Screening for otitis media with effusion in preschool children

Improving the Accuracy of Otitis Media with Effusion Diagnosis in Pediatric Patients Using Deep Learning

Otitis media with effusion (OME), primarily seen in children aged 2 years and younger, is characterized by the presence of fluid in the middle ear, often resulting in hearing loss and aural fullness. While deep learning networks have been explored to aid OME diagnosis, prior work did not often specify if pediatric images were used for training, causing uncertainties about their clinical relevance, especially due to important distinctions between the tympanic membranes of small children and adults. We trained cross-validated ResNet50, DenseNet201, InceptionV3, and InceptionResNetV2 models on 1150 pediatric tympanic membrane images from otoendoscopes to classify OME. When assessed using a separate dataset of 100 pediatric tympanic membrane images, the models achieved mean accuracies of 92.9% (ResNet50), 97.2% (DenseNet201), 96.0% (InceptionV3), and 94.8% (InceptionResNetV2), compared to the seven otolaryngologists that achieved accuracies between 84.0% and 69.0%. The results showed that even the worst-performing model trained on fold 3 of InceptionResNetV2 with an accuracy of 88.0% exceeded the accuracy of the highest-performing otolaryngologist at 84.0%. Our findings suggest that these specifically trained deep learning models can potentially enhance the clinical diagnosis of OME using pediatric otoendoscopic tympanic membrane images.

Ventilation tubes (grommets) for otitis media with effusion (OME) in children

BACKGROUND

Otitis media with effusion (OME) is an accumulation of fluid in the middle ear cavity, common amongst young children. It may cause hearing loss which, when persistent, may lead to developmental delay, social difficulty and poor quality of life. Management includes watchful waiting, autoinflation, medical and surgical treatment. Insertion of ventilation tubes has often been used as the preferred treatment.

OBJECTIVES

To evaluate the effects (benefits and harms) of ventilation tubes (grommets) for OME in children.

SEARCH METHODS

We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science, ClinicalTrials.gov, ICTRP and additional sources for published and unpublished trials on 20 January 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in children (6 months to 12 years) with OME for ≥ 3 months. We included studies that compared ventilation tube (VT) insertion with five comparators: no treatment, watchful waiting (ventilation tubes inserted later, if required), myringotomy, hearing aids and other non-surgical treatments.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were determined following a multi-stakeholder prioritisation exercise and were: 1) hearing; 2) OME-specific quality of life; 3) persistent tympanic membrane perforation (as a severe adverse effect of the surgery). Secondary outcomes were: 1) persistence of OME; 2) other adverse effects (including tympanosclerosis, VT blockage and pain); 3) receptive language skills; 4) speech development; 5) cognitive development; 6) psychosocial skills; 7) listening skills; 8) generic health-related quality of life; 9) parental stress; 10) vestibular function; 11) episodes of acute otitis media. We used GRADE to assess the certainty of evidence for key outcomes. Although we included all measures of hearing assessment, the proportion of children who returned to normal hearing was our preferred method, due to challenges in interpreting the results of mean hearing thresholds.

MAIN RESULTS

We included 19 RCTs (2888 children). We considered most of the evidence to be very uncertain, due to wide confidence intervals for the effect estimates, few participants, and a risk of performance and detection bias. Here we report our key outcomes at the longest reported follow-up. There were some limitations to the evidence. No studies investigated the comparison of ventilation tubes versus hearing aids. We did not identify any data on disease-specific quality of life; however, many studies were conducted before the development of specific tools to assess this in otitis media. Short-acting ventilation tubes were used in most studies and thus specific data on the use of long-acting VTs is limited. Finally, we did not identify specific data on the effects of VTs in children at increased risk of OME (e.g. with craniofacial syndromes). Ventilation tubes versus no treatment (four studies) The odds ratio (OR) for a return to normal hearing after 12 months was 1.13 with VTs (95% confidence interval (CI) 0.46 to 2.74; 54% versus 51%; 1 study, 72 participants; very low-certainty evidence). At six months, VTs may lead to a large reduction in persistent OME (risk ratio (RR) 0.30, 95% CI 0.14 to 0.65; 20.4% versus 68.0%; 1 study, 54 participants; low-certainty evidence). The evidence is very uncertain about the chance of persistent tympanic membrane perforation with VTs at 12 months (OR 0.85, 95% CI 0.38 to 1.91; 8.3% versus 9.7%; 1 RCT, 144 participants). Early ventilation tubes versus watchful waiting (six studies) There was little to no difference in the proportion of children whose hearing returned to normal after 8 to 10 years (i.e. by the age of 9 to 13 years) (RR for VTs 0.98, 95% CI 0.94 to 1.03; 93% versus 95%; 1 study, 391 participants; very low-certainty evidence). VTs may also result in little to no difference in the risk of persistent OME after 18 months to 6 years (RR 1.21, 95% CI 0.84 to 1.74; 15% versus 12%; 3 studies, 584 participants; very low-certainty evidence). We were unable to pool data on persistent perforation. One study showed that VTs may increase the risk of perforation after a follow-up duration of 3.75 years (RR 3.65, 95% CI 0.41 to 32.38; 1 study, 391 participants; very low-certainty evidence) but the actual number of children who develop persistent perforation may be low, as demonstrated by another study (1.26%; 1 study, 635 ears; very low-certainty evidence). Ventilation tubes versus non-surgical treatment (one study) One study compared VTs to six months of antibiotics (sulphisoxazole). No data were available on return to normal hearing, but final hearing thresholds were reported. At four months, the mean difference was -5.98 dB HL lower (better) for those receiving VTs, but the evidence is very uncertain (95% CI -9.21 to -2.75; 1 study, 125 participants; very low-certainty evidence). No evidence was identified regarding persistent OME. VTs may result in a low risk of persistent perforation at 18 months of follow-up (no events reported; narrative synthesis of 1 study, 60 participants; low-certainty evidence). Ventilation tubes versus myringotomy (nine studies) We are uncertain whether VTs may slightly increase the likelihood of returning to normal hearing at 6 to 12 months, since the confidence intervals were wide and included the possibility of no effect (RR 1.22, 95% CI 0.59 to 2.53; 74% versus 64%; 2 studies, 132 participants; very low-certainty evidence). After six months, persistent OME may be reduced for those who receive VTs compared to laser myringotomy, but the evidence is very uncertain (OR 0.27, 95% CI 0.19 to 0.38; 1 study, 272 participants; very low-certainty evidence). At six months, the risk of persistent perforation is probably similar with the use of VTs or laser myringotomy (narrative synthesis of 6 studies, 581 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

There may be small short- and medium-term improvements in hearing and persistence of OME with VTs, but it is unclear whether these persist after longer follow-up. The RCTs included do not allow us to say when (or how much) VTs improve hearing in any specific child. However, interpretation of the evidence is difficult: many children in the control groups recover spontaneously or receive VTs during follow-up, VTs may block or extrude, and OME may recur. The limited evidence in this review also affects the generalisability/applicability of our findings to situations involving children with underlying conditions (e.g. craniofacial syndromes) or the use of long-acting tubes. Consequently, RCTs may not be the best way to determine whether an intervention is likely to be effective in any individual child. Instead, we must better understand the different OME phenotypes to target interventions to children who will benefit most, and avoid over-treating when spontaneous resolution is likely.

Long-term follow-up after recurrent otitis media and ventilation tube insertion: Hearing outcomes and middle-ear health at six years of age

OBJECTIVES

To investigate the long-term impact of recurrent otitis media (rOM) and ventilation tube insertion (VTI) in early childhood on hearing outcomes and middle-ear health three to five years later, in a prospective pregnancy cohort study.

METHODS

Children were classified into rOM (n = 314), VTI (n = 94), and reference (n = 1735) groups, according to their otitis media (OM) history in their first three years of life. Audiometry at frequencies 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz, and tympanometry were performed when children were approximately six years of age.

RESULTS

A binary logistic regression incorporating a range of potential confounding variables showed that hearing outcomes and middle-ear health status in children who had early childhood rOM with or without undergoing VTI were not significantly different to those in the reference group. The only significant difference was found in the VTI group for both tympanometry (OR = 2.190; 95% CI = 1.123, 4.270) and audiometry outcomes at 4000 Hz (OR = 3.202; 95% CI 1.341, 6.717), in the left ear only. The median score of the better ear 4FA was 20 dB in children in all groups.

CONCLUSION

Children with rOM with or without undergoing VTI in the first three years of childhood had comparable hearing outcomes and middle-ear health status to those with no history of the disease, at around the age of six years. Although children who underwent VTI had an increased risk of abnormal middle-ear status and some elevation in hearing levels in their left ear only, their audiometry results were still within normal limits, indicating that the impact of VTI in early childhood is unlikely to have clinically significant adverse impact on later hearing outcomes.

Autoinflation compared to ventilation tubes for treating chronic otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is the most common cause of acquired hearing loss and surgery in children. Autoinflation has been suggested as an alternative treatment for OME.

OBJECTIVES

The aim of the study was to compare treatment outcome with a new autoinflation device versus ventilation tube (VT) surgery or watchful waiting in children with chronic bilateral OME from the waiting list for surgery.

METHODS

Forty-five children performed autoinflation during four weeks, forty-five were submitted to VT surgery, and twenty-three were enrolled as control group. Tympanometry was performed in the autoinflation and the control groups and audiometry in all groups.

RESULTS

An equivalent hearing improvement was achieved in the autoinflation and the VT group at one (p=.19), six (p=.23) and twelve (p=.31) months with no significant alteration in the control group. In the autoinflation group 80% of the children avoided surgery and no complications were reported compared to 34% complication rate in the VT group.

