Otitis media with effusion

Determining the presence or absence of middle ear disorders: an evidence-based systematic review on the diagnostic accuracy of selected assessment instruments

PURPOSE

To conduct an evidence-based systematic review on the state of the evidence and the diagnostic accuracy of multifrequency tympanometry (MFT), 1000 Hz tympanometry, and wideband acoustic transfer functions in determining the presence or absence of middle ear disorders.

METHOD

A systematic search of the literature published between 1975 and 2011 was conducted. Articles meeting the selection criteria were appraised by 2 reviewers and vetted by a 3rd for methodological quality.

RESULTS

Ten studies were included and focused on participants with otosclerosis or otitis media. Two studies investigated 1000 Hz tympanometry, 7 examined MFT, and 2 addressed wideband reflectance (WBR). Methodological quality varied. Positive likelihood ratios (LR+) were predominantly uninformative for MFT and were mixed for 1000 Hz tympanometry. LR+ values for WBR ranged from diagnostically suggestive to informative. Negative likelihood ratios (LR-) for 1000 Hz tympanometry and WBR were at least diagnostically suggestive. LR- values for MFT were mixed, with half considered clinically uninformative and half considered diagnostically suggestive.

CONCLUSIONS

Although some of the results are promising, limited evidence and methodological considerations restrict the conclusions that can be drawn regarding the diagnostic accuracy of these technologies. Additional investigations are needed to determine which tools can most accurately predict middle ear status.

Wideband acoustic transfer functions predict middle-ear effusion

OBJECTIVES/HYPOTHESIS

Compare the accuracy of wideband acoustic transfer functions (WATFs) measured in the ear canal at ambient pressure to methods currently recommended by clinical guidelines for predicting middle-ear effusion (MEE).

STUDY DESIGN

Cross-sectional validating diagnostic study among young children with and without MEE to investigate the ability of WATFs to predict MEE.

METHODS

WATF measures were obtained in an MEE group of 44 children (53 ears; median age, 1.3 years) scheduled for middle-ear ventilation tube placement and a normal age-matched control group of 44 children (59 ears; median age, 1.2 years) with normal pneumatic otoscopic findings and no history of ear disease or middle-ear surgery. An otolaryngologist judged whether MEE was present or absent and rated tympanic-membrane (TM) mobility via pneumatic otoscopy. A likelihood-ratio classifier reduced WATF data (absorbance, admittance magnitude and phase) from 0.25 to 8 kHz to a single predictor of MEE status. Absorbance was compared to pneumatic otoscopy classifications of TM mobility.

RESULTS

Absorbance was reduced in ears with MEE compared to ears from the control group. Absorbance and admittance magnitude were the best single WATF predictors of MEE, but a predictor combining absorbance, admittance magnitude, and phase was the most accurate. Absorbance varied systematically with TM mobility based on data from pneumatic otoscopy.

CONCLUSIONS

Results showed that absorbance is sensitive to middle-ear stiffness and MEE, and WATF predictions of MEE in young children are as accurate as those reported for methods recommended by the clinical guidelines.

Innate immunity and the role of defensins in otitis media

Otitis media is the most common pediatric disease in developed countries and a significant cause of morbidity and hearing loss in developing countries. The innate immune system is essential to protecting the middle ear from infection. Defensins, broad-spectrum cationic antimicrobial peptides, have been implicated in prevention of and the early response to acute otitis media; however, the mechanisms by which defensins and other antimicrobial molecules mediate this protection have not been completely elucidated. In both animal otitis media models and human middle ear epithelial cell culture models, β-defensins are highly induced and effectively kill the common pathogens associated with otitis media. We review the importance of innate immunity in protecting the middle ear and recent advances in understanding the roles of defensins and other antimicrobial molecules in the prevention and treatment of otitis media. The extremely high prevalence of otitis media, in spite of sophisticated innate and adaptive immune systems, is a vexing problem for clinicians and scientists. We therefore also review mechanisms by which bacteria evade innate immune defenses.

Comparison of screening methods for conductive hearing loss identification in children: low-cost proposal

Objective

To evaluate the effectiveness of two screening methods (imitanciometry screening and questionnaire) to identify children at risk for conductive hearing loss, comparing this data with complete audiologic evaluation.

Methods

Of 507 children aged between three and six, 111 completed all procedures. The observational methods used were: imitanciometry screening, a questionnaire to identify risk factors for hearing loss and complete audiologic evaluation. Results obtained in the first two instruments were compared with results from complete audiologic evaluation (gold standard). From these comparisons, sensitivity and specificity, accuracy, positive and negative predictive values, and odds ratio were determined for the two screening methods and for the combination of both methods.

Results

The two methods applied in series (questionnaire and after imitanciometry screening) showed a greater odds ratio and better correlation between sensitivity and proportion of false-positives (ROC curve).

Conclusion

Combining the two tests in series improved screening accuracy. This combination was the best tool for identifying children at risk for conductive hearing loss.

Hearing impairment in otitis media with effusion: a cross-sectional study based in Pokhara, Nepal

OBJECTIVE

Otitis media with effusion (OME) is a major cause of childhood hearing impairment (HI) in the developing world, but its prevalence has never been quantified in Nepal. This study therefore set out to determine the proportion of cases of OME complicated by HI and to identify associated factors.

METHODS

This was a cross-sectional prevalence survey carried out in rural, urban and Tibetan schools in and around Pokhara, Nepal. HI was the primary outcome, and was defined as a middle-frequency pure tone average >25 dB on audiological testing. The study population was defined as children aged four years and older, attending primary school and with a diagnosis of OME.

