Otitis media and tympanostomy tube insertion during the first three years of life: developmental outcomes at the age of four years

Contribution of Treatment with Ear Popper for Hearing in Children with Middle Ear Effusion

OBJECTIVES

we aim to assess the contribution of the EarPopper device to hearing in children with middle ear effusion (MEE).

METHODS

The study has three parts, including 1. tympanometry and audiometry before and six weeks after using the EarPopper to evaluate the treatment's effect over time compared to a control group; 2. tympanometry before and immediately after using the EarPopper to evaluate immediate changes in middle ear pressure (MEP); 3. length of effect 90 min after use to assess pressure fluctuations over time.

RESULTS

Part 1 was a follow-up six weeks after using the device, and the patients in the study group that completed the study showed a significant improvement in hearing threshold. The average gain in hearing threshold ranged from 9.1 dB to 14 dB compared to the control group's max improvement of 1.1 dB. In addition, MEP was significantly improved in the study group, as most Type Bs improved to Type A and C. Part 2 was the tympanometry immediately after using EarPopper and showed the majority of Type Cs turned into Type As. The majority of Type Bs remained unchanged. Part 3 was a follow-up 90 min after use; Type Cs that had improved to Type A demonstrated a decrease in pressure and return to negative pressure.

CONCLUSIONS

use of the EarPopper device for six weeks is associated with an improved hearing threshold and middle ear status.

Impact of ventilation tube insertion on long-term language outcomes at 6 and 10 years of age: A prospective pregnancy cohort study

OBJECTIVE

Investigating the impact of early childhood ventilation tube insertion (VTI) on long-term language outcomes.

DESIGN

Longitudinal cohort study.

SETTING

A total of 2900 pregnant women participated in the Raine Study between 1989 and 1991 in Western Australia, and 2868 children have been followed up.

PARTICIPANTS

Based on parental reports, 314 children had a history of recurrent otitis media but did not undergo VTI (rOM group); another 94 received VTI (VTI group); while 1735 had no history of rOM (reference group) in the first 3 years of childhood. Children with data on outcomes and confounders were included in analyses of PPVT-R at ages 6 (n = 1567) and 10 years (n = 1313) and CELF-III at 10 years (n = 1410) (approximately 5% in the VTI group and 15% in the rOM group).

MAIN OUTCOME MEASURES

Peabody Picture Vocabulary Test-Revised edition and Clinical Evaluation of Language Fundamentals® Preschool-3.

RESULTS

At 6 years, mean PPVT-R scores were significantly lower in the VTI group than the reference group (β = -3.3; 95% CI [-6.5 to -0.04], p = .047). At 10 years, while the difference between the VTI and reference groups was less pronounced for PPVT-R scores, there was a small but consistent trend of lower measures, on average, across CELF-III scores (expressive: β = -3.4 [-7.1 to 0.27], p = .069; receptive: β = -4.1 [-7.9 to -0.34], p = .033; total: β = -3.9 [-7.5 to -0.21], p = .038). There was no evidence to suggest that language outcomes in the rOM group differed from the reference group.

CONCLUSION

Lower scores of language outcomes in school-aged children who received VTI in early childhood may suggest a long-term risk which should be considered alongside the potential benefits of VTI.

The effects of prolonged pacifier use on language development in infants and toddlers

Pacifiers are a common soothing tool used by parents to calm and comfort infants and toddlers. While pacifiers can provide temporary relief, there is growing concern about the potential long-term effects of prolonged pacifier use on language and cognitive development. Previous studies have suggested that prolonged use of pacifiers may have negative consequences on language outcomes in infants and toddlers, especially during the first few years of life known to be a critical period for language development. Previous studies have shown that children who use pacifiers extensively have smaller vocabulary sizes at 1 and 2 years of age which can have subsequent effects on socioemotional. In addition, significant association between greater frequency of daytime pacifier use and worsening of cognitive outcomes was shown. Furthermore, research has shown a strong dose-response association between intense pacifier use up to 4 years of age and lower IQ at 6 years. Recently, the importance of oral motor movements and sensorimotor production for speech perception in infants as young as 6 months has been highlighted, raising important questions on the effect of oral motor movement restrictions at an early age. Together, these findings raise concern about the potential long-term effects of prolonged pacifier use on language and cognitive development at a critical time in child development. However, it is still debatable within the scientific field the potential relationship between pacifier use and language development in early life most likely due to the complexity of studying child development. This mini review aims to provide valuable insights for parents, caregivers, and healthcare professionals in making informed decisions and understand regarding pacifier use for infants and toddlers.

Ventilation tubes (grommets) for otitis media with effusion (OME) in children

BACKGROUND

Otitis media with effusion (OME) is an accumulation of fluid in the middle ear cavity, common amongst young children. It may cause hearing loss which, when persistent, may lead to developmental delay, social difficulty and poor quality of life. Management includes watchful waiting, autoinflation, medical and surgical treatment. Insertion of ventilation tubes has often been used as the preferred treatment.

OBJECTIVES

To evaluate the effects (benefits and harms) of ventilation tubes (grommets) for OME in children.

SEARCH METHODS

We searched the Cochrane ENT Register, CENTRAL, Ovid MEDLINE, Ovid Embase, Web of Science, ClinicalTrials.gov, ICTRP and additional sources for published and unpublished trials on 20 January 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in children (6 months to 12 years) with OME for ≥ 3 months. We included studies that compared ventilation tube (VT) insertion with five comparators: no treatment, watchful waiting (ventilation tubes inserted later, if required), myringotomy, hearing aids and other non-surgical treatments.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were determined following a multi-stakeholder prioritisation exercise and were: 1) hearing; 2) OME-specific quality of life; 3) persistent tympanic membrane perforation (as a severe adverse effect of the surgery). Secondary outcomes were: 1) persistence of OME; 2) other adverse effects (including tympanosclerosis, VT blockage and pain); 3) receptive language skills; 4) speech development; 5) cognitive development; 6) psychosocial skills; 7) listening skills; 8) generic health-related quality of life; 9) parental stress; 10) vestibular function; 11) episodes of acute otitis media. We used GRADE to assess the certainty of evidence for key outcomes. Although we included all measures of hearing assessment, the proportion of children who returned to normal hearing was our preferred method, due to challenges in interpreting the results of mean hearing thresholds.

MAIN RESULTS

We included 19 RCTs (2888 children). We considered most of the evidence to be very uncertain, due to wide confidence intervals for the effect estimates, few participants, and a risk of performance and detection bias. Here we report our key outcomes at the longest reported follow-up. There were some limitations to the evidence. No studies investigated the comparison of ventilation tubes versus hearing aids. We did not identify any data on disease-specific quality of life; however, many studies were conducted before the development of specific tools to assess this in otitis media. Short-acting ventilation tubes were used in most studies and thus specific data on the use of long-acting VTs is limited. Finally, we did not identify specific data on the effects of VTs in children at increased risk of OME (e.g. with craniofacial syndromes). Ventilation tubes versus no treatment (four studies) The odds ratio (OR) for a return to normal hearing after 12 months was 1.13 with VTs (95% confidence interval (CI) 0.46 to 2.74; 54% versus 51%; 1 study, 72 participants; very low-certainty evidence). At six months, VTs may lead to a large reduction in persistent OME (risk ratio (RR) 0.30, 95% CI 0.14 to 0.65; 20.4% versus 68.0%; 1 study, 54 participants; low-certainty evidence). The evidence is very uncertain about the chance of persistent tympanic membrane perforation with VTs at 12 months (OR 0.85, 95% CI 0.38 to 1.91; 8.3% versus 9.7%; 1 RCT, 144 participants). Early ventilation tubes versus watchful waiting (six studies) There was little to no difference in the proportion of children whose hearing returned to normal after 8 to 10 years (i.e. by the age of 9 to 13 years) (RR for VTs 0.98, 95% CI 0.94 to 1.03; 93% versus 95%; 1 study, 391 participants; very low-certainty evidence). VTs may also result in little to no difference in the risk of persistent OME after 18 months to 6 years (RR 1.21, 95% CI 0.84 to 1.74; 15% versus 12%; 3 studies, 584 participants; very low-certainty evidence). We were unable to pool data on persistent perforation. One study showed that VTs may increase the risk of perforation after a follow-up duration of 3.75 years (RR 3.65, 95% CI 0.41 to 32.38; 1 study, 391 participants; very low-certainty evidence) but the actual number of children who develop persistent perforation may be low, as demonstrated by another study (1.26%; 1 study, 635 ears; very low-certainty evidence). Ventilation tubes versus non-surgical treatment (one study) One study compared VTs to six months of antibiotics (sulphisoxazole). No data were available on return to normal hearing, but final hearing thresholds were reported. At four months, the mean difference was -5.98 dB HL lower (better) for those receiving VTs, but the evidence is very uncertain (95% CI -9.21 to -2.75; 1 study, 125 participants; very low-certainty evidence). No evidence was identified regarding persistent OME. VTs may result in a low risk of persistent perforation at 18 months of follow-up (no events reported; narrative synthesis of 1 study, 60 participants; low-certainty evidence). Ventilation tubes versus myringotomy (nine studies) We are uncertain whether VTs may slightly increase the likelihood of returning to normal hearing at 6 to 12 months, since the confidence intervals were wide and included the possibility of no effect (RR 1.22, 95% CI 0.59 to 2.53; 74% versus 64%; 2 studies, 132 participants; very low-certainty evidence). After six months, persistent OME may be reduced for those who receive VTs compared to laser myringotomy, but the evidence is very uncertain (OR 0.27, 95% CI 0.19 to 0.38; 1 study, 272 participants; very low-certainty evidence). At six months, the risk of persistent perforation is probably similar with the use of VTs or laser myringotomy (narrative synthesis of 6 studies, 581 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

