Persistence of middle-ear effusion after acute otitis media in children

Diagnosing Middle Ear Dysfunction in 10- to 16-Month-Old Infants Using Wideband Absorbance: An Ordinal Prediction Model

Purpose The aim of this study was to develop an ordinal prediction model for diagnosing middle ear dysfunction in 10- to 16-month-old infants using wideband absorbance. Method Wideband absorbance, tympanometry, and distortion product otoacoustic emissions were measured in 358 ears of 186 infants aged 10-16 months (M _age = 12 months). An ordinal reference standard (normal, mild, and severe middle ear dysfunction) was created from the tympanometry and distortion product otoacoustic emission results. Absorbance from 1000 to 5657 Hz was used to model the probability of middle ear dysfunction with ordinal logistic regression. Model performance was evaluated using measures of discrimination (c-index) and calibration (calibration curves). Performance measures were adjusted for overfitting (bias) using bootstrap resampling. Probabilistic and simplified methods for interpreting the model are presented. The probabilistic method displays the probability of ≥ mild and ≥ severe middle ear dysfunction, and the simplified method presents the condition with the highest probability as the most likely diagnosis (normal, mild, or severe middle ear dysfunction). Results The c-index of the fitted model was 0.919 (0.914 after correction for bias), and calibration was satisfactory for both the mild and severe middle ear conditions. The model performed well for the probabilistic method of interpretation, and the simplified (most likely diagnosis) method was accurate for normal and severe cases but diagnosed some cases with mild middle ear dysfunction as normal. Conclusions The model may be clinically useful, and either the probabilistic or simplified paradigm of interpretation could be applied, depending on the context. In situations where the main goal is to identify severe middle ear dysfunction and ease of interpretation is highly valued, the simplified interpretation may be preferable (e.g., in a screening clinic that may not be concerned about missing some mild cases). In a diagnostic clinical environment, however, it may be beneficial to use the probabilistic method of interpretation.

Factors Associated with Clinical Outcomes in Acute Otitis Media

Acute otitis media (AOM) is a common disease in childhood. If predictors of outcome in AOM were known, it would be possible to individualize therapy. Our aim was to identify factors that predict the outcome in AOM. We enrolled 368 children with AOM (ages, 10 to 86 months). The severity of symptoms and the severity of tympanic membrane changes were graded with a scoring system. Nasopharyngeal colonization with middle ear pathogens was determined on day 1. Three outcomes were assessed: persistence of symptoms at day 5, persistence of tympanic membrane changes at day 28, and recurrence of acute symptoms prior to day 28. Persistence of symptoms at day 5 was associated with younger age (35 versus 44 months; p < .001), higher symptom score on day 1 (3.5 versus 2.9; p < .05), and colonization with Streptococcus pneumoniae (61% versus 41%; p < .05). Persistence of tympanic membrane changes at day 28 was associated with younger age (39 versus 45 months; p < .01), higher tympanic membrane score on day 1 (4.1 versus 3.6; p < .01), and nasopharyngeal colonization with S pneumoniae, especially drug-resistant S pneumoniae (33% versus 13%; p < .05). Recurrence of acute symptoms prior to day 28 occurred in 14% of the children. Streptococcus pneumoniae was the only pathogen associated with an increased recurrence rate (23%) as compared to the group without pathogens (7%; p < .05). Age, severity of disease at presentation, and nasopharyngeal colonization patterns were proven to be important determinants of outcome in AOM.

Montelukast is as effective as penicillin in treatment of acute otitis media: an experimental rat study

Background

Leukotrienes are the major factors in the formation of edema and mucus, as well as development of tuba Eustachii dysfunction in acute otitis media. We developed an experimental acute suppurative otitis media model and compared the responses of rats to penicillin and combinations of leukotriene antagonist with respect to histopathological observations conducted in early and late phases.

Material/Methods

A total of 83 ears from 56 Wistar rats were used in this study. Pneumococcus suspension was injected trans-tympanically into all rats. Subjects were classified into 4 different groups with 14 rats in each. In Group A, intramuscular penicillin G was injected for a period of 5 days. In Group B, intraperitoneal montelukast was injected for 21 days in addition to penicillin. In Group C, intraperitoneal montelukast isotonic NaCl in Group D was injected into rats for 21 days.

Results

No significant difference was found between the groups, except for mucosal vascularization with respect to mucosal and TM parameters in early phases. Furthermore, considerable deviations were observed for the recuperation of TM and mucosal inflammation for groups in which subjects were injected with montelukast as compared to other groups of the study in the late phases.

Conclusions

When the parameters of inflammation in the rat middle ear were compared with each other, most of these parameters did not show any statistically significant beneficial effects in montelukast and penicillin groups.

The diagnosis and management of acute otitis media

This evidence-based clinical practice guideline is a revision of the 2004 acute otitis media (AOM) guideline from the American Academy of Pediatrics (AAP) and American Academy of Family Physicians. It provides recommendations to primary care clinicians for the management of children from 6 months through 12 years of age with uncomplicated AOM. In 2009, the AAP convened a committee composed of primary care physicians and experts in the fields of pediatrics, family practice, otolaryngology, epidemiology, infectious disease, emergency medicine, and guideline methodology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Southern California Evidence-Based Practice Center to develop a comprehensive review of the new literature related to AOM since the initial evidence report of 2000. The resulting evidence report and other sources of data were used to formulate the practice guideline recommendations. The focus of this practice guideline is the appropriate diagnosis and initial treatment of a child presenting with AOM. The guideline provides a specific, stringent definition of AOM. It addresses pain management, initial observation versus antibiotic treatment, appropriate choices of antibiotic agents, and preventive measures. It also addresses recurrent AOM, which was not included in the 2004 guideline. Decisions were made on the basis of a systematic grading of the quality of evidence and benefit-harm relationships. The practice guideline underwent comprehensive peer review before formal approval by the AAP. This clinical practice guideline is not intended as a sole source of guidance in the management of children with AOM. Rather, it is intended to assist primary care clinicians by providing a framework for clinical decision-making. It is not intended to replace clinical judgment or establish a protocol for all children with this condition. These recommendations may not provide the only appropriate approach to the management of this problem.