CONCLUSION

Autoinflation achieved an equivalent improvement in hearing thresholds compared to VT surgery for treating OME.

SIGNIFICANCE

Autoinflation may be a reasonable first-line treatment for children with OME to potentially avoid surgery.Article Summary: The Moniri autoinflation device is well tolerated and an effective alternative to ventilation tubes for treatment of chronic otitis media with effusion in young children.What's known on this subject: Previous studies have shown that autoinflation may reduce effusion in children with otitis media with effusion; however limited compliance to treatment, lack of adequate hearing evaluation, short follow-up time and also lack of comparative data to ventilation tube surgery have been reported.What this study adds: A new device was developed to allow for the performance of autoinflation in young children. The effect is compared to ventilation tube surgery and equivalent improvement in hearing is achieved in the short and the long-term follow-up.

A multicenter, randomized, active-controlled, clinical trial study to evaluate the efficacy and safety of navigation guided balloon Eustachian tuboplasty

To assess the safety and efficacy of navigation-guided balloon Eustachian tuboplasty (BET) compared to medical management (MM) alone in patients with chronic Eustachian tube dilatory dysfunction (ETD). This is a prospective, multicenter, 1:1 parallel-group, randomized controlled trial (RCT). It aims to assess the efficacy of navigation-guided BET compared to MM alone in patients with chronic ETD. The primary outcome measure was an improvement in the Eustachian tube dysfunction questionnaire (ETDQ)-7 score at the 6-week follow-up compared with baseline. Secondary outcome measures included changes in the signs and symptoms during the follow-up, changes in the score for each subcategory of ETDQ-7, type of tympanometry, pure tone audiometry, and the availability of a positive modified Valsalva maneuver. Navigation-guided BET was safely performed in all patients. A total of 38 ears of 31 patients (19 ears of 16 patients in the BET group and 19 ears of 15 patients in the control group) completed the planned treatment and 6 weeks of follow-up. More patients in the BET group (1.99 ± 0.85) had less symptomatic dysfunction than in the control group (3.40 ± 1.29) at 6 weeks post-procedure (P = 0.001). More patients experienced tympanogram improvement in the BET group at 6 weeks compared to the control group (36.5% vs. 15.8%) with a positive modified Valsalva maneuver (36.6% vs. 15.8%, P = 0.014). Additionally, air–bone gap change was significantly decreased in the BET group compared to the control group at the 6-week follow-up visit (P = 0.037). This prospective, multicenter, RCT study suggests that navigation-guided BET is a safe and superior treatment option compared to MM alone in patients with chronic ETD.

Oral steroids for hearing loss associated with otitis media with effusion in children aged 2-8 years: the OSTRICH RCT

BACKGROUND

Children with hearing loss associated with otitis media with effusion (OME) are commonly managed through surgical intervention, hearing aids or watchful waiting. A safe, inexpensive, effective medical treatment would enhance treatment options. Small, poorly conducted trials have found a short-term benefit from oral steroids.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of a 7-day course of oral steroids in improving hearing at 5 weeks in children with persistent OME symptoms and current bilateral OME and hearing loss demonstrated by audiometry.

DESIGN

Double-blind, individually randomised, placebo-controlled trial.

SETTING

Ear, nose and throat outpatient or paediatric audiology and audiovestibular medicine clinics in Wales and England.

PARTICIPANTS

Children aged 2-8 years, with symptoms of hearing loss attributable to OME for at least 3 months, a diagnosis of bilateral OME made on the day of recruitment and audiometry-confirmed hearing loss.

INTERVENTIONS

A 7-day course of oral soluble prednisolone, as a single daily dose of 20 mg for children aged 2-5 years or 30 mg for 6- to 8-year-olds, or matched placebo.

MAIN OUTCOME MEASURES

Acceptable hearing at 5 weeks from randomisation. Secondary outcomes comprised acceptable hearing at 6 and 12 months, tympanometry, otoscopic findings, health-care consultations related to OME and other resource use, proportion of children who had ventilation tube (grommet) surgery at 6 and 12 months, adverse effects, symptoms, functional health status, health-related quality of life, short- and longer-term cost-effectiveness.

RESULTS

A total of 389 children were randomised. Satisfactory hearing at 5 weeks was achieved by 39.9% and 32.8% in the oral steroid and placebo groups, respectively (absolute difference of 7.1%, 95% confidence interval -2.8% to 16.8%; number needed to treat = 14). This difference was not statistically significant. The secondary outcomes were consistent with the picture of a small or no benefit, and we found no subgroups that achieved a meaningful benefit from oral steroids. The economic analysis showed that treatment with oral steroids was more expensive and accrued fewer quality-adjusted life-years than treatment as usual. However, the differences were small and not statistically significant, and the sensitivity analyses demonstrated large variation in the results.

CONCLUSIONS

OME in children with documented hearing loss and attributable symptoms for at least 3 months has a high rate of spontaneous resolution. Discussions about watchful waiting and other interventions will be enhanced by this evidence. The findings of this study suggest that any benefit from a short course of oral steroids for OME is likely to be small and of questionable clinical significance, and that the treatment is unlikely to be cost-effective and, therefore, their use cannot be recommended.

FUTURE WORK

Studies exploring optimal approaches to sharing natural history data and enhancing shared decision-making are needed for this condition.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49798431 and EudraCT 2012-005123-32.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 61. See the NIHR Journals Library website for further project information.

Audiological Profile in Older Children and Adolescents with Unrepaired Cleft Palate

Objective

To study the audiological profile in the cleft population comprising older children and adolescents with unrepaired cleft palate and to arrive at a consensus regarding management of otitis media with effusion in this unique group.

Setting

Tertiary care institute in Chandigarh, Punjab, India.

Design

Prospective study based on all patients older than 7 years with unrepaired cleft palate, attending the plastic surgery outpatient department, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Punjab, India, from January 2001 to December 2002. Patients with submucous cleft were excluded from the study. General characteristics, otoscopic findings, pure tone audiometry, and impedence audiometry of all patients were recorded.

Results

Patients’ ages ranged from 8 to 18 years, with a mean of 10.5 years. Regarding otological complaints, 86.7% were asymptomatic. Otoscopic findings revealed mild retraction as the most common finding in 50% of the ears. Type B curve was the most common tympanometric finding. The highest and lowest hearing thresholds recorded were 45 db and 15 db, respectively, with a mean of 27.11 db.

Conclusion

The audiological profile of this unique group, which neither had undergone palatoplasty nor had received treatment for the ear condition, demonstrates a mild to moderate hearing impairment. This definitely requires treatment, but owing to the lack of a prospective control group, it is difficult to conclude whether these patients are benefited by conservative treatment alone or by an early aggressive surgical treatment for otitis media with effusion (OME).

Intranasal Steroid Use for Otitis Media with Effusion: Ongoing Opportunities for Quality Improvement

Objectives Our objectives were (1) to assess patterns of intranasal steroid administration when otitis media with effusion (OME) has been diagnosed in children, (2) to investigate whether usage varies according to visit setting, and (3) to determine if practice gaps are such that quality improvement could be tracked. Study Design Cross-sectional analysis of an administrative database. Subjects and Methods National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005 to 2012; univariate, multivariate, and stratified analyses of intranasal steroid usage were performed. The primary outcome was intranasal steroid administration, and the primary predictor was a diagnosis of OME. The impact of location of service was also analyzed. Results Data representing 1,943,177,903 visits demonstrated that intranasal steroids were administered in 10.0% of visits in which OME was diagnosed, in comparison to 3.5% of visits in which OME was not diagnosed (univariate odds ratio, 3.07; 95% confidence interval [CI], 1.85-5.08; P < .001). After adjusting for age, sex, race/ethnicity, and other confounding conditions, multivariate analysis demonstrated that OME remained associated with an increase in intranasal steroid usage (odds ratio, 3.58; 95% CI, 1.60-8.01; P = .002). This practice pattern was more prevalent in the ambulatory office setting (risk difference 6.6%, P < .001) and less seen in a hospital-based office or emergency department. Conclusion Despite randomized controlled trials showing a lack of efficacy for isolated OME, nasal steroids continue to be used in treating children with OME in the United States. Related quality improvement opportunities to prevent usage of an ineffective treatment exist.

Frequency of Serous Otitis Media in Children without Otolaryngological Symptoms

Introduction Otitis media with effusion is the fluid in the middle ear with no signs or symptoms of acute ear infection. Objective This study aims to research the frequency of serous otitis media in patients referred to the pediatric clinic between 3-16 years of age without any active ear, nose, and throat complaints. Methods This study included 589 children patients (280 boys, 309 girls; mean age: 9.42; range 3-16) who were administered to the pediatric clinic without otolaryngologic complaints. Patients underwent examination with flexible nasopharyngoscopy for adenoid hypertrophy. An otorhinolaryngologist examined all children on both ears using an otoscope and tested with tympanometry. We used tympanometry results to diagnose SOM. Results The study included 589 patients that underwent fiber optic examination of the nasopharynx with an endoscope. Adenoid vegetation was present in 58 patients (9.8%) and was not detected in 531 patients (90.2%). We found serous otitis media in 94 (15.9%) patients. We obtained Type A tympanogram in 47 (81%) of 58 patients with adenoid vegetation, 6 (10.3%) Type B, and 5 (8.6%) Type C. When comparing 58 patients with adenoid vegetation with 538 patients without adenoid vegetation for serous otitis media, the frequency was not statistically significant (p > 0.05). Conclusion We believe that in children without any ear, nose, and throat complaints, it is possible to detect serous otitis media with adenoid vegetation. Thus, pediatric patients should undergo screening at regular intervals.