There may be small short- and medium-term improvements in hearing and persistence of OME with VTs, but it is unclear whether these persist after longer follow-up. The RCTs included do not allow us to say when (or how much) VTs improve hearing in any specific child. However, interpretation of the evidence is difficult: many children in the control groups recover spontaneously or receive VTs during follow-up, VTs may block or extrude, and OME may recur. The limited evidence in this review also affects the generalisability/applicability of our findings to situations involving children with underlying conditions (e.g. craniofacial syndromes) or the use of long-acting tubes. Consequently, RCTs may not be the best way to determine whether an intervention is likely to be effective in any individual child. Instead, we must better understand the different OME phenotypes to target interventions to children who will benefit most, and avoid over-treating when spontaneous resolution is likely.

Middle ear effusion, ventilation tubes and neurological development in childhood

BACKGROUND

Otitis media with middle ear effusion (MEE) can be treated with ventilation tubes (VT) insertion, and it has been speculated that prolonged MEE in childhood can affect neurological development, which in turn may be important for later academic achievements.

OBJECTIVE

To investigate the association between middle ear effusion (MEE), treatment with ventilation tubes (VT) and childhood neurological development.

STUDY DESIGN

We examined 663 children from the Copenhagen Prospective Studies on Asthma in Childhood 2010 (COPSAC2010) unselected mother-child cohort study. Children were followed by study pediatricians with regular visits from pregnancy until 3 years of age. MEE was diagnosed using tympanometry at age 1, 2 and 3 years. Information regarding VT from age 0-3 years was obtained from national registries. We assessed age at achievement of gross motor milestones from birth, language scores at 1 and 2 years, cognitive score at 2.5 years and general development score at age 3 years using standardized quantitative tests.

RESULTS

Children with MEE had a lower 1-year word production vs. children with no disease: (median 2, IQR [0-6] vs. 4, IQR [1-7]; p = 0.017), and a lower 1-year word comprehension (median 36; IQR [21-63] vs. 47, IQR [27-84]; p = 0.03). Children with VT had a lower 2-5-year cognitive score vs. children with no disease; estimate -2.34; 95% CI [-4.56;-0.12]; p = 0.039. No differences were found between children with vs. without middle ear disease regarding age at achievement of gross motor milestones, word production at 2 years or the general developmental score at 3 years.

CONCLUSION

Our study supports the previous findings of an association between MEE and concurrent early language development, but not later neurological endpoints up to the age of 3. As VT can be a treatment of those with symptoms of delayed development, we cannot conclude whether treatment with VT had positive or negative effects on neurodevelopment.

One-dimensional convolutional neural network and hybrid deep-learning paradigm for classification of specific language impaired children using their speech

BACKGROUND AND OBJECTIVE

Screening children for communicational disorders such as specific language impairment (SLI) is always challenging as it requires clinicians to follow a series of steps to evaluate the subjects. Artificial intelligence and computer-aided diagnosis have supported health professionals in making swift and error-free decisions about the neurodevelopmental state of children vis-à-vis language comprehension and production. Past studies have claimed that typical developing (TD) and SLI children show distinct vocal characteristics that can serve as discriminating facets between them. The objective of this study is to group children in SLI or TD categories by processing their raw speech signals using two proposed approaches: a customized convolutional neural network (CNN) model and a hybrid deep-learning framework where CNN is combined with long-short-term-memory (LSTM).

METHOD

We considered a publicly available speech database of SLI and typical children of Czech accents for this study. The convolution filters in both the proposed CNN and hybrid models (CNN-LSTM) estimated fuzzy-automated features from the speech utterance. We performed the experiments in five separate sessions. Data augmentations were performed in each of those sessions to enhance the training strength.

RESULTS

Our hybrid model exhibited a perfect 100% accuracy and F-measure for almost all the session-trials compared to CNN alone which achieved an average accuracy close to 90% and F-measure ≥ 92%. The models have further illustrated their robust classification essences by securing values of reliability indexes over 90%.

CONCLUSION

The results confirm the effectiveness of proposed approaches for the detection of SLI in children using their raw speech signals. Both the models do not require any dedicated feature extraction unit for their operations. The models may also be suitable for screening SLI and other neurodevelopmental disorders in children of different linguistic accents.

Phonological neighborhood measures and multisyllabic word acquisition in children

Multisyllabic words constitute a large portion of children's vocabulary. However, the relationship between phonological neighborhood density and English multisyllabic word learning is poorly understood. We examine this link in three, four and six year old children using a corpus-based approach. While we were able to replicate the well-accepted positive association between CVC word acquisition and neighborhood density, no similar relationship was found for multisyllabic words, despite testing multiple novel neighborhood measures. This finding raises the intriguing possibility that phonological organization of the mental lexicon may play a fundamentally different role in the acquisition of more complex words.

Hearing Thresholds in Young Children With Otitis Media With Effusion With and Without Cleft Palate

Objective:

To investigate hearing thresholds in children born with cleft palate and in children with otitis media with effusion but no cleft palate.

Design:

Prospective longitudinal group comparison study.

Setting:

University hospital.

Participants:

Sixteen children born with nonsyndromic cleft palate with or without cleft lip (CP±L) and 15 age-matched children with otitis media with effusion (OME) but without cleft.

Main Outcome Measures:

Hearing was tested at repeated occasions beginning with neonatal auditory brainstem response (ABR) at 1-4 months of age, and age-appropriate hearing tests from 9 to 36 months of age.

Results:

The median ABR thresholds in both groups were elevated but did not differ significantly. At 12 months of age, the median 4 frequency averages at 500-1000-2000-4000 Hz (4FA) were indicative of mild hearing loss but significantly better in the CP±L-group than in the group without cleft ( P < .01). There were no significant group-wise differences regarding the median 4FA at 24 and 36 months of age, and at 36 months, the median 4FA were normal in both groups. Both groups exhibited a significant improvement over time from the neonatal ABR thresholds to the 4FA at 36 months (CP±L-group P < .05; without CP±L-group P < .01).

Conclusion:

The hearing loss in children with CP±L was not more severe than among children with OME but without cleft palate; rather, at 12 months of age, the thresholds were significantly better in the CP±L-group than those in the group without cleft. The air conduction thresholds improved with age in both groups.

Assessing consonant production in children with cochlear implants

OBJECTIVE

The objective of this study was to investigate the development of consonant inventory and accuracy in pediatric cochlear implant (CI) recipients and compare their performance to typical hearing (TH) children.

METHODS

One hundred and twenty nine children with CIs, implanted between 6-38 months of age, and 30 age-matched children with TH participated in this study. Spontaneous speech samples were collected at 3.5 and 4.5 years chronological age and the first 100 different words spoken by each participant were transcribed. Two consonant production measures were subsequently calculated to assess consonant acquisition and mastery. The percentage of Consonants Correct (CC) was used for measuring accuracy and Consonant Diversity (CD), an inventory measure, was used to identify the number of different consonants spoken by each participant. Repeated measures analyses of variance were conducted to examine the differences in consonant production scores based on presence of CI (participants with CI versus typical hearing (TH) participants), and chronological age at data collection (3.5 years versus 4.5 years).

RESULTS

CI recipients displayed lower consonant production scores compared to TH children. Children with the most device experience (32-38 months at 3.5 years) performed on par with their TH peers.

