Clinical Practice Guideline: Otitis Media with Effusion

The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline “Otitis Media With Effusion in Young Children,” which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children aged 1 to 3 years with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology- Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced practice nursing to revise the OME guideline.

The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media (AOM).

The subcommittee made recommendations that clinicians should (1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME; (2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk; and (3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown).

The subcommittee also made recommendations that (4) hearing testing be conducted when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME; (5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; and (6) when a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure. Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that (1) population-based screening programs for OME not be performed in healthy, asymptomatic children and (2) antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management.

The subcommittee gave as options that (1) tympanometry can be used to confirm the diagnosis of OME and (2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery), and provide additional relevant information such as history of AOM and developmental status of the child. The subcommittee made no recommendations for (1) complementary and alternative medicine as a treatment for OME based on a lack of scientific evidence documenting efficacy and (2) allergy management as a treatment for OME based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed.

The purpose of this guideline is to inform clinicians of evidence-based methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children older than 12 years because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed.

This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. (Otolaryngol Head Neck Surg 2004;130:S95.)

The case for early identification of hearing loss in children. Auditory system development, experimental auditory deprivation, and development of speech perception and hearing

Human infants spend the first year of life learning about their environment through experience. Although it is not visible to observers, infants with hearing are learning to process speech and understand language and are quite linguistically sophisticated by 1 year of age. At this same time, the neurons in the auditory brain stem are maturing, and billions of major neural connections are being formed. During this time, the auditory brain stem and thalamus are just beginning to connect to the auditory cortex. When sensory input to the auditory nervous system is interrupted, especially during early development, the morphology and functional properties of neurons in the central auditory system can break down. In some instances, these deleterious effects of lack of sound input can be ameliorated by reintroduction of stimulation, but critical periods may exist for intervention. Hearing loss in newborn infants can go undetected until as late as 2 years of age without specialized testing. When hearing loss is detected in the newborn period, infants can benefit from amplification (hearing aids) and intervention to facilitate speech and language development. All evidence regarding neural development supports such early intervention for maximum development of communication ability and hearing in infants.

Auditory neuropathy in childhood

OBJECTIVES

Auditory neuropathy is a recently described disorder in which patients demonstrate hearing loss for pure tones, impaired word discrimination out of proportion to pure tone loss, absent or abnormal auditory brainstem responses, and normal outer hair cell function as measured by otoacoustic emissions and cochlear microphonics. We have identified eight pediatric patients having hearing deficits that are most likely due to a neuropathy of the eighth nerve. In this study, the results of audiologic testing performed with these eight children are described.

STUDY DESIGN

Retrospective review of audiologic findings in eight children with auditory neuropathy.

METHODS

Each subject was tested with pure tone and speech audiologic testing, auditory brainstem response, and click-evoked otoacoustic emissions. Results of these tests were tabulated and summarized.

RESULTS

Pure tone audiologic testing revealed five children with upsloping sensorineural hearing loss, two with high frequency loss, and one with a mild, flat configuration. Six children demonstrated poor word discrimination scores, and the other two had fair to good word discrimination. All eight subjects had normal distortion product and transient otoacoustic emissions. All eight children demonstrated absent or marked abnormalities of brainstem auditory evoked potentials. These findings suggest that while cochlear outer hair cell function is normal, the lesion is located at the eighth nerve.

CONCLUSIONS

Recent advances in otoacoustic emissions testing permit differentiation of neural deafness from sensory deafness. This paper describes the clinical presentation and audiologic findings in pediatric auditory neuropathy, as well as the recommended management of these patients. Otolaryngologists should be aware of this disorder and implications for its management, which differs from treatment of sensorineural hearing loss.

Prevalence of external auditory canal exostoses in surfers

OBJECTIVE

To determine (1) the prevalence of external auditory exostoses in a population of surfers and (2) the relationship between the length of time spent surfing and the prevalence, severity, and location of the exostoses.

DESIGN

Cross-sectional epidemiological study.

SETTING

General community.

PATIENTS

Three hundred seven avid surfers (93.5% males and 6.5% females; age distributions: 11.2% were < or =20, 67.9% were 21 to 40, 17.5% were 41 to 50, and 3.3% were >50 years).

