The aetiology of glue ear--a case-control study

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

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

From the American Academy of Pediatrics: Technical report--Secondhand and prenatal tobacco smoke exposure

Secondhand tobacco smoke (SHS) exposure of children and their families causes significant morbidity and mortality. In their personal and professional roles, pediatricians have many opportunities to advocate for elimination of SHS exposure of children, to counsel tobacco users to quit, and to counsel children never to start. This report discusses the harms of tobacco use and SHS exposure, the extent and costs of tobacco use and SHS exposure, and the evidence that supports counseling and other clinical interventions in the cycle of tobacco use. Recommendations for future research, policy, and clinical practice change are discussed. To improve understanding and provide support for these activities, the harms of SHS exposure are discussed, effective ways to eliminate or reduce SHS exposure are presented, and policies that support a smoke-free environment are outlined.

Association of the FBXO11 gene with chronic otitis media with effusion and recurrent otitis media: the Minnesota COME/ROM Family Study

OBJECTIVE

The FBXO11 gene is the human homologue of the gene mutated in the novel deaf mouse mutant jeff (Jf), a single gene model of otitis media. We have evaluated single nucleotide polymorphisms (SNPs) in the FBXO11 gene for association with chronic otitis media with effusion/recurrent otitis media (COME/ROM).

DESIGN

A total of 13 SNPs were genotyped across the 98.7 kilobases of genomic DNA encompassing FBXO11. Data were analyzed for single SNP association using generalized estimating equations, and haplotypes were evaluated using Pedigree Disequilibrium Test methods.

PATIENTS

The Minnesota COME/ROM Family Study, a group of 142 families (619 subjects) with multiple affected individuals with COME/ROM.

MAIN OUTCOME MEASURES

Genetic association of COME/ROM with polymorphisms in FBXO11.

RESULTS

The FBXO11 SNPs are contained in a single linkage disequilibrium haplotype block. Ten of the 13 SNPs were sufficiently polymorphic in the sample to permit analysis. In univariate genetic analysis, 1 reference SNP (hereinafter rs) (rs2134056) showed nominal evidence of association to COME/ROM (P = .02), and 2 SNPs approached significance (rs2020911, P = .06; rs3136367, P = .09). In multivariable analyses, including known risk factors for COME/ROM (sex, exposure to smoking, attending day care centers, no prior breastfeeding, and having allergies), the evidence of independent association was reduced for each SNP (eg, rs2134056, from P = .02 to P = .08). In subsequent analyses using the Pedigree Disequilibrium Test, the association of FBXO11 SNP rs2134056 (P = .06) with COME/ROM was confirmed. Incorporating multiple SNPs in 2- and 3-locus SNP haplotypes, those haplotypes containing rs2134056 also exhibited evidence of association of FBXO11 and COME/ROM (P values ranging from .03 to .10).

CONCLUSION

We have observed evidence consistent with an association between polymorphisms in FBXO11, the human homologue of the Jeff mouse model gene, and COME/ROM.

Risk factors for otitis media with effusion in Chinese schoolchildren: a nested case-control study and review of the literature

OBJECTIVE

To identify the risk factors for otitis media with effusion (OME) in Chinese schoolchildren and analyse the results with reference to the review of the literature.

METHODS

The study subjects were 6-7-year-old children drawn from a school-screening program for OME in Hong Kong. Both positive and negative screens attended a hospital clinic for further assessment with repeated otoscopic examination and tympanometry as well as pure tone audiometry within 3 weeks after the initial school-screening. During the visit, parents were interviewed to provide information with regard to the children's birth history, neonatal history, socio-economic background, otological history, past health, and medical history. These data formed the basis in the estimation of potential risk factors for OME.