RESULTS

One hundred and eleven schoolchildren with a combined total of 172 ears affected by OME underwent audiometric assessment. HI was most prevalent in the rural Nepali population; 27% (95%CIs 18-38%) had HI, with a mean hearing loss of 22 dB (15-25 dB). In the Tibetan population, 16% (8-29%) had HI, with a mean loss of 17 dB (12-22 dB). The urban Nepali population had the least HI; 4% (1-13%) were affected, with a mean loss of 16 dB (15-19 dB). The difference in prevalence between the urban and rural Nepali populations was statistically significant (p>0.05). Logistic regression analysis did not identify any associated factors.

CONCLUSIONS

HI is a common complication of OME in Nepal. There is hitherto-unreported variation between populations in the number of cases of OME complicated by HI. This study identified higher rates of morbidity amongst rural populations but was unable to identify associated factors.

Biofilm formation by bacteria isolated from upper respiratory tract before and after adenotonsillectomy

Failure of antibiotics to eradicate the microbial pathogens primarily responsible for otorhinolaryngological diseases has led to the hypothesis that these microorganisms may be structured in a biolfilm. Aim of the study was to evaluate the ability to produce biofilm among bacteria isolated from tonsils and/or adenoids and nasopharynx. Biopsies and swabs were collected during surgery and after 3 and 6 months in 32 children undergoing adenoidectomy and/or tonsillectomy. Production of biofilm by Staphylococcus aureus, Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae was evaluated in vitro by means of spectrophotometry after growth in microplates and staining with crystalviolet. Of the isolates from intraoperative samples, 44.7% were either moderate or strong biofilm producers compared with 27% of isolates at 6 months after surgery. A decrease in biofilm production was observed for H. influenzae and S. aureus. In conclusion, the rate of isolation and ability to form biofilm decreased in bacteria isolated subsequent to adenoidectomy and/or tonsillectomy. This suggests a role for biofilm in pathogenesis of recurrent and chronic pharyngeal diseases and rhinopharingitis.

Antihistamines and/or decongestants for otitis media with effusion (OME) in children

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2006.Otitis media with effusion (OME) is common and may cause hearing loss with associated developmental delay. Treatment remains controversial. The effectiveness of antihistamines, decongestants and antihistamine/decongestant combinations in promoting the resolution of effusions has been assessed by randomized controlled trials.

OBJECTIVES

The objective of this review was to determine whether antihistamine, decongestant or combination therapy is effective in treating children who present with OME.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 1 February 2011, following a previous search in 2006.

SELECTION CRITERIA

Randomized controlled trials (RCTs) using antihistamines, decongestants or antihistamine/decongestant combinations as treatment for OME in children. We excluded trials that randomized on the basis of acute otitis media (AOM) even though OME was also studied in follow up.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from the published reports using standardized data extraction forms and methods. The two authors assessed the methodological quality of the included studies independently. We expressed dichotomous results as a risk ratio with 95% confidence intervals using a fixed-effect model when homogeneous and a random-effects model when heterogeneous. Nearly all outcomes analyzed were homogeneous. We discussed continuous results qualitatively. We conducted statistical analysis using RevMan 5.1 software.

MAIN RESULTS

Sixteen studies (1880 participants) were included in the review. No statistical or clinical benefit was found for any of the interventions or outcomes studied. However, treated study subjects experienced 11% more side effects than untreated subjects (number needed to treat to harm = 9).

AUTHORS' CONCLUSIONS

The pooled data demonstrate no benefit and some harm from the use of antihistamines or decongestants alone or in combination in the management of OME, therefore we recommend against their use.

Prevalence of Otitis Media With Effusion Among Children in Xi'an, China: A Randomized Survey in China's Mainland

Objectives:

We sought to identify the prevalence of otitis media with effusion (OME) in urban Chinese children in Xi'an, China.

Methods:

Five kindergartens and 3 primary schools were randomly selected in the urban area of Xi'an. Screening otoscopic and tympanometric examinations were performed on 2,902 children (1,491 boys and 1,411 girls) 2 to 8 years of age. Children with an abnormal tympanogram and simultaneous otomicroscopic signs of effusion were given a diagnosis of OME.

Results:

The overall prevalence of OME was 4.3%. By age group, the prevalence was 14.0% in 2-year-olds, 8.3% in 3-year-olds, 5.0% in 4-year-olds, 4.9% in 5-year-olds, 2.8% in 6-year-olds, 1.7% in 7-year-olds, and 3.2% in 8-year-olds. The prevalence rate for OME was 4.7% for boys versus 3.9% for girls, and 3.0% in the right ear versus 2.7% in the left, showing no statistically significant difference between genders or between ear sides (p > 0.05).

Conclusions:

The prevalence of OME in urban areas of Xi'an is not high in comparison with that of the same age group in surrounding areas.

Exhaled nitric oxide levels in children with chronic adenotonsillar disease

Exhaled nitric oxide (eNO) is a highly reactive biological mediator that has recently been associated with chronic tonsillar disease in adults, but there are no published data concerning eNO levels in their pediatric counterparts. The aim of this study is to measure mean eNO levels in children with chronic adenotonsillitis or adenotonsillar hypertrophy, and assess the effects of potential confounding factors. Children aged 3-17 years were divided into three groups (chronic adenotonsillitis, adenotonsillar hypertrophy and controls). Their eNO levels were measured in accordance with the international guidelines, and their other clinical and anamnestic characteristics were recorded. The mean eNO level in the children with chronic adenotonsillitis was slightly higher than that in the other groups, but there was no statistically significant between-group difference. Age (p=0.009), allergy (p=0.05) and body mass index (p=0.03), but not the mean grade of adenoidal or tonsil hypertrophy, were all statistically related to mean eNO levels. These preliminary results indicate the lack of an increase in mean eNO levels in children with chronic adenotonsillar disease, with no substantial difference between children with chronic adenotonsillitis and those with adenotonsillar hypertrophy.

