle-ear infection. Before referral to an ENT surgeon, children with persistent OME presenting to general practitioners could be considered for such treatment, depending on the individual child and possible adverse sequelae.

Perception of voicing cues by children with early otitis media with and without language impairment

Research on the relationship between early otitis media with effusion (OME), language impairment, and central auditory processing has been equivocal. Identification and discrimination tasks provide us with a sensitive method of assessing speech perception on both an auditory and a phonetic level. The present study examined identification and discrimination of initial bilabial stop consonants differing in voicing by 9-year-old children with a history of severe OME. The groups studied were controlled for language impairment. The ability of these children to perceive major and minor voicing cues was examined using multiple voicing cues. Long-term effects of OME were found for both identification and discrimination performance. Children with OME produced an overall inconsistency in categorization, which suggests poorer phonetic processing. Discrimination was measured by means of "just noticeable differences" (JND). Children with early OME experience demonstrated a greater mean JND than children without early OME experience. Finally, in cases of language impairment with early OME, there was no additional deterioration of auditory or phonetic processing. It appears that either early OME or language impairment can lead to poorer perception.

Developmental implications of early-life otitis media

This symposium addressed possible relationships between early-life otitis media (OM) and various components of child development. The existence and nature of such relationships are of substantial theoretical and practical consequence. Particularly at issue are policies concerning optimal frequencies of examination and screening for middle-ear disease as well as the relative appropriateness of conservative vs. aggressive regimens of management.

Predictive factors for the resolution of childhood otitis media with effusion following initial surgical treatment

A prospective study of outcome after treatment for glue ear was performed in a sample of 143 children aged between 1 and 11 years. The resolution or recurrence of effusion following initial surgery was analysed in relation to six potentially relevant factors. Multivariate analysis showed that resolution of effusion was statistically more frequent in ears found to have a dry tap at surgery, children with a history of atopy, those who underwent adenoidectomy and it was related to the age of the child at operation. Older children had a better prognosis. Univariate analysis suggested that girls have a significantly better outcome than boys, but this was not confirmed in multivariate analysis. The results suggest that there should be a longer period of observation in atopic individuals and older children. Furthermore, the study showed that ears with dry taps should not be treated with ventilation tubes.

The effects of early bilateral otitis media with effusion on educational attainment: a prospective cohort study

The relationship between long-lasting, bilateral otitis media with effusion (OME) between the ages of 2 and 4 and educational attainment, in particular, reading and spelling ability at 7 years of age, was studied in a prospective cohort study of 946 children. After selection, three groups were distinguished: 151 children with long-lasting, bilateral OME at preschool age, 37 preschool children treated with ventilation tubes, and 82 children with no history of OME at that age. Early bilateral OME was found to affect spelling ability, but not reading ability, at 7 years. The effects of OME did not appear to increase with the number of observations of OME. Also, recurrent hearing loss did not have more detrimental effects than continuous hearing loss. Effects of treatment with ventilation tubes were not found. Only the teachers' ratings of writing ability indicated a slight advantage of treatment with ventilation tubes. In conclusion, the educational consequences of early OME appear to be very small.

The effects of early bilateral otitis media with effusion on language ability: a prospective cohort study

The current study, which is a follow-up on the epidemiological Nijmegen Otitis Media study, examines the relationship between early otitis media with effusion (OME) and later language ability in a group of children with systematically documented bilateral OME. In the Nijmegen Otitis Media study, children were screened using tympanometry at regular intervals of 3 months, between their second and fourth birthdays. At age 7, three groups of children participated in language testing: 82 OME-free children, 151 children with early bilateral OME, and 37 children treated with ventilation tubes at preschool age. A history of OME, even up to nine instances, did not have negative consequences for language performance at age 7. Intermittent, as opposed to more continuous, OME was not found to affect language ability negatively. The suggested benefit of treatment with ventilation tubes was not found.

Screening and assessment of childhood deafness: experience from a centralized multi-disciplinary service

A paediatric hearing assessment unit was set up in Lothian in 1978 to provide a clear referral pathway for children with suspected sensorineural hearing impairment and particularly for those children detected by the health visitor screening test. Over a 6-year-period the incidence of bilateral sensorineural deafness was 1.3/1000 suggesting that all children in the region were being seen. The mean age of diagnosis fell significantly over this period. Children in high risk groups, through adverse perinatal events or a positive family history, were not detected any earlier than other children. They were therefore not contributing to this improved earlier age of diagnosis. These findings support the continuation of health visitor screening but changes in practice are needed to encourage earlier diagnosis in high-risk groups.

Long-term effects of otitis media with effusion on language, reading and spelling

The long-term effects of early OME on language and educational attainment were studied in 47 children of 7-8 years of age who had participated in an earlier pre-school study on otitis media with effusion (OME) and language development. At pre-school age OME was diagnosed by quarterly tympanometric screens (maximum nine) and language was assessed by a standard Reynell test. At school age the ears of the children were assessed by otomicroscopy, tympanometry and audiometry, and the development status by several language, reading and spelling tests. The association between early OME and language development found at pre-school age was no longer present at school age.

