Incidence of acute otitis media

Comparing telehealth with office-based visits for common pediatric otolaryngology complaints

OBJECTIVE

The objective of this study was to evaluate the feasibility of telehealth visits and compare office-based visits for pediatric patients undergoing evaluation of recurrent acute otitis media or sleep-disordered breathing.

METHODS

A retrospective cohort study compared telehealth patients with matched controls seen in the office. The feasibility of a thorough patient evaluation in a single telehealth visit without a follow-up office visit was assessed. Both groups were also compared for completeness of physical exam, management, follow-up recommendations, and correlation of physical exam findings with intraoperative findings.

RESULTS

100 children [mean age (SD) = 20.7 (15.6) months] with a chief complaint of recurrent acute otitis media and 128 children [5.4 (3.2) years] with a chief complaint of sleep-disordered breathing were evaluated. Recommendations for surgery, additional studies, or routine follow-up were similar between telehealth and office-based groups. Physical exam feasibility was significantly different for the nasal cavity, oropharynx, and middle ear (P < .001). Patients who underwent office-based consultation were much more likely to have findings of middle ear fluid at the time of tympanostomy tube placement (79.3% vs 39.3%, P = .002). There was no significant difference between preoperative and intraoperative tonsil size discrepancies (P = .749).

CONCLUSION

Telehealth can be used successfully for the evaluation of pediatric patients with sleep-disordered breathing; however, reliance on history alone may result in unnecessary tympanostomy tube placement in patients with recurrent acute otitis media. Physical examination of the oropharynx, nasal cavity, and middle ear via telehealth presents a unique challenge in pediatric otolaryngology.

Facial palsy associated with acute otitis media

OBJECTIVE: Facial palsy secondary to acute otitis media is rarely encountered today. The aim of the present study was to review the characteristics of the disease and propose the proper management.

STUDY DESIGN: File review.

SETTING: University-affiliated tertiary referral center.

MAIN OUTCOME MEASURES: Disease course, management and outcome were recorded.

RESULTS: Sixty-five children with facial palsy were identified, of whom 13 (20%) had acute otitis media. The otitis media preceded the facial palsy in all cases by 1 to 21 days (average 5 days). House-Brackmann grade ranged from 2 to 5 (average 3.5). The recovery period was varied and unpredictable, ranging in duration from 1 to 180 days (average 68 days). Treatment was conservative, except for insertion of a ventilation tube in 2 cases.

CONCLUSIONS: Considering that all the patients recovered, conservative treatment, including myringotomy and intravenous antibiotics, may be the correct approach to facial palsy associated with acute otitis media.

Otitis media in Indigenous Australian children: review of epidemiology and risk factors

Background:

Otitis media represents a major health concern in Australian Indigenous children (‘Indigenous children’), which has persisted, despite public health measures, for over 30 years.

Methods:

Global searches were performed to retrieve peer-reviewed and ‘grey’ literature investigating the epidemiology of and risk factors for otitis media in Indigenous children, published between 1985 and 2012.

Results:

In Indigenous children, the prevalence of otitis media subtypes is 7.1–12.8 per cent for acute otitis media, 10.5–30.3 per cent for active chronic otitis media and 31–50 per cent for tympanic membrane perforation. The initial onset of otitis media in Indigenous children occurs earlier and persists for longer after the first year of life, compared with non-Indigenous children. Indigenous children are colonised by otopathogens more frequently, at younger ages and with a higher bacterial load. Poor community and domestic infrastructure, overcrowding and exposure to tobacco smoke increase the risk of otitis media in Indigenous children; however, the availability of swimming pools plays no role in the prevention or management of otitis media.

Conclusion:

Despite awareness of the epidemiological burden of otitis media and its risk factors in Indigenous children, studies undertaken since 1985 demonstrate that otitis media remains a significant public health concern in this population.

Antimicrobial susceptibility pattern of clinical isolates from cases of ear infection using amoxicillin and cefepime

The aim of the present study was to determine the sensitivity pattern of clinical isolates of otitis media. During the last few decades, the occurrence of otitis media seems to have been rising probably because of prevalence of multidrug-resistant Pseudomonas aeruginosa and β-lactamase producing Staphylococcus aureus in the pathogenesis of otitis media. Pseudomonas aeruginosa and Staphylococcus aureus were the most common causative microorganisms of ear infection. Keeping in view the importance of these pathogens, the present study had been designed to determine the sensitivity pattern of clinical isolates of otitis media. These isolates were collected from different hospitals and pathological laboratories of Karachi and their sensitivity against cefepime and amoxicillin were determined by using disk diffusion method. The results have shown that Pseudomonas aeruginosa was the most common causative microorganism of ear infection. Cefepime, a fourth generation cephalosporin appeared to be an effective antibiotic against Pseudomonas aeruginosa and Staphylococcus aureus.

