Surgery for otitis media with effusion in children and its relationship to parental smoking

The effect of passive smoking on the etiology of serous otitis media in children

Serous otitis media (SOM) is a disease mostly seen in the pediatric age group and characterized by serous effusion in the middle ear. The disease which is mostly silent can cause permanent hearing loss if it is not diagnosed and treated early. Passive smoking is one of the environmental factors in the etiopathology of the disease and risk factors for SOM formation in children. In our study, smoking habits of family members of 75 children with SOM and 50 healthy controls were investigated. At the end of the study, the correlation between SOM and passive smoke exposed was statistically significant in children (p < 0.01). In this study, the effect of passive smoking, which is a preventable and controllable risk factor in the etiology of the SOM in children is emphasized.

Tobacco Smoke Exposure and Eustachian Tube Disorders in US Children and Adolescents

OBJECTIVES

To describe the association between active, environmental tobacco smoke (ETS) exposure and the prevalence of eustachian tube dysfunction (ETD) in the U.S. pediatric population.

STUDY DESIGN

Cross-sectional.

SETTING

U.S. representative demographic and audiometric data from the National Health and Nutrition Examination Survey (NHANES);2005-2010.

SUBJECTS AND METHODS

The study consisted of 2,977 children aged 12-19 years. ETD was defined as middle ear pressure <100mm H20. ETS was defined as non-active smoking in individuals with serum cotinine over the limit of detection (≥0.015 ng/mL) and <10 ng/mL(N = 1559).

RESULTS

The prevalence of ETD was 6.1%. After multivariate adjustment for age, sex, body mass index, education level, ethnicity, or having a cold, sinus problem or earache during the last 24 hours, compared to unexposed children, the odds ratios (95% confidence interval) of ETD for those exposed to ETS ages 12-15 in the first, second and third tertile of cotinine concentrations were, respectively, 1.38 (0.53-3.60), 0.99 (0.53-3.60) and 2.67 (1.12-6.34). Similarly, the odds ratios (95% confidence interval) of ETD for those exposed to ETS ages 16-19 in the first, second and third tertile of cotinine concentrations were, respectively, 1.28 (0.48-3.41), 0.99 (0.40-2.48) and 2.86 (1.19-6.88).

CONCLUSION

These data suggest that children and adolescents exposed to high concentrations of ETS may have an increased prevalence of ETD.

From the American Academy of Pediatrics: Technical report--Secondhand and prenatal tobacco smoke exposure

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.

Smoke exposure and outcome of endoscopic sinus surgery in children

OBJECTIVE

The study goal was to determine whether cigarette smoke exposure in children who are undergoing endoscopic sinus surgery (ESS) for chronic sinusitis will have an impact on the outcome.

DESIGN

We conducted a cohort study in a tertiary care children's hospital setting.

PATIENTS AND METHODS

The study population consisted of 118 patients who underwent ESS between January 1994 and June 1999. The mean age was 6.5 (range, 2 to 13 years). The outcome of ESS was measured > or =1 year after the operation. A questionnaire was mailed to the caretakers to measure success. Those who required revision subsequently were considered as failures.

RESULTS

Multivariate logistic regression analysis was performed with smoke exposure as an independent variable and outcome measured as success of procedure. The overall success rate was 83%. Univariate analysis of smoke exposure and outcome of surgery revealed that children exposed to smoke in household had a 70% success rate compared with children not exposed to smoke, who had a 90% success rate (P = 0.007). Multivariate analysis revealed smoke exposure continued to be an independent predictor of success.

CONCLUSION

ESS in children with cigarette smoke exposure predisposes to a poorer outcome. This needs to be taken into consideration when recommending ESS for those children.

Smoking in parents of children with asthma and bronchiolitis in a pediatric emergency department

OBJECTIVES

To determine smoking habits, levels of nicotine-addiction, readiness to quit, and beliefs about the effects of environmental tobacco smoke (ETS) of parents of children with bronchiolitis and asthma who present to a children's emergency department (ED).

DESIGN/METHODS

This was a cross-sectional prevalence study of parents or legal guardians of children with asthma or bronchiolitis presenting to a pediatric ED.