CONCLUSIONS

The two measures used in this study together appear capable of comprehensively describing the changes in consonant production skills of children. Results from this study indicate that while most CI participants display lower scores compared to TH children, many of the CI users are able to produce speech sounds on par with TH children.

Quality Assessment of the Clinical Practice Guideline for Tympanostomy Tubes in Children

Objectives

To determine the association between the introduction of statements 6 and 7 in the 2013 clinical practice guideline (CPG) for tympanostomy tubes in children and the identification of preoperative middle ear fluid (acute otitis media / otitis media with effusion [AOM/OME]) in children undergoing bilateral myringotomy and tube (BMT) placement.

Study Design

Case series with chart review.

Setting

Tertiary care children’s medical center.

Subjects and Methods

Patients who underwent BMT for recurrent AOM were retrospectively reviewed. We examined 240 patients before (BG; 2012) and 240 patients after (AG; 2014) the introduction of the CPG.

Results

The baseline characteristics of the 2 groups were comparable. The total annual number of BMT placements performed at our institution decreased from 3957 (BG) to 3083 (AG). There was no significant increase in the rate of preoperative AOM/OME identification following CPG introduction (BG 78.3% vs AG 83.3%, P = .164). The rate of identification of AOM/OME in the operating room (OR) increased from 54.2% (BG) to 71.3% (AG, P < .001). The rate of identification of AOM/OME both in the clinic and in the OR increased from 55.1% (BG) to 71.3% (AG, P < .001). Cases with concordant clinic and OR AOM/OME occurred among younger children ( P = .045), those with fewer episodes of AOM ( P = .043), and those with shorter time between the clinic and OR dates ( P = .008).

Conclusions

Following the introduction of the CPG, there was no change in the rate of identification of AOM/OME prior to recommending BMT placement in children with recurrent AOM. The lack of improved compliance with statements 6 and 7 may be related to multiple clinician- and patient-derived factors.

Effectiveness of Tympanostomy Tubes for Otitis Media: A Meta-analysis

CONTEXT

Tympanostomy tube placement is the most common ambulatory surgery performed on children in the United States.

OBJECTIVES

The goal of this study was to synthesize evidence for the effectiveness of tympanostomy tubes in children with chronic otitis media with effusion and recurrent acute otitis media.

DATA SOURCES

Searches were conducted in Medline, the Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews, Embase, and the Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Abstracts and full-text articles were independently screened by 2 investigators.

DATA EXTRACTION

A total of 147 articles were included. When feasible, random effects network meta-analyses were performed.

RESULTS

Children with chronic otitis media with effusion treated with tympanostomy tubes compared with watchful waiting had a net decrease in mean hearing threshold of 9.1 dB (95% credible interval: -14.0 to -3.4) at 1 to 3 months and 0.0 (95% credible interval: -4.0 to 3.4) by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after placement of tympanostomy tubes. Associated adverse events are poorly defined and reported.

LIMITATIONS

Sparse evidence is available, applicable only to otherwise healthy children.

CONCLUSIONS

Tympanostomy tubes improve hearing at 1 to 3 months compared with watchful waiting, with no evidence of benefit by 12 to 24 months. Children with recurrent acute otitis media may have fewer episodes after tympanostomy tube placement, but the evidence base is severely limited. The benefits of tympanostomy tubes must be weighed against a variety of associated adverse events.

The Impact of Tympanostomy Tubes on Speech and Language Development in Children with Cleft Palate

Objective Describe the impact of hearing loss, tympanostomy tube placement before palatoplasty, and number of tubes received on speech outcomes in children with cleft palate. Study Design Case series with chart review. Setting Tertiary care children's hospital. Subjects and Methods Records from 737 children born between April 2005 and April 2015 who underwent palatoplasty at a tertiary children's hospital were reviewed. Exclusion criteria were cleft repair at an outside hospital, intact secondary palate, absence of postpalatoplasty speech evaluation, sensorineural or mixed hearing loss, no tubes, first tubes after palatoplasty, or first clinic after 12 months of age. Data from 152 patients with isolated cleft palate and 166 patients with cleft lip and palate were analyzed using Wilcoxon rank-sum, χ², and Fisher exact test and logistic regression. Results Most patients (242, 76.1%) received tubes before palatoplasty. Hearing loss after tubes, but not before, was associated with speech/language delays at 24 months ( P = .005) and language delays ( P = .048) and speech sound production disorders (SSPDs, P = .040) at 5 years. Receiving tubes before palatoplasty was associated with failed newborn hearing screen ( P = .001) and younger age at first posttubes type B tympanogram with normal canal volume ( P = .015). Hearing loss after tubes ( P = .021), language delays ( P = .025), SSPDs ( P = .003), and velopharyngeal insufficiency ( P = .032) at 5 years and speech surgery ( P = .022) were associated with more tubes. Conclusion Continued middle ear disease, reflected by hearing loss and multiple tubes, may impair speech and language development. Inserting tubes before palatoplasty did not mitigate these impairments better than later tube placement.

Variation in Utilization and Need for Tympanostomy Tubes across England and New England

OBJECTIVES

To compare rates of typmanostomy tube insertions for otitis media with effusion with estimates of need in 2 countries.

STUDY DESIGN

This cross-sectional analysis used all-payer claims to calculate rates of tympanostomy tube insertions for insured children ages 2-8 years (2007-2010) across pediatric surgical areas (PSA) for Northern New England (NNE; Maine, Vermont, and New Hampshire) and the English National Health Service Primary Care Trusts (PCT). Rates were compared with expected rates estimated using a Monte Carlo simulation model that integrates clinical guidelines and published probabilities of the incidence and course of otitis media with effusion.

RESULTS

Observed rates of tympanostomy tube placement varied >30-fold across English PCT (N = 150) and >3-fold across NNE PSA (N = 30). At a 25 dB hearing threshold, the overall difference in observed to expected tympanostomy tubes provided was -3.41 per 1000 child-years in England and -0.01 per 1000 child-years in NNE. Observed incidence of insertion was less than expected in 143 of 151 PCT, and was higher than expected in one-half of the PSA. Using a 20 dB hearing threshold, there were fewer tube insertions than expected in all but 2 England and 7 NNE areas. There was an inverse relationship between estimated need and observed tube insertion rates.

CONCLUSIONS

Regional variations in observed tympanostomy tube insertion rates are unlikely to be due to differences in need and suggest overall underuse in England and both overuse and underuse in NNE.

Incidence and Determinants of Ventilation Tubes in Denmark

Background and objectives

Many children are treated for recurrent acute otitis media and middle ear effusion with ventilation tubes (VT). The objectives are to describe the incidence of VT in Denmark during 1997–2011 from national register data, furthermore, to analyze the determinants for VT in the Copenhagen Prospective Studies on Asthma in Childhood₂₀₁₀ (COPSAC₂₀₁₀) birth cohort.

Methods

The incidence of VT in all children under 16 years from 1997–2011 were calculated in the Danish national registries. Determinants of VT were studied in the COPSAC₂₀₁₀ birth cohort of 700 children.

Results

Nationwide the prevalence of VT was 24% in children aged 0 to 3 three years, with a significant increase over the study period. For all children 0–15 years, the incidence of VT was 35/1,000. In the VT population, 57% was male and 43% females. In the COPSAC₂₀₁₀ birth cohort, the prevalence of VT during the first 3 years of life was 29%. Determinants of VT were: maternal history of middle ear disease; aHR 2.07, 95% CI [1.45–2.96] and siblings history of middle ear disease; aHR 3.02, [2.11–4.32]. Paternal history of middle ear disease, presence of older siblings in the home and diagnosis of persistent wheeze were significant in the univariate analysis but the association did not persist after adjustment.

Conclusion

The incidence of VT is still increasing in the youngest age group in Denmark, demonstrating the highest incidence recorded in the world. Family history of middle ear disease and older siblings are the main determinants for VT.

Prevalence and Predictors of Persistent Speech Sound Disorder at Eight Years Old: Findings From a Population Cohort Study

PURPOSE

The purpose of this study was to determine prevalence and predictors of persistent speech sound disorder (SSD) in children aged 8 years after disregarding children presenting solely with common clinical distortions (i.e., residual errors).

METHOD

Data from the Avon Longitudinal Study of Parents and Children (Boyd et al., 2012) were used. Children were classified as having persistent SSD on the basis of percentage of consonants correct measures from connected speech samples. Multivariable logistic regression analyses were performed to identify predictors.

