Factors affecting resolution of otitis media with effusion in children

Pediatric maxillary expansion has a positive impact on hearing? A systematic review and meta-analysis

OBJECTIVE

Hearing loss is a highly prevalent condition in the pediatric population. Pediatric maxillary expansion is a widespread treatment to address transverse maxillary deficiency. First reports describing an association between improvements for patients with HL and PME initiated in the 1960s. In this systematic review and meta-analysis we aim to review the role of maxillary expansion in reducing conductive hearing loss in pediatric population.

REVIEW METHODS

Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database were checked. Main outcome was expressed as the difference between air-bone gap, compliance, ear volume and conductive hearing thresholds before and after treatment and the 95% confidence interval.

RESULTS

A total of 10 studies (218 patients) met inclusion criteria. The pooled data in the meta-analysis under a random effects model shows a statistically significant difference of 10.57dB mean reduction after palatal expansion. The air-bone gap was significantly reduced by 5.39dB (CI 95% 3.68, 7.10). Compliance and volume were assessed in three studies, with a non-significant positive difference in the compliance (0.14) and a statistically significant difference for volume (0.80) after palatal expansion.

CONCLUSION

This systematic review and meta-analysis found a positive effect of pediatric maxillary expansion in conductive hearing loss in well-select children. However, results cannot be extrapolated for children with conductive hearing loss without an accompanying orthodontic indication (maxillary constriction). It showed that the existing prospective studies exhibited qualitative pitfalls, limiting the ability to obtain conclusive evidence about the role of pediatric maxillary expansion on conductive hearing loss in children.

Effects of maxillary expansion on hearing and voice function in non-cleft lip palate and cleft lip palate patients with transverse maxillary deficiency: a multicentric randomized controlled trial

INTRODUCTION

The association between the treatment of transverse maxillary deficiency and the recovery of hearing and voice functions has gained attention in recent years.

OBJECTIVE

This prospective controlled trial aimed to evaluate the effects of rapid maxillary expansion on hearing and voice function in children with non-cleft lip palate and bilateral cleft lip palate with transverse maxillary deficiency METHODS: 53 patients (26 non-cleft and 27 bilateral cleft lip palate; mean age, 11.1±1.8 years) requiring rapid maxillary expansion for correction of narrow maxillary arches were recruited for this trial. Eight sub-groups were established based on the degree of hearing loss. Pure-tone audiometric and tympanometric records were taken for each subject at four different time periods. The first records were taken before rapid maxillary expansion (T0), the second after expansion (T1) (mean, 0.8 months), the third after three months (T2) (mean, 3 months) and the fourth at the end of retention period (T3) (mean, 6 months). ANOVA and Tukey HSD post-hoc tests were used for data analysis. Additionally, voice analysis was done using an updated PRAAT software program in a computerized speech lab at T0 and T2. A paired-samplet-test was used for comparisons of mean values of T0 and T2 voice parameters within both groups.

RESULTS

Rapid maxillary expansion treatment produced a significant increase in the hearing levels and middle ear volumes of all non-cleft and bilateral cleft lip palate patients with normal hearing levels and with mild conductive hearing loss, during the T0-T1, T1-T2, T0-T2, and T0-T3 observation periods (p<0.05). The significant increase was observed in right middle ear volumes during the T0-T1, T0-T2 and T0-T3 periods in non-cleft patients with moderate hearing loss. For voice analysis, significant differences were observed only between the T0 and T2 mean fundamental frequency (F0) and jitter percentage (p<0.05) in the non-cleft group. In the cleft group, no significant differences were observed for any voice parameter between the T0 and T2 periods.

CONCLUSION

Correction of the palatal anatomy by rapid maxillary expansion therapy has a beneficial effect on both improvements in hearing and normal function of the middle ear in both non-cleft and bilateral cleft lip palate patients. Similarly, rapid maxillary expansion significantly influences voice quality in non-cleft patients, with no significant effect in BCLP patients.

Quality of life in children with otitis media--a cohort study

BACKGROUND

Studies about health-related quality of life (HRQOL) in children with otitis media have primarily focused on short-term effects of the disease, and how treatment with insertion of ventilation tubes (VTs) affects the HRQOL. More knowledge is needed about how long-term HRQOL is associated with different factors like insertion of VT and use of antibiotics.

OBJECTIVE

We aimed to analyse HRQOL in children with otitis media 1 year after inclusion and to what extent insertion of VT, use of antibiotics, diagnoses, symptoms in the children, day-care attention, parental absence from work and parental smoking were associated with the long-term HRQOL in children with otitis media.

METHODS

A cohort study including 397 children was carried out. The children were followed for 13 months, and symptoms, HRQOL and so on were identified by means of questionnaires.