The efficacy of live attenuated influenza vaccine against influenza-associated acute otitis media in children

BACKGROUND

Acute otitis media (AOM) is a frequent complication of influenza in young children. Influenza vaccination is known to protect against AOM by preventing influenza illness. We sought to determine the efficacy of the live attenuated influenza vaccine (LAIV) against influenza-associated AOM compared with placebo and trivalent inactivated influenza vaccine (TIV). LAIV is approved for eligible children aged ≥ 2 years in the United States and in several other countries.

METHODS

AOM incidence data from 6 randomized, double-blind, placebo-controlled trials and 2 randomized, double-blind, TIV-controlled trials in children 6 to 83 months of age were pooled and analyzed.

RESULTS

A total of 290 cases of AOM were identified in 24,046 study subjects. LAIV efficacy against influenza-associated AOM was 85.0% (95% confidence interval [CI], 78.3%-89.8%) compared with placebo and 54.0% (95% CI, 27.0%-71.7%) compared with TIV. Efficacy trended higher in those ≥ 24 months of age compared with those aged 6 to 23 months. In placebo-controlled trials, among children who acquired influenza despite vaccination, AOM was diagnosed in 10.3% of LAIV recipients and 16.8% of placebo recipients, representing a 38.2% (95% CI, 11.0%-58.2%) relative reduction in the development of AOM. In TIV-controlled studies, among subjects with breakthrough influenza illness, the proportions of LAIV and TIV recipients who developed AOM were similar.

CONCLUSIONS

Children receiving LAIV had a high level of protection against influenza-associated AOM when compared with placebo or TIV. This was most evident in children older than 2 years, for whom LAIV is indicated. LAIV recipients who contracted breakthrough influenza illness despite vaccination developed AOM at a significantly lower rate than did unvaccinated children who developed influenza.

Incidence and recurrence of acute otitis media in Taiwan's pediatric population

OBJECTIVE

To report the incidence and recurrence of acute otitis media (AOM) in Taiwan's pediatric population.

METHODS

Information from children (aged <= 12 years) with a diagnosis of AOM was retrieved from the 2006 National Healthcare Insurance claims database. We calculated the cumulative incidence rate and the incidence density rate of recurrent AOM within one year after the initial diagnosis in 2006. We used a multivariate logistic regression model to assess the predictors for recurrence of AOM.

RESULTS

The annual incidence rate of AOM was estimated to be 64.5 cases per 1,000 children. The overall one-year cumulative incidence rate of recurrence was 33.1%, and the incidence density rate was 33.5 cases per 100 person-years, with the highest figure (41.2 cases per 100 person-years) noted for children aged 0-2 years. Recurrence was significantly associated with age, gender, place of treatment, and physician specialty.

CONCLUSION

AOM remains a major threat to children's health in Taiwan. Male children and very young children require more aggressive preventive strategies to reduce the risk of recurrence.

Facial palsy in children: emergency department management and outcome

OBJECTIVE

To describe the characteristics of children who present to an emergency department (ED) with facial palsy and determine the association of outcome with etiology, degree of initial paralysis, and ED management.

METHODS

This was a retrospective cohort study of children who presented to an ED with facial nerve paralysis (FNP).

RESULTS

There were 85 patients with a mean age of 8.0 (SD, 6.1) years; 60% (n = 51) of the patients were male, and 65.9% (n = 56) were admitted to the hospital. Bell palsy (50.6%) was the most common etiology followed by infectious (22.4%), traumatic (16.5%), congenital (7.1%), and neoplastic etiologies (3.5%). Patients with Bell palsy had shorter recovery times (P = 0.049), and traumatic cases required a longer time for recovery (P = 0.016). Acute otitis media (AOM)-related pediatric FNP had shorter recovery times than non-AOM-related cases (P = 0.005) in infectious group. Patients given steroid therapy did not have a shorter recovery time (P = 0.237) or a better recovery (P = 0.269). There was no difference in recovery rate of pediatric patients with Bell palsy between hospitalization or not (P = 0.952).

CONCLUSION

Bell palsy, infection, and trauma were most common etiologies of pediatric FNP. Recovery times were shorter in pediatric patients with Bell palsy and AOM-related FNP, whereas recovery took longer in traumatic cases. Steroid therapy did not seem beneficial for pediatric FNP. Hospitalization is not indicated for pediatric patients with Bell palsy.

Economic evaluation of pneumococcal conjugate vaccination in Finland

The aim of this study was to evaluate cost-effectiveness of pneumococcal conjugate vaccine (PCV7) in children <5 y of age. A Markov simulation model was used to compare the cost-effectiveness of 4 doses (assumed 50.5 euros per dose) of PCV7 with no intervention. Only direct effects of the vaccine were taken into account. In Finland, vaccination of a birth cohort of 57,500 healthy infants would potentially prevent annually 60 cases of invasive PD, 1,400 cases of pneumococcal pneumonia, 15,000 episodes of acute otitis media, 3,000 otological surgery procedures and 0.9 deaths in children aged <5 y. Investing 12.0 million euros to vaccinate a birth cohort would save annually 6.3 million euros in medical, and 2.0 million euros in productivity and other, costs. Therefore, investing 1 euros in a vaccination programme would return 0.53 euros in medical costs and 0.70 euros in societal costs. In the base case, vaccination would cost society 139,986 euros per life y gained. To achieve cost savings from a health care provider (societal) perspective, without considering herd effects or replacement phenomenon, the price of PCV7 should be 50% (70%) of the price used in the base case.

