Atopy in children with otitis media with effusion

Clinical practice guidelines for the diagnosis and management of otitis media with effusion (OME) in children in Japan - 2022 update

This is an update of the 2015 Guidelines developed by the Japan Otological Society and Oto-Rhino-Laryngeal Society of Japan defining otitis media with effusion (OME) in children (younger than 12 years old) and describing the disease rate, diagnosis, and method of examination. Recommended therapies that received consensus from the guideline committee were updated in consideration of current therapies used in Japan and based on available evidence.

METHOD

Regarding the treatment of OME in children, we developed Clinical Questions (CQs) and retrieved documents on each theme, including the definition, disease state, method of diagnosis, and medical treatment. In the previous guidelines, no retrieval expression was used to designate a period of time for literature retrieval. Conversely, a literature search of publications from March 2014 to May 2019 has been added to the JOS 2015 Guidelines. For publication of the CQs, we developed and assigned strengths to recommendations based on the collected evidence.

RESULTS

OME in children was classified into one group lacking the risk of developing chronic or intractable disease and another group at higher risk (e.g., children with Down syndrome, cleft palate), and recommendations for clinical management, including follow-up, is provided. Information regarding management of children with unilateral OME and intractable cases complicated by adhesive otitis media is also provided.

CONCLUSION

In clinical management of OME in children, the Japanese Clinical Practice Guidelines recommends management not only of complications of OME itself, such as effusion in the middle ear and pathologic changes in the tympanic membrane, but also pathologic changes in surrounding organs associated with infectious or inflammatory diseases.

Role of Allergy in Eustachian Tube Dysfunction

PURPOSE OF REVIEW

Eustachian tube dysfunction (ETD) presents with symptoms of aural fullness and pressure, muffled hearing, tinnitus, and otalgia. When severe, it can lead to many common ear disorders such as otitis media with effusion, tympanic membrane retraction/perforation, and cholesteatoma. These diseases are prevalent in both the pediatric and adult population and significantly impact quality of life. The pathophysiology of ETD in the absence of an obstructive lesion has long been debated but is thought to be related to functional obstruction (i.e., inefficient tensor veli palatini muscle) and/or nasal cavity and nasopharyngeal inflammation. In the acute setting, the most common cause of nasal inflammation is an upper respiratory infection. When symptoms become chronic, however, the inflammation is thought to be associated with nasal irritants such as nasal allergens, i.e., allergic rhinitis (AR). The purpose of this review is to summarize our current understanding of the relationship between allergy and ETD.

RECENT FINDINGS

Past studies are either lacking or have reported equivocal findings regarding the relationship between allergy and ETD, and the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis has deemed the current level of evidence linking AR and ETD as low quality. A more recent study using a large adult population dataset did support an association between AR and ETD, but did not find that all cases of ETD are related to allergies. Furthermore, current evidence suggests that the use of medications that can decrease intranasal inflammation, such as intranasal corticosteroids or oral antihistamines, does not result in significant symptomatic improvement in patients with ETD. However, these studies included all patients with ETD, and evidence is lacking regarding the treatment effect of these medications on the subset of patients with concurrent AR and ETD. Current best evidence does support an association between AR and ETD; however, not all patients with ETD suffer from AR, and vice versa. Further research is necessary to understand the mechanism behind this positive association and to elucidate the cause of chronic ETD in patients without associated allergies.

Allergy and Otitis Media in Clinical Practice

PURPOSE OF REVIEW

Otitis media (OM) is a disease with very high prevalence in infancy, substantial burden on healthcare resources, and relevant impact on the quality of life of families. The link between OM and allergy is controversial and still debated. However, a fundamental premise has to be placed before introducing this topic: there is the need to use clear and unambiguous terms. Literature abounds with misleading terms that significantly affect the methodology and consequently the outcomes. Moreover, it is essential to differentiate patients according to the OM type (i.e., acute OM, OM with effusion, and chronic suppurative OM), the allergic disease, and mainly the age.

RECENT FINDINGS

There are some recent studies exploring this issue through different approaches, such as epidemiological, mechanistic, and therapeutic. To identify allergy as a pathogenic factor for OM could improve the management of OM patients. Vice versa, to suspect allergy in OM patients could be reasonable in selected patients. The current narrative review provides an overview of the evidence concerning the potential role of allergy in OM. As there are conflicting findings, a possible interpretation of pathophysiological events and a pragmatic approach are proposed.

The association between allergic rhinitis and otitis media: A national representative sample of in South Korean children

Although many studies have reported that allergic rhinitis is an independent risk factor highly related to otitis media in children, there is still lack of epidemiological studies on demographics. The objective of this study was to identify if allergic rhinitis was an independent risk factor for otitis media in children aged between 7 and 12 years by using the nationwide survey data representing the local population of South Korea. This is a secondary study based on the ENT examination data (eg. acute otitis media, otitis media with effusion, chronic otitis media). The subjects of this study were 472 children (248 male and 224 female) who completed the Korea National Health and Nutrition Examination Survey 2015. The presence of otitis media was examined by otolaryngologists using tympanometric measurements, audiometric measurements, and otoscopic examination. Allergic rhinitis was diagnosed by Korean-version of International Study of Asthma and Allergies in Childhood, a total serum immunoglobulin E test, an allergen-specific immunoglobulin E test, a blood eosinophil test, an eosinophil cationic protein test, a nasal cytology for eosinophils test, a skin reaction test, and an antigen simultaneous test. Confounding factors included age, gender, the levels of income for households, and household composition. The relationship between allergic rhinitis and otitis media was analyzed by a complex sample logistic regression analysis and the odds ratio and 95% confidence interval were presented. The results of a complex sample design logistic regression revealed that allergic rhinitis in children was significantly associated with otitis media (p < 0.05). Even after adjusting all confounding factors, children with allergic rhinitis had twice significantly higher risk of otitis (OR = 2.04; 95% CI: 1.30-3.18) than children without allergic rhinitis. This epidemiologic study confirmed the independent relationship between pediatric allergic rhinitis and otitis media. In the future, longitudinal study will be needed to verify causality of allergic rhinitis and otitis media.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Risks for comorbidity in children with atopic disorders: an observational study in Dutch general practices

OBJECTIVE

This study aimed to investigate both atopic and non-atopic comorbid symptoms and diseases in children with physician-diagnosed atopic disorders (atopic eczema, asthma and allergic rhinitis).