Diagnostic accuracy of nasopharyngeal swabs in detecting biofilm-producing bacteria in chronic adenoiditis: a preliminary study

OBJECTIVES

Biofilms are organized bacterial communities that are playing an increasing role in otolaryngological diseases such as chronic or recurrent middle ear otitis and adenotonsillitis. Various cultural techniques are available to detect biofilm-producing bacteria (BPB), but microbiological analysis of bioptic staining is the reference diagnostic procedure. To our knowledge, the accuracy of nasopharyngeal swabs in diagnosing BPB has never been assessed.

STUDY DESIGN

A prospective study of diagnostic accuracy.

SETTING

Outpatient clinics of the Departments of Specialist Surgical Sciences and Maternal and Pediatric Sciences, University of Milan, Italy.

SUBJECTS AND METHODS

Forty-two pediatric subjects with chronic adenoiditis (aged 4-18 years) underwent adenoidectomy, during which multiple transoral nasopharyngeal swabs and adenoidal biopsies were performed. BPB were detected by spectrophotometry, and the accuracy of detecting BPB in nasopharyngeal swabs was compared with that of biopsy.

RESULTS

BPB were detected in 73.8% of the nasopharyngeal swabs and in 69.1% of the biopsies. The sensitivity and specificity of the nasopharyngeal swabs were, respectively, 75.9% (95% confidence interval [CI], 60.3%-91.4%) and 30.8% (95% CI, 5.7%-55.9%); positive and negative predictive values were, respectively, 71.0% (95% CI, 55.0%-86.9%) and 36.4% (95% CI, 7.9%-64.8%); and the area under the receiver-operating characteristic curve was 0.5 (95% CI, 0.4-0.7).

CONCLUSIONS

In comparison with biopsy, nasopharyngeal swabs seem to be inaccurate in detecting BPB and should be cautiously used in clinical practice. As these preliminary findings may have been due to the well-known resistance of biofilm to mechanical injuries (such as swab rubbing) or the small study population, they need to be confirmed in larger patient series.

Ventilation tube treatment: a systematic review of the literature

OBJECTIVE

The aim of this review was to study the effectiveness of ventilation tube (VT) treatment in children with secretory otitis media (SOM), assessed by improved hearing, normalized language and quality of life (QoL), and recurrent acute otitis media (rAOM), assessed by number of episodes of AOM and QoL. Data Sources. Cochrane Library, PubMed, and Embase databases were searched for randomized and nonrandomized controlled trials and cohort studies in English, Scandinavian, German, and French languages between 1966 and April 2007. Additional literature was retrieved from reference lists in the articles.

REVIEW METHODS

A total of 493 abstracts were evaluated independently by 2 members of the project group, 247 full-text versions were assessed for inclusion criteria and quality using structured evaluation forms, and 63 articles were included in the review.

RESULTS AND CONCLUSIONS

This review shows that there is strong scientific evidence (grade 1) that VT treatment of SOM improves hearing for at least 9 months and that QoL is improved for up to 9 months (grade 2 scientific evidence). There was insufficient evidence to support an effect of VT treatment for rAOM. There was also insufficient evidence to determine whether the design or material of the VT or the procedure used for insertion had any influence on the effect; however, there was some evidence (grade 3) that aspiration of secretion at insertion does not prolong VT treatment. Further research is needed to address these issues.

Quality measures for the care of children with otitis media with effusion

BACKGROUND

Current national efforts provide an opportunity to integrate performance measures into clinical practice and improve outcomes for children.

OBJECTIVE

The goal of this study was to explore issues in developing and testing measures of care for children with otitis media with effusion (OME).

METHODS

We assessed compliance with diagnostic, evaluation, and treatment measures for OME adapted from preliminary work of the Physician Consortium for Performance Improvement, using chart data in a convenience sample of practices from 2 primary care networks (Cincinnati Pediatric Research Group and the American Academy of Pediatrics Quality Improvement Innovation Network). Children aged 2 months to 12 years with at least 1 visit with a specified OME code during a 1-year period were included.

RESULTS

Of 23 practices, 4 could not locate eligible visits. Nineteen practices submitted 378 abstractions (range: 3-37 per practice) with 15 identifying <30 eligible visits. Performance on diagnosis (33%) and hearing evaluation (29%) measures was low but high on measures of appropriate medication use (97% decongestant/antihistamine, 87% antibiotics, and 95% corticosteroids). Thirty-five percent of records documented antibiotic use concurrent with OME; only 16% of the 94 cases that cited reason for prescribing were appropriate. Using methods that consider appropriate clinical action, a more accurate rate for appropriate use of antibiotics was 68%.

CONCLUSIONS

Coding, case finding, and evaluating appropriateness of treatment are some of the issues that will need to be considered to assess the care of children with OME. This study emphasizes the importance of testing proposed quality of care measures in "real-world" settings.

Evaluating the perceptual and pathophysiological consequences of auditory deprivation in early postnatal life: a comparison of basic and clinical studies

Decades of clinical and basic research in visual system development have shown that degraded or imbalanced visual inputs can induce a long-lasting visual impairment called amblyopia. In the auditory domain, it is well established that inducing a conductive hearing loss (CHL) in young laboratory animals is associated with a panoply of central auditory system irregularities, ranging from cellular morphology to behavior. Human auditory deprivation, in the form of otitis media (OM), is tremendously common in young children, yet the evidence linking a history of OM to long-lasting auditory processing impairments has been equivocal for decades. Here, we review the apparent discrepancies in the clinical and basic auditory literature and provide a meta-analysis to show that the evidence for human amblyaudia, the auditory analog of amblyopia, is considerably more compelling than is generally believed. We argue that a major cause for this discrepancy is the fact that most clinical studies attempt to link central auditory deficits to a history of middle ear pathology, when the primary risk factor for brain-based developmental impairments such as amblyopia and amblyaudia is whether the afferent sensory signal is degraded during critical periods of brain development. Accordingly, clinical studies that target the subset of children with a history of OM that is also accompanied by elevated hearing thresholds consistently identify perceptual and physiological deficits that can endure for years after peripheral hearing is audiometrically normal, in keeping with the animal studies on CHL. These studies suggest that infants with OM severe enough to cause degraded afferent signal transmission (e.g., CHL) are particularly at risk to develop lasting central auditory impairments. We propose some practical guidelines to identify at-risk infants and test for the positive expression of amblyaudia in older children.