RESULTS

In the univariate analysis of 127 cases and 173 controls, significantly elevated odds ratios (OR) for OME were detected on the symptoms of atopy (OR = 2.21, p = 0.04), hearing loss (OR = 4.13, p = 0.001), nasal obstruction (OR = 1.94, p = 0.005), rhinorrhoea (OR = 1.61, p = 0.04), tonsillitis in the past 12 months (OR = 1.82, p = 0.02), and previous history of acute otitis media (OR = 6.89, p < 0.001). However, only three of them were found to be significant in the multivariate logistic regression model: nasal obstruction (OR = 1.67, 95% CI: 1.01-2.75); acute tonsillitis (OR = 1.68, 95% CI: 1.00-2.80), and previous acute otitis media episodes (OR = 5.75, 95% CI: 2.60-12.69).

CONCLUSIONS

Risk factors identified in the Chinese schoolchildren for OME were comparable with previous western reports. A previous attack of acute otitis media was a major determinant for middle ear effusion.

The relationship between otitis media with effusion and contact with other children in a british cohort studied from 8 months to 3 1/2 years. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood

OBJECTIVE

It is generally acknowledged that otitis media with effusion is more prevalent among children attending grouped day care. This study aimed to refine this by determining the relationships with the numbers of children at the place of day care, the age of the child and the number of siblings he/she had.

METHODS

ALSPAC (the Avon Longitudinal Study of Pregnancy and Childhood) is a population based longitudinal study starting early in pregnancy and following the children throughout their lives. Nested within this study, a randomly selected group of 1590 children, the Children in Focus, were invited to attend a clinic for hands on examinations. Tympanometry was carried out at ages 8, 12, 18, 25, 31, 37 and 43 months of age. Bilateral otitis media with effusion (OME) was identified if both ears showed a flat trace. Multi-level modelling with logistic regression adjusted for a number of social and environmental influences.

RESULTS

Of the 1590 children invited to the 8-month clinic, 300 (19%) were excluded from the analysis because of failure to attend or because of missing data. The analyses were based on 1290 children. The prevalence of bilateral OME decreased with age, from 24.6% at 8 months to 11.9% at 43 months. Children with older siblings and those attending day care with four or more other children were at an increased risk of OME. The adjusted odds ratios (AOR) were 1.52 (95% confidence interval [CI] = 1.23, 1.88) and 1.36 (95% CI = 1.02, 1.82), respectively. The risk associated with older siblings declined with age and by 3 years these children were no longer more likely to have OME than children with no older siblings. No such interaction with age was found for children in group day care and these children continued to be at an increased risk over the entire age period of the study. There was no increased risk associated with day care when no other children attended (AOR = 1.18, 95% CI = 0.88, 1.58) or when one to three others were present (AOR = 1.10, 95% CI = 0.85, 1.42). Although there was no relationship with the number of hours spent in day care, children who had started attending group care with four or more other children before 9 months of age did have an increased risk compared with children starting later AOR = 1.88, 95% CI = 1.12, 3.14.

CONCLUSIONS

These results provide evidence that early contact with other children increases the risk of OME and that children attending day care with four or more other children remain at an increased risk of OME at least until 31/2 years.

T-cell subsets in adenoids and peripheral blood related to age, otitis media with effusion and allergy

Adenoids and peripheral blood samples from 29 children (20-120 months of age) undergoing adenoidectomy for long-standing otitis media with effusion (OME) (n=16) or obstructive adenoid hyperplasia (n=13) were investigated by flow cytometry for their T-lymphocyte profile. Eleven of the enrolled children were allergic to inhalant and/or food allergens. For the whole group, the percentage of helper T cells belonging to the memory phenotype (CD4+/CD45RO+ cells) was significantly higher in adenoids than in blood (p<0.0001), while the same cell category increased with age in peripheral blood (p<0.01). A highly significant negative regression (p<0.001) was found between age and the percentage ratio of CD4+ cells that were CD45RO+ in adenoids and blood. Allergic children had a higher CD4+/CD8+ ratio for cells expressing CD45RO+ (p<0.05) in adenoids. The results of this study indicate that adenoids participate in the development of an immunological memory. Our findings support a relationship between allergy and memory cells in adenoids.

Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children

BACKGROUND

A systematic quantitative review was conducted of evidence relating parental smoking to acute otitis media, recurrent otitis media, middle ear effusion, and adenoidectomy and/or tonsillectomy.

METHODS

Forty five relevant publications were identified after consideration of 692 articles selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified 13 studies of acute otitis media, nine of recurrent otitis media, five of middle ear effusion, nine of glue ear surgery, and four of adenotonsillectomy. A quantitative meta-analysis was possible for all outcomes except acute otitis media, using random effects modelling where appropriate to pool odds ratios from each study.

RESULTS

Evidence for middle ear disease is remarkably consistent, with pooled odds ratios if either parent smoked of 1.48 (95% CI 1.08 to 2.04) for recurrent otitis media, 1.38 (1.23 to 1.55) for middle ear effusion, and 1.21 (0.95 to 1.53) for outpatient or inpatient referral for glue ear. Odds ratios for acute otitis media are in the range 1.0 to 1.6. No single study simultaneously addresses selection bias, information bias and confounding, but where these have been investigated or excluded in the design or analysis, the associations with parental smoking persist virtually unchanged. Large French and British studies are inconsistent with regard to the association of parental smoking and tonsillectomy.

CONCLUSIONS

There is likely to be a causal relationship between parental smoking and both acute and chronic middle ear disease in children.

Sociodemographic and educational correlates of hearing loss in Hispanic children

Sociodemographic and educational correlates of hearing loss were examined in Cuban-American, Mexican-American and Puerto Rican children 6-19 years of age. Logistic regression analyses indicated a greater risk of bilateral hearing loss among children living in crowded housing conditions or without health insurance, as well as among those who were below expected school grade level and whose parents reported low educational attainment levels. However, the strengths of these associations were small to moderate in magnitude and were not always consistent across the ethnic subgroups. These findings provide some evidence that hearing-impaired Hispanic children are more likely to reside in economically disadvantaged families and to be below their expected school grade level.

Sidestream smoke inhalation decreases respiratory clearance of 99mTc-DTPA acutely

BACKGROUND

The permeability of the alveolar-capillary barrier to an inhaled aerosol of technetium 99m labelled diethylenetriamine penta-acetate (99mTc-DTPA) is used as an index of alveolar epithelial injury. Permeability is greatly increased in active smokers.

AIMS

To determine the effect of sidestream smoke inhalation on permeability as this has not been described previously.

METHODS

We measured lung clearance of inhaled 99mTc-DTPA aerosol in 20 normal non-smoking subjects before and after exposure to one hour's sidestream smoke inhalation.

RESULTS

Measured carbon monoxide (CO) levels rose to maximum of 23.5 +/- 6.2 ppm (mean +/- SD) from baseline values of 0.6 +/- 1.3 (p < 0.001) and plasma cotinine levels to a maximum of 9.5 +/- 4.5 nmol/L (mean +/- SD). The half time (T1/2 in minutes) for 99mTc-DTPA clearance rose from baseline 69.1 +/- 15.6 (mean +/- SD) to 77.4 +/- 17.8 (p < 0.05) after smoke exposure. No effect of 99mTc-DTPA scanning or of sidestream smoke was demonstrated on lung function.

CONCLUSIONS

We conclude that low level sidestream smoke inhalation decreases 99mTc-DTPA clearance acutely in humans. The mechanism of this unexpected result is not established but may include differences in constituents between sidestream and mainstream smoke, alterations in pulmonary microvascular blood flow, or changes in surfactant due to an acute phase irritant response.