Effect of recurrent otitis media on language profile in children with fragile x syndrome

Objective

Language is almost always affected in fragile X syndrome (FXS), and a delay in language acquisition is one of the first characteristics. The aim of this work was to study the effect of recurrent middle ear infections on the language profile in boys with FXS. Study design: Prospective case series.

Setting

Academic Medical Center.

Subjects and Methods

The present study was conducted on 30 males, ranging in age from 4–10 years. They were diagnosed as having a full mutation of DNA. The males were divided into two groups: Group A included 15 children with a history of recurrent middle ear infections more than four times per year during the first 4 years of life, and Group B did not have a history of recurrent middle ear infections during the first 4 years of life. Language assessments were done for all participants using the Standardized Arabic Language test.

Results

Results showed significant delays in language development in children with FXS. Relative strengths in semantics compared to syntax and pragmatics were observed in all boys. The recurrent ear infections of the boys played an important role in the language development delay. The mean of receptive, expressive, and total language age was better and higher among boys without a history of recurrent middle ear infections compared to boys with recurrent middle ear infections.

Conclusion

Recurrent otitis media in boys with FXS exacerbates the language problems that exist in this syndrome.

Otitis media

Otitis media represents a broad spectrum of disease, which include acute otitis media and otitis media with effusion. As immunization with the pneumococcal conjugate vaccine has become more widespread, the microbiological landscape of otitis media has changed, which affects the treatment options facing clinicians worldwide. This review discusses the diagnosis and medical management of acute and chronic suppurative otitis media, the changes noted over the past decade, and briefly expounds on the surgical management of their severe complications.

Factors associated with the presence of drug-resistant bacteria and recurrent acute otitis media in children--a study in a private clinic

CONCLUSIONS

The proportion of drug-resistant bacteria was lower than previous reports. In children with acute otitis media (AOM), lower age, presence of multiple bacteria, and otitis media with effusion (OME) represented significant factors for recurrent AOM and the presence of drug-resistant bacteria.

OBJECTIVE

Recently, the proportion of drug-resistant bacteria has been increasing in children with AOM. We studied the proportion of drug-resistant bacteria and background factors for detection of drug-resistant bacteria and recurrent AOM in a private clinic.

SUBJECTS AND METHODS

Subjects comprised 170 patients <12 years old with AOM. Middle ear fluid was collected and pathogenic bacteria were identified. The following factors were considered: age, sex, use of antibiotics in the past 1 month, past history of recurrent AOM, presence of OME, and multiple bacteria of the three main strains (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis).

RESULTS

A total of 169 strains were detected in 77% of children with AOM. Drug-resistant bacteria comprised 44 of the 169 strains (26%). Lower age (p=0.001) and presence of multiple bacteria (p<0.001) represented significant factors for the presence of drug-resistant bacteria. OME was a significant factor for recurrent AOM (p<0.001).

Presence of herpesviruses in middle ear fluid of children with otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is a disease that frequently occurs in children. Etiopathogenesis of the diseases has not been completely elucidated. There are limited numbers of studies on the presence of herpesviruses in otitis media cases with OME. The present study was undertaken to determine the rate of some herpesviruses in OME cases of children.

METHODS

A total of 92-middle ear fluids were collected from 51 children. The samples were analyzed using polymerase chain reaction (PCR) for detection of herpesviruses including Herpes simplex virus (HSV), cytomegalovirus (CMV), Varicella zoster virus (VZV), and Epstein-Barr virus (EBV).

RESULTS

PCR analysis of the 92 samples showed that genomes of EBV in 12 (13.04%), HSV in seven (7.60%), CMV in five (5.43%), and VZV in three (3.26%) were present. Two of these samples were positive for both HSV and EBV genomes. Therefore, 25 (27.17%) of the samples were determined to be infected with any of the herpesviruses tested.

CONCLUSIONS

In the present study, herpesviruses were determined at a high rate in middle ear fluids of children with OME. However, the present study is a preliminary study and more extensive studies, especially experimental studies, are required to elucidate the role of herpesviruses in pathogenesis of OME and whether there is a relation between rate of herpesviruses in OME cases, and the reactivation of latent infections.

Otitis media today: a challenge for physicians and the community

Acute otitis media is one of the most common causes of medical consultation worldwide, and has a high economic impact. In this review, a clear definition between acute otitis media and otitis media with effusion is presented. The microbiology and characterization of the main bacterial isolates in acute otitis media and the susceptibility patterns are reviewed, and the latest concepts in antimicrobial treatment are discussed. The need for courses that improve the capability of primary care physicians to diagnose acute otitis media using pneumatic otoscopy, and for parental education is also discussed.

Black/white differential use of health services by young children in a rural Mississippi community

BACKGROUND AND OBJECTIVES

Use of health services in rural communities has not been well studied. We explored how black and white children used health services in a rural Mississippi community.

METHODS

Data were prospectively collected for 396 children attending a private practice to determine if race was associated with the use of health services in this community.

RESULTS

White children made more sick contacts than black children (P < 0.001). Black children (36%) were more likely to be treated in the emergency room than white children (24%; P = 0.013). There was no black-white difference in the hospitalization rates, although white children were more likely to undergo ear-nose-throat (ENT) surgery for pressure equalizing tube (PET) placement, and/or tonsillectomy and adenoidectomy (T and A; P < 0.001). Even after controlling for various confounders, the frequency of all physician sick contacts was twice as high for white children than for black children (RR = 2.17; 95% C.I. = 1.32-3.58).

