Middle ear disease in children. Pathogenesis, diagnosis, and management

Laterality and otorhinolaryngology: a review

BACKGROUND

Laterality of paired organs involves the function of the eyes, ears, hands and feet. Whilst most people have a right-handed preference, about 10 per cent are left-handed. Similarly, the right eye is usually preferred to the left. Medicine is both taught and practised for those with right hand and eye preference, and left-handed medical students and doctors must negotiate the right-handed world.

OBJECTIVE

This brief review looks at society's attitudes, medical training and the practice of otolaryngology in the UK towards laterality and handedness.

METHOD

Literature review.

RESULTS

Studies suggest that left-handers are more versatile and so are more ambidextrous. Conversely, this may result in problems when a right-hander tries to undertake a procedure with the non-dominant hand.

CONCLUSION

Cultures and attitudes are changing towards those who are left-handed. Left-handed surgeons may encounter difficulties in the clinical environment throughout their training.

Acute Otitis Media

A typical case of acute otitis media in a pediatric patient is presented. The pathophysiology of the disorder, as well as its incidence, etiology, complications, and sequelae are discussed. Past treatment methods and current therapeutic recommendations pertaining to antibiotics and other adjuncts are included.

Development and validation of a novel ear simulator to teach pneumatic otoscopy

INTRODUCTION

Otoscopy is an important skill in diagnosing conditions of the middle ear. This study evaluated the ability of a novel ear simulator to teach medical students diagnostic and pneumatic otoscopy. We hypothesized that exposure to this simulator improves the ability of medical students to apply an appropriate pneumatic pressure during insufflation and accurately identify the presence of a middle ear effusion in a simulated setting.

METHODS

An ear simulator was created to teach otoscopic skills to medical students. Third-year medical students attended a workshop on pediatric otoscopy, including a demonstration, videos, and verbal instruction on otoscope use. A cohort of these students then practiced pneumatic otoscopy with the simulator. All students, as well as a group of experts who had not been exposed to the trainer, then diagnosed the presence or absence of middle ear fluid in six simulator ears and pneumatic pressures generated were recorded.

RESULTS

Interaction with the simulator enabled students to insufflate with pressures in the proper range (0.4-20 in H2O) more often, apply an average pressure (12.7 in H2O) in the appropriate range, and diagnose middle ear fluid more accurately (79.2%) than students who were not exposed to the trainer (57.3%). The students exposed to the simulator also performed closer to the level of the experts who diagnosed presence of effusion 100% accurately with an average insufflation pressure of 3.8 in H2O.

DISCUSSION

Medical students trained with the ear simulator applied appropriate pneumatic pressure more consistently and diagnosed the presence of effusion more accurately and more like experts than students not exposed to the simulator. This ear trainer is a valuable tool for teaching pneumatic otoscopy.

Otolaryngologic manifestations of immunodeficiency

Otolaryngologists are frequently consulted to manage infectious and noninfectious complications of immune deficiency. Although defects of host defense and recurrent or severe infections are the most obvious manifestations of immune deficiency, patients are often at increased risk for autoimmune and malignant disease as well. Knowledge of primary and acquired immune deficiencies will facilitate appropriate identification, treatment, and referral of patients with these defects. When immunodeficiency is known or suspected, it is particularly important to have a high index of suspicion for unusual or severe manifestations of infection, to have a low threshold for obtaining imaging to aid in diagnosis, and to treat infections for longer periods of time with higher doses of antibiotic. Surgery may be required for definitive treatment of infections that do not respond to medical therapy and for management of complications of infectious disease

Otitis media following tympanostomy tube placement in children with IgG2 deficiency

Children with IgG2 deficiency commonly develop recurrent acute otitis media. It is believed that these infections are secondary to impaired antibody response rather than eustachian tube dysfunction and are therefore less responsive to treatment with tympanostomy tubes. The authors compared the incidence of acute otitis media in IgG2-deficient patients following tympanostomy tube placement with controls in a retrospective cohort study. The charts of 20 patients (10 with IgG2 deficiency and 10 controls) were reviewed. Episodes of otitis media were recorded for 12 months. IgG2-deficient patients experienced three times as many occurrences of otitis media as did controls. This suggests that otitis media is much more common in these patients following tympanostomy tube placement. We believe that an immunodeficiency workup should be considered in patients with multiple episodes of otitis media following placement of tympanostomy tubes.