MAIN OUTCOME MEASURES

Questionnaires focusing on surfing habits (number of years, geographic region, and number of days per year of surfing) were correlated with otoscopic findings. A simple grading system was devised, based on the degree of external auditory canal stenosis. Grades of normal, mild, moderate, and severe corresponded to 100%, 99% to 66%, 65% to 33%, and less than 33% effective patent surface area, respectively.

RESULTS

There was a 73.5% overall prevalence of external auditory exostoses and a 19.2% overall prevalence of osteomas in the group studied. Of 441 ears with exostoses, 54.2% were mild, 23.6% were moderate, and 22.2% were severe. Of individuals who had surfed for 10 years or less, 44.7% had normal ear canals and only 6% had severely obstructed auditory canals. In comparison, in the group that had surfed for longer than 20 years, only 9.1% had normal auditory canals and 16.2% were severely affected. Of surfers with no exostoses, 61.1% had surfed for 10 years or less. In contrast, of surfers with severe exostoses, 82.4% had surfed for more than 10 years. Finally, the lesions seemed to affect all external auditory canal quadrants equally.

CONCLUSION

A positive association exists between the amount of time individuals spend surfing and the presence and severity of exostoses of the external auditory canal.

Intralabyrinthine schwannomas

Intralabyrinthine schwannomas are unusual tumors of the vestibule, cochlea, semicircular canals, or some combination of these three, which in the past have been reported as incidental findings at autopsy or surgery. We summarize eight cases of intralabyrinthine schwannomas diagnosed by magnetic resonance imaging at the House Ear Clinic during the past 3 years. We discuss the typical clinical presentation and treatment of cochlear vs. vestibular intralabyrinthine schwannomas.

Comparison of newborn hearing screening by transient otoacoustic emissions and auditory brainstem response using ALGO-2

The aim of this study is to compare pass rates for two different hearing screening methods in well newborns as a function of age. A previous study by this group compared click evoked otoacoustic emissions (EOAE) and automated auditory brainstem response (ABR) using the ALGO-1 infant hearing screener (Natus Medical, Foster City, CA). Since that study, a new generation automated ABR screener, the ALGO-2, has been developed. In this study, 232 ears in 116 healthy newborn infants aged 5-48 h were tested using the ALGO-2 screener and EOAE. Overall, 92% of ears passed the ABR, while 57% passed the EOAE screen. The ABR pass rate was higher than in the previous study, where 88.5% of ears passed the ABR screen using ALGO-1. The EOAE pass rate in the present study was lower than in the previous study, in which 79% passed the EOAE screen. Pass rates for both EOAE and ABR improved significantly with increasing infant age. There was no significant difference in the test time required for ALGO-2 (5.7 min) compared with EOAE (5.2 min). The results are compared with earlier studies and implications for universal hearing screening are discussed.

Newborn hearing screening by otoacoustic emissions and automated auditory brainstem response

The aim of this study is to compare pass rates for two different hearing screening methods in well newborns as a function of age. Hearing screening tests were performed on 400 ears in 200 healthy newborn infants at the University of california-Irvine Medical Center. The screening methods used were automated auditory brainstem response (ABR) and click evoked otoacoustic emissions (EOAE). The infants' ages ranged from 5 to 120 h, with an average age of 24 h. Overall, 88.5% of ears passed the ABR screen, and 79% passed the EOAE screen. There was no significant difference in the ABR pass rate for infants aged 0-24 h of age as compared with infants aged > 24 h compared with the group aged 0-24 h (P < 0.01). Results are compared with earlier studies and implications for universal hearing screening are discussed.

Choristoma of the Middle Ear: A Component of a New Syndrome?

CASE REPORT

Salivary choristoma of the middle ear is a rare entity. The authors report the 26th known case, which is unique in several respects: the patient had abnormalities of the first and second branchial arches, as well as the otic capsule and facial nerve in ways not yet reported. Our patient presented with bilateral preauricular pits, conchal bands, an ipsilateral facial palsy, and bilateral Mondini-type deformities. A review of the literature revealed salivary choristomas of the middle ear to be frequently associated with branchial arch abnormalities, most commonly the second, as well as abnormalities of the facial nerve.

