Relationship of environmental tobacco smoke to otitis media in young children

Risk factors for otitis media with effusion in children with adenoid hypertrophy

The aim of this study was to determine the most important risk factors in the development of otitis media with effusion (OME) in children with adenoid hypertrophy. A total of 539 patients undergoing surgery for adenoid hypertrophy (AH Group) (n = 429) or adenoid hypertrophy and otitis media with effusion (AH + OME Group) (n = 110) between February 2012 and February 2018 constituted the study group. Data were obtained on neonatal history (breastfeeding, bottle feeding), past health and medical history (presence of atopy or allergic rhinitis, snoring at night, cough, tonsillitis in the past 12 months), environmental factors (presence of pets, attending to daycare centers, district of school), family history (passive smoking at home, number of siblings, family size, parental education), and family income. The groups did not differ from each other for age (p = 0.684) and gender (p = 0.728). Our data support the presence of atopy or allergic rhinitis (p < 0.001), frequent (> 5) tonsillitis (p < 0.001), attending to daycare centers (p < 0.001), exposure to smoke (p < 0.001), having 3 or more siblings (p < 0.001), and 4 or more people in the household (p < 0.001) as the main risk factors for OME. Comprehensive knowledge of modifiable risk factors found in this study could help to minimise the complications of OME in children.

The Role of Thiocyanate in Modulating Myeloperoxidase Activity during Disease

Thiocyanate (SCN⁻) is a pseudohalide anion omnipresent across mammals and is particularly concentrated in secretions within the oral cavity, digestive tract and airway. Thiocyanate can outcompete chlorine anions and other halides (F⁻, Br⁻, I⁻) as substrates for myeloperoxidase by undergoing two-electron oxidation with hydrogen peroxide. This forms their respective hypohalous acids (HOX where X⁻ = halides) and in the case of thiocyanate, hypothiocyanous acid (HOSCN), which is also a bactericidal oxidative species involved in the regulation of commensal and pathogenic microflora. Disease may dysregulate redox processes and cause imbalances in the oxidative profile, where typically favoured oxidative species, such as hypochlorous acid (HOCl), result in an overabundance of chlorinated protein residues. As such, the pharmacological capacity of thiocyanate has been recently investigated for its ability to modulate myeloperoxidase activity for HOSCN, a less potent species relative to HOCl, although outcomes vary significantly across different disease models. To date, most studies have focused on therapeutic effects in respiratory and cardiovascular animal models. However, we note other conditions such as rheumatic arthritis where SCN⁻ administration may worsen patient outcomes. Here, we discuss the pathophysiological role of SCN⁻ in diseases where MPO is implicated.

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

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

Environmental contributions to otitis media requiring tympanostomy tubes

OBJECTIVE

Otitis media requiring tympanostomy tubes (OMwTT) is a prevalent disease process that has been previously shown to have a strong familial link. The impact from the environmental versus genetic contributions to this link is unknown. The objective was to determine the environmental involvement in the development of OMwTT.

METHODS

Using an extensive genealogical database linked to medical records, we evaluated the risk of OMwTT in children of probands as compared to children of controls, individually matched 5:1 on sex and birth year, from a conditional logistic regression model. The model included adjustments for geographic and socioeconomic environmental risk factors mapped to residence location of study subjects within 63 small health statistical areas of ∼33,500 persons each.

RESULTS

37,814 case probands diagnosed with OMwTT and 181,339 controls were included in our analysis. Children of probands with OMwTT had an overall 2.5× higher risk of also having OMwTT as compared to the children of controls (p < 10^-9), independent of environmental factors (PM_2.5 [particulate matter] air pollution, education level of parents, and density of primary care providers).

CONCLUSION

After accounting for geographic and socioeconomic differences that may influence risk between cases and controls, our findings suggest evidence of a genetic predisposition in families of OMwTT patients. Further characterization of high-risk pedigrees is needed for future genomic studies.

Impact of environmental volatile organic compounds on otitis media in children: Correlation between exposure and urinary metabolites

INTRODUCTION

Volatile organic compounds (VOCs) induce inflammatory responses. Tobacco smoke contains numerous VOCs and is a risk factor for otitis media effusion (OME); however, no previous studies have investigated the association between VOCs and OME.