Pressure-equalization (PE) tubes in treatment of otitis media: national survey of otolaryngologists

This study was designed to describe those indicators for the insertion of pressure-equalization (PE) tubes given highest priority by board-certified otolaryngologists. An original questionnaire was mailed to 1000 board-certified otolaryngologists practicing in the United States. The respondents rated the relative importance of 22 indicators on a 6-point scale. These indicators were grouped into four categories: Medical History, Physical Examination, Audiologic Evaluation, and Related Indicators. With a return rate of 52.7%, approximately 1 of every 9 board-certified, practicing otolaryngologists in the United States was represented in the study. The five indicators with the highest ratings were: "persistence of fluid for 3 or more months per episode," "presence of speech-language delay," "presence of bilateral conductive hearing loss of 20 dB or more," "total number of episodes of otitis media," and "lack of response to suppressive antibiotic therapy." Additional analyses of the data yielded information regarding characteristics of the responding physicians and the self-generated indicators.

Bacterial findings in middle ear effusion in children

During 1983-87, tympanostomy tubes were inserted in a total of 4952 ears of 2575 children remitted to the ENT Department of our hospital because of chronic or recurrent otitis media problems. The children were included in a prospective study and referred to one of three groups for comparison of findings. Group 1 included all 6- to 12-month-old infants undergoing primary tube treatment; group 2, all children 1 year or older who had their first ventilation tube(s) inserted in connection with adenoidectomy; and group 3, all children in whom tympanostomy had been performed one or more times previously. Middle ear effusion was aspirated from 2392 ears (48%); 67.6% of all ears were negative for bacteria and 22.1% of the ears with effusion grew pathogenic bacteria. S. pneumoniae was the most frequently cultured pathogen among the 6 to 12 month olds in group 1, but in groups 2 and 3 H. influenzae occurred more frequently than S. pneumoniae. Beta-lactamase-producing strains of pathogenic bacteria were formed in only 4% of all ears with effusion: H. influenzae in 1.2% and B. catarrhalis in 2.8%. Compared with figures from the United states, the frequency of beta-lactamase-producing strains is low in the present series. This is probably explained by differences in antimicrobial treatment practices; in Finland and the Scandinavian countries, penicillin V is the primary drug for acute otitis media. In light of present results, it seems well-suited for treatment of otitis media in young children.

Poverty and child health

Poverty is now more heavily concentrated in children than at any other time in U.S. history. Poverty's influence on child health is pervasive and creates a variety of clinical challenges. This discussion reviews the clinical expression of poverty in childhood and assesses our clinical and political capacity to reduce its tragic impact.

The effect of antecedent influenza A virus infection on the adherence of Hemophilus influenzae to chinchilla tracheal epithelium

The adherence of Hemophilus influenzae (type b and nontypable) to ciliated chinchilla respiratory epithelium was investigated using a whole organ perfusion technique. Nontypable H influenzae (NTHi) were shown to be more adherent than type b to these organized and differentiated tracheal organ cultures. Bacteria were found adhering to ciliated cells. Antecedent influenza A virus infection had no effect on adherence of NTHi for at least 48 hours. However, 72 hours after exposure to the virus, infected tissues demonstrated significantly fewer adherent bacteria than did controls. To summarize, influenza A virus infection was not found to augment the initiation of NTHi adherence to ciliated respiratory epithelium in this model.