The incidence, prevalence and burden of OM in unselected children aged 1-8 years followed by weekly otoscopy through the "common cold" season

BACKGROUND

There is a continuing interest in defining the incidence, prevalence and burden of otitis media (OM) in the individual and population for purposes of assigning "risk factors". Often overlooked in past studies are the contributions of cold-like illnesses (CLIs) and sampling interval to those estimates.

OBJECTIVE

Describe the incidence of symptomatic (AOM) and asymptomatic (OME) OM, the prevalence of OM, the contribution of CLI incidence, burden and other OM "risk factors" to the incidence and burden of OM, and the effect of sampling interval on those measures in children.

METHODS

148 children (74 male; 131 white, aged 1.0-8.6 years) were followed from November 1 to April 30 by weekly pneumatic otoscopy to diagnose OM presence/absence and by daily parental diary to assign CLI episodes. Data for previously identified OM "risk factors" were collected on 127. Results were summarized using standard measures of incidence, prevalence and burden, and multiple regression techniques were used to identify OM "risk factors".

RESULTS

The basal OM prevalence was 20% with peaks in December and March and the temporal pattern was correlated with CLI prevalence. The incidence of OME (per 27,232 child-days) was 317, AOM was 74 and CLI was 456. The seasonal pattern of AOM and OME incidences tracked and was correlated with that for CLIs. New OM episodes were usually of short duration (<or=7 days in 40%, <or=4 weeks in 75-90%) and the usual OM burden was low (median=12%). OM and breastfeeding histories and CLI incidence/prevalence were significant predictors of OME and AOM incidence and OM burden. Longer sampling intervals were less efficient in capturing AOM and OME durations and incidences, but not OM burden.

CONCLUSIONS

These results demonstrate a high incidence and prevalence of OM, most OM episodes were of short duration and longer sampling intervals introduced biases into some parameter estimates. There was a significant relationship between OM and CLI incidence, prevalence and burden suggesting that CLI experience should be controlled for in assessing independent "risk factors" for AOM and OME.

Cost-effectiveness of influenza vaccination of healthy children

Influenza vaccination of children 6-23 months of age is recommended in the United States and Canada because of high rates of influenza-associated hospitalisations, but few other countries have adopted similar policies. Most children with influenza are treated in the primary care setting, and the cost-effectiveness of influenza vaccination of children has not been fully established. We used a decision analysis model to assess the cost-effectiveness of influenza vaccination of children 6 months to 13 years of age in Finland. The analyses were based on comprehensive clinical data on virologically confirmed influenza infections, hospital medical records, and national registers. We estimated the impact of influenza on outpatient and hospitalised children and their families, and performed the analyses from the health care provider and societal perspective. Influenza vaccination resulted in savings in all programs including children <or=13 years of age from both the health care provider and societal perspective. Investing 1.7 million euros in vaccination of children <5 years of age yielded savings of 2.7 million euros in health care costs. From the health care provider perspective, the savings per vaccinated child ranged between 5.7 and 12.6 euros in any program including children up to 13 years of age. The vaccination was cost saving in all age groups even with assumed vaccine efficacy of 60%. The results show that influenza vaccination would be cost saving in all children <or=13 years of age in Finland, which advocates reconsideration of the current influenza vaccine recommendations in all countries.

Cost-effectiveness of universal pneumococcal vaccination for infants in Italy

This study aimed at estimating the health and economic outcomes of universal infant vaccination with seven-valent pneumococcal conjugate vaccine (PCV-7) in Italy. A Markov model simulated lifetime evolution of a birth cohort (538,138 children): universal vaccination would avert 769 invasive infections, 18 deaths and 1323 life years. At base-case analysis, universal three-dose vaccination would cost euro 26,449 (95% CI: 1975-62,075) and euro 38,286 (95% CI: 22,164-70,801) per life year-saved in the societal and the NHS perspective, respectively. In the hypothesis of a 5-year long protection period, vaccination would cost euro 32,694 and euro 43,115 per life-year saved. Considering yearly incidence of invasive pneumococcal disease reported for Veneto and Sardinia regions, PCV-7 vaccination would result highly cost-effective determining a cost of euro 10,479 and euro 16,890 per life year-save in the NHS and the societal perspective, respectively.

Facial nerve paralysis secondary to acute otitis media in infants and children

Nowadays, facial paralysis is an uncommon complication of acute inflammation of the middle ear, with an estimated incidence of 0.005%; it was not so rare in the pre-antibiotic era, occurring in 0.5-0.7% of middle ear inflammatory processes. We would like to highlight this complication of acute otitis media, a common paediatric complaint. We present three new cases of facial palsy in children with acute otitis media and discuss the etiological mechanisms and different approaches to the treatment; a flow chart for facial paralysis in acute otitis media is also presented. Our three patients recovered completely after mastoidectomy (first two cases) and myringotomy with antibiotic therapy (third case). Facial paralysis is an uncommon complication of otitis media which requires appropriate care. Following our experience and revision of literature on the subject, antibiotic therapy and myringotomy are the first-line procedures. Surgery should be employed in case of acute or coalescent mastoiditis, suppurative complications and lack of clinical regression.