Routine Electrocardiography Request in Adenoidectomy: Is it necessary?

To evaluate the relevance of routine electrocardiographic request in pre-operative work-up of children undergoing adenoidectomy. This is a two year prospective study of children with obstructive adenoid that had adenoidectomy. This is a tertiary hospital based study at the Otorhinolaryngology Department of University College Hospital, Ibadan. Children (≤12 years) with clinical and radiological evidence of an obstructive adenoid were investigated. Information obtained with an interviewer assisted questionnaire included the biodata, clinical presentation of the patients, ECG findings, echocardiographic findings, cardiothoracic ratio, palatal airway and ratio of adenoid diameter to the nasopharyngeal diameter. The adenoid volume was measured after adenoidectomy. The results were analyzed using SPSS version 14 and level of statistical significance was P < 0.05. There were seventy four patients; 45 (60.8%) males and 29 (39.2%) females with a mean age of 38.35 months, S.D ± 30.32 (range 5-144 months). All the patients presented with mouth breathing and recurrent mucopurulent rhinorrhea. Mild snoring was detected in 18 (25%) patients, moderate snoring in 39 (54.17%) patients and severe snoring in 15 (20.83%) patients. Mild apnea was observed in 55 (74.32%) patients and moderate in 19 (25.68%) patients. Only seven (9.46%) patients had abnormal electrocardiographic findings but their ejection fraction on echocardiography ranged from 63 to 72% with a mean value of 68.17%, S.D ± 3.22. Cardiac complications of enlarged obstructive adenoid appear not to be common. Routine preoperative electrocardiography should therefore be restricted to only the high risk patients.

The link between otitis media with effusion and allergy: a potential role for intranasal corticosteroids

We reviewed the evidence linking otitis media with effusion (OME) and atopy, with the goal of clarifying the possible role of intranasal corticosteroids (INSs) in OME treatment. In August 2009, the MEDLINE database was searched for primary studies on OME epidemiology, pathophysiology, and treatment. Relevant clinical guidelines were obtained. Interpreting OME research is complicated by variable disease definitions, patient populations, methodologies, and outcomes assessments, along with the possibility of spontaneous resolution. However, evidence links OME with atopic conditions including allergic rhinitis; observed prevalence of allergic rhinitis in patients with chronic or recurrent OME ranges from 24% to 89%. Such findings have prompted evaluations of common allergy medications for OME treatment. While short-term use of INSs alone or combined with antibiotics has shown benefit in some studies, more prolonged treatment protocols and long-term clinical outcomes will require critical assessment. Evidence suggesting epidemiologic and pathophysiologic links between allergy and OME has prompted investigation into a potential role for INSs in OME management, with promising initial results. Benefits of considering medical treatment in patients with OME prior to surgery include both the potential reductions in allergic inflammation and the naturally occurring spontaneous resolution of OME in these patients.

Designing computerized decision support that works for clinicians and families

Evidence-based decision-making is central to the practice of pediatrics. Clinical trials and other biomedical research provide a foundation for this process, and practice guidelines, drawing from their results, inform the optimal management of an increasing number of childhood health problems. However, many clinicians fail to adhere to guidelines. Clinical decision support delivered using health information technology, often in the form of electronic health records, provides a tool to deliver evidence-based information to the point of care and has the potential to overcome barriers to evidence-based practice. An increasing literature now informs how these systems should be designed and implemented to most effectively improve outcomes in pediatrics. Through the examples of computerized physician order entry, as well as the impact of alerts at the point of care on immunization rates, the delivery of evidence-based asthma care, and the follow-up of children with attention deficit hyperactivity disorder, the following review addresses strategies for success in using these tools. The following review argues that, as decision support evolves, the clinician should no longer be the sole target of information and alerts. Through the Internet and other technologies, families are increasingly seeking health information and gathering input to guide health decisions. By enlisting clinical decision support systems to deliver evidence-based information to both clinicians and families, help families express their preferences and goals, and connect families to the medical home, clinical decision support may ultimately be most effective in improving outcomes.

Adenoid reservoir for pathogenic biofilm bacteria

Biofilms of pathogenic bacteria are present on the middle ear mucosa of children with chronic otitis media (COM) and may contribute to the persistence of pathogens and the recalcitrance of COM to antibiotic treatment. Controlled studies indicate that adenoidectomy is effective in the treatment of COM, suggesting that the adenoids may act as a reservoir for COM pathogens. To investigate the bacterial community in the adenoid, samples were obtained from 35 children undergoing adenoidectomy for chronic OM or obstructive sleep apnea. We used a novel, culture-independent molecular diagnostic methodology, followed by confocal microscopy, to investigate the in situ distribution and organization of pathogens in the adenoids to determine whether pathogenic bacteria exhibited criteria characteristic of biofilms. The Ibis T5000 Universal Biosensor System was used to interrogate the extent of the microbial diversity within adenoid biopsy specimens. Using a suite of 16 broad-range bacterial primers, we demonstrated that adenoids from both diagnostic groups were colonized with polymicrobial biofilms. Haemophilus influenzae was present in more adenoids from the COM group (P = 0.005), but there was no significant difference between the two patient groups for Streptococcus pneumoniae or Staphylococcus aureus. Fluorescence in situ hybridization, lectin binding, and the use of antibodies specific for host epithelial cells demonstrated that pathogens were aggregated, surrounded by a carbohydrate matrix, and localized on and within the epithelial cell surface, which is consistent with criteria for bacterial biofilms.