CONCLUSION

Overall, black children used disproportionately fewer health services than their white counterparts, but used significantly higher emergency room services. Private insurance coverage was the single most significant variable that accounted for the black-white differential use of the emergency room.

Disappearance of middle ear effusion in acute otitis media monitored daily with tympanometry

BACKGROUND

Disappearance of middle ear effusion is one of the most important outcomes in the treatment of acute otitis media (AOM).

AIM

To evaluate the duration of effusion in AOM treated by antimicrobials and to find factors influencing it.

METHODS

Parents of 90 children with AOM monitored daily the disappearance of effusion with tympanometry. The children were randomly allocated to be treated with either oral amoxicillin or cefuroxime-axetil for 10 d. Daily monitoring lasted for 14 d or until the tympanogram was normal (curve A or C) in both ears. Pneumatic otoscopy was carried out every 2 wk.

RESULTS

Normal tympanograms were obtained after a median time of 7.5 d (range 1-58 d) among 75 successfully monitored patients. In two-thirds (69%) of them, effusion resolved in 14 d. The median duration of effusion did not differ significantly between the two treatment groups (8 vs 7 days, p=0.7). The children who had unilateral AOM cured more rapidly than those with bilateral AOM (5 vs 19 d, p<0.001). In logistic regression analysis adjusted for age, bilaterality explained treatment failure at 2 wk with an odds ratio of 28.1 (95% CI 4.6-169.5, p<0.001).

CONCLUSION

The choice of antimicrobials did not influence the duration of middle ear effusion, which was much shorter than had been thought previously. Children with unilateral AOM were cured much more quickly than those with bilateral AOM.

The effect of montelukast sodium on the duration of effusion of otitis media

This study tests the hypothesis that montelukast sodium, a selective leukotriene receptor antagonist, will decrease the duration of the effusion of otitis media. Tympanometry and spectral gradient acoustic reflectometry were used to confirm the effusion of otitis media in patients between 2 and 12 years of age. Patients were treated with amoxicillin for 10 days and montelukast sodium or placebo for 30 days in a random, double-blind manner. Sixty patients completed the study: 31 received placebo and 29 received montelukast sodium. At a 4-week follow-up visit, 5 ears (16%) were free of effusion in the placebo group and 17 (58%) in the montelukast sodium group. The difference was significant. The efficacy of montelukast sodium in clearing the effusion was 49%.

Presence of human herpesviruses in young children with acute otitis media

Some herpesviruses have been detected in middle ear fluid (MEF) of patients with acute otitis media (AOM), but their role in middle ear disease is unknown. We examined 73 middle ear fluid samples from 73 children with acute otitis media for the presence of four major herpesviral DNA, respiratory viral genomes, and bacterial DNA by multiplex polymerase chain reaction (PCR). Herpesviruses were detected in 16 specimens (22%), with 18 viral infections were identified overall. Respiratory viruses were detected in 35 specimens (48%), 39 viral infections overall. Bacterial DNA was detected in 51 specimens (70%), 60 bacterial infections overall. Clinical outcome was compared in patients with and without herpesvirus DNA, respiratory viral genomes, or bacterial DNA. Progression to otitis media with effusion (OME) was more common when herpesviral DNA was present. Presence of herpesvirus DNA may reflect an immunocompromised state that may make it difficult to eliminate bacteria from the middle ear after infection.

Effect of botulinum toxin type A on nasal symptoms in patients with allergic rhinitis: a double-blind, placebo-controlled clinical trial

OBJECTIVE

To investigate the possible beneficial effects of botulinum toxin type A (BTX-A) on nasal symptoms in patients with allergic rhinitis (AR).

MATERIAL AND METHODS

Thirty-four patients (21 females, 13 males; mean age 28 years) were included in the study. AR was diagnosed by means of history, clinical examination and skin prick test. Patients were randomly divided into 3 subgroups a follows: in Group A, 20 units of BTX-A was injected into each nasal cavity (total 40 units); in Group B, 30 units of BTX-A was injected into each nasal cavity (total 60 units); and in Group C, 2 ml of isotonic saline was injected as placebo. The symptoms of AR (rhinorrhea, nasal obstruction, sneezing, itching) were scored by the patient on a six-point scale (from 0 to 5). All of the patients were followed up at Weeks 1, 2, 4, 6 and 8; at each visit an anterior rhinoscopic examination was done and symptom scores were recorded.

RESULTS

There was no statistically significant difference between Groups A and B in terms of average symptom scores. Rhinorrhea, nasal obstruction and sneezing scores in Groups A and B were significantly better than those in Group C at all time points. Although itching scores were significantly lower at Weeks 1 and 2, there was no difference in the Week 4, 6 and 8 scores in Groups A and B. When total symptom scores were evaluated, the results for Groups A and B were similar but significantly better than those for Group C.

CONCLUSION

In selected cases, injection of 40 units of BTX-A into the turbinates, as a single agent, may help the symptomatic control of AR for up to 8 weeks.

Lack of association of race/ethnicity and otitis media in the first 2 years of life

Race has been identified as a risk factor for otitis media (OM) in several studies. To further explore this, a database of visits with age at visit < 24 months was constructed from data captured electronically at a public health clinic in North Carolina between July 1994 and December 1996. Among 3,108 children with at least 1 visit, 45% were African-American, 26% were Latino, and 29% were White. There were no differences among the groups in episodes of OM per child or ratio of OM episodes to total visits per child. A cohort of 166 children with follow-up throughout their first 2 years of life was identified. In this group, being uninsured or having exposure to out-of-home child care was associated with an increased risk of OM. Race/ethnicity had no association with frequency of OM as measured by episodes per child, proportion with > or = 1 episode, or proportion with > or = 3 episodes.