Hearing Loss in Young Adults Who Had Ventilation Tube Insertion in Childhood

It is known that insertion of ventilation tubes can cause damage to the tympanic membrane and hearing deterioration in the long term. To investigate long-term effects of recurrent otitis media and of ventilation tube insertion, we used a study group (n = 358 subjects), with or without a history of otitis media and/or ventilation tube insertion, derived from a birth cohort that had been followed for 16 years. At 18 years of age, a standardized audiometric and otoscopic examination was performed. We found that ventilation tube insertion in childhood was associated with a mean persistent hearing loss in young adults of about 5 to 10 dB at the group level with a sensorineural component of 3 to 4 dB. This hearing loss could not be explained by the disease load of otitis media in childhood. Repeated insertions of ventilation tubes caused a greater deterioration of hearing than did a single insertion. Structural changes of the tympanic membrane were a mediating factor in the causal relationship between ventilation tube insertion and hearing loss. We conclude that ventilation tube insertion in childhood may induce hearing deterioration in the long term.

An open randomised study of autoinflation in 4- to 11-year-old school children with otitis media with effusion in primary care

BACKGROUND

Otitis media with effusion (OME) is a very common problem in primary care, but one that lacks an evidence-based non-surgical treatment.

OBJECTIVE

To determine the clinical effectiveness of nasal balloon autoinflation for the treatment of OME in children.

DESIGN

A pragmatic, two-arm, open randomised controlled trial.

SETTING

Forty-three general practices from 17 UK primary care trusts recruited between January 2012 and February 2013.

PARTICIPANTS

School children aged 4-11 years with a history of OME symptoms or related concerns in the previous 3 months, and a type B tympanogram, diagnostic of a middle ear effusion, in one or both ears.

INTERVENTION

Three hundred and twenty children were randomised, 160 to each group, using independent web-based computer-generated randomisation (with minimisation based on age, sex and baseline severity of OME) to either nasal balloon autoinflation performed three times per day for 1-3 months plus usual care, or usual care alone.

MAIN OUTCOME MEASURES

The proportion of children demonstrating clearance of middle ear fluid in at least one ear (with normal tympanograms) at 1 and 3 months, assessed blind to treatment. An ear-related measure of quality of life (QoL) [a 14-point questionnaire on the impact of OME (OMQ-14)], weekly diary recorded symptoms, compliance and adverse events were all secondary outcomes.

RESULTS

At 1 month, the proportion of children with normal tympanograms was 47.3% (62/131) in those allocated to autoinflation and 35.6% (47/132) in those receiving usual care [adjusted relative risk (RR) 1.36, 95% confidence interval (CI) 0.99 to 1.88]. At 3 months, the proportions were 49.6% (62/125) and 38.3% (46/120), respectively (adjusted RR 1.37, 95% CI 1.03 to 1.83; number needed to treat = 9). The change in OMQ-14 also favoured the intervention arm (adjusted global score difference -0.42; p = 0.001). Reported compliance was good: 89% in the first month and 80% in months 2 and 3. Adverse events included otalgia in 4% of treated children compared with 1% in the control group. Minor nosebleeds (14% vs. 15%) and respiratory tract infections (18% vs. 13%) were noted.

CONCLUSION

We found the use of autoinflation in young children with OME to be feasible in primary care and effective in both clearing effusions and improving child and parent ear-related QoL and symptoms. This method has scope to be used more widely. Further research is needed for very young children, and to inform prudent use in different health settings.

Clinical Practice Guideline: Otitis Media with Effusion (Update)

OBJECTIVE

This update of a 2004 guideline codeveloped by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME), defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection. Changes from the prior guideline include consumer advocates added to the update group, evidence from 4 new clinical practice guidelines, 20 new systematic reviews, and 49 randomized control trials, enhanced emphasis on patient education and shared decision making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of OME.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing OME and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy, identify children who are most susceptible to developmental sequelae from OME, and educate clinicians and patients regarding the favorable natural history of most OME and the clinical benefits for medical therapy (eg, steroids, antihistamines, decongestants). Additional goals relate to OME surveillance, hearing and language evaluation, and management of OME detected by newborn screening. The target patient for the guideline is a child aged 2 months through 12 years with OME, with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for all clinicians who are likely to diagnose and manage children with OME, and it applies to any setting in which OME would be identified, monitored, or managed. This guideline, however, does not apply to patients <2 months or >12 years old.

ACTION STATEMENTS

The update group made strong recommendations that clinicians (1) should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child; (2) should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both; (3) should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy; (4) should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or 3 months from the date of diagnosis (if onset is unknown); (5) should recommend against using intranasal or systemic steroids for treating OME; (6) should recommend against using systemic antibiotics for treating OME; and (7) should recommend against using antihistamines, decongestants, or both for treating OME.The update group made recommendations that clinicians (1) should document in the medical record counseling of parents of infants with OME who fail a newborn screening regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss; (2) should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors; (3) should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age (if diagnosed as being at risk prior to this time); (4) should not routinely screen children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort; (5) should educate children with OME and their families regarding the natural history of OME, need for follow-up, and the possible sequelae; (6) should obtain an age-appropriate hearing test if OME persists for 3 months or longer OR for OME of any duration in an at-risk child; (7) should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development; (8) should reevaluate, at 3- to 6-month intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; (9) should recommend tympanostomy tubes when surgery is performed for OME in a child <4 years old; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); (10) should recommend tympanostomy tubes, adenoidectomy, or both when surgery is performed for OME in a child ≥4 years old; and (11) should document resolution of OME, improved hearing, or improved quality of life when managing a child with OME.

The management of Otitis Media with Effusion in children with cleft palate (mOMEnt): a feasibility study and economic evaluation

BACKGROUND

Cleft lip and palate are among the most common congenital malformations, with an incidence of around 1 in 700. Cleft palate (CP) results in impaired Eustachian tube function, and 90% of children with CP have otitis media with effusion (OME) histories. There are several approaches to management, including watchful waiting, the provision of hearing aids (HAs) and the insertion of ventilation tubes (VTs). However, the evidence underpinning these strategies is unclear and there is a need to determine which treatment is the most appropriate.

OBJECTIVES

To identify the optimum study design, increase understanding of the impact of OME, determine the value of future research and develop a core outcome set (COS) for use in future studies.

DESIGN

The management of Otitis Media with Effusion in children with cleft palate (mOMEnt) study had four key components: (i) a survey evaluation of current clinical practice in each cleft centre; (ii) economic modelling and value of information (VOI) analysis to determine if the extent of existing decision uncertainty justifies the cost of further research; (iii) qualitative research to capture patient and parent opinion regarding willingness to participate in a trial and important outcomes; and (iv) the development of a COS for use in future effectiveness trials of OME in children with CP.

SETTING

The survey was carried out by e-mail with cleft centres. The qualitative research interviews took place in patients' homes. The COS was developed with health professionals and parents using a web-based Delphi exercise and a consensus meeting.

PARTICIPANTS

Clinicians working in the UK cleft centres, and parents and patients affected by CP and identified through two cleft clinics in the UK, or through the Cleft Lip and Palate Association.

RESULTS

The clinician survey revealed that care was predominantly delivered via a 'hub-and-spoke' model; there was some uncertainty about treatment strategies; it is not current practice to insert VTs at the time of palate repair; centres were in a position to take part in a future study; and the response rate to the survey was not good, representing a potential concern about future co-operation. A COS reflecting the opinions of clinicians and parents was developed, which included nine core outcomes important to both health-care professionals and parents. The qualitative research suggested that a trial would have a 25% recruitment rate, and although hearing was a key outcome, this was likely to be due to its psychosocial consequences. The VOI analysis suggested that the current uncertainty justified the costs of future research.

CONCLUSIONS

There exists significant uncertainty regarding the best management strategy for persistent OME in children with clefts, reflecting a lack of high-quality evidence regarding the effectiveness of individual treatments. It is feasible, cost-effective and of significance to clinicians and parents to undertake a trial examining the effectiveness of VTs and HAs for children with CP. However, in view of concerns about recruitment rate and engagement with the clinicians, we recommend that a trial with an internal pilot is considered.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. This study was part-funded by the Healing Foundation supported by the Vocational Training Charitable Trust who funded trial staff including the study co-ordinator, information systems developer, study statistician, administrator and supervisory staff.

Oral Antibiotic Use for Otitis Media with Effusion: Ongoing Opportunities for Quality Improvement

OBJECTIVES

(1) To evaluate the probability of antibiotic administration associated with ICD-9 diagnosis of otitis media with effusion (OME) in the absence of acute otitis media, (2) to determine whether usage varies according to visit setting, and (3) to ascertain if practice gaps are such that future practice changes might be measured.

STUDY DESIGN

Cross-sectional analysis of an administrative database.

SETTING

Ambulatory visits in the United States.

SUBJECTS AND METHODS

National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005-2010; univariate, multivariate, and stratified analyses of antibiotic usage were performed. The study population was restricted to children without acute or unspecified otitis media. The primary outcome was the probability of oral antibiotic administration when OME was diagnosed. The impact of the location of service and subspecialty care was also analyzed.

RESULTS

Data from 1,390,404,196 pediatric visits demonstrated that oral antibiotics were administered for 32% of visits with an OME diagnosis, even in the absence of acute otitis media (odds ratio, 4.31; 95% confidence interval: 2.88-6.44; P < .001). The highest antibiotic administration was seen in the emergency department (risk difference, 37.1%; number needed to harm, 3). No significant increased risk of antibiotic usage was seen during otolaryngology visits. Diagnoses of infections at nonotologic sites were associated with a 1.98 to 26.60 increase in odds of oral antibiotic administration.