Role of adenoidectomy in otitis media and respiratory function

Adenoidectomy is among the most frequent surgical procedures performed on children. The rationale for adenoidectomy is to remove a chronically infected or enlarged and obstructing adenoid. Adenoidectomies are performed on children who have recurrent or chronic otitis media with effusion, on children with chronic rhinosinusitis, and on children with nasopharyngeal obstruction causing sleep disturbances and continuous mouth breathing. Various underlying factors that lead to adenoidectomy are also associated with asthma. Asthma is associated with recurrent respiratory tract infections predisposing individuals to recurrent or chronic otitis media and chronic rhinosinusitis. Children with asthma also have an increased risk of sleep-disordered breathing that is treated with adenoidectomy in the presence of nasopharyngeal obstruction. In nonasthmatic children, adenoidectomy does not influence the development of IgE-mediated allergy, bronchial hyperreactivity, or exhaled nitric oxide concentrations, all of which are surrogate asthma markers. Adenoidectomy in selected asthmatic children may relieve comorbidities associated with asthma.

Surgical treatment of acute recurrent throat infections in children

OBJECTIVE

The purpose of this study was to define the contribute of surgery and watchful waiting in the treatment of feverish episodes and other clinical manifestations related to acute recurrent throat infections in children.

METHODS

An observational, retrospective and multi-centric study was carried out on 407 subjects, aged 2-11, with a minimum two-year follow-up. Chi square test and Fisher's test were used for the statistical analysis.

RESULTS

Watchful waiting prevented, similarly to surgery, recurrences of feverish episodes, but did not favourably impact on other clinical manifestations (respiratory obstruction, otitis media, group A beta hemolyticus streptococcus positive laboratory findings) as compared to surgery (p<0.001).

CONCLUSIONS

The higher effectiveness of surgical treatment, as compared to watchful waiting, was documented in the study patients, considering all the clinical manifestations related to acute recurrent throat infections.

Development and analysis of a low-cost screening tool to identify and classify hearing loss in children: a proposal for developing countries

OBJECTIVE

A lack of attention has been given to hearing health in primary care in developing countries. A strategy involving low-cost screening tools may fill the current gap in hearing health care provided to children. Therefore, it is necessary to establish and adopt lower-cost procedures that are accessible to underserved areas that lack other physical or human resources that would enable the identification of groups at risk for hearing loss. The aim of this study was to develop and analyze the efficacy of a low-cost screening tool to identify and classify hearing loss in children.

METHODS

A total of 214 2-to-10 year-old children participated in this study. The study was conducted by providing a questionnaire to the parents and comparing the answers with the results of a complete audiological assessment. Receiver operating characteristic (ROC) curves were constructed, and discriminant analysis techniques were used to classify each child based on the total score.

RESULTS

We found conductive hearing loss in 39.3% of children, sensorineural hearing loss in 7.4% and normal hearing in 53.3%. The discriminant analysis technique provided the following classification rule for the total score on the questionnaire: 0 to 4 points - normal hearing; 5 to 7 points - conductive hearing loss; over 7 points - sensorineural hearing loss.

CONCLUSION

Our results suggest that the questionnaire could be used as a screening tool to classify children with normal hearing or hearing loss and according to the type of hearing loss based on the total questionnaire score.

Disparities in Children With Otitis Media

Objectives. To determine the difference between children with private and public insurance at the time of referral to a pediatric otolaryngologist.

Study Design. Prospective study.

Setting. Tertiary care hospital.

Subjects and Methods. Data relating to the severity of a patient’s otitis media (number of infections, doctor visits, antibiotic courses) were collected by phone interview. All patients referred to a pediatric otolaryngologist at an urban tertiary care hospital over a 5-month period were included.

Results. One hundred eighty-three children were studied: 87 consecutive patients in the private third-party insurance group (PIN) and 96 patients in the state-based Medicaid insurance group (PA). During the 6 months prior to referral, children in the PIN group had a median 4 acute otitis media infections with 5 courses of oral antibiotics and 6 primary care visits compared to 3 infections with 3 courses of antibiotics and 4 primary care visits for the PA group ( P = .0009, P ≤ .0001, P = .0003, respectively). For recurrent acute otitis media, the PA group had a significantly longer time with disease prior to referral than the PIN group ( P = .0478).

Conclusion. Children in this metropolitan area referred for tympanostomy tube placement with PIN are younger, have more episodes of acute otitis media, receive more antibiotic courses, and have more primary care visits in the 6 months prior to referral than their PA counterparts. Additional research is required to determine why these differences exist, especially in light of ongoing changes to the health care system.

Effect of middle ear effusion on the brain-stem auditory evoked response of Cavalier King Charles Spaniels

Brain-stem auditory evoked responses (BAER) were assessed in 23 Cavalier King Charles Spaniels with and without middle ear effusion at sound intensities ranging from 10 to 100 dB nHL. Significant differences were found between the median BAER threshold for ears where effusions were present (60 dB nHL), compared to those without (30 dB nHL) (P=0.001). The slopes of latency-intensity functions from both groups did not differ, but the y-axis intercept when the x value was zero was greater in dogs with effusions (P=0.009), consistent with conductive hearing loss. Analysis of latency-intensity functions suggested the degree of hearing loss due to middle ear effusion was 21 dB (95% confidence between 10 and 33 dB). Waves I-V inter-wave latency at 90 dB nHL was not significantly different between the two groups. These findings demonstrate that middle ear effusion is associated with a conductive hearing loss of 10-33 dB in affected dogs despite the fact that all animals studied were considered to have normal hearing by their owners.

Association of otoscopic findings and hearing level in pediatric patients with otitis media with effusion

OBJECTIVE

To find the association between the abnormalities of tympanic membrane characteristics and the hearing level in pediatric patients with otitis media with effusion.