RESULTS

Two hundred forty-nine parents/legal guardians comprised the study group. The mean age (+/-SD) was 30.0 (+/-8.9) years; 88% were female; 51% were nonwhite; 37% were educated beyond high school. The self-reported smoking prevalence was 41% (95% CI = 32-51). Smoking prevalence among parents of wheezing children varied according to education, income, and race, but not according to gender, age, or employment status. Of the 102 smokers in the sample, 84 (82.4%, 95% CI = 73-88) reported that they wanted to quit; 78 (76.5%, 95% CI = 68-84) stated that they wanted to quit within the next month. Forty-nine percent (95% CI = 39-59) scored above 4 on the Fagerstrom Test for Nicotine Dependence and were considered nicotine-dependent. The majority of smokers admitted to smoking around their children (66.7%, 95% CI = 57-75). Many parents knew that ETS might contribute to the development of the following illnesses: colds/upper respiratory tract infections - 77.5%, otitis media - 68.6%, pneumonia - 50%, wheezing/asthma attacks - 86.3%, and SIDS - 31.4%.

CONCLUSION

The prevalence of smoking and nicotine addiction among parents of children with asthma or bronchiolitis who bring their children to a pediatric ED is high. Many parents have some knowledge about the effects of ETS, and the majority would like to quit. Future studies to help determine the best way to deliver advice to parents on ETS exposure reduction and smoking cessation are warranted.

Smoking and tympanoplasty: implications for prognosis and the Middle Ear Risk Index (MERI)

OBJECTIVES/HYPOTHESIS

The objectives of this study are to review the effects of smoking on preoperative middle ear disease severity, long-term surgical outcome, type and extent of surgery required, the need for ossicular chain reconstruction, and the long-term hearing results.

STUDY DESIGN

A retrospective chart review.

MATERIALS AND METHODS

The charts of 74 smokers and non-smokers who underwent over-under tympanoplasty were reviewed. An analysis of the disease severity (using the Middle Ear Risk Index [MERI]) at presentation and type of surgery was performed. A review of graft take and delayed failure (late perforation or atelectasis after 6 mo) and audiologic data were performed.

RESULTS

Fifteen patients smoked a mean of 20 cigarettes daily for a mean of 15 years. The MERI was well matched for both groups. There was a trend toward smokers having a higher incidence of otorrhea preoperatively and requiring a more extensive surgical procedure. All patients had full take of the tympanic membrane graft at 6 months; however, delayed surgical failure was seen in 20% of non-smokers compared with 60% of smokers (P = .050). No statistically significant difference was seen in hearing outcome.

CONCLUSIONS

Cigarette smoking is associated with more severe middle ear disease preoperatively. More extensive surgery is often needed in smokers to eradicate the disease. Most significantly, smoking is associated with a threefold increase in the chance of long-term graft failure. Based on the results of this study, the MERI has been revised to include smoking as a risk factor.

Evaluation of the effect of passive smoking on otitis media in children by an objective method: urinary cotinine analysis

OBJECTIVES

We aimed to determine objectively the effect of the passive smoking on otitis media with effusion (OME) and recurrent otitis media (ROM) by using the method of cotinine urinalysis.

STUDY DESIGN

We designed a prospective case-control study with follow-up of the case group for 1 year after insertion of tympanostomy tubes to evaluate postoperative complications such as otorrhea and early extrusion (<6 months), in case a significant risk factor was found.

METHODS

One hundred fourteen children between 3 and 8 years of age requiring tympanostomy tubes because of OME and ROM were chosen and compared with 40 age-matched children. Exposure to environmental tobacco smoke was assessed by cotinine urinalysis, which was performed by means of the radioimmunoassay method.

RESULTS

In this study, 73.7% (84 of 114) of the children in the case group and 55.0% (22 of 40) of the children in the control group were found to be "exposed" (P = .0461). This difference was statistically significant. Comparing the cotinine urinalysis results with parental smoking histories, 23.1% (9 of 39) of the children without parental smoking histories were "exposed" to tobacco smoke versus 84.3% (97 of 115) of the children with parental smoking histories (at least one person smoking).