REVIEW OF THE LITERATURE

All 25 cases were reviewed and the results reported with respect to clinical presentation, associated abnormalities, operative findings, and hearing results. It has been proposed that choristoma of the middle ear may represent a component of a syndrome along with unilateral hearing loss, abnormalities of the incus and/or stapes, and anomalies of the facial nerve.

CONCLUSION

Eighty-six percent of the reported patients with choristoma have three or four of the four criteria listed to designate middle ear salivary choristoma as part of a syndrome. In the remaining four patients, all of the structures were not assessed.

Congenital aural cholesteatoma: results of surgery in 60 cases

From 1978 to 1993, 59 patients (60 ears) with congenital middle ear cholesteatoma were treated at the House Ear Clinic. The median patient age at presentation was 5 years, and the period of postoperative follow-up was 4.8 years. An intact canal wall was maintained in 58 of 60 cases and a closed middle ear space in all cases. In 12 operations, lateral graft tympanoplasty eradicated the cholesteatoma in one stage; 32 patients required a second-stage surgery to rule out recurrence, and the remaining 16 cases required three or more operations to eradicate disease and reconstruct the hearing mechanism. Thirty-five (63%) of 56 patients had a postoperative air-conduction threshold pure-tone average (PTA) within 10 dB of the best bone-conduction PTA; 91% were within 20 dB. Average speech reception threshold improved from 32 dB hearing level (HL) preoperatively to 20 dB HL postoperatively.

Effects of difluoromethylornithine chemoprevention on audiometry thresholds and otoacoustic emissions

OBJECTIVES

To determine the effects of long-term, low-dose difluoromethylornithine (DFMO) on audiometric thresholds and distortion product otoacoustic emission (DPOAE) levels in humans.

DESIGN

A prospective, randomized, placebo-controlled phase 2 clinical trial of DFMO in participants with a prior adenomatous colonic polyp.

SETTING

Academic tertiary care referral center.

PARTICIPANTS

One hundred twenty-three volunteer subjects with colorectal polyps and normal hearing for the frequencies 250 through 2000 Hz.

INTERVENTIONS

Subjects were randomized to receive placebo or oral DFMO at daily dosages between 0.075 and 0.4 g/m(2) of body surface area for 12 months.

OUTCOME MEASURES

Pure-tone audiometric thresholds for the frequencies 250, 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hz and DPOAE levels were measured at baseline and 1, 3, 6, 9, and 12 months after starting treatment with DFMO or placebo and 3 months after cessation of treatment if there was a suggestion of possible changes at the 12-month measurement.

RESULTS

At these low dosages, there was little evidence for shifts in auditory pure-tone thresholds, and there were no statistically significant shifts in DPOAE levels. For auditory pure-tone thresholds, there was a subtle, approximately 2- to 3-dB hearing level decrease in hearing sensitivity for the 2 higher DFMO dosages, but only at the 2 lowest frequencies, 250 and 500 Hz.

CONCLUSIONS

Administration of low-dose DFMO for 12 months did not produce hearing loss, in contrast to prior studies that used higher dosages.

External and middle ear effects on infant hearing screening test results

This study investigated the relationship between external and middle ear factors and hearing screening results by automated auditory brain stem response (ABR) and transient-evoked otoacoustic emissions (EOAEs). The ears of 200 healthy newborns aged 5 to 48 hours underwent screening by ABR and EOAE, followed by otoscopic examination. The pass rates for ABR and EOAE were 91% and 58.5%, respectively. On otoscopic examination, 28% (112/400) ears had occluding vernix obscuring the view of the tympanic membrane. Cleaning of vernix was successfully performed in all but 2 ears that had occluding vernix. Cleaning of vernix significantly increased the pass rates of all 400 ears for ABR and EOAE to 96% and 69%. Decreased tympanic membrane mobility was found in 22.7% (90/396) of ears that were evaluated otoscopically. Decreased tympanic membrane mobility had a significant effect on EOAE screening; only 33.4% of ears passed EOAE testing. Decreased tympanic membrane mobility did not significantly affect pass rates for ABR screening; 95% of these ears passed the automated ABR screen. Implications for newborn hearing screening are discussed.