METHODS

All children aged 0-18 years listed in a nationwide primary care database (the Netherlands Institute for Health Services Research-Primary Care Database) with routinely collected healthcare data in 2014 were selected. Children with atopic disorders were matched on age and gender with non-atopic controls within the same general practice. A total of 404 International Classification of Primary Care codes were examined. Logistic regression analyses were performed to examine the associations between the presence of atopic disorders and (non-)atopic symptoms and diseases by calculating ORs.

RESULTS

Having one of the atopic disorders significantly increased the risk of having other atopic-related symptoms, even if the child was not registered as having the related atopic disorder. Regarding non-atopic comorbidity, children with atopic eczema (n=15 530) were at significantly increased risk for (infectious) skin diseases (OR: 1.2-3.4). Airway symptoms or (infectious) diseases (OR: 2.1-10.3) were observed significantly more frequently in children with asthma (n=7887). Children with allergic rhinitis (n=6835) had a significantly distinctive risk of ear-nose-throat-related symptoms and diseases (OR: 1.5-3.9). Neither age nor gender explained these increased risks.

CONCLUSION

General practitioners are not always fully aware of relevant atopic and non-atopic comorbidity. In children known to have at least one atopic disorder, specific attention is required to avoid possible insufficient treatment and unnecessary loss of quality of life.

What Role Does Allergy Play in Chronic Ear Disease and Laryngitis?

IgE-mediated allergy plays a well-established role in both nasal and pulmonary diseases due to the common epithelium and shared mediator responses of the upper and lower airways. This "unified airway" concept has also been described in other sites within the head and neck that contain similar respiratory mucosa: the middle ear and the larynx. This review will highlight the data suggesting a role for IgE-mediated allergic disease in chronic laryngopharyngeal and middle ear disease and the role for allergy testing to aid in diagnosis and treatment of these disorders.

Multi-morbidities of allergic rhinitis in adults: European Academy of Allergy and Clinical Immunology Task Force Report

This report has been prepared by the European Academy of Allergy and Clinical Immunology Task Force on Allergic Rhinitis (AR) comorbidities. The aim of this multidisciplinary European consensus document is to highlight the role of multimorbidities in the definition, classification, mechanisms, recommendations for diagnosis and treatment of AR, and to define the needs in this neglected area by a literature review. AR is a systemic allergic disease and is generally associated with numerous multi-morbid disorders, including asthma, eczema, food allergies, eosinophilic oesophagitis (EoE), conjunctivitis, chronic middle ear effusions, rhinosinusitis, adenoid hypertrophy, olfaction disorders, obstructive sleep apnea, disordered sleep and consequent behavioural and educational effects. This report provides up-to-date usable information to: (1) improve the knowledge and skills of allergists, so as to ultimately improve the overall quality of patient care; (2) to increase interest in this area; and (3) to present a unique contribution to the field of upper inflammatory disease.

Allergic rhinitis and allergy are risk factors for otitis media with effusion: A meta-analysis

OBJECTIVE/HYPOTHESIS

We systematically reviewed the associations between allergic rhinitis or allergy and otitis media with effusion, by reference to published data.

STUDY DESIGN

A meta-analysis of case-controlled studies.

DATA SOURCE

Five databases (Pubmed, Highwire, Medline, Wanfang, and China National Knowledge Infrastructure) were searched for relevant studies in the English language published prior to November 12, 2015.

STUDIES CHOSEN

Studies with clearly defined experimental and control groups, in which the experimental groups had otitis media with effusion together with allergic rhinitis or allergy, were selected.

METHODS

We performed a meta-analysis on data from the identified cross-sectional and case-controlled studies using fixed- or random-effects models (depending on heterogeneity). We used Reviewer Manager 5.3 software to this end.

RESULTS

Seven studies met the inclusion criteria. The prevalence of allergic rhinitis in patients with otitis media with effusion and the control groups differed significantly in three studies (P<0.00001), as did the prevalence of allergy (in six studies; P=0.003).

CONCLUSION

Allergic rhinitis and allergy appear to be risk factors for otitis media with effusion.

The Role of Food Allergy in Otitis Media with Effusion

OBJECTIVE: To detect the relationship between food allergy and otitis media with effusion (OME).

MATERIALS AND METHODS: This study was performed on three different groups. The patient group was made up of 56 patients with OME (group I). There were 28 patients with food allergy in group II and these patients were investigated for OME. The control group consisted of 28 patients without any complaints concerning food allergy or OME (group III).

RESULTS: Food allergy was detected in 25 patients with OME (44.6%) (group I). In patients with food allergy (group II), OME was detected in 7 patients (25%). In the control group (group III) food allergy was diagnosed in 5 patients (18%) and OME in 1 patient (3%). The incidence of food allergy in OME group was statistically significant when compared to the normal group ( P > 0.05).

CONCLUSIONS: This study demonstrates that food allergy may play a role in the etiopathogenesis of OME. (Otolaryngol Head Neck Surg 2004;130: 747-50.)

Clinical Practice Guideline: Otitis Media with Effusion (Update)

OBJECTIVE

This update of a 2004 guideline codeveloped by the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME), defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection. Changes from the prior guideline include consumer advocates added to the update group, evidence from 4 new clinical practice guidelines, 20 new systematic reviews, and 49 randomized control trials, enhanced emphasis on patient education and shared decision making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of OME.

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing OME and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy, identify children who are most susceptible to developmental sequelae from OME, and educate clinicians and patients regarding the favorable natural history of most OME and the clinical benefits for medical therapy (eg, steroids, antihistamines, decongestants). Additional goals relate to OME surveillance, hearing and language evaluation, and management of OME detected by newborn screening. The target patient for the guideline is a child aged 2 months through 12 years with OME, with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for all clinicians who are likely to diagnose and manage children with OME, and it applies to any setting in which OME would be identified, monitored, or managed. This guideline, however, does not apply to patients <2 months or >12 years old.

ACTION STATEMENTS

The update group made strong recommendations that clinicians (1) should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child; (2) should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both; (3) should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy; (4) should 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 3 months from the date of diagnosis (if onset is unknown); (5) should recommend against using intranasal or systemic steroids for treating OME; (6) should recommend against using systemic antibiotics for treating OME; and (7) should recommend against using antihistamines, decongestants, or both for treating OME.The update group made recommendations that clinicians (1) should document in the medical record counseling of parents of infants with OME who fail a newborn screening regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss; (2) should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors; (3) should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age (if diagnosed as being at risk prior to this time); (4) should not routinely screen children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort; (5) should educate children with OME and their families regarding the natural history of OME, need for follow-up, and the possible sequelae; (6) should obtain an age-appropriate hearing test if OME persists for 3 months or longer OR for OME of any duration in an at-risk child; (7) should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development; (8) should reevaluate, at 3- to 6-month intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; (9) should recommend tympanostomy tubes when surgery is performed for OME in a child <4 years old; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); (10) should recommend tympanostomy tubes, adenoidectomy, or both when surgery is performed for OME in a child ≥4 years old; and (11) should document resolution of OME, improved hearing, or improved quality of life when managing a child with OME.