Factors affecting the occurrence of acute otitis media during the first year of life

A regional birth cohort of 5,356 infants was enrolled into a follow-up study in order to investigate the determinants of the development of infectious diseases in children. The infants were examined at three months, six months and twelve months of age by the physicians at the well-baby clinics. At these occasions the number of episodes of acute otitis media in the infants, the duration of breast-feeding, the number of siblings, the type of day care, parental smoking, the presence of animal pets at home and the number and type of other illnesses than otitis were registered. Two thirds of the infants had no episodes of acute otitis media. The median age for the first episode of acute otitis media was eight months. About 10% of the infants had experienced recurrent otitis media (three episodes or more) during their first year of life. Significant associations were found between the occurrence of acute otitis media and the number of siblings, the type of day care, the sex of the infant, the duration of breast feeding, maternal socioeconomic status and prematurity.

Finnish approach to the treatment of acute otitis media. Report of the Finnish Consensus Conference

The theme of the first consensus conference to be held in Finland was the treatment of acute otitis media. The statements and recommendations accepted by the conference, which was organized according to the National Institutes of Health model, are presented in this report. On the basis of scientific knowledge, clinical experience, and conditions in Finland, the conference delegates concluded that penicillin V, in large doses, is still the drug of first choice in this disease. The importance of surgical drainage of the middle ear was stressed, as was the necessity of careful follow-up of the patient until the condition is completely healed. Decongestants were considered rather useless. In the prevention of recurrent attacks, adenoidectomy but not tonsillectomy was regarded as being of help, tympanostomy of probable benefit, antimicrobial (sulfonamide) prophylaxis worth considering in selected cases, but the effect of pneumococcal vaccination poor. The conference delegates agreed that uncomplicated acute otitis media should, as before, usually be treated by physicians taking care of children at the primary health care level.

Dilemmas in primary care: antibiotic treatment of acute otitis media

Antibiotic treatment of acute otitis media (AOM) accounts for a significant number of all antibiotic prescriptions each year. In the primary care setting, initial antibiotic selection is rarely based on direct evidence, such as cultures of middle ear fluid. Initial antibiotic therapy by the primary care practitioner involves the evaluation and application of information related to prevalence of infecting organisms; in vitro antibiotic spectrum and penetration into middle ear fluid; initial cure rate, relapse and recurrence rates; and antibiotic cost, safety, and convenience. The influence of these factors on the initial antibiotic choice for AOM is reviewed. Several therapeutic dilemmas confronting the prescriber are discussed and a rational approach to initial antibiotic therapy is presented.

Comparison of tympanometry and otomicroscopy during healing of otitis media

One hundred ears in 50 children with acute otitis media during healing were examined with tympanometry and the objective measures were compared with the subjective evaluation of otomicroscopy by four otolaryngologists independently. Tympanometric findings could more often correctly suggest reduced tympanic membrane mobility than did otomicroscopy, but both methods gave an equally good indication of middle ear effusion. However, otomicroscopy was necessary when evaluating the colour and the appearance of the tympanic membrane and revealed middle ear effusion in a few cases with 'normal' tympanometry. As a rule: normal tympanometry (Jerger type A) was closely correlated with a normal tympanic membrane and a normal middle ear without effusion; pathological tympanometry (Jerger type B) was accompanied by middle ear effusion and needed follow-up; ears with tympanometric pressure more negative than -150 mmH2O but more positive than a flat curve needed otomicroscopy to identify middle ear effusion.

Acute otitis media: a common presentation in the emergency department

Acute otitis media is a common pediatric infection that requires appropriate evaluation of the young child to assure that there are no accompanying systemic infections or complications. The examination of the ear must not only assess the appearance of the tympanic membrane, but determine its mobility. Treatment should be initiated with antibiotics and symptomatic relief. Good follow-up must be arranged.