RESULTS

HRQOL in children with otitis media was significantly improved after 13 months. The improvement of HRQOL was significantly lower for children with sleep problems compared with children without sleep problems. The improvement in HRQOL was significantly lower in children whose parents had been absent from work during the preceding 3 months due to the child' s otitis media compared with children with parents not being absent from their work. There were no statistically significant differences in the improvement of HRQOL in children who had received a VT during the follow-up period compared with children without a VT.

CONCLUSION

HRQOL in children with otitis media was significantly improved after 13 months. The improvement in HRQOL was significantly lower for children with sleep problems. The improvement in HRQOL was significantly lower in children whose parents had been absent from work due to the child's otitis media. There were no statistically significant differences in the improvement of HRQOL in children who had received a VT during the follow-up period.

Associations between symptoms, clinical findings and the short-term prognosis among children with otitis media: a cohort study

OBJECTIVE

Otitis media (OM) is a common childhood disease and a frequent reason for seeking medical care in general practice. Only few studies have focused on what happens after diagnosis and initial treatment of OM. In particular, there is a lack of research on how different patient- and disease-related factors influence the course of OM. The aim of this study was to analyze to what extent symptoms at the time of initial diagnosis are associated with the short-term course of otitis media.

METHODS

Cohort study in general practice comprising 747 children between 0 and 7 years with a new ear symptom. At the first consultation the GPs registered symptoms, results of otoscopy and tympanometry, together with diagnosis and treatment. The children were followed up four weeks later.

RESULTS

Sleep problems at inclusion are statistically significant associated with having one or more symptom after four weeks in children between 0 and 2 years (OR: 2.02 (95% confidence interval (CI): 1.24-3.31)). If the result of tympanometry is a flat curve, the OR for being referred is 3.24 (CI: 1.61-6.55) in children between 0 and 2 years compared to children without a flat curve. The OR for being referred in children between 2 and 7 years with a flat curve is 8.94 (CI: 4.18-19.11) when compared to children without a flat curve.

CONCLUSION

Sleep problems at inclusion were the only symptom statistically significant associated with having one or more symptoms after four weeks in children between 0 and 2 years.

Effects of rapid maxillary expansion on middle ear function: one-year follow-up

OBJECTIVE

To evaluate the effects of rapid maxillary expansion (RME) on middle ear function before, after, 3 months and one year from expansion procedure.

PATIENTS AND METHODS

Eighteen patients with mean age of 8.1 years (±3.7) and posterior cross-bite were followed from pre expansion to one year after RME, regarding their hearing quality and middle ear function. Nine of them presented middle ear dysfunction (MED) and nine presented normal function (NF) before rapid maxillary expansion. Audiometric and tympanometric exams were taken before rapid maxillary expansion, after RME (15 days), 3 months and one year after rapid maxillary expansion.

RESULTS

Among those in the MED group, no patient had acoustic reflex (AR) before rapid maxillary expansion; 67% presented type C tympanometric curve, 22% had type A and 11% had As type tympanometric curve. One year after rapid maxillary expansion, all patients presented AR and showed type A tympanometric curves. In NF group, all patients showed AR and type A tympanometric curves in all records. In both groups no audiograms presented significant variations along study.

CONCLUSION

Rapid maxillary expansion has no deleterious effect in hearing quality and seems to improve middle ear function in children with posterior cross-bite in a one-year perspective.

Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort

OBJECTIVES

To compare tympanostomy tube insertion for children with otitis media in 2002 with the recommendations of two sets of expert guidelines.

DESIGN

Retrospective cohort study.

SETTING

New York metropolitan area practices associated with five diverse hospitals.

PARTICIPANTS

682 of 1046 children who received tympanostomy tubes in the five hospitals for whom charts from the hospital, primary care physician, and otolaryngologist could be accessed.

RESULTS

The mean age was 3.8 years. On average, children with acute otitis media had fewer than four infections in the year before surgery. Children with otitis media with effusion had less than 30 consecutive days of effusion at the time of surgery. Concordance with recommendations was very low: 30.3% (n=207) of all tympanostomies were concordant with the explicit criteria developed for this study and 7.5% (n=13) with the 1994 guideline from the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology-Head and Neck Surgery. Children who had previously had tympanostomy tube surgery, who were having a concomitant procedure, or who had "at risk conditions" were more likely to be discordant.

CONCLUSIONS

A significant majority of tympanostomy tube insertions in the largest and most populous metropolitan area in the United States were inappropriate according to the explicit criteria and not recommended according to both guidelines. Regardless of whether current practice represents a substantial overuse of surgery or the guidelines are overly restrictive, the persistent discrepancy between guidelines and practice cannot be good for children or for people interested in improving their health care.