RESULTS

The estimated prevalence of persistent SSD was 3.6%. Children with persistent SSD were more likely to be boys and from families who were not homeowners. Early childhood predictors identified as important were weak sucking at 4 weeks, not often combining words at 24 months, limited use of word morphology at 38 months, and being unintelligible to strangers at age 38 months. School-age predictors identified as important were maternal report of difficulty pronouncing certain sounds and hearing impairment at age 7 years, tympanostomy tube insertion at any age up to 8 years, and a history of suspected coordination problems. The contribution of these findings to our understanding of risk factors for persistent SSD and the nature of the condition is considered.

CONCLUSION

Variables identified as predictive of persistent SSD suggest that factors across motor, cognitive, and linguistic processes may place a child at risk.

The management of Otitis Media with Effusion in children with cleft palate (mOMEnt): a feasibility study and economic evaluation

BACKGROUND

Cleft lip and palate are among the most common congenital malformations, with an incidence of around 1 in 700. Cleft palate (CP) results in impaired Eustachian tube function, and 90% of children with CP have otitis media with effusion (OME) histories. There are several approaches to management, including watchful waiting, the provision of hearing aids (HAs) and the insertion of ventilation tubes (VTs). However, the evidence underpinning these strategies is unclear and there is a need to determine which treatment is the most appropriate.

OBJECTIVES

To identify the optimum study design, increase understanding of the impact of OME, determine the value of future research and develop a core outcome set (COS) for use in future studies.

DESIGN

The management of Otitis Media with Effusion in children with cleft palate (mOMEnt) study had four key components: (i) a survey evaluation of current clinical practice in each cleft centre; (ii) economic modelling and value of information (VOI) analysis to determine if the extent of existing decision uncertainty justifies the cost of further research; (iii) qualitative research to capture patient and parent opinion regarding willingness to participate in a trial and important outcomes; and (iv) the development of a COS for use in future effectiveness trials of OME in children with CP.

SETTING

The survey was carried out by e-mail with cleft centres. The qualitative research interviews took place in patients' homes. The COS was developed with health professionals and parents using a web-based Delphi exercise and a consensus meeting.

PARTICIPANTS

Clinicians working in the UK cleft centres, and parents and patients affected by CP and identified through two cleft clinics in the UK, or through the Cleft Lip and Palate Association.

RESULTS

The clinician survey revealed that care was predominantly delivered via a 'hub-and-spoke' model; there was some uncertainty about treatment strategies; it is not current practice to insert VTs at the time of palate repair; centres were in a position to take part in a future study; and the response rate to the survey was not good, representing a potential concern about future co-operation. A COS reflecting the opinions of clinicians and parents was developed, which included nine core outcomes important to both health-care professionals and parents. The qualitative research suggested that a trial would have a 25% recruitment rate, and although hearing was a key outcome, this was likely to be due to its psychosocial consequences. The VOI analysis suggested that the current uncertainty justified the costs of future research.

CONCLUSIONS

There exists significant uncertainty regarding the best management strategy for persistent OME in children with clefts, reflecting a lack of high-quality evidence regarding the effectiveness of individual treatments. It is feasible, cost-effective and of significance to clinicians and parents to undertake a trial examining the effectiveness of VTs and HAs for children with CP. However, in view of concerns about recruitment rate and engagement with the clinicians, we recommend that a trial with an internal pilot is considered.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. This study was part-funded by the Healing Foundation supported by the Vocational Training Charitable Trust who funded trial staff including the study co-ordinator, information systems developer, study statistician, administrator and supervisory staff.

The Importance of Integration of Stakeholder Views in Core Outcome Set Development: Otitis Media with Effusion in Children with Cleft Palate

Background

Approximately 75% of children with cleft palate (CP) have Otitis Media with Effusion (OME) histories. Evidence for the effective management of OME in these children is lacking. The inconsistency in outcome measurement in previous studies has led to a call for the development of a Core Outcome Set (COS). Despite the increase in the number of published COS, involvement of patients in the COS development process, and methods to integrate the views of patients and health professionals, to date have been limited.

Methods and Findings

A list of outcomes measured in previous research was identified through reviewing the literature. Opinion on the importance of each of these outcomes was then sought from key stakeholders: Ear, Nose and Throat (ENT) surgeons, audiologists, cleft surgeons, speech and language therapists, specialist cleft nurses, psychologists, parents and children. The opinion of health professionals was sought in a three round Delphi survey where participants were asked to score each outcome using a bespoke online system. Parents and children were also asked to score outcomes in a survey and provided an in-depth insight into having OME through semi-structured interviews. The results of the Delphi survey, interviews and parent/patient survey were brought together in a final consensus meeting with representation from all stakeholders. A final set of eleven outcomes reached the definition of “consensus in” to form the recommended COS: hearing; chronic otitis media (COM); OME; receptive language skills; speech development; psycho social development; acute otitis media (AOM); cholesteatoma; side effects of treatment; listening skills; otalgia.

Conclusions

We have produced a recommendation about the outcomes that should be measured, as a minimum, in studies of the management of OME in children with CP. The development process included input from key stakeholders and used novel methodology to integrate the opinion of healthcare professionals, parents and children.

Vision and hearing deficits and associations with parent-reported behavioral and developmental problems in international adoptees

To determine the occurrence of vision and hearing deficits in international adoptees and their associations with emotional, behavioral and cognitive problems. The Minnesota International Adoption Project (MnIAP) was a 556-item survey that was mailed to 2,969 parents who finalized an international adoption in Minnesota (MN) between January 1990 and December 1998 and whose children were between 4 and 18 years-old at the time of the survey. Families returned surveys for 1,906 children (64%); 1,005 had complete data for analyses. The survey included questions about the child's pre-adoption experiences and post-placement medical diagnoses, and the Child Behavior Checklist (CBCL). Multivariate logistic regression assessed associations between hearing and vision problems and problems identified by the CBCL. Information on hearing and vision screening and specific vision and hearing problems was also collected via a telephone survey (HVS) from 96/184 children (52%) seen between June 1999 and December 2000 at the University of Minnesota International Adoption Clinic. In both cohorts, 61% of children had been screened for vision problems and 59% for hearing problems. Among those children screened, vision (MnIAP = 25%, HVS = 31%) and hearing (MnIAP = 12%, HVS = 13%) problems were common. For MnIAP children, such problems were significant independent predictors for T scores >67 for the CBCL social problems and attention subscales and parent-reported, practitioner-diagnosed developmental delay, learning and speech/language problems, and cognitive impairment. Hearing and vision problems are common in international adoptees and screening and correction are available in the immediate post-arrival period. The importance of identifying vision and hearing problems cannot be overstated as they are risk factors for development and behavior problems.

Specific language impairment: a convenient label for whom?

BACKGROUND

The term 'specific language impairment' (SLI), in use since the 1980s, describes children with language impairment whose cognitive skills are within normal limits where there is no identifiable reason for the language impairment. SLI is determined by applying exclusionary criteria, so that it is defined by what it is not rather than by what it is. The recent decision to not include SLI in DSM-5 provoked much debate and concern from researchers and clinicians.

AIMS

To explore how the term 'specific language impairment' emerged, to consider how disorders, including SLI, are generally defined and to explore how societal changes might impact on use the term.

METHODS & PROCEDURES

We reviewed the literature to explore the origins of the term 'specific language impairment' and present published evidence, as well as new analyses of population data, to explore the validity of continuing to use the term.

OUTCOMES & RESULTS AND CONCLUSIONS & IMPLICATIONS

We support the decision to exclude the term 'specific language impairment' from DSM-5 and conclude that the term has been a convenient label for researchers, but that the current classification is unacceptably arbitrary. Furthermore, we argue there is no empirical evidence to support the continued use of the term SLI and limited evidence that it has provided any real benefits for children and their families. In fact, the term may be disadvantageous to some due to the use of exclusionary criteria to determine eligibility for and access to speech pathology services. We propose the following recommendations. First, that the word 'specific' be removed and the label 'language impairment' be used. Second, that the exclusionary criteria be relaxed and in their place inclusionary criteria be adopted that take into account the fluid nature of language development particularly in the preschool period. Building on the goodwill and collaborations between the clinical and research communities we propose the establishment of an international consensus panel to develop an agreed definition and set of criteria for language impairment. Given the rich data now available in population studies it is possible to test the validity of these definitions and criteria. Consultation with service users and policy-makers should be incorporated into the decision-making process.

Otitis media and ear tubes

The placement of myringotomy tubes remains an effective treatment of recurrent acute otitis media and chronic otitis media with effusion. Infants and young children are prone to these entities because of their immature anatomy and immunology. Several host, pathogenic, and environmental factors contribute to the development of these conditions. The identification and modification of some these factors can preclude the need for intervention. The procedure continues to be one of the most common outpatient pediatric procedures. Close vigilance and identification of potential complications is of utmost importance in the ongoing management of the child with middle ear disease.