The family study of otitis media: design and disease and risk factor profiles

Recurrent acute otitis media (RAOM) and chronic otitis media with effusion (COME) exhibit familial aggregation, but environmental risk factors (day care attendance, cigarette smoke exposure, and bottle feeding) are also important in their development. The Family Study of OM was designed to ascertain the RAOM/ COME status of families whose children participated in Otitis Media Research Center studies between 1978 and 1984. Probands were treated with tympanostomy tubes, and had their RAOM/COME status ascertained as criteria for entry into these studies. For the Family Study of OM parents were interviewed about their otitis media and risk factor history; mothers were interviewed about their children's history, and pertinent medical records were obtained. Members of 173 families were examined with otomicroscopy and multifrequency tympanometry; 19% of parents and 32% of siblings were classified as affected, which is substantially higher than RAOM/COME rates from previous reports. Risk factor profiles differed significantly (P < .001) between parents and their children. Younger generation (adjusted odds ratio [OR] = 4.18, 95% confidence interval [CI], 2.74, 6.36) day care attendance (OR = 1.96, 95% CI, 1.32, 2.91) and male gender (OR = 1.42, 95% CI, 1.03, 1.97) were significantly related to RAOM/ COME using logistic regression. Analyses confirm 1) higher disease rates in families with an affected member compared to existing studies of the general population, 2) increased risk of RAOM/COME associated with known risk factors, and 3) increased risk for parents irrespective of risk factors. Additional analyses will explore competing models of disease susceptibility using genetic models and known risk factors.

Relationship of environmental tobacco smoke to otitis media in young children

Otitis media (OM) continues to be a major health problem of children in the United States. The role of environmental tobacco smoke (ETS) as a predisposing factor has not been completely discerned. This study and discussion is an investigation and review of the influence of passive cigarette smoking on OM in children, and its effect on the practice of otolaryngology within the pediatric population. A prospective study of 175 children with recurrent OM and requiring tympanostomy tubes (case group) was compared to an age-matched group of 175 children (controls) to determine the role passive cigarette smoking has on the incidence of this disease. The results revealed that the case group more commonly had exposure to ETS (P = .04). Prospective follow-up of the case group revealed no significant difference in the clinical course of the children who were exposed to ETS and those who were not.

Smoking and Middle Ear Disease: Are they Related? A Review Article

The relationship between passive smoking and middle ear disease was reviewed. The hypothesis that acute otitis media, serous otitis media, and related diseases in children are caused by inhalation of second-hand smoke has been accepted by many. We reviewed the literature on this topic. There are many studies that do not support the hypothesis. There is no indication that the smokers themselves have a higher incidence of middle ear disease. Considering the difficulty of publishing negative studies, the need for academics to publish significant findings, and the poor foundation for some authors” conclusions in the literature, we find that the literature does not offer sufficient support for the hypothesis that second-hand smoke causes middle ear disease to accept the hypothesis.

Tobacco smoke and otitis media in the chinchilla model

To determine whether tobacco smoke contributes to the pathogenesis of acute otitis media, chinchillas were exposed to mainstream tobacco smoke or sham conditions (cigarettes not lit) in a Walton smoke exposure machine for 20-minute cycles two or three times daily. After 6 to 8 weeks of daily exposure, 12 chinchillas were nasally injected with Streptococcus pneumoniae, and 18 chinchillas were injected into both middle ears with nontypable Haemophilus influenzae. Smoke or sham exposures were continued for 2 to 4 weeks after injection. Otitis media developed in none of the 12 nasally injected chinchillas and in all 18 chinchillas whose middle ears were injected with nontypable Haemophilus influenzae. Persistence of middle ear effusion and persistence of nontypable Haemophilus influenzae in the middle ear effusion were not different between the smoke- and sham-exposed groups. This suggests that mainstream smoke exposure does not change the natural course of otitis media in the chinchilla model.

Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life

The relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion (OME) was evaluated in a cohort of 698 healthy infants prospectively monitored by tympanometry in the home every 2 to 4 weeks until 2 years of age. Except for an experimental group of children who were offered early tube placement, the study children received conventional care from their personal physician or clinic. We used LISREL, a structural equation modeling procedure (computer software), to explore associations between environmental variables and OME onset and duration while controlling for interrelations among the variables. Supine feeding position and early initiation of group child care were associated with earlier onset of OME. Shorter duration of breast-feeding, increased packs of cigarettes smoked per day in the home, and increased hours per week in group child care were associated with an increase in the amount of time with OME during one or more of the age blocks studied (birth to 6, 6 to 12, 12 to 18, and 12 to 24 months). For a decrease in the amount of time with OME during the first 2 years of life, prolonged breast-feeding and upright feeding position should be encouraged, and cigarette smoke exposure should be minimized. Limiting early child care in large groups might also be advisable.

Exposure to environmental tobacco smoke as a risk factor for recurrent acute otitis media in children under the age of five years

Exposure to environmental tobacco smoke (ETS) has remained a controversial risk factor for otitis media in children. This study evaluates the association between exposure to ETS and recurrent acute otitis media (RAOM) in 85 cases and 85 age and gender matched controls under the age of 5 years. Cases and controls were obtained from outpatient otolaryngology and ophthalmology clinics, respectively, at the Children's Hospital of Eastern Ontario. Cases were defined as having four or more physician documented AOM episodes in the preceding 12 months and controls were otitis free in the prior 12 months. Exposure status was assessed via parental questionnaire. Controlling for other risk factors (via conditional logistic regression), such as daycare attendance, socioeconomic status, prematurity and family history of otitis media, a significant association between ETS and RAOM was evident (odds ratio = 2.68, 95% CI = 1.27-5.65). When categorized, a significant exposure response relationship between increasing level of exposure to ETS and increased risk of RAOM was evident. The population etiologic fraction indicated that up to 34% of RAOM cases may be accounted for by ETS exposure. We conclude that exposure to ETS is an important and modifiable risk factor for RAOM in children under the age of 5 years.

The effect of parental smoking on outcome after treatment for glue ear in children

A sample of 201 children aged between 2 and 9 years with bilateral chronic otitis media with effusion (OME) were treated prospectively and at random by adenoidectomy, adenotonsillectomy, or with neither procedure. In all cases only a unilateral grommet was inserted and the contralateral unoperated ear was examined one year post-operatively for persistence or resolution of the effusion. A self-administered questionnaire was completed by the parents concerning their smoking habits. The resolution of effusion following surgery was assessed in relation to smoking by by the mother and father separately and in combination. Clearance of glue was statistically less frequent where the child's mother or where both parents smoked. This was related to the number of cigarettes smoked by the mother or both parents. The adverse effect was demonstrable whether or not adenoidectomy or adenotonsillectomy had been performed for treatment. The findings lend further support or professional and governmental opinions of a deleterious effect of passive smoke exposure on children and in this case parental smoking has been shown to have an adverse effect on the outcome of OME following surgical treatment.

Statistical methods for determining risk factors of chronic otitis media with effusion

We use logistic regression with paired Bernouilli outcomes to analyse data on subjects who have either one or two organs (e.g. ears) each of which may develop disease. In this model, subject-specific covariates are related to the probability of developing disease. The proposed method is applied to determine risk factors for chronic otitis media with effusion.

A randomised controlled trial of surgery for glue ear

OBJECTIVE

To assess the effect of five different surgical treatments for glue ear (secretory otitis media) on improvement in hearing and, assuming one or more treatments to be effective, to identify the appropriate indications for surgery.

DESIGN

Randomised controlled trial of children receiving (a) adenoidectomy, bilateral myringotomy, and insertion of a unilateral grommet; (b) adenoidectomy, unilateral myringotomy, and insertion of a unilateral grommet; (c) bilateral myringotomy and insertion of a unilateral grommet; and (d) unilateral myringotomy and insertion of a grommet. Children were followed up at seven weeks, six months, 12 months, and 24 months by symptom history and clinical investigations.

SETTING

Otolaryngology department in an urban hospital.

PATIENTS

149 Children aged 4-9 years who were admitted for surgery for glue ear and who had no history of previous operations on tonsils, adenoids, or ears and no evidence of sensorineural deafness. Inadequate follow up information on levels of hearing and on middle ear function was obtained from 22.