Acute otalgia in children - findings and diagnosis

One hundred and seventy-one children up to 15 years of age and with acute otalgia were examined to find out whether otalgia or any other symptoms were so closely related to acute otitis media (AOM) as to make otoscopic examination unnecessary. AOM was diagnosed in 46%, simplex otitis in 15%, serous otitis media (SOM) in 17%, and normal eardrums in 22%. Children with AOM had fever and spontaneous perforation of the eardrums in 78% and 30% of the cases, respectively. Of the children who had not AOM (54%), the otalgia could in most cases be classified as referred pain due to, for instance, discomfort when swallowing, nasal obstruction or throat pain. Other reasons were general irritability due to fever, teething or moderate hearing loss. The difficulties in diagnosing AOM simply on the basis of symptoms were demonstrated in the investigation. Symptoms such as otalgia, otorrhea, fever or upper respiratory tract infection (URI), possibly except for the combination of otorrhea and fever, can occur without AOM. A correct otoscopic examination and evaluation of the eardrums is necessary in children with otalgia, other symptoms of URI or in doubtful cases of acute illness. Physicians without possibilities to evaluate the eardrums properly should thus refer the patient to an otologist without delay.

The role of respiratory syncytial virus and other viral pathogens in acute otitis media

We utilized recently developed enzyme immunoassay techniques to examine the role of selected viruses in the etiology of acute otitis media. Viral pathogens were found in middle ear fluids obtained from 13 (24%) of 53 children with acute otitis media; respiratory syncytial virus accounted for ten of the 13 viral agents identified. In addition, respiratory syncytial viral antigen was found in nasopharyngeal washings obtained from 15 of the 53 children. Seven of these children had RSV identified as the sole middle ear pathogen, whereas six children had otitis caused by Streptococcus pneumoniae as either the sole middle ear pathogen or in combination with RSV. Similarly, all three children with respiratory infections caused by influenza virus had ear infections caused by bacterial pathogens, either alone or in combination with influenza virus. These findings suggest that, in patients with viral respiratory infection, coexisting acute otitis media may be associated with the recovery of either viruses or bacteria from the middle ear exudates.

Ampicillin-resistant Haemophilus influenzae. 2. Therapeutic considerations

The increasing incidence of Haemophilus influenzae resistant to ampicillin has clinical implications not only for pediatricians but also for family physicians, because the bacterium is recognized more frequently as the etiologic agent for diseases in adults as well as in young children. Ampicillin is no longer the automatic choice for treatment of patients thought to have life-threatening H influenzae disease, and empiric treatment of otitis media must be reexamined. Chloramphenicol, as well as ampicillin, must be considered for the treatment of meningitis and other serious systemic H influenzae infections. Once the infective organism has been isolated and tested for resistance, ampicillin alone may be used if indicated or desired. Alternatives to ampicillin for middle ear infection are trimethoprim-sulfamethoxazole (Bactrim, Septra), erythromycin-sulfonamide (Pediazole), and cefaclor (Ceclor). Isolation and susceptibility tests are seldom done because they necessitate tympanocentesis.

Current clinical methods, indications and interpretation of eustachian tube function tests

Eustachian tube (ET) dysfunction is the most important factor in the pathogenesis of otitis media and related conditions. The importance of the function of the ET in relation to the middle ear-mastoid air cell system is compared to the critical role that laryngeal function has in its relation to the tracheobronchial-pulmonary system. However, because of its obscure location, the ET is not as easily assessed by clinical or laboratory methods as is the larynx, and therefore, its function is not as well understood. Most clinicians do not include ET function testing as part of their evaluation of patients with middle ear (ME) disease. Pneumatic otoscopy, the Toynbee test, tympanometry, the 9-step inflation-deflation tympanometric test, and the patulous tube test can be performed when the tympanic membrane is intact. The modified inflation-deflation test employing the pump-manometer of the electroacoustic impedance bridge can assess the function of the ET when the tympanic membrane is not intact. These tests are helpful in the diagnosis of the presence or absence of abnormal ET function; if a dysfunction is present, these tests help to determine whether or not the tube is obstructed (mechanically or functionally) or abnormally patent, and in some instances, the degree of the malfunction. Even though testing of the function of the ET in the clinical setting has severe limitations at present, and further research is needed, information can be gained which is useful in the diagnosis and management of ME disease. Failing to recognize and assess the function of the ET in relation to the ME and mastoid in selected patients is as irrational as ignoring the function of the larynx in patients with disease of the lower respiratory tract.

