Acute otitis media in children. A medical social study from general practice

Sleep in Parkinson's disease

Sleep disturbances are common in Parkinson's disease and comprise the entire spectrum of sleep disorders. On the one hand regulation of sleep and wakefulness is affected in Parkinson's disease, leading to the development of disorders, such as insomnia and daytime sleepiness. While on the other hand control of motor activity during sleep is impaired, with subsequent manifestation of parasomnias (mainly REM sleep behavior disorders, but also, albeit more rarely, sleepwalking, and overlap parasomnia). Restless legs syndrome has been reported to be frequent in patients with Parkinson's disease, although there is no consensus on whether it is more frequent in Parkinson's disease than in the general population. The same is true for sleep-related breathing disorders. Regarding the diagnosis of sleep disorders in patients with Parkinson's disease, one of the main challenges is correctly identifying excessive daytime sleepiness as there are many potential confounding factors, for example it is necessary to distinguish sleep-related breathing disorders from medication effects, and to distinguish restless legs syndrome from the concomitant presence of potential mimics specific to Parkinson's disease, such as akathisia, nocturnal leg cramps, nocturnal hypokinesia, early morning dystonia, etc. The correct diagnosis of REM sleep behavior disorder is also not always easy, and video-polysomnography should be performed in order to exclude mimic-like movements at the end of sleep apneas or violent periodic leg movements of sleep. These aspects and specific considerations about diagnosis and treatment of sleep disorders in patients with Parkinson's disease will be reviewed.

Epidemiology of acute suppurative otitis media

The incidence of acute otitis media in childhood reported in the literature varies considerably, particularly for children in the first year of life. In three cohorts of otherwise healthy children, followed from birth to the age of 9 years, the authors have attempted to determine more accurately the incidence and prevalence of acute otitis media in childhood. The incidence is highest in the first year of life, at about 22 per cent, after which time it gradually decreases from 15 per cent in the second and 10 per cent in the third and fourth years of life to 2 per cent in the eighth year. By the end of the third year of life, 50 per cent of all children have had at least one episode of acute otitis media; by the age of 9 years, 75 per cent have had an episode. The prevalence is almost constant at about 25 per cent during the first five years of life, dropping to 7 per cent during the eighth and ninth years of life. For the entire series, no sexual differences could be demonstrated with regard to incidence and prevalence of acute otitis media. By far, the majority of attacks (80 per cent) during the first two years were bilateral, whereas after the sixth year of life, 86 per cent of the children experienced unilateral disease.

Ear disease in a group general practice. A review of world communities

This five-year survey of ear disease in a London population of 10,000 is considered to be a valid description of the incidence of ear disease presenting in a general practice community, since all patients were examined and diagnosed either by the author or by the district hospital Ear, Nose and Throat Department. The results agreed generally with the findings of the National Morbidity Surveys, but a more comprehensive range of ear disease is described. There is general agreement, between this and other surveys in the United Kingdom and the United States, that the most common ear diseases presenting in general practice populations are acute suppurative otitis media and impacted wax, followed by presbyacusis, secretory otitis media, chronic suppurative otitis media, vertigo and traumatic deafness due to noise, blast or head injury. However, the incidence of these and other diseases differs greatly in many countries throughout the world and some aetiological factors are suggested. The evidence in this paper points to the continuing need for the investigation of the incidence and aetiology of some ear diseases in many parts of the world.

Middle ear disease in samples from the general population. Prevalence and incidence of otitis media and its sequelae. The study of men born in 1913-23

A study of 1371 men 20, 30, 50 and 60 years old and living in Göteborg was performed to obtain information on the incidence and prevalence of otitis media in a non-selected population. In addition to anamnestical data, a thorough examination of the ENT-status was made by one observer. There was no indication that otitis media has become a more rare disease since the early part of the century. However, the course of the disease does seem to be shorter and milder in more recent decades. This conclusion is supported by a substantially higher frequency of grave pathologic changes in the tympanic membranes in the two oldest cohorts compared with the two younger. A further indication is that mastoidectomies have become a rare type of operation during recent decades.