MAIN OUTCOME MEASURES

Mean hearing loss (dB) of the three worst heard frequencies between 250 and 4000 Hz, results of impedance tympanometry, and parental views on their child's progress.

RESULTS

In the 127 children for whom adequate information was available ears in which a grommet had been inserted performed better in the short term (for at least six months) than those in which no grommet had been inserted, irrespective of any accompanying procedure. Most of the benefit had disappeared by 12 months. Adenoidectomy produced a slight improvement that was not significant, though was sustained for at least two years. The ears of children who had had an adenoidectomy with myringotomy and grommet insertion, however, continued to improve so that two years after surgery about 50% had abnormal tympanometry compared with 83% of those who had had only myringotomy and grommet insertion, and 93% of the group that had had no treatment. Logistic regression analyses identified preoperative hearing level as the single best predictor of good outcome from surgery. Other variables contributed little additional predictive power.

CONCLUSIONS

If the principal objective of surgery for glue ear is to restore hearing then our study shows that insertion of grommets is the treatment of choice. The addition of an adenoidectomy will increase the likelihood of restoration of normal function of the middle ear but will not improve hearing. When deciding appropriate indications for surgery, a balance has to be made between performing unnecessary operations and failing to treat patients who might benefit from surgical intervention. Preoperative audiometry scores might be the best predictor in helping to make this decision.

Impedance tympanometry and the home environment in seven-year-old children

The distribution of tympanogram types among 872 seven-year-old children from a random population sample was related to 14 features of the home environment reported by parents in a questionnaire. Parental smoking was an important determinant of middle ear underpressure and effusion, and accounted for much of the associations observed with dampness, crowding and rented accommodation. Gas cooking was associated with a higher prevalence of effusion, but a lower prevalence of underpressure; this may deserve further study. After adjustment for seasonal variation, tenure and household smokers, the weekly mean temperature in the bedrooms of 34 children with Type B tympanograms was 18.2 degrees C, compared to 17.9 degrees C for 190 children with Type A tympanograms. The equivalent figures for bedroom relative humidity were 51.8 per cent and 52.7 per cent. It is unlikely that heating or ventilation of the home is an important determinant of middle ear effusion and underpressure in this age-group.

Passive smoking, salivary cotinine concentrations, and middle ear effusion in 7 year old children

OBJECTIVE

To assess the contribution of passive exposure to tobacco smoke to the development of middle ear underpressure and effusion.

DESIGN

Cross sectional observational study.

SETTING

One third of the primary schools in Edinburgh.

SUBJECTS

892 Children aged 6 1/2 to 7 1/2 were examined, and satisfactory tympanograms were obtained in 872. Results of assay of salivary cotinine concentrations were available for 770 children, and satisfactory tympanograms were available for 736 of these.

END POINT

Correlation of the prevalence of middle ear underpressure and effusion with concentrations of the marker of nicotine, cotinine, in the saliva of the children.

MEASUREMENTS AND MAIN RESULTS

Middle ear pressure and compliance were measured in both ears by impedance tympanometry. Salivary cotinine concentrations were assayed by gas-liquid chromatography. Cotinine concentrations increased with the number of smokers in the household. Girls had higher concentrations than boys, and children living in rented housing had higher concentrations than those living in housing owned by their parents. There was a trend towards more abnormal tympanometric findings with increasing cotinine concentration, the odds ratio for a doubling of the cotinine concentration being 1.14 (95% confidence interval 1.03 to 1.27). After adjustment for the sex of the child and housing tenure the odds ratio for a doubling of the cotinine concentration was 1.13 (1.00 to 1.28).

CONCLUSIONS

The results of this study are consistent with those of case-control studies of children attending for an operation to relieve middle ear effusion. They indicate that the disease should be added to the list of recognised hazards associated with passive smoking. About one third of the cases of middle ear effusion in this study were statistically attributable to exposure to tobacco smoke.