A pharmacoeconomic evaluation of seven-valent pneumococcal conjugate vaccine in Spain

BACKGROUND

Streptococcus pneumoniae is a leading cause of illness in children. Seven-valent pneumococcal conjugate vaccine (PCV-7), recently approved in the United States, is the first vaccine to provide protective immunity against pneumococcal disease in children under the age of 2. PCV-7 is nearly 100% effective in preventing invasive pneumococcal infections and has been shown to significantly decrease the incidence of pneumonia and otitis media.

OBJECTIVE

The objective of this study was to evaluate the health outcomes, costs, and cost-effectiveness of vaccination with PCV-7, compared with no vaccination for children in Spain.

METHODS

A health state model was used to determine the health and economic outcomes in vaccinated and unvaccinated groups among children less than 5 years old. This analysis was conducted for a 10-year time horizon, beginning with initial vaccinations. Information on the burden of pneumococcal disease, in terms of data on the incidence and seroprevalence of disease, was collected from published and unpublished records, supplemented, and verified by Spanish pediatric and infectious disease experts. The efficacy of PCV-7 was based on updated findings of the Kaiser Permanente Efficacy Study. A cost-of-illness estimate for each pneumococcal disease was determined using decision tree analysis that considered direct and indirect costs. A birth cohort analysis compared the expected cost of vaccinated populations to age-matched unvaccinated populations.

RESULTS

Implementing a PCV-7 vaccine program in Spain in a birth cohort of 360000 is expected to save approximately 16 lives and 132000 cases of pneumococcal disease over 10 years, resulting in total savings estimated at Euros 81 million (ESP13.5 billion), of which Euros 43.5 million (ESP7.1 billion) are direct medical savings. At a vaccine cost up to Euros 56.87 per dose (ESP9,462, the total cost of vaccinating a birth cohort of 360000 will be offset by the total savings owing to reduced morbidity.

CONCLUSIONS

Implementing a universal PCV-7 vaccination program in Spain will significantly decrease the mortality and morbidity associated with pneumococcal infections in young children. At an assumed cost of Euros 48.56 (ESP8080) per dose, PCV-7 vaccination of Spanish children under the age of 5, followed over a 10-year period, is cost saving from the societal perspective and cost-effective from the payer perspective at Euros 22500 per LYG (ESP3,734713), comparing favorably with other preventive programs in Spain.

Otitis media aguda en un centro de salud

BACKGROUND

Acute otitis media (AOM) is a serious public health problem and is considered one of the most common diagnoses in pediatric outpatient units. The aim of this study was to asses the incidence and distribution of AOM by age, sex, number of visits per episode, and the most frequent symptoms and signs in four pediatric primary care units.

PATIENTS AND METHODS

A 12-month (1 September 2000 to 31 August 2001), prospective study was carried out in a primary care center on the outskirts of Madrid.

RESULTS

During the study period there were 1,098 consultations for AOM in 521 patients. The overall incidence per 100,000 children aged less than 14 years was 12,080 cases (95 % CI: 11,120-13,090). The highest incidence per 100,000 children was in children aged 12-23 months with 38,780 cases (95 % CI: 33,340-44,430). A total of 34.5 % of the children diagnosed with AOM were aged less than 2 years. Ninety-six percent of the children received antibiotics. Most (81.4 %) of the children were completely cured while symptoms persisted in 15.4 %. A minority of the children (3.5 %) were referred to the otolaryngology department.

The epidemiology of acute bullous myringitis and its relationship to recurrent acute otitis media in children less than 2 years of age

OBJECTIVE

To evaluate the epidemiological characteristics of acute bullous myringitis (BM), i.e. inflammation of the tympanic membrane with blister(s) in children <2 years and study the relationship between bullous myringitis and recurrent acute otitis media.

METHODS

2028 children aged 7-24 months in a prospective longitudinal cohort study in the Finnish Otitis Media vaccine trial. The main outcome measures were the incidence of bullous myringitis and the incidence of acute otitis media (AOM) before and after the event of bullous myringitis.

RESULTS

82 children had a total of 86 events of acute bullous myringitis. The incidence of bullous myringitis was 5.7 per 100 person years (95% CI, 4.6-7.1 per 100 person years). The number of events with bullous myringitis was 4.6% of the number of all AOM events diagnosed during the follow-up. Recurrent AOM (> or =6 AOM events) occurred in 33% of children with bullous myringitis in comparison with 23% of control children with at least one event of AOM (RR 1.7; 95% CI, 1.01-2.7). The incidence of AOM in children with bullous myringitis was 1.8 per person year (95% CI, 1.4-2.2 per person year) before the event of bullous myringitis and 2.9 per person year (95% CI, 2.3-3.5 per person year) after the event of bullous myringitis. The higher incidence rate of AOM lasted for 2 months after the office visit of bullous myringitis.