A randomized, placebo-controlled trial of the effect of antihistamine or corticosteroid treatment in acute otitis media

OBJECTIVES

To determine whether the adjunctive drugs antihistamine and corticosteroid improve immediate and long-term outcomes of acute otitis media (AOM).

STUDY DESIGN

Children with AOM (3 mos-6 y) were enrolled in a randomized, double-blind, placebo-controlled trial. All 179 children received one dose of intramuscular ceftriaxone and were assigned to receive either chlorpheniramine maleate (0.35 mg/kg/d) and/or prednisolone (2 mg/kg/day) or placebo for 5 days. Main outcome measures were rate of treatment failure during the first 2 weeks, duration of middle ear effusion, and rate of recurrences of AOM to 6 months.

RESULTS

Clinical outcomes and recurrence rates did not differ significantly with treatment. Children who received antihistamine alone had significantly longer duration of middle ear effusion (median, 73 days) than subjects in other treatment groups (median, 23 to 36 days, P=.04). Temporary normalization of tympanometric findings on day 5 occurred more frequently in the corticosteroid-treated group (P=.04).

CONCLUSIONS

Five-day treatment with antihistamine or corticosteroid, in addition to antibiotic, did not improve AOM outcomes. Antihistamine use during an acute episode of OM should be avoided, since the drug may prolong the duration of middle ear effusion. The efficacy of 7- to 10-day treatment of AOM with corticosteroid, in addition to antibiotic, deserves further investigation.

Black-white differences in health care utilization among US children with frequent ear infections

OBJECTIVE

To examine differences in patterns of and barriers to health care utilization between black and white children who have frequent ear infections (FEI).

METHODS

Analysis was conducted using the 1997 and 1998 National Health Interview Survey-Sample Child Files. Data on 25 497 children under 18 years of age and 1985 who were reported by the parent/guardian to have had "3 or more ear infections during the past 12 months" were analyzed. The data were weighted and analyzed to represent all black and white children nationwide, accounting for the complex survey design.

RESULTS

Of white and black children under 18 years of age in the United States, 8.0 and 6.6%, respectively, had FEI in the past year. Among those with FEI, whites and blacks exhibited significantly different patterns in the type of health insurance they had and in the usual source of care. After accounting for sociodemographic factors, health insurance, and usual source of care, there were still significant differences in health care use between whites and blacks. The affected black children had an increased risk of getting delayed care because of transportation problems (odds ratio [OR]: 2.32) and a reduced likelihood of seeing a medical specialist (OR: 0.49) and having surgery (OR: 0.39) in comparison to white children.

CONCLUSION

Although black children with FEI were as likely as white children to be covered by health insurance and have a usual place of health care, they were significantly more likely to face barriers in obtaining the care, especially the more specialized care.

The role of respiratory viruses in otitis media

Evidence derived from numerous studies ranging from animal experiments to extensive clinical trials supports a crucial role for respiratory viruses in acute otitis media. Viral infection of the upper respiratory tract initiates the whole cascade of events that ultimately leads to development of acute otitis media, and viruses contribute to the pathogenesis of this disease by several mechanisms. Recent data indicate that at least some types of viruses actively invade the middle ear and may also interfere with the outcome of otitis media. The availability of effective vaccines against the principal viruses predisposing to acute otitis media could be expected to result in a substantial reduction in the incidence of this disease.

Cellular distribution of mucosa-associated lymphoid tissue with otitis media in children

This study examined mucosa-associated lymphoid tissue (MALT) in the eustachian tube (ET), middle ear (ME), and mastoid antrum (MA) in 163 celloidin-embedded temporal bones from children with or without otitis media. Otitis media was defined by the presence of histopathologically identified inflammatory cell infiltration in the mucosa or cavity of the ME. We found MALT in the ET in 30 cases (46.2%), in the ME in 19 cases (29.2%), and in the MA in 4 cases (6.2%) out of 65 cases of otitis media, and in the ET in 7 (7.1%), in the ME in 0, and in the MA in 0 out of 98 specimens without otitis media. No MALT appeared in any children under the age of 1 month. Immunohistochemical methods were used to investigate MALT in 12 horizontally cut temporal bones with OM. The follicular area contained OPD4-positive (helper-inducer T) cells and a few CD8-positive (cytotoxic and suppressor T) cells, whereas the parafollicular area contained OPD4-positive and CD8-positive T cells. CD57-positive (natural killer) cells were confined to the germinal center. CD30-positive (activated T and B) cells were observed throughout the follicles. A few CD15-positive (granulocyte, monocyte) cells were found in the follicles. Histopathologic and immunohistochemical findings were indistinguishable for MALT in the ET, ME, and MA. Our results suggest that MALT may be a mechanism for producing a rapid and massive local immune reaction to repeated bacterial infections via the ET.

Increasing importance of viruses in acute otitis media

Acute otitis media is generally considered a simple bacterial infection that can be effectively treated with antibiotics. However, despite the extensive use of broad-spectrum antibiotics, poor clinical response to treatment of acute otitis media is common in children. Numerous studies ranging from animal experiments to extensive clinical studies have clearly demonstrated that respiratory viruses play a crucial role in the aetiology and pathogenesis of acute otitis media. Viral infection of the upper respiratory tract initiates the whole cascade of events that finally leads to the development of acute otitis media as a complication. Respiratory viruses induce a release of inflammatory mediators in the nasopharynx, increase bacterial colonization and adherence, and have a suppressive effect on the host's immune defense. Recent data indicate that at least some types of viruses actively invade the middle ear. Viruses also seem to enhance the inflammatory process in the middle ear and impair the outcome of the disease. Vaccines against the major viruses predisposing to acute otitis media hold a great promise for the prevention of this disease. Major advances in the management of acute otitis media will require further research into the mechanisms of viral infection, viral-bacterial interaction and the host inflammatory response during viral infection.