CONCLUSIONS

Our results indicate that sidestream smoking increases the risk of OME and ROM. Legal regulations and guidelines must be established to protect children from passive smoking. Because cotinine urinalysis is a noninvasive and reliable method for the determination of passive smoking, it can be used for that purpose.

[Study of passive smoking measured by urinary cotinine in maternal and child protective health centers in North-Pas-de-Calais]

BACKGROUND

The aim of the study was to determine the circumstances of exposure to environmental tobacco smoke, to evaluate its importance by measurement of urinary cotinine, and to study the relationship with the children's medical history.

POPULATION AND METHODS

It was a prospective investigation realized in 20 outpatient pediatric clinics. The parents answered a questionnaire to assess the child's exposure as well as the child's medical and surgical history. Cotinine was measured in urine samples collected during the visit. Concentrations > 6 ng/mL were considered to be positive.

RESULTS

Two hundred and one children were included in the study (mean age 17 months, extremes: 1-72 months), 107 of whom were exposed to environmental tobacco smoke. Urinary cotinine was found to be positive in 27 cases (13%). There was a positive relation between passive tobacco exposure and positive urinary cotinine (P < 0.001). Eighty of 201 mothers and 135 of 185 fathers smoked. There was a relation between positive urinary cotinine and the mother's smoking, as well as with a history of upper respiratory tract infection (rhinitis, otitis media) or adenoidectomy. No relation was found between a history of bronchiolitis and passive smoking.

CONCLUSIONS

Passive tobacco exposure is very frequently encountered in our region. Urinary cotinine, which can be easily measured, might constitute an efficient tool in order to convince the parents of the reality of passive smoking.

Maternal cigarette smoking and invasive meningococcal disease: a cohort study among young children in metropolitan Atlanta, 1989-1996

OBJECTIVES

This study assessed the association between maternal cigarette smoking during pregnancy and the risk of invasive meningococcal disease during early childhood.

METHODS

Using a retrospective cohort study design, cases from an active surveillance project monitoring all invasive meningococcal disease in the metropolitan Atlanta area from 1989 to 1995 were merged with linked birth and death certificate data files. Children who had not died or acquired meningococcal disease were assumed to be alive and free of the illness. The Cox proportional hazards analysis was used to assess the independent association between maternal smoking and meningococcal disease.

RESULTS

The crude rate of meningococcal disease was 5 times higher for children whose mothers smoked during pregnancy than for children whose mothers did not smoke (0.05% vs 0.01%). Multivariate analysis revealed that maternal smoking (risk ratio [RR] = 2.9; 95% confidence interval [CI] = 1.5, 5.7) and a mother's having fewer than 12 years of education (RR = 2.1; 95% CI = 1.0, 4.2) were independently associated with invasive meningococcal disease.

CONCLUSIONS

Maternal smoking, a likely surrogate for tobacco smoke exposure following delivery, appears to be a modifiable risk factor for sporadic meningococcal disease in young children.

Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children

BACKGROUND

A systematic quantitative review was conducted of evidence relating parental smoking to acute otitis media, recurrent otitis media, middle ear effusion, and adenoidectomy and/or tonsillectomy.

METHODS

Forty five relevant publications were identified after consideration of 692 articles selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified 13 studies of acute otitis media, nine of recurrent otitis media, five of middle ear effusion, nine of glue ear surgery, and four of adenotonsillectomy. A quantitative meta-analysis was possible for all outcomes except acute otitis media, using random effects modelling where appropriate to pool odds ratios from each study.

RESULTS

Evidence for middle ear disease is remarkably consistent, with pooled odds ratios if either parent smoked of 1.48 (95% CI 1.08 to 2.04) for recurrent otitis media, 1.38 (1.23 to 1.55) for middle ear effusion, and 1.21 (0.95 to 1.53) for outpatient or inpatient referral for glue ear. Odds ratios for acute otitis media are in the range 1.0 to 1.6. No single study simultaneously addresses selection bias, information bias and confounding, but where these have been investigated or excluded in the design or analysis, the associations with parental smoking persist virtually unchanged. Large French and British studies are inconsistent with regard to the association of parental smoking and tonsillectomy.