Delayed, Reversible Hearing Loss Caused by Difluoromethylornithine (DFMO)

OBJECTIVES/HYPOTHESIS

Difluoromethylornithine (DFMO) is an anticancer experimental drug that is ototoxic. The objectives of these three experiments were to: 1) determine a dose and dosing schedule of DFMO that produces significant hearing loss (HL) in newborn gerbils; 2) compare the HL level for control and newborn gerbils receiving daily subcutaneous injections of DFMO; and 3) to determine if DFMO-related HL is significantly reversible following discontinuation of DFMO treatment.

STUDY DESIGN

Prospective, non-randomized experimental design with placebo controls.

METHODS

Click-evoked auditory brainstem response (ABR) testing was performed for 21-day-old Mongolian gerbils following daily subcutaneous injections of DFMO or saline. Three experiments were carried out using different injection schedules and doses of DFMO. In experiment 3, animals were retested at 42 days of age following a 3-week recovery from DFMO.

RESULTS

Animals administered an 18-day regimen of DFMO at 1 g/kg per day (from day 3 to day 20) had click thresholds of 25 to 65 dB nHL, whereas animals receiving daily injections of saline had thresholds of 5 to 20 dB nHL. Animals retested after 3 weeks of recovery from DFMO treatment had thresholds ranging from 5 to 20 dB nHL. Differences were statistically significant.

CONCLUSIONS

DFMO causes mild to moderate HL in neonatal gerbils that recovers after discontinuation of the drug.

Neonatal hearing screening with otoscopy, auditory brain stem response, and otoacoustic emissions

A study was performed to investigate the relationship between external and middle ear factors and hearing screening results by auditory brain stem response (ABR) and transient evoked otoacoustic emissions (EOAEs). The ears of 200 well newborns aged 5 hours to 48 hours underwent screening by ABR and EOAEs, followed by otoscopic examination. The pass rates for ABR and EOAE screening were 88.5% and 79%, respectively. On otoscopic examination, 13% (53 of 400) ears had occluding vernix obscuring the view of the tympanic membrane. Cleaning of vernix was attempted in ears that failed ABR or EOAE screening. Seventeen ears that failed ABR were cleaned, and 12 (71%) of them passed repeat ABR. Thirty-three ears that failed EOAE screening were cleaned, and 22 (67%) of them passed repeat emissions testing. Cleaning vernix increased the pass rates for ABR and EOAE screening to 91.5% and 84%, respectively. Decreased tympanic membrane mobility was found in 9% of ears that could be evaluated otoscopically. Increased failure rates for both ABR and EOAE screening were found in infant ears with decreased tympanic membrane mobility, but significance testing could not be performed because of inadequate sample size. Prevalence of occluding external canal vernix and middle ear effusion as a function of increasing infant age were studied. Implications for newborn hearing screening are discussed.

Cerebellopontine angle epidermoids: results of surgical treatment

Epidermoids, or congenital cholesteatomas, constitute about 0.2% to 1.5% of intracranial tumors, and 3% to 5% of tumors of the cerebellopontine angle (CPA). We review the surgical management of CPA epidermoids in 13 patients at the House Ear Clinic for the years 1978 to 1993. There were seven male and six female patients, ranging in age from 27 to 59 years (average, 40 years). Tumors ranged in size from 3.5 cm to 7.0 cm, and the surgical approach was tailored to the tumor extent and location. All patients complained at presentation of unilateral hearing loss, and nine had poor speech discrimination (less than 50%) preoperatively. Serviceable hearing was preserved in two patients. Two patients presented with facial nerve symptoms, and four cases had postoperative permanent facial nerve paralysis (House-Brackmann Grade V or VI). There were no surgical deaths. Four patients required second surgeries to remove residual cholesteatoma. Compared with prior series, we describe a higher rate of total tumor removed, as well as a higher rate of second operations, indicating a more aggressive approach to these lesions.

