Racial Disparity in Tympanostomy Tube Placement in Inpatient Pediatric Admissions

This study aims to evaluate if race and ethnicity affect rates of tympanostomy tube (TT) placement during inpatient pediatric admissions in children with otologic conditions. A review of the 2016 Kids' Inpatient Database was conducted based on the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes for common otologic conditions. Among 85 827 weighted pediatric inpatient discharges with ICD-10-CM codes for common otologic conditions, 213 underwent TT placement. Odds ratios (ORs) for children of Hispanic ethnicity and Asian or Pacific Islander race undergoing TT placement when compared to other ethnicities and races were 0.60 (P = .011) and 0.21 (P = .040), respectively. Multiple logistic regression showed Hispanic ethnicity was associated with lower rates of TT placement when compared to non-Hispanic white children (OR = 0.62; 95% confidence interval = 0.40-0.96). Future studies should assess why these differences exist and if these differences are associated with racial/ethnic bias or attributed to patient/family preference.

Specialists' adherence to guidelines on tympanostomy tube insertion

INTRODUCTION

Tympanostomy tube insertion is very frequent in Denmark. Using electronic patient-reported outcome (ePRO) data, we investigated Danish ear, nose og throat (ENT) specialists' adherence to the 2015 national clinical guideline (NCG) on first-time tympanostomy tube (TT) insertion in children aged 0-5 years with otitis media (OM).

METHODS

Data on children aged 0-5 years with OM undergoing first-time TT insertion were extracted from the Danish ENT Specialists Organisation (DØNHO) database. Pre-operative questionnaires were used to obtain information on symptom duration, and the number of acute OM (AOM) episodes was analysed. The following criteria were established to define NCG adherence: 1) A symptom duration of three months or longer, 2) three or more AOM episodes within six months and 3) four or more AOM episodes within 12 months. These criteria are in accordance with the NCG definition of chronic OM with effusion (COME) and recurrent AOM (RAOM).

RESULTS

A total of 1,495 children were included in the study. In total, 91.0% of the parents reported a symptom duration of three months or more and/or RAOM within 6-12 months prior to TT insertion in accordance with the adherence criteria; 4.6% reported a symptom duration of less than three months with few or no episodes of AOM and did not meet the recommended TT insertion criteria. Finally, 4.4% of the parents were undecided with respect to symptom duration, number of AOM episodes or both at 6-12 months prior to TT insertion.

CONCLUSIONS

Using solely ePRO data, we found that Danish practicing ENT specialists adhere to the 2015 NCG in regard to OM symptom duration and RAOM.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Australian Aboriginal children have higher hospitalization rates for otitis media but lower surgical procedures than non-Aboriginal children: A record linkage population-based cohort study

Introduction

Otitis media (OM) is one of the most common infectious diseases affecting children globally and the most common reason for antibiotic prescription and paediatric surgery. Australian Aboriginal children have higher rates of OM than non-Aboriginal children; however, there are no data comparing OM hospitalization rates between them at the population level. We report temporal trends for OM hospitalizations and in-hospital tympanostomy tube insertion (TTI) in a cohort of 469,589 Western Australian children born between 1996 and 2012.

Materials and methods

We used the International Classification of Diseases codes version 10 to identify hospitalizations for OM or TTI recorded as a surgical procedure. Using age-specific population denominators, we calculated hospitalization rates per 1,000 child-years by age, year and level of socio-economic deprivation.

Results

There were 534,674 hospitalizations among 221,588 children hospitalized at least once before age 15 years. Aboriginal children had higher hospitalization rates for OM than non-Aboriginal children (23.3/1,000 [95% Confidence Interval (CI) 22.8,24.0] vs 2.4/1,000 [95% CI 2.3,2.4] child-years) with no change in disparity over time. Conversely non-Aboriginal children had higher rates of TTI than Aboriginal children (13.5 [95% CI 13.2,13.8] vs 10.1 [95% CI 8.9,11.4]). Children from lower socio-economic backgrounds had higher OM hospitalization rates than those from higher socio-economic backgrounds, although for Aboriginal children hospitalization rates were not statistically different across all levels of socio-economic disadvantage. Hospitalizations for TTI among non-Aboriginal children were more common among those from higher socio-economic backgrounds. This was also true for Aboriginal children; however, the difference was not statistically significant. There was a decline in OM hospitalization rates between 1998 and 2005 and remained stable thereafter.

Conclusion

Aboriginal children and children from lower socio-economic backgrounds were over-represented with OM-related hospitalizations but had fewer TTIs. Despite a decrease in OM and TTI hospitalization rates during the first half of the study for all groups, the disparity between Aboriginal and non-Aboriginal children and between those of differing socioeconomic deprivation remained.

Characteristics of children with refractory acute otitis media treated at the pediatric emergency department

INTRODUCTION

Refractory acute otitis media (rAOM) is defined as the persistence of signs and symptoms of AOM for more than 48 to 72 hours after the initiation of antibiotic treatment. These patients are often referred to the pediatric emergency department (PED). We sought to study rAOM cases referred to our PED, and to evaluate their clinical characteristics and response to our local management guidelines.

METHODS

A retrospective chart review of all children treated for rAOM between 1/2012-3/2014 was performed. Data recorded included demographics, clinical presentation, antibiotic treatments, need for surgery, and culture results.

RESULTS

A total of 255 patients were included with a mean age of 19 months. Prior to admission, all the children had received at least one course of antibiotics. Amoxicillin was the most common first-line antibiotic prescribed while amoxicillin-clavulanic acid was the most common second and third-line antibiotic given. Intravenous ceftriaxone was the treatment administered at the PED. Myringotomy and pressure equalizing tube (PET) insertion were required in 60% of cases. Middle ear cultures (55 ears) were positive for Streptococcus pneumoniae in two, and Moraxella catarrhalis in only one culture. There were no differences between the mean age of children who had PET insertion and those who did not with regards to fever, rhinorrhea, and preschool or school attendance. Children presenting with otorrhea were less likely to undergo surgery (P = 0.013).

CONCLUSIONS

This is the first study evaluating the established local practice guideline with regards to clinical characteristics and need for surgical management. We showed that myringotomy and PET insertion due to antibiotic failure is commonly performed for cases of rAOM. The majority of the middle ear cultures were sterile.

'Asymptomatic' South Auckland preschool children have significant hearing loss and middle ear disease

BACKGROUND

Seven hundred children were recalled for hearing screening at age 2-3 years due to a problem with their newborn hearing screen. They had all been well babies with no identified risk factors for hearing loss and hence were not scheduled for targeted follow-up to retest hearing.

METHODS

There were 485 children (69%) that attended the recall. The average age was 36 months (SD 3.7). Family ethnicity was Pacific Island (36%), Asian (26%), NZ European (13%), and Māori (11%), and there was a high level of deprivation in the study population. Children were screened using distortion product otoacoustic emission (DPOAE) and a parent or caregiver completed a 14-item questionnaire about ear health. The children that did not pass screening were given appointments for audiology testing. Children with hearing loss and/or middle ear problems were referred for otolaryngology review and further hearing assessments.