Patient-recorded outcomes and quality of life in evidence-based medicine databases on most common ear, throat and nose procedures: a systematic review

BACKGROUND

The Cochrane database of systematic reviews is an evidence-based medicine (EBM) database that provides the highest quality evidence of the effect of various treatments. Quality of life (QoL) is an important aspect when treatment effect is considered.

OBJECTIVE

To assess how often patient-reported outcome measures (PROM), and specifically the quality of life aspect, were evaluated in the randomised controlled trial projects (RCTs) included in the Cochrane database of systematic reviews of the most common ear, throat and nose operations. Also, to explore the same in ongoing trials registered in ClinicalTrials.gov.

METHODS

Structured literature search. SEARCH STRATEGY AND EVALUATION METHOD: The Cochrane database of systematic reviews that evaluated the effects of ventilation tube insertion, adenoidectomy, tonsillectomy and endoscopic sinus surgery was assessed. The RCTs on which the reviews' conclusions were based were explored, and the outcome variables were recorded. A similar search was carried out in the ClinicalTrials.gov trial register.

RESULTS

In the Cochrane database, we identified seven systematic reviews with 30 RCT projects. Fourteen (49%) collected some sort of PROM and of those, three (10%) used a validated QoL instrument. After the year 2000, the respective figures were 12 of 15 (80%) and 3 of 15 (20%). In ClinicalTrials.gov, we found 500 ongoing studies on the most common ENT operations, nine being RCTs relevant to this review. Five (55%) and three (30%) of the ongoing RCTs in ClinicalTrial.gov assess PROM and QoL topics in ENT surgery, respectively.

CONCLUSIONS

Since the introduction of QoL instruments in the 1990s, their use has gradually increased, but validated QoL instruments have been used in only one of 10 RCTs included in EBM databases. Ongoing RCTs consider QoL only slightly more often.

Hearing 25 years after surgical treatment of otitis media with effusion in early childhood

OBJECTIVE

To determine the long-term hearing following surgical treatment of chronic OME in early childhood (myringotomy or ventilation tube) and to determine the impact of the occurrence and the extension of specific eardrum pathology on the hearing level.

PATIENTS AND METHODS

In 1977-1978, 224 consecutive children (91 girls and 133 boys) with chronic bilateral OME were enrolled and treated by adenoidectomy, bilateral myringotomy and insertion of a ventilation tube on the right side only. In 2002, a follow-up examination included otomicroscopy and audiometry. Hearing thresholds were compared to an age- and gender-matched normative data set. For the determination of the impact of specific eardrum pathology on the hearing, multiple linear regression modelling was used in adjustment for age and concomitant eardrum pathologies.

RESULTS

Long-term hearing after chronic OME and associated treatment is not different from age and gender-matched normal hearing. Treatment modality (myringotomy or ventilation tube) has no impact on the long-term hearing level. The regression analyses showed that the presence of myringosclerosis is associated with an overall hearing loss in myringotomised ears (4-5 dB), but not in tubed ears, for which only high frequencies were affected. Conversely, tensa atrophy is associated with an overall hearing loss in tubed ears (3-4 dB), but not in myringotomised ears, for which only high frequencies were affected.

CONCLUSIONS

Hearing 25 years after surgical treatment of chronic OME is not different from age and gender matched normal hearing. In addition, treatment modality (myringotomy or ventilation tube) has no impact on the long-term hearing level. However, atrophy is associated with a hearing loss in tubed ears, whereas myringosclerosis is associated with a hearing loss in myringotomised ears. The hearing loss associated with pathology is of limited magnitude (up to about 5 dB PTA). Even though pathology does occur more frequently and more extensively in tubed ears, the effect on the hearing at the group level is too small to have an impact. It is important to note, that this may be due to a type 2-error (number of patients too small to show an effect).

To tube or not to tube: indications for myringotomy with tube placement

PURPOSE OF REVIEW

To examine the current indications for myringotomy with tube placement.

RECENT FINDINGS

In 2004, revised clinical practice guidelines for otitis media with effusion (OME) and acute otitis media (AOM) were published. Because of the rate of spontaneous resolution of otitis in children, these guidelines suggest more 'watchful waiting' in both disease processes. Recent literature has recommended an even longer observation period in children with OME of up to 9-18 months. In adults, indications for myringotomy with tube placement have remained unchanged. We will discuss the changes in indications for myringotomy with tube placement and review the recent literature and trends in this area.

SUMMARY

In children, indicator guideline changes have been shown to not affect speech, language, and cognitive development, but further study is needed to find the right balance of observation, antibiotics, and myringotomy with tube placement for otitis media. Future vaccines may further decrease the number of children requiring myringotomy with tube placement for otitis media.

Korean clinical practice guidelines: otitis media in children

Acute otitis media (AOM) and otitis media with effusion (OME) are common infections in children, and their diagnosis and treatment have significant impacts on the health of children and the costs of providing national medical care. In 2009, the Korean Otologic Society organized a committee composed of experts in the field of otolaryngology, pediatrics, and family medicine to develop Korean clinical practice guidelines (CPG) for otitis media in children with the goal of meeting regional medical and social needs in Korea. For this purpose, the committee adapted existing guidelines. A comprehensive literature review was carried out primarily from 2004 to 2009 using medical search engines including data from Korea. A draft was written after a national questionnaire survey and several public audits, and it was editorially supervised by senior advisors before publication of the final report. These evidence-based guidelines for the management of otitis media in children provide recommendations to primary practitioners for the diagnosis and treatment of children younger than 15 yr old with uncomplicated AOM and OME. The guidelines include recommendations regarding diagnosis, treatment options, prevention and parent education, medical records, referral, and complementary/alternative medicine for treating pediatric otitis media.

Tympanostomy tube placement in children with autism

OBJECTIVE

To understand rate of tympanostomy tube placement (TTP) in children with autism spectrum disorder (ASD) and, if different from rate of TTP in the general population, consider reasons underlying the difference.

METHODS

Questions pertaining to TTP were asked during caregiver interview. Totally, 2080 children with ASD were characterized through collection of demographic information; medical history; and cognitive, adaptive, and behavioral assessments. Frequencies of TTP in the ASD sample were compared with general population rates according to the most recent literature. Relationships between TTP and factors that may impact the rate of TTP were investigated.

RESULTS

Totally, 15.5% of children with ASD received TTP. The older the age, the higher the rate of TTP, with 17.0% of children aged 13 to 17 years having received TTP. Chi-square results comparing general population TTP rates to the sample indicated significantly higher rates among the ASD population. Logistic regression indicated 2 significant predictors for TTP: otitis media frequency and race. Furthermore, irritability rates in children approached predictive significance (β = 0.015, p < .10).

CONCLUSIONS

The authors found that approximately 1 in 6 children with ASD underwent TTP, more than double the rate in the general population. The rate may simply be higher because physicians are swift to perform TTP in children at risk for speech delay. At this time, there exists a lack of data on the outcomes of TTP in children with ASD. More evidence is needed to understand the usefulness of TTP in children with ASD given the high rate of procedures being performed.

Taxometric analyses of specific language impairment in 6-year-old children

PURPOSE

To determine whether language scores at age 6 years suggest that specific language impairments (SLIs) distribute in a categorical or in a dimensional fashion.

METHOD

A taxometric analysis of language scores from 601 six-year-old children who were free of neonatal risk factors was performed. From among 4 candidate indicators of SLI, 2 were eligible for the mean above minus below a cut (MAMBAC) procedure (Meehl & Yonce, 1994): number of different words (NDW) produced in a language sample and average percentage phonemes repeated correctly in 3- and 4-syllable nonwords (3-4 PPC). Graphs of these MAMBAC variables were inspected to determine whether they patterned in a manner suggesting the presence of a discrete category, having either a central peak or a steep curve peaking near the final interval.

RESULTS

MAMBAC curves for NDW and 3-4 PPC did not suggest the presence of a taxon, and results did not vary during consistency checks in which MAMBAC parameters and cutoff values for language deficits were manipulated.

CONCLUSIONS

Results suggest that for these measures, children with specific language deficits are those falling at the lower end of a continuous distribution of language skills rather than a qualitatively distinct group.

Exploring a corpus-based approach for detecting language impairment in monolingual English-speaking children

OBJECTIVES

This paper explores the use of an automated method for analyzing narratives of monolingual English speaking children to accurately predict the presence or absence of a language impairment. The goal is to exploit corpus-based approaches inspired by the fields of natural language processing and machine learning.

