The occurrence of acute otitis media in infants. A life-table analysis

Impact of COVID-19 Pandemic on the Incidence of Pediatric Acute Otitis Media in Seoul, South Korea

OBJECTIVE

The implementation of nonpharmaceutical interventions (NPIs) for coronavirus disease 2019 (COVID-19) may affect the incidence of infectious diseases. This study aimed to evaluate the changes in the incidence of pediatric acute otitis media (AOM) after the COVID-19 outbreak in Seoul, South Korea.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary referral center.

PATIENTS

We ascertained the daily number of COVID-19 and pediatric AOM patients between January 20, 2020, and June 19, 2020. During the same period, the number of children using public transportation was used as an index for implementing NPIs. The same period 1 year ago was set as the control period.

INTERVENTION

Diagnostic.

MAIN OUTCOME MEASURE

The differences in the incidence of AOM and implementation of NPIs between the COVID-19 pandemic and control period were analyzed using segmented regression analyses. Negative values of difference meant that the number in the COVID-19 pandemic period declined compared with the control period.

RESULTS

The study period was divided into two sections based on the change point of the COVID-19 cases. In the first period, the increased number of COVID-19 cases decreased, and in the second period, the number of COVID-19 cases increased again. Similar trends were observed in the incidence of AOM and NPI implementation. Before the change point, the study found a significant decreasing trend in the differences in pediatric AOM cases and children using public transportation. However, these trends changed after the change point, with a significant increase in both indices.

CONCLUSION

Our findings indicate that NPIs for COVID-19 may influence the incidence of pediatric AOM.

Using Geometric Morphometric Analysis of Magnetic Resonance Imaging to Assess the Anatomy of the Eustachian Tube in Children with and without Otitis Media

Otitis media (OM) is among the most common of childhood illnesses. It has long been hypothesized that children under age two are predisposed to OM due to differences in the anatomy of the Eustachian tube (ET), including the angle of the ET. OM in later childhood is less common but does occur, begging the question, are there shape differences in the ET that persist underlying later occurrences of OM? To answer this question, a novel method, which applied geometric and morphometric shape analysis to landmarks obtained from MRI data, was used. MRI scans were performed on 16 children (5 control, 3 cOME, and 8 rAOM) between 2011 and 2015. Sixteen landmarks representing the shape of the ET, cranial base, and palate were analyzed. The results of a Procrustes ANOVA indicate that the shape of the ET varies significantly (p < 0.01) between the OM and control groups. The shape differences between the OM group and the control are a medial and low attachment site of the tensor veli palatini (TVP) muscle, a posterior and high torus tubarius, and an anteriorly projected palate. These results support previous findings that a relatively horizontal ET is associated with a predisposition for OM. This study used a novel approach to examine anatomical differences in children with and without OM. First, the data set is unique in that it includes MRI scans of children with a confirmed OM diagnosis. Second, the use of MRI scans in craniofacial anatomy OM research is novel and allows for the collection of soft tissue landmarks and the visualization of soft tissue structures. Third, geometric morphometric shape analysis is a statistical method that captures shape differences, offering a more universal picture of nuanced changes within the entire set of landmarks, in contrast to more traditional linear and angular measurements used in prior OM studies examining craniofacial anatomy.

Streptococcus pneumoniae as cause of acute otitis media (AOM) in Slovak children in the pneumococcal conjugate vaccine era (2008-2019)

AIM

Little data is available on pneumococcal serotypes and their antimicrobial resistance in the pneumococcal conjugate vaccination era in young children with acute otitis media (AOM). Here such data is provided from Slovakia, acountry with sequential introduction and parallel-use of the three commercially available pneumococcal conjugate vaccines (PCVs; PCV7; PCV13; PCV10).

METHODS

This observational study takes advantage of the fact that tympanocentesis is the standard of care in children with AOM in Slovakia. Over the 12 year observation period, participating pediatric ENT specialists sent samples taken during tympanocentesis from children with AOM to their local MEDIRIX laboratories for identification of bacteria. Pneumcoccal isolates were serotyped and tested for antimicrobial resistance. Incidence data could be calculated from 1 region.

RESULTS

Study participation and completeness of typing increased over time. Based on testing of 1,131 isolates over 12 years, PCV7-serotypes rapidly waned after PCV7 introduction in 2009 and had virtually disappeared in 2014. The maximum fraction of PCV10-only isolates (1, 5, 7F) was 2.7 % (2009) whereas the additional 3 PCV-serotypes (3, 6A, 19A) in PCV13 represented the largest proportion of pneumococcal AOM cases as of 2010. This finding remained unchanged during the period of highest PCV10-market share (2012-2017) and even until the end of the observation period (2019). The fraction of untypeable pneumococci (<6 %) and non-PCV13-serotypes (16-34 %) increased 2012-2017, but decreased again thereafter. Serotype 19A evolved as the most relevant (multidrug-) resistant pneumococcal serotype, again particularly during the time with high sales of PCV10 (2012-2017). Incidence data from the Bratislava region document a huge impact of PCV use (77 % vaccine uptake: mainly PCV13) on AOM in children < 6 years. Serotypes 19A and 3 remain the only relevant pneumococcal serotypes in young Slovakian children with AOM.

CONCLUSIONS

As AOM is one of the most common bacterial infections in children < 6 years, the observed benefits of PCVs in reducing vaccine serotypes have been tremendous. With sequential / parallel-use of PCVs, serotypes 3 and (MDR-) 19A today make the largest proportion (about 2/3) of pneumococcal AOM in Slovakia. This data will help to further guide the choice of pneumococcal conjugate vaccines for pediatricians and parents.

Effectiveness of the 7- and 13-Valent Pneumococcal Conjugate Vaccines Against Vaccine-Serotype Otitis Media

Background

Despite the demonstrated impact of pneumococcal vaccine (PCV) implementation on otitis media (OM), demonstration of real-life serotype-specific effectiveness of the 7-valent and 13-valent PCVs (PCV7 and PCV13) is lacking owing to the paucity of culture-positive cases. Furthermore, prelicensure PCV13 efficacy against OM was not studied.

Methods

The study was conducted from October 2009 to July 2013. Case patients were children aged 5–35 months with OM (mostly complex OM [recurrent/nonresponsive, spontaneously draining, chronic with effusion]) from whom middle-ear fluid culture was obtained; controls were contemporary children with rotavirus-negative gastroenteritis in a prospective population-based rotavirus surveillance, from the same age group with similar ethnic distribution and geographic location. Vaccine effectiveness (VE) was estimated as 1 minus the odds ratio using unconditional logistic regression, adjusting for time since PCV implementation, age, and ethnicity.

Results

A total of 223 case patients and 1370 controls were studied. Serotypes 19F and 19A together caused 56.1% of all vaccine-type (VT) OM. VE of ≥2 PCV doses in children aged 5–35 months was demonstrated as follows: PCV7 against OM due to PCV7 serotypes, 57.2% (95% confidence interval, 6.0%–80.5%); PCV13 against OM due to PCV13 serotypes, 77.4% (53.3%–92.1%); PCV13 against OM due to the 6 additional non-PCV7 serotypes 67.4% (17.6%–87.1%); PCV13 against OM due to serotype 19F, 91.3% (1.4%–99.2%); and PCV13 against OM due to serotype 3, 85.2% (23.9%–98.4%). PCV7 and PCV13 VE against OM due to serotype 19A in children aged 12–35 months was 72.4% (95% confidence interval, 6.2%–91.9%) and 94.6% (33.9%–99.6%), respectively.

Conclusions

PCV7 and PCV13 were effective against complex OM caused by the targeted serotypes.

Epidemiology of Otitis Media With Otorrhea Among Bangladeshi Children: Baseline Study for Future Assessment of Pneumococcal Conjugate Vaccine Impact

BACKGROUND

Otitis media (OM) poses a high disease burden on Bangladeshi children, but little is known about its etiologies. We conducted a surveillance study in the largest pediatric hospital to characterize pathogens responsible for OM.

METHODS

In the outpatient ear-nose-throat department of Dhaka Shishu Hospital, which serves 0 to 18-year-old children, we collected ear swabs from OM children with otorrhea from April 2014 to March 2015. We cultured all specimens for bacterial pathogens and assessed serotype and antimicrobial susceptibility of Streptococcus pneumoniae (Spn) and Haemophilus influenzae (Hi) isolates.

