Population-based, age-specific myringotomy with tympanostomy tube insertion rates in Calgary, Canada

Evaluation of Multidisciplinary Team Clinic for Patients With Isolated Cleft Lip

OBJECTIVE

To report the incidences of secondary lip and nose operations, otolaryngology procedures, speech-language therapy, neurodevelopmental concerns, and dental and orthodontic issues in children with isolated cleft lip to inform multidisciplinary cleft team protocols.

SETTING

An American Cleft Palate-Craniofacial Association-approved team at a tertiary academic children's hospital.

DESIGN

Retrospective cohort study of patients evaluated through longitudinal clinic visits by a multidisciplinary cleft palate and craniofacial team between January 2000 and June 2018.

PATIENTS, PARTICIPANTS

Children with nonsyndromic cleft lip with or without cleft alveolus (n = 92).

RESULTS

Median age at final team visit was 4.9 years (interquartile range: 2.4-8.2 years). Secondary plastic surgery procedures were most common between ages 3 and 5 (135 per 1000 person-years), and the majority of these procedures were minor lip revisions. The rate of tympanostomy tube insertion was highest before age 3 (122 per 1000 person-years). By their final team visit, 88% of patients had normal hearing and 11% had only slight to mild conductive hearing loss. No patients had speech errors attributable to lip abnormalities. Psychological interventions, learning disabilities, and dental or orthodontic concerns were uncommon.

CONCLUSIONS

Most patients with isolated cleft lip may not require long-term, longitudinal evaluation by cleft team specialists. Cleft teams should develop limited follow-up protocols for these children to improve resource allocation and promote value-based care in this patient population.

Increase in tympanostomy tube placements despite pneumococcal vaccination, a population-based study

AIM

The aim was to estimate the impact of the 10-valent pneumococcal vaccine (PHiD-CV) on tympanostomy tube placements (TTP) in children under five years of age in Iceland.

METHODS

This population-based observational cohort study followed 11 consecutive birth-cohorts 2005-2015 from birth until their fifth birthday. Population registries were merged using national identification numbers. The risk of TTP was compared between birth-cohorts adjusted for the number of previous otitis media diagnoses and antimicrobial prescriptions. A Cox regression model was applied and the hazard ratio (HR) of TTP was estimated between each birth-cohort and the last vaccine non-eligible birth-cohort. The vaccine impact of PHiD-CV10 on TTP was estimated as 1-HR ×100%.

RESULTS

In total, 51 247 children were followed for 210 724 person-years, of which 14 351 underwent 20 373 procedures. The estimated vaccine impact on TTP was -6% (95% CI -16% to 2.7%). Children in the vaccine-eligible cohorts had fewer previous otitis media diagnoses and had been prescribed fewer antimicrobials prior to the procedure than children in the vaccine non-eligible cohorts.

CONCLUSION

Despite high uptake of PHiD-CV10, tympanostomy procedures increased in Iceland during the study period. Vaccine-eligible children had milder disease prior to the procedure. The reason underlying these findings are speculative.

Effectiveness of the Ten-valent Pneumococcal Conjugate Vaccine Against Tympanostomy Tube Placements in a Cluster-randomized Trial

BACKGROUND

We evaluated the impact of the new pneumococcal Haemophilus influenzae protein D conjugate vaccine (PHiD-CV10, GSK Vaccines) on tympanostomy tube placements (TTPs).

METHODS

Finnish Invasive Pneumococcal disease vaccine trial was a nationwide phase III/IV cluster-randomized, double-blind trial. Children younger than 19 months received PHiD-CV10 in two thirds of clusters (N = 52) or hepatitis B or A vaccine as control in 26 clusters according to 3 + 1 or 2 + 1 schedules (infants younger than 7 months) or catch-up schedules. A secondary objective of the trial was to assess vaccine effectiveness (VE) against TTPs in children who received at least one vaccine dose before or after 7 months of age. Blinded follow-up lasted from the date of first vaccination (from February 2009 through October 2010) to December 31, 2011. Outcome data were collected through the National Care register and Social Insurance Institution reimbursement register.