CONCLUSIONS

Acute bullous myringitis is not a rare disease; it was diagnosed in 5.7% of children <2 years in a 1-year follow-up. It was present in almost 1 of every 20 AOM events. Acute bullous myringitis increases the subsequent risk of recurrent AOM.

Risk factors for the development of otitis media

Otitis media (OM) is the most frequently diagnosed disease in infants and young children. Large, prospective studies suggest an increase in incidence of this disease during the past 10 to 20 years, possibly reflecting a change in host and environmental risk factors for the development of OM. Good knowledge of host (intrinsic) and environmental (extrinsic) risk factors for the development of otitis media is important in identifying a child at risk for recurrent and persistent OM. This could result in primary and/or secondary prevention of OM and a decrease in complications and sequelae.

A pharmacoeconomic evaluation of 7-valent pneumococcal conjugate vaccine in Canada

The objective of this study was to evaluate the projected health benefits, costs, and cost-effectiveness of pneumococcal conjugate vaccination for infants and children aged <5 years in Canada. A health state model incorporating incidence, vaccine efficacy, costs, and transitional probabilities for the health states (well, meningitis, bacteremia, otitis media, pneumonia, and death) was constructed for a 10-year time horizon. Implementation of a pneumococcal conjugate vaccine program in Canada for each annual birth cohort of 340,000 persons observed over 10 years would be expected to save approximately 12 lives and 100,000 cases of pneumococcal disease over 10 years, resulting in total savings of $67 million (Canadian dollars [Can$]). Vaccination of healthy infants would result in net savings for society if the vaccine costs less than Can$50 per dose. Moreover, for a vaccine purchase price of Can$67.50, infant vaccination would cost society Can$79,000 per life-year gained. Pneumococcal conjugate vaccination is a potentially cost-effective means of pneumococcal disease prevention.

Impact of the pneumococcal conjugate vaccine on otitis media

CONTEXT

The heptavalent pneumococcal conjugate vaccine (PCV) is recommended for infants to protect against invasive disease, but its impact on otitis might also have public health importance.

OBJECTIVE

To examine the impact of PCV on the incidence of otitis media, frequent otitis media and tympanostomy tube procedures and to assess whether the effectiveness of the vaccine wanes after age 24 months and varies by race, sex or season.

DESIGN, SETTING AND PATIENTS

From 1995 to 1998, 37 868 children at Kaiser Permanente in Northern California were randomized to receive PCV or a control vaccine in a double blind trial and were followed through April 1999.

INTERVENTIONS

Children received a primary series at 2, 4 and 6 months of age and a booster at 12 to 15 months.

MAIN OUTCOME MEASURES

Visits for otitis, frequent visits for otitis and tympanostomy tube procedures. Otitis was ascertained from diagnosis checklists routinely marked by physicians.

RESULTS

Control children averaged 1.8 otitis visits per year. Children given PCV had fewer otitis visits than control children in every age group, sex, race and season examined. Intention-to-treat analysis permitted rejection of the null hypothesis that PCV is ineffective against otitis media (P < 0.0001). In children who completed the primary series per protocol, PCV reduced otitis visits by 7.8% [95% confidence interval (CI), 5.4 to 10.2%] and antibiotic prescriptions by 5.7% (CI 4.2 to 7.2%). Frequent otitis was reduced by amounts that increased with otitis frequency, from a 10% reduction in the risk of 3 visits to a 26% reduction in the risk of 10 visits within a 6-month period. Tube placements were reduced by 24% (CI 12 to 35%).

CONCLUSION

In children followed up to 3.5 years, PCV provided a moderate amount of protection against ear infections while reducing frequent otitis media and tube procedures by greater amounts.

Histopathologic differences due to bacterial species in acute otitis media

OBJECTIVE

To compare selected features of histopathology in acute otitis media caused by various bacteria and examine potential differences due to bacterial species, as well as possible correlation to experimental and human clinical findings.

METHODS

Rat models of acute otitis media caused by Streptococcus pneumoniae (MC), non-typeable or type b Haemophilus influenzae (NTHI/HIB) or Moraxella catarrhalis (MC) were studied longitudinally up to 6 months after bacterial challenge. Findings related to dynamics of goblet cell density, modeling and remodeling of bone tissue structures and polyp, as well as fibrous adhesion formation and persistence are presented.

RESULTS

Middle ear goblet cell density progressed to peak 2 weeks after bacterial inoculation, thereafter gradually normalizing. However, density and accordingly middle ear secretory capacity was still significantly increased after 6 months in all bacteria, except MC. The HI species induced the highest increase. Initial osteoresorption was followed by massive osteoneogenesis, progressing to a peak after 2-3 months, followed by some degree of normalization, concurrently classic remodeling. Primarily SP, but also the HI species induced more new bone formation than MC. Mucosal polyp and fibrous adhesion formation occurred regardless of bacterial species. Most polyps appeared in the early phases and the HI species induced formation of more polyps and adhesions than the other bacteria.