Prevalence of tympanogram asymmetries and fluctuations in otitis media with effusion: implications for binaural hearing

It has been suggested that asymmetric or fluctuating hearing in otitis media with effusion (OME) could lead to abnormal binaural hearing. In a cohort of children with tympanogram data obtained at 3-monthly intervals from 2 to 4 years, 6.4% had asymmetric or unilateral B tympanograms on more than half the test occasions, or had 5 or more fluctuations between symmetric and asymmetric tympanograms. Hence there are sufficient cases for studies of sequelae or treatment in unilateral and fluctuating OME. Few of these cases would have received medical attention under a bilateral referral criterion.

Hearing and language in preschool very low birthweight children

To get more insight into preschool language and hearing in high-risk very low birthweight (VLBW) children, we conducted a prospective study in a cohort of 79 children. The prevalence of language impairment and hearing loss at age 3-4 years, their relationship to each other as well as to perinatal conditions, neurodevelopmental outcome and the home environment are described. Mild hearing loss was found in 26%, moderate hearing loss in 13% and severe hearing loss in 3% of the children. None of the children was deaf. Abnormal tympanometry was found in 57% of the children. Hearing loss at age 4 years was related to a less optimal neonatal condition and was not related to the obstetrical condition or to neonatal cerebral ultrasound findings. Language impairment was found in 21% of the children at age 3.6 years. Receptive and expressive language was not related to perinatal conditions. There was no relation between the language assessments and the audiological assessments. Cognition and the home environment of the child were the only independent variables in the prediction of language in preschool VLBW children.

The otological profile of a cohort of Dutch 7.5-8-year-olds

The otological characteristics of a birth cohort of 7.5-8-year-old Dutch children are reported. Questionnaire information was available for 1004 children, while otomicroscopic, tympanometric and pure-tone audiometric data were available for 946 children. Twenty-nine per cent of the children had been treated surgically for various ENT diseases. Fifty-five per cent of the children had normal tympanic membranes, 19% mild abnormalities, and 26% moderate to severe abnormalities. At this age the prevalence of bilateral otitis media with effusion (OME), as shown by a type B tympanogram was 2.5%, while that of unilateral OME was 7%. A pure-tone average hearing level of > or = 15 dB in the better-hearing ear was found in 4% of the children. The presence of OME was associated with a mean hearing loss of 20 dB. This study shows that structural and functional middle-ear abnormalities are highly prevalent in Dutch school children.

Sonotubometry with a tubal catheter as an index for the use of a ventilation tube in otitis media with effusion

Insertion of a ventilation tube is considered to be an effective treatment for otitis media with effusion (OME), although it may entail complications such as residual perforation and poor hearing after tube extrusion. In order to reduce problems associated with ventilation tubes, we examined the Eustachian tube function in 25 adults with OME by two methods. One was a sonotubometric measurement (sonotubometry) with both a tubal catheter and a nasal olive tip, and the other was an air-pressure equilization method (deflation test). Sixty percent of the ears showed poor tubal function in both types of sonotubometry. The number of negative cases in sonotubometry with a tubal catheter was higher in ears with a larger volume of effusion, and in ears with poor tubal function by deflation testing. Judging from the volume of effusion and results of the deflation tests, the prognosis could be fairly good in many positive cases. We conclude that sonotubometry with a tubal catheter is useful in the management of OME, especially in evaluating the efficacy of ventilation tubes.

Can meta-analysis help uncertainty in surgery for otitis media in children

While otitis media is perhaps the most common disease of childhood that receives medical attention, there is little agreement concerning the efficacy of the medical and surgical therapies employed to try to alleviate its symptoms or hasten its natural resolution. Because various surgeries including adenoidectomy, myringotomy, and insertion of tympanostomy tubes are frequently involved in the treatment of otitis media with effusion (OME), it is likely the most expensive condition being managed in national terms. In an attempt to elucidate the most appropriate management of this condition, a meta-analysis was attempted to the 12 randomized control trials of surgical treatments for OME in children, published between 1966 and 1990. Heterogeneity both in the populations and comparisons studied and in the outcomes presented made meta-analysis an inappropriate method for clarifying this area of clinical uncertainty. Important elements in the design of randomized control trials that should be included in future studies of treatment for OME are therefore discussed.

The preventive value of audiometric screening of preschool and young school-children

The routine to screen 4- and 7-year-old children with audiometry has been studied with regard to its preventive value. Out of 2,330 4-year-olds, 27 children with secretory otitis media (SOM) were treated with myringotomy and 9 of these with grommets as a consequence of identification by screening. One child with unilateral, sensorineural impairment received special teacher's assistance 2 h per week as a consequence of identification by screening. When the same children were screened at the age of 7, 6 children with SOM were treated with myringotomy after identification by screening audiometry. Children with SOM at the age of 4 had impaired hearing at the age of 7, identified by screening, 4 times more frequently than other children. The study suggests that audiometric screening in Sweden does not have important preventive effects on hearing impairments or on sequelae of auditory deprivation.

