Otitis media

Otitis media in children

Otitis media is the term used for a group of conditions characterized by inflammation of the middle-ear cleft. These conditions are particularly common in children where they present important diagnostic and therapeutic dilemmas.

Functional tubal therapy for persistent otitis media with effusion in children: myth or evidence?

Otitis media with effusion (OME), a form of inflammatory middle ear disease, is a common reason for young children to visit their family doctor and to have surgery. Tubal dysfunction plays a major role in the pathogenesis. In case of persistent OME, there seems to be a logical rationale for a favourable effect on the tubal dysfunction of a functional active motoric approach combined with behavioral changes (hygiene), and as a consequence for a therapeutic effect on the middle ear disease. The basic principles of this functional treatment are: active ventilation of the middle ear, correction of immature and undesirable deviant mouth habits, increasing swallowing frequency, activating jaw and palate movements, and encouraging the use of chewing gum. The bases for this functional therapy are critically analysed, and it may be concluded that all of these principles rely upon evidence based physiological mechanisms. However, the limited available clinical data from the literature are reviewed, and appear as methodologically weak. The results of an own prospective randomized pilot study comparing functional treatment with watchful waiting may be considered encouraging, since a borderline significance level was reached with a small amount of subjects.

Oxidant and antioxidant levels in children with acute otitis media and tonsillitis: a comparative study

OBJECTIVE

Recurrent episodes of acute otitis media (AOM) and acute tonsillitis (AT) are a common problem in infectious disorders during childhood and are major cause of morbidity in children. The organism maintains defense systems including nonenzymatic antioxidants such as Vitamins A, E and C and reduced glutathione (GSH) against reactive oxygen species (ROS). In the present study, lipid peroxidation status and nonenzymatic antioxidant capacity were investigated in children with AOM and AT. Our aim was to compare the lipid peroxidation and responses of the body's antioxidant status in the closely associated infections such as AOM and acute tonsillitis.

METHODS

The study included 23 (14 males, 9 females) children with AOM, 27 (14 males, 13 females) with AT and 29 (16 males, 13 females) healthy control subjects. The ages of the study and control subjects were between 2 and 7 years. Serum beta-carotene, retinol, Vitamin E, Vitamin C, and whole blood malondialdehyde (MDA) (as an indicator of lipid peroxidation) and GSH levels were studied in all subjects.

RESULTS

There was a statistically significant difference between the groups for all parameters (P<0.05). All of the antioxidant vitamins such as beta-carotene, retinol, Vitamin E, and Vitamin C levels were observed to be significantly decreased in the both patient groups. Nevertheless, GSH levels were also decreased in the patient groups. MDA levels were found to be higher in children with AOM and AT than in the healthy control subjects. When compared the AOM and AT groups, there was statistically significant difference between the groups for whole blood MDA (P<0.05).

CONCLUSION

Even though they seem to react in a similar way against ROS, in the cases of AOM and AT, it is possible to see the different approaches in these tissues for the oxidative stress.

[The effect of AM3 in the resolution of otitis media with effusion (OME) in paediatric patients]

OBJECTIVE

Otitis media with effusion (OME) is one of the most frequent diseases and the main cause of hearing loss in childhood. The medical treatment for OME includes antibiotics, antihistamine-decongestant combinations, steroids and Eustachian-tube autoinflation as the Valsalva manoeuvre.

METHODS

A total of 62 children aged 2 to 8 years with a diagnosis of OME were enrolled in a prospective study to assess the resolution of OME. Patients were given antibiotics treatment with or without associated AM3.

RESULTS

After 2 months of treatment, the rate of complete resolution of OME was greater in AM3 treated group than in the non-AM3 treated group (57.6% vs 27.6%) with a statistically significant difference (p<0.017).

CONCLUSIONS

These results show that AM3 treatment has a beneficial effect on OME resolution when it is associated to antibiotic treatment.

Vaccines for otitis media: proposals for overcoming obstacles to progress

Otitis media is a common problem with enormous morbidity worldwide. The development of vaccines to prevent otitis media would have an important human and economic impact. A striking lack of progress in the development, production and clinical testing of vaccines to prevent otitis media has occurred in the past decade. This review outlines a series of specific proposals intended to advance vaccine development for otitis media.