CONCLUSION

Acute middle ear infection with the Haemophilus species induce the highest increase of mucosal secretory capacity, lasting for at least 6 months after the acute incident. Thus, a subsequent development of secretory otitis media seems more likely following infection with these bacteria. Equivalently, mucosal scarring observed as polyp and fibrous adhesion formation was more severe following Haemophilus infection. S. pneumoniae induced the most marked changes of bone tissue structures, seen as initial osteoresorption and subsequent osteoneogenesis. Overall, infection with M. catarrhalis induced the mildest changes.

The hearing profile of Nigerian school children

The paucity of up-to-date and representative epidemiological data on hearing disorders in Nigeria has been observed as undermining the effective advocacy of prevention initiatives. This study attempts to address this problem by evaluating the prevalence and pattern of hearing impairment in school entrants. Parental interviews, otoscopy, pure-tone audiometric screening (frequency 0.5-4 kHz) and tympanometric examinations were conducted for a representative sample of 359 school children in an inner city area of Lagos. The prevalence of hearing loss was 13.9%. Middle ear abnormalities were noted in 20.9% of the study population, of which 18.7% were reported with otitis media with effusion. Impacted cerumen, documented in 189 children (52.6%), was the most common disorder. It showed significant association with hearing loss (P<0.001) and school performance (P<0.01). Tympanic membrane abnormalities were observed in 144 (40.1%) children. Of these, 45 (31.3%) showed abnormal tympanograms while 28 (19.4%) reported hearing loss (P<0.05). The early detection and management of hearing problems is relatively rare, thus precluding the determination of possible aetiological factors for the observed abnormalities. Poor public awareness, dearth of relevant facilities and the lack of early screening programmes are major known contributory factors. The well established national immunisation programme offers a cost-effective platform within the primary health-care system for addressing the high prevalence of hearing abnormalities in school children.

Correlation between respiratory alterations and respiratory diseases due to urban pollution

BACKGROUND

Air pollution is strongly correlated with allergic and infectious diseases. Chronicity of the stimulation and immaturity of the defense system make children prone to respiratory diseases. The aim of this study was to assess the adverse effects of urban levels of air pollution, correlating children's respiratory diseases and ultrastructural studies in rats, compared to controls in a clean area.

METHODS

An epidemiological survey was conducted with 2000 school children (age range 7-14 years old), divided into two groups of 1000 children each: the Red group from São Paulo city (17,000,000 inhabitants) and the Green group from a rural area around the city of Tupã with no air pollution at all. A questionnaire was given to the children's parents in order to estimate history of respiratory diseases and predisposing factors. A total of 69 rats were housed for 6 months in the center of São Paulo, and ultrastructural studies of the epithelium of the airways were done and compared to 56 control animals in the rural area.

RESULTS

The Red group of children had a statistically significant (P < 0.005) high prevalence of respiratory diseases such as rhinitis, sinusitis, and upper respiratory infections (URI). Rats exposed to air pollution developed ultrastructural ciliary alterations.

CONCLUSION

The results obtained in the present investigation suggest that chronic exposure to urban levels of air pollution may cause respiratory diseases in children and ultrastructural ciliary alterations in the epithelium of the airways in rats, when compared to controls in a pollution-free rural area.

Vaccination against middle-ear bacterial and viral pathogens

Considerable evidence suggests that otitis media (OM) can be prevented by systemic immunization. Building on the highly effective H. influenzae type b (Hib) conjugate vaccine technology, pneumococcal conjugate vaccines are being developed to circumvent T-independence of these antigens and provide durable immunity at a very young age. Several pneumococcal conjugate vaccines are currently in clinical testing. Potential vaccine antigens of nontypable H. influenzae (NTHi) include OMP, HMW, pili, and fimbriae. Several OMPs show extensive homology among strains, but surface, determinants of others are highly variable so that antibodies to surface epitopes of one strain will not bind to surface epitopes of another. Several M. catarrhalis OMP and HMW antigens have vaccine potential, but no functional correlates of protection have been identified, and there is no clear evidence that antibody to M. catarrhalis is associated with OM protection. Attenuated viral vaccines also hold promise of preventing childhood OM. Two clinical trials with killed influenza vaccines have shown a significant reduction in OM among vaccine recipients compared to control children during periods of high influenza disease activity in the community. Passive immunoprophylaxis also has potential for preventing OM. Human bacterial polysaccharide immune globulin was protective for pneumococcal OM in children and in the chinchilla OM model. High-dose respiratory syncytial virus-enriched immunoglobulin reduced the incidence and severity of RSV lower respiratory tract infection in high-risk children. Passive immunoprophylaxis may also be effective in children with specific immune deficiencies, such as IgG2 deficiency, and patients who fail to respond to vaccines.