RESULTS

About one third (36%; n = 176) of children did not pass DPOAE screening; 82 (17%) had abnormal type B tympanograms and hearing loss; 29 underwent insertion of ventilation tubes, and one had a perforated tympanic membrane. There was a significant association between failed tympanometry and hearing loss (Chi-squared = 16.67, p < .001). Five children had permanent sensorineural hearing loss (SNHL), two of whom required cochlear implants for idiopathic hearing loss, with no specific risk factors. Overall 380 of 485 children screened were deemed to have normal hearing (i.e. 22% failed hearing). From the questionnaire, 15% of the caregivers with no suspicion of hearing problems did have children with significant hearing loss. Regression analysis showed that Pacific/Māori ethnicity was significantly associated with risk of hearing loss, together with questionnaire items identifying hearing problems and breathing problems.

CONCLUSIONS

There is a high proportion of children in South Auckland with unsuspected hearing loss; a different approach to hearing screening is warranted for this population with high rates of middle ear disease at age 3.

Internationally adopted children with cleft lip and/or cleft palate: Middle ear findings and hearing during childhood

OBJECTIVE

Adopted children with cleft lip and/or cleft palate form a diverse group of patients. Due to increased age at palatal repair, adopted children have a higher risk of velopharyngeal insuffiency and poor speech outcome. Delayed palate repair may also lead to longer lasting Eustachian tube dysfunction. Decreased function of the Eustachian tube causes otitis media with effusion and recurrent acute otitis media, which can lead to other middle ear problems and hearing loss.

METHODS

One-hundred-and-thirty-two adopted children treated by the Cleft palate team in Wilhelmina Children's Hospital during January 1994 and December 2014 were included. Retrospectively, middle ear findings, the need for ventilation tube insertion and hearing during childhood were assessed. Findings were compared with 132 locally born children with cleft lip and/or cleft palate.

RESULTS

Adopted children had a mean age of 26.5 months old when they arrived in our country. After the age of two the total number of otitis media with effusion episodes and the need for ventilation tube placement did not significantly differ among adopted and non-adopted children. Adopted children had significantly more tympanic membrane perforations. Hearing threshold levels normalized with increasing age. Although within normal range, adopted children showed significantly higher pure tone averages than locally born children when they were eight to ten years old.

CONCLUSION

In general, adopted patients with cleft lip and/or cleft palate did not have more middle ear problems or ventilation tubes during childhood. However, theyhave more tympanic membrane perforations.

Trends in Otitis Media and Myringotomy With Tube Placement Among American Indian and Alaska Native Children and the US General Population of Children After Introduction of the 13-valent Pneumococcal Conjugate Vaccine

BACKGROUND

American Indian/Alaska Native (AI/AN) children have experienced higher otitis media (OM) outpatient visit rates than other US children. To understand recent trends, we evaluated AI/AN OM rates before and after 13-valent pneumococcal conjugate vaccine introduction.

METHODS

We analyzed outpatient visits listing OM as a diagnosis among AI/AN children <5 years of age from the Indian Health Service National Patient Information Reporting System for 2010-2013. OM outpatient visits for the general US child population <5 years of age were analyzed using the National Ambulatory Medical Care and National Hospital Ambulatory Care Surveys for 2010-2011.

RESULTS

The 2010-2011 OM-associated outpatient visit rate for AI/AN children (63.5 per 100/year) was similar to 2010-2011 rate for same-age children in the general US population (62.8) and decreased from the 2003 to 2005 AI/AN rate (91.4). Further decline in AI/AN OM visit rates was seen for 2010-2011 to 2012-2013 (P < 0.0001). The AI/AN infant OM visit rate (130.5) was 1.6-fold higher than the US infant population. For 2010-2011, the highest AI/AN OM visit rate for <5 year olds was from Alaska (135.0).

CONCLUSIONS

AI/AN <5-year-old OM visits declined by one third from 2003-2005 to 2010-2011 to a rate similar to the US general population <5 years. However, the AI/AN infant OM rate remained higher than the US infant population. The highest AI/AN <5-year-old OM rate occurred in Alaska.

Do race/ethnicity or socioeconomic status affect why we place ear tubes in children?

INTRODUCTION

Despite recent concerns about potential overuse of tympanostomy tube (TT) placement to treat otitis media in children, utilization of this common procedure in the U.S. has been shown to be relatively less common among minority children. It is not known if the indications for TT differ by child race/ethnicity and/or socioeconomic status (SES). Our objective is to analyze the association of patient- and neighborhood-level demographics and SES with clinical indications for TT.

METHODS

We conducted a retrospective chart review of children who underwent TT at single urban academic tertiary pediatric care center in a 6-month period (8/2013-3/2014). Children with congenital anomalies or syndromic diagnoses were excluded (50/137 children, 36.5%). Children were grouped by primary TT indication, recurrent acute otitis media (RAOM) or chronic otitis media with effusion (OME). Group characteristics were compared using t-tests and chi-square analyses, and logistic regression was performed to assess the association between demographics and TT indication.

RESULTS

87 children were included in this analysis (mean age = 2.8 years, 1-6 years). The most common indication for TT was RAOM (53%), and these children had a mean of 6 AOM episodes/year. Indications for TT varied significantly by the patient's neighborhood SES (median neighborhood income $70,969.09-RAOM vs $58, 844.95-OME, p-value = 0.009). Those undergoing TT for RAOM were less likely to live in a high-poverty neighborhood (OR = 0.36,p-value = 0.02), whereas children who underwent TT for OME were more likely to live in a high-poverty neighborhood. There was no significant difference in indication by race/ethnicity or insurance type.

CONCLUSIONS

In this population, TT indications differed by SES. Among children receiving tubes, those from high poverty areas were more likely than those from low poverty neighborhoods to receive tubes for the indication of OME as opposed to RAOM. This finding suggests that concerns for appropriate use of TT in the setting of RAOM may be specific to a more affluent population. Future prospective patient-centered research will evaluate cultural and economic influences for families pursuing TT placement, as well as factors considered by physicians who make surgical recommendations.

Audiologic Outcomes after Myringotomy with Pressure Equalizing Tube Insertion in Cleft Palate Children with Otitis Media with Effusion

OBJECTIVES

To examine: 1) the audiology outcomes in cleft palate patients with otitis media with effusion (OME) after myringotomy with pressure equalizing tube (PE tube), 2) the extrusion time of the PE tubes, and 3) the recurrence of the disease.

MATERIAL AND METHOD

Study population were patients with cleft palate who received treatment in a multidisciplinary program “Smart Smile & Speech Project” at Srinagarind Hospital from January 1, 2006 to December 31, 2009. Retrospective chart review was conducted to identify patients with OME who had received treatment by myringotomy with PE tube at least one year or more before the time of study. Thirty-six patients (69 ears) were enrolled in the study. The patient’s parents or caregiver(s) were contacted by telephone call or mail for a patient’s follow-up of hearing evaluation. The audiology outcomes before and after myringotomy with PE tube were compared.