METHODS

Sixty-three pediatric patients with otitis media with effusion had undergone ear examinations by pneumatic otoscopy to assess the color, transparency, mobility, fluid level and retraction of the tympanic membrane. An audiogram was done in the same setting, average hearing threshold and air-bone gap were measured. Otoscopic findings and the result of the hearing test were analyzed to identify the association between the abnormalities of the tympanic membrane characteristics and elevated hearing threshold.

RESULTS

Hearing loss was found in 92.1% of the patients. Mean hearing level was 31.7+/-10.3 dB. From linear regression analysis, the patients with dull or opaque tympanic membrane had a significantly higher hearing threshold of 7.2 dB than the patient with translucent ear drum after adjusting for mobility and retraction. The patients with tympanic membrane retraction had a higher hearing threshold of 5.1 dB than the patient who had no retraction after adjusting for transparency and mobility. Mobility had a significant relationship to elevated hearing threshold in the univariate analysis but not in multivariable analysis.

CONCLUSION

Opacity and retraction were the two characteristics of abnormal tympanic membrane that were associated with elevated hearing threshold in the patients with otitis media with effusion. Hearing test is suggested if opacity or retraction of the tympanic membrane is found.

Comparison between myringotomy and tympanostomy tubes in combination with adenoidectomy in 3-7-year-old children with otitis media with effusion

The specific aim of this study was to compare, by means of a randomized clinical trial, the efficacy between the two surgical combinations - adenoidectomy with myringotomy and tympanostomy (A+T) and adenoidectomy with myringotomy (A+M) - in reducing middle ear disease in children with otitis media with effusion (OME). Seventy-eight 3-7-year-old patients (156 ears) with a history of bilateral middle ear effusion for at least 3 months were randomly assigned to either A+T or A+M. Hearing threshold levels, recurrence rate of the effusion and episodes of acute otitis media (AOM) and otorrhea were evaluated for a follow-up period of 1 year. Audiometry testing showed that there was no statistically significant difference in the hearing loss levels of both groups during the whole follow-up period. Free of AOM episodes were 72% of the patients in the A+T group and 75% of those in the A+M group. None of the patients with A+M had episodes with otorrhea which contrasted with the 40% occurrence rate in the A+T group. During the follow-up period we documented a 10% recurrence rate of OME in the A+T group and 14% recurrence rate in the A+M group. Overall our data suggests that the insertion of tympanostomy tubes in association with adenoidectomy provides no additional benefit to adenoidectomy in association with myringotomy alone in terms of hearing loss or AOM episode occurrences in patients with bilateral otitis media with effusion. Furthermore no relationship was found between the choice of operative intervention and the recurrence rate of OME despite the slightly greater relative risk in the A+M group.

Long-term middle-ear ventilation with subannular tubes

Objective:

Long-term tympanostomy tubes are associated with a significant rate of complications, particularly persistent perforation. We describe the outcomes of 57 subannular ventilation tube insertions in 45 consecutive patients.

Design:

Retrospective case series.

Subjects:

We studied 45 consecutive patients with chronic otitis media with effusion and hearing loss (n = 54 cases), associated with adhesive otitis media (n = 7), tympanic membrane retraction (n = 17) and tympanic membrane perforation (n = 3). The mean follow up was 48 months (range, nine to 95 months).

Results:

The mean duration of ventilation for tubes still in situ was 22 months (range, one to 76 months; n = 29), and for tubes which extruded or were removed 23 months (range, one to 85 months; n = 28). The mean improvement in air–bone gap was 14 dB (range, −14 to 35 dB). Complications included blockage (16 per cent), perforation after extrusion (9 per cent), granulation (5 per cent) and infection (4 per cent).

Conclusion:

Subannular ventilation tubes provide an effective option for management of intractable middle-ear effusion and eustachian tube dysfunction.

Primary care management of otitis media among Australian children

Acute otitis media (AOM) is diagnosed on the basis of acute onset of pain and fever; a red, bulging tympanic membrane; and middle ear effusion. AOM is managed with analgesia (paracetamol or non-steroidal anti-inflammatory drugs). Antibiotic therapy is minimally effective for most patients; it is most effective for children < 2 years with bilateral otitis media and for children with discharging ears. National guidelines recommend antibiotic therapy for Indigenous children with AOM. Evidence for corticosteroids, topical analgesia and xylitol are scant. Otitis media with effusion (OME) is diagnosed as the presence of middle ear effusion (type B tympanogram or immobile tympanic membrane on pneumatic otoscopy) without AOM criteria. Well children with OME with no speech and language delays can be observed for the first 3 months; perform audiological evaluation and refer to an ear, nose and throat (ENT) specialist if they have bilateral hearing impairment > 30 dB or persistent effusion. Children with effusions persisting longer than 3 months can benefit from a 2-4-week course of amoxycillin. Chronic suppurative otitis media is a chronic discharge through a tympanic membrane perforation. It is managed with regular ear cleaning (dry mopping or povidone-iodine [Betadine] washouts) until discharge resolves; topical ear drops (eg, ciprofloxacin); audiological evaluation; and ENT review.

Surgery for otitis media among Indigenous Australians

Otitis media with effusion and recurrent acute otitis media are ubiquitous among Indigenous children. Otitis media causes conductive hearing loss that may persist throughout early childhood and adversely affect social interactions, language acquisition and learning. Control of otitis media usually restores hearing to adequate levels. Surgery is to be considered when otitis media has not responded to medical treatment. In non-Indigenous populations, tympanostomy tubes ("grommets"), with or without adenoidectomy, can control otitis media; how these findings relate to Indigenous Australians is not known. Tympanic membrane perforation is a frequent sequela of early childhood otitis media among Indigenous children. It occurs as early as 12 months of age and causes conductive hearing loss. Perforation is associated with recurrent aural discharge, particularly in the tropics and in desert regions. Medical and public health management is required until a child is old enough to undergo surgical closure of the perforation, usually by an age of 7-10 years. Surgical closure of the tympanic membrane stops the aural discharge and improves the hearing sufficiently to avoid the need for hearing aids in most cases. The success rate of surgery conducted in rural and remote Australia is below urban benchmarks; improving this will probably require funding for community-based follow-up.