CONCLUSIONS

There is likely to be a causal relationship between parental smoking and both acute and chronic middle ear disease in children.

Snoring, apnoea and ENT symptoms in the paediatric community

This study was designed to determine the prevalence of snoring and assess the extent of associated ENT symptoms in children up to 10 years of age. A questionnaire was presented to the parents of 245 children chosen at random from the General Practice list of the town of Frome, Somerset, UK. The prevalence of snoring was found to be 27%. This increased to 47% in the presence of an upper respiratory infection. Snoring was found to be significantly (P < 0.001) associated with a history of poor hearing, restless sleep, and having a cold. Less significant (P < 0.01) associations occurred with parental smoking, eczema, sleep talking, moving around the bed at night, sore throats, having a runny nose and mouth breathing. Snoring is a common symptom in children up to 10 years of age. Without evidence of other ENT disease the snoring child does not require referral to an ENT department for further investigation.

The effects of in vitro cotitine on nasal ciliary beat frequency

Cotitine is one of the main metabolites of nicotine. It is stable and in vivo has a relatively long circulating half life. Nasal ciliated cells from non-smoking individuals were exposed in vitro to solutions of cotitine corresponding to serum levels in active and passive smokers. Ciliary beat frequency was measured by a computerized photometric technique. There was a significant drop in ciliary beat frequency compared with control ciliated cells in phosphate buffered saline. It is concluded that cotitine in active or passive smoking has a marked effect on ciliary function. It may be a factor leading to diminished mucociliary clearance and persistent middle ear effusion.

Relationship of environmental tobacco smoke to otitis media in young children

Otitis media (OM) continues to be a major health problem of children in the United States. The role of environmental tobacco smoke (ETS) as a predisposing factor has not been completely discerned. This study and discussion is an investigation and review of the influence of passive cigarette smoking on OM in children, and its effect on the practice of otolaryngology within the pediatric population. A prospective study of 175 children with recurrent OM and requiring tympanostomy tubes (case group) was compared to an age-matched group of 175 children (controls) to determine the role passive cigarette smoking has on the incidence of this disease. The results revealed that the case group more commonly had exposure to ETS (P = .04). Prospective follow-up of the case group revealed no significant difference in the clinical course of the children who were exposed to ETS and those who were not.

Smoking and Middle Ear Disease: Are they Related? A Review Article

The relationship between passive smoking and middle ear disease was reviewed. The hypothesis that acute otitis media, serous otitis media, and related diseases in children are caused by inhalation of second-hand smoke has been accepted by many. We reviewed the literature on this topic. There are many studies that do not support the hypothesis. There is no indication that the smokers themselves have a higher incidence of middle ear disease. Considering the difficulty of publishing negative studies, the need for academics to publish significant findings, and the poor foundation for some authors” conclusions in the literature, we find that the literature does not offer sufficient support for the hypothesis that second-hand smoke causes middle ear disease to accept the hypothesis.

Tobacco smoke and otitis media in the chinchilla model

To determine whether tobacco smoke contributes to the pathogenesis of acute otitis media, chinchillas were exposed to mainstream tobacco smoke or sham conditions (cigarettes not lit) in a Walton smoke exposure machine for 20-minute cycles two or three times daily. After 6 to 8 weeks of daily exposure, 12 chinchillas were nasally injected with Streptococcus pneumoniae, and 18 chinchillas were injected into both middle ears with nontypable Haemophilus influenzae. Smoke or sham exposures were continued for 2 to 4 weeks after injection. Otitis media developed in none of the 12 nasally injected chinchillas and in all 18 chinchillas whose middle ears were injected with nontypable Haemophilus influenzae. Persistence of middle ear effusion and persistence of nontypable Haemophilus influenzae in the middle ear effusion were not different between the smoke- and sham-exposed groups. This suggests that mainstream smoke exposure does not change the natural course of otitis media in the chinchilla model.