RESULTS

The results of the hearing, comparing before and after myringotomy with PE tube at least 1 year, were found improvement in 11 ears (16%). The hearing did not improve in 58 ears (84%) all due to extrusion of the PE tube prior to the time of study (69/69, 100%). Recurrence of the disease was observed in 30 patients (84%). Persistent tympanic membrane perforation with chronic otorrhea was found in 7 ears (10%).

CONCLUSION

After at least 1 year of myringotomy with PE tube, the audiology outcomes in the patients of cleft palate with OME did not improve and additionally a high recurrence rate was observed.

Ethnic differences in acute hospitalisations for otitis media and elective hospitalisations for ventilation tubes in New Zealand children aged 0-14 years

AIMS

This paper describes ethnic differences in acute hospitalisations for otitis media (OM) and elective hospitalisations for ventilation tube insertion in New Zealand children aged 0-14 years. Ethnic differences in first attendances at Ear Nose and Throat (ENT) outpatient clinics are also described.

METHOD

The analysis included all hospital admissions of children aged 0-14 years during 2002-2008 which met the following criteria: Acute admissions with an ICD-10-AM primary diagnosis code of otitis media; and elective admissions with a primary procedure code of ventilation tube insertion. First attendances at ENT outpatient clinics during 2007-2008 were also reviewed. Explanatory variables included ethnicity, gender, age, and NZ Deprivation Index decile.

RESULTS

Among 0-4 year olds, Māori and Pacific children were more likely to be admitted acutely for otitis media than European children. In contrast, both Māori and Pacific children had lower rates of elective admissions for ventilation tube insertion, with ethnic differences being most marked for children from the most deprived areas. Māori and Pacific children aged 5-14 years also had higher acute otitis media admission rates than European children. In contrast to their younger counterparts however, they also had higher rates of ventilation tube insertion. Exploration of ENT outpatient data for children 0-4 years revealed similar first appointment rates for European and Māori children, but lower rates for Pacific and Asian children. For the 5-14 age group, first appointment rates were higher for Māori and Pacific children than for European children. However, Māori and Pacific children in both age groups had higher rates of non-attendance at their first ENT appointments than European children.

CONCLUSION

This study highlights ethnic differences in access to ventilation tubes amongst New Zealand's 0-4 year olds, with the greatest inequalities being seen for Māori, Pacific and Asian children living in the most deprived areas. For Māori and Pacific children, such differences cannot be attributed to lower rates of AOM or OME compared to European children. The fact that similar patterns are not seen for children aged 5-14 years potentially suggests that routine Well Child hearing screening may be playing a role in identifying unmet need in this older age group. Such disparities also suggest that factors over and above OM prevalence may be influencing access to ventilation tubes. Further research is required to determine why Māori and Pacific children (0-4 years) have similar/lower ENT appointment rates than European children, despite a higher burden of middle ear disease, as well as higher non-attendance rates at outpatient clinics. Given the importance of early detection and treatment of OM for children's ongoing well-being and education, a greater understanding of the reasons for these inequalities is urgently required.

Association of pneumococcal conjugate vaccination with rates of ventilation tube insertion in Denmark: population-based register study

OBJECTIVE

To examine if the introduction of pneumococcal conjugate vaccine (PCV) in Denmark was associated with a decrease in the rate of ventilation tube (VT) insertions performed by office-based practising ear, nose and throat (ENT) specialists.

DESIGN

Population-based register study based on prospectively collected data.

SETTING

Central Denmark Region. Data on VT insertions performed by any office-based practising ENT specialist in the region were collected from the National Health Service Registry.

PARTICIPANTS

All children below the age of 2 years with a first-time VT insertion from 2001 through 2011.

MAIN OUTCOME MEASURES

Age-stratified and gender-stratified standardised incidence rates of first-time VT insertion, and incidence rate ratio for PCV period 2008-2011 compared with pre-PCV period 2001-2007.

RESULTS

The annual incidence rate of first-time VT insertion in small children increased steadily from 64/1000 person-years in 2001 to 100/1000 person-years in 2011. The incidence rate ratio was 1.27 (95% CI 1.24 to 1.30) in the PCV period compared with the pre-PCV period.

CONCLUSIONS

The introduction of PCV into the Danish childhood immunisation programme in 2007 was not associated with a subsequent decrease in the rate of VT insertions among children below the age of 2 years. Instead, the rate continued to rise, as before the introduction of PCV.

TRIAL REGISTRATION NUMBER

Danish Data Protection Agency: 2007-58-0010.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effectiveness of setting numerical targets in the surgical training of residents: a trial to achieve an optimal balance

During the past 10 years, residency training in otorhinolaryngology-head and neck surgery (ORL-HNS) in Japan, especially at university hospitals, has emphasized subspecialization, resulting in insufficiencies in basic surgical techniques with an extreme bias toward acquiring subspecialty surgical case experience. To address this problem, we developed a target-oriented program intended to achieve a more balanced approach to surgical training and performed a 1-year trial of the program at the Jikei University School of Medicine. Fourteen residents with 1 to 4 years of ORL-HNS experience completed the trial. Each resident's competencies in six basic surgical procedures were assessed on the basis of the number of cases handled by the resident, and each resident's case selection bias after implementation of the target-oriented training was examined. The case selection bias in the trial group residents was reduced and their balance in case experience was shown to be improved in comparison with that in control group residents who were trained in the conventional way. In addition, opinion surveys of the participants and supervising otorhinolaryngologists (trainers) indicated that they felt that the new training system had been effective in improving the balance in case experience and improving motivation, and creating greater awareness of training goals and progress.

Prevalence of ventilation tubes in children with a tracheostomy tube

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Can head position after anesthesia cause occlusion of the tympanostomy tube?

OBJECTIVE

Owing to anecdotal evidence, in bilateral tympanostomy, there is a risk of tube occlusion in the ear that stays superior during the recovery after anesthesia. This observational analysis was designed to evaluate the side difference of tympanostomy tube occlusions owing to head position during the operation and postoperative recovery. It was part of a prospective clinical trial with bilateral tympanostomy tube insertion that was conducted to evaluate the effect of albumin coating tympanostomy tube sequelae.

METHODS

In the bilateral tympanostomy, the right ear was always operated on first. After left ear tube insertion and during the recovery phase after anesthesia, the patient was turned to lie on the right side. The number of tube sequelae were studied during a 9-month follow-up period.

RESULTS

At the first 1-month follow-up visit, 7 right ear tubes and 18 left ear tubes had occluded (p = .043). The same tendency was seen throughout the follow-up. Also, according to a survival analysis, in which survival functions according to laterality were compared using the log-rank test, stratified by tube coating, the left tube occluded at a significantly higher rate.