RESULTS

More than 47,000 children were enrolled. In 30,527 infants younger than 7 months of age at enrolment, 4369 TTPs were reported in 3594 subjects. The incidence was 7.9 per 100 person-years in the infant control cohort. The VE estimate was 13% [95% confidence interval (CI): -2% to 26%] for combined PHiD-CV10 3 + 1 and 2 + 1 infant schedules. The VE estimates for the 3 + 1 and 2 + 1 infant schedules when estimated separately were similar. For the catch-up schedules, the VE was 11% (95% CI: -7% to 26%) for children enrolled at 7-11 months of age and -1% (95% CI: -21% to 16%) for children enrolled at 12-18 months of age.

CONCLUSIONS

Our study results suggest that PHiD-CV10 immunization according to a 3 + 1 or 2 + 1 schedule initiated before 12 months of age may reduce the frequency of TTPs, although the primary analysis did not reach statistical significance.

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.

Increasing rate of middle ear ventilation tube insertion in children in Denmark

OBJECTIVE

To study the incidence rates of middle ear ventilation tube insertion in children aged 0 to 15 years in Denmark from 1997 to 2010.

METHODS

Using two national registers, the Danish National Health Service Register and the Danish National Patient Register, practically all cases of middle ear ventilation tube insertion performed in Denmark in the period were identified. A possible change in incidence rate over time was examined using Poisson regression analysis, while the cumulative incidence proportion was estimated using life-tables.

RESULTS

A total of 502,569 uni- or bilateral ventilation tube insertions distributed among 269,459 different children were identified. From 1997 to 2010 the age standardized incidence rate in 0-15-year-olds increased from 26 to 40 per 1000 person years with an estimated annual increase of 2.0% (95% confidence interval 1.9-2.1%). The largest increase in incidence rate was found in 1-year-olds with an annual increase of 4.5% (95% confidence interval 4.4-4.6%). Age-specific incidence rates remained at maximum around the age of 14 months throughout the period. The cumulative incidence proportion for the 2010 birth cohort by the time they reach the age of 5 years was estimated to 29% (95% confidence interval 28-29%).

CONCLUSION

The rate for middle ear ventilation tube insertion in Denmark was high compared to other developed countries, and an estimated 3 in 10 children born in 2010 will undergo at least one ventilation tube insertion before their fifth birthday.

Long-term effect of pneumococcal conjugate vaccines on tympanostomy tube placements

BACKGROUND

We have previously shown that the 7-valent pneumococcal conjugate vaccine (PncCRM) given in infancy is effective in reducing tympanostomy tube placements up to 4 to 5 years of age. This study aimed to assess the effectiveness of pneumococcal conjugate vaccines PncCRM and PncOMPC from 2 up to 13 years of age.

METHODS

Altogether 2497 children participated in the Finnish Otitis Media Vaccine trial conducted in 1995 to 1999 and were vaccinated at 2, 4, 6 and 12 months of age with PncCRM or PncOMPC or hepatitis B vaccine as controls. The data for tympanostomy tube placements were collected from health registers including hospital and private office operations. Vaccine efficacy was estimated by comparing incidences of tympanostomies from 2 to 12-13 years of age in each of the pneumococcal vaccine groups with the control group.

RESULTS

Register data were searched for 2474 subjects. A total of 535 tympanostomy tube placements were identified in the health registers from 1998 through 2008 with a cumulative incidence of 14.6% from 2 to 13 years of age in the control group. The vaccine impact was age-dependent: from 2 through 5 years of age the vaccine effectiveness was 34% (95% confidence interval: 1% to 52%) for PncCRM and 6% (-28 to 31) for the PncOMPC vaccine. For the age group of 6 to 12-13 years the vaccine effectiveness estimates for the PncCRM and PncOMPC groups were -13% (-137 to 46) and -2% (-123 to 54), respectively.

CONCLUSIONS

PncCRM vaccine reduced the tympanostomy tube placements up to 5 years of age. No impact on new surgical procedures could be demonstrated after that but the benefit achieved was sustained.

Reducing the frequency of acute otitis media by individualized care

OBJECTIVE

We sought to determine if use of more stringent diagnostic criteria for acute otitis media (AOM) than currently advocated by the American Academy of Pediatrics, tympanocentesis and pathogen-specific antibiotic treatment (individualized care) would result in reducing the incidence of recurrent AOM and consequent tympanostomy tube surgery.