RESULTS

We recorded 1111 OM episodes; 88% (981/1111) involved otorrhea, and we collected samples from 91% (891/981) of these children. Fifty-one percent (452/891) were culture positive (contaminants excluded), with Hi (21%, 187/891) and Spn (18%, 164/891) most commonly detected. Overall, 45 distinct single and mixed pathogens were revealed. Dominant pneumococcal serotypes were 19A, 19F, 3 and 14; 98% of Hi isolates were nontypeable. Pneumococcal conjugate vaccine (PCV)10 and PCV10 + 6A serotypes accounted for 8% and 9% of all OM and 46% and 49% of pneumococcus-positive cases, respectively, and were more likely to be nonsusceptible to at least 1 antibiotic (erythromycin and/or trimethoprim-sulfamethoxazole) than nonvaccine serotypes (91% vs. 77%). Staphylococcus aureus (9%, 83/891) and Pseudomonas aeruginosa (4%, 38/891) were also found.

CONCLUSIONS

Nontypeable Hi (NTHi) and Spn are predominant causes of OM in Bangladesh. PCV10, introduced in March 2015, is likely to reduce pneumococcal and overall OM burden. Data collected post-PCV10 will provide comprehensive insight into the effects of this vaccine on these pathogens.

Impact of influenza vaccine on childhood otitis media in Taiwan: A population-based study

PURPOSE

Acute otitis media (AOM) is a common infectious disease in children and usually accompanied by a preceding viral respiratory tract infection, especially in the preschool-age population. The study aimed to evaluate impact of influenza vaccine on childhood otitis media.

METHODS

This retrospective cohort study included data for 803,592 children (<10 years old) recorded in Taiwan's National Health Insurance Research Database. AOM incidence and tympanostomy tube insertion incidence in each influenza season before and after the introduction of traditional injectable trivalent influenza vaccine (TIV) were compared using the Poisson regression analysis to estimate the incidence rate ratios (IRRs) and 95% confidence intervals (CIs).

RESULTS

In children < 2 years old, the age group eligible for free influenza vaccination, there was a significant reduction in seasonal AOM incidence after TIV introduction in 2004 (from 98.4 episodes/1000 person-seasons [95% CI: 96.4-100.5] to 66.1 episodes/1000 person-seasons [95% CI: 64-68.1]). In addition, with the increased vaccine coverage rate, the outpatient visits for AOM in the influenza season of 2005 and 2006 were significantly lower than that in 2004 (IRR = 0.85 and 0.80, respectively, p < 0.0001).

CONCLUSIONS

A significant reduction in primary care consultations for children <2 years old was observed after the introduction of the TIV in Taiwan in 2004. With the increased vaccine coverage, there was an additional decline in 2005 and 2006. In addition of the direct protection provided by the vaccination, we believe that TIV may have induced some herd immunity that further contributed to the reduction in influenza attack rates and the rates of associated AOM in that age group. These reductions were observed only in vaccine-eligible children, while older children, who were not enrolled in the influenza vaccination program during the study period, have experienced increases in the AOM incidence during the 2004-2006 period compared to the 2000-2003 period.

Cranial Indicators Identified for Peak Incidence of Otitis Media

Acute otitis media (AOM) is one of the most common pediatric conditions worldwide. Peak age of occurrence for AOM has been identified within the first postnatal year and it remains frequent until approximately six postnatal years. Morphological differences between adults and infants in the cartilaginous Eustachian tube (CET) and associated structures may be responsible for development of this disease yet few have investigated normal growth trajectories. We tested hypotheses on coincidence of skeletal growth changes and known ages of peak AOM occurrence. Growth was divided into five dental eruption stages ranging from edentulous neonates (Stage 1) to adults with erupted third maxillary molars (Stage 5). A total of 32 three-dimensional landmarks were used and Generalized Procrustes Analysis was performed. Next, we performed principal components analysis and calculated univariate measures. It was found that growth change in Stage 1 was the most rapid and comprised the largest amount of overall growth in upper respiratory tract proportions (where time is represented by the natural logarithmic transformation of centroid size). The analysis of univariate measures showed that Stage 1 humans did indeed possess the relatively shortest and most horizontally oriented CET's with the greatest amount of growth change occurring at the transition to Stage 2 (eruption of deciduous dentition at five postnatal months, commencing peak AOM incidence) and ceasing by Stage 3 (approximately six postnatal years). Skeletal indicators appear related to peak ages of AOM incidence and may contribute to understanding of a nearly ubiquitous human disease. Anat Rec, 2017. © 2017 Wiley Periodicals, Inc. Anat Rec, 300:1721-1740, 2017. © 2017 Wiley Periodicals, Inc.

Acute Otitis Media During Infancy: Parent-reported Incidence and Modifiable Risk Factors

BACKGROUND

Age at exposure to acute otitis media (AOM) risk factors such as day care attendance, lack of breastfeeding and tobacco smoke is little studied but important for targeting AOM prevention strategies. Moreover, studies are typically restricted to clinically diagnosed AOM, while a significant subset can occur outside the health care system, depending on the country setting. This study aims to determine risk factor exposure and effect of its timing within the first year of life on parent-reported AOM symptom episodes.

METHODS

In the WHeezing and Illnesses STudy LEidsche Rijn birth-cohort study, 1056 children were prospectively followed during their first year of life. Group day care attendance, breastfeeding and tobacco smoke exposure were recorded monthly and parent-reported AOM symptoms daily. Generalized estimating equations were used to estimate the association between the time-varying risk factors and AOM symptom episodes, while correcting for confounding by indication.

RESULTS

The first-year incidence rate of parent-reported AOM was 569/1000 child-years [95% confidence interval (CI): 523-618]. Children who attended day care had higher odds of developing AOM symptom episodes compared with those not attending (odds ratio: 5.0; 95% CI: 2.6-9.6). Tobacco smoke exposure and (a history of) breastfeeding were not associated with AOM. Test for interaction revealed that the effect of day care increased with each month younger in age.

CONCLUSIONS

First-year day care attendance is a major risk factor for AOM symptom episodes among infants in the community. This adjusted effect estimate is higher than previously reported and is age-dependent. AOM prevention strategies in day care facilities should therefore focus in particular on the youngest age groups.

Otitis media: health and social consequences for aboriginal youth in Canada’s north

OBJECTIVES

Otitis media is endemic among Inuit, First Nations and Métis children in northern Canada, with prevalence rates in some communities as high as 40 times that found in the urban south. Hearing impairment, much of it attributable to chronic otitis media, is the most common health problem in parts of the arctic, and conductive hearing loss among children may affect as many as two-thirds.

STUDY DESIGN AND METHODS

There is a need for systematic data based on consistent disease definitions and measures, and taking account of cross-cultural methodological issues and sampling.

RESULTS

Otitis media is most likely to develop in infancy. Susceptibility has been linked to immune defects and to a variety of environmental factors. Among the most significant are diet, the decline in initiation and maintenance of breastfeeding, and exposure to cigarette smoke. Hearing loss has been related to difficulties in language acquisition, and to subsequent issues with literacy and school achievement, including learning disabilities and attention deficits. The economic and social costs of otitis media are substantial.

CONCLUSION

Approaches to treatment and prevention have enjoyed limited success. Public health and medical practice need to be informed by the traditional knowledge and practices of indigenous peoples.

Human enterovirus and rhinovirus infections are associated with otitis media in a prospective birth cohort study

BACKGROUND

Human enteroviruses (HEVs) and rhinoviruses (HRVs) have been linked to acute otitis media (AOM).

OBJECTIVES

The present study evaluates the aforementioned association in a birth cohort setting.

STUDY DESIGN

The cohort included 286 healthy infants (191 boys) followed from birth up to the age of 2 years in the Type 1 Diabetes Prediction and Prevention study in Finland. Stool samples were collected monthly and analyzed for the presence of HRV and HEV RNA using RT-PCR. Clinical symptoms were recorded by a questionnaire every 3-6 months.

RESULTS

Altogether 610 AOM episodes were reported during the follow-up. 9.8% of the stool samples were positive for HRV and 6.8% for HEV. HRV positivity peaked at the age of 3-6 months declining gradually after this age, whereas HEV positivity peaked later, at the age of 12-24 months. The risk of AOM was increased in children who were HEV positive at least once at the age of 6-12 months (OR 2.2 [95%CI 1.1-4.2], P=0.023) or who were HRV positive at least once at the age of 18-24 months (OR 2.3 [95%CI 1.0-5.2], P=0.042). Having an older sibling, short breast-feeding and maternal smoking during pregnancy were also significantly associated with AOM.