Grommets in otitis media with effusion: an individual patient data meta-analysis

AIMS

To identify subgroups of children with otitis media with effusion (OME) that might benefit more than others from treatment with ventilation tubes.

METHODS

An individual patient data (IPD) meta-analysis on seven randomised controlled trials (n = 1234 children in all), focusing on interactions between treatment and baseline characteristics--hearing level (HL), history of acute otitis media, common colds, attending day-care, gender, age, socioeconomic status, siblings, season, passive smoking, and history of breast feeding. Outcome measures that could be studied were mean time spent with effusion (n = 557), mean hearing levels (n = 557 in studies that randomised children, and n = 180 in studies that randomised ears), and language development (n = 381).

RESULTS

In the trials that treated both ears the only significant interaction was between day-care and surgery, occurring where mean hearing level was the outcome measure. None of the other baseline variables showed an interaction effect with treatment that would justify subgrouping. In the trials that treated only one ear, the baseline hearing level showed a significant but not pervasive interaction with treatment-that is, only with a cut-off of 25 dB HL.

CONCLUSIONS

The effects of conventional ventilation tubes in children studied so far are small and limited in duration. Observation (watchful waiting) therefore seems to be an adequate management strategy for most children with OME. Ventilation tubes might be used in young children that grow up in an environment with a high infection load (for example, children attending day-care), or in older children with a hearing level of 25 dB HL or greater in both ears persisting for at least 12 weeks.

A 14-Year Prospective Follow-up Study of Children Treated Early in Life With Tympanostomy Tubes: Part 1: Clinical Outcomes

OBJECTIVE

To determine 14-year otological outcomes in young children treated with early insertion of ventilation tubes (VTs) for recurrent acute otitis media or otitis media with effusion (OME).

DESIGN

Prospective 14-year follow-up.

SETTING

Central Hospital of Central Finland, a tertiary care hospital. Patients Three hundred five consecutive infants and young children aged 5 to 16 months with otitis media were enrolled for early initial tympanostomy tube insertion. The final study group comprised 237 patients (77.7%) attending the 14-year checkup.

MAIN OUTCOME MEASURES

At the 14-year checkups, abnormal otological findings were recorded and results compared with those of the 5-year checkups.

RESULTS

From 5 to 14 years' follow-up, the number of healed ears increased from 156 (65.8%) to 177 (74.7%), while the number healed of ears with abnormal outcomes decreased from 81 (34.2%) to 60 (25.3%). Of 156 healed ears, 142 (91.0%) remained healed, and 35 (43.2%) of 81 ears with abnormal outcomes healed. The proportion of abnormal outcomes was higher among ears with OME (P = .02) and with 3 or more VT insertions (P<.001). Repeated tympanostomy tube insertion was performed in 141 ears (59.5%), more often in those with OME (P = .003), and ear surgery was performed in 9 ears (3.8%), 8 with OME.

CONCLUSIONS

Early VT treatment is recommended for young children with recurrent acute otitis media or persistent OME. Parents should be informed of the long follow-up, of the possible need for repeated VT insertion, and of potential sequelae that sometimes necessitate surgical intervention. Patients healed after 5 years do not need further follow-up.

Zygomatic abscess with temporal myositis - a rare extracranial complication of acute otitis media

Acute mastoiditis is the most common complication of acute otitis media (AOM) and its early recognition and management still poses a challenge due to potentially serious consequences. The incidences of extracranial and intracranial suppurative complications of AOM in children have decreased significantly, yet they remain a serious clinical problem, especially when caused by bacteria resistant to antibiotics. The authors presented a case of rare AOM complication - zygomatic abscess with temporal myositis. A 6-year-old boy was admitted to the ENT Department with 4 weeks of ear pain, treated for AOM with cefuroxime axetyl and amoxicilline, with acute mastoiditis and subsequent abscess formation in zygomatic and preauricular region. The inflammatory process spread through anterior air cells to the zygomatic cells leading to a fistula formation in the zygomatic bone and breakthrough into the temporal muscle. The surgical procedures applied were: myringotomy with drainage, cortical mastoidectomy and revision of zygomatic area and treatment with antibiotics (ceftriaxon). Enterococcus faecalis and Streptococcus viridans were found in the culture of middle ear and mastoid effusion. After half a year of follow-up the child had a normal hearing. Severe complications of AOM are rare today. An early diagnosis in order to promote adequate management and prevent inherently suppurative complications is essential.