METHODS

A 5-year longitudinal, prospective study in Rochester, NY, was conducted from July 2006 to July 2011 involving 254 individualized care children. When this individualized care group developed symptoms of AOM, strict diagnostic criteria were applied and a tympanocentesis was performed. Pathogen resistance to empiric high-dose amoxicillin/clavulanate (80 mg/kg of amoxicillin component) caused a change in antibiotic to an optimized choice. Legacy controls (n = 208) were diagnosed with the same diagnostic criteria by the same physicians as the individualized care group and received the same empiric amoxicillin/clavulanate (80 mg/kg of amoxicillin component) but no tympanocentesis or change in antibiotic. Community control children (n = 1020) were diagnosed according to current American Academy of Pediatrics guidelines and treated with high-dose amoxicillin (80 mg/kg) without tympanocentesis as guideline recommended.

RESULTS

5.9% of children of the individualized care group compared with 14.4% of Legacy controls and 27.3% of community controls became otitis prone, defined as 3 episodes of AOM within a 6-month time span or 4 AOM episodes within a 12-month time span (P < 0.0001). 2.4% of the individualized care group compared with 6.3% of Legacy controls, and 14.8% of community controls received tympanostomy tubes (P < 0.0001).

CONCLUSIONS

Individualized care of AOM significantly reduces the frequency of AOM and tympanostomy tube surgery. Use of strict diagnostic criteria for AOM and empiric antibiotic treatment using evidence-based knowledge of circulating otopathogens and their antimicrobial susceptibility profile also produces improved outcomes.

Prevalence of ventilation tubes in children with a tracheostomy tube

OBJECTIVES

To estimate the prevalence of operative ear disease in pediatric patients with tracheostomy tubes, as well as to identify risk factors predictive of operative otologic interventions in this patient cohort.

METHODS

We hypothesize that the prevalence of operative middle ear disease in patients with a tracheostomy tube is greater than that of the population at large. To validate our anecdotal observations, we queried the CHCA hospital database (PHIS) regarding the association between tympanostomy tube placements in children with tracheostomies. To further investigate, a retrospective chart review was undertaken at our regional tertiary care children's hospital to determine the frequency at which tympanostomy tubes were placed in children who have a tracheostomy. Risk factors were analyzed, applying independent samples t-tests and Pearson's Chi-square test. Univariate and multivariate logistic regression models were constructed to estimate odds ratios (OR) and 95% confidence intervals (CI) for predictors of operative ear disease. Institutional review board (IRB) approval was obtained.

RESULTS

Of a population of 181 patients with tracheostomies, 37 (or 20%, 95% CI 15-26%) have undergone placement of ventilation tubes in the past 3 years. No statistically significant difference was noted with regards to gender or race. The operative group had an average age of 23.0 months at the time of tracheostomy, compared to 52.5 months in the non-operative group (p=0.0022). In addition, home living situation, term birth, and craniofacial abnormalities were more frequently observed in the operative versus the non-operative group. Multivariate logistic regression models revealed the same factors as predictors of operative ear disease.

CONCLUSION

The presence of a tracheostomy is associated with an increased risk of requiring ventilation tube placement over the population at large. Risk factors for operative middle ear disease among these children include age at time of the tracheostomy, craniofacial abnormalities, term birth, and home living situation.

Epidemiological and economic burden of pneumococcal diseases in Canadian children

BACKGROUND

With the arrival of a new conjugate pneumococcal vaccine, it is important to estimate the burden of pneumococcal diseases in Canadian children. The epidemiological data and the economic cost of these diseases are crucial elements in evaluating the relevance of a vaccination program.

METHODS

Using provincial databases, ad hoc surveys and published data, age-specific incidence rates of pneumococcal infections were estimated in a cohort of 340,000 children between six months and nine years of age. The costs of these diseases to the health system and to families were also evaluated using data from Quebec and Manitoba.

RESULTS

Cumulative risks were one in 5000 for pneumococcal meningitis, one in 500 for bacteremia and one in 20 for pneumonia, leading to 16 deaths in the cohort. About 262,000 otitis media episodes and 32,000 cases of myringotomy with ventilation tube insertion were attributable to Streptococcus pneumoniae. Societal costs were estimated at $125 million, of which 32% was borne by the health system and 68% was borne by families. Invasive infections represented only 2% of total costs, while 84% were generated by otitis media.

CONCLUSION

Pneumococcal infections represent a significant burden for Canadian children and society that could be significantly reduced through immunization.