METHODS AND MATERIALS

We extract a large variety of features from language samples and use them to train language models and well known machine learning algorithms as the underlying predictors. The methods are evaluated on two different datasets and three language tasks. One dataset contains samples of two spontaneous narrative tasks performed by 118 children with an average age of 13 years and a second dataset contains play sessions from over 600 younger children with an average age of 6 years.

RESULTS

We compare results against a cut off baseline method and show that our results are far superior, reaching F-measures of over 85% in two of the three language tasks, and 48% in the third one.

CONCLUSIONS

The different experiments we present here show that corpus based approaches can yield good prediction results in the problem of language impairment detection. These findings warrant further exploration of natural language processing techniques in the field of communication disorders. Moreover, the proposed framework can be easily adapted to analyze samples in languages other than English since most of the features are language independent or can be customized with little effort.

Evaluating the perceptual and pathophysiological consequences of auditory deprivation in early postnatal life: a comparison of basic and clinical studies

Decades of clinical and basic research in visual system development have shown that degraded or imbalanced visual inputs can induce a long-lasting visual impairment called amblyopia. In the auditory domain, it is well established that inducing a conductive hearing loss (CHL) in young laboratory animals is associated with a panoply of central auditory system irregularities, ranging from cellular morphology to behavior. Human auditory deprivation, in the form of otitis media (OM), is tremendously common in young children, yet the evidence linking a history of OM to long-lasting auditory processing impairments has been equivocal for decades. Here, we review the apparent discrepancies in the clinical and basic auditory literature and provide a meta-analysis to show that the evidence for human amblyaudia, the auditory analog of amblyopia, is considerably more compelling than is generally believed. We argue that a major cause for this discrepancy is the fact that most clinical studies attempt to link central auditory deficits to a history of middle ear pathology, when the primary risk factor for brain-based developmental impairments such as amblyopia and amblyaudia is whether the afferent sensory signal is degraded during critical periods of brain development. Accordingly, clinical studies that target the subset of children with a history of OM that is also accompanied by elevated hearing thresholds consistently identify perceptual and physiological deficits that can endure for years after peripheral hearing is audiometrically normal, in keeping with the animal studies on CHL. These studies suggest that infants with OM severe enough to cause degraded afferent signal transmission (e.g., CHL) are particularly at risk to develop lasting central auditory impairments. We propose some practical guidelines to identify at-risk infants and test for the positive expression of amblyaudia in older children.

Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children

BACKGROUND

Otitis media with effusion (OME; 'glue ear') is common in childhood and surgical treatment with grommets (ventilation tubes) is widespread but controversial.

OBJECTIVES

To assess the effectiveness of grommet insertion compared with myringotomy or non-surgical treatment in children with OME.

SEARCH STRATEGY

We searched the Cochrane ENT Disorders Group Trials Register, other electronic databases and additional sources for published and unpublished trials (most recent search: 22 March 2010).

SELECTION CRITERIA

Randomised controlled trials evaluating the effect of grommets. Outcomes studied included hearing level, duration of middle ear effusion, language and speech development, cognitive development, behaviour and adverse effects.

DATA COLLECTION AND ANALYSIS

Data from studies were extracted by two authors and checked by the other authors.

MAIN RESULTS

We included 10 trials (1728 participants). Some trials randomised children (grommets versus no grommets), others ears (grommet one ear only). The severity of OME in children varied between trials. Only one 'by child' study (MRC: TARGET) had particularly stringent audiometric entry criteria. No trial was identified that used long-term grommets.Grommets were mainly beneficial in the first six months by which time natural resolution lead to improved hearing in the non-surgically treated children also. Only one high quality trial that randomised children (N = 211) reported results at three months; the mean hearing level was 12 dB better (95% CI 10 to 14 dB) in those treated with grommets as compared to the controls. Meta-analyses of three high quality trials (N = 523) showed a benefit of 4 dB (95% CI 2 to 6 dB) at six to nine months. At 12 and 18 months follow up no differences in mean hearing levels were found.Data from three trials that randomised ears (N = 230 ears) showed similar effects to the trials that randomised children. At four to six months mean hearing level was 10 dB better in the grommet ear (95% CI 5 to 16 dB), and at 7 to 12 months and 18 to 24 months was 6 dB (95% CI 2 to 10 dB) and 5 dB (95% CI 3 to 8 dB) dB better.No effect was found on language or speech development or for behaviour, cognitive or quality of life outcomes.Tympanosclerosis was seen in about a third of ears that received grommets. Otorrhoea was common in infants, but in older children (three to seven years) occurred in < 2% of grommet ears over two years of follow up.

AUTHORS' CONCLUSIONS

In children with OME the effect of grommets on hearing, as measured by standard tests, appears small and diminishes after six to nine months by which time natural resolution also leads to improved hearing in the non-surgically treated children. No effect was found on other child outcomes but data on these were sparse. No study has been performed in children with established speech, language, learning or developmental problems so no conclusions can be made regarding treatment of such children.

Perda auditiva leve: desempenho no Teste da Habilidade de Atenção Auditiva Sustentada

TEMA: a perda auditiva na infância é um fator de risco para o atraso no desenvolvimento. OBJETIVO: verificar o desempenho de crianças diagnosticadas com perda auditiva de grau leve - condutiva e sensorioneural, no Teste da Habilidade de Atenção Auditiva Sustentada (THAAS), visando constatar se este teste sofre influência da presença de uma perda auditiva. MÉTODO: estudo clínico do THAAS em 3 grupos: Grupo 1 (G1) grupo controle formado por crianças com audição normal, Grupo 2 (G2) crianças com deficiência auditiva sensorioneural bilateral de grau leve e Grupo 3 (G3) composto por crianças com perda auditiva condutiva bilateral de grau leve. Estudo prospectivo. Participantes: 90 crianças com idade entre 7 e 11 anos de idade, sendo 30 de cada grupo. Intervenções: Audiometria Tonal Limiar, Imitanciometria e THAAS. RESULTADOS: os grupos sensorioneural e condutivo apresentaram desempenho inferior ao grupo controle em todas as respostas do THAAS. CONCLUSÃO: o THAAS sofreu influência das perdas auditivas de grau leve, condutivas e sensorioneurais, sendo o pior comprometimento para perdas sensorioneurais.

Growth hormone treatment does not affect incidences of middle ear disease or hearing loss in infants and toddlers with Turner syndrome

CONTEXT

No randomized, controlled, prospective study has evaluated the effect of growth hormone (GH) on the rates of middle ear (ME) disease and hearing loss in girls with Turner syndrome (TS).

DESIGN

A 2-year, prospective, randomized, controlled, open-label, multicenter, clinical trial ('Toddler Turner Study'; August 1999 to August 2003) was carried out.

SETTING

The study was conducted at 11 US pediatric endocrine centers.

SUBJECTS

Eighty-eight girls with TS, aged 9 months to 4 years, were enrolled.

INTERVENTION

The interventions comprised recombinant GH (50 microg/kg/day, n = 45) or no treatment (n = 43) for 2 years.

MAIN OUTCOME MEASURES

The outcome measures included occurrence rates of ear-related problems, otitis media (OM) and associated antibiotic treatments, tympanometric assessment of ME function and hearing assessment by audiology.

RESULTS

At baseline, 57% of the girls (mean age = 1.98 +/- 1.00 years) had a history of recurrent OM, 33% had undergone tympanostomy tube (t-tube) insertion and 27% had abnormal hearing. There was no significant difference between the treatment groups for annual incidence of OM episodes (untreated control: 1.9 +/- 1.4; GH-treated: 1.5 +/- 1.6, p = 0.17). A quarter of the subjects underwent ear surgeries (mainly t-tube insertions) during the study. Recurrent or persistent abnormality of ME function on tympanometry was present in 28-45% of the girls without t-tubes at the 6 postbaseline visits. Hearing deficits were found in 19-32% of the girls at the annual postbaseline visits. Most of these were conductive deficits, however, 2 girls had findings consistent with sensorineural hearing loss, which was evident before 3 years of age.

CONCLUSIONS

Ear and hearing problems are common in infants and toddlers with TS and are not significantly influenced by GH treatment. Girls with TS need early, regular and thorough ME monitoring by their primary care provider and/or otolaryngologist, and at least annual hearing evaluations by a pediatric audiologist.

A nonword repetition task for speakers with misarticulations: the Syllable Repetition Task (SRT)

PURPOSE

Conceptual and methodological confounds occur when non(sense) word repetition tasks are administered to speakers who do not have the target speech sounds in their phonetic inventories or who habitually misarticulate targeted speech sounds. In this article, the authors (a) describe a nonword repetition task, the Syllable Repetiton Task (SRT), that eliminates this confound and (b) report findings from 3 validity studies.