CONCLUSIONS

The position of the patient's head when awake after anesthesia may have an influence on tube occlusion. In this study, the tube located superiorly was occluded more often. This tendency remained during the follow-up. We concluded that there is a possible association between the position of the head during early recovery and occlusion of the tympanostomy tube.

Current indications for adenoidectomy in a sample of children in the Netherlands

OBJECTIVE

To study current indications for adenoidectomy in Dutch children.

METHODS

During 6 months, ENT surgeons in 1 academic and 7 general hospitals in the Netherlands filled out a questionnaire concerning all children below 15 years of age that were selected for adenoidectomy either as a single procedure or combined with myringotomy or tympanostomy tube placement. This questionnaire collected data on patient characteristics, ENT history, and indication(s) for the procedure.

RESULTS

Questionnaires were returned on 159 children. The study population was comparable to the general population of children undergoing adenoidectomy in the Dutch Health Care Services database concerning age and sex. Adenoidectomy alone was performed in 38%, adenoidectomy and myringotomy in 15%, and adenoidectomy and tympanostomy tube placement in 47%. In children selected for adenoidectomy alone, indications were recurrent upper respiratory tract infections or chronic rhinosinusitis in 60%, persistent otitis media with effusion or recurrent acute otitis media in 33%, and obstructive symptoms in 42%. In children selected for adenoidectomy and myringotomy and those selected for adenoidectomy and tympanostomy tube placement, indications were persistent otitis media with effusion or recurrent acute otitis media in 96% and 99%, recurrent upper respiratory tract infections or chronic rhinosinusitis in 88% and 59%, and obstructive symptoms in 33% and 24%, respectively.

CONCLUSION

In Dutch ENT practices, almost two-thirds of adenoidectomies are combined with myringotomy or tympanostomy tube placement. The most common indication for adenoidectomy combined with myringotomy or tympanostomy tubes is middle ear disease. For adenoidectomy alone, recurrent upper respiratory tract infection is the most common indication.

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

OBJECTIVES

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

DESIGN

Retrospective cohort study.

SETTING

New York metropolitan area practices associated with five diverse hospitals.

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

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.

Effect of Ototopical Medications on Tympanostomy Tube Biofilms

OBJECTIVE

Examine how ototopical medications affect biofilms on fluoroplastic tympanostomy tubes.

STUDY DESIGN

In vitro comparison of different ototopical medications against a clinical isolate of Pseudomonas aeruginosa biofilm on tympanostomy tubes treated for 5, 10, 14, and 21 days.

METHODS

Under sterile conditions 21 tympanostomy tubes were cut in half. These were attached to pegs of two Calgary Biofilm Devices via rubber cement. Device 1 evaluated microbial growth as colony forming units (CFUs). Device 2 evaluated presence of biofilms. Tubes were prepped for biofilm growth, incubated, and stressed for 72 hours. Afterward, one tube per device was removed and forcefully washed. One was sonificated for 5 minutes, serially diluted, and plated for CFUs. Formalin preserved the other for biofilm evaluation by scanning electron microscopy. Next, tubes were exposed to five drops of Ciprofloxacin, Ciprofloxacin/Dexamethasone, Dexamethasone, Ofloxacin, or saline for 1 hour. Afterward, the ototopicals were removed and sterile broth was placed in the wells as a nutrient. This was repeated every 12 hours for 5, 10, 14, and 21 days of treatment. Prior to the last dose of treatment intervals, a streak plate was performed to evaluate for microbial growth in the wells. The tubes were evaluated for CFUs and biofilms at each interval as previously described.

RESULTS

Microbial activity in CFUs decreased by day 5 and continued through day 21 for the antibiotic containing drops. Despite treatment, the biofilm was never eradicated and continued to progress.

CONCLUSIONS

Infectivity of the biofilm is neutralized by antibiotic ototopicals; however, the biofilm will progress despite treatment.

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.

Otitis media surgery: large variability between Finland and Norway

OBJECTIVE

Bi-national comparison of surgical treatment for paediatric otitis media.

METHODS

Registry based cross-sectional study with complete data on surgery for otitis media in 2002; 21,811 Finnish and Norwegian children aged 0-16 years.

RESULTS

Total rates for otitis media surgery were 82.5 and 146.5 per 10,000 children in Norway and Finland, respectively. Adenoidectomies were four times more frequently performed in Finland and rates for tympanostomy tube insertions differed 2-3-fold, Finland having the higher rate. The contrast in surgery rates was most striking in the age group 0-2 years. Further, the more sparsely populated regions had significantly higher overall surgery rates.

CONCLUSION

The large variability in the incidence of otitis media surgery between two similar countries questions whether present guidelines ensure equal treatment in similarly affected children and pinpoints the difficulty in giving advice on age, time and type of surgery.

Accurate consent for insertion and later removal of grommets

Each year in the UK over 30 000 patients undergo insertion of grommets. The grommet insertion may cause many problems like persistent otorrhoea, scarred drum, retraction pockets and retention. The grommets may be extruded from the middle ears by the normal epithelial migration mechanism once they have served their purpose. These may become infected and require removal. We have analysed the Department of Health Hospital Episode Statistics relating to the insertion and removal of grommets (ventilation tubes). We have shown that 7.6 per cent of patients who have grommets inserted will have grommets removed.

Reduction of frequent otitis media and pressure-equalizing tube insertions in children after introduction of pneumococcal conjugate vaccine

OBJECTIVE

Streptococcus pneumoniae is an important cause of otitis media in children. In this study we estimated the effect of routine childhood immunization with heptavalent pneumococcal conjugate vaccine on frequent otitis media (3 episodes in 6 months or 4 episodes in 1 year) and pressure-equalizing tube insertions.

PATIENTS AND METHODS

The study population included all children who were enrolled at birth in TennCare or selected upstate New York commercial insurance plans as of July 1998 and continuously followed until 5 years old, loss of health plan enrollment, study outcome, or end of the study. We compared the risk of developing frequent otitis media or having pressure-equalizing tube insertion for 4 birth cohorts (1998-1999, 1999-2000, 2000-2001, and 2001-2002) by using Cox regression analysis. We used data from the National Immunization Survey to estimate the heptavalent pneumococcal conjugate vaccine uptake for children in these 4 birth cohorts in Tennessee and New York.

RESULTS

The proportion of children in Tennessee and New York who received at least 3 doses of heptavalent pneumococcal conjugate vaccine by 2 years of age increased from < or = 1% for the 1998-1999 birth cohort to approximately 75% for the 2000-2001 birth cohort. By age 2 years, 29% of Tennessee and New York children born in 2000-2001 had developed frequent otitis media, and 6% of each of these birth cohorts had pressure-equalizing tubes inserted. Comparing the 2000-2001 birth cohort to the 1998-1999 birth cohort, frequent otitis media declined by 17% and 28%, and pressure-equalizing tube insertions declined by 16% and 23% for Tennessee and New York children, respectively. For the 2000-2001 to the 2001-2002 birth cohort, frequent otitis media and pressure-equalizing tubes remained stable in New York but increased in Tennessee.