Pharmacoeconomic evaluation of 10- and 13-valent pneumococcal conjugate vaccines

INTRODUCTION

There are three different pneumococcal vaccines available for infants, each oriented to a specific set of serotypes. The vaccination of newborns will prevent pneumococcal disease in this vaccinated group via direct effects, and will also affect the non-vaccinated population through indirect or "herd" immunity.

OBJECTIVE

To develop a model that compares the health and economic consequences between the three vaccines.

METHOD

We developed a simulation model for an entire population, providing vaccine to children less than 2 years of age. The vaccines varied by serotypes covered and included a 7- (4, 6B, 9V, 14, 18C, 19F and 23F), 10- (1, 4, 5, 6B, 7F, 9V, 14, 18C, 19F and 23F) and 13-valent (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F) vaccines. The base case was PCV-7, and clinical and economic outcomes were estimated for the vaccinated persons and for other persons through assumptions about a herd effect. By comparison, clinical and economic outcomes for the population were also estimated for the 10 and 13 serotype vaccines.

RESULTS

In the base case (PCV-7), with the seven serotype vaccine, there were 9.38 cases of hospitalized pneumonia, 0.22 cases of meningitis, 3.69 cases of bacteremia, 60.19 cases of otitis media, and 373 cases of pneumonia, per 100,000 persons in the population, at all ages. With the 10-valent vaccine and a herd effect, invasive pneumonia fell to 8.71 cases, meningitis to 0.21 cases, and bacteremia to 3.39 cases. Otitis media fell to 57 cases and pneumonia to 344 cases. There were further reductions with the 13-valent vaccine, with invasive pneumonia falling to 8.37 cases, bacteremia to 3.33 cases, otitis media to 51.9 cases and all-cause pneumonia to 336.2 cases. Among the vaccines evaluated, PCV-13 was associated with the lowest health services costs and the greatest improved health outcomes.

CONCLUSIONS

Increased serotype coverage of the 13-valent vaccine is expected to have a substantial public health and economic impact on infectious disease, when considering direct and indirect effects.

The impact of ear, nose and throat surgery on children's subsequent use of health services: An 8-year cohort study

AIM

High rates of paediatric ear, nose and throat (ENT) surgery persist. Little is known about its impact on health service utilisation. This study investigated whether children who had ENT surgery used more health services prior to surgery (excluding the perisurgery period), and, if so, whether surgery resulted in reduced utilisation.

METHODS

A retrospective population cohort study of health services use (measured by Medicare claims) by 6239 New South Wales children from the time of their birth in January 1990 until December 1997. We compared: (i) number of claims during the 8-year period for the 359 children who had privately-funded ENT surgery (tonsillectomy, myringotomy or adenoidectomy) with claims made by 5880 children who did not have ENT surgery; and (ii) among children who had surgery: we compared claims made before surgery with those made after surgery.

RESULTS

Children who had privately funded ENT surgery (comprising 59% of all paediatric ENT surgery) used significantly more services than other children in total (103.8 claims vs. 57.1 over 8 years) and in each three months of age from birth to eight years, including services for non-ENT-related conditions. Tonsillectomy resulted in a decline in claims, but not to the level of children who did not have surgery. Most children who had myringotomy continued high-level health services use following surgery.

CONCLUSIONS

High volume health services utilisation is a potential predictor of ENT surgery in this population. These results suggest a need to investigate non-clinical factors that influence service utilisation, which may include higher parental expectations or anxiety regarding their children's health.

Finnish adenoidectomy and tympanostomy rates in children; national variation

OBJECTIVES

To assess upper respiratory surgery rates in Finnish children and compare the rates of adenoidectomy and tympanostomy tubes in 2002 with the 1987 cohort.

METHODS

Descriptive study of national upper respiratory surgery in Finland in 1987 and 2002; adenoidectomies, tympanostomy tubes and combination of these two. Surgical rates were viewed in the light of child density and number of primary care physicians and otorhinolaryngologists.

RESULTS

Rates of adenoidectomy and tympanostomy tubes were highest in Western Finland and lowest in Eastern Finland (p<0.00001). Peak-age for adenoidectomy and tympanostomy tubes was in the second year of life. Surgery was most common in boys (p<0.00001). Both the numbers of otorhinolaryngologists and operations increased from 1987 to 2002; the largest surgery increase, 7.3%, was found in Western Finland.