Risk factors for otitis media effusion in children who have adenoid hypertrophia

OBJECTIVE

Many studies have shown that children with adenoid hypertrophy (AH) are more likely to have chronic otitis media with effusion (COME). However, not every child with AH has COME. In this study, we investigated the socio-demographic risk factors of children who underwent surgery for AH, including a subgroup with COME. Our aim was to identify the factors involved in the development of COME.

METHODS

The study population consisted of 170 pediatric patients (118 males, 52 females) who underwent adenoidectomy between 2005 and 2008. The patients were divided into two groups, those with AH alone and those with AH and COME (AH+COME). Major factors such as age, gender, breast-milk feeding, bottle-feeding, tobacco smoke exposure, familial predisposition, allergies, congenital diseases, and school attendance were compared between the two groups.

RESULTS

AH alone was detected in 102 of the patients, 68% of whom were male, and AH+COME in the remaining 68, of whom 72% were male. The mean age was 6.5 years in the AH group and 5.3 years in the AH+COME group. There were no significant differences between the two groups with respect to breast-feeding, bottle-feeding, familial predisposition, tobacco exposure, and allergies. However, the relationships between COME and male sex, congenital diseases, and school attendance were significant.

CONCLUSIONS

COME is seen in young children with AH. Among the socio-demographic features examined in this study, only male sex, congenital diseases, and school attendance were statistically significant risk factors for COME development.

Does the type of rhinitis influence development of otitis media with effusion in children?

Otitis media with effusion (OME) is characterized by the presence of fluid in the middle ear cavity behind an intact eardrum and is considered a multifactorial condition with Eustachian tube dysfunction as the underlying pathophysiologic condition. One of the most debated causes of OME is allergy, in particular allergic rhinitis. The aim of this paper is to review the role of rhinitis in the development of OME and in particular the role of both allergic (AR) and non-allergic rhinitis (NAR). Most of the recent literature confirms the role of AR in the development of OME, while there are few reports on the role of NAR. In non-allergic children affected by obstructive adenoid hypertrophy, the presence of mast cells in the nasal smear was associated with a high risk of developing a chronic OME.

What does tympanostomy tube placement in children teach us about the association between atopic conditions and otitis media?

Otitis media is the most common infection second only to viral upper respiratory infection in the outpatient setting. Tympanostomy tube insertion (TTI) is the most common ambulatory surgical procedure in the USA. While many risk factors for otitis media have been identified, atopic conditions have been underrecognized as risk factors for recurrent and persistent otitis media. Given that asthma and other atopic conditions are the most common chronic conditions during childhood, it is worth examining the association between atopic conditions and risk of otitis media, which can provide insight into how atopic conditions influence the risk of microbial infections. This paper focuses its discussion on otitis media; however, it is important that the association between atopic conditions and risk of otitis media be interpreted in the context of the association of atopic conditions with increased risks of various microbial infections.

Otitis media with effusion: an effort to understand and clarify the uncertainties

Otitis media with effusion--defined as the accumulation of middle-ear effusion behind an intact tympanic membrane without signs or symptoms of acute infection--is one of the most common causes of hearing loss in children in developed countries, potentially leading to language deficits. Although treatment of chronic or relapsing otitis media with effusion is considered imperative, none of the preventative or nonsurgical management measures currently available have proven effective. Tympanostomy tube placement remains the recommended treatment option for high-risk children or for cases of unresponsive otitis media with effusion. This can be attributed to the uncertainties surrounding its pathogenesis. Multiple factors and several possible pathogenetic models have been proposed to explain the production and persistence of middle-ear effusion; only a few of them are supported by sufficient evidence. In this review, the authors will present current knowledge on the pathogenesis, consequences, diagnosis and management of otitis media with effusion. An effort will be made to clarify those aspects sufficiently supported by evidence-based studies, and to underline those that remain unfounded.

Current and future directions in pediatric allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common pediatric problem that significantly affects sleep, learning, performance, and quality of life. In addition, it is associated with significant comorbidities and complications.

OBJECTIVE

The aim was to provide an update on the epidemiology, comorbidities, pathophysiology, current treatment, and future direction of pediatric AR.

METHODS

Literature reviews in each of these areas were conducted, and the results were incorporated.

RESULTS

The prevalence of AR is increasing in the pediatric population and is associated with significant morbidity, comorbidities, and complications. The mainstay of current treatment strategies includes allergen avoidance, pharmacotherapy, and allergen specific immunotherapy.

CONCLUSIONS

In the future, diagnosis will be improved by microarrayed recombinant allergen testing and therapy will be expanded to include emerging treatments such as sublingual immunotherapy and combination products.

Allergic rhinitis is associated with otitis media with effusion: a birth cohort study

BACKGROUND

Childhood otitis media with effusion is a common disease and a link to allergic diseases has been suggested.

OBJECTIVE

To investigate the association between atopic disease and otitis media with effusion diagnosed according to strict objective case definitions by age 6 years.

METHODS

We evaluated 291 children in the 6th year of life from the Copenhagen Prospective Studies on Asthma in Childhood (COPSAC) 2000 birth cohort. Otitis media with effusion was diagnosed based on tympanometric and objective evaluation. Asthma, eczema, allergic- and non-allergic rhinitis was diagnosed prospectively by pre-defined algorithms. Nasal mucosal swelling was assessed using acoustic rhinometry and nasal eosinophilia from scrapings. Analyses were performed using logistic regression and adjusted for dog, cat and smoking exposure, paternal atopy, household income, older siblings, gender and number of acute otitis media episodes.

RESULTS

Otitis media with effusion was diagnosed in 39% of the cohort and was associated with allergic rhinitis (aOR = 3.36, CI = 1.26-8.96, P = 0.02), but not with nasal mucosal swelling, nasal oeosinophilia, non-allergic rhinitis, asthma or eczema.

CONCLUSION

Otitis media with effusion is closely associated with allergic rhinitis presumably caused by allergic inflammation, but not mechanical nasal mucosal swelling. These findings warrant an increased awareness of otitis media with effusion in children with allergic rhinitis.