CONCLUSIONS

HRV and HEV infections are frequent during the first months of life. The observed trend for increased risk of AOM in HRV and HEV positive children is in line with the results from hospital series suggesting that these viruses may play an independent role in the pathogenesis of AOM.

Ultrasound characterization of the mastoid for detecting middle ear effusion: A preliminary clinical validation

Ultrasound detection of middle ear effusion (MEE) is an emerging technique in otolaryngology. This study proposed using ultrasound characterization of the mastoid to noninvasively measure MEE-induced mastoid effusion (ME) as a new strategy for determining the presence of MEE. In total, 53 patients were enrolled (Group I: normal, n = 20; Group II: proven MEE through both otoscopy and tympanometry, n = 15; Group III: patients with MEE having effusions observed during grommet surgery, n = 18). A 2.25-MHz delay-line transducer was used to measure backscattered signals from the mastoid. The Nakagami parameter was estimated using the acquired signals to model the echo amplitude distribution for quantifying changes in the acoustic structures of mastoid air cells. The median Nakagami parameter and interquartile range were 0.35 (0.34-0.37) for Group I, 0.39 (0.37-0.41) for Group II, and 0.43 (0.39-0.51) for Group III. The echo amplitude distribution observed for patients with MEE was closer to Rayleigh distribution than that without MEE. Receiver operating characteristic (ROC) curve analysis further revealed that the area under the ROC was 0.88, sensitivity was 72.73%, specificity was 95%, and accuracy was 81.13%. The proposed method has considerable potential for noninvasive and comfortable evaluation of MEE.

Bifidobacterium animalis subsp. lactis BB-12 in reducing the risk of infections in early childhood

BACKGROUND

Specific probiotic bacteria have proven to be effective in the prevention and treatment of infectious diseases in early life in at-risk populations. The impact of administration of Bifidobacterium animalis subsp. lactis BB-12 (BB-12) on the risk of acute infectious diseases was studied in healthy children.

METHODS

In this double-blind, placebo-controlled study, 109 1-mo-old infants were assigned randomly to a probiotic group receiving a BB-12-containing tablet (n = 55) or a placebo (n = 54). Test tablets were administered to the infants twice a day (daily dose of BB-12 10 billion colony-forming units) until the age of 2 y with a novel slow-release pacifier or a spoon. Breastfeeding habits, pacifier use, dietary habits, medications, and all signs and symptoms of acute infections were registered in diaries by parents and in questionnaires by trained professionals.

RESULTS

The infants receiving BB-12 were reported to have experienced fewer respiratory tract infections (RTIs; 87 vs. 100%; risk ratio: 0.87; 95% confidence interval: 0.76, 1.00; P = 0.033) than the controls. No significant differences between the groups were observed in reported gastrointestinal symptoms, otitis media, or fever. The baseline characteristics of the two groups were similar, as was the duration of breastfeeding.

CONCLUSION

Administration of BB-12 in early childhood may reduce RTIs.

Eustachian Tube Function in 6-Year-Old Children with and without a History of Middle Ear Disease

OBJECTIVE

To test the hypothesis that eustachian tube opening efficiency, measured as the fractional gradient equilibrated (FGE), is lower in 6-year-old children with no middle ear disease but a well-documented history of recurrent acute otitis media, as compared with children with a negative disease history (control).

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary care pediatric hospital.

SUBJECTS AND METHODS

Bilateral eustachian tube function was evaluated in 44 healthy 6-year-old children (19 boys, 29 white). None had middle ear disease at the time of testing, but 23 had a history of recurrent acute otitis media. Twenty-one had no significant past otitis media. Eustachian tube function was measured with a pressure chamber protocol that established negative middle ear gauge pressures (referenced to the chamber pressure) and recorded that pressure before and after a swallow. FGE was calculated as the change in middle ear gauge pressure with swallowing divided by the preswallow pressure. Between-group comparisons of the preswallow pressures and FGEs were made with a 2-tailed Student's t test.

RESULTS

FGE was independent of the preswallow middle ear gauge pressure. For the 39 and 44 evaluable ears in the control and recurrent acute otitis media groups, the mean preswallow pressures were -194 daPa (95% confidence interval [95% CI] = -211 to -177) versus -203 (95% CI = -216 to -190; P > .40), and FGEs were 0.32 (95% CI = 0.21-0.43) vs 0.16 (95% CI = 0.08-0.24; P = .016), respectively.

CONCLUSION

In children with past recurrent acute otitis media, residual eustachian tube opening inefficiency is maintained after they have "outgrown" their middle ear disease.

Infectious complications and ventilation tubes in pediatric cochlear implant recipients

OBJECTIVES/HYPOTHESIS

At many centers, ventilating tubes (VTs) are placed routinely in otitis-prone pediatric cochlear implant recipients. However, this practice is controversial, as many otologists believe VTs represent a possible route for contamination of the device. Toward better understanding of the safety of VTs, we reviewed our center's infectious complications and their relationship to the presence of tubes.

STUDY DESIGN

Retrospective cohort study.

METHODS

All patients undergoing cochlear implantation at our institution between 1990 and 2012 were reviewed for complications and their association with the presence of VTs.

RESULTS

A total of 478 patients (557 ears) were reviewed, representing over 2,978 patient-years of follow-up. In 135 ears (24.2%), a VT was present at time of, or placed at some point after, implantation. The remainder either never had a VT or it had extruded prior to implantation. Overall, 63 complications occurred, of which 17 were infectious. The most common were cellulitis (four), device infection (five), and meningitis (four). Only one occurred while a tube was present, and was a device infection in an ear having a retained VT in place for almost 4 years. No difference was observed in overall rates of infectious complications between the group with VTs and those who never had VTs.

CONCLUSIONS

This series, the largest to date, indicates that infectious complications after cochlear implantation are rarely associated with the presence of VTs, supporting the concept that, overall, VTs are safe in cochlear implant recipients. Close monitoring is essential, including prompt removal of tubes when they are no longer needed.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1671-1676, 2016.

Impact of the Seven-valent Pneumococcal Conjugate Vaccine on Acute Otitis Media in Japanese Children: Emergence of Serotype 15A Multidrug-resistant Streptococcus pneumoniae in Middle Ear Fluid Isolates

BACKGROUND

Streptococcus pneumoniae is one of the most common bacteria causing acute otitis media (AOM). In Japan, a 7-valent pneumococcal conjugate vaccine (PCV7) was introduced for voluntary vaccination of children in 2010, and it became a recommended vaccination in April 2013. We surveyed the serotypes and antimicrobial susceptibility profile of S. pneumoniae isolates obtained from the middle ear fluid of Japanese children with AOM.

METHODS

Between April and September 2013, a total of 176 S. pneumoniae isolates were obtained from the middle ear fluid of children aged 0-3 years with AOM. Isolates were collected from various regions of Japan. Minimum inhibitory concentrations were measured by the broth microdilution method. Serotyping was performed by observing the Quellung reaction.

RESULTS

Although 45.5% of the strains were susceptible to penicillin G, 42.6% were penicillin-intermediate strains and 11.9% were penicillin-resistant strains. Serotype 19A (27.3%), serotype 15A (14.2%) and serotype 3 (11.9%) showed a high frequency. Although PCV7 types only accounted for 4.5% of all strains, 44.9% were PCV13 types and 55.1% were non-PCV types. Serotype 15A strains were 100% nonsusceptible to penicillin G and all of these strains showed multidrug resistance. Serotype 15A was frequent in children up to 1 year old.

CONCLUSION

After this research was completed, PCV7 was switched to a PCV13 that also contained serotype 3 and serotype 19A. We need to consider the possibility that serotype 15A, which is not included in PCV13, may increase and cause intractable AOM in the future.

Effect of pneumococcal conjugate vaccination on nasopharyngeal carriage in children with early onset of acute otitis media - a randomized controlled trial

CONCLUSION

Although children vaccinated with heptavalent pneumococcal conjugate vaccine (PCV) had fewer episodes of acute otitis media (AOM), this trial was unable to prove a simultaneous decrease in nasopharyngeal carriage.

OBJECTIVE

Carriage rates of AOM pathogens in the nasopharynx are high among children, and colonization is the first step towards infection. The possible impact of PCV on carriage is therefore of interest, particularly in children with recurrent AOM. The aims of this study were to examine the effect of heptavalent PCV on carriage of AOM pathogens in children at high risk of developing recurrent disease, and to monitor carriage of resistant pathogens in vaccinated and unvaccinated children.

METHODS

A total of 109 children with an onset of AOM before 6 months of age, 89 of whom developed recurrent disease, were enrolled in a trial. Fifty-two children were vaccinated and all were closely monitored for 3 years.