CONCLUSION

Large national differences in rates of paediatric adenoidectomy and tympanostomy tubes in Finland propose that national guidelines have not had an impact on the selection of children for surgery.

Respiratory infections in schoolchildren: co-morbidity and risk factors

AIMS

To assess co-morbidity and risk factors for otitis media, tonsillopharyngitis, and lower respiratory infections in school children.

METHODS

Logistic regression analysis of co-morbidity and risk factors for airway infections in a population based sample of 10 year old children living in Oslo, Norway.

MAIN OUTCOME MEASURES

otitis media, tonsillopharyngitis, and lower respiratory infections in past 12 months.

RESULTS

Airway infections in 10 year old children were common, and significant co-morbidity was found between the various airway infections. Home dampness was a risk factor for all infections, adjusted odds ratios ranging from 1.2 (95% CI 1.0 to 1.5) to 1.4 (95% CI 1.1 to 1.6) for otitis media and tonsillopharyngitis respectively. Atopic disease was a constitutional risk factor, particularly strong for lower airway infections (adjusted odds ratio 2.4, 95% CI 1.8 to 3.1). African or Asian ethnicities were associated with the airway infections, adjusted odds ratios ranging from 1.2 (95% CI 0.9 to 1.7) to 1.7 (95% CI 1.2 to 2.3).

CONCLUSIONS

Respiratory tract infections were common in 10 year old children. There was substantial co-morbidity between upper and lower airway infections. Environmental and constitutional factors were identified and positively associated with the infections. Results support the hypothesis of 1957 that the whole respiratory tract is one unit.

The seven-valent pneumococcal conjugate vaccine reduces tympanostomy tube placement in children

BACKGROUND

The novel pneumococcal conjugate vaccine, PncCRM, has been shown to prevent acute otitis media caused by vaccine serotypes and to reduce otitis surgery. Our aim was to assess long term efficacy of the vaccine on tympanostomy tube placements.

METHODS

Children with complete follow-up in the Finnish Otitis Media Vaccine Trial up to 24 months of age and still living in the study area (1490 of 1662 randomized at 2 months of age) were invited to a single visit at 4-5 years of age. The children had been vaccinated at 2, 4, 6 and 12 months of age with PncCRM or hepatitis B vaccine (control). Tympanostomy tube placements reported by parents at the visit were verified from hospital and private medical center records. Additionally, tympanostomy tube placements of all children were verified from the hospital discharge registry. Vaccine efficacy (VE) was estimated by comparing all events of tympanostomy tube placement between vaccine groups.

RESULTS

During the vaccine trial (2-24 months of age), VE (95% confidence interval) in preventing tympanostomy tube placement was only 4% (-19-23%). Altogether 756 children were enrolled for the follow-up study. After 24 months of age, the rate of surgery was 3.5 per 100 person-years in the PncCRM and 5.7 per 100 person-years in the control children, giving VE of 39% (4-61%). In the hospital-based data of all children (N = 1490), VE of 44% was obtained (19-62%).

CONCLUSIONS

Receipt of PncCRM vaccine at infancy was associated with a reduction in tympanostomy tube placement from 2 to 4-5 years of age.

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

OBJECTIVE

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

SUBJECT AND METHODS

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

RESULTS

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

CONCLUSIONS

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

A pharmacoeconomic evaluation of 7-valent pneumococcal conjugate vaccine in Canada

The objective of this study was to evaluate the projected health benefits, costs, and cost-effectiveness of pneumococcal conjugate vaccination for infants and children aged <5 years in Canada. A health state model incorporating incidence, vaccine efficacy, costs, and transitional probabilities for the health states (well, meningitis, bacteremia, otitis media, pneumonia, and death) was constructed for a 10-year time horizon. Implementation of a pneumococcal conjugate vaccine program in Canada for each annual birth cohort of 340,000 persons observed over 10 years would be expected to save approximately 12 lives and 100,000 cases of pneumococcal disease over 10 years, resulting in total savings of $67 million (Canadian dollars [Can$]). Vaccination of healthy infants would result in net savings for society if the vaccine costs less than Can$50 per dose. Moreover, for a vaccine purchase price of Can$67.50, infant vaccination would cost society Can$79,000 per life-year gained. Pneumococcal conjugate vaccination is a potentially cost-effective means of pneumococcal disease prevention.