Recent advances in the pathogenesis, diagnosis, and management of otitis media

1. Otitis media is one of the most common diseases of childhood. 2. Pathogenesis is related to eustachian tube dysfunction. 3. Etiology is primarily bacterial (S. pneumoniae, 40 per cent; H. influenzae, 20 per cent). Bacteria are also present in chronic otitis media with effusion ("secretory otitis"). 4. H. Influenzae is present in all age groups, and 15 to 30 per cent are ampicillin-resistant. 5. Diagnosis is by pneumatic otoscopy, or tympanometry, or both. 6. Tympanocentesis and/or myringotomy is important diagnostic-therapeutic procedure in selected patients. 7. Ampicillin (or amoxicillin) is initial therapy of choice. 8. Erythromycin and sulfonamide, trimethoprim-sulfamethoxazole, or cefaclor is recommended for those who have poor clinical response to initial antimicrobial therapy. 9. Efficacy is yet to be shown for antimicrobial prophylaxis, decongestants, antihistamines, myringotomy and tympanostomy tubes, and adenoidectomy with or without tonsillectomy. 10. Attendant conductive hearing loss is probably related to abnormalities in cognition, language, and learning.

Managing ear infection in children

Serous or suppurative middle ear effusion in children 2 years of age or older is common and is relatively easy to diagnose and treat. However, assessing and managing apparent ear infection in younger children--particularly infants--are more difficult tasks, and in many of these young patients the middle ear is found to be normal.

Comparison of cefaclor and amoxicillin for acute otitis media with effusion

A double-blind randomized clinical trial was conducted comparing cefaclor and amoxicillin for the treatment of acute otitis media with effusion in 110 children (150 ears). Each child underwent unilateral or bilateral tympanocentesis and then randomly received a 14-day course of either amoxicillin or cefaclor. Of 57 children in the cefaclor group, only 3 children (5.3%) had persistent or recurrent symptoms during the 14-day course of treatment, as compared to 5 of 53 children (9.4%) in the amoxicillin group, but this difference is not significant. After completion of the 14 days of therapy, 45 of 76 ears (59.2%) of the children in the cefaclor group were effusion-free, as compared to only 28 of 64 ears (43.7%) of the children in the amoxicillin group. When adjusted for age and race, this difference is statistically significant (p = .03). However, the difference between the effect of the two antimicrobials is not statistically significant in children. Cefaclor is a reasonable choice for antimicrobial therapy for acute otitis media with effusion, and from these study findings, it appears that cefaclor may be more effective than amoxicillin in resolving the middle ear effusion at the completion of 14-day therapy.

Acute maxillary sinusitis in children

We sought to correlate the clinical, radiographic, and bacteriologic findings in maxillary sinusitis in 30 children who had both upper-respiratory-tract symptoms and abnormal maxillary radiographs. Cough, nasal discharge, and fetid breath were the most common signs, but fever was present inconsistently. Facial pain or swelling and headache were prominent symptoms in older children. Bacterial colony counts of greater than or equal to 10(4) colony-forming units per milliliter were found in 34 of 47 sinus aspirates obtained from 23 children. The most common species recovered were Streptococcus pneumoniae, Haemophilus influenzae, and Branhamella catarrhalis. No anaerobic bacteria were isolated. Viruses were isolated from only two sinus aspirates. There was a poor correlation between the predominant species of bacteria recovered from either the nasopharyngeal or throat culture and the bacteria isolated from the sinus aspirate. This study demonstrates that children with both upper-respiratory-tract symptoms and abnormal sinus radiographs are likely to harbor bacteria in their sinuses, suggesting that such children have bacterial sinusitis.