Otitis media in infancy and the development of asthma and atopic disease

Otitis media is a frequent respiratory infection of early childhood and it is important to fully understand the long-term complications and sequelae. Literature examining otitis media in early childhood and subsequent development of atopic disease is sparse despite there being vast literature on the association between respiratory infections and atopic disease. Current data support the hypothesis that otitis media infections in early life, especially frequent or severe infections, influence the developing immune system, resulting in increased risk for asthma. Recent findings have also reported an association between otitis media and eczema. Atopic children and those with a family history of atopy appear to be at greater risk. Future work should investigate the specific mechanisms involved. It is possible that vaccines and preventive strategies aimed at reducing the burden of otitis media could also reduce the burden of childhood asthma and atopic disease.

Allergic diseases in children with otitis media with effusion

OBJECTIVES

Recent studies have shown that allergic diseases may be associated with the pathogenesis of recurrent otitis media with effusion (OME). We aimed to assess the relationship between OME and allergic diseases and other types of disease in children with OME. We also evaluated the between group differences in the characteristics of middle ear effusion.

MATERIALS AND METHODS

We evaluated 370 patients diagnosed with OME between January 2007 and December 2012 and, as a control group, 100 children with no medical history of OME but who had undergone blood tests and MAST-CLA (multiple allergosorbent test - chemiluminescent assay) were selected.

RESULT

Among the allergic diseases, the incidence of allergic rhinitis alone was significantly higher in children with OME (33.8%) than without OME (16.0%) (p<0.05). The rate of adenoid, but not tonsil, hypertrophy was significantly greater in patients with than without OME also (p<0.05). When we evaluated the characteristics of middle ear effusion (MEE) in patients with OME, we found that 186 had serous, 129 had mucous and 55 had purulent MEE. Of these patients, 75 (40.3%), 36 (27.9%) and 14 (25.5%), respectively, had allergic rhinitis and the rates of allergic rhinitis and asthma were significantly higher in the serous group than in the mucous group (p<0.05).

CONCLUSION

Allergic rhinitis was significantly more frequent among pediatric patients with than without OME, although the rates of other allergic diseases did not differ in these two groups. The likelihoods of allergic rhinitis and asthma were higher in patients with serous than with mucous MEE.

Impact of allergic rhinitis in school going children

Allergic rhinitis (AR) is the most common chronic pediatric disorder. The International Study for Asthma and Allergies in Childhood phase III found that the global average of current rhinoconjunctivitis symptoms in the 13-14 year age-group was 14.6% and the average prevalence of rhinoconjunctivitis symptoms in the 6-7 year age-group was 8.5%. In addition to classical symptoms, AR is associated with a multidimensional impact on the health related quality of life in children. AR affects the quality of sleep in children and frequently leads to day-time fatigue as well as sleepiness. It is also thought to be a risk factor for sleep disordered breathing. AR results in increased school absenteeism and distraction during class hours. These children are often embarrassed in school and have decreased social interaction which significantly hampers the process of learning and school performance. All these aspects upset the family too. Multiple co-morbidities like sinusitis, asthma, conjunctivitis, eczema, eustachian tube dysfunction and otitis media are generally associated with AR. These mostly remain undiagnosed and untreated adding to the morbidity. To compound the problems, medications have bothersome side effects which cause the children to resist therapy. Children customarily do not complain while parents and health care professionals, more often than not, fail to accord the attention that this not so trivial disease deserves. AR, especially in developing countries, continues to remain a neglected disorder.

The link between otitis media with effusion and allergy: a potential role for intranasal corticosteroids

We reviewed the evidence linking otitis media with effusion (OME) and atopy, with the goal of clarifying the possible role of intranasal corticosteroids (INSs) in OME treatment. In August 2009, the MEDLINE database was searched for primary studies on OME epidemiology, pathophysiology, and treatment. Relevant clinical guidelines were obtained. Interpreting OME research is complicated by variable disease definitions, patient populations, methodologies, and outcomes assessments, along with the possibility of spontaneous resolution. However, evidence links OME with atopic conditions including allergic rhinitis; observed prevalence of allergic rhinitis in patients with chronic or recurrent OME ranges from 24% to 89%. Such findings have prompted evaluations of common allergy medications for OME treatment. While short-term use of INSs alone or combined with antibiotics has shown benefit in some studies, more prolonged treatment protocols and long-term clinical outcomes will require critical assessment. Evidence suggesting epidemiologic and pathophysiologic links between allergy and OME has prompted investigation into a potential role for INSs in OME management, with promising initial results. Benefits of considering medical treatment in patients with OME prior to surgery include both the potential reductions in allergic inflammation and the naturally occurring spontaneous resolution of OME in these patients.

Early-life otitis media and incident atopic disease at school age in a birth cohort

BACKGROUND

Otitis media is a common and costly disease that peaks in early childhood. Recent reviews concluded that the relationship between otitis media and atopy is not well understood, and that further research is warranted.

METHODS

Logistic regression was used to analyze data from a German Birth Cohort (n = 1690; born 1997–1999). Parental questionnaires were used to assess children for physician-diagnosed otitis media throughout the first 2 years of life and for incident atopic disease (asthma, allergic rhinitis, and eczema) during the sixth year of life. Odds ratios were adjusted for gender, older siblings, city, parental education, breast-feeding, and daycare. Parallel analyses were completed for the full birth cohort and for a population subset with atopic mothers.

RESULTS

The adjusted odds of asthma were elevated for children with early-life otitis media, but were statistically significant only for those children with at least 3 episodes (adjusted odds ratio: 4.26 [95% confidence interval: 1.34–13.6]). Associations between early-life otitis media and allergic rhinitis were largely inconsistent. There was a positive association between early-life otitis media and late-onset allergic eczema (≥2 episodes: 2.68 [1.35–5.33], ≥3 episodes: 3.84 [1.80–8.18]). Similar results were found for the maternal atopy subgroup but with greater effect estimates.

CONCLUSIONS

Children diagnosed with otitis media during infancy were at greater risk for developing late-onset allergic eczema and asthma during school age, and associations were stronger for frequent otitis. These results indicate that frequent otitis media during infancy may predispose children to atopic disease in later life.