OBJECTIVES

We used urinary metabolites and exposure to environmental risk factors to investigate the association between VOC and polycyclic aromatic hydrocarbon exposure and recurrent OME in children.

METHODS

Children with recurrent OME who visited the Otorhinolaryngology Department of Seoul National University Hospital between November 2014 and June 2015 were prospectively enrolled in the study. Recurrent OME was defined as more than two OME episodes over a 6-month period lasting longer than 2 months. The control group consisted of children without OME in the last year. Demographic information, including age, sex, and previous medical history was obtained, and endoscopic examinations of the tympanic membrane were performed. Urinary concentrations of 1-hydroxypyrene, 2-naphthol, hippuric acid, trans, trans-muconic acid (t,t-MA), mandelic acid, phenyl glyoxylic acid, and methyl hippuric acid were analyzed using high-performance liquid chromatography/tandem mass spectroscopy. Environmental factors assessed included house type, age, renovations, the presence of furniture <6 months old, proximity to a road, and exposure to passive smoking.

RESULTS

We enrolled 11 children with OME and 39 controls. Age and sex did not differ between groups. Exposure to passive smoking was significantly more common in the OME group than in the controls (P < 0.001). Urinary concentrations of t.t.-MA were significantly higher in the OME group (126.33 μg/g cr) than in controls (52.661 μg/g cr; P = 0.003). Other metabolites including 1-hydroxypyrene, 2-naphthol, hippuric acid, mandelic acid, phenyl glyoxylic acid, and methyl hippuric acid did not demonstrated significant relation with the OME.

CONCLUSIONS

Levels of t,t-MA, a biomarker of benzene exposure, were significantly higher in the OME group than in controls. Passive smoking was significantly more common in the OME group. Our findings suggest that high t,t-MA levels which were probably originated from passive smoking and other pollutants could be indicative OME in children.

Effect of urban particles on human middle ear epithelial cells

OBJECTIVES

The aim of this study was to examine the cytotoxic effect and inflammatory response of human middle ear epithelial cells (HMEECs) induced by urban particles (UP).

MATERIALS AND METHODS

Cell viability following UP exposure was assessed in HMEECs using the CCK 8 assay. The expression levels of the inflammation-related genes (COX-2 and MUC5AC) were analyzed using semi-quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and COX-2 production was analyzed using western blotting.

RESULTS

Treatment with UP decreased cell viability in HMEECs in a dose- and time-dependent manner. UP exposure induced the significantly increased expression of COX-2 and MUC5AC. Western blotting showed dose dependently increased expression of COX-2 production.

CONCLUSIONS

UP decreased cell viability, increased the inflammatory response, and increased mucin gene production in HMEECs. These findings indicate that exposure to UP can contribute to the development of otitis media.

Association of time-location patterns with urinary cotinine among asthmatic children under household environmental tobacco smoke exposure

INTRODUCTION

Environmental tobacco smoke (ETS) is a hazardous component of indoor air, and may increase the risk of respiratory diseases, atherosclerosis and otitis media in children. In this study, we explored the relationship between time inside the house, ETS exposure and urinary cotinine level, and also determined the association of time inside the house on asthma phenotypes when children exposed to ETS.

METHODS

A total of 222 asthmatic children and 205 non-asthmatic controls were recruited in the Genetic and Biomarker study for Childhood Asthma (GBCA). Structured questionnaires and time-location pattern questionnaires were administered by face-to-face interview. Urinary cotinine was measured by liquid chromatography tandem mass spectrometry (LC/MS/MS). The level of household ETS exposure was assessed using the cotinine/creatinine ratio (CCR).

RESULTS

In general, urinary cotinine and CCR were higher in subjects exposed to household ETS than those who never had ETS at home. A significant positive relationship was found between average time inside the house and urinary CCR in asthmatic children with current ETS at home (β=0.278, p=0.02). After adjustment for age and gender, average time inside the house was positively related to severe wheeze in asthmatic children with household ETS within 1 month (OR: 1.26, 95%: 1.02-1.64).