Air pollution and otitis media: a review of evidence from epidemiologic studies

Otitis media (main types: acute otitis media and otitis media with effusion) is one of the most common childhood infections, particularly before the age of 3 years. The main causes are viral and/or bacterial ear infections, commonly accompanied by or following upper respiratory tract infection. Besides these infections, other risk factors, such as male sex, young age, genetic predisposition, low socioeconomic status, low vitamin A and C intake, and bottle-feeding are discussed. There is indication that exposure to environmental tobacco smoke is a major environmental risk factor, although additional effects of the exposure to ambient air pollutants is uncertain. Although some studies reported statistically significant increased risk for otitis media in children with high exposure to ambient air pollutants, the risks were not consistent among the studies. Owing to the scarcity of available data, far-reaching conclusions cannot be drawn yet. However, the evidence of an increased risk for environmental tobacco smoke exposure and identified increased risk for ambient air pollution exposure in some studies should stimulate future research using otitis media as one of the major outcomes in air pollution epidemiology.

Sensorineural hearing loss in children

During the past three to four decades, the incidence of acquired sensorineural hearing loss (SNHL) in children living in more developed countries has fallen, as a result of improved neonatal care and the widespread implementation of immunisation programmes. The overall decrease has been accompanied by a relative increase in the proportion of inherited forms of SNHL. The contribution made by one gene in particular, GJB2, to the genetic load of SNHL has strongly affected the assessment and care of children with hearing loss. These changes in the incidence of SNHL have not been seen in children living in less developed countries, where the prevalence of consanguinity is high in many areas, and both genetic and acquired forms of SNHL are more common, particularly among children who live in poverty. Focused genetic counselling and health education might lead to a decrease in the prevalence of inherited SNHL in these countries. Establishment of vaccination programmes for several vaccine-preventable infectious diseases would reduce rates of acquired SNHL. Although the primary purpose of such programmes is the prevention of serious and in many cases fatal infections, a secondary benefit would be a reduction in disease-related complications such as SNHL that cause permanent disability in survivors.

Outpatient antibiotic use in Europe and association with resistance: a cross-national database study

BACKGROUND

Resistance to antibiotics is a major public-health problem and antibiotic use is being increasingly recognised as the main selective pressure driving this resistance. Our aim was to assess outpatient use of antibiotics and the association with resistance.

METHODS

We investigated outpatient antibiotic use in 26 countries in Europe that provided internationally comparable distribution or reimbursement data, between Jan 1, 1997, and Dec 31, 2002, by calculating the number of defined daily doses (DDD) per 1000 inhabitants per day, according to WHO anatomic therapeutic chemical classification and DDD measurement methodology. We assessed the ecological association between antibiotic use and antibiotic resistance rates using Spearman's correlation coefficients.

FINDINGS

Prescription of antibiotics in primary care in Europe varied greatly; the highest rate was in France (32.2 DDD per 1000 inhabitants daily) and the lowest was in the Netherlands (10.0 DDD per 1000 inhabitants daily). We noted a shift from the old narrow-spectrum antibiotics to the new broad-spectrum antibiotics. We also recorded striking seasonal fluctuations with heightened winter peaks in countries with high yearly use of antibiotics. We showed higher rates of antibiotic resistance in high consuming countries, probably related to the higher consumption in southern and eastern Europe than in northern Europe.

INTERPRETATION

These data might provide a useful method for assessing public-health strategies that aim to reduce antibiotic use and resistance levels.

Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children

BACKGROUND

Otitis media with effusion (OME), or 'glue ear', is very common in children, especially between the ages of one and three years with a prevalence of 10% to 30% and a cumulative incidence of 80% at the age of four years. OME is defined as middle ear effusion without signs or symptoms of an acute infection. OME may occur as a primary disorder or as a sequel to acute otitis media. The functional effect of OME is a conductive hearing level of about 25 to 30 dB associated with fluid in the middle ear. Both the high incidence and the high rate of spontaneous resolution suggest that the presence of OME is a natural phenomenon, its presence at some stage in childhood being a normal finding. Notwithstanding this, some children with OME may go on to develop chronic otitis media with structural changes (tympanic membrane retraction pockets, erosion of portions of the ossicular chain and cholesteatoma), language delays and behavioural problems. It remains uncertain whether or not any of these findings are direct consequences of OME. The most common medical treatment options include the use of decongestants, mucolytics, steroids, antihistamines and antibiotics. The effectiveness of these therapies has not been established. Surgical treatment options include grommet (ventilation or tympanostomy tube) insertion, adenoidectomy or both. Opinions regarding the risks and benefits of grommet insertion vary greatly. The management of OME therefore remains controversial.

OBJECTIVES

To assess the effectiveness of grommet insertion compared with myringotomy or non-surgical treatment in children with OME. The outcomes studied were (i) hearing level, (ii) duration of middle ear effusion, (iii) well-being (quality of life) and (iv) prevention of developmental sequelae possibly attributable to the hearing loss (for example, impairment in impressive and expressive language development (measured using standardised tests), verbal intelligence, and behaviour).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2003), MEDLINE (1966 to 2003), EMBASE (1973 to 2003) and reference lists of all identified studies. The date of the last systematic search was March 2003, and personal non-systematic searches have been performed up to August 2004.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the effect of grommets on hearing, duration of effusion, development of language, cognition, behaviour or quality of life. Only studies using common types of grommets (mean function time of 6 to 12 months) were included.

DATA COLLECTION AND ANALYSIS

Data from studies were extracted by two reviewers and checked by the other reviewers.

MAIN RESULTS

Children treated with grommets spent 32% less time (95% confidence interval (CI) 17% to 48%) with effusion during the first year of follow-up. Treatment with grommets improved hearing levels, especially during the first six months. In the randomised controlled trials that studied the effect of grommet insertion alone, the mean hearing levels improved by around 9 dB (95% CI 4 dB to 14 dB) after the first six months, and 6 dB (95% CI 3 dB to 9 dB) after 12 months. In the randomised controlled trials that studied the combined effect of grommets and adenoidectomy, the additional effect of the grommets on hearing levels was improvement by 3 to 4 dB (95% CI 2 dB to 5 dB) at six months and about 1 to 2 dB (95% CI 0 dB to 3 dB) at 12 months. Ears treated with grommets had an additional risk for tympanosclerosis of 0.33 (95% CI 0.21 to 0.45) one to five years later. In otherwise healthy children with long-standing OME and hearing loss, early insertion of grommets had no effect on language development or cognition. One randomised controlled trial in children with OME more than nine months, hearing loss and disruptions to speech, language, learning or behaviour showed a very marginal effect of grommets on comprehensive language.

AUTHORS' CONCLUSIONS

The benefits of grommets in children appear small. The effect of grommets on hearing diminished during the first year. Potentially adverse effects on the tympanic membrane are common after grommet insertion. Therefore an initial period of watchful waiting seems to be an appropriate management strategy for most children with OME. As no evidence is yet available for the subgroups of children with speech or language delays, behavioural and learning problems or children with defined clinical syndromes (generally excluded from the primary studies included in this review), the clinician will need to make decisions regarding treatment for such children based on other evidence and indications of disability related to hearing impairment. This review does not resolve the discrepancy between parental and clinical observation of a beneficial treatment effect and the results in the reviewed RCT showing only a short-term effect on hearing and virtually no effect on development. Is the perceived, often dramatic, effect of grommets only a short-term one? Are some children more sensitive to OME-related hearing loss than others? If so, how do we identify them?Further research should focus upon indications. Studies should use sufficiently large sample sizes to show significant interactions. There is a need to determine the most suitable variables and appropriate "softer" outcomes to be the subject of these interaction tests. Interesting options include measures of speech-in-noise and binaural hearing. The generally modest results in the trials which are included in this review should make it easier to justify randomisation of more severely affected and higher-risk children in appropriately constructed trials. Randomised controlled trials are necessary in these children before more detailed conclusions about the effectiveness of grommets can be drawn.