Aspectos diagnósticos da otite média com derrame na faixa etária pediátrica

OBJETIVOS: apresentar e discutir aspectos diagnósticos da otite média com derrame (OMD) na prática clínica da atenção primária à saúde. MÉTODOS: foram pesquisadas as bases de dados Medline, Lilacs e SciELO (1994-2004). Identificados 523 artigos, dos quais 30 foram considerados para o presente trabalho. RESULTADOS: os estudos revelaram disparidade entre as definições, inconsistência no quadro clínico e falta de padronização dos critérios diagnósticos. Isto contribuiu para a inadequação diagnóstica da OMD. As evidências que levaram ao diagnóstico de efusão foram: a) pelo menos duas anormalidades do tímpano relacionadas à coloração, opacificação e mobilidade; e/ou b) membrana timpânica (MT) tipicamente retraída, côncava, e com alteração da coloração; e/ou c) mobilidade reduzida ou ausente na otoscopia pneumática (OP). A OP mostrou ser mais acurada que a otoscopia simples (OS), sendo considerada como método de escolha para o diagnóstico clínico da OMD. Quando houver dúvida na otoscopia pneumática, pode-se indicar a timpanometria, que aumenta a acurácia deste diagnóstico. CONCLUSÕES: na prática clínica, o diagnóstico da OMD deve ser realizado, primariamente pela otoscopia pneumática, em toda criança com suspeita de OMD. Em caso de dúvida deve-se indicar a timpanometria.

The prevalence of atopic symptoms in children with otitis media with effusion

OBJECTIVE

To determine the prevalence of allergic symptoms in children with otitis media with effusion (OME).

STUDY DESIGN

A validated questionnaire from the International Study of Asthma and Allergies in Childhood was used to determine the prevalence of allergic symptoms in children. The questionnaire was completed by the parents of children with OME undergoing ventilation tube insertion, and the results were compared with a large reference group of school children of the same age.

SUBJECTS AND METHODS

Children aged 6 or 7 years old with OME confirmed intraoperatively during ventilation tube insertion between 2001 and 2005 (n=89). The prevalence of allergic symptoms and nasal symptoms in children with OME was compared with an age-matched reference group.

RESULTS

There was no difference in the prevalence of allergic symptoms suggesting rhinoconjunctivitis, asthma, or eczema between the OME and reference group. The prevalence of nasal symptoms, however, was greater in the children with OME than in the reference group 38.2 percent versus 23.5 percent (odds ratio=2.01; 95% confidence interval, 1.30-3.10; P<0.001).

CONCLUSION

The prevalence of allergic symptoms was similar in 6- to 7-year-old children with OME and the reference group, suggesting a limited effect of allergy in the pathogenesis of OME in this age group. Nasal symptoms were more common in the OME group, which may reflect a higher prevalence of adenoidal hyperplasia.

The link between allergic rhinitis and chronic otitis media with effusion in atopic patients

The significant incidence of atopy associated with otitis media with effusion (OME) has suggested a role of allergy in the pathogenesis of OME. Analysis of inflammatory mediators indicates that the mucosa of the middle ear can respond to antigen in the same way as does the mucosa of the lower respiratory tract. Recent characterization of the mucosa and effusion from atopic patients with OME reveals a Th2 cytokine and cellular profiles consistent with an allergic response, supporting the role of allergy in OME. In addition, animal studies demonstrate that inhibiting characteristic allergy cytokines can prevent the production of middle ear effusion. As the understanding of allergy and its role in the inflammation of OME continues to deepen, this will introduce focused treatments of OME in the atopic population.

Increased risk of otitis media with effusion in allergic children presenting with adenoiditis

OBJECTIVE

Otitis media with effusion (OME) is a common disorder in childhood. The aim of the study was to assess the association of atopy and endoscopic features with the presence of OME.

SUBJECTS AND METHODS

This cross-sectional study evaluated 287 children presenting with acute upper-airway infections persistent for at least ten days and tested through nasal endoscopy and skin-prick test.

RESULTS

Fifty-three patients had a diagnosis of OME; out of them, 23 showed acute rhinosinusitis, ten adenoiditis, and 20 both features. OME was diagnosed in 26 atopic children and in 27 nonatopic ones. On a multivariable analysis, allergic rhinitis, endoscopic pattern of adenoiditis, and younger age were all shown to be independently associated with a diagnosis of OME.

CONCLUSIONS

This study suggests that allergic rhinitis and adenoiditis are significant risk factors to OME development and that the risk becomes higher when these two conditions are concomitantly present.

Prevalence of tympanometric alterations in children with chronic sinusitis

OBJECTIVE

Due to its anatomical and functional connections, middle ear disorders frequently occur in sinusitis. Its prevalence, however, is likely to be underestimated. We evaluated the prevalence of middle ear dysfunction, as assessed by tympanometry, in children with chronic sinusitis in a large group of patients with chronic respiratory symptoms, and its possible relationship with respiratory allergy.

METHODS

From a population of 1,810 children with respiratory symptoms referred to our Pediatric Allergy center, subjects with chronic sinusitis diagnosed by clinical criteria were selected. Children underwent testing of middle ear function by tympanometry and of allergy by skin tests with environmental allergens. Patients were divided into three groups according to age.

RESULTS

Two hundred and eighty-eight children (15.9%) had clinical diagnosis of chronic sinusitis according to the established criteria. Twenty-four patients were in group 1, 220 in group 2, and 44 in group 3. Altered middle ear pressure was found in 76.4% of patients, with a significantly higher rate of altered tympanograms in younger children (p<0.001). A positive skin prick test was found in 29.9% of children, with a significantly higher rate of positivity in older children (p=0.01).

CONCLUSIONS

The decrease with age in the rate of tympanometric alterations is likely to be associated to the anatomic development of the upper airways, while the presence of atopy does not seem to play a role in their occurrence.

The links between allergy and otitis media with effusion

PURPOSE OF REVIEW

In this review we will examine evidence indicating that allergic inflammation is present in middle ear effusion. We will also discuss several of the problems relating to the diagnosis of allergy and allergic sensitization, and why anti-allergy treatments have been unsuccessful. This will provide a rationale for future studies in the field linking allergic inflammation with otitis media with effusion.

RECENT FINDINGS

Recent findings in atopic children demonstrated higher levels of eosinophils, T lymphocytes, and interleukin-4+ and interleukin-5+ cells compared with nonatopic patients. T-helper 2 cells and cytokines were found not only in middle ear effusions in atopic children but also in specimens from adenoid tissue. This demonstrates a strong correlation between allergic reaction in the middle ear and the upper airway.

SUMMARY

In summary, as our knowledge of the allergic and nonallergic influences on inflammation broadens, the paradigms of treatment may be altered. The accumulating experimental and clinical data suggest that it may be wiser to screen every child with otitis media with effusion for allergic rhinitis and ultimately to manage those with allergic inflammation differently to nonatopic individuals with otitis media with effusion.