Bactericidal antibody and susceptibility to otitis media caused by nontypable strains of Haemophilus influenzae

We have developed a bactericidal antibody assay to determine the role of circulating antibody to nontypable strains of Haemophilus influenzae in children with otitis media. Antibody infecting strain was present in the acute sera of 2/20 children with otitis media caused by H. influenzae NT; 15/18 of these patients had covalescent specimens with titers greater than or equal to 1:2 (X2 = 13.0, P < 0.001). The acute sera of 95 children with otitis media caused by various organisms were screened for bactericidal activity against a randomly selected H. influenzae NT stain. Antibody was present in 0/28 acute sera of patients whose infection was caused by H. influenzae NT and in 18/67 (26.9% of those whose middleear exudates were sterile or contained other bacterial species (X2 = 9.95, P < 0.01). A bactericidal antibody response generally follows infection of the middlw ear with H. influenzae NT. The absence of antibody to a single strain in the sera of some children appears to be associated with susceptibility to this infection.

Effect of upper respiratory tract infection on eustachian tube ventilatory function in the preschool child

A prospective tympanometric and microbiologic study of 28 pre-schoolchildren was undertaken to better define the effect of acute URI on induction of eustachian tube dysfunction. Significant negative middle ear pressure was present in 12.7% of tympanograms from well children. However, abnormal tympanograms were detected during 74.7% of acute URIs. The abnormality was present on day 1 or 2 of illness in the majority of cases; 10.1% of illnesses were complicated by OME. Respiratory viruses or Sp were etiologically implicated in 40.5% of illnesses; isolation rates of Pn and HF from well and ill children were similar. Although colonization of the nasopharynx of well children with Pn or HF was associated with a higher incidence of abnormal middle ear pressure, colonization with Pn or HF during URI did not influence the frequency of tympanogram abnormality.

Screening for middle ear disease in a school for the deaf

During the 1977-78 academic year, a study was conducted at the Western Pennsylvania School for the Deaf (WPSD) to evaluate, in a population of profoundly deaf students: 1) the incidence of middle ear (ME) effusion; 2) the correlation between high negative ME pressure (HNP) and ME effusion; and 3) the effect of HNP (> -100 mm H2L) on auditory acuity. All 446 students at WPSD were screened three times (fall, winter, and spring) by both otoscopy and tympanometry and were then classified as belonging to one of five categories according to the status of their ME. Otoscopic, tympanometric, and audiometric evaluations were conducted monthly for 41 study-group students with HNP and 41 controls with normal ears. Tabulations of the incidence of ME conditions over the year-long period showed that 8% of the students had effusion, 21% HNP, 1% inactive disease, 26% residual disease, and 44% normal ME. The majority of severe ME problems occurred in children between the ages of two and eight years. HNP proved insufficient to predict the occurrence of an effusion in children aged 6 to 21 years. However, only 21% of the ears in which HNP was identified returned to and remained normal for the entire year, as contrasted with the initially normal or "controls," of which 77% remained normal. In this profoundly deaf population, the correlation between HNP and threshold shifts proved difficult to document. A small but significantly greater fluctuation in threshold during the period of a year was noted, however, when the students with HMP were compared with the controls.

Acute gram-negative bacillary infections of middle ear and mastoid

Thirty-three patients with acute purulent otitis media and mastoiditis caused by Gram-negative bacilli are presented. The main features of the disease include: predilection for young male infants, a high rate of complications that include sepsis, mastoiditis and osteomyelitis of the base of the skull. Patients that are diagnosed early respond well to drainage and ventilation of the infected middle ear combined with in vitro effective antibacterial therapy. Patients that receive prior inappropriate antibacterial therapy tend to have prolonged courses and require mastoid surgery. It is suggested that early myringotomy and bacterial cultures be performed in all patients with acute middle ear infections.