CONCLUSIONS

Our study suggests that the major source of ETS exposure for children is due to longer period of exposures among children living with adult smokers at home. Home-smoking restrictions that effectively prevent children from being exposed to ETS would be worthwhile.

Cigarette smoking and mechanisms of susceptibility to infections of the respiratory tract and other organ systems

The predisposition of cigarette smokers for development of oral and respiratory infections caused by microbial pathogens is well recognised, with those infected with the human immunodeficiency virus (HIV) at particularly high risk. Smoking cigarettes has a suppressive effect on the protective functions of airway epithelium, alveolar macrophages, dendritic cells, natural killer (NK) cells and adaptive immune mechanisms, in the setting of chronic systemic activation of neutrophils. Cigarette smoke also has a direct effect on microbial pathogens to promote the likelihood of infective disease, specifically promotion of microbial virulence and antibiotic resistance. In addition to interactions between smoking and HIV infection, a number of specific infections/clinical syndromes have been associated epidemiologically with cigarette smoking, including those of the upper and lower respiratory tract, gastrointestinal tract, central nervous and other organ systems. Smoking cessation benefits patients in many ways, including reduction of the risk of infectious disease.

Effect of diesel exhaust particles on human middle ear epithelial cells

OBJECTIVE

In the present study, we investigate whether diesel exhaust particles (DEPs) cause cytotoxicity and induce inflammation or increase the expression of mucin in immortalized human middle ear epithelial cell lines (HMEECs). Several publications have shown an association between traffic-related air pollutants and otitis media. Additionally, DEP have been shown to cause inflammation and an allergic response in the airways.

METHODS

Cell viability following DEP treatment was investigated in HMEECs using the MTT assay. We measured the expression of the inflammatory cytokines TNF-α and COX-2 and the mucin genes MUC5AC and MUC5B using semiquantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and Western blotting.

RESULTS

Cell viability tests showed that exposure to more than 80 μg/mL of DEP caused a decrease in cell viability. DEP exposure also increased the expression of MUC5AC, but did not induce the expression of MUC5B in HMEECs.

CONCLUSION

DEP decreased cell viability, induced an inflammatory response, and increased mucin gene expression in HMEECs. These findings support the hypothesis that environmental diesel exposure is a risk factor for otitis media.

Environmental tobacco smoke and children's health

Passive exposure to tobacco smoke significantly contributes to morbidity and mortality in children. Children, in particular, seem to be the most susceptible population to the harmful effects of environmental tobacco smoke (ETS). Paternal smoking inside the home leads to significant maternal and fetal exposure to ETS and may subsequently affect fetal health. ETS has been associated with adverse effects on pediatric health, including preterm birth, intrauterine growth retardation, perinatal mortality, respiratory illness, neurobehavioral problems, and decreased performance in school. A valid estimation of the risks associated with tobacco exposure depends on accurate measurement. Nicotine and its major metabolite, cotinine, are commonly used as smoking biomarkers, and their levels can be determined in various biological specimens such as blood, saliva, and urine. Recently, hair analysis was found to be a convenient, noninvasive technique for detecting the presence of nicotine exposure. Because nicotine/cotinine accumulates in hair during hair growth, it is a unique measure of long-term, cumulative exposure to tobacco smoke. Although smoking ban policies result in considerable reductions in ETS exposure, children are still exposed significantly to tobacco smoke not only in their homes but also in schools, restaurants, child-care settings, cars, buses, and other public places. Therefore, more effective strategies and public policies to protect preschool children from ETS should be consolidated.

A review of interventions for reduction of residential environmental tobacco smoke exposures among children

OBJECTIVE

To describe individual-level interventions to reduce residential environmental tobacco smoke (ETS) exposure among children and to summarize the evidence of the effectiveness of the interventions.

PATIENTS AND METHODS

A search of electronic databases (from 1987 to 1998) was conducted for studies designed to reduce ETS exposure of children through the use of interventions that included strategies other than parental smoking cessation. Twelve articles that presented nine unique interventions (six interventions were designed for well children and three interventions targeted children with asthma) were found. Information about location, target population, design, sample size, tested intervention and results were summarized for each study.