Sinusitis and Eustachian tube dysfunction in children

Because of its anatomic and functional connections, middle ear disorders frequently occur in sinusitis. Its prevalence, however, is likely to be underestimated. We evaluated the prevalence of Eustachian tube dysfunction in children with chronic sinusitis, in a large group of patients with chronic respiratory symptoms and its possible relationship with respiratory allergy. From a population of 1810 children with respiratory symptoms referred to our Pediatric Allergy Center, subjects with chronic sinusitis diagnosed by clinical criteria were selected. The children underwent testing of Eustachian tube function by tympanometry and of allergy by skin tests with common environmental allergens. Patients were divided into three groups according to age: group 1, <3 yr; group 2, between 3 and 6 yr, group 3, older than 6 yr. Overall 402 children (22.2%) had clinical diagnosis of chronic sinusitis according to the established criteria. Thirty-three patients were in group 1, 299 in group 2, and 70 in group 3. Altered middle ear pressure was found in 69.1% of patients, with a significantly higher rate of altered tympanograms in younger children (p=0.001). A positive skin-prick test was found in 29.8% of children, with a significantly higher rate of positivity in older children (p=0.015). The decrease in the rate of Eustachian tube dysfunction with age is likely to be associated with the anatomic development of the upper airways, while the presence of atopy does not seem to play a role in their occurrence.

Acute otitis media in schoolchildren: allergic diseases and skin prick test positivity

CONCLUSIONS

Single and repeated episodes of acute otitis media (AOM) in 10-year-old children were associated with reported allergic disease. Further, skin prick test (SPT)-negative children with reported asthma and allergic rhinoconjunctivitis had increased risk of AOM. We suggest that optimal treatment of allergic symptoms may have an effect on AOM in school children.

OBJECTIVE

The objective of the study was to estimate associations between AOM, allergic diseases and SPT positivity in 10-year-old children.

MATERIALS AND METHODS

Population-based cross-sectional study of 3406 10-year-old children living in Oslo. Main outcome measures were questionnaire-based information on AOM and reported physician-diagnosed allergic diseases with symptoms during the last year. In addition, 2657 children were skin prick tested. Logistic regression analyses were performed to estimate associations and control for potential confounders.

RESULTS

One or more episodes of AOM were present in 13.8% (n=470) of the children; 9.7% (n=331) had single episodes, while 4.1% (n=139) had two or more infections. We found a statistically significant association between AOM and reported allergic diseases, strongest for AOM and asthma with odds ratio 2.7 (95% confidence interval 1.8-4.0) and 2.3 (95% confidence interval 1.3-4.3) for single and two or more episodes of AOM, respectively. The risk for AOM was increased in asthmatic SPT-negative children compared with asthmatic SPT-positive children, the odds ratios were 3.0 (1.7-5.4) and 1.5 (0.8-2.8), respectively. The same tendency was found for allergic rhinoconjunctivitis.

A community based questionnaire study on the association between symptoms suggestive of otitis media with effusion, rhinitis and asthma in primary school children

OBJECTIVES

To evaluate the association between symptoms suggestive of otitis media with effusion (OME), rhinitis and asthma in an unselected population of primary school children and investigate whether our previous observation of such an association in a secondary care setting was valid in the community.

METHODOLOGY

A specifically designed questionnaire was administered to 332 new entrant primary school children across 11 state and independent primary schools in the East Berkshire district between March and June 1996. It had six sections, to ascertain symptoms suggestive of OME, rhinitis, asthma, other atopic features, treatment for any of these, and a possible family history of atopy. Within the first three sections, each question was scored and weighted depending on the importance of each in establishing the possible diagnoses, with three scoring bands: '0' indicating the absence; '1-5' the possibility and '> or =6' a strong likelihood that the above conditions were present. The outcome measures were the number of children with or without symptoms suggestive of OME, rhinitis, asthma, and the correlation of these symptom scores with each other and OME with eczema, other atopic manifestations, family history of atopy and educational system.

RESULTS

Thirty two point eight percent, thirty six point six percent and twenty four percent had symptoms suggestive of OME, rhinitis and asthma, respectively with scores of either 1-5 or > or =6. There was a highly significant correlation between otological (OME) and nasal scores (p=0.00000), particularly obstructive nasal symptoms (p=0.00000) and > or =6 upper respiratory tract infections/year (p=0.00000); otological and chest scores suggestive of asthma (p=0.00001), and a family history of asthma (p=0.00178). No association was found between scores for OME and eczema, urticaria, food or drug allergies. No differences were noted between the sexes or educational systems.

CONCLUSION

The highly significant association between the symptom scores suggestive of OME and rhinitis in this unselected population, indicates the importance of enquiring about nasal symptoms in children with chronic OME, as appropriate treatment of rhinitis may improve the child's quality of life, reduce health care utilisation and possibly reduce the need for OME surgery.

The role of allergic rhinitis in the development of otitis media with effusion: effect on eustachian tube function

PURPOSE

The pathogenesis of otitis media with effusion (OME) is considered multifactorial, with viral upper respiratory tract infection and eustachian tube dysfunction. Allergy may be related to the pathogenesis of OME or to another etiological factor. We investigated the role of allergic rhinitis (AR) in children with OME and evaluated eustachian tube function in patients with AR.

MATERIALS AND METHODS

We prospectively analyzed the prevalence of AR, serum eosinophil count, and serum total IgE concentrations in 123 children with OME and in 141 controls. IgE concentration in middle ear effusion was compared in children with OME with and without AR, and eustachian tube function after a nasal provocation test was compared between patients with AR and controls.

RESULTS

The prevalence of AR in children with OME (28.4%) and control subjects (24.1%) did not differ significantly. These 2 groups also showed no differences in total eosinophil count and serum and middle ear effusion IgE concentration. Abnormalities in eustachian tube function were the same in patients with AR and controls.

CONCLUSIONS

Allergic rhinitis may not be related to the development of OME in children.

Glucocorticosteroids in allergic inflammation: clinical benefits in otitis media with effusion

Allergy and otitis media with effusion are often considered as comorbidities. Evidence points to a role for allergy in the pathogenesis of otitis media with effusion in reports of increased prevalence of allergy in patients with otitis media with effusion and presence of late-phase allergic-response inflammatory mediators and cytokines in the middle-ear effusion of allergic subjects. However, the exact mechanism remains unknown. Many speculations have been made, but well-controlled studies to prove the efficacy of anti-allergic medication in the treatment of otitis media with effusion are lacking. Therefore, we do not recommend the use of glucocorticosteroids in allergic patients with otitis media with effusion.