Craniofacial morphology and otitis media with effusion in children

Otitis media with effusion (OME) affects 28-38% of pre-school children, and it occurs due to the dysfunction of the auditory tube. Anatomical development of the auditory tube depends on the craniofacial growth and development. Deviations of normal craniofacial morphology and growth using cephalometric studies, may predict the evolution of otitis. Our goal in this paper is to determine if there are differences in craniofacial morphology between children with adenoid enlargement, with and without otitis media with effusion. This is a prospective study in which the sample consisted of 67 children (male and female) from 5 to 10 years old. All patients presented chronic upper airway obstruction due to tonsil and adenoid enlargement (>80% degree of obstruction). Thirty-three patients presented otitis media with effusion, for more than 3 months and 34 did not. The latter composed the control group. Standardized lateral head radiographs were obtained for all subjects. Radiographs were taken with patient positioned by a cephalostat and stayed with mandibles in centric occlusion and lips at rest. Radiographs were digitalized and specific landmarks were identified using a computer program Radiocef 2003, 5th edition. Measurements, angles and lines were taken of the basicranium, maxilla and mandible according to the modified Ricketts analysis. In addition, facial height and facial axis were determined. Children with otitis media with effusion present differences in the morphology of the face, regarding these measures: N-S (anterior cranial base length), N-ANS (upper facial height), ANS-PNS (size of the hard palate), Po-Or.N-Pog (facial depth), Ba-N.Ptm-Gn (facial axis), Go-Me (mandibular length) and Vaia--Vaip (inferior pharyngeal airway).

Squamous metaplasia and BCL-6 in pediatric adenoid accompanied by otitis media with effusion

PURPOSE

Deterioration of local immunity in the adenoids may make them vulnerable to infection by microorganisms, resulting in otitis media with effusion. To determine the factors associated with this condition, we evaluated adenoid size, mucosal barrier, squamous changes of ciliated epithelium, IgA secretion, and BCL-6 expression in adenoids.

MATERIALS AND METHODS

Seventeen children diagnosed with otitis media with effusion (OME group) and 20 children without any history of OME (control group) were enrolled. Their adenoids were sized by lateral view X-ray and stained with hematoxylin and eosin to detect squamous metaplasia. The adenoids were also stained with cytokeratin to evaluate mucosal barriers, and with anti- IgA antibody and anti- BCL-6 antibody to determine expression of IgA and BCL-6.

RESULTS

The OME group showed greater incidence of squamous metaplasia, fewer ciliated cells, and lower expression of BCL-6 (p < 0.05 each). Deterioration of the mucosal barrier was detected in the OME group (p > 0.05). IgA secretion and adenoid size were the same for the OME and the control groups.

CONCLUSION

These results suggest that increased squamous metaplasia and lower BCL-6 expression in adenoids may be associated with increased susceptibility to OME.

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

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

The aetiology of otitis media with effusion: a review

Otitis media with effusion (OME) is the most common cause of deafness in children in the developed world. In this article we aim to present an overview of current research developments on the aetiology of OME and the resulting implications for treatment. In the model we describe, the primary event is inflammation of the middle ear mucosa, usually due to the presence of bacteria. This leads to the release of inflammatory mediators, which cause secretion of a mucin-rich effusion by up-regulating mucin genes. Prolonged stimulation of the inflammatory response and poor mucociliary clearance lead to persistence of the middle ear fluid, giving rise to the clinical presentation of OME. We describe OME in the following sequence: the initial production of the effusion, the composition of the effusion produced, and factors impairing clearance of the effusion.

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.

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.

Tympanic membrane atrophy, scarring, atelectasis and attic retraction in persistent, untreated otitis media with effusion and following ventilation tube insertion

Two hundred and twenty two children with persistent bilateral otitis media with effusion (OME) were treated with unilateral ventilation tube insertion and no treatment to the contralateral ear. The tympanic membrane changes in the operated and unoperated ears were compared during a 12 year follow-up. Segmental atrophy resulted from tube insertion whereas minor scarring and thickening of the pars tensa was related to the middle ear condition. Eight three percent of untreated ears and 85% of those treated with tubes did not develop atelectasis. Sixty percent of untreated ears and 64% of treated ears did not develop attic retraction. Very few cases (1.5 and 2%) in untreated and treated ears, respectively developed severe atelectasis. The overall duration of OME was assessed from the pre-operative history of hearing loss, the 3 month period of pre-operative observation and the post-operative time with effusion. There is a relationship between duration of the disease and development of both atelectasis and attic retraction.