METHOD

Ninety-five preschool children with speech delay and 63 with typical speech completed an assessment battery that included the Nonword Repetition Task (NRT; C. Dollaghan & T. F. Campbell, 1998) and the SRT. SRT stimuli include only 4 of the earliest occurring consonants and 1 early occurring vowel.

RESULTS

Study 1 findings indicated that the SRT eliminated the speech confound in nonword testing with speakers who misarticulate. Study 2 findings indicated that the accuracy of the SRT to identify expressive language impairment was comparable to findings for the NRT. Study 3 findings illustrated the SRT's potential to interrogate speech processing constraints underlying poor nonword repetition accuracy. Results supported both memorial and auditory-perceptual encoding constraints underlying nonword repetition errors in children with speech-language impairment.

CONCLUSION

The SRT appears to be a psychometrically stable and substantively informative nonword repetition task for emerging genetic research and other research with speakers who misarticulate.

Early histories of school-aged children with attention-deficit/hyperactivity disorder

In a prospective study of developmental outcomes in relation to early-life otitis media, behavioral, cognitive, and language measures were administered to a large, diverse sample of children at 2, 3, 4, 6, and 9-11 years of age (N = 741). At 9-11 years of age, 9% of the children were categorized as having attention-deficit/hyperactivity disorder (ADHD) based on parent report. Compared to the non-ADHD group, the ADHD group had higher (i.e., less favorable) scores on parent and teacher versions of the Child Behavior Checklist at all ages. Children in the ADHD group also had lower scores on cognitive and receptive language measures in preschool. The findings support the concept that ADHD is a cognitive as well as a behavioral disorder.

Contemporary indications for ventilation tube placement

PURPOSE OF REVIEW

To discuss the current indications for ventilation tube placement

RECENT FINDINGS

In the past year, several studies have challenged the current guidelines for ventilation tube placement and antibiotic use for otitis media in children. Critics argue that some of these studies have poor scientific validity, yet these studies are being referenced, and sometimes misinterpreted, by the media. Fueled by these media reports, many concerned parents are now questioning otolaryngologists as to the efficacy and safety of ventilation tube placement. Whereas the indications for tube placement in children may be in a state of flux, the indications for tube placement in adults has (and is) fairly static. I will discuss the current published guidelines and the potential for changing trends in tube placement rates. I will also review the literature for the past year regarding postoperative management and adjuvant therapies.

SUMMARY

Although there have been no radical changes in the indications for ventilation tube placement, recent studies have challenged the current clinical indicators and the ramifications of these studies may be more evident in the years to come.

Recurrent otitis media with effusion in preterm infants with histologic chorioamnionitis--a 3 years follow-up study

BACKGROUND

Recurrent otitis media with effusion (OME) is a leading cause of acquired hearing loss in childhood. Histological chorioamnionitis (HCA) is an important cause of preterm delivery and neonatal morbidity and mortality. Here, we tested the hypothesis of an association between recurrent OME during the first 3 years of life and HCA in very low birth weight (VLBW) infants.

METHODS

A total of 110 randomly selected VLBW preterm newborns with HCA and 135 gestational age and gender-matched, HCA-negative VLBW infants were evaluated prospectively during the first 3 years of life for the presence of OME, as diagnosed on the basis of otoscopy, type B or C tympanogram, ipsilateral absence of transient evoked otoacoustic emissions responses, and ipsilaterally increased threshold at diagnostic auditory brain responses evaluation. Potential risk factors for OME were also examined in the two groups.

RESULTS

The HCA-positive infants showed a approximately six times higher frequency of recurrent OME (P<0.0001), increased frequency (>5/yr) of clinical otitis media episodes (P=0.000020), approximately five times higher frequency of adenoid hypertrophy (P<0.00001), a significant seasonal pattern of birth with autumn predominance (P<0.00001), and the first OME occurred earlier (P<0.0001), as compared to the HCA-negative counterparts. Recurrent OME was significantly associated with HCA (O.R.=17.76, 95% CI: 8.98-35.13, P<0.00001), adenoid hypertrophy (O.R.=9.96, 95% CI: 5.17-19.18, P<0.00001), frequency of acute otitis episodes >5/yr (O.R.=8.91, 95% CI: 1.96-40.41, P=0.0005), and birth in autumn (O.R.=5.58, 95% CI: 2.79-11.12, P<0.00001).

CONCLUSIONS

These findings indicate that HCA is a previously unrecognized risk factor for the development of recurrent bilateral OME in VLBW preterm infants during the first 3 years of life.

Which children would benefit most from tympanostomy tubes (grommets)? A personal evidence-based review

Otitis media with effusion (OME) is a common condition in young children. OME causes some hearing loss, and can cause permanent changes in the tympanic membrane as well as other symptoms. In most cases OME is of short duration. As long-lasting bilateral OME for decades has been associated with delayed cognitive and language development, parents and ENT specialists have a positive attitude towards treatment with tympanostomy tubes (TT).

METHOD

This personal evidence-based review is build on own observations and research combined with newer studies and guidelines.

RESULTS

The review argues for a relatively restrictive treatment policy concerning the use of TT in children with OME without signs or symptoms of impaired social or linguistic function.

CONCLUSION

Six months with bilateral OME and significant hearing loss should be present before treatment with TT in otherwise healthy children. At the moment we have no evidence for the subgroups of children excluded from the RCTs, i.e. children with speech/language delays, behaviour and learning problems, or syndromes. Clinicians will need to make their own decisions regarding treatment of such children. The situation just now is that some children are over-treated and some are under-treated. There is an urgent need for prospective cohort studies and randomised studies on children with long-lasting OME in an attempt to characterise the children who would benefit most from TT.

Eya4-deficient mice are a model for heritable otitis media

Otitis media is an extremely common pediatric inflammation of the middle ear that often causes pain and diminishes hearing. Vulnerability to otitis media is due to eustachian tube dysfunction as well as other poorly understood factors, including genetic susceptibility. As EYA4 mutations cause sensorineural hearing loss in humans, we produced and characterized Eya4-deficient (Eya4(-/-)) mice, which had severe hearing deficits. In addition, all Eya4(-/-) mice developed otitis media with effusion. Anatomic studies revealed abnormal middle ear cavity and eustachian tube dysmorphology; thus, Eya4 regulation is critical for the development and function of these structures. We suggest that some human otitis media susceptibility reflects underlying genetic predisposition in genes like EYA4 that regulate middle ear and eustachian tube anatomy.

The effect of early insertion of grommets on the development of speech in children with cleft palates

The aim of this study was to find out whether simultaneous primary palatoplasty and myringotomy was advantageous in the management of otitis media with effusion in children with cleft lip and palate and whether this combined operation resulted in improvement in the early development of speech. Assessments of hearing and speech were made in 50 consecutive patients with cleft lip and palate who had the combined operation (the cleft group). The results were compared with those of an age- and sex-matched control group. The incidence of otitis media with effusion in the cleft group was 24%, compared with 14% in the control group. Assessment of speech using the cleft audit protocol for speech showed that 90% of patients with clefts had speech-intelligibility ratings that were either normal or showed only minor defects, compared with 98% of controls. Among patients with clefts, there was no evidence of cleft-type characteristics of speech in 58%.

A performance curve for assessing change in Percentage of Consonants Correct Revised (PCC-R)

PURPOSE

Interpreting the rapidly changing speech skills of young children recovering from neurological injury is difficult because developmental expectations are generally available only at relatively lengthy intervals (e.g., 6 or 12 months). In this research note, the authors describe the process of generating a Percentage of Consonants Correct-Revised (PCC-R; L. D. Shriberg, D. Austin, B. A. Lewis, J. L. McSweeny, & D. L. Wilson, 1997a) performance curve and illustrate some of its applications for assessing change in performance over time.

METHOD

The authors compiled mean PCC-R scores from 16 samples of typically developing children (18-172 months) and used curve fitting to test more than 11,000 statistical models of monthly growth in PCC-R. They selected a parsimonious and developmentally plausible model with R(2) = .9839 (p < .0005) and used it to generate the PCC-R, standard deviation, and standard error expected at each monthly age.

RESULTS

The PCC-R performance curve distinguished among 65 children (37-57 months of age) diagnosed independently with normal or disordered speech with a high degree of success. More important, the PCC-R performance curve can be used to identify the points at which children (18-172 months) recovering from neurological injury achieve normal-range consonant production.