Negative middle ear pressure and hearing thresholds in secretory otitis media. A double-blind crossover study with Lunerin

No significant effect of an oral decongestant (Lunerin: brompheniramine maleate and phenylpropanolamine hydrochloride) can be shown in this study. Negative middle ear pressure, effusions in the middle ear and hearing threshold levels were evaluated in 26 cleft palate children over a 3 month period, applying a double-blind crossover method. Variations in middle ear pressure occurred in all patients during the trial. The shape of the tympanograms gave no information additional to the clinical evaluation.

Recurrence of otitis media after antibiotic therapy: comparison of cephradine and amoxycillin

The long-term effectiveness of cephradine and amoxycillin in the treatment of otitis media was evaluated in one hundred children ranging in age from 4 months to 14 years. The immediate clinical response was comparable in both treatment groups, but the recurrence rate during a 12-month follow-up period was considerably lower in the patients treated with cephradine. The incidence of side-effects was similar in the two groups.

Design factors in the characterization and identification of otitis media and certain related conditions

Because the state of our knowledge of many aspects of the etiology and pathogenesis of otitis media and related conditions is deficient, precise characterizations of certain aspects of the disease may not be possible. In fact although most studies in the past have failed to define the specific disease state to be investigated, the specific type of otitis media or related condition to be studied must be as clearly defined as is clinically possible in order for any prospective study of otitis media to be valid. The state of the art of the presently available methods to identify these conditions also poses certain limitations; at present, there are five methods to identify otitis media and related conditions: history, audiometry, tympanocentesis/myringotomy, otoscopy (including otomicroscopy), and impedance measurements (tympanometry and assessment of the middle earl muscle reflex), and they all have inherent elements of unreliability. Historical information obtained from parents or the child is usually unreliable; a positive history may aid in defining the problem, but a negative otologic history does not rule out the presence of otitis media since it is frequently asymptomatic. Audiometry has been shown to be a poor method of identifying otitis media. Although tympanocentesis or myringotomy is the most reliable way to identify otitis media with effusion (OME), it is invasive, frequently requires an anesthetic, and is usually a confounding variable. In an effort to establish the diagnostic value of otoscopy, tympanometry, and the presence or absence of the middle ear muscle reflex in identifying OME, the diagnostic findings by these three methods, were compared with the findings at myringotomy in 239 children (425 ears). The study showed that even experienced clinicians had some difficulty in identifying those ears with effusion (sensitivity) and had even greater difficulty in making a diagnosis of those ears without an effusion (specificity). Tympanometry employing patterns that have been validated with myringotomy findings was found to be as accurate as expert otoscopy. On the other hand, the presence or absence of the middle ear muscle reflex was found not to be a useful method of diagnosing the presence of OME due to its extremely low specificity. An algorithm derived from the combination of the three methods had highest sensitivity and specificity. From this study, the following recommendations regarding the identification of OME are suggested. All investigators who employ otoscopy should be validated by comparing their assessments either with the findings at myringotomy or with a previously validated otoscopist. Interobserver realiability of all otoscopists should be established prior to and maintained during clinical studies of OME. Only electroacoustic impedance instruments in which the tympanometric patterns have been validated should be used. Tympanometry employing validated tympanometric patterns has a high degree of sensitivity and specificity, and as such can provide an objective method to identify OME...

Microbiology of recurrent and chronic otitis media with effusion

A study was conducted of 274 children who had recurrent acute or chronic otitis media with effusion. Forty-five percent of the ears with effusion were found to contain bacteria, and 11% contained bacteria that were "probable pathogens" (S. pneumoniae, H. influenzae, and S. pyogenes). Bacteria were also found in 40% of the ears without effusions. The type of organism found did not vary with the age of the patient studied or the season of the year. The significance of these bacteria in the etiology of recurrent acute or chronic otitis media with effusion remains to be demonstrated.