CONCLUSIONS

After heptavalent pneumococcal conjugate vaccine introduction, children were less likely to develop frequent otitis media or have pressure-equalizing tube insertions.

Decreasing rates of middle ear surgery in Western Australian children

OBJECTIVE

To investigate temporal, social, demographic, and health care utilization factors associated with myringotomy with ventilation tube insertion (MVTI) in Western Australian (WA) children.

DESIGN

Observational retrospective population-based cohort study using hospital administrative data.

SETTING

All WA hospitals.

PARTICIPANTS

A total of 53 673 children younger than 15 years who underwent surgery for MVTI in the period 1981-2004.

MAIN OUTCOME MEASURES

Age-specific incidence rates and incidence rate ratios.

RESULTS

The rate of MVTI in children younger than 15 years peaked in 1997 at 6.7 per 1000 person-years and decreased to 5.6 per 1000 person-years by 2004. Based on 2004 rates, 8.4% of WA children will undergo at least 1 MVTI procedure before reaching age 15 years. The rate of MVTI was 37% lower in Indigenous children, and the procedures were performed at an older age compared with non-Indigenous children. Higher rates of MVTI were associated with areas of higher economic resources, lower education and occupation status, and living in metropolitan areas.

CONCLUSIONS

The rate of MVTI in WA is showing evidence of a decline, even among children younger than 5 years. There remains an issue regarding equity of access to care for Indigenous children. Increasing parental economic resources may be associated with higher rates of MVTI independent of educational status.

Audiological issues in children with cleft lip and palate in one area of the U.K

OBJECTIVE

The purpose of this study was to determine the extent of multidisciplinary care and audiological services rendered to children with CL/P who underwent surgical repair of the cleft in 1998 and 1999. This followed proposals to radically reorganize cleft lip and palate services in the U.K. after unsatisfactory findings in a national review.

METHOD

Information was obtained from questionnaires sent to clinicians (audiologists; ear, nose, and throat surgeons; and community pediatricians) from audiology teams, and parents were asked to retrieve information from their Personal Child Health Record. Standards chosen were based on the Clinical Standards Advisory Group, the South Thames Audiology Audit Group, and the National Deaf Children's Society.

RESULTS

None of the agreed standards were achieved at an acceptable level.

CONCLUSIONS

This demonstrates the need for better communication systems between teams, including better use by parents and professionals of the Personal Child Health Record. A clinical care pathway is suggested here with other recommendations.

Indication for hyperbaric oxygen treatment as a predictor of tympanostomy tube placement

INTRODUCTION

Hyperbaric oxygen therapy (HBO2) has been utilized for many years for a multitude of disease entities. One commonly encountered side-effect is otic barotrauma.

OBJECTIVE

To determine if patients with specific disease processes are at increased risk of requiring tympanostomy tubes during HBO2.

METHODS

Data was obtained from Jan. 2000 to Dec. 2004, retrospectively. The requirement for tympanostomy tubes during a course of HBO2 was established.

RESULTS

325 met inclusion criteria. Fifteen percent of patients overall (95% CI= 11-19%) required tympanostomy tubes. Tubes were required in: 5% necrotizing soft tissue infection (p=0.33); 10% failed/threatened graft (p=0.39); 15% problem wounds; 17% chronic refractory osteomyelitis (CRO) (p=0.64); 22% soft tissue radionecrosis (STRN)/osteoradionecrosis (ORN) (p=0.02); 33% of crush injuries (p=0.10). Twenty-nine percent of nasopharyngeal radiation injury patients (p=0.001) and 10% of the non-nasopharyngeal radiation patients (p=0.36) received tympanostomy tubes.

CONCLUSION

A significant increase in tympanostomy tubes were required in nasopharyngeal radiation injury patients.

Clinical manifestations and risk factors of children receiving triple ventilating tube insertions for treatment of recurrent otitis media with effusion

OBJECTIVE

Our goal was to determine risk factors for children receiving additional ventilating tube insertions after initial tube insertion and to determine the changes of clinical manifestations in children who have undergone 3 ventilating tube insertion procedures.

STUDY DESIGN

We retrospectively analyzed medical and operation records of 423 young patients who had ventilating tube insertion because of chronic otitis media with effusion from January 1993 to December 1998. The single-operation group included patients who had 1 ventilating tube insertion only, and the triple-operation group included patients who received ventilating tube insertion 3 times because of recurring chronic otitis media with effusion.

RESULTS

At the first operation, there were significant differences between the single- and triple-operation groups in mean age, the proportion who received a concurrent adenoidectomy, the mean indwelling period of the first ventilating tube, the proportion who developed postoperative otorrhea within 1 month, and the proportion who had early extrusion of the ventilating tube within 3 months of surgery. In the triple-operation group, the accumulated number of adenoidectomies, the indwelling period of the ventilating tube, and the time interval before subsequent ventilating tube insertion after ventilating tube extrusion significantly increased as ventilating tube insertion procedures were performed repeatedly. Although there was no difference when compared with the single-operation group, the proportion of glue-like effusion significantly decreased as ventilating tube insertion procedures were performed repeatedly. There were no significant differences between the single- and triple-operation groups in male/female ratio, site of ventilating tube insertion, and the proportion of patients with glue-like effusion at the first ventilating tube insertion.

CONCLUSIONS

The probability of receiving additional ventilating tube insertion because of recurrent otitis media with effusion significantly increased in younger patients at the time of first ventilating tube insertion. The concurrent adenoidectomy, duration of the ventilating tube, postoperative otorrhea within 1 month, and early extrusion of the ventilating tube also influenced the probability of additional ventilating tube insertion.

Prevalence of middle ear pathologies in children with bilateral sensorineural hearing loss

OBJECTIVES

In poor countries, hearing aids are too expensive for sensorineural hearing loss (SNHL) children's parents to offer for their children. These children may have middle ear problem, this will aggravate the level of hearing loss which may lead to delay in their ability to speak. This study is to highlight the prevalence of middle ear pathology in SNHL children.

METHODS

Two hundred children with bilateral sensorineural hearing loss (SNHL) were selected in our study from the outpatient clinic of ENT department of Sohag University Hospital, Egypt. Children were classified into three categories according to their middle ear status. They were normal middle ear, middle ear with unhealthy tympanic membrane or otitis media with intact drum and chronic suppurative otitis media with perforation.

RESULTS

Seventy percent of cases were normal, 25% had middle ear problem with intact tympanic membrane and 5% had chronic suppurative otitis media with perforation.

CONCLUSION

Thirty percent of SNHL children have middle ear pathology which aggravate the degree of hearing loss. Regular evaluation of SNHL children to treat those having middle ear pathology medically and/or surgically and this may help those having no ability to have hearing aids to learn language early.