RESULTS

There was no difference statistically between vaccinated children and controls concerning the carriage of any of the major AOM pathogens. There was evidence of within-child clustering for S. pneumoniae (p = 0.002) and H. influenzae (p < 0.001), indicating that children continued to carry either species over time. Resistance rates were generally low and comparable with national levels.

Near-elimination of otitis media caused by 13-valent pneumococcal conjugate vaccine (PCV) serotypes in southern Israel shortly after sequential introduction of 7-valent/13-valent PCV

BACKGROUND

Otitis media (OM) is common in early childhood. Streptococcus pneumoniae caused approximately 30%-60% of episodes before the pneumococcal conjugate vaccine (PCV) era. The 7-valent PCV (PCV7) was introduced to the Israeli National Immunization Plan in July 2009, and was gradually replaced by the 13-valent PCV (PCV13) starting in November 2010. We aimed at assessing the impact of PCV7/PCV13 sequential introduction on pneumococcal and overall OM necessitating middle ear fluid culture in children aged <2 years in southern Israel.

METHODS

This was a prospective, population-based, active surveillance. Our medical center is the only one in the region, enabling incidence calculation. All pneumococcal episodes submitted for culture between July 2004 and June 2013 were included. Three subperiods were defined: pre-PCV, PCV7, and PCV13.

RESULTS

Overall, 6122 OM episodes were recorded, and 1893 were pneumococcal. Compared with the pre-PCV period, OM caused by PCV7 plus serotype 6A and the 5 additional PCV13 serotypes (5VT : 1, 3, 5, 7F, 19A) decreased by 96% and 85%, respectively (incidence rate ratios [IRRs], 0.04 [95% confidence interval {CI}, .02-.08] and 0.15 [95% CI, .07-.30], respectively) in a 2-step pattern: In the PCV7 period, only OM caused by PCV7 + 6A serotypes was decreased; in the PCV13 period, 5VT OM rates decreased, along with an additional PCV7 + 6A OM reduction. A nonsignificant increase in non-PCV13 serotype OM was observed (IRR, 1.07 [95% CI, .72-1.58]). In total, 77% and 60% reductions of all-pneumococcal and all-cause OM incidences, respectively, were observed.

CONCLUSIONS

A substantial 2-step reduction of pneumococcal OM rates, with near-elimination of PCV13 disease, was observed shortly after PCV7/PCV13 introduction.

Twelve-year survey (2001-2012) of the antimicrobial susceptibility of Streptococcus pneumoniae isolates from otorhinolaryngology clinics in Miyagi Prefecture, Japan

INTRODUCTION

Streptococcus pneumoniae is one of the most common bacteria causing otorhinolaryngological infections, such as acute otitis media and upper respiratory tract infection. Our group surveyed the drug susceptibility profile of S. pneumoniae isolates from otorhinolaryngology patients.

MATERIALS AND METHODS

A total of 41,069 S. pneumoniae isolates were detected at Miyagi Medical Association Health Center between May 2001 and December 2012. Specimens were obtained from patients at 40 otorhinolaryngology outpatient clinics in Miyagi Prefecture, Japan. The minimum inhibitory concentrations (MICs) of 8 antimicrobial agents were measured using the broth microdilution method according to Clinical and Laboratory Standards Institute guidelines.

RESULTS

In children aged 0-2 years old, the MIC50 values of penicillins decreased after 2010 (PCG: 1 μg/ml (2010) to 0.06 μg/ml (2012); ABPC: 1 μg/ml (2010) to 0.25 μg/ml (2012)). The prevalence of penicillin-resistant S. pneumoniae (PRSP) decreased from 35.2% (2010) to 14.6% (2012) in rhinorrhea specimens and from 43.4% (2010) to 14.3% (2012) in otorrhea specimens. Susceptibility to cephems (ceftriaxone and cefditoren) and carbapenems (panipenem) also showed improvement after 2010. For macrolides (clarithromycin) and lincosamides (clindamycin), MIC50 values increased in all age groups during the study period, and a high level of resistance was seen until 2012. There were no marked changes of susceptibility to fluoroquinolones (LVFX) during the study period.

CONCLUSION

Improvement of susceptibility of S. pneumoniae to β-lactams occurred after 2010 in Miyagi Prefecture, Japan.

Risk factors for carriage of AOM pathogens during the first 3 years of life in children with early onset of acute otitis media

CONCLUSION

Risk factors associated with increased carriage rates are the same in children with recurrent acute otitis media (rAOM) as in healthy children. These are also known to be risk factors for the development of AOM itself.

OBJECTIVES

The aim of this study was to describe risk factors for nasopharyngeal carriage in a cohort of young children at high risk of developing rAOM.

METHODS

Children with an onset of AOM before 6 months of age, indicating an 80% risk of developing rAOM, were enrolled in a vaccination trial on heptavalent PCV. These children were monitored for 3 years during healthy and AOM periods with nasopharyngeal cultures, physical examinations, and questionnaires.

RESULTS

A total of 109 children were included at a mean age of 5 months; 105 were followed for 3 years, 89 (82%) of whom developed rAOM. Risk factors associated with increased carriage of all major AOM pathogens were age <2 years, concurrent AOM, and fulfilment of rAOM criteria. Having siblings in day care was associated with increased carriage of Streptococcus pneumoniae and Haemophilus influenzae, recent antibiotic treatment was associated with H. influenzae and Moraxella catarrhalis carriage, and winter season was associated with M. catarrhalis carriage alone.

Lactobacillus rhamnosus GG supplementation for preventing respiratory infections in children: a meta-analysis of randomized, placebo-controlled trials

OBJECTIVE

To systematically review the effectiveness of administering Lactobacillus rhamnosus GG (LGG) for preventing respiratory infections in children.

DESIGN

Systematic Review and Meta-analysis.

DATA SOURCES

Electronic databases and trial registries.

RESULTS

Four RCTs involving 1805 participants met the inclusion criteria. Compared with placebo, LGG administration was associated with a reduced incidence of acute otitis media (four RCTs, n=1805, RR 0.76, 95% CI 0.64-0.91, fixed effects model, NNT 17, 95% CI 11-46), a reduced risk of upper respiratory infections (one RCT, n=281, RR 0.62, 95% CI 0.50-0.78, NNT 4, 95% CI 3-8) and antibiotic treatments (four RCTs, n=1805, RR 0.80, 95% CI 0.71-0.91, fixed effects model). There was no significant difference between the LGG and the control groups in the risk of overall respiratory infections and the incidence of lower respiratory infections. However, subgroup analysis of two studies on children older than 1 year showed significant reduction in the risk of overall respiratory infections (two RCTs, n=794, RR 0.73, 95% CI 0.57-0.92, random effects model, NNT 8, 95% CI 5-14). Adverse effects were similar in both groups. No serious adverse events were reported.

CONCLUSION

The administration of Lactobacillus rhamnosus GG compared with placebo has the potential to reduce the incidence of acute otitis media, the upper respiratory infections and antibiotic use in children.

Otitis media and ear tubes

The placement of myringotomy tubes remains an effective treatment of recurrent acute otitis media and chronic otitis media with effusion. Infants and young children are prone to these entities because of their immature anatomy and immunology. Several host, pathogenic, and environmental factors contribute to the development of these conditions. The identification and modification of some these factors can preclude the need for intervention. The procedure continues to be one of the most common outpatient pediatric procedures. Close vigilance and identification of potential complications is of utmost importance in the ongoing management of the child with middle ear disease.

Tympanostomy with and without adenoidectomy for the prevention of recurrences of acute otitis media: a randomized controlled trial

BACKGROUND

The prevention of otitis media, particularly among infants, remains a controversial issue. We evaluated the efficacy of insertion of tympanostomy tubes with and without adenoidectomy for preventing recurrent acute otitis media (AOM) in young children.

METHODS

We randomly assigned 300 children aged 10 months to 2 years who had recurrent AOM to groups receiving tympanostomy tubes (Tymp) (n = 100), tympanostomy tubes with adenoidectomy (TympAde) (n = 100) or neither (Contr) (n = 100). All the children were followed up for 12 months.

RESULTS

The primary outcome was intervention failure (2 AOM episodes in 2 months, 3 in 6 months or persistent effusion lasting for 2 months). Intervention failed in 21% of cases (21/100) in the Tymp group, 16% (16/100) in the TympAde group and 34% (34/100) in the Contr group. The absolute differences were -13% [95% confidence interval (CI) -25% to -1%, P = 0.04] between the Tymp and Contr groups and -18% (95% CI -30 to -6%, P =0.004) between the TympAde and Contr groups.