Neurotologic follow-up after radiation of posterior fossa tumors

OBJECTIVE

Stereotactic radiation treatment, also known as gamma knife surgery or radiosurgery, has come into acceptance as a treatment alternative to surgical removal for posterior fossa tumors. The purpose of this article is to describe the role of the neurotologist in the optimal management of neurotologic complications after stereotactic radiation, as illustrated by five patients.

STUDY DESIGN

Retrospective chart review.

PATIENTS

Five patients who underwent stereotactic radiation of posterior fossa tumors.

MAIN OUTCOME MEASURES

Presence or absence of neurotologic complications (tumor growth, hearing loss, imbalance/ataxia, vertigo, and facial paralysis) or neurosurgical complaints (facial numbness, motor weakness, headache, hydrocephalus, and subarachnoid cysts).

RESULTS

Postradiation neurotologic complaints included vertigo, imbalance/ataxia, and progressive hearing loss in four of the five patients. Continued tumor growth occurred in two patients; two patients had no growth; in one patient the tumor became smaller. The complications of facial nerve paralysis, facial numbness, motor weakness, headache, hydrocephalus, cerebellar edema, and posterior fossa arachnoid cyst formation occurred less frequently.

CONCLUSIONS

Stereotactic radiation of posterior fossa tumors can produce significant neurotologic problems. It is imperative that neurotologists remain involved in the follow-up care of patients with posterior fossa tumors to offer optimal treatment alternatives for the neurotologic disorders.

Identification of a key residue in Kv7.1 potassium channel essential for sensing external potassium ions

A glutamate at position 290 in the human K_v7.1 S5-pore linker is required for its inhibition by high concentrations of extracellular potassium.

K_v7.1 voltage-gated K⁺ (K_v) channels are present in the apical membranes of marginal cells of the stria vascularis of the inner ear, where they mediate K⁺ efflux into the scala media (cochlear duct) of the cochlea. As such, they are exposed to the K⁺-rich (∼150 mM of external K⁺ (K⁺_e)) environment of the endolymph. Previous studies have shown that K_v7.1 currents are substantially suppressed by high K⁺_e (independent of the effects of altering the electrochemical gradient). However, the molecular basis for this inhibition, which is believed to involve stabilization of an inactivated state, remains unclear. Using sequence alignment of S5-pore linkers of several K_v channels, we identified a key residue, E290, found in only a few K_v channels including K_v7.1. We used substituted cysteine accessibility methods and patch-clamp analysis to provide evidence that the ability of K_v7.1 to sense K⁺_e depends on E290, and that the charge at this position is essential for K_v7.1’s K⁺_e sensitivity. We propose that K_v7.1 may use this feedback mechanism to maintain the magnitude of the endocochlear potential, which boosts the driving force to generate the receptor potential of hair cells. The implications of our findings transcend the auditory system; mutations at this position also result in long QT syndrome in the heart.

Transient hilar lymphadenopathy due to bacterial endocarditis

Transient hilar and mediastinal lymphadenopathy accompanying right-sided bacterial endocarditis without concurrent roentgenographically-demonstrable pulmonary parenchymal abnormalities has not, to our knowledge, been previously reported. The roentgenographic finding of hilar or mediastinal lymphadenopathy should not be considered incompatible with the diagnosis of bacterial endocarditis in the appropriate clinical setting. Possible mechanisms for the development of lymphadenopathy secondary to bacterial endocarditis are discussed.

Features from normal and sensorineural listeners' nonsense syllable test errors

Identification errors for initial consonants of consonants-vowels-consonants-vowels from lists A and B of the Nonsense Syllable Test were analyzed for 10 normal-hearing and 8 sensorineural hearing-impaired listeners. The Nonsense Syllable Test stimuli were presented binaurally through earphones at 6 increasing sensation levels. Listeners' verbal responses were recorded and transcribed, converted to symmetric confusion matrices, and submitted to analysis of individual differences scaling for symmetrical matrices. Results from 2- through 5-dimensional analyses revealed that voicing, place of articulation, frication, and sibilancy were the salient features used by both listener types in their perceptions of the initial consonants. Findings suggest that consideration of composition of the stimulus set is important when assessing a listener's response to specific speech discrimination tests.