CONCLUSION

Oral antibiotics continue to be administered in children with OME in the absence of acute infection, with risk varying by location of service. There is a potential opportunity for quality improvement through reducing antibiotic administration for pediatric OME.

Oral steroids for the resolution of otitis media with effusion (OME) in children (OSTRICH): study protocol for a randomised controlled trial

BACKGROUND

Otitis media with effusion (OME) is an accumulation of fluid in the middle ear affecting about 80 % of children by the age of 4 years. While OME usually resolves spontaneously, it can affect speech, behaviour and development. Children with persistent hearing loss associated with OME are usually offered hearing aids or insertion of ventilation tubes through the tympanic membrane. Oral steroids may be a safe and effective treatment for OME, which could be delivered in primary care. Treatment with oral steroids has the potential to benefit large numbers of children and reduce the burden of care on them and on health services. However, previous trials have either been too small with too short a follow-up period, or of too poor quality to give a definite answer. The aim of the Oral Steroids for the Resolution of Otitis Media with Effusion in Children (OSTRICH) trial is to determine if a short course of oral steroids improves the hearing of children with OME in the short and longer term.

METHODS/DESIGN

A total of 380 participants (children of 2 to 8 years of age) are recruited from Hospital Ear, Nose and Throat departments in Wales and England. A trained clinician seeks informed consent from parents of children with symptoms for at least 3 months that are attributable to OME and with confirmed bilateral hearing loss at study entry. Participants are randomised to a course of oral steroid or a matched placebo for 1 week. Outcomes include audiometry, tympanometry and otoscopy assessments; symptoms; adverse effects; functional health status; quality of life; resource use; and cost effectiveness. Participants are followed up at 5 weeks, and at 6 and 12 months after the day of randomisation. The primary outcome is audiometry-confirmed satisfactory hearing at 5 weeks.

DISCUSSION

An important evidence gap exists regarding the clinical and cost effectiveness of short courses of oral steroid treatment for OME. Identifying an effective, safe, nonsurgical intervention for OME in children for use in primary care would be of great benefit to children, their families and the NHS.

TRIAL REGISTRATION

ISRCTN

ISRCTN49798431 (Registered 7 December 2012).

Antihistamine Use for Otitis Media with Effusion

Objectives

The otitis media with effusion (OME) clinical practice guideline endorsed by the American Academy of Otolaryngology—Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians recommends against using antihistamines. Avoiding antihistamines was previously endorsed as a performance measure by the National Quality Foundation, but data regarding current practice patterns are lacking. Thus, our objectives were to evaluate (1) antihistamine usage in association with OME, (2) whether practice varies according to visit setting, and (3) if usage patterns are such that a future change would be measurable.

Study Design

Cross-sectional analysis.

Setting

Ambulatory visits in the United States.

Subjects and Methods

National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys, 2005-2010; univariate, multivariate, and stratified analyses of antihistamine usage were performed.

Results

A total of 133,968 observations representing 1.49 × 109 pediatric visits met inclusion criteria. Antihistamines were used in 9.5% of OME visits, as opposed to 5.5% of visits without OME (univariate odds ratio, 1.83; 95% confidence interval, 1.02-3.29; P = .042). Multivariate analysis confirmed that OME was associated with a significant increase in nonsedating antihistamine usage (odds ratio, 3.53; 95% confidence interval, 1.62-7.71; P = .002), when adjusted for age, sex, race/ethnicity, allergic conditions and nasal inflammatory diagnoses.

Conclusions

Oral antihistamines are significantly more likely to be administered when OME is diagnosed. Although antihistamine use for OME is proportionally low, the high prevalence of OME creates an opportunity for quality improvement. Future changes in clinician behavior in response to an updated guideline or related performance metric could be monitored.

Effect of nasal balloon autoinflation in children with otitis media with effusion in primary care: an open randomized controlled trial

BACKGROUND

Otitis media with effusion is a common problem that lacks an evidence-based nonsurgical treatment option. We assessed the clinical effectiveness of treatment with a nasal balloon device in a primary care setting.

METHODS

We conducted an open, pragmatic randomized controlled trial set in 43 family practices in the United Kingdom. Children aged 4-11 years with a recent history of ear symptoms and otitis media with effusion in 1 or both ears, confirmed by tympanometry, were allocated to receive either autoinflation 3 times daily for 1-3 months plus usual care or usual care alone. Clearance of middle-ear fluid at 1 and 3 months was assessed by experts masked to allocation.

RESULTS

Of 320 children enrolled, those receiving autoinflation were more likely than controls to have normal tympanograms at 1 month (47.3% [62/131] v. 35.6% [47/132]; adjusted relative risk [RR] 1.36, 95% confidence interval [CI] 0.99 to 1.88) and at 3 months (49.6% [62/125] v. 38.3% [46/120]; adjusted RR 1.37, 95% CI 1.03 to 1.83; number needed to treat = 9). Autoinflation produced greater improvements in ear-related quality of life (adjusted between-group difference in change from baseline in OMQ-14 [an ear-related measure of quality of life] score -0.42, 95% CI -0.63 to -0.22). Compliance was 89% at 1 month and 80% at 3 months. Adverse events were mild, infrequent and comparable between groups.

INTERPRETATION

Autoinflation in children aged 4-11 years with otitis media with effusion is feasible in primary care and effective both in clearing effusions and improving symptoms and ear-related child and parent quality of life.

TRIAL REGISTRATION

ISRCTN, No. 55208702.

The Importance of Integration of Stakeholder Views in Core Outcome Set Development: Otitis Media with Effusion in Children with Cleft Palate

Background

Approximately 75% of children with cleft palate (CP) have Otitis Media with Effusion (OME) histories. Evidence for the effective management of OME in these children is lacking. The inconsistency in outcome measurement in previous studies has led to a call for the development of a Core Outcome Set (COS). Despite the increase in the number of published COS, involvement of patients in the COS development process, and methods to integrate the views of patients and health professionals, to date have been limited.

Methods and Findings

A list of outcomes measured in previous research was identified through reviewing the literature. Opinion on the importance of each of these outcomes was then sought from key stakeholders: Ear, Nose and Throat (ENT) surgeons, audiologists, cleft surgeons, speech and language therapists, specialist cleft nurses, psychologists, parents and children. The opinion of health professionals was sought in a three round Delphi survey where participants were asked to score each outcome using a bespoke online system. Parents and children were also asked to score outcomes in a survey and provided an in-depth insight into having OME through semi-structured interviews. The results of the Delphi survey, interviews and parent/patient survey were brought together in a final consensus meeting with representation from all stakeholders. A final set of eleven outcomes reached the definition of “consensus in” to form the recommended COS: hearing; chronic otitis media (COM); OME; receptive language skills; speech development; psycho social development; acute otitis media (AOM); cholesteatoma; side effects of treatment; listening skills; otalgia.

Conclusions

We have produced a recommendation about the outcomes that should be measured, as a minimum, in studies of the management of OME in children with CP. The development process included input from key stakeholders and used novel methodology to integrate the opinion of healthcare professionals, parents and children.

Diseases of the middle ear in childhood

Middle ear diseases in childhood play an important role in daily ENT practice due to their high incidence. Some of these like acute otitis media or otitis media with effusion have been studied extensively within the last decades. In this article, we present a selection of important childhood middle ear diseases and discuss the actual literature concerning their treatment, management of complications and outcome. Another main topic of this paper deals with the possibilities of surgical hearing rehabilitation in childhood. The bone-anchored hearing aid BAHA(®) and the active partially implantable device Vibrant Soundbridge(®) could successfully be applied for children. In this manuscript, we discuss the actual literature concerning clinical outcomes of these implantable hearing aids.

Autoinflation for treatment of persistent otitis media with effusion in children: a cross-over study with a 12-month follow-up

OBJECTIVES

The aims of the present study were to evaluate the efficacy of and compliance with a new device for autoinflation in the treatment of persistent otitis media with effusion (OME) in young children.

METHODS

Forty-five children with persistent OME with a bilateral type B or C2 tympanogram for at least three months and history of subjective hearing loss, waiting for grommet surgery, were randomised to a treatment and a control group. Twenty-three children aged between three and eight years started as the treatment group with the new device for autoinflation. Another 22 children, aged between two and eight years were included as controls. After a period of four weeks, a cross-over was performed. Both groups underwent otomicroscopy, tympanometry and audiometry at inclusion and after one and two months for the evaluation of treatment efficiency. The primary outcome measurements were improvement in middle-ear pressure and hearing thresholds at eight weeks. Both groups were then followed up for another 10 months.

RESULTS

In the treatment group, the mean middle-ear pressure for both ears and the mean hearing thresholds for the best ear improved by 166 daPa (p<0.0001) and 6 dB (p<0.0001), respectively after four weeks, while in the control group, non-significant alterations were observed. After the cross-over of the control group to treatment, equivalent improvements in the mean middle-ear pressure and the mean hearing thresholds of 187 daPa (p<0.0001) and 7 dB (p<0.01), respectively were achieved also in this group. After treatment in both groups at eight weeks, four of 45 children were submitted to grommet surgery. During the long-term follow-up another five children were submitted to surgery due to recurrence of disease. All the children managed to perform the manoeuvre and no side-effects were detected.

CONCLUSION

The device demonstrated efficiency in improving both middle-ear pressure and hearing thresholds in most children after four weeks of treatment. It might therefore be possible to consider this method of autoinflation in children with persistent OME during the watchful waiting period.