Sequelae of recurrent acute otitis media. Ten-year follow-up of a prospectively studied cohort of children

In a cohort of 113 children prospectively followed from birth to the age of 3, two subgroups were discerned: one with recurrent acute otitis media (rAOM), the other subgroup with no AOM at all ("healthy" children). At further follow-up at the age of 10, no child had AOM or secretory otitis media (SOM), but between 3 and 7 y of age the rAOM subgroup was characterized by a significantly higher incidence of AOM as well as protracted secretory otitis media (SOM) episodes than was the "healthy" subgroup. The two subgroups did not differ significantly in hearing-thresholds at pure tone audiometry. After the age of 7, the incidence of AOM was the same in both groups. It is concluded that children with frequent AOM episodes before the age of 3 need long-term follow-up to school age, but seem not be predisposed to chronic SOM.

Is there a relationship between proximity to industry and the occurrence of otitis media with effusion in school entrant children?

In a study of the relationship between the prevalence of persistent otitis media with effusion (OME) in school entrant children in Redcar and Cleveland and the distance of the homes of these children from known industrial emission points, 1156 school entrant children were screened for the presence of persistent OME. The social disadvantage scores and map references were determined from the postcode area of each of the study entrants and map references were also obtained of known industrial emission points in the locality. Analyses were conducted on the association between the presence of OME and distance from emission sources and between the presence of OME and disadvantage score. A significantly greater proportion of study entrants with OME lived within 1000 meters of an industrial emission point than further away. However, there was no trend established between the proportion of study entrants with OME and increasing distance from an emissions source, nor was there any significant relationship established between the social disadvantage score of the areas of residence of the study entrants and the presence of OME. Further research is required to establish the effect of confounding variables on this relationship.

Patterns of persistent otitis media in the first year of life in aboriginal and non-aboriginal infants

Australian Aboriginal infants experience very early otitis media (OM). A previous study reported that OM with effusion (OME) or acute OM (AOM) was observed in the first 8 weeks of life in 95% of 22 Aboriginal infants, but that OME was seen in only 30% of 10 non-Aboriginal infants. Tympanic membrane perforation was reported for 1 Aboriginal subject at 8 weeks of age. This requires further investigation, because early OM onset has been demonstrated in non-Aboriginal groups to increase the risk of chronic and persistent ear disease in later childhood. This prospective study used otoscopy and tympanometry to describe the course of OM in infants examined repeatedly from soon after birth. Disease course was described in two ways, based upon earlier findings from other studies of Aboriginal schoolchildren. First, patterns of disease in the first year were identified; non-Aboriginal infants had occasional episodes of OME or AOM from which they recovered spontaneously, usually within 1 month; Aboriginal infants had persistent AOM, OME, or tympanic membrane perforation with discharge that rarely, if ever, resolved to normal. Second, conditional probabilities were calculated for ear state transitions at consecutive ear examinations, and a model of the course of OM was proposed for the Aboriginal infants. Results also suggested that binaural patterns of chronic OM described previously in Aboriginal schoolchildren may already be established in the first year of life. These findings will help service providers determine when to intervene to avoid the chronic consequences of early OM.

Acute otitis media in childhood: a study of 20,532 cases

We present a study of acute otitis media among 20,532 Spanish children during a 6-month period from January through June 1991. The study was done by distributing a questionnaire to all Spanish pediatricians. Of the patients 51.7% were girls and 48.3% boys; 68.7% of all children were younger than 5 years. The most frequent symptoms were otalgia or irritability, 92.7%; fever, 63.5%; otorrhea, 24.9%; vomiting, 21.4%; and another concomitant upper respiratory tract infection, 65.5%. Otitis was bilateral in 45.6% of the cases. The most frequently used antibiotic was cefixime (38%), followed by amoxicillin-clavulanate (22.2%), amoxicillin (15.3%), 2nd-generation cephalosporins (13.5%) and macrolides (8.8%). In 11.8% of the patients, a change in the initial antibiotic therapy was required due to adverse effects. Resolution of symptoms occurred in 77.8% of the patients.

Demonstration of Mycoplasma hyorhinis as a possible primary pathogen for porcine otitis media

A study of the pathology of the ear was performed on 479 pigs ranging in age from 1 day to 1 year. Histologically, 364 (76.0%) of 479 pigs were affected with otitis. Eustachitis was the most common and preceded an inflammation of other sites of the ear, and an acute eustachitis occurred from as early as 1 week of life. Immunohistochemical examination of frozen cryostat sections revealed Mycoplasma hyorhinis (Mhr) antigens on the luminal surface of the eustachian epithelia in 14 (50.0%) of 28 piglets examined. All the pigs positive for Mhr had an acute eustachitis. Ultrastructural examination on the auditory tubes with positive immunostaining disclosed many mycoplasmas among the cilia. Mhr was isolated from the auditory tubes and tympanic cavities of 19 (67.9%) and 16 (57.1%) of 28 piglets examined, respectively. Porcine otitis media may be caused primarily by Mhr infection in the auditory tube.

Co-amoxiclav in recurrent acute otitis media: placebo controlled study

OBJECTIVE

To determine the efficacy of coamoxiclav in children aged 6 months to 12 years with recurrent acute otitis media.