Comparative study between the normally hearing child and the hard of hearing child, by acoustic impedance measurements of the ear

In the first part, the author makes a comparative study of the tympanometric results obtained from the normally hearing child and the hard of hearing child. The frequency of serous otitis media is statistically higher in the deaf child. The author compares such results of tympanometry as obtained from the child, considers the contribution of this technique to the field of pediatric audiology and suggests a classification of tympanograms in terms of the probe-tone frequency of the impedancemeter. The second part concerns the acoustico-facial reflex. This study compares the recording of the stapedius reflex obtained by pure tone and Narrow-Band noise acoustic stimulation, thanks to Madsen electro-acoustic bridge, in two groups of children, the one consisting of normal hearing children and the other of children suffering from severe perception hearing loss. The study of the stapedius reflex threshold makes it possible to analyse the dynamics of the field of perception in both groups. After an analysis of the results, the author outlines the importance attributable to the study of the stapedius reflex in the child as a means of objectively examining the auditive function and a means of differential diagnosis in cases of sensorineural impairment of the hearing function.

Tympanometry in the diagnosis of middle-ear effusion

Tympanometry measures the flow of sound energy in the external ear canal under conditions of changing ear-canal pressure. To evaluate this technic as a means of detecting middle-ear effusion, we studied acoustic susceptance and conductance in 91 children. We made the measurements using tones of 220 and 660 Hz over a pressure range of -300 to +300 mm of water. The mean value for susceptance at 660 Hz gave best results: 83 of 84 tympanograms of ears with middle-ear effusion had values less than 0.16 millimhos (mmho). Among 128 studies of normal ears, 113 had values greater than or equal to 0.16 mmho (P less than 0.001). We conclude that a mean acoustic susceptance at 660 Hz less than 0.16 mmho in a child four months of age or older indicates the presence of middle-ear effusion.

Improved diagnosis of middle ear effusions employing the objective otoscope

A new quantitative diagnostic otoscope presently under development supplements the conventional otoscopic examination with a quantitative pneumatic system and objective measurements derived from tympanometry. The instrument provides information to assist in the diagnosis of the presence of middle ear effusion (MEE), the middle ear pressure and tympanic membrane status during the visual examination. Uncertainty introduced by subjective judgement involved with traditional pneumatic otoscopy is eliminated enabling a more rapid and accurate diagnosis. Clinical evaluations were performed in which 92% accuracy was achieved for the diagnosis of the presence of MEE in 38 ears. The results were verified at myringotomy. The instrument is being designed for use by physicians and paraprofessionals.

Antibacterial therapy and middle ear effusions

Antimicrobial drugs chosen for their activity against the causative pathogens of otitis media provide effective treatment for acute attacks. Prolonged administration of some of these agents has recently been shown to be of value in the prevention of symptomatic otitis. The role of drug therapy in the management of chronic or recurrent middle ear effusion is unknown at present.

Acute otitis media. A clinical bacteriological and serological study of children with frequent episodes of acute otitis media

A series of episodes of acute otitis media was studied with reference to bacterial findings and specific serological responses in 48 children with histories of frequent episodes before. D. pneumoniae and H. influenzae were the most frequently isolated pathogens. Re-isolations after therapy were often made in episodes with slow healing or therapeutic failure. Most children harboured pathogens in nasopharynx even when they had no signs of respiratory tract infections. Homologous relapses were seen only in few cases and never with pneumococcus type 3 and only once with H. influenzae type b. Specific serological responses were demonstrable generally in children over 2 years of age. D. pneumococcus type 3 and H. influenzae type b generally provoked antibody response. No levels indicating immunoglobulin deficiencies could be found in the children.