A new device for treatment of persistent otitis media with effusion

OBJECTIVES

Most children suffer from otitis media with effusion (OME) before starting school. Insertion of grommets into the eardrum for treatment of OME is one of the most common operations performed in childhood. The efficiency and compliance of treatment with a new non-invasive device was evaluated in children with bilateral OME with disease duration of at least 3 months.

METHODS

A device for autoinflation was developed to enable a combined modified Valsalva and Politzer maneuver. Ten children, aged 3-8 years (mean: 5 years and 2 months) with OME tested the device for estimation of its ability to ventilate the middle ear. Another thirty-one children, with persistent bilateral OME for at least three months, were divided into a treatment and a control group. Twenty-one children (42 ears), aged 2-7 year (mean: 4 years and 6 months), participated as the treatment group and ten patients (20 ears), aged 3-7 years (mean: 4 years and 5 months), were included as controls. Tympanometry and otomicroscopy were performed at inclusion and at the end of the study.

RESULTS

In the treatment group the middle ear pressure was normalized in 52% and improved in 31% of the ears with 7 children (33%) achieving bilateral and 8 (38%) unilateral normalization. In the control group the middle ear pressure was normalized in 15%, improved in 15% and deteriorated in 10% of the ears with one child (10%) achieving bilateral and one child (10%) unilateral normalization. Statistically significant differences (p < 0.001) were observed in the pressure difference and the tympanometry type changes between the treatment and the control group. Otomicroscopic examination revealed that the number of ears judged as OME was reduced by 62% in the treatment group in comparison with 20% in the control group. All children managed to perform the maneuver and no side effects were neither reported nor detected.

CONCLUSIONS

The device was efficient in ventilation of the middle ear with normalization or improvement of the negative middle ear pressure and otomicroscopic findings in young children with persistent OME.

Autoinflation for hearing loss associated with otitis media with effusion

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2006.Otitis media with effusion (OME) or 'glue ear' is an accumulation of fluid in the middle ear, in the absence of acute inflammation or infection. It is the commonest cause of acquired hearing loss in childhood and the usual reason for insertion of 'grommets'. Potential treatments include decongestants, mucolytics, steroids, antihistamines and antibiotics. Autoinflation devices have been proposed as a simple mechanical means of improving 'glue ear'.

OBJECTIVES

To assess the effectiveness of autoinflation compared with no treatment in children and adults with otitis media with effusion.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 12 April 2013.

SELECTION CRITERIA

We selected randomised controlled trials that compared any form of autoinflation to no autoinflation in individuals with 'glue ear'.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, assessed risk of bias and extracted data from included studies.

MAIN RESULTS

Eight studies, with a total of 702 participants, met the inclusion criteria. Overall, the studies were predominantly assessed as being at low or unclear risk of bias; unclear risk was mainly due lack of information. There was no evidence of selective reporting.Pooled estimates favoured the intervention, but did not show a significant effect on tympanometry (type C2 and B) at less than one month, nor at more than one month. Similarly, there were no significant changes for discrete pure-tone audiometry and non-discrete audiometry. Pooled estimates favoured, but not significantly, the intervention for the composite measure of tympanogram or audiometry at less than one month; at more than one month the result became significant (RRI 1.74, 95% CI 1.22 to 2.50). Subgroup analysis based on the type of intervention showed a significant effect using a Politzer device under one month (RRI 7.07, 95% CI 3.70 to 13.51) and over one month (RRI 2.25, 95% CI 1.67 to 3.04).None of the studies demonstrated a significant difference in the incidence of side effects between interventions.

AUTHORS' CONCLUSIONS

All of the studies were small, of limited treatment duration and had short follow-up. However, because of the low cost and absence of adverse effects it is reasonable to consider autoinflation whilst awaiting natural resolution of otitis media with effusion. Primary care could prove a beneficial place to evaluate such interventions and there is ongoing research in this area. Further research should also consider the duration of treatment, the long-term impact on developmental outcomes in children and additional quality of life outcome measures for children and families.

Differential diagnosis in allergy

The otolaryngic allergist must be able to distinguish between common nonallergic diagnoses that present very similarly to allergic conditions. This article describes a few of the vast myriad of conditions that must be ruled out before a diagnosis of allergy may be made. After reading this article clinicians will be able to identify various conditions, which will enhance their ability to appropriately make correct decisions for prompt and efficient management of their patients with allergic or nonallergic diseases of the head and neck.

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

BACKGROUND

Otitis media with effusion (OME; 'glue ear') is common in childhood and surgical treatment with grommets (ventilation tubes) is widespread but controversial.

OBJECTIVES

To assess the effectiveness of grommet insertion compared with myringotomy or non-surgical treatment in children with OME.

SEARCH STRATEGY

We searched the Cochrane ENT Disorders Group Trials Register, other electronic databases and additional sources for published and unpublished trials (most recent search: 22 March 2010).

SELECTION CRITERIA

Randomised controlled trials evaluating the effect of grommets. Outcomes studied included hearing level, duration of middle ear effusion, language and speech development, cognitive development, behaviour and adverse effects.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 10 trials (1728 participants). Some trials randomised children (grommets versus no grommets), others ears (grommet one ear only). The severity of OME in children varied between trials. Only one 'by child' study (MRC: TARGET) had particularly stringent audiometric entry criteria. No trial was identified that used long-term grommets.Grommets were mainly beneficial in the first six months by which time natural resolution lead to improved hearing in the non-surgically treated children also. Only one high quality trial that randomised children (N = 211) reported results at three months; the mean hearing level was 12 dB better (95% CI 10 to 14 dB) in those treated with grommets as compared to the controls. Meta-analyses of three high quality trials (N = 523) showed a benefit of 4 dB (95% CI 2 to 6 dB) at six to nine months. At 12 and 18 months follow up no differences in mean hearing levels were found.Data from three trials that randomised ears (N = 230 ears) showed similar effects to the trials that randomised children. At four to six months mean hearing level was 10 dB better in the grommet ear (95% CI 5 to 16 dB), and at 7 to 12 months and 18 to 24 months was 6 dB (95% CI 2 to 10 dB) and 5 dB (95% CI 3 to 8 dB) dB better.No effect was found on language or speech development or for behaviour, cognitive or quality of life outcomes.Tympanosclerosis was seen in about a third of ears that received grommets. Otorrhoea was common in infants, but in older children (three to seven years) occurred in < 2% of grommet ears over two years of follow up.

AUTHORS' CONCLUSIONS

In children with OME the effect of grommets on hearing, as measured by standard tests, appears small and diminishes after six to nine months by which time natural resolution also leads to improved hearing in the non-surgically treated children. No effect was found on other child outcomes but data on these were sparse. No study has been performed in children with established speech, language, learning or developmental problems so no conclusions can be made regarding treatment of such children.

Natural history of untreated otitis media

OBJECTIVE/HYPOTHESIS

Data from cohort studies and untreated groups in randomized controlled trials can be identified through systematic literature review and synthesized with meta-analysis to estimate natural history of acute otitis media (AOM) and otitis media with effusion (OME).

STUDY DESIGN

Systematic literature review and meta-analysis.

METHOD

Source articles were identified by MEDLINE search through August 2002 plus manual crosschecks of bibliographies and published meta-analyses. Data were abstracted independently by two investigators and combined with random effects meta-analysis to estimate spontaneous resolution, 95% confidence intervals (CI), and heterogeneity. Sensitivity analysis was performed.

RESULTS

Sixty-three articles met inclusion criteria. AOM symptoms improved within 24 hours without antibiotics in 61% of children (95% CI, 50-72%), rising to 80% by 2 to 3 days (95% CI, 69-90%). Suppurative complications were comparable if antibiotics were withheld (0.12%) or provided (0.24%). Children entered recurrent AOM trials with a mean rate of 5.5 or more annual episodes but averaged only 2.8 annual episodes while on placebo (95% CI, 2.2-3.4). No AOM episodes occurred in 41%, and only 17% remained otitis prone (3 or more episodes). OME after untreated AOM had 59% resolution by 1 month (95% CI, 50-68%) and 74% resolution by 3 months (95% CI, 68-80%). OME of unknown duration had 28% spontaneous resolution by 3 months (95%, CI 14-41%), rising to 42% by 6 months (95% CI, 35-49%). In contrast, chronic OME had only 26% resolution by 6 months and 33% resolution by 1 year.

CONCLUSIONS

The natural history of otitis media is very favorable. Combined estimates of spontaneous resolution provide a benchmark against which to judge new or established interventions. The need for surgery in children with recurrent AOM or chronic OME should be balanced against the likelihood of timely spontaneous resolution and the potential risk of learning, language, or other adverse sequelae from persistent middle ear effusion. Further research is needed to identify prognostic factors that can target children unlikely to improve spontaneously for earlier intervention.

Cost-utility analysis of topical intranasal steroids for otitis media with effusion based on evidence from the GNOME trial

OBJECTIVES

To estimate the cost-effectiveness of topical intranasal steroids for the treatment of otitis media with effusion (OME) in primary care from the perspective of the UK National Health Service.

METHODS

An economic evaluation was conducted based on evidence from the double-blind, randomized, placebo-controlled GPRF [General Practice Research Framework] Nasal Steroids for Otitis Media with Effusion (GNOME) trial. Participants comprised 217 children aged 4-11 years who had at least one episode of otitis media or related ear problem in the previous 12 months and had tympanometrically confirmed bilateral OME. Children were randomly allocated to receive either mometasone furoate 50 microg or placebo spray once daily into each nostril for 3 months. The main outcome measure was the incremental cost per quality-adjusted life-year (QALY) gained for topical steroids compared with placebo. The nonparametric bootstrap method was used to present cost-effectiveness acceptability curves at alternative willingness to pay thresholds.