CONCLUSIONS

Insertion of tympanostomy tubes alone or with adenoidectomy was effective in preventing recurrent AOM episodes in children younger than 2 years of age.

Genetic background and the risk of otitis media

OBJECTIVE

Otitis media is a multifactorial disease where genetic background may have an important role. For genome-wide association studies, it is important to understand the degree of heritability. The objective of this study was to estimate the heritability of recurrent acute otitis media and chronic otitis media with effusion.

METHODS

Children operated because of recurrent or chronic otitis media at the Helsinki University Central Hospital, Finland, as well as their families were recruited during 2008-2009. A cohort of 2436 subjects was enrolled consisting of 1279 children and their parents. The study subjects answered a questionnaire concerning their otitis media history and treatment, as well as tobacco exposure, allergy and asthma history. Heritability estimates were calculated for recurrent acute, chronic and any episodes of otitis media using software especially designed for estimating heritability in family cohorts.

RESULTS

Altogether 901 subjects suffered from recurrent otitis media and 559 from chronic otitis media with effusion. The heritability estimates in our cohort were 38.5% for recurrent (P=7.3 × 10(-9)), 22.1% for chronic (P=4.6 × 10(-3)) and 47.8% for any otitis media (P=1.5 × 10(-11)).

CONCLUSIONS

Our results demonstrate a moderately strong and statistically significant genetic component for both recurrent acute otitis media and chronic otitis media with effusion. These results highlight the importance of unraveling the genetic factors for otitis media that are still poorly known.

Viral interference induced by live attenuated virus vaccine (OPV) can prevent otitis media

Background

The goal of this study was to evaluate whether a live attenuated poliovirus vaccine (OPV) has clinically relevant interfering effect with non-polio infections causing otitis media in young children.

Methods

Open trial in which the intervention group (64 children) received OPV at the age of 2, 3, 6 and 12 months. The control group (250 children) received IPV (inactivated polio vaccine) at the age of 6 and 12 months. Clinical symptoms were recorded by a questionnaire at the age of 3, 6, 12, 18 and 24 months.

Results

Otitis media episodes were less frequent in the OPV than in the control group. A significant difference was seen at the age of 6–18 months (IRR = 0.76 [95% CI 0.59–0.94], P = 0.011) and was particularly clear among children, who attended daycare (IRR 0.37 [95% CI 0.19–0.71], P = 0.003).

Conclusions

OPV provides some protection against otitis media. This effect may be mediated by viral interference with non-polio viruses.

Epidemiology of acute otitis media in children of Latin America and the Caribbean: a systematic review and meta-analysis

BACKGROUND

Acute otitis media (AOM) is one of the most common childhood diseases requiring antimicrobial prescription in pre-school children. This systematic review aimed to estimate the AOM incidence, bacterial etiology and use of resources in children aged <6 years in Latin America and the Caribbean (LA&C).

METHODS

A systematic search using keywords otitis or middle ear and inflammation was performed for articles published during 1988-2008 in MEDLINE, Cochrane Library, EMBASE, LILACS, generic and academic internet searches, Ministries of Health, PAHO, regional proceedings, reference lists and consulting experts. Pairs of reviewers independently selected articles and assessed their methodological quality with a checklist of essential items from the STROBE statement according to pre-specified criteria. Studies involving immune-competent children with AOM were considered. Arcsine transformations were used for proportion meta-analyses.

RESULTS

Annual AOM incidence in four studies in children aged <5 years ranged from 1,171-36,000 episodes/100,000 children. Meta-analysis on etiology and pneumococcal serotypes included 18 studies and 125, 519 children with AOM from six LA&C countries. Meta-analysis per serotype showed that Streptococcus pneumoniae (32.4%; 95%CI=27.1-38.0%) and Haemophilus influenzae (26%; 95%CI=19.5-33.1%), including non-typeable H. influenzae (18.3%; 95%CI=9.5-33.1%) were the most prevalent. The most commonly observed pneumococcal serotype was 19F (24.0%; 95% CI 17.0-32.0%). Data on use of health resources were scarce.

CONCLUSIONS

Streptococcus pneumoniae and H. influenzae were the most frequent AOM bacterial pathogens, consistent with the international literature from other regions. Future studies on AOM incidence and health resources usage will help better define the impact of this disease.

Novel method for non-invasive induction of a middle-ear biofilm in the rat

Otitis media and other middle ear diseases are extremely common among all children worldwide. Chronic otitis media is strongly associated with the presence of a bacterial middle ear biofilm, which if left untreated, may result in hearing loss or delays in the development of speech and language. Many animal models and methods used to study the progression of various middle ear diseases exist. However, there are no reported approaches to biofilm induction in which this infectious process can be investigated. Here we report a unique, non-invasive method of biofilm induction in the rat through repeated bacterial inoculations and pressure changes within the ear.

Incidence and recurrence of acute otitis media in Taiwan's pediatric population

OBJECTIVE

To report the incidence and recurrence of acute otitis media (AOM) in Taiwan's pediatric population.

METHODS

Information from children (aged <= 12 years) with a diagnosis of AOM was retrieved from the 2006 National Healthcare Insurance claims database. We calculated the cumulative incidence rate and the incidence density rate of recurrent AOM within one year after the initial diagnosis in 2006. We used a multivariate logistic regression model to assess the predictors for recurrence of AOM.

RESULTS

The annual incidence rate of AOM was estimated to be 64.5 cases per 1,000 children. The overall one-year cumulative incidence rate of recurrence was 33.1%, and the incidence density rate was 33.5 cases per 100 person-years, with the highest figure (41.2 cases per 100 person-years) noted for children aged 0-2 years. Recurrence was significantly associated with age, gender, place of treatment, and physician specialty.

CONCLUSION

AOM remains a major threat to children's health in Taiwan. Male children and very young children require more aggressive preventive strategies to reduce the risk of recurrence.

Bifidobacterium animalis subsp. lactis BB-12 in reducing the risk of infections in infancy

The impact of controlled administration of Bifidobacterium animalis subsp. lactis BB-12 (BB-12) on the risk of acute infectious diseases was studied in healthy newborn infants. In this double-blind, placebo-controlled study, 109 newborn 1-month-old infants were assigned randomly to a probiotic group receiving a BB-12-containing tablet (n 55) or to a control group receiving a control tablet (n 54). Test tablets were administered to the infants twice a day (daily dose of BB-12 10 billion colony-forming units) from the age of 1-2 months to 8 months with a novel slow-release pacifier or a spoon. Breastfeeding habits, pacifier use, dietary habits, medications and all signs and symptoms of acute infections were registered. At the age of 8 months, faecal samples were collected for BB-12 determination (quantitative PCR method). The baseline characteristics of the two groups were similar, as was the duration of exclusive breastfeeding. BB-12 was recovered (detection limit log 5) in the faeces of 62% of the infants receiving the BB-12 tablet. The daily duration of pacifier sucking was not associated with the occurrence of acute otitis media. No significant differences between the groups were observed in reported gastrointestinal symptoms, otitis media or use of antibiotics. However, the infants receiving BB-12 were reported to have experienced fewer respiratory infections (65 v. 94%; risk ratio 0·69; 95% CI 0·53, 0·89; P = 0·014) than the control infants. Controlled administration of BB-12 in early childhood may reduce respiratory infections.

Birth characteristics and acute otitis media in early life

OBJECTIVE

To assess whether preterm birth and low birth weight were associated with single and recurrent episodes of acute otitis media (AOM) the first 18 months of life.

METHODS

The study population consisted of 33,192 children in the Norwegian Mother and Child Cohort, conducted at the Norwegian Institute of Public Health. The majority of all pregnant women in Norway were invited to participate and the response rate was 44%. Participating women received questionnaires during pregnancy and when the child was 6 and 18 months. Main outcome measures were maternal reports of AOM at ages 6, 11 and 18 months. Information on birth weight and gestational age was obtained from the Medical Birth Registry of Norway. Regression analyses were performed controlling for a variety of potential confounders.

RESULTS

Preterm birth was slightly associated with both single and recurrent episodes of AOM the first 18 months of age. The adjusted relative risk (aRR) for having any episode of AOM was 1.37, 95%CI (1.12-1.68) if born before week 33, and the aRR for having recurrent AOM was 1.34, 95%CI (1.01-1.77) if born in weeks 33-36 (reference group: >or=37 weeks). A corresponding tendency was not found for low birth weight.