Respiratory illnesses in early life and asthma and atopy in childhood

BACKGROUND

The relation between respiratory illnesses in early life and the development of asthma and atopy in childhood is incompletely understood.

OBJECTIVE

We sought to examine the relationship between respiratory illnesses in early life and atopic diseases at school age.

METHODS

We performed a prospective birth cohort study of the relationship between respiratory illnesses in the first year of life and asthma, atopy (sensitization to >or=1 allergen), and allergic rhinitis at school age in 440 children with a parental history of atopy. Logistic regression was used to examine the relationship between respiratory illnesses and asthma, atopy, and allergic rhinitis. The relationship between respiratory illnesses in early life and repeated measures of wheezing between the ages of 1 and 7 years was investigated by using a proportional hazards models.

RESULTS

Physician-diagnosed croup (adjusted odds ratio [OR], 0.30; 95% CI, 0.12-0.72) and having 2 or more physician-diagnosed ear infections (adjusted OR, 0.58; 95% CI, 0.35-0.98) in the first year of life were inversely associated with atopy at school age. Physician-diagnosed bronchiolitis before age 1 year was significantly associated with asthma at age 7 years (adjusted OR, 2.77; 95% CI, 1.23-6.22). Recurrent nasal catarrh (>or=3 episodes of a runny nose) in the first year of life was associated with allergic rhinitis at age 7 years (adjusted OR, 2.99; 95% CI, 1.03-8.67).

CONCLUSION

The relationship between early-life respiratory illnesses and asthma and atopy is complex and likely dependent on the type of infection and immune response it initiates.

CLINICAL IMPLICATIONS

Certain respiratory illnesses in early life modify the risk of atopy and asthma at school age.

IgE sensitization, respiratory allergy symptoms, and heritability independently increase the risk of otitis media with effusion

BACKGROUND AND AIMS

Epidemiological evidence examining the role of atopy and/or allergy in the pathogenesis of otitis media with effusion (OME) is inconclusive. The aim of this study was to assess any increased risk for OME attributable to allergy-related factors, in a well-characterized population using a case-control design and multivariate analysis.

SUBJECTS AND METHODS

Eighty-eight 1-7-year-old children with OME, diagnosed by clinical and tympanometric evaluation and 80 matched controls were enrolled. A standardized questionnaire was completed, in order to assess factors related to OME and allergy-related symptoms and diagnoses using strict clinical definitions. Specific IgE was measured by skin-prick tests and/or CAP-FEIA.

RESULTS

The patient and control groups were well matched. Factors conferring increased risk for OME in the univariate analysis included IgE sensitization, dyspnea, wheezing, asthma, paroxysmal sneezing, rhinitis, eczema, 'any allergic disease,' family history of otitis media, and family history of allergy. After multivariate analysis IgE sensitization, wheezing, nasal obstruction, family history of otitis, and child-care attendance remained as independent risk factors for development of OME.

CONCLUSION

IgE sensitization and respiratory allergy symptoms are independent risk factors for the development of OME, suggesting that both immunological and mechanical pathways may contribute to the development of the disease. Otitis heritability provides additional risk, as well as frequent exposure to viral upper respiratory tract infections in children attending daycare. Treatment and/or prevention of OME using anti-allergic medications should be further examined.

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.

Glucocorticosteroids in allergic inflammation: clinical benefits in allergic rhinitis, rhinosinusitis, and otitis media

Allergic rhinitis, rhinosinusitis, and otitis media are among the most common health problems encountered in general practice. Although frequently trivialized, they affect the quality of life, represent a significant socioeconomic burden, and are associated with some serious complications. In addition, allergic rhinitis, rhinosinusitis, and otitis media are often considered as comorbidities. These disorders involve an inflammatory process of the respiratory mucosa of the nose, paranasal sinuses, or middle ear. Because of their well-known anti-inflammatory effects, the role of glucocorticosteroids in the management of these three disorders has been questioned, evaluated, and, in some cases, established.

Allergic Rhinitis: Broader Disease Effects and Implications for Management

Allergic rhinitis is a burdensome disease for a significant part of the population in both adults and children. Poorly controlled allergic rhinitis can trigger exacerbations of asthma, sinusitis, and otitis media, diseases with which it shares common pathophysiologic elements. Consequently, early diagnosis and treatment should be a priority for patients and physicians, not only to control the symptoms of allergic rhinitis but also to improve the management of associated diseases. Several pharmacologic therapies can be considered in an armamentarium that includes antihistamines (intranasal and systemic), intranasal cromolyn, intranasal anticholinergic agents, intranasal steroids, systemic steroids, immunotherapy, and, most recently, leukotriene receptor antagonists. Often, combinations of these treatments are used to maximize control of refractory symptoms.

Demonstration of RANTES and eosinophilic cataionic protein in otitis media with effusion with allergy

Regulated upon activation, normal T cell-expressed and -secreted (RANTES) is a chemokine which is an effective eosinophil and memory T cell chemoattractant and activator, and eosinophil is an important effector cell in allergic disease. It may contribute to the pathogenesis of otitis media with effusion (OME). Eosinophil cataionic protein (ECP), one of the major components of basic granules of eosinophils which is identified in middle ear effusion (MEE). We measured RANTES and ECP in MEEs of OME to determine whether RANTES is increased in the MEEs of OME with allergy. We also evaluated the correlation between RANTES and ECP to determine the role of RANTES as an eosinophil activator in the pathogenesis in OME with allergy. Both RANTES and ECP in MEE of OME with allergy were significantly higher than controls. There was a significant correlation between the contents of RANTES and ECP. Our results suggest the allergic role of chemokine in the pathogenesis of OME.

Relationships between atopy and bacterial infections

Atopy in its most common forms (asthma, allergic rhinitis, and atopic dermatitis) has a significant impact on society in terms of health care costs and quality of life. Aside from having significant morbidity from these diseases, patients with atopy have also been noted to have a high incidence of comorbidities, including bacterial infections such as otitis media and sinusitis. In this paper, current evidence is reviewed that supports the close associations among allergic rhinitis and the two commonly diagnosed bacterial diseases, otitis media and sinusitis.

[Serous otitis media and allergy in our health district]

We studied the role of allergic diseases in patients with otitis media with effusion (OME).