Pneumococcal conjugate vaccination in children with recurrent acute otitis media: a therapeutic alternative?

BACKGROUND

Based on two clinical trials in healthy infants the American Academy of Pediatrics (AAP) advices immunization with a 7-valent pneumococcal conjugate vaccine in children with recurrent acute otitis media (AOM).

OBJECTIVE

To study the efficacy of a 7-valent pneumococcal conjugate vaccine on acute otitis media recurrences, its immunogenicity and impact on nasopharyngeal Streptococcus pneumoniae carriage in children with a history of frequent acute otitis media.

METHODS

In this double-blind, randomized study, 74 Belgian children, aged 1-7 years, with at least 2 clinically diagnosed episodes of acute otitis media in the previous year were enrolled. Children were immunized with either a 7-valent pneumococcal conjugate vaccine followed by a 23-valent pneumococcal polysaccharide booster or a control hepatitis A vaccine. Total follow-up was 26 months.

RESULTS

Despite adequate serum IgG responses to all conjugate vaccine pneumococcal serotypes, no reduction of acute otitis media episodes was observed in the pneumococcal vaccine group as compared to the control group (rate ratio: 1.16; 95% CI: 0.69-1.96). Overall nasopharyngeal pneumococcal carriage remained stable. However, a transient shift from conjugate vaccine related S. pneumoniae serogroups to non-vaccine related serogroups was noted following conjugate vaccination.

CONCLUSION

Clinically no protective effect of pneumococcal conjugate vaccination on acute otitis media recurrences was found in children with a history of frequent AOM.

Otitis media, tympanostomy tube placement, and use of antibiotics. Cross-sectional community study repeated after five years

OBJECTIVE

To investigate potential links between antimicrobial drug use for acute otitis media (AOM) and tympanostomy tube placements, and the relationship between parental views and physician antimicrobial prescribing habits.

DESIGN

Cross-sectional community study repeated after five years.

SUBJECTS

Representative samples of children aged 1-6 years in four well-defined communities in Iceland, examined in 2003 (n = 889) and 1998 (n = 804).

MAIN OUTCOME MEASURES

Prevalence of antimicrobial treatments for AOM, tympanostomy tube placements, and parental expectations of antimicrobial treatment. Results. Tympanostomy tubes had been placed at some time in 34% of children in 2003, as compared with 30% in 1998. A statistically significant association was found between tympanostomy tube placement rate and antimicrobial use for AOM in 2003. In the area where antimicrobial use for AOM was lowest in 1998, drug use had further diminished significantly. At the same time, the prevalence of tympanostomy tube placements had diminished from 26% to 17%. Tube placements had increased significantly, from 35% to 44%, in the area where antimicrobial use for AOM was highest. Parents in the area where antimicrobial consumption was lowest and narrow spectrum antimicrobials were most often used were less likely to be in favour of antimicrobial treatment.

CONCLUSIONS

Comparison between communities showed a positive correlation between antimicrobial use for AOM and tympanostomy tube placements. The study supports a restrictive policy in relation to prescriptions of antibiotics for AOM. It also indicates that well-informed parents predict a restrictive prescription policy.

A national survey amongst UK otolaryngologists regarding the treatment of Ménière's disease

Since Dr Prosper Ménière described the vertiginous syndrome that now bears his name, a large variety of medical and surgical treatments have been introduced. To determine the way in which this condition is currently managed in the United Kingdom, a postal survey amongst consultant otolaryngologists was carried out. It revealed that 52 per cent were actively involved in the treatment of patients with Ménières disease using a wide range of medical and surgical therapies that have little or no evidence base. The survey found that 94 per cent of surgeons prescribe betahistine, 63 per cent diuretics and 71 per cent advise salt restriction to their patients, while 52 per cent of surgeons continue to recommend saccus decompression and 50 per cent are still inserting a grommet. However, two thirds of respondents now advocate the use of gentamicin therapy despite it only being introduced to this country just over 10 years ago. The results of this study and their relevance to the recommended present day management of Meniere's disease are discussed.

Hearing loss after "refractory" secretory otitis media

CONCLUSIONS

The results indicate that SOM of extreme duration, and maybe also the treatment of SOM, are risk factors for developing permanent hearing loss, both conductive and sensorineural.

OBJECTIVE

Fluctuating or persisting hearing loss of varying degrees is known to accompany secretory otitis media (SOM). The aim of this study was to detect possible hearing sequelae in young adults who had suffered from "refractory" SOM during childhood. MATERIAL AND MEDTHODS: A total of 33 subjects (age 16-25 years) with previous SOM that had persisted for a mean of 11 years (range 6-19 years) were retrospectively examined at a mean of 18 years after their first myringotomy or tube insertion and compared to 15 healthy controls. The follow-up included audiometric examinations (pure-tone audiometry, distorted speech and impedance audiometry), otomicroscopy and scrutiny of medical records.

RESULTS

The SOM group had poorer hearing at all frequencies with the exception of 1.5 kHz in the range 0.125-16 kHz. Those with the greatest number of myringotomies and tube insertions and those with the longest duration of SOM had significantly poorer hearing at high frequencies (8-16 kHz) than those with fewer tube insertions and a shorter duration of SOM. The SOM group scored lower on distorted speech tests than the controls.

Tympanocentesis for the management of acute otitis media in children: a survey of Canadian pediatricians and family physicians

OBJECTIVE

To evaluate the current knowledge, practice patterns, skills, and attitudes of Canadian pediatricians and family physicians regarding the role of diagnostic tympanocentesis in the management of acute otitis media in children.

DESIGN

Survey.

SETTING AND PARTICIPANTS

A self-completion questionnaire was mailed to a random selection of 302 pediatricians and 196 family physicians practicing in hospitals and community settings across Canada in 2002. A second questionnaire was sent to those who did not respond to the first mailing.

MAIN OUTCOME MEASURES

The demographic features of respondents and their attitudes, beliefs, and behaviors regarding tympanocentesis for acute otitis media were collected via a 2-page questionnaire consisting of open-ended and multiple-choice questions.

RESULTS

The overall response rate was 56%. Only 4% of pediatricians and family physicians surveyed received training in tympanocentesis, and none currently perform the procedure. Higher proportions of those who learned to perform tympanocentesis graduated from medical school before 1970 and received postgraduate training outside of Canada compared with those who did not learn to perform tympanocentesis. Pediatricians were more likely than family physicians to make referrals to otolaryngologists for tympanocentesis for acute otitis media (62% vs 48%; P = .04).

CONCLUSIONS

Few Canadian pediatricians and family physicians in our survey learned to perform tympanocentesis, and none currently perform the procedure. It is not clear whether current practices for tympanocentesis in children with acute otitis media are adequate.

Myringotomy and tympanostomy tube placement in children with sickle cell disease

OBJECTIVE

To assess the event rate of myringotomy and tube placement (M&T) in the pediatric patient population with sickle cell disease (SCD).