RESULTS

Only one of the six interventions designed for well children produced significant reductions in ETS exposure, while all three of the interventions that targeted children with asthma reported small to moderate reductions in ETS exposure or respiratory symptoms.

CONCLUSIONS

The number of interventions for ETS reduction published to date is miniscule relative to the magnitude of the associated health problems. Some ETS reduction interventions for children have shown significant reductions in exposure, but most interventions, especially those designed for well children, have had little effect. Little is known about which specific intervention components may be effective. Parental characteristics that may predict positive response to intervention efforts have not been identified. More research is needed to develop effective interventions that can be integrated with physician visits in the perinatal and early childhood periods. Adapting standard guidelines on counselling for parental smoking cessation may be a promising approach if the barriers identified by health professionals can be addressed adequately.

Effects of cigarette smoking on mucin production in human middle ear epithelial cells

OBJECTIVE

Otitis media (OM) is the most common disease in preschool age children related to passive cigarette smoking as risk factor. In this study, we investigate whether the cigarette smoking can induce the inflammation in human middle ear epithelial cell, and cigarette smoke-induced inflammation can increase the expression of MUC5AC gene and protein that was known to play an important role in OM with effusion.

METHODS

After treatment of cigarette smoke solution (CSS) on immortalized human middle ear epithelial cells (HMEECs) with or without pretreatment by epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (AG1478), we observed expression of tumor necrosis factor-alpha (TNF-α), EGFR, MUC5AC mRNA by quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and EGFR, MUC5AC protein by western blotting.

RESULTS

Treatment of CSS increased expression of TNF-α mRNA dose dependently. Treatment of CSS upregulated the EGFR and MUC5AC mRNA in a time-dependent manner. CSS-induced upregulation of EGFR and MUC5AC mRNA was suppressed by the pretreatment of AG1478. EGFR and MUC5AC proteins were upregulated by the treatment of CSS and suppressed by the pretreatment of AG1478.

CONCLUSIONS

Treatment of CSS on HMEECs increased the expression of MUC5AC mRNAs and proteins which play a major role in OM with effusion.

Prevalence of recurrent otitis media in habitually snoring school-aged children

INTRODUCTION

The pathophysiology of obstructive sleep apnea (OSA) and recurrent otitis media (ROM) is intimately associated with the presence of adenotonsillar hypertrophy in children. However, it remains unclear whether habitually snoring children have a higher prevalence of ROM and whether they require tympanostomy tube placement more frequently.

METHODS

Questionnaires collected from parental surveys of 5- to 7-year-old children attending the public schools in Louisville, KY were retrospectively reviewed for the presence of habitual snoring (HS), ROM, and the need for tympanostomy tube insertion.

RESULTS

There were 16,321 surveys with complete datasets (51.2% boys; 18.6% African American (AA) with a mean age of 6.2+/-0.7 years). Of these children, 1844 (11.3%) were HS (53% boys; 25.9% AA); and, of these, 827 HS had also a positive history of ROM (44.8%) with a slight predominance in males (55%). In addition, 636 of these children underwent placement of tympanostomy tubes (i.e., 34.4% of all HS and 76.9% of ROM). Among the 14,477 non-snoring children (NS), ROM was reported in 4247 NS children (29.3%; p<0.000001; odds ratio [OR]: 1.95; confidence interval [CI]: 1.77-2.16) of which 57.6% were boys, and 1969 NS with ROM underwent tympanostomy tube placement (i.e., 46.3% of those with ROM and 13.6% of all non-snoring children). Thus, the risk for tympanostomy tube placement was also greater among HS compared to NS children (p<0.00001; OR: 2.19; CI: 1.98-2.43).

CONCLUSIONS

Habitual snoring is associated with a significant increase in the prevalence of recurrent otitis media and the need for tympanostomy tube placement. Further studies aiming to assess the prevalence of obstructive sleep apnea among children with ROM are needed.

Passive smoking after tympanostomy and risk of recurrent acute otitis media

OBJECTIVE

Exposure to environmental tobacco smoke has been reported to be a risk factor for childhood otitis media. The effect of parental smoking on the risk of otitis media after the insertion of tympanostomy tubes is unknown. We evaluated the effect of parental smoking on the risk of recurrent otitis media in children who had received tympanostomy tubes.