Tympanometric screening in children on admission to a paediatric ward: a preliminary study

Tympanometric screening of children admitted to paediatric wards has not previously been undertaken. In order to describe the middle ear status and to estimate the point prevalence of middle ear effusion (MEE) in this population a preliminary study based on a single tympanometry test was undertaken. MEE was defined by the finding of a flat curve in the tympanogram of at least one ear. 601 children were admitted during the study period. 427 (71%) entered the study and this group was representative of the total population that was referred. 82% were found to have an abnormal middle ear pressure and MEE was diagnosed in 59% of the children. 76% of the children were 0- to 4-year-olds. 31% were admitted due to respiratory infections and 41% presented with catarrhalic symptoms. MEE was associated with the age group of 0- to 4-year-olds and with the presence of catarrhalic symptoms. The population of paediatric in-patients represents the highest frequency of abnormal tympanometry findings hitherto reported. It should be emphasized that the one-time finding of a flat tympanogram does have the correlation but no congruence with MEE and the finding of this high prevalence of MEE needs to be followed up by studies using independent methods for confirmation of the middle ear fluid.

A randomised controlled trial of surgery for glue ear

OBJECTIVE

To assess the effect of five different surgical treatments for glue ear (secretory otitis media) on improvement in hearing and, assuming one or more treatments to be effective, to identify the appropriate indications for surgery.

DESIGN

Randomised controlled trial of children receiving (a) adenoidectomy, bilateral myringotomy, and insertion of a unilateral grommet; (b) adenoidectomy, unilateral myringotomy, and insertion of a unilateral grommet; (c) bilateral myringotomy and insertion of a unilateral grommet; and (d) unilateral myringotomy and insertion of a grommet. Children were followed up at seven weeks, six months, 12 months, and 24 months by symptom history and clinical investigations.

SETTING

Otolaryngology department in an urban hospital.

PATIENTS

149 Children aged 4-9 years who were admitted for surgery for glue ear and who had no history of previous operations on tonsils, adenoids, or ears and no evidence of sensorineural deafness. Inadequate follow up information on levels of hearing and on middle ear function was obtained from 22.

MAIN OUTCOME MEASURES

Mean hearing loss (dB) of the three worst heard frequencies between 250 and 4000 Hz, results of impedance tympanometry, and parental views on their child's progress.

RESULTS

In the 127 children for whom adequate information was available ears in which a grommet had been inserted performed better in the short term (for at least six months) than those in which no grommet had been inserted, irrespective of any accompanying procedure. Most of the benefit had disappeared by 12 months. Adenoidectomy produced a slight improvement that was not significant, though was sustained for at least two years. The ears of children who had had an adenoidectomy with myringotomy and grommet insertion, however, continued to improve so that two years after surgery about 50% had abnormal tympanometry compared with 83% of those who had had only myringotomy and grommet insertion, and 93% of the group that had had no treatment. Logistic regression analyses identified preoperative hearing level as the single best predictor of good outcome from surgery. Other variables contributed little additional predictive power.

CONCLUSIONS

If the principal objective of surgery for glue ear is to restore hearing then our study shows that insertion of grommets is the treatment of choice. The addition of an adenoidectomy will increase the likelihood of restoration of normal function of the middle ear but will not improve hearing. When deciding appropriate indications for surgery, a balance has to be made between performing unnecessary operations and failing to treat patients who might benefit from surgical intervention. Preoperative audiometry scores might be the best predictor in helping to make this decision.

The occurrence of otitis media with effusion in Dutch pre-school children

Published data on the frequency of otitis media with effusion in pre-school children do not give a uniform view about the age-specific rates. A cohort of 1439 2-year-old children in the Netherlands was followed using serial tympanometry on 9 consecutive occasions up to 4 years of age. The screening rate decreased from 87% on the first occasion to 73% on the last round. The prevalence rates in this study are high compared to results quoted in the literature. At least 80% of the children had otitis media with effusion on at least one occasion before the age of four. Distinct seasonal variation was found in the rates. It is postulated that middle ear effusion is a 'physiological' phenomenon at pre-school age with some pathological exceptions.

Otitis media with effusion and habitual mouth breathing in Dutch preschool children

Habitual mouth breathing (HMB) is defined as the habit of in- and exhaling (part of) the air through the mouth, when an individual is at rest and the nose is sufficiently free. It is postulated that HMB is a risk factor for otitis media with effusion (OME) in preschool children. The results are presented of a prospective cohort study on 253 3-year-old children, free from OME, with a follow-up period of 3 months, to determine the role of HMB in the etiology of OME. The risk ratio for OME of habitual mouth breathers, compared to nose breathers, was found to be 2.4 (95% confidence interval (C.I.): 0.99-5.70). Moreover, there is a clear and significant linear trend in the proportion of OME in 3 breathing categories: nose breathing, intermediate and mouth breathing. This relation remains after correction for confounding. It is concluded that HMB is a risk factor for OME. It is estimated that about 20% of the incidence of OME is caused by HMB. The high incidence of OME means that HMB carries a great deal of impact. Suggestions are made for the prevention and treatment of HMB.