Adenoidectomy for otitis media with effusion in 2-3-year-old children

OBJECTIVE

To compare the efficacy of three surgical treatment combinations - myringotomy and tympanostomy tube insertion (M&T), adenoidectomy with M&T (A-M&T), and adenoidectomy with myringotomy (A-M) - in reducing middle-ear disease in young children with chronic OME.

METHODS

Children 24-47 months of age, with a history of bilateral middle-ear effusion (MEE) for at least 3 months, unilateral for 6 months or longer or unilateral for 3 months after extrusion of a tympanostomy tube, unresponsive to recent antibiotic, were randomly assigned to either M&T, A-M&T, or A-M. Treatment assignment was stratified by age (24-35 months, 36-47 months), nasal obstruction (no, yes) and previous history of M&T (no, yes). Subjects were followed monthly and with any signs or symptoms of ear disease for up to 36 months.

RESULTS

Ninety-eight subjects were randomly assigned to the three treatment groups. Fifty-six subjects (57%) were 24-35 months of age; 63% had nasal obstruction, and 36% had previously undergone M&T. During the 36 months after entry, subjects were noted to have MEE for the following percentages of time: 18.6% in the M&T group, 20.6% in the A-M&T group, and 31.1% in the A-M group (M&T vs. A-M&T, p=0.87; M&T vs. A-M, p=0.01). By 36 months, there were no differences in the number of further surgical procedures for ear disease needed among the groups.

CONCLUSIONS

Adenoidectomy with or without tube insertion provided no advantage to young children with chronic OME in regard to time with effusion compared to tube insertion alone. Fewer tympanostomy tubes were placed in children undergoing A-M as their initial procedure, but this should be balanced by the performance of the more invasive surgical procedure and their increased time with effusion.

Acute and chronic otitis media

Otitis media (OM) is a common illness in young children. OM has historically been associated with frequent and severe complications. Nowadays it is usually a mild condition that often resolves without treatment. For most children, progression to tympanic membrane perforation and chronic suppurative OM is unusual (low-risk populations); this has led to reevaluation of many interventions that were used routinely in the past. Evidence from a large number of randomized controlled trials can help when discussing treatment options with families. Indigenous children in the United States, Canada, Northern Europe, Australia, and New Zealand experience more OM than other children. In some places, Indigenous children continue to suffer from the most severe forms of the disease. Communities with more than 4% of the children affected by chronic tympanic membrane perforation have a major public health problem (high-risk populations). Higher rates of invasive pneumococcal disease, pneumonia, and chronic suppurative lung disease (including bronchiectasis) are also seen. These children will often benefit from effective treatment of persistent (or recurrent) bacterial infection.

Triagem auditiva em escolares de 5 a 10 anos

OBJETIVO: analisar o desempenho de escolares na triagem auditiva, considerando-se o sexo masculino e feminino e a faixa etária-grupos I, II e III. MÉTODOS: foram avaliados 287 escolares de cinco a dez anos, do sexo feminino e masculino, que frequentavam o PRODECAD (Programa de Desenvolvimento e Integração da Criança e do Adolescente) da UNICAMP. A triagem auditiva foi constituída pela meatoscopia, imitanciometria - timpanometria e pesquisa do reflexo acústico, além dos testes que compõem a avaliação simplificada do processamento auditivo. RESULTADOS: na imitanciometria, 60,6% (N=174/287) dos escolares passaram. Constatou-se que houve diferença estatisticamente significante entre a curva timpanométrica e os grupos estudados. A curva do tipo A foi mais frequente nas crianças maiores, do grupo III. Além disso, o Grupo III apresentou maior número de resposta presente para o reflexo acústico, sendo a diferença entre os grupos estudados estatisticamente significantes. Observa-se que os escolares desse estudo apresentaram mais dificuldade em memorizar sequência de sons ou ordenação temporal do que localizar a fonte sonora. CONCLUSÃO: com base na análise dos resultados obtidos neste estudo foi possível concluir que na imitanciometria, 60,6% dos escolares passaram, ou seja, apresentaram condições de orelha média normais, além de integridade de vias auditivas até o tronco encefálico. Passaram na triagem do processamento auditivo, 56% dos escolares. Com relação aos grupos estudados, os grupos I e II apresentaram um número maior de crianças que falharam na triagem auditiva, considerando-se tanto a imitanciometria, como os testes de processamento auditivo.

The high prevalence of otitis media with effusion in children with cleft lip and palate as compared to children without clefts

OBJECTIVES

Children with cleft lip and palate universally present with otitis media with effusion. This prevalence has not been systematically studied. The purpose of the present study was to examine and compare the prevalence of otitis media with effusion, hearing sensitivity, and audiometry method utilised for assessment in children with and without clefts.

METHODS

Two groups of children (children with unilateral cleft lip and palate, N=22, and children without clefts, N=20) were followed prospectively and longitudinally from 1 to 5 years of age. Data were collected at four points (1, 1.5, 3, and 5 years of age). Assessments at each of the four points included: (1) otomicroscopy, (2) tympanometry, and (3) hearing assessment.

RESULTS

Overall the children with unilateral cleft lip and palate demonstrated a significantly higher prevalence of otitis media with effusion (121 ears, 74.7%) than children without clefts (31 ears, 19.4%) (p<0.001). This higher prevalence was also significant at 1, 1.5, 3, and 5 years of age (p<0.001). Of those ears with otitis media with effusion, 83.1% of the ears exhibited a hearing loss (PTA >20 dB), with this loss more prevalent in the cleft group (89.7% UCLP and 70.0% non-cleft). The hearing loss was significantly more pronounced in the cleft (group 35.71 dB HL UCLP and 26.41 dB HL non-cleft group). Children with unilateral cleft lip and palate utilised a lower age-appropriate audiometry testing method than age-matched children with no cleft at 1, 1.5, and 3 years of age.