METHODS

Four hundred and forty-nine children with confirmed SCD have been followed over a period of 11.5 years at two hospital-based pediatric hematology and otolaryngology offices, and three tertiary care hospitals. Children with SCD who had undergone M&T were identified via computer search of International Classification of Diseases codes by the medical records departments of the three hospitals, and from two databases of the hematology offices. The inpatient and outpatient medical records of all children identified were reviewed.

RESULTS

For the 449 patients, mean duration of SCD follow-up was 6.13 +/- 3.36 years. Of these, eight patients (four boys, four girls, mean age 9 +/- 3.5 years; four patients had hemoglobin SC disease, and four patients had sickle cell anemia type SS) underwent M&T. Two children met criteria for severe SCD. The event rate for M&T insertion was 0.29/100 person-years, 95% CI (0.15, 0.58).

CONCLUSIONS

The event rate for M&T in children with SCD, compared to a historical control group, is lower than that of the general population. Type and severity of SCD were not predictive of the need for tube insertion. Children with sickle cell disease do not have an increased rate of M&T insertion.

Long-term Paparella II grommet use in the management of persistent childhood otitis media: a 5-year follow-up study

A comprehensive 5-year follow-up study of Paparella grommet use in UK. Study group consists of children previously treated with short-term grommets and with persistent glue ear. Mean functional period was 3.73 years with 52% being retainde for the full 5 year duration of the study. Infection and perforation rates increased with the duration of grommet in-situ and this was especially marked after 36 months. We advise the elective removal of these long-term grommets after 3 years of function to reduce compication rate.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

International perspectives on management of acute otitis media: a qualitative review

BACKGROUND

Current opinions regarding the management of acute otitis media (AOM) in children vary across Western countries. With antibiotic resistance rising and more evidence regarding the limited clinical efficacy of antibiotics becoming available, interest in managing AOM other than with antibiotics is renewed.

OBJECTIVES

To compare international rates of antibiotic prescription and surgery for AOM. To provide current evidence regarding the efficacy of various treatment options for AOM and their potential complications.

METHODS

Qualitative (narrative) review.

RESULTS

The percentage of patients given antibiotics for AOM varies from 31% in The Netherlands to more than 90% in most other Western countries. The 1998 prevalence of penicillin-resistant S. pneumoniae strains, on the other hand, ranges from 3% in The Netherlands to 53% in France. The surgical rate for tympanostomy tubes varies from 2 per 1000 children per year in the United Kingdom to 20 per 1000 in The Netherlands. The benefit of both antibiotic and surgical therapy in AOM appears to be limited, with numbers needed to treat ranging from 8 to 25 for antibiotic therapy, depending on the definition of outcome.

CONCLUSIONS

International rates of antibiotic prescription and surgery for AOM vary strongly, which can be explained largely by the lack of uniform evidence-based guidelines. International debates with the aim of overcoming cultural differences regarding the management of otitis media, and of reaching agreement on guidelines on the basis of current evidence are necessary.

The microbiology of glue ear in Australian Aboriginal children

OBJECTIVE

To study the bacterial cultures of middle ear aspirates from 27 Aboriginal children with otitis media with effusion.

METHODS

Standard bacteriological techniques were used to analyse the middle-ear aspirates collected during surgery to insert grommets in 27 Aboriginal children. Swabs of the tympanic membrane were taken for comparison.

RESULTS

Forty-five aspirates were collected from 59 myringotomies. Positive cultures were obtained from 19 of these (13 children) with potentially pathogenic organisms identified in 11 children including Staphylococcus, Pseudomonas, Haemophilus influenzae, Moraxella, Achromobacter, Enterobacter and Corynebacterium.

CONCLUSION

This is only the second study to look at the bacteria in middle ear effusions in Aboriginal children. Streptococcus pneumoniae was notable in its absence as was found in a previous study.

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

Population-based rates of myringotomy with tympanostomy tube insertions in Calgary from 1997 to 2000 were determined with the use of administrative databases. Age-specific rates (procedures per 1,000 people per year) were 12.8, 54.2 and 11.1 for ages 0 to 11 months, 12 to 23 months and 0 to 15 years, respectively. Repeated procedures were performed on 7.1% of children <5 years of age.

Physician and population determinants of rates of middle-ear surgery in Ontario

CONTEXT

Small-area variations in surgical rates raise concerns about access to care, treatment appropriateness, and the quality and cost of care.

OBJECTIVE

To measure small-area variations in rates of myringotomy with insertion of tympanostomy tubes (TTs) and to identify determinants of rate variation.

DESIGN AND SETTING

Retrospective analyses using hospital discharge data for patients who had undergone a myringotomy with insertion of TT by county in Ontario between April 1, 1996, and March 31, 1999. Information on possible determinants was taken from a survey of otolaryngologists and primary care physicians in 1996 and from the 1996 Canadian census and physician demographic databases for 1996-1999.

PARTICIPANTS

A total of 75 358 hospitalizations for TT placement of children and adolescents (aged </=14 years).

MAIN OUTCOME MEASURE

Small-area variation in rates of TT.

RESULTS

An almost 10-fold difference between the areas with the highest and lowest rates was found (extremal quotient, 9.6; 95% confidence interval [CI], 8.2-11.1; P<.001). Higher rates occurred in counties with higher percentages of high school graduates (parameter estimate, 0.01; 95% CI, 0-0.02; P =.049); and where referring physicians were more likely to be male (parameter estimate, 0.01; 95% CI, 0-0.02; P =.01), North American-trained (parameter estimate, 0.01; 95% CI, 0.01-0.02; P<.001), and have higher propensities to refer for surgery (parameter estimate, 0.40; 95% CI, 0.09-0.72; P =.02). Otolaryngologist opinion was not a significant predictor.

CONCLUSION

Substantial area variation in TT rates was observed. The opinion of primary care physicians was the dominant modifiable determinant, suggesting an area of research that may be important in reducing area variation in TT procedures.

Restricted use of antibiotic prophylaxis for recurrent acute otitis media in the era of penicillin non-susceptible Streptococcus pneumoniae

OBJECTIVE/INTERVENTION: To compare the annual rates of acute otitis media (AOM) episodes, antibiotic days, and ventilating tube insertion during the first 3 years of life before and after a practice change to restrict use of antibiotic chemoprophylaxis for recurrent AOM.

METHODS SETTING

The sole pediatric private practice in a rural Kentucky community.

PATIENTS

Population-based sample of all children born consecutively in two different 13 month intervals. Cohort 1 (n=251) was born before and Cohort 2 (n=274) was born after restricted use of chemoprophylaxis and documented emergence of widespread penicillin non-susceptible Streptococcus pneumoniae (PNSP).

DESIGN

Retrospective case cohort comparison.

MAIN OUTCOME MEASURES

Suppurative AOM diagnosed by validated experienced otoscopists using stringent tympanic membrane criteria.