Clinical features of acute otitis media among children

The anamnestic and clinical data on all of the 2254 attacks of acute otitis media (AOM) registered among 14200 children (less than 16 years) at risk during a one-year period were analysed. On the basis of otoscopic findings AOM was classified into three grades: 25.0% of the cases were considered mild, 39.0% moderate and 36.0% severe. Spontaneous perforation was found in 4.6% of the cases. 76.2% of the attacks were preceded by a respiratory infection, but only 1.4% were sequelae of some epidemic childhood disease. Earache was present in 73.5% of the attacks; in 81.0% of these it had lasted less than 24 hours. 39.4% of all the attacks were bilateral; during the first 2 years of life the proportion was 53.7%, decreasing thereafter with increasing age, and being only 18.7% among those 10-15 years old. In unilateral attacks the right ear was affected slightly, but not significantly, more often.

Immunofluorescent study on middle ear mucosa

To clarify the developmental course of the immunological defense system in the middle ear, immunoglobulin-forming cells of different classes and secretory proteins, such as secretory component (SC) and lactoferrin (Lf), were investigated in the middle ear mucosa of 20 developing and 5 normal adult guinea pigs by use of direct immunofluorescence technique. Changes in the middle ear mucosa were also observed after antigenic challenges directly to the tympanic cavity of 6 developing and 39 adult guinea pigs. IgA- and IgM-forming cells began to appear in the tubal mucosa at the seventh postnatal day, while it was scarcely possible to find IgG1- and IgG2-forming cells in developing guinea pigs. Immunoglobulin-forming cells of all classes increased in the middle ear mucosa after the antigenic stimuli. The injection of antigens to the tympanic cavity of developing animals induced the most striking accumulation of immunoglobulin-forming cells in the middle ear mucosa. Results of this study showed that local synthesis of IgA, as well as other classes, is latent in the middle ear, that the middle ear of immature animals is vulnerable to antigenic stimuli, and that the middle ear of developing animals possesses potential immune responsiveness.

The development of mucosal immunity in guinea pig middle ears

Recent studies have suggested to us that the middle ear is an organ capable of responding immunologically to antigenic substance. However, it is still not known when and how the middle ear starts to provide the immunologic defense system. To clarify this, we investigated immunoglobulin forming cells of different classes and secretory proteins, such as secretory component and lactoferrin, in the mucous membrane of eustachian tube and tympanic bulla of 20 developing and 5 normal adult guinea pigs by the use of a direct immunofluorescence technique. Other organs, such as nose, larynx, trachea, small intestine, spleen and lymph node were also subjected to this investigation. Changes in the middle ear mucosa were also observed after antigenic challenges directly to the tympanic cavity of 6 developing and 39 adult guinea pigs. IgA and IgM forming cells began to appear in the tubal mucosa on 7th postnatal day, wile it was scarcely possible to find IgG1 and IgG2 forming cells in developing guinea pigs. Immunoglobulin forming cells of all classes increased in the middle ear mucosa after the antigenic stimuli. Results of this study showed that local synthesis of IgA, as well as other classes, is latent in the middle ear, that the middle ear of immature animals is vulnerable to antigenic stimuli, and that the middle ear of developing animals possesses potential immune responsiveness.

Otitis media and developmental disability. Epidemiologic considerations

Review of the literature indicates that: a) otitis media is a common disorder with risk being highest in the pre- and early school years, b) no marked differences in sex distribution of incidence exist, c) frequent recurrences are the hallmark of this disease, and d) mild hearing deficit lasting for months is not uncommon. A retrospective study in a defined population is suggested as an initial effort to investigate the proposed associations between developmental disability and hearing loss, developmental disability and history of otitis media, and finally, hearing loss and history of otitis media. Such an approach, however, a) could not determine the absolute risk of developmental disability in children with otitis media, and b) would underestimate the frequency of otitis media, since occult otitis media would not be thus identified. The determination of an accurate incidence of otitis media and of the absolute risk of developmental disability in children with otitis media calls for a prospective study. Such an investigation is likely to be justified only as a part of a collaborative study designed to measure multiple outcomes from a limited number of antecedents.