CONCLUSIONS

The finding indicates a modest increased risk of having AOM in children born preterm, and preterm birth seems to be more important than low birth weight in determining risk of having AOM in early life.

The role of new vaccines in the prevention of otitis media

Otitis media is one of the most common infectious diseases of infancy; a reduction in its incidence would have a significant economic and social impact. Vaccines may play a role in the prevention of otitis media. This report discusses vaccines against pneumococci and influenza viruses. We reviewed the literature for results of studies examining the role of these vaccines in the prevention of otitis media. The 23-valent polysaccharide anti-pneumococcal vaccine did not modify the incidence of otitis media in children aged 2 years less, the age group with the highest incidence of otitis. The heptavalent anti-pneumococcal vaccine did not significantly reduce the incidence of otitis media overall. This vaccine did, however, reduce the number of episodes of otitis media with effusion and the number of recurrences; it also altered the profile of causative microorganisms by increasing otitis caused by different microorganisms. We found the inactivated anti-influenza virus vaccine to be effective in reducing otitis media during peak incidence periods of influenza. As these new vaccines are currently available in Brazil, otolaryngologists must be aware of their potential role and impact in the reduction of otitis media, to counsel patients appropriately.

Specific probiotics in reducing the risk of acute infections in infancy--a randomised, double-blind, placebo-controlled study

A randomised, double-blind, placebo-controlled study was conducted to determine whether probiotics might be effective in reducing the risk of infections in infancy. Infants requiring formula before the age of 2 months were recruited from community well-baby clinics. Infant formula supplemented with the probiotics Lactobacillus rhamnosus GG and Bifidobacterium lactis Bb-12 or placebo was administered daily until the age of 12 months. Incidence of early infections (before the age of 7 months) and incidence of recurrent (three or more) infections during the first year of life were recorded as the main outcome measures of the study. During the first 7 months of life, seven out of thirty-two (22 %) infants receiving probiotics and twenty out of forty (50 %) infants receiving placebo experienced acute otitis media (risk ratio (RR) 0.44 (95 % CI 0.21, 0.90); P = 0.014) and antibiotics were prescribed for ten out of thirty-two (31 %) infants receiving probiotics and twenty-four out of forty (60 %) infants receiving placebo (RR 0.52 (95 % CI 0.29, 0.92); P = 0.015). During the first year of life, nine out of thirty-two (28 %) infants receiving probiotics and twenty-two out of forty (55 %) infants receiving placebo encountered recurrent respiratory infections (RR 0.51 (95 % CI 0.27, 0.95); P = 0.022). These data suggest that probiotics may offer a safe means of reducing the risk of early acute otitis media and antibiotic use and the risk of recurrent respiratory infections during the first year of life. Further clinical trials are warranted.

Early acute otitis media: predictor for AOM and respiratory infections in schoolchildren?

OBJECTIVE

It has been reported that acute otitis media (AOM) and respiratory infectious morbidity still are common in schoolchildren. However, the significance of early initiation of AOM on later respiratory infections is not known. The aim of the study was to assess whether early initiation of AOM is a predictor for AOM and other respiratory infections in schoolchildren, and if environmental exposures and host factors in early life predict later AOM.

METHODS

A population-based, prospective study of 3754 children born in Oslo in 1992/93, of which 2549 children were followed from birth to 10 years. Main outcome measures were questionnaire-based information on AOM and other respiratory infections at ages 6 months, 1 year and 10 years.

RESULTS

Of the 190 (5.3%) children with one or more episodes of AOM before 6 months, 97 (51.1%) remained susceptible the next 6 months. The total number of children with one or more episodes of AOM from 6 to 12 months was 812 (25.1%). Of the 336 (13.2%) with AOM at 10, 95 (28.3%) also had AOM the first year of life. One or more episodes of tonsillopharyngitis or lower respiratory infections were experienced in 624 (24.4%) of the children at 10 years. There was a predominance of boys with AOM the first year of life, while girls were more prone to AOM at age 10. AOM the first year of life was not strongly associated with AOM at age 10 with crude and adjusted odds ratios 1.3 (95% CI 1.0-1.6) and 1.2 (95% CI 0.9-1.5), respectively. A corresponding tendency was found for other respiratory infections (tonsillopharyngitis or lower respiratory infections) at age 10. Tobacco smoke exposure at birth, early life atopic eczema and otitis media surgery increased the risk of AOM at age 10.

CONCLUSIONS

We found no strong association between early AOM and AOM and other respiratory infections in schoolchildren. Parental smoking at birth, early life atopic eczema and female gender were only weakly associated with AOM in 10-year olds while otitis media surgery was strongly associated with AOM in schoolchildren.

Mathematical model comparisons of potential non-typeable Haemophilus influenzae vaccine effects

Vaccines to prevent acute otitis media (AOM) caused by non-typeable Haemophilus influenzae (NTHi) are under development. Because NTHi is highly variable and colonization rates are high, special vaccine characteristics and trial designs might be needed. We examined in mathematical models the equilibrium NTHi-caused AOM rate given hypothetical vaccines that generated immunity identical to corresponding maximal naturally acquired immunity. Vaccines were examined with single effects and combinations of immunity affecting (1) AOM rates given colonization (pathogenicity), (2) susceptibility to colonization, and (3) contagiousness given colonization. Percent reductions in AOM across all preschool children were (1) 34%, (2) 31%, (3) 9%, (1 and 2) 57%, (2 and 3) 50%, and (1, 2, and 3) 75%. Effects on children in daycare vs. not in daycare were (1) 18 vs. 48%, (2) -1 vs. 57%, (3) 13 vs. 5%, (1 and 2) 30 vs. 79%, (2 and 3) 33 vs. 60%, and (1, 2, and 3) 64 vs. 85%. Pure pathogenicity effects (1 alone) will need to be supplemented by transmission effects. The effects of susceptibility (2 alone) are diminished or negative because children protected against colonization have lower levels of immunity to (1) and (3) than unvaccinated children. For trials to predict population effects, both colonization and AOM outcomes must be studied and all three effects must be evaluated. This need arises because, unlike H. influenzae type B, high NTHi exposure diminishes cumulative vaccine effects and high colonization rates generate rapid accumulation of natural immunity that alters the indirect effects of vaccine immunity on transmission differently by age and daycare status.

Spectral gradient acoustic reflectometry in the diagnosis of middle-ear fluid in children

Diagnosis of otitis media is based on detection of middle-ear fluid (MEF) and is both important and difficult to achieve. Also non-infectious MEF is important to detect, since it can compromise hearing. In this prospective, blinded study, spectral gradient acoustic reflectometry (SG-AR) was evaluated as an indicator of MEF among children. Sensitivity, specificity and positive and negative predictive values of SG-AR in detecting MEF were calculated in children undergoing ambulatory surgery for recurrent or secretory otitis media using otomicroscopic myringotomy as the reference method of confirming middle-ear status. Final study material consisted of 376 ears. Pattern recognition of SG-AR curves reached the best combination of sensitivity and specificity (69 and 97%, respectively), and the best combination of positive (PPV) and negative (NPV) predictive values (93 and 83%, respectively), in detection of MEF. With a spectral gradient value of <80 degrees , the sensitivity was 75% and specificity 71%. With <50 degrees , PPV was 78%, and with >or=100 degrees , NPV was 86%. The diagnostic power of SG-AR was comparable to that reported with pneumatic otoscopy and tympanometry. It was equally effective in detecting both MEF cases and healthy ears. Pattern recognition seems to improve its performance. We recommend the use of pattern recognition of SG-AR as a screening method for MEF among children.

Detection of middle-ear fluid in children with spectral gradient acoustic reflectometry: a screening tool for nurses?

OBJECTIVE

To evaluate the validity of spectral gradient acoustic reflectometry (SG-AR) in the hands of nurses in screening children for middle-ear fluid (MEF).

DESIGN

Prospective, blinded study.

SETTING

A satellite study within the Finnish Otitis Media Vaccine Trial in primary care in 1995-99.

PATIENTS

Some 739 ear examinations among a cohort of 271 children under the age of 2 years during different healthcare contacts (acute sick visits, check-up visits after otitis media, and scheduled healthy control visits at 24 months of age).

MAIN OUTCOME MEASURES

Specificity, sensitivity and positive and negative predictive values of SG-AR performed by nurses in detecting MEF using pneumatic otoscopy by trained physicians as a reference.

RESULTS

SG-AR was successful in 585 (79%) ears. None of the cut-off points assessed resulted in both excellent sensitivity and specificity. Nevertheless, at the sick visits, positive predictive values at 50 and 60 degrees were as high as 94% and 89%, respectively. However, negative predictive value for the cut-off point of 100 degrees was considerably lower, at 75%. At the non-acute visits, negative predictive values were excellent.