RESULTS

Children were mostly white with the majority (50-65%) enrolled in daycare during each year. The first episode of AOM was experienced by 6 and 12 months of age in 64 and 86%, respectively. Rates of children with recurrent AOM in Cohorts 1 and 2 were 28 and 31% in Year 1, 17 and 23% in Year 2, and 7 and 10% in Year 3, respectively. Rates of new onset AOM and persistent AOM episodes were similar between cohorts in the first 2 years. Number of days of antibiotic prophylaxis were reduced from 11.2 to 3.4 days in Year 1, from 11.9 to 2.6 days in Year 2, and from 6.9 to 0.7 days in Year 3, respectively (P<0.0001 for each year). Total antibiotic days for Years 1, 2 and 3 were reduced commensurately with prophylactic days from 61.7 to 55.5 days (nonsignificant), from 56.3 to 45.8 days (P=0.047), and from 38.7 to 25.7 days (P<0.0001), respectively. For each year a non-significant trend for increased ventilating tube placement from Cohort 1 to Cohort 2, respectively, was observed, 2 versus 2.2%, 4 versus 5.8%, and 0.8 versus 2.6%. Daycare attendance and white race were consistently significant risk factors for AOM and recurrent AOM.

CONCLUSIONS

In the era of PNSP, restricted use of antibiotic chemoprophylaxis for recurrent AOM was not associated with significantly increased rates of new onset AOM episodes or tube placement in the first 24 months of life. Total antibiotic days were also significantly reduced in Cohort 2 during Years 2 and 3.

Hearing aids versus ventilation tubes in persistent otitis media with effusion: a survey of clinical practice

A postal survey was carried out to determine the current clinical practice amongst consultant otolaryngologists in the UK, regarding re-insertion of ventilation tubes or recommendation of hearing aids in cases of recurrence of otitis media with effusion (OME) after ventilation tube extrusion. Amongst the 319 respondents, 15 (4.70 per cent) routinely, 146 (45.77 per cent) sometimes, and 158 (49.53 per cent) either never, or very rarely, recommend hearing aids. Hearing aids and ventilation tubes were both suggested to be equally good options by some consultants but they preferred surgery for a number of reasons. There were inconsistencies in practice and some of the reasons for re-inserting ventilation tubes are not evidence-based. A hearing aid is a non-invasive option and this survey shows a need for a randomized control trial of hearing aids and ventilation tubes in the management of persistent and recurrent OME.

Sex distribution in children with tympanosclerosis after insertion of a tympanostomy tube

Tympanostomy tube insertion is an accepted treatment for otitis media with effusion in children. Several clinical studies have shown that tube insertion may cause myringosclerosis. During the period 1988 to 1997 we treated 533 ears from 311 children who had otitis media with effusion by inserting tympanostomy tubes. Most of these (431 ears from 251 children) were re-examined in 1998 and sex and occurrence of myringosclerosis at the tube insertion site were noted. Myringosclerosis was observed in 31% of ears of girls treated with tubes, whereas in boys 71% of ears showed myringosclerosis. This difference between sexes may indicate a genetic predisposition such as that seen in atherosclerosis.

Causes of tonsillar disease and frequency of tonsillectomy operations

OBJECTIVE

To characterize the factors that influence the frequency of tonsillectomy and adenoidectomy operations.

DESIGN AND SETTING

Nationwide questionnaire. Analysis of patients undergoing tonsillectomy or adenoidectomy at Helsinki University Central Hospital, Helsinki, Finland.

PARTICIPANTS

Four hundred eighty-three of 819 individuals randomly selected from the Finnish National Public Registry. Two thousand two hundred thirty-one individuals younger than 30 years who underwent tonsillectomy (888 patients), adenotonsillectomy (294 patients), or adenoidectomy (1049 patients) at Helsinki University Central Hospital from January 1, 1997, through December 31, 1998.

MAIN OUTCOME MEASURES

Age of the individual at the time of operation. Indication for the operation.

RESULTS

The frequency of adenoidectomies was 24% (116 persons) and that of tonsillectomies 8% (39 persons) among the 483 individuals who returned the questionnaire. The frequency of tonsillectomy operations by age was multimodal; the frequency of tonsillectomies increased in preschool-aged children, declined thereafter, and increased again in teenagers. Tonsillar hyperplasia was the most frequent among children younger than 10 years, peritonsillar abscesses among teenagers, and chronic tonsillitis among individuals older than 20 years. The proportion of females was higher than males among teenaged patients. However, the cause and sex distribution could not explain the multimodality in the age-specific frequency. The age-specific frequency of tonsillectomies performed because of peritonsillar abscesses still followed a multimodal distribution.

CONCLUSIONS

Factors relating to respiratory tract infections, maturation of the immune system, and the onset of puberty contribute to the cause of tonsillar disease. Distinct indications for tonsillectomy should be defined for preschool-aged children, teenagers, and individuals older than 20 years.

The burden of otitis media

Otitis media is the most frequent reason that children go to the doctor for illness. In developing countries, where children have limited access to medical care, suppurative complications of otitis media (OM) are frequent and permanent hearing loss results. In developed countries, the most common morbidity of OM is conductive hearing loss due to middle ear effusion. Infants with severe and recurrent OM and persistent middle ear effusion are at risk for problems in behavior and development of speech, language and cognitive abilities. Parent stress is frequent. The cost of otitis media is large (>$5 billion in the United States). Selection and spread of multi-drug resistant bacterial pathogens arising from extensive use of antimicrobial agents for OM is a problem for management of all diseases due to the pathogens. The incidence and severity of OM may diminish with introduction of new bacterial and viral vaccines.

Alteration of clinical picture and treatment of pediatric acute otitis media over the past two decades

The clinical picture of acute otitis media (AOM) has changed greatly over the last few decades: serious complications have almost disappeared but more and more children suffer from recurrent middle ear infections and prolonged silent effusion. In this retrospective study we registered all AOM attacks among children under 10 in two rural municipal areas of Finland during 12-month-periods in 1978-79 and 1994-95. In addition to epidemiological data, the clinical picture and given treatments were recorded. Between study periods the number of children with recurrent AOM attacks increased heavily. The percentage of spontaneous otorrhea decreased from 6.0 to 3.3% (P=0.01) and the proportion of afebrile patients increased from 64.0 to 73.4% (P=0.002). In 1978-79 there were significantly more cases of diagnostic symptoms lasting over 24 h. Prescribing penicillin-V as a primary treatment decreased from 80.2 to 10.5% in favor of broad-spectrum antibiotics. The primary treatment with penicillin-V was associated with a decreased risk of recurrences. Acute tympanocentesis was performed less often and the incidence of surgical treatments (adenoidectomy and/or tympanostomy tube insertion) doubled from 6.2 to 12.4% of the acute cases. Although the clinical picture of AOM has become milder, children are treated with wider spectrum antibiotics. Nevertheless, a large number of children suffer from sequelae and there is a greater need for surgical treatments than 20 years ago.