A willingness-to-pay assessment of parents' preference for shorter duration treatment of acute otitis media in children

OBJECTIVE

To assess parental willingness to pay (WTP) for a shorter course of antibacterial treatment versus conventional antibacterial therapy for acute otitis media (AOM).

METHODS

The study population consisted of 562 parents of children who had been seen and treated by a paediatrician for an episode of AOM between February and November 2002 in Montreal, Quebec, Canada. At the end of the AOM treatment, a questionnaire that included demographic information about the parents and child, details of the child's AOM history, a global wellbeing (i.e. quality of life) assessment, an evaluation of treatment compliance and a scripted WTP question was administered over the telephone. Descriptive analyses were performed in addition to a multivariate analysis to estimate possible predictors of parental WTP.

RESULTS

The children with AOM were representative of the AOM patient population, with 46% being <2 years of age and the majority attending day-care or school. Parents were willing to pay a median of 31.66 Can dollars (2002 values) for a mono-dose (one dose, on 1 day) and 26.63 Can dollars for a tri-dose (one dose daily, for 3 days) antibacterial treatment. Regression analyses demonstrated that the amount parents were willing to pay was positively associated with increasing household income, increasing number of AOM episodes during the previous year and experiencing adverse effects of treatment.

CONCLUSION

Parents of children with AOM were willing to pay more for their child to benefit from a shorter duration of antibacterial treatment than for a standard course. Short duration of treatment appears to be associated with better compliance and parents' perception of better general wellbeing for their child.

Oestrogen Deficiency and Growth Hormone Treatment in Childhood Are Not Associated with Hearing in Adults with Turner Syndrome

BACKGROUND/AIMS

Women with Turner syndrome (TS) have an increased prevalence of hearing loss, with conductive (CHL) and sensorineural (SNHL) components. The association between hearing loss and clinical parameters, particularly oestrogen and previous growth hormone (GH) treatment, was investigated.

METHODS

A cross-sectional study of pure tone audiometry tests in an adult TS population. Previous ENT history, karyotype, anthropomorphic measurements and the impact of oestrogen and childhood GH therapy were assessed. One hundred and thirty-eight women (median age 29, range 16-67 years) completed the study.

RESULTS

Normal hearing was found in 20.3% of women, CHL in 18.8%, SNHL in 57.2% and confounding factors in 3.6%. Neither CHL nor SNHL were associated with oestrogen deficiency or GH treatment independent of age. CHL but not SNHL was more common in those with a history of recurrent otitis media (p < 0.01) and monosomy 45,X (p < 0.01).

CONCLUSIONS

Current regimens of oestrogen and GH therapy have no impact on adult hearing loss in TS, independent of age. The prevalence of SNHL increases with age. CHL but not SNHL is associated with ENT history and karyotype. According to present evidence, the only possible intervention to reduce hearing loss in women with TS remains assiduous treatment of ENT problems in childhood.

Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial

OBJECTIVES

To assess the effect of a tailored professional intervention, including academic detailing, on antibiotic prescribing for acute cough.

METHODS

In a cluster-randomized controlled before and after study 85 Flemish GPs included adult patients with acute cough consulting in the periods February-April 2000 and 2001. The intervention consisted of a clinical practice guideline for acute cough, an educational outreach visit and a postal reminder to support its implementation in January 2001. Antibiotic prescribing rates and patients' symptom resolution were the main outcome measures.

RESULTS

Thirty-six of 42 GPs received the intervention and 35 of 43 GPs served as controls; 1503 patients were eligible for analysis. Only in the intervention group were patients less likely to receive antibiotics after the intervention [OR(adj) (95% CI)=0.56 (0.36-0.87)]. Prescribed antibiotics were also more in line with the guideline in the intervention group [1.90 (0.96-3.75)] and less expensive from the perspective of the National Sickness and Invalidity Insurance Institute [MD(adj) (95% CI)= Euro -6.89 [-11.77-(-2.02)]]. No significant differences were found between the groups for the time to symptom resolution.

CONCLUSIONS

An (inter)actively delivered tailored intervention implementing a guideline for acute cough is successful in optimizing antibiotic prescribing without affecting patients' symptom resolution. Further research efforts should be devoted to cost-effectiveness studies of such interventions.