CONCLUSION

SG-AR is a useful device for nurses in screening MEF among children. It detects ears with both very high and very low probability of MEF and is especially effective in detecting MEF during sick visits and in ruling out MEF among non-acute patients. We recommend the use of the SG-AR cut-off point of 60 degrees as a sign of MEF when screening sick children, and the cut-off point of 100 degrees as a sign of a healthy ear among non-symptomatic patients.

[Recurrent respiratory tract infections: how should we investigate and treat?]

Recurrent respiratory tract infections are a common reason for visits to primary care practitioners or hospital physicians. They are placed at the junction of several medical specialities: paediatrics, ENT, pneumology, allergology, immunology, infectiology. The great diversity of the laboratory tests requested and on the other hand the proposed treatments, are the consequences of the diversity of the patients encountered and the paucity of the evidence based-medicine studies in this setting. The dilemma is how to identify the child for which recurrent respiratory tract infections are the witness of underlying condition, without performing repeated medical examinations, laboratory tests and treatments for normal children for which immunologic development occurs normally. The essential tools are the history analysis, physical examination and few laboratory tests. The other questions are how to include, for these patients, influenza and pneumococcal vaccines in the immunization program and how to assess the benefit/risk ratio and the cost of surgical treatments. This paper presents the thought of an expert group trying to define the situations where biological tests or treatments are useful.

[Antibiotic therapy in otorhinolaryngology]

First, the general principles for an antibiotic therapy are stated. The indications have to be well thought through. Frequent viral ENT infections, as well as numerous bacterial infections, should not be treated with antibiotics. Due to the current antibiotic sensitivity of the main ENT pathogens, the antibiotic choice for an empiric therapy is emphasized, and also the advantage of an optimized therapy based on the results of Gram stain (supercalculated empiric therapy) and an antibiogram (specific therapy). Pus characteristics may be the first step in diagnosing the pathogens. The degree of severity of an infection determines the oral or parenteral route of administration. As a rule, antibiotic therapy has to be checked after 2-3 days. The grouping of the different ENT infections with a similar spectrum of pathogens gives a better view of the therapeutic principles and reduces repetitions. The current recommendations for antibiotic treatment of numerous ENT infections with different degrees of severity are indicated. After the presentation of the appropriate antibiotics with their current spectrum of efficacy, the initial therapy, treatment in case of penicillin allergy, and of severe cases and complications or therapeutic failure are mentioned.

Adenoidectomy versus chemoprophylaxis and placebo for recurrent acute otitis media in children aged under 2 years: randomised controlled trial

OBJECTIVE

To evaluate the efficacy of adenoidectomy compared with long term chemoprophylaxis and placebo in the prevention of recurrent acute otitis media in children aged between 10 months and 2 years.

DESIGN

Randomised, double blind, controlled trial.

SETTING

Oulu University Hospital, a tertiary centre in Finland.

PARTICIPANTS

180 children aged 10 months to 2 years with recurrent acute otitis media.

INTERVENTION

Adenoidectomy, sulfafurazole (sulphisoxazole) 50 mg/kg body weight, given once a day for six months or placebo. Follow up lasted for two years, during which time all symptoms and episodes of acute otitis media were recorded.

MAIN OUTCOME MEASURES

Intervention failure (two episodes in two months or three in six months or persistent effusion) during follow up, number of episodes of acute otitis media, number of visits to a doctor because of any infection, and antibiotic prescriptions Number of prescriptions, and days with symptoms of respiratory infection.

RESULTS

Compared with placebo, interventions failed during both the first six months and the rest of the follow up period of 24 months similarly in the adenoidectomy and chemoprophylaxis groups (at six months the differences in risk were 10% (95% confidence interval -9% to 29%) and 18% (-2% to 38%), respectively). No significant differences were observed between the groups in the numbers of episodes of acute otitis media, visits to a doctor, antibiotic prescriptions, and days with symptoms of respiratory infection.

CONCLUSIONS

Adenoidectomy, as the first surgical treatment of children aged 10 to 24 months with recurrent acute otitis media, is not effective in preventing further episodes. It cannot be recommended as the primary method of prophylaxis.

International perspectives on management of acute otitis media: a qualitative review

BACKGROUND

Current opinions regarding the management of acute otitis media (AOM) in children vary across Western countries. With antibiotic resistance rising and more evidence regarding the limited clinical efficacy of antibiotics becoming available, interest in managing AOM other than with antibiotics is renewed.

OBJECTIVES

To compare international rates of antibiotic prescription and surgery for AOM. To provide current evidence regarding the efficacy of various treatment options for AOM and their potential complications.

METHODS

Qualitative (narrative) review.

RESULTS

The percentage of patients given antibiotics for AOM varies from 31% in The Netherlands to more than 90% in most other Western countries. The 1998 prevalence of penicillin-resistant S. pneumoniae strains, on the other hand, ranges from 3% in The Netherlands to 53% in France. The surgical rate for tympanostomy tubes varies from 2 per 1000 children per year in the United Kingdom to 20 per 1000 in The Netherlands. The benefit of both antibiotic and surgical therapy in AOM appears to be limited, with numbers needed to treat ranging from 8 to 25 for antibiotic therapy, depending on the definition of outcome.

CONCLUSIONS

International rates of antibiotic prescription and surgery for AOM vary strongly, which can be explained largely by the lack of uniform evidence-based guidelines. International debates with the aim of overcoming cultural differences regarding the management of otitis media, and of reaching agreement on guidelines on the basis of current evidence are necessary.

Epidemiología e impacto de la otitis media aguda en la Comunidad Valenciana

OBJECTIVE

To assess the burden (incidence, treatment and complications) of acute otitis media (AOM) and otitis media with effusion (OME) in children younger than 5 years of age from Valencia, Spain.

SUBJECT AND METHODS

We performed a retrospective cohort study of 1,399 children followed-up for the first 5 years of life. Seventeen pediatricians reviewed the medical records of their patients born in 1995 and 1996 and followed-up from birth until the age of 5 years. For each child, the number of otitis episodes, treatment, complications, and surgical interventions was obtained.

RESULTS

There were 2,961 episodes of AOM in the first 5 years of life (2.23 cases/child). Four hundred seventy-six cases (16.1 %) occurred before 1 year of age and 1,346 between the first and second year of life (45.5 %). By the third year of life, 59.8 % had had at least one episode. In most children (80.9 %), diagnosis was made in primary care and required a median of 1.81 visits/episode for follow-up. A total of 94.5 % were treated with antibiotics (amoxicillin-clavulanate 38.8 %, cefuroxime 14.3 %, clarithromycin 8.2 % and amoxicillin 5.9 %) and 8.5 % required a change of antibiotic therapy. Two hundred seventeen children (15.2 %) had at least one episode of OME. Twenty-six patients (1.8 %, 95 % CI: 1.2-2.7 %) required insertion of ventilation tubes. Twenty-four patients (1.7 %) had secondary hypoacusis. There was one case of meningitis and two cases of chronic otorrhea. No cases of mastoiditis were recorded.

CONCLUSIONS

The incidence of AOM in Valencia is 40,014 episodes/100,000 children younger than 5 years/year (95 % CI: 39,700-40,300). It represents a significant burden due to the large number of visits, antibiotic use, associated surgical procedures and need for auditory rehabilitation.

Otitis media aguda en un centro de salud

BACKGROUND

Acute otitis media (AOM) is a serious public health problem and is considered one of the most common diagnoses in pediatric outpatient units. The aim of this study was to asses the incidence and distribution of AOM by age, sex, number of visits per episode, and the most frequent symptoms and signs in four pediatric primary care units.

PATIENTS AND METHODS

A 12-month (1 September 2000 to 31 August 2001), prospective study was carried out in a primary care center on the outskirts of Madrid.

RESULTS

During the study period there were 1,098 consultations for AOM in 521 patients. The overall incidence per 100,000 children aged less than 14 years was 12,080 cases (95 % CI: 11,120-13,090). The highest incidence per 100,000 children was in children aged 12-23 months with 38,780 cases (95 % CI: 33,340-44,430). A total of 34.5 % of the children diagnosed with AOM were aged less than 2 years. Ninety-six percent of the children received antibiotics. Most (81.4 %) of the children were completely cured while symptoms persisted in 15.4 %. A minority of the children (3.5 %) were referred to the otolaryngology department.