METHODS

We enrolled 217 children aged 1-4 years who underwent insertion of tympanostomy tubes because of middle ear disease. The children were followed-up for 12 months. Otitis media episodes were recorded in patient diaries by primary care physicians. Parental smoking habits were assessed by a questionnaire at the start of the trial and after the 12 month follow-up had ended. The main outcome measure was risk of recurrent otitis media as defined by four or more otitis media episodes after tympanostomy. Altogether 198 children completed the follow-up.

RESULTS

Maternal smoking was associated with a highly increased risk of recurrent acute otitis media (OR 4.15, 95% CI 1.45-11.9) after the insertion of tympanostomy tubes.

CONCLUSION

Exposure to passive smoking is associated with four-fold risk of recurrent otitis media after tympanostomy. This finding should be used to encourage parents to stop smoking even after the insertion of tympanostomy tubes to their children.

Trends in otitis media among children in the United States

BACKGROUND

The prevalence of repeated otitis media (OM) increased during the 1980s, but it is unknown if the increase has continued.

OBJECTIVES

To determine trends in the prevalence of OM, early-onset OM, and repeated OM among US children from 1988 to 1994 and to identify factors that may explain any observed changes.

METHODS

The Third National Health and Nutrition Examination Survey was administered in 2 phases: phase I (1988-1991) and phase II (1991-1994), each comprising a national probability sample. OM (ever having had OM), early-onset OM (first episode at <12 months of age), and repeated OM (>or=3 episodes) were assessed for 8261 children <6 years of age.

RESULTS

After controlling for risk factors for OM, the prevalence of OM from phase I to phase II increased from 66.7% to 69.7% (odds ratio [OR] = 1.1; 95% confidence interval [CI] =.99, 1.1), early-onset OM increased from 41.1% to 45.8% (OR = 1.1; 95% CI = 1.03, 1.2), and repeated OM increased from 34.8% to 41.1% (OR = 1.2; 95% CI = 1.1, 1.4). This observed increase corresponds to 561,000 and 720,000 more children having early-onset OM and repeated OM, respectively. Child care use, early breastfeeding termination, asthma, and access to health care did not significantly increase from phase I to phase II. The prevalence of early-onset OM and repeated OM was higher for affluent children, but the greatest increase in prevalence was among impoverished children. There was an increase in allergic conditions from phase I to phase II for poor children (22.6% to 30.2%).

CONCLUSIONS

The prevalence of early-onset OM and repeated OM continued to increase among preschool children in the United States. Further research to investigate this increasing prevalence should explore changes in management practice and an increase in prevalence of allergic conditions among poor children.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

A retrospective chart review.

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Selected secondhand smoke research: summary and comment

Secondhand smoke is one of the more controversial public health issues. It is controversial because laws regulating secondhand smoke create conflict between the rights of smokers and non-smokers. The results of secondhand smoke research frequently focus on risk factors in four areas: heart disease, cancer, respiratory disorders, and middle ear discase. While many studies have found hazards in each of these four areas, there is some disagreement regarding the degree and extent of the threat posed by these hazards. Future research should discover more risks associated with secondhand smoke and suggest appropriate educational, medical, legal, and environmental remedies for this problem. Then society can establish prevention programs and enact laws which protect non-smokers, but at the same time infringe as little as possible on the rights of others.

Prediction of 8-month MEE from neonatal risk factors and test results in SCBU and full-term babies

The incidence and persistence of middle ear effusion (MEE) may be affected by children's birth history and environment. Factors such as bottle-feeding, presence of parental smoking, admission to special care and a history of colds are all thought to increase the risk of persistent MEE. The aim of the present study was to determine those risk factors and neonatal test results that best predict presence of MEE (as measured by 220 Hz tympanometry) at 8 months of age. One hundred Special Care Baby Unit (SCBU) and non-SCBU babies were assessed neonatally and at 8 months of age with tympanometry. At each assessment, various risk factors were collected. Failure of 8-month tympanometry was best predicted by neonatal (660 Hz) tympanometry and the presence or absence of breast-feeding for SCBU babies. This provides further evidence that 660 Hz tympanometry may provide information about neonatal MEE. For non-SCBU babies the risk of failing 8-month tympanometry was most significantly affected by a history of colds and parental smoking. The number of babies with each combination of risk factors in the present study is rather small and this has caused confidence intervals (CIs) to be wide and some unexpected results. However, an extended study with a larger and more balanced sample may facilitate accurate prediction neonatally of those children at risk of 8-month MEE.