Oral prednisolone is an effective adjuvant therapy for acute otitis media with discharge through tympanostomy tubes

OBJECTIVE

To determine the efficacy of a short course of oral prednisolone as an adjuvant therapy for acute otitis media draining through tympanostomy tubes.

STUDY DESIGN

In a randomized, double-blind, placebo-controlled study, children with acute discharge (<48 hours) through tympanostomy tubes received either prednisolone (2 mg/kg/d; n = 23) or placebo (n = 27) for 3 days. All children received amoxicillin/clavulanate (40/10 mg/kg/d) for 7 days. The children were examined daily at the study clinic until the drainage ceased.

RESULTS

The median duration of otorrhea in the prednisolone group was 1.0 days (25% to 75% range, 1.0 to 2.0 days), compared with 3.0 days (25% to 75% range, 2.0 to 4.0 days) in the children receiving placebo (P <.001). The duration of otorrhea was </=2 days in 21 (91%) children in the prednisolone group, compared with 8 (30%) children in the placebo group (P <.001).

CONCLUSIONS

Oral prednisolone appears to be modestly effective adjuvant therapy for acute otitis media with discharge through tympanostomy tubes in children. Further studies seem warranted to determine whether short-term use of steroids early during the course of acute otitis media would also reduce the duration of middle ear effusion in children with intact tympanic membranes.

Prevalence of various respiratory viruses in the middle ear during acute otitis media

BACKGROUND

Vaccines against respiratory viruses may be able to reduce the frequency of acute otitis media. Although the role of respiratory viruses in the pathogenesis of acute otitis media is well established, the relative importance of various viruses is unknown.

METHODS

We determined the prevalence of various respiratory viruses in the middle-ear fluid in 456 children (age, two months to seven years) with acute otitis media. At enrollment and after two to five days of antibiotic therapy, specimens of middle-ear fluid and nasal-wash specimens were obtained for viral and bacterial cultures and the detection of viral antigens. The viral cause of the infections was also assessed by serologic studies of serum samples obtained during the acute illness and convalescence.

RESULTS

A specific viral cause of the respiratory tract infections was identified in 186 of the 456 children (41 percent). Respiratory syncytial virus was the most common virus identified in middle-ear fluid: it was detected in the middle-ear fluid of 48 of the 65 children (74 percent) infected by this virus (P< or =0.04 for the comparison with any other virus). Parainfluenza viruses (15 of 29 children [52 percent]) and influenzaviruses (10 of 24 children [42 percent]) were detected in the middle-ear fluid significantly more often than enteroviruses (3 of 27 children [11 percent]) or adenoviruses (1 of 23 children [4 percent]) (P< or =0.01 for all comparisons).

CONCLUSION

Respiratory syncytial virus is the principal virus invading the middle ear during acute otitis media. An effective vaccine against upper respiratory tract infections caused by respiratory syncytial virus may reduce the incidence of acute otitis media in children.

A longitudinal study of otitis media with effusion among 2- to 5-year-old African-American children in child care

OBJECTIVE

To prospectively document the prevalence of otitis media with effusion (OME) in 86 African-American children between ages 2 and 5 years.

STUDY DESIGN

Eighty-six children in center-based child care whose ear status had been followed from infancy continued to be observed. Middle ear status was assessed by pneumatic otoscopy and tympanometry biweekly.

RESULTS

The prevalence of OME decreased as children became older. The mean proportion of examinations demonstrating bilateral OME (BOME) ranged from 12% between 24 to 30 months to 4% between 54 to 60 months of age. The mean proportion of exams revealing bilateral normal ears increased from 77% at 24 to 30 months to 88% at 54 to 60 months of age. Although 60 children had experienced BOME that lasted 4 months or longer in the 6- to 24-month age period, only 8 of these children experienced at least 4 months of continuous BOME between 24 to 60 months.

CONCLUSIONS

The proportion of time with BOME decreased progressively with increasing age in this population. Only 8 of 60 children who had experienced more than 4 consecutive months of BOME before 2 years of age continued to manifest persistent effusion or experience recurrences of prolonged BOME after 2 years of age.

[Role of corticosteroid therapy in non-malignant diseases]

INTRODUCTION

As short-term corticosteroid therapy is widely used in clinical practice, it is important to determine its precise indications and limits of use.

CURRENT KNOWLEDGE AND KEY POINTS

Duration of short-term corticosteroid therapy is arbitrarily considered to be up to 21 days. Anti-inflammatory, antiproliferative or analgesic actions represent the main pharmacological features of steroids. They are related to the interactions of steroids with cytokines and immune cells. Results of randomized double-blind and uncontrolled clinical studies were included in this review. Furthermore, clearly demonstrated results that were obtained more particularly in neurology, otorhinolaryngology, pneumology, infectious diseases, rheumatologic and traumatic processes are summarized.

FUTURE PROSPECTS AND PROJECTS

Indications for short-term corticosteroid therapy are well established. However, further clinical studies are required, as current prescription of corticosteroid is still empirical in the management of most diseases.