RESULTS

Children receiving topical steroids accrued nonsignificantly higher costs (incremental cost/child: pound11, 95% confidence interval [CI]: - pound199 to pound222) and nonsignificantly fewer QALYs (incremental QALY gain/child: -0.0166, 95% CI: -0.0652 to 0.0320) than those receiving placebo. Topical steroids had a 24.19% probability of being cost-effective at a pound20,000 per QALY gained threshold, a 23.82% probability of being more effective and a 46.25% probability of being less costly. Sensitivity and subgroup analyses showed incremental costs and benefits to be highly sensitive to the methods used and the patient group considered, although differences between groups did not reach statistical significance in any analysis.

CONCLUSIONS

Topical steroids are unlikely to be a cost-effective treatment for OME in general practice.

Topical intranasal corticosteroids in 4-11 year old children with persistent bilateral otitis media with effusion in primary care: double blind randomised placebo controlled trial

OBJECTIVE

To determine the clinical effectiveness of topical intranasal corticosteroids in children with bilateral otitis media with effusion.

DESIGN

Double blind randomised placebo controlled trial.

SETTING

76 Medical Research Council General Practice Research Framework practices throughout the United Kingdom, between 2004 and 2007.

PARTICIPANTS

217 children aged 4-11 years who had at least one practice recorded episode of otitis media or a related ear problem in the previous 12 months, and with bilateral otitis media with effusion confirmed by a research nurse using otoscopy plus micro-tympanometry (B/B or B/C2, modified Jerger types).

INTERVENTION

Mometasone furoate 50 microg or placebo spray given once daily into each nostril for three months.

MAIN OUTCOME MEASURES

Proportions of children cured of bilateral otitis media with effusion assessed with tympanometry (C1 or A type) at one month (primary end point), three months, and nine months; adverse events; three month diary symptoms. Results 41% (39/96) of the topical steroid group and 45% (44/98) of the placebo group were cured in one or both ears at one month (difference favouring placebo 4.3% (95% confidence interval -9.3% to 18.1%). Poisson regression was done with adjustment for four pre-specified covariates (clinical severity, P=0.003; atopy, P=0.67; age, P=0.92; season, P=0.71). The adjusted relative risk at one month was 0.97 (95% confidence interval 0.74 to 1.26). At three months, 58% of the topical steroid group and 52% of the placebo group were cured (relative risk 1.23, 0.84 to 1.80). Diary symptoms did not differ between the two groups, and no significant harms were reported.

CONCLUSIONS

Topical steroids are unlikely to be an effective treatment for otitis media with effusion in general practice. High rates of natural resolution occurred by 1-3 months.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38988331; National Research Register NO575123823; MREC 03/11/073.

Mapping analyses to estimate health utilities based on responses to the OM8-30 Otitis Media Questionnaire

PURPOSE

To investigate the statistical relationship between the OM8-30 health-related quality of life measure for children with otitis media with effusion (OME) and measures of health utility (Health Utilities Index [HUI] Mark 3 and Mark 2) and to develop models to estimate HUI3 and HUI2 health utilities from OM8-30 scores.

METHODS

A placebo-controlled, randomised trial (GNOME) evaluating intranasal mometasone in 217 children with OME provided concurrent responses to OM8-30 and HUI at three time points. Ordinary least squares (OLS), generalised linear models and two-step regression analyses were used to predict HUI3 and HUI2 utilities based on OM8-30 facet and domain scores.

RESULTS

OLS models including all nine OM8-30 facets with or without predicted hearing level (HL) produced the best predictions of HUI3 utilities (mean absolute error: 0.134 with HL and 0.132 without; R(2): 0.63 with HL and 0.596 without). An OLS model predicting HUI3 utilities based on the two OM8-30 domain scores, reported hearing difficulties, predicted HL, age and sex also produced accurate predictions.

CONCLUSION

Regression equations predicting HUI3 and HUI2 utilities based on OM8-30 facet and domain scores have been developed. These provide an empirical basis for estimating quality-adjusted life years (QALYs) for interventions in children with OME.

Atopic disease and exhaled nitric oxide in an unselected population of young adults

BACKGROUND

Several studies have reported elevated levels of fractional exhaled nitric oxide (FeNO) in atopic patients, particularly in asthmatic patients, suggesting that FeNO is a marker of bronchial inflammation. However, the independent influence of different atopic entities (eczema, allergic rhinitis, and asthma) on FeNO has never been studied in the general population.

OBJECTIVE

To study the influence of a questionnaire-based diagnosis of atopic diseases and IgE and lung function measurements on FeNO levels.

METHODS

This study was part of a follow-up on otitis media of a birth cohort of 1,328 children born in Nijmegen, the Netherlands, between September 1, 1982, and August 31, 1983. Within the birth cohort, the incidence of asthma, allergic rhinitis, and eczema was determined, and off-line FeNO, spirometry, and IgE measurements were performed at the age of 21 years.

RESULTS

FeNO measurements were successfully performed in 361 participants. Median FeNO levels were significantly higher in those with vs without eczema (23.6 vs 18.0 ppb; P < .0001), those with vs without allergic rhinitis (20.7 vs 17.8 ppb; P = .0001), and those with vs without atopic asthma (23.3 vs 18.1 ppb; P = .02) but not in those with vs without asthma (20.8 vs 18.3 ppb; P = .24). Eczema, allergic rhinitis, smoking, sex, and atopic sensitization appeared to be independently associated with log FeNO in this population sample, whereas (atopic) asthma was not. No effect on FeNO levels was observed for lung function parameters.

CONCLUSION

Eczema, allergic rhinitis, and atopic status were all independently associated with elevated FeNO levels, whereas (atopic) asthma was not. This finding implies that future studies into the role of FeNO in asthma should consider the influence of atopic disease outside the lungs.

Children with developmental language delay at 24 months of age: results of a diagnostic work-up

The aim of this study was to evaluate if a diagnostic work-up should be recommended for 2-year-old children with developmental language delay (LD), or if the widely chosen 'wait and see' strategy is adequate. Children with LD were identified in paediatric practices during routine developmental check-ups using a German parent-report screening questionnaire (adapted from the MacArthur Communicative Development Inventories). A standardized German instrument and the Netherlands version of Bayley Scales of Infant Development (2nd ed.) were used to assess language ability and nonverbal cognitive development respectively in 100 children with LD (65 males, 35 females; mean age 24.7 mo [SD 0.9]) and a control group of 53 children with normal language development (33 males, 20 females; mean age 24.6 mo [SD 0.8]). Neurological and audiometric testing were also performed. Sixty-one per cent of the LD group had specific expressive LD and 17% specific receptive-expressive LD. In 22%, LD was associated with other neurodevelopmental problems, 6% showed significant deficits in nonverbal cognitive abilities, and in 12%, nonverbal cognitive abilities were borderline. Four per cent fulfilled the criteria of childhood autism. LD at 2 years proved to represent a sensitive marker for different developmental problems. Adequate early intervention requires a clear distinction between specific expressive or receptive-expressive LD and LD associated with other neurodevelopmental problems. Though catch-up development is to be expected in a substantial proportion of 'late talkers', our data demonstrate that a general 'wait and see' approach is not justified in young children with LD. A proposal for a rational diagnostic work-up is presented.

Identification of children in the first four years of life for early treatment for otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is the most common cause of acquired hearing loss in childhood and has been associated with delayed language development and behavioural problems. This condition has a point-prevalence of about 20% at the age of two years, a time of rapid language development. It is most often asymptomatic. Effective treatment exists for clearing effusions. Some have argued, therefore, that children should be screened and treated early if found to have clinically important OME. However, there is a high rate of spontaneous resolution of effusions and, for some children, effusions may represent a physiological response that does not reduce hearing significantly or impact negatively on language development or behaviour. Previous reviews of the effect of screening and treatment have included studies using non-randomised designs.

OBJECTIVES

The aim of this review was to assess evidence from randomised controlled trials about the effect, on language and behavioural outcomes, of screening and treating children with clinically important OME in the first four years of their life. The focus was on the first four years of life because this is the time of most rapid language development. The consequences of hearing loss are likely to be most serious during this time. In addition, children of this age are least likely to be able to report or seek help for impaired hearing, particularly if these problems have a slow onset and are subtle.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2006), MEDLINE (1950 to 2006) and EMBASE (1974 to 2006) in February 2002, and again in January 2006, and the reference lists of all studies. We also contacted the first authors of the studies we included in the original review.

SELECTION CRITERIA

1. Randomised controlled trials evaluating interventions for OME among children with OME identified through screening.2. Comparison of outcomes for children randomised to be screened for OME and outcomes for children who were not randomised to be screened for OME.

DATA COLLECTION AND ANALYSIS

Four authors independently extracted data and assessed trial quality, two in the original review and two for the update.

MAIN RESULTS

We identified no trials comparing outcomes for children randomised to be screened for OME with outcomes for children who were not randomised to be screened for OME. We identified three trials evaluating interventions for OME among children with OME identified through screening, one of which generated three published studies. These were trials of treatment in children identified through screening rather than trials of treatment programs. From these trials, we found no evidence of clinically important benefit in language development from screening and treating children with clinically important OME.

AUTHORS' CONCLUSIONS

The identified randomised trials do not show an important benefit on language development and behaviour from screening of the general population of asymptomatic children in the first four years of life for OME. However, these trials were all conducted in developed countries. Evidence generated in the developed world, where children may enjoy better nutrition, better living conditions and less severe and different infections may not be applicable to children in developing countries. The screening aspect of some of these studies was aimed primarily at identifying suitable children in whom to evaluate the effects of treatment, rather than to evaluate the effects of screening programs. Younger children and children with milder disease may have been included in these treatment trials compared to children who are offered treatment in pragmatic settings.