CONCLUSIONS

Children with unilateral cleft lip and palate present with a significantly higher prevalence of otitis media with effusion than children without cleft. Also, the hearing loss associated with otitis media with effusion is demonstrated in this study. Furthermore, the method of audiometry has been examined and children with unilateral cleft lip and palate had to be assessed with a lower level of method than children without cleft.

Hearing assessment in infants and children: recommendations beyond neonatal screening

Congenital or acquired hearing loss in infants and children has been linked with lifelong deficits in speech and language acquisition, poor academic performance, personal-social maladjustments, and emotional difficulties. Identification of hearing loss through neonatal hearing screening, regular surveillance of developmental milestones, auditory skills, parental concerns, and middle-ear status and objective hearing screening of all infants and children at critical developmental stages can prevent or reduce many of these adverse consequences. This report promotes a proactive, consistent, and explicit process for the early identification of children with hearing loss in the medical home. An algorithm of the recommended approach has been developed to assist in the detection and documentation of, and intervention for, hearing loss.

Management of children with otitis media: a summary of evidence from recent systematic reviews

Health-care professionals who manage children are regularly confronted with clinical questions regarding the management of the full spectrum of otitis media: acute otitis media; otitis media with effusion; and chronic suppurative otitis media. Given the variety of potential therapies available, the wide spectrum of middle ear disorders, and the lack of consensus about management strategies, clinicians are in a difficult position when managing these children. In this review, we seek to summarise the current best evidence for answering otitis media management questions by collating existing systematic reviews.

Acute otitis media: antimicrobial treatment or the observation option?

The "observation option" was a recommendation cited in the American Academy of Pediatrics/American Academy of Family Physicians clinical practice guideline for the diagnosis and management of acute otitis media (AOM) in 2004. This option's premise is that antibiotic treatment of some uncomplicated AOM cases can be deferred if certain criteria are met, including diagnostic certainty and disease severity. Although this recommendation was controversial, physicians expressed relief at its publication because they felt that not all cases of AOM needed treatment with antibiotics. Studies of the guideline's acceptability, practicality, applicability, and effectiveness have been positive. The Centers for Disease Control and Prevention support it wholeheartedly. Nevertheless, reluctance persists, and the medical community has voiced some objections. During this current crisis of antibiotic resistance, the observation option has become a point of contention.

Surgery for otitis media and infectious susceptibility in 10-year old school children

OBJECTIVES

Assess infectious susceptibility in children previously operated for otitis media and evaluate reliability of parental reported otitis media surgery in the same group of children.

METHODS

Population based, cross-sectional survey of 10-year olds in the city of Oslo, Norway studying otitis media and surgical intervention in n=3406 with reliability assessments in a subset of n=2027.

RESULTS

Ten percent of children had otitis media surgery. Peak age was 2.5 years for adenoidectomy and tympanostomy tubes and 3 years for myringotomy. The crude odds ratio (cOR) with 95% confidence interval (95% CI) for one or more episodes of otitis media at 10 years in children with previous otitis media surgery was 3.4 (2.7-4.4). Intervention after the child was 4 years increased the risk further, crude odds ratio 4.2 (2.9-6.1). Kappa coefficients for agreement in answers to questions on otitis media surgery performed in children between 0 and 4 years were 0.9 for adenoidectomy, 1.0 for tympanostomy tubes, and 0.6 for myringotomy.

CONCLUSION

Otitis media in 10-year old children was associated with previous surgical intervention, particularly when performed after 4 years of age. Parental reports of tympanostomy tubes and adenoidectomy in early childhood were found reliable.

Language Characteristics of Individuals with Down Syndrome

On average, language and communication characteristics of individuals with Down syndrome (the most common genetic cause of intellectual disability) follow a consistent profile. Despite considerable individual variability, receptive language is typically stronger than expressive language, with particular challenges in phonology and syntax. We review the literature on language and literacy skills of individuals with Down syndrome, with emphasis on the areas of phonology, vocabulary, syntax, and pragmatics. We begin by describing the hearing, oral-motor, cognitive, social, and prelinguistic and early nonverbal communication characteristics of individuals with Down syndrome. We conclude with a discussion of clinical implications and research directions.

Upper respiratory tract infections (including otitis media)

Upper respiratory tract infections (including otitis media) are the most common illnesses affecting children. Most illnesses are mild and resolve completely without specific treatment, but the frequency of infection and association with fever and constitutional symptoms creates significant distress for the child and the family. By understanding the evidence available from high-quality studies, the clinician can advise the families on appropriate action. The goal of this article is to support clinicians in answering the following questions: (1) What happened to children with these conditions when no additional treatment was provided? (2) Which interventions have been assessed in well-designed studies? (3) Which interventions have been shown to improve outcomes? (4) How large is the overall benefit?

Contemporary indications for ventilation tube placement

PURPOSE OF REVIEW

To discuss the current indications for ventilation tube placement

RECENT FINDINGS

In the past year, several studies have challenged the current guidelines for ventilation tube placement and antibiotic use for otitis media in children. Critics argue that some of these studies have poor scientific validity, yet these studies are being referenced, and sometimes misinterpreted, by the media. Fueled by these media reports, many concerned parents are now questioning otolaryngologists as to the efficacy and safety of ventilation tube placement. Whereas the indications for tube placement in children may be in a state of flux, the indications for tube placement in adults has (and is) fairly static. I will discuss the current published guidelines and the potential for changing trends in tube placement rates. I will also review the literature for the past year regarding postoperative management and adjuvant therapies.

SUMMARY

Although there have been no radical changes in the indications for ventilation tube placement, recent studies have challenged the current clinical indicators and the ramifications of these studies may be more evident in the years to come.