Is it possible to diagnose acute otitis media accurately in primary health care?

BACKGROUND

Acute otitis media causes human suffering and enormous costs to society. Symptoms of acute otitis media overlap those of the common cold, and diagnostic methods confirming the diagnosis are used only occasionally. Uncertainty in diagnostics may lead either to overdiagnosis and unnecessary treatment or to underdiagnosis and an increase in complications.

OBJECTIVE

Our aim was to evaluate the inter-rater agreement in diagnosis of acute otitis media for children in primary health care.

METHODS

The GP on duty and the otorhinolaryngology resident at a primary health care clinic examined the same 50 children with caregiver-suspected acute otitis media. The otorhinolaryngologist photographed the tympanic membranes. Afterwards, two experienced clinicians evaluated the photographs with and without tympanograms. Diagnostic rates and diagnostic methods between clinicians were compared.

RESULTS

The otorhinolaryngologist diagnosed acute otitis media in 44% and the GP in 64%. The GP based the diagnoses on symptoms and on the colour of the tympanic membrane, whereas the otorhinolaryngologist paid more attention to the movement and position of the tympanic membrane.

CONCLUSION

The use of a pneumatic otoscope and tympanometry reduces the number of acute otitis media diagnoses by >30%, suggesting that acute otitis media may be misdiagnosed often. Between clinicians, there was a substantial discrepancy in diagnoses of acute otitis media.

Nasopharyngeal carriage of anaerobes during health and acute otitis media by two years of age

The nasopharyngeal acquisition of anaerobic bacteria was longitudinally examined among a homogeneous group of Caucasian infants by 2 years of age. Nasopharyngeal swab (NP) samples were collected at scheduled healthy visits at 2, 6, 12, 18, and 24 months of age, and nasopharyngeal aspirates (NPA) during every visit for acute otitis media (AOM). The infants were divided into 4 groups according to the number (0, 1, 2-3, and > 3) of AOM episodes experienced by 2 years of age. At 2 years, the cumulative carriage rates of anaerobic species in these infant groups were 29%, 62%, 89%, and 89%, respectively. Anaerobic species were found in 15/220 (6.8%) of the NP samples and in 34/71 (47.9%) of the NPA samples. Our present results indicate that anaerobic species do not belong to the indigenous nasopharyngeal microflora but only transiently colonize the nasopharynx during AOM.

Antibiotic treatment of acute otorrhea through tympanostomy tube: randomized double-blind placebo-controlled study with daily follow-up

OBJECTIVE

The role of routine antimicrobial treatment of acute middle-ear infections is under debate, because the efficacy of antimicrobials in the resolution of middle-ear fluid has not been unambiguously proven. Acute tube otorrhea is regarded as evidence of acute otitis media, and for methodologic reasons it was chosen to provide objectivity for diagnostics and outcome assessment. The objective of this study was to assess whether amoxicillin-clavulanate accelerates the resolution of acute tube otorrhea.

DESIGN AND SETTING

Randomized, double-blind, placebo-controlled study in outpatient setting.

PATIENTS

Volunteer sample of basically healthy 6- to 72-month-old children with a tympanostomy tube. Eligibility required having acute tube otorrhea of <48 hours' of duration and no prior treatment within the last 2 weeks. The mean age of the participants was 25 months; they had a history of 3 episodes of acute otitis media (median), and 99% had manifestations of a concomitant respiratory infection. Of 79 randomized patients, 7 were withdrawn because of adverse events; 66 patients completed the study.

INTERVENTIONS

Amoxicillin-clavulanate (N = 34; 45 mg/kg/d) or matching placebo (N = 32) for 7 days and daily suction of middle-ear fluid through tympanostomy tube.

MAIN OUTCOME MEASURES

Duration of acute tube otorrhea and duration of bacterial growth in middle-ear fluid.

RESULTS

The median duration of tube otorrhea was significantly shorter in amoxicillin-clavulanate than in the placebo group (3 vs 8 days). At the end of the 7-day medication period, tube otorrhea was resolved in 28 of 34 children receiving amoxicillin-clavulanate compared with 13 of 32 children on placebo (treatment-control difference 41%; 95% confidence interval, 20%-63%; number needed to treat, 2.4). The median duration of bacterial growth in middle-ear fluid was shorter in amoxicillin-clavulanate than in the placebo group (1 vs 8 days).

CONCLUSIONS

Oral antibiotic treatment significantly accelerates the resolution of acute tube otorrhea by reducing bacterial growth in middle-ear fluid.

Importance of respiratory viruses in acute otitis media

Acute otitis media is usually considered a simple bacterial infection that is treated with antibiotics. However, ample evidence derived from studies ranging from animal experiments to extensive clinical trials supports a crucial role for respiratory viruses in the etiology and pathogenesis of acute otitis media. Viral infection of the upper respiratory mucosa initiates the whole cascade of events that finally leads to the development of acute otitis media as a complication. The pathogenesis of acute otitis media involves a complex interplay between viruses, bacteria, and the host's inflammatory response. In a substantial number of children, viruses can be found in the middle-ear fluid either alone or together with bacteria, and recent studies indicate that at least some viruses actively invade the middle ear. Viruses appear to enhance the inflammatory process in the middle ear, and they may significantly impair the resolution of otitis media. Prevention of the predisposing viral infection by vaccination against the major viruses would probably be the most effective way to prevent acute otitis media. Alternatively, early treatment of the viral infection with specific antiviral agents would also be effective in reducing the occurrence of acute otitis media.

Effects of large dosages of amoxicillin/clavulanate or azithromycin on nasopharyngeal carriage of Streptococcus pneumoniae, Haemophilus influenzae, nonpneumococcal alpha-hemolytic streptococci, and Staphylococcus aureus in children with acute otitis media

Prior use of antibiotics is associated with carriage of resistant bacteria. Colonization by Streptococcus pneumoniae, Haemophilus influenzae, nonpneumococcal alpha-hemolytic streptococci (NPAHS), and Staphylococcus aureus was evaluated in children receiving antibiotic therapy for acute otitis media and in untreated, healthy control subjects. Children were randomly assigned to receive either amoxicillin/clavulanate (90 mg/kg per day) or azithromycin. Swabs were obtained before initiating therapy and again 2 weeks and 2 months after initiating therapy. We also obtained swabs from control subjects at the time of enrollment and 2 weeks and 2 months after enrollment. The decrease in the rate of carriage of S. pneumoniae and H. influenzae at 2 weeks was significant only in the amoxicillin/clavulanate group (P<.001 and P=.005, respectively). The rate of nasopharyngeal colonization with NPAHS among treated patients increased from 23% to 39% at 2 months (P=.01). This increase was similar for both treatment groups. These results suggest that the competitive balance between organisms is altered by antibiotic therapy.

Histopathologic differences due to bacterial species in acute otitis media

OBJECTIVE

To compare selected features of histopathology in acute otitis media caused by various bacteria and examine potential differences due to bacterial species, as well as possible correlation to experimental and human clinical findings.

METHODS

Rat models of acute otitis media caused by Streptococcus pneumoniae (MC), non-typeable or type b Haemophilus influenzae (NTHI/HIB) or Moraxella catarrhalis (MC) were studied longitudinally up to 6 months after bacterial challenge. Findings related to dynamics of goblet cell density, modeling and remodeling of bone tissue structures and polyp, as well as fibrous adhesion formation and persistence are presented.

RESULTS

Middle ear goblet cell density progressed to peak 2 weeks after bacterial inoculation, thereafter gradually normalizing. However, density and accordingly middle ear secretory capacity was still significantly increased after 6 months in all bacteria, except MC. The HI species induced the highest increase. Initial osteoresorption was followed by massive osteoneogenesis, progressing to a peak after 2-3 months, followed by some degree of normalization, concurrently classic remodeling. Primarily SP, but also the HI species induced more new bone formation than MC. Mucosal polyp and fibrous adhesion formation occurred regardless of bacterial species. Most polyps appeared in the early phases and the HI species induced formation of more polyps and adhesions than the other bacteria.

CONCLUSION

Acute middle ear infection with the Haemophilus species induce the highest increase of mucosal secretory capacity, lasting for at least 6 months after the acute incident. Thus, a subsequent development of secretory otitis media seems more likely following infection with these bacteria. Equivalently, mucosal scarring observed as polyp and fibrous adhesion formation was more severe following Haemophilus infection. S. pneumoniae induced the most marked changes of bone tissue structures, seen as initial osteoresorption and subsequent osteoneogenesis. Overall, infection with M. catarrhalis induced the mildest changes.