Autoinflation for hearing loss associated with otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) or 'glue ear' is an accumulation of fluid in the middle ear, in the absence of acute inflammation or infection. It is the commonest cause of acquired hearing loss in childhood and the usual reason for insertion of 'grommets'. Potential treatments include decongestants, mucolytics, steroids, antihistamines and antibiotics. Autoinflation devices have been proposed as a simple mechanical means of improving 'glue ear'.

OBJECTIVES

To determine the effects of autoinflation in adults and children with otitis media with effusion.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, CENTRAL (The Cochrane Library Issue 1, 2006), MEDLINE (1951 to 2006), EMBASE (1974 to 2006) and twelve other databases, using the Cochrane Ear, Nose and Throat Disorders Group search strategy.

SELECTION CRITERIA

We selected randomised controlled trials that compared any form of autoinflation to no autoinflation in individuals with 'glue ear'.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, assessed quality and extracted data from included studies.

MAIN RESULTS

Six studies met the inclusion criteria. Improvement occurred for the composite measure of tympanogram or audiometry at less than one month (Relative Risk of Improvement (RRI) 2.47, 95% confidence interval (CI) 0.93 to 6.58) and at more than one month (RRI 2.20, 95% CI 1.71 to 2.82). Subgroup analysis based on the type of intervention showed a significant effect using a Politzer device under one month (RRI 7.07, 95% CI 3.70 to 13.51) and over one month (RRI 2.25, 95% CI 1.67 to 3.04). Pooled estimates showed non-significant change in tympanometry (type C2 and B) at less than one month (RRI 1.65, 95% CI 0.49 to 5.56) and non-significant improvement in tympanometry at greater than one month (RRI 1.89, 95% CI 0.77 to 4.67). Non-significant improvements occurred for discrete pure tone audiometry (RRI 0.80, 95% CI 0.22 to 2.88) and non-discrete audiometry (WMD 6.95 dB, 95% CI 21.03 to 7.13). None of the studies demonstrated a significant difference in the incidence of side effects between interventions.

AUTHORS' CONCLUSIONS

All of the studies were small, of limited treatment duration and short follow up. However, because of the low cost and absence of adverse effects it is reasonable to consider autoinflation whilst awaiting natural resolution of otitis media with effusion. Further research should consider the duration of treatment and the long-term impact of autoinflation on developmental outcomes in children.

Prediction of asthma in young adults using childhood characteristics: Development of a prediction rule

OBJECTIVE

To develop an easily applicable prediction rule for asthma in young adulthood using childhood characteristics.

METHODS

A total of 1,055 out of 1,328 members of a Dutch birth cohort were followed from 2 to 21 years of age. Univariate and multivariate logistic regression analyses were used to evaluate the predictive value of childhood characteristics on asthma at 21 years of age. A prognostic function was developed, and the area under the receiving operating characteristic (ROC) curve was used to estimate the predictive ability of the prognostic models.

RESULTS

Of the 693 responding subjects, 86 (12%) were diagnosed with asthma. Independent prognostic factors at ages 2 and 4 years were female gender (odds ratios (OR) 1.9 and 2.1; 95% confidence intervals (CI) 1.2-3.2 and 1.3-2.5), smoking mother (OR 1.6 and 1.6; CI 1.0-2.7 and 1.0-2.6), lower respiratory tract illness (OR 1.9 and 2.4; CI 1.0-3.6 and 1.4-4.0), and atopic parents (OR 2.1 and 1.9; CI 1.3-3.4 and 1.2-3.1). The predictive power of both models was poor; area under ROC curve was 0.66 and 0.68, respectively.

CONCLUSION

Asthma in young adulthood could not be predicted satisfactorily based on childhood characteristics. Nevertheless, we propose that this method is further tested as a tool to predict development of asthma.

Recurrent childhood upper respiratory tract infections do not reduce the risk of adult atopic disease

BACKGROUND

Children of large families and those attending day care are at increased risk of respiratory tract infections, which in turn may protect against the development of allergic disease. Longitudinal studies investigating these associations beyond childhood are, however, scarce.

OBJECTIVE

To investigate the association between childhood recurrent upper respiratory tract infections (URTI) and asthma, allergic rhinitis (AR) and eczema in adulthood.

METHODS

A birth cohort of 1055 members followed prospectively from the ages of 2 to 21 years. Detailed information on URTI between the ages of 2 and 4 years was collected at 3 monthly intervals in a standardized interview. At the age of 8 years, a parental questionnaire regarding URTI between the ages of 4 and 8 years was used. The incidence of asthma and atopic disease at the age of 21 years was determined using a standardized questionnaire.

RESULTS

Of the original cohort, 693 (66%) members completed the questionnaire. Children who experienced recurrent URTI before the age of 2 years, between the ages of 2-4 years and between ages of 4 and 8 years were not less likely to have asthma at 21 years of age than children who did not experience recurrent URTI, relative risk (RR) 0.97 (95% confidence interval (CI) 0.65-1.46), RR 1.45 (CI 0.95-2.21) and RR 1.51 (CI 0.97-2.36), respectively. Neither were recurrent URTI associated with a decreased risk of AR, nor eczema at the age of 21 years.

CONCLUSIONS

Recurrent URTI in childhood did not reduce the risk of atopic disease in young adulthood.

Role of grommet in otitis media with effusion: A necessity or nuisance? A comparative study

Otitis media with effusion is one of the commonest otological problems in paediatric age group. The condition occurs in childhood as overt or covert hearing loss presenting as an educational or behavioural problem. As there is widespread controversy regarding its precise aetiology, natural history and pathogenesis a treatment dilemma still persists. The main goal of this study is to compare the efficacy of different modalities of medical and surgical treatment designed for this condition and analysis of the results statistical.

Natural course of tympanic membrane pathology related to otitis media and ventilation tubes between ages 8 and 18 years

OBJECTIVE

To present the course of tympanic membrane pathology in childhood and young adulthood after otitis media (OM) in early life.

STUDY DESIGN

Prospective follow-up study.

SETTING

Community study of a birth cohort.

PATIENTS

Three hundred fifty-eight subjects with a positive and negative history of OM (OM+ or OM-) or ventilation tube insertion (VT+ or VT-) derived from a birth cohort that had been followed-up from preschool to adult age.

METHODS

Standardized otomicroscopic examination performed at ages 8 and 18 years.

MAIN OUTCOME MEASURES

Tympanic membrane abnormalities (i.e., tympanosclerosis, atrophy, atelectasis and retraction pockets of the pars tensa, and retraction of the pars flaccida).

RESULTS

At the age of 8 years, tympanic membrane pathology was highly prevalent in the both OM+ subcohorts (OM+VT+, 92% and OM+VT-, 46%), whereas in the OM- ears (11%), tympanic membrane abnormalities were rare. In the subsequent 10-year period, many tympanic membrane abnormalities disappeared spontaneously, although the prevalence of tympanosclerosis remained substantial in the OM+VT+ cohort.

CONCLUSION

The natural course of most tympanic membrane pathology associated with OM in early life is favorable over time, suggesting an intrinsic repair capacity of the tympanic membrane. Tympanosclerosis, the most prevalent sequelae of OM and treatment with VT, however, shows little tendency of resolution.

Prevalence and risk factors of otitis media with effusion in Trabzon, a city in northeastern Turkey, with an emphasis on the recommendation of OME screening

This cross-sectional study was undertaken to assess the prevalence and risk factors for otitis media with effusion (OME) in Trabzon, a city in northeastern Turkey, and evaluate the need for screening for OME in the normal population. In kindergartens, daycare centers, public and private schools in the rural and central areas of Trabzon, 1,077 children aged between 5 and 12 years were examined. OME prevalence was 11.14% (120/1,077). Young age, attendance at kindergarten/daycare, low economical status, the mother's working status (housewife), history of snoring and acute otitis media, antibiotic use in the previous 3 months and active upper respiratory tract infection (URTI) were found to be the risk factors for OME. A history of hearing loss reported by the parents and teachers was found significant in the diagnosis of OME despite the low predictive value. When the parents suspected that their child had experienced hearing loss (in 36 cases), they did not refer them to a healthcare facility. To conclude, the approach to OME in developing countries should be more interventional as healthcare coverage is usually low and behavioral factors such as the demand for healthcare is poor.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Otitis media with effusion

The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline "Otitis Media With Effusion in Young Children," which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children 1 to 3 years old with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced-practice nursing to revise the OME guideline. The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media. The subcommittee made recommendations that clinicians should 1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME, 2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk, and 3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or diagnosis (if onset is unknown). The subcommittee also made recommendations that 4) hearing testing be conducted when OME persists for 3 months or longer or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME, 5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected, and 6) when a child becomes a surgical candidate (tympanostomy tube insertion is the preferred initial procedure). Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that 1) population-based screening programs for OME not be performed in healthy, asymptomatic children, and 2) because antihistamines and decongestants are ineffective for OME, they should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management. The subcommittee gave as options that 1) tympanometry can be used to confirm the diagnosis of OME and 2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery) and provide additional relevant information such as history of acute otitis media and developmental status of the child. The subcommittee made no recommendations for 1) complementary and alternative medicine as a treatment for OME, based on a lack of scientific evidence documenting efficacy, or 2) allergy management as a treatment for OME, based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed. The purpose of this guideline is to inform clinicians of evidence-based methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children more than 12 years old, because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child-development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed. This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition and may not provide the only appropriate approach to diagnosing and managing this problem.