Environmental tobacco smoke and otitis media

Environmental tobacco smoke (secondhand smoke) is a health hazard experienced by one half to two thirds of the nation's children younger than 5 years of age. Although the role of environmental tobacco smoke in the genesis of pulmonary disease in children has been increasingly recognized, somewhat less attention has been paid to the role of environmental tobacco smoke in the development of childhood otitis. This presentation will review current data regarding environmental tobacco smoke, with a particular emphasis on its effects on the ears and eustachian tube. Current American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. education efforts will also be discussed.

Exposure to environmental tobacco smoke as a risk factor for recurrent acute otitis media in children under the age of five years

Exposure to environmental tobacco smoke (ETS) has remained a controversial risk factor for otitis media in children. This study evaluates the association between exposure to ETS and recurrent acute otitis media (RAOM) in 85 cases and 85 age and gender matched controls under the age of 5 years. Cases and controls were obtained from outpatient otolaryngology and ophthalmology clinics, respectively, at the Children's Hospital of Eastern Ontario. Cases were defined as having four or more physician documented AOM episodes in the preceding 12 months and controls were otitis free in the prior 12 months. Exposure status was assessed via parental questionnaire. Controlling for other risk factors (via conditional logistic regression), such as daycare attendance, socioeconomic status, prematurity and family history of otitis media, a significant association between ETS and RAOM was evident (odds ratio = 2.68, 95% CI = 1.27-5.65). When categorized, a significant exposure response relationship between increasing level of exposure to ETS and increased risk of RAOM was evident. The population etiologic fraction indicated that up to 34% of RAOM cases may be accounted for by ETS exposure. We conclude that exposure to ETS is an important and modifiable risk factor for RAOM in children under the age of 5 years.

Parental cigarette smoking and tonsillectomy in children

The deleterious effects of parental smoking on the upper respiratory tracts of children are becoming increasingly recognized. This study examines the effect of parental smoking on the frequency of tonsillitis and incidence of tonsillectomy in children. A group of children being admitted for tonsillectomy and a control group of children from an orthoptic clinic were studied. Details recorded about the children included a history of tonsillectomy and the number of courses of antibiotics taken for sore throats in the previous 12 months. Parents were questioned about their smoking habits. A marked and statistically significant association has been found between the incidence of tonsillectomy in children and parental smoking in the home environment. There was a higher frequency of attacks of tonsillitis requiring antibiotic treatment in those children whose parents smoked. This effect may be mediated by altered oropharyngeal flora, mucociliary dysfunction, increased cross infection or a combination of these. If parents are encouraged to stop smoking there will be a reduction in tobacco smoke levels in the home environment and this should lead to a fall in both the incidence of tonsillitis and the need for tonsillectomy in their children.

The effect of parental smoking on outcome after treatment for glue ear in children

A sample of 201 children aged between 2 and 9 years with bilateral chronic otitis media with effusion (OME) were treated prospectively and at random by adenoidectomy, adenotonsillectomy, or with neither procedure. In all cases only a unilateral grommet was inserted and the contralateral unoperated ear was examined one year post-operatively for persistence or resolution of the effusion. A self-administered questionnaire was completed by the parents concerning their smoking habits. The resolution of effusion following surgery was assessed in relation to smoking by by the mother and father separately and in combination. Clearance of glue was statistically less frequent where the child's mother or where both parents smoked. This was related to the number of cigarettes smoked by the mother or both parents. The adverse effect was demonstrable whether or not adenoidectomy or adenotonsillectomy had been performed for treatment. The findings lend further support or professional and governmental opinions of a deleterious effect of passive smoke exposure on children and in this case parental smoking has been shown to have an adverse effect on the outcome of OME following surgical treatment.

Parental smoking and persistent otitis media with effusion in children

A total of 163 children were entered into a case-control study to determine whether any causal relationship exists between otitis media with effusion (OME) requiring grommet insertion and parental smoking. One hundred children with persistent OME formed the case group and 63 children with normal ears formed the control group. The prevalence of parental smoking in each group was then compared. Information was collected by questionnaire and further details about the subjects with regard to surgery of the upper respiratory tract were also gathered. Analysis of findings in this study and previous reports has failed to demonstrate a significantly increased prevalence of smoking in at least one parent, amongst children with persistent otitis media with effusion requiring surgical intervention.