CONCLUSION

The curve-fitting approach holds promise as a means of interpreting temporal variations in speech production at a finer grain than existing normative data currently allow.

Grommets in otitis media with effusion: the most frequent operation in children. But is it associated with significant complications?

INTRODUCTION

Otitis media with effusion is one of the most frequent diseases in children, and its management requires the attention of general practitioners, pediatricians and ear, nose and throat (ENT) surgeons. The main complications associated with tympanostomy tube insertion, are: (1) purulent otorrhea (10-26% of cases), in which local otic preparations might be effective, and biofilm-resistant tubes may decrease this complication in the future; (2) myringosclerosis (39-65% of operated ears), with usually no serious sequelae; (3) segmental atrophy (16-75% of cases); (4) atrophic scars and pars flaccida retraction pockets (28 and 21% of operated ears, respectively); (5) tympanic membrane perforations (3% of cases, although with T-tubes, the incidence may be as high as 24%); (6) cholesteatoma (1% of cases), although tympanostomy tubes may sometimes prevent, rather than contribute to its development; (7) granulation tissue (5-40% of instances), when the duration of tube retention is prolonged.

CONCLUSION

It would appear that the complications associated with tympanostomy tube insertion are more frequent than anticipated, reaching 80% of operated ears under specific circumstances and in certain subgroups of children. These complications may resolve with conservative management, but in persistent cases surgical removal of the tubes is mandatory.

Identification of children in the first four years of life for early treatment for otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is the most common cause of acquired hearing loss in childhood and has been associated with delayed language development and behavioural problems. This condition has a point-prevalence of about 20% at the age of two years, a time of rapid language development. It is most often asymptomatic. Effective treatment exists for clearing effusions. Some have argued, therefore, that children should be screened and treated early if found to have clinically important OME. However, there is a high rate of spontaneous resolution of effusions and, for some children, effusions may represent a physiological response that does not reduce hearing significantly or impact negatively on language development or behaviour. Previous reviews of the effect of screening and treatment have included studies using non-randomised designs.

OBJECTIVES

The aim of this review was to assess evidence from randomised controlled trials about the effect, on language and behavioural outcomes, of screening and treating children with clinically important OME in the first four years of their life. The focus was on the first four years of life because this is the time of most rapid language development. The consequences of hearing loss are likely to be most serious during this time. In addition, children of this age are least likely to be able to report or seek help for impaired hearing, particularly if these problems have a slow onset and are subtle.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2006), MEDLINE (1950 to 2006) and EMBASE (1974 to 2006) in February 2002, and again in January 2006, and the reference lists of all studies. We also contacted the first authors of the studies we included in the original review.

SELECTION CRITERIA

1. Randomised controlled trials evaluating interventions for OME among children with OME identified through screening.2. Comparison of outcomes for children randomised to be screened for OME and outcomes for children who were not randomised to be screened for OME.

DATA COLLECTION AND ANALYSIS

Four authors independently extracted data and assessed trial quality, two in the original review and two for the update.

MAIN RESULTS

We identified no trials comparing outcomes for children randomised to be screened for OME with outcomes for children who were not randomised to be screened for OME. We identified three trials evaluating interventions for OME among children with OME identified through screening, one of which generated three published studies. These were trials of treatment in children identified through screening rather than trials of treatment programs. From these trials, we found no evidence of clinically important benefit in language development from screening and treating children with clinically important OME.

AUTHORS' CONCLUSIONS

The identified randomised trials do not show an important benefit on language development and behaviour from screening of the general population of asymptomatic children in the first four years of life for OME. However, these trials were all conducted in developed countries. Evidence generated in the developed world, where children may enjoy better nutrition, better living conditions and less severe and different infections may not be applicable to children in developing countries. The screening aspect of some of these studies was aimed primarily at identifying suitable children in whom to evaluate the effects of treatment, rather than to evaluate the effects of screening programs. Younger children and children with milder disease may have been included in these treatment trials compared to children who are offered treatment in pragmatic settings.

Tympanostomy tubes and developmental outcomes at 9 to 11 years of age

BACKGROUND

Developmental impairments in children have been attributed to persistent middle-ear effusion in their early years of life. Previously, we reported that among children younger than 3 years of age with persistent middle-ear effusion, prompt as compared with delayed insertion of tympanostomy tubes did not result in improved cognitive, language, speech, or psychosocial development at 3, 4, or 6 years of age. However, other important components of development could not be assessed until the children were older.

METHODS

We enrolled 6350 infants soon after birth and evaluated them regularly for middle-ear effusion. Before 3 years of age, 429 children with persistent effusion were randomly assigned to undergo the insertion of tympanostomy tubes either promptly or up to 9 months later if effusion persisted. We assessed literacy, attention, social skills, and academic achievement in 391 of these children at 9 to 11 years of age.

RESULTS

Mean (+/-SD) scores on 48 developmental measures in the group of children who were assigned to undergo early insertion of tympanostomy tubes did not differ significantly from the scores in the group that was assigned to undergo delayed insertion. These measures included the Passage Comprehension subtest of the Woodcock Reading Mastery Tests (mean score, 98+/-12 in the early-treatment group and 99+/-12 in the delayed-treatment group); the Spelling, Writing Samples, and Calculation subtests of the Woodcock-Johnson III Tests of Achievement (96+/-13 and 97+/-16; 104+/-14 and 105+/-15; and 99+/-13 and 99+/-13, respectively); and inattention ratings on visual and auditory continuous performance tests.

CONCLUSIONS

In otherwise healthy young children who have persistent middle-ear effusion, as defined in our study, prompt insertion of tympanostomy tubes does not improve developmental outcomes up to 9 to 11 years of age. (ClinicalTrials.gov number, NCT00365092 [ClinicalTrials.gov].).

What is new in otitis media?

The "wait and see" approach in acute otitis media (AOM), consisting of postponing the antibiotic administration for a few days, has been advocated mainly to counteract the increased bacterial resistance in respiratory infections. This approach is not justified in children less than 2 years of age and this for several reasons. First, AOM is an acute inflammation of the middle ear caused in about 70% of cases by bacteria. Redness and bulging of the tympanic membrane are characteristic findings in bacterial AOM. Second, AOM is associated with long-term dysfunction of the inflamed eustachian tube (ET), particularly in children less than 2 years of age. In this age group, the small calibre of the ET together with its horizontal direction result in impaired clearance, ventilation and protection of the middle ear. Third, recent prospective studies have shown poor long-term prognosis of AOM in children below 2 years with at least 50% of recurrences and persisting otitis media with effusion (OME) in about 35% 6 months after AOM. Viruses elicit AOM in about 30% of children. A prolonged course of AOM has been observed when bacterial and viral infections are combined because viral infection is also associated with ET dysfunction in young children. Bacterial and viral testing of the nasopharyngeal aspirate is an excellent tool both for initial treatment and recurrence of AOM. Antibiotic treatment of AOM is mandatory in children less than 2 years of age to decrease inflammation in the middle ear but also of the ET particularly during the first episode. The best choice is amoxicillin because of its superior penetration in the middle ear. Streptococci pneumoniae with intermediary bacterial resistance to penicillin are particularly associated with recurrent AOM. Therefore the dosage of amoxicillin should be 90 mg/kg per day in three doses. In recurrent AOM with beta-lactamase-producing bacilli, amoxicillin should be associated with clavulanic acid at a dose of 6.4 mg/kg per day. The duration of the treatment is not established yet but 10 days is reasonable for a first episode of AOM. OME may be a precursor initiating AOM but also a complication thereof. OME needs a watchful waiting approach. When associated with deafness for 2-3 months in children over 2 years of age, an antibiotic should be given according to the results of the bacterial resistance in the nasopharyngeal aspirate. The high rate of complications of tympanostomy tube insertion outweighs the beneficial effect on hearing loss. The poor results of this procedure are due to the absence of effects on ET dysfunction. Pneumococcal vaccination has little beneficial effects on recurrent AOM and its use in infants needs further studies. Treatment with amoxicillin is indicated in all children younger than 2 years with a first episode of AOM presenting with redness and bulging of the tympanic membrane. Combined amoxicillin and clavulanic acid should be given in patients with beta-lactamase-producing bacteria. The duration of treatment is estimated to be at least 10 days depending on the findings by pneumo-otoscopy and tympanometry. Bacterial and viral testing of the nasopharyngeal aspirate is highly recommended particularly in children in day care centres as well as for regular follow-up. The high recurrence rate is due to the long-lasting dysfunction of the eustachian tube and the immune immaturity of children less than 2 years of age.