Two-step PCR-based assay for identification of bacterial etiology of otitis media with effusion in infected Lebanese children

We developed and evaluated a two-step PCR-based assay with universal primers and genus- or species-specific primers for the detection of the most prevalent bacterial etiologies of otitis media with effusion (OME) in children from Lebanese hospitals. These etiologies included Haemophilus, Streptococcus, and Moraxella (Branhamella) catarrhalis, which were detected in middle-ear effusion (MEE) samples taken from children with OME. A total of 47 MEE samples were aspirated from 36 patients during insertion of a tympanostomy tube performed particularly for OME. The duration of effusion in all patients was > or =2 months. DNA was extracted from MEE samples, and PCR was initially done with DNA extracts by using the universal primers RW01 and DG74, which flank an approximately 370-bp fragment found in the 16S rRNA gene of all bacterial species. For the identification of specific bacteria, we used in three separate reaction mixtures the following genus- or species-specific primers: (i) a Haemophilus-specific probe (probe RDR125) as a primer along with DG74, (ii) a Streptococcus-specific primer (primer STR1; designed by us) along with DG74, and (iii) an M. catarrhalis-specific primer pair (primer pair MCA1-MCA2). Thirty-five MEE samples (74.5%) gave the expected 370-bp band, indicating the presence of bacterial DNA in the tested samples. Of the 35 PCR-positive samples tested, 33 (94.3%) were positive for Haemophilus, 3 (8.6%) were positive for Streptococcus, and 10 (28.6%) were positive for M. catarrhalis. Ten samples (28.6%) exhibited a mixed infection and were positive for both Haemophilus and M. catarrhalis. Culture was simultaneously performed for all 47 MEE samples. Ten of the 47 MEE samples (21.3%) exhibited bacterial growth. These 10 were PCR positive for bacterial DNA. The remaining 25 PCR-positive samples were negative by culture, thus showing about 53% discordance between PCR results and those of culture. The PCR assay proved to be more sensitive than culture, more rapid, less cumbersome, and more cost-effective than the available PCR-Southern hybridization-based assays.

The role of immune complex in otitis media with effusion

Fifteen chinchillas were inoculated with immune complexes of Streptococcus pneumoniae into the tympanic cavity, and with formalin-killed bacteria into the opposite side. Middle ear effusion (MEE) were found in 14 ears having inoculation with immune complexes and in only four ears having inoculation with formalin-killed S. pneumoniae. In another experiment, 20 chinchillas received intra-tympanic inoculation with live S. pneumoniae after systemic immunization with formalin-killed S. pneumoniae of the same strain. As a control, 12 chinchillas were inoculated with live bacteria of the same strain into the tympanic cavity without pre-immunization. MEE was observed in nine of pre-immunized animals and persistent MEE lasting for more than 3 weeks was observed in seven of the animals. In control, persistent MEE was not observed. Though six animals developed otitis media with effusion (OME). The results suggest that the formation of immune complexes in the tympanic cavity plays an important role in the occurrence of persistent MEE after pneumococcal otitis media.

Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life

OBJECTIVE

As part of a long-term study of possible effects of early-life otitis media on speech, language, cognitive, and psychosocial development, we set out to delineate the occurrence and course of otitis media during the first 2 years of life in a sociodemographically diverse population of infants, and to identify related risk factors.

METHODS

We enrolled healthy infants by age 2 months who presented for primary care at one of two urban hospitals or one of two small town/rural and four suburban private pediatric practices. We intensively monitored the infants' middle-ear status by pneumatic otoscopy, supplemented by tympanometry, throughout their first 2 years of life; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated infants for otitis media according to specified guidelines.

RESULTS

We followed 2253 infants until age 2 years. The proportions developing > or = 1 episode of middle-ear effusion (MEE) between age 61 days (the starting point for data analysis) and ages 6, 12, and 24 months, respectively, were 47.8%, 78.9%, and 91.1%. Overall, the mean cumulative proportion of days with MEE was 20.4% in the first year of life and 16.6% in the second year of life. Tympanostomy-tube placement was performed on 1.8% and 4.2% of the infants during the first and second years of life, respectively. By every measure, the occurrence of MEE was highest among urban infants and lowest among suburban infants; these differences were greatest in the earliest months of life. Overall, unadjusted mean cumulative proportions of days with MEE were higher among boys than girls, higher among black than white infants, and higher among Medicaid than private health insurance enrollees. Cumulative proportions of days with MEE varied directly with the number of smokers in the household and with the number of other children to whom infants were exposed, whether at home or in day care, and varied inversely with birth weight, maternal age, level of maternal education, a socioeconomic index, and duration of breastfeeding. After adjustment, using multivariate analysis, the only variables that each remained independently and significantly related to the cumulative proportion of days with MEE were: during the first year of life, study site grouping, sex, the socioeconomic index, breastfeeding for > or = 4 months, the number of smokers in the household, and an index rating the degree of exposure to other children at home or in day care; and during the second year of life, sex, the socioeconomic index, and the child exposure index. The duration of breastfeeding and the degree of exposure to tobacco smoke contributed little to the explained variance; most was attributable to differences in the socioeconomic index and the child exposure index.

CONCLUSIONS

Contrary to findings in many previous reports, the prevalence of otitis media during the first 2 years of life among lower-socioeconomic-status black infants appears to be as high as, if not higher than among lower-socioeconomic-status white infants, and certainly higher than among middle-class white infants. Among middle-class white infants the prevalence may also be higher than commonly assumed. The most important sociodemographic risk factors for otitis media appear to be low socioeconomic status and repeated exposure to large numbers of other children, whether at home or in day care.

Prospective surveillance for otitis media with effusion among black infants in group child care

OBJECTIVE

To document the prevalence of otitis media with effusion (OME) in 102 black children observed prospectively between 6 and 24 months of age.

METHODS

Study children attended nine different center-based child care facilities. Middle ear status was assessed by pneumatic otoscopy and tympanometry every 2 weeks.

RESULTS

All children, except one, had OME during the period of observation. The proportion of child-examinations revealing bilateral OME ranged from 76% between 6 and 12 months of age to 30% between 21 and 24 months of age. Effusions were considered purulent in only 13% of examinations revealing middle ear fluid. The mean incidence of purulent OME was 2.13 episodes per child per year. Sixty-six children had at least 4 months of continuous bilateral OME during the period of observation; 57 were followed without placement of tympanostomy tubes. Bilateral OME had resolved before the second birthday in 95% of these children, and within 3 months of achieving the 4-month criterion in 50% of subjects.