MATERIAL AND METHODS

The 40 patients diagnosed with OME in the Otorhinolaryngology Service in 2001 were referred to the Allergy Unit for evaluation. The patients were assessed through anamnesis, prick test and specific IgE determination for the allergens in our area.

RESULTS

In 72 % of the patiens allergologic study was negative. One patient had perennial rhinitis with sensitization to house dust mites and another had seasonal rhinitis with sensitization to Gramineae pollen. Five patients showed high total IgE. Two patients had positive skin prick test and specific IgE to Gramineae pollen but were asymptomatic and a further two patients had negative anamnesis and specific IgE to Gramineae and olive pollen, respectively.

CONCLUSION

Allergic disease does not cause OME except in some patients with allergic rhinitis.

T(H)2 cytokine expression in atopic children with otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) is more common in atopic children. Few studies have looked for the presence of inflammatory mediators in the middle-ear effusions of this population.

OBJECTIVE

We hypothesize that atopic children with OME have a different inflammatory cell and cytokine profile than nonatopic patients with the disease.

METHODS

Twenty-six patients with OME undergoing myringotomy and ventilation tube placement were recruited at the McGill University Hospital Center. The atopic status was determined for each patient by using standard skin testing. By means of immunocytochemistry, fluid specimens were assessed for T lymphocytes (CD3), eosinophils (major basic protein), neutrophils (elastase), mast cells (tryptase), and basophils (BB1). By using in situ hybridization, the expression of IL-4, IL-5, and IFN-gamma was assessed.

RESULTS

There is a higher percentage of eosinophils and T lymphocytes in atopic patients with OME (n = 8) compared with that seen in nonatopic patients (n = 18, P <.01). There is a higher percentage of neutrophils in nonatopic patients with OME compared with that seen in atopic patients (P <.01). In examining cytokine profiles, there is a higher percentage of cells expressing IL-4 and IL-5 in atopic patients with OME compared with that seen in nonatopic patients (P <.01).

CONCLUSION

The predominance of eosinophils, T lymphocytes, and T(H)2 mediators in the middle-ear effusions of atopic children provides evidence that allergy might play a role in the pathogenesis of OME.

Common respiratory infections early in life may reduce the risk of atopic dermatitis

Infections that occur early in life may protect against atopic disease later in life. To investigate the relationship between common acute respiratory infections and atopic dermatitis in early childhood, we closely observed a cohort of 329 children from the ages of 2 to 24 months. We assessed the effect of proven viral infections and acute otitis media on the occurrence of atopic dermatitis. If the child had his or her first respiratory infection before the age of 6 months, the child's remaining risk of developing atopic dermatitis was reduced by 49% (95% confidence interval, -24% to 79%). The individual risk of developing atopic dermatitis was similarly reduced after infection experienced at >/=6 months of age, but the remaining risk was low, because most cases of atopic dermatitis had manifested by this time. Our results are consistent with the hypothesis that early infections may reduce the risk of atopic disease.

The link between allergic rhinitis and otitis media

Past studies implicated allergy in the pathogenesis of otitis media. However, definitive proof of the assertion is lacking. Epidemiologic studies, including one recently published by Rylander and Megevand, consistently identify allergy as a risk factor for otitis media. Also, higher than expected frequencies of allergy are reported for patients with otitis media, but it is unclear if this is an epiphenomenon associated with referral bias. This possibility is exemplified by the results of two reviewed papers where Velepic and colleagues reported a 25% prevalence of allergy in otitis media patients while Alles and colleagues reported a prevalence of 89%. Other studies documented biochemical components of allergic inflammation in the effusions recovered from children with otitis media, and Hurst and colleagues published a recent paper continuing on that theme. However, it is not known if a local allergic reaction is required for the production of these components and if they are produced exclusive of other inflammatory products. Three published studies explored mechanisms by which allergy could cause otitis media. Tikkanen and colleagues reexamined at age 10 a group of 56 subjects with previously diagnosed milk allergy and showed that despite decreased reactivity to milk protein a high prevalence of otitis media was retained. This suggests that it is the allergic condition, not the specific allergy to milk that increases otitis media risk. Downs and colleagues exposed the middle ears of rats to histamine and provoked changes in the pressure regulating and clearance functions of the Eustachian tube. Those changes could prolong an otitis media episode, but middle ear histamine is not limited to the allergic condition. Gentile and colleagues challenged the nose of allergic and nonallergic subjects with histamine followed by interleukin-6 or placebo and measured nasal, pulmonary, Eustachian tube and middle ear functions. Interleukin-6 did not change the Eustachian tube or middle ear functions but did cause increased secretions in allergic patients.

The prevalence of atopic disorders in children with chronic otitis media with effusion

We studied 209 children, referred to a multi-disciplinary 'Glue ear/Allergy' clinic at our hospital with a history of chronic or recurrent otitis media with effusion (OME), in order to determine the prevalence of atopic disease in this population. Referrals were made either from within the hospital by Ear, Nose and Throat (ENT) Surgeons and Audiological Physicians (internal), or by General Practitioners (external). Assessment of atopic status was based on medical history, physical examination, nasal smears and skin-prick testing (SPT) in all children; and on blood eosinophil counts and total immunoglobulin E (IgE) levels in a randomly selected subset. The main outcome measures were number of children with rhinitis, asthma, eczema, positive SPT, raised IgE level (> 100 IU/l), and nasal and blood eosinophilia. We found allergic rhinitis in 89%, asthma in 36%, and eczema in 24%. SPTs were positive to one or more of eight common inhalant aeroallergens in 57% of children. Blood tests in the selected subset revealed eosinophilia in 40% and a raised serum IgE in 28%. The worldwide prevalence of allergic rhinitis in children has been estimated to be 20%. The 89% prevalence found in this study is very high and there are a number of reasons which suggest that there may be a causal relationship. Whole-population studies will be required to confirm these findings, which could have important therapeutic implications for OME.

The aetiology of otitis media with effusion: a review

Otitis media with effusion (OME) is the most common cause of deafness in children in the developed world. In this article we aim to present an overview of current research developments on the aetiology of OME and the resulting implications for treatment. In the model we describe, the primary event is inflammation of the middle ear mucosa, usually due to the presence of bacteria. This leads to the release of inflammatory mediators, which cause secretion of a mucin-rich effusion by up-regulating mucin genes. Prolonged stimulation of the inflammatory response and poor mucociliary clearance lead to persistence of the middle ear fluid, giving rise to the clinical presentation of OME. We describe OME in the following sequence: the initial production of the effusion, the composition of the effusion produced, and factors impairing clearance of the effusion.