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

OBJECTIVES

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Environmental risk factors for respiratory infections

In this study, the authors investigated the possible relationship between environmental-including dietary-factors and respiratory and ear infections in children. A sample of 304 children, aged 4-5 y, in Geneva, Switzerland, was studied. Mothers filled out a questionnaire that the authors provided. The questionnaire included items on food frequency, infections, and background factors (e.g., education, housing conditions, parents' smoking habits). Allergy was a risk factor for all infections, and mother's age was a protective factor. Humid conditions at home was a significant risk factor for cold, sore throat, and otitis (odds ratios = 2.71, 3.03, and 2.77, respectively); mold in the home was a significant risk factor for otitis (odds ratio = 2.80); and attending day-care centers was a significant risk factor for cold and bronchitis (odds ratios = 1.36 and 1.89, respectively). Dietary factors were not related to disease risk nor were environmental tobacco smoke or housing conditions generally related to an increased risk.

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

BACKGROUND

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

POPULATION AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Factors associated with tympanostomy tube insertion among preschool-aged children in the United States

OBJECTIVES

Recurrent and persistent otitis media is often treated by tympanostomy tube insertion to ventilate the middle ear and restore hearing. This study examined the factors that predict which children are most likely to receive tympanostomy tubes through 3 years of age.

METHODS

Multiple logistic regression was conducted on data from a nationally representative sample of children (N = 8285).

RESULTS

By 3 years of age, 6.8% of US children had tubes inserted. Logistic regression indicated that after control for number of ear infections, children without any gaps in health insurance, who attended a day-care center, who were White, whose birth-weight was less than 1500 g, and who lived in the Midwest or South were significantly more likely to have tympanostomy tubes.

CONCLUSIONS

These data suggest that differences exist as to who receives tubes. Of particular concern are differences by race/ethnicity and continuity of health insurance coverage. With expansions in health care coverage to larger proportions of uninsured children, it will be important to monitor these programs to ensure that all children who may need tympanostomy tubes have access to them.

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.

Otitis-prone children and controls: a study of possible predisposing factors. 2. Physical findings, frequency of illness, allergy, day care and parental smoking

In a retrospective study of 179 otitis-prone children and 305 controls, various possible predisposing factors for acute otitis media (AOM) were compared. The children were matched with the controls for age and sex. There were 61% boys and 39% girls in the otitis-prone group and 58% boys and 42% girls among the controls. Information about the family and living conditions, the children's illnesses, ear, nose and throat (ENT) operations and possible allergies were obtained from a questionnaire, and the children were called for a physical examination. The otitis-prone children had more middle-ear problems with pathological tympanograms and conductive hearing loss than the controls. No differences were found in bacterial colonization of the nasopharynx. Besides AOM and secretory otitis media, the otitis-prone children had more other ENT diseases and had consequently undergone more ENT operations and hospitalizations than the controls. There were no differences between the two groups regarding allergy, day care or parental smoking alone, but on comparing children with combinations of these factors there were more otitis-prone children than controls exposed, indicating an additive effect. The combination of different factors, less important separately, may for some children mean the difference between becoming otitis-prone or not.

[Rhinopharyngitis and recurrent acute otitis media: Risks and guidelines]

Rhinopharyngitis is a common disease in the pediatric population. Acute otitis media is the most frequent complication. Eustachian tube obstruction is responsible for underaeration of the middle-car. Congestion of the respiratory mucosa and adenoid hypertropy result in persistent middle ear effusion and recurrent acute otitis media. Other predisposing factors are allergy, passive smoking, persistent middle ear effusion, young-age at first diagnosis of acute otitis media. Adenoidectomy and/or tympanostomy tubes are indicated in the treatment of recurrent acute otitis media.