CONCLUSIONS

Persistent bilateral OME occurs commonly between 6 and 18 months of age in infants who enter group child care during the first year of life. In this study, spontaneous resolution of bilateral effusion by 2 years of age was typical.

Otitis media and reading achievement: a review

Nineteen studies on the relationship between otitis media (OM) or otitis media with effusion (OME) (secretory otitis media (SOM)) and reading achievement were reviewed. The result is that the children catch up in cognitive development when their ears and hearing become normal at about school age. The correlations that have been found between SOM and reading achievement are so small that they have no practical importance for the average child. At the present time we have no knowledge that justifies intervention against SOM as a general preventive task to ensure the cognitive development, or reading achievement. The absent or very small correlation between SOM and reading in the reviewed studies, 'explaining' only 2-4% of the variance, has no implications in comparison with other important factors. Reading achievement was more closely correlated with cognitive, language, and linguistic factors, and to a series of socioenvironmental and classroom related factors. The high frequency of SOM, with resulting hearing loss, and the long duration and high rate of occurrence of OM in 'otitis-prone' children, and clinical observations underlines the need for further research.

Prediction of acute otitis media with symptoms and signs

We carried out a prospective study to analyse if it would be possible to predict the coexistence of acute otitis media on the basis of symptoms and signs of infection. Of the 658 patients admitted to hospital during the period concerned, 197 (29.9%) had otitis media. For each child with otitis, the next patient of the same age was chosen as a control. The risk of having otitis media was increased among patients with cough, rhinitis and earache. All three variables together correctly classified 67% of those not having otitis media and 63% of those with acute otitis, compared with the 50% which would theoretically be achieved by chance alone. Prediction was worst (55%) among patients younger than 2 years of age not having otitis media and best among older patients who had otitis media, i.e. 78%. Prediction on these grounds would have caused significant over-treatment, and one-third of the otitis cases among the youngest group would have been missed. Thus it is important to always examine the ears of a child with an infection in order to reliably exclude the possibility of acute otitis media.

Outcome of acute otitis media with abnormal tympanometric patterns in children

OBJECTIVE

To assess the ability of ED tympanometry to identify those children with acute otitis media who are at greater risk for treatment failure, recurrent infection, or persistent middle ear effusion.

METHODS

A prospective observational study was performed in the EDs of a county hospital and a university medical center. One hundred seventeen children, aged 5 months to 5 years, with acute otitis media and abnormal tympanometric patterns were categorized into three groups--low compliance, high pressure, and low pressure--based on the initial patterns. All the children received oral amoxicillin for ten days. They had repeat tympanometry and otoscopy at 14- and 60-day follow-up visits, and were followed to determine clinical outcomes.

RESULTS

Initial treatment success was equivalent for all groups: low compliance 93% (95% confidence interval 81%-97%), high pressure 91% (95% CI 71%-98%), low pressure 89% (95% CI 59%-99%). Rates of relapse, reinfection, 90-day non-recurrence, and persistent otoscopic and tympanometric middle ear effusion did not differ significantly between groups.

CONCLUSION

ED tympanometry of children with acute otitis media is unable to provide prognostic information regarding treatment failure, recurrent infection, or persistent middle ear effusion.

Persistence of middle ear dysfunction after recurrent acute otitis media

The presence of otitis media with effusion (OME) and high negative pressure (-200 to -400 mm H2O), were investigated in the follow-up of a randomized double-blind placebo-controlled trial on the efficacy of amoxicillin/clavulanic acid in the treatment of acute otitis media. All children in this study were recruited from a general practice population. Tympanometry results 1 month from the start of an episode of acute otitis media were taken as outcome criteria. Bilateral middle ear dysfunction was defined as bilateral OME, unilateral OME and contralateral or bilateral high negative pressure. Bilateral middle ear dysfunction was present in 47.9% of the patients. Of all the investigated factors of possible influence (age, sex, season, laterality of acute otitis media, therapy, and clinical course of acute otitis media), only season showed a statistically significant influence on the persistence of OME/high negative pressure (P = 0.001). Bilateral middle ear dysfunction was shown to be of prognostic value for the risk of a recurrence of acute otitis media (odds ratio 3.75).

Prognostic factors for persistent middle ear effusion after acute otitis media in children

The present study was carried out to determine the clinical course of acute otitis media (AOM) in children and to analyze the risk factors that lead to persistent effusion. One hundred and twenty children aged 9 months to 10 years diagnosed as having AOM were included in this study. Sixty-two children (52%) recovered from AOM without middle ear effusions within a month. In 26 cases (22%), middle ear effusions resolved after 1 to 3 months, while 32 children (26%) had persistent effusions for more than 3 months after the onset of acute inflammation. Statistical analysis between the group showing quick recovery and that with persistent effusion was carried out in relation to various clinical factors at the onset. The significant risk factors were: younger age, bilateral AOM, presence of otorrhea, tympanogram type B or C2 on an AOM ear. Moreover, the most significant prognostic factor was a tympanogram type B or C2 on an opposite ear at the acute onset. On the other hand, factors such as sex, fever, history of otitis media, season at onset or complications did not correlate with the duration of persistent effusion. From these results we conclude that careful examination should be performed not only on the ear with AOM but also on the opposite ear in order to predict the course of otitis media.