Otitis media and speech and language: a meta-analysis of prospective studies

OBJECTIVE

Considerable controversy surrounds whether a history of otitis media with effusion (OME) in early childhood causes later speech and language problems. We conducted a meta-analysis of prospective studies to determine: 1) whether a history of OME in early childhood is related to receptive language, expressive language, vocabulary, syntax, or speech development in children 1 to 5 years old and 2) whether hearing loss caused by otitis media in early childhood is related to children's receptive language or expressive language through 2 years of age.

METHODS

We searched online databases and bibliographies of OME studies and reviews for prospective or randomized clinical trials published between January 1966 and October 2002 that examined the relationship of OME or OME-associated hearing loss in early childhood to children's later speech and language development. The original search identified 38 studies, of which 14 had data suitable for calculating a pooled correlation coefficient (correlational studies) or standard difference between parallel groups (group studies). Random-effects meta-analysis was used to pool data when at least 3 studies had usable data for a particular outcome.

RESULTS

We performed 11 meta-analyses. There were no significant findings for the analyses of OME during early childhood versus receptive or expressive language during the preschool years in the correlation studies. Similarly, there were no significant findings for OME versus vocabulary, syntax, or speech during the preschool years. Conversely, there was a significant negative association between OME and preschoolers' receptive and expressive language (lower language) (0.24 and 0.25 standard difference, respectively) in the group studies. Additionally, hearing was also related to receptive and expressive language in infancy (3%-9% of variance).

CONCLUSIONS

Our results indicate no to very small negative associations of OME and associated hearing loss to children's later speech and language development. These findings may overestimate the impact of OME on outcomes, because most studies did not adjust for known confounding variables (such as socioeconomic status) and excluded data not suitable for statistical pooling, especially from methodologically sound studies. Although some OME language differences were detectable by meta-analysis due to increased statistical power, the clinical relevance for otherwise healthy children is uncertain.

Should children be screened to undergo early treatment for otitis media with effusion? A systematic review of randomized trials

BACKGROUND

Otitis media with effusion (OME) is the most common cause of acquired hearing loss in childhood and has been associated with delayed language development and behavioural problems. Some have argued that children should be screened and treated early if found to have clinically important OME. The aim of this review was to assess evidence from randomized controlled trials about the effectiveness of screening and treating children with clinically important OME in the first 4 years of their life. The primary outcome was language development.

METHODS

We searched the Cochrane Controlled Trials Register, MEDLINE and EMBASE and reference lists of all included studies in February 2003. We also contacted the first authors of the studies included in this review. Search terms included otitis media; otitis media with effusion; glue ear; OME; screen; children; treatment; language; and behaviour. Data extraction and methodological quality assessment were performed by at least two of us for each study independently, using methods described in the Cochrane Collaboration Handbook.

RESULTS

From the three included randomized controlled trials evaluating interventions among children with OME identified through screening, we found no evidence of clinically important benefit in language development.

CONCLUSIONS

The identified randomized trials do not show an important benefit on language development from screening the general population of asymptomatic children in the first 4 years of life to undergo early treatment for OME. Screening asymptomatic children in the first 4 years of life for OME is not recommended.

The Etiology, Pathophysiology, and Management of Otitis Media with Effusion

Otitis media with effusion (OME) is a common and important condition that may result in developmental delay in children, and significant health care resources are devoted to its management. Newer techniques including polymerase chain reaction are implicating organisms not previously considered important in etiology. The role of gastroesophageal reflux as a cause of OME is likely to receive greater research attention. Regarding prevention, more is being learned about potentially modifiable risk factors such as environmental smoke, care outside the home, and breast feeding. Although immunization may to play a role in the future, existing evidence suggests that the general population of children should not be immunized in order to prevent OME. Several major studies have recently added to the understanding of epidemiology and management. Large trials in the United States, the Netherlands, and the UK suggest that OME is not an appropriate condition to include in a screening program. In addition, the advantages of early treatment with ventilation tubes over watchful waiting in terms of language development tend be modest and diminish by about 18 months. Treatment with hearing aids should be further evaluated. The search for effective medical management continues, and better ways are being identified of targeting interventions to those children with OME who are most likely to benefit.

Hearing deficits in young adults who had a history of otitis media in childhood: use of personal stereos had no effect on hearing

OBJECTIVE

To test the hypothesis proposed in a recent French study that a history of recurrent otitis media (OM) in childhood increases susceptibility to hearing loss from frequent exposure to a personal stereo (PS) during development to early adulthood.

METHODS

A subcohort of 358 young adults selected from a historic cohort study, all 18 years old and with a well-documented OM history (secretory and acute), provided data on the sound level and length of exposure to PSs. Four contrasting groups were formed: those with the highest or lowest PS exposure combined with a positive or negative history of OM (n = 238). The main outcome measure was hearing thresholds from pure-tone audiometry (0.5-8 kHz).

RESULTS

Young adults with a history of recurrent OM in childhood did not show greater susceptibility to hearing loss from PS use than their peers without a history of OM. However, a history of recurrent OM was associated with significant mean air-conduction hearing loss of 4 dB and a mean bone-conduction hearing loss of 2 dB compared with the participants without a history of OM (Fig 1).

CONCLUSIONS

Recurrent OM in childhood may have an irreversible effect on the middle ear and the cochlea and may lead to hearing deficits in later life. No interaction with PS exposure is seen.

Screening children in the first four years of life to undergo early treatment for otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is the most common cause of acquired hearing loss in childhood and has been associated with delayed language development and behavioural problems. This condition has a prevalence of about 20% at the age of two years, a time of rapid language development. It is most often asymptomatic. Effective treatment exists for clearing effusions. Some have argued, therefore, that children should be screened and treated early if found to have clinically important OME. However, there is a high rate of spontaneous resolution of effusions and for some children, effusions may represent a physiological response that does not reduce hearing significantly or impact negatively on language development or behaviour. Previous reviews of the effect of screening and treatment have included studies using non-randomised designs.

OBJECTIVES

The aim of this review was to assess evidence from randomised controlled trials about the effectiveness, on language and behavioural outcomes, of screening and treating children with clinically important OME in the first four years of their life. The focus was on the first four years of life because this is the time of most rapid language development. The consequences of hearing loss are likely to be most serious during this time. In addition, children of this age are least likely to be able to report or seek help for impaired hearing, particularly if these problems have a slow onset and are subtle.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (the Cochrane Library Issue 1, 2002), MEDLINE (1966-2002) and EMBASE (1974-2002) (all in February 2002) and reference lists of all studies. We also contacted the first authors of the studies we included in this review.

SELECTION CRITERIA

1. Randomised controlled trials evaluating interventions for OME among children with OME identified through screening. 2. Comparison of outcomes for children randomised to be screened for OME and outcomes for children who were not randomised to be screened for OME.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

We identified no trials comparing outcomes for children randomised to be screened for OME with outcomes for children who were not randomised to be screened for OME. We identified three trials evaluating interventions for OME among children with OME identified through screening. From these trials, we found no evidence of clinically important benefit in language development from screening and treating children with clinically important OME. Although there was a beneficial effect on the resolution of OME and improved hearing in the short-term (six months), this effect largely disappeared in the long-term (12 months).

REVIEWER'S CONCLUSIONS

The identified randomised trials do not show an important benefit from screening of the general population of asymptomatic children in the first four years of life for OME on language development and behaviour.

Use of Adenoidectomy and Adenotonsillectomy in Children with Otitis Media with Effusion

We conducted a prospective study of 48 children, aged 2 to 14 years, who had persistent bilateral otitis media with effusion, enlarged adenoids, and a bilateral conductive hearing loss. Half of these patients underwent adenoidectomy and the other half adenotonsillectomy. All patients were followed every 2 weeks for up to 6 months. At 2 months postoperatively, the overall success rate in terms of the resolution of middle ear effusion was 85.1%. Success rates were 82.6% in the adenoidectomy group and 87.5% in the adenotonsillectomy group; the difference was not statistically significant. Our findings demonstrate that both adenoidectomy and adenotonsillectomy are effective for the treatment of persistent otitis media with effusion, and they confirm the findings of other studies. Based on our findings and those of other investigators, we offer a four-step approach to the management of these children.

Does early detection of otitis media with effusion prevent delayed language development?

OBJECTIVE

To consider whether earlier detection of otitis media with effusion (OME) in asymptomatic children in the first 4 years of life prevents delayed language development.

METHODS

MEDLINE and other databases were searched and relevant references from articles reviewed. Critical appraisal and consensus development were in accordance with the methods of the Canadian Task Force on Preventive Health Care.

RESULTS

No randomised controlled trials assessing the overall screening for OME and early intervention to prevent delay in acquiring language were identified, although one trial evaluated treatment in a screened population and found no benefit. The "analytic pathway" approach was therefore used, where evidence is evaluated for individual steps in a screening process. The evidence supporting the use of tools for early detection such as tympanometry, microtympanometry, acoustic reflectometry, and pneumatic otoscopy in the first 4 years of life is unclear. Some treatments (mucolytics, antibiotics, steroids) resulted in the short term resolution of effusions as measured by tympanometry. Ventilation tubes resolved effusions and improved hearing. Ventilation tubes in children with hearing loss associated with OME benefited children in the short term, but after 18 months there was no difference in comparison with those assigned to watchful waiting. Most prospective cohort studies that evaluated the association between OME and language development lacked adequate measurement of exposure or outcome, or suffered from attrition bias. Findings with regard to the association were inconsistent.

CONCLUSIONS

There is insufficient evidence to support attempts at early detection of OME in the first 4 years of life in the asymptomatic child to prevent delayed language development.