Quantitative bacterial culture from adenoid lymphatic tissue with special reference to Haemophilus [corrected]

Homogenized adenoid tissue from 55 children (28-153 months) undergoing adenoidectomy because of nasopharyngeal obstruction was investigated by means of quantitative aerobic bacterial culture. The children were divided into two groups, the hypertrophy alone group--AH (n = 29)--and the hypertrophy with longstanding secretory otitis media group--SOM (n = 26). A nasopharyngeal culture was obtained preoperatively from 38 of the cases. Non-typeable H. influenzae (NTHI) was found in twice as many cases in the AH group as in the SOM group, 21/29 (72%) compared to 11/26 (42%) (p < 0.05) and in a significantly higher mean concentrations, 5.7 x 10(5) CFU/g compared to 1.9 x 10(5) CFU/g (p = 0.02). For the other aerobic potentially pathogenic bacteria no such difference was found. The bulk of the NTHI-positive cases and the cases with the highest concentrations were found in the children below the age of 6 years. In the nasopharyngeal cultures NTHI alone or together with S. pneumoniae and/or B. catarrhalis was found in 29% of the cases in both the AH group and SOM group. NTHI was found in only 50% of the nasopharyngeal cultures corresponding to a positive quantitative culture (10/20). These findings suggest that NTHI is harboured within the adenoid and could thereby chronically stimulate the local immune defense. However, the present study indicates that there is no aerobic bacterial overload in the adenoid tissue in children with SOM compared to children without middle-ear disease.

Silent reading and secretory otitis media in school children

In an unselected cohort of 366 8-year-old children, the relationship between secretory otitis media and reading achievement was investigated. The children underwent 10 impedance audiometries and 5 pure tone audiometries during their first year at school. At the beginning of the second grade they all had a Silent Reading Word Test (OS-400). The background parameters were recorded by an interview with one of the parents. There was a significant but small correlation between type B tympanograms in the first grade and silent word reading. No association between silent reading score and otological history or pure tone screening was found. In a stepwise multiple regression model, 37% of the variance could be 'explained' by the included variables. The 'classroom factor' could 'explain' about 17% of the variance, followed by phonology at the start of school (6%), gender (5%), social group of the mother (4%), type B tympanogram (2%), absence from school (2%) and allergy (1%).

Effects of recurrent otitis media in infancy on auditory perception and speech

INTRODUCTION

Recurrent otitis media is commonly encountered in children before 3 years of age. Conductive hearing loss up to 40 dB is frequently associated with suppurative otitis media. Good hearing is believed to be critical to the development of normal language. This study was undertaken to evaluate the effect of recurrent otitis media on auditory perception and speech.

PATIENTS AND METHODS

The experimental group consisted of 33 children with a history of at least three episodes of acute otitis media before 2 years of age. A control group of 29 children experienced one or fewer episodes of otitis media in the first 2 years of age. At the time of investigation, all children were 8 to 10 years of age and had attended similar pre-school, kindergarten, and elementary school programs. None showed evidence of mental retardation nor behavioral or emotional disorders. Speech ability was assessed by a battery of tests specific for Slovene language. Subtests of the Wechsler Intelligence Scale for Children were used as well as the Reading and Writing Test.

RESULTS

Auditory perception disorders were evident in 88% of children investigated who had a history of at least three episodes of otitis media by 2 years of age. Decreased auditory stimulation during the time of auditory maturation could prevent the development of these functions completely. No statistically significant differences were observed in the development of articulation. These observations underscore the importance of early management of recurrent otitis media during the first 2 years of age.

Host factors and early therapeutic response in acute otitis media

To evaluate the relationship between eradication of bacterial infection and clinical improvement in children with otitis media, we reviewed the clinical outcome of bacterial otitis media in patients enrolled in double-blind trials of antibacterial therapy from 1979 to 1988. Cultures of middle ear exudates showed the distribution of bacterial pathogens to be similar to that observed in other geographic areas. Two hundred ninety-three patients had otitis media caused by bacterial pathogens and underwent repeat tympanocentesis after 3 to 6 days of therapy. Bacteriologic success was demonstrated in 253 patients (86%); 40 patients (14%) had bacteriologic failure. Children who had bacteriologic failure were younger than those with bacteriologic success (median age 10.6 vs 18.5 months; p = 0.001); 38% of patients who had bacteriologic failure were black, compared with 18% of patients with bacteriologic success (p = 0.007). Gender, history of frequent otitis media, and presence of bilateral otitis media were not risk factors for bacteriologic failure. Clinical success was demonstrated in 261 patients (89%); 32 patients (11%) had clinical failure. Agreement between clinical and bacteriologic response was 86% (95% confidence interval: 81.6% to 89.6%). Ninety-three percent (236/253) of subjects whose infection was eliminated had clinical resolution, whereas 37% (15/40) of those with bacteriologic failure had persisting symptoms or signs of clinical failure. We conclude that failure to eliminate bacteria from the middle ear is often associated with persistent signs and symptoms. Bacteriologic failure affects children less than 18 months of age almost exclusively. Bacteriologic and clinical failure are frequently discordant; mechanisms unrelated to the bacterial infection may explain some of the persisting clinical signs.

Statistical methods for determining risk factors of chronic otitis media with effusion

We use logistic regression with paired Bernouilli outcomes to analyse data on subjects who have either one or two organs (e.g. ears) each of which may develop disease. In this model, subject-specific covariates are related to the probability of developing disease. The proposed method is applied to determine risk factors for chronic otitis media with effusion.

Morphometric studies of the continuum of otitis media

Morphometric changes in the epithelium and subepithelium of the middle ear mucosa from children younger than 10 years of age were measured at the promontory in 85 temporal bones with otitis media and in 29 normal temporal bones by use of quantitative and semiquantitative methods. Comparisons of morphologic analysis in different otitis media types showed that acute inflammatory changes were usually seen in purulent otitis media with effusion and serous otitis media with effusion, and chronic inflammatory changes were more severe in mucoid otitis media with effusion and chronic otitis media. There were overlaps, however, in histopathologic findings between different types of otitis media that suggest a continuum of otitis media types, with one type of otitis media changing into another type.