DESIGN

A randomised double blind placebo controlled clinical trial.

SETTING

General practice in the Netherlands.

PATIENTS

121 children with recurrent acute otitis media, defined by onset of otalgia and otoscopic signs of middle ear infection within four to 52 weeks after the previous attack. Confirmation of diagnosis and randomisation was done by otolaryngologists.

INTERVENTION

Oral co-amoxiclav or placebo in weight related doses for seven days.

MAIN OUTCOME MEASURE

An irregular clinical course defined as the presence of otalgia or a body temperature greater than or equal to 38 degrees C, or both, after three days.

RESULTS

Eleven (16%; 95% confidence interval 9% to 28%) children had an irregular course in the co-amoxiclav group and 10 (19%; 9% to 31%) in the placebo group (difference not significant). Age, dichotomised at 2 years, was the only significant prognostic factor for irregular course of the disease (odds ratio 5.9; 1.8 to 19.1). Among children aged below 2 years, 28% (4/14) in the co-amoxiclav group and 58% (7/12) in the placebo group had irregular courses. For children 2 years and older these percentages were 13% (7/52) and 7% (3/41).

CONCLUSION

Children with recurrent acute otitis media are at greater risk of an irregular clinical course of the disease than children with a first episode of acute otitis media. Co-amoxiclav has no significant benefit over placebo in treating children over 2 years with acute otitis media.

Treatment failure in otitis-prone children with prophylactic tympanostomy tubes is correlated with nasopharyngeal Haemophilus influenzae colonization

Tympanostomy tubes are used to prevent recurrent otitis media among otitis-prone children. However, not all children benefit from this treatment. In the present study 28 children (19 boys, 9 girls) were given bilateral tympanostomy tubes at age 9-22 months (mean 14 months). They were observed 6 months before and after tube insertion. The treatment was considered successful for 20 children. Among these, 16 completely lacked or had one episode of middle ear discharge and 4 had otorrhea on two occasions. A total of 8 children suffered from three or more episodes of otorrhea and were considered as treatment failures. In the failure group, the nasopharyngeal average carrier rate of H. influenzae 6 months before and after tube insertion was 64% vs. 29% in the group responding well to the treatment (p less than 0.001). Nonencapsulated forms of H. influenzae were in a great majority. In the failure group 7 out of 8 presented middle ear discharge as soon as within 2 weeks after tube insertion whereas this occurred in only 3 out of 20 in the responding group. IgG, IgG1 and IgG2 antibody response to pneumococcal polysaccharide (6A, 19F) were equally distributed in the two groups. The present data suggest that one reason for an unsatisfactory response to treatment with prophylactic tympanostomy tubes is nasopharyngeal colonization and subsequent middle ear infections caused by H. influenzae.

Double-blind comparison of cefixime and cefaclor in the treatment of acute otitis media in children

In a double-blind study cefixime, an oral cephalosporin of the third generation, was compared to cefaclor in the treatment of acute otitis media in 397 children aged 6 months to 12 years. Clinical evaluation was carried out at the beginning, at day 10-12 and day 28-35 after the start of the treatment. Specimens for bacterial culture and sensitivity testings were taken from the nasopharynx at the initial visit. Patients were randomized either to cefixime in a dose of 8 mg/kg/day or cefaclor in a dose 40 mg/kg/day in the proportion of 2 cefixime patients to 1 cefaclor patient. Two daily doses were administered for 7 days. At day 10-12, 93.5% in the cefixime group and 90.5% in the cefaclor group (p = 0.08) were clinically cured or improved. At day 28-35 the rate of cured or improved patients had decreased, mostly due to reinfections, to 90.1% in the cefixime group and to 86.6% in the cefaclor group (p = 0.12), respectively. 375 patients (69.9%) had positive bacterial culture in the nasopharynx of at least one strain of Haemophilus influenzae, Streptococcus pneumoniae, Branhamella (Moraxella) catarrhalis or combinations of these 3.73.6% of the B. catarrhalis strains were beta-lactamase producing and 11.4% of the H. influenzae strains, respectively. All isolated bacteria were sensitive to cefixime. Adverse events were reported in 17.9% in the cefixime and 10.6% in the cefaclor group. Most reactions were of moderate or mild nature and mostly affected skin or the gastrointestinal region. No serious adverse experiences occurred. In view of the good clinical results obtained cefixime seems to be at least as effective as cefaclor in the treatment of acute otitis media in children.

Age-dependent changes in bacterial adherence to epithelial cells of nasopharynx in vivo

Epithelial cells were scraped from the posterior wall of the nasopharynx (NPH) of 20 consecutive patients (age range 1 to 52 years, 9 males, 11 females) undergoing ENT surgery under general anaesthesia. The cellular mixture was immediately homogenized, filtrated through a 5 microns pore filters and centrifuged (10 min, 1,500 rpm). Non-ciliated, squamous epithelial cells caught by the filter were harvested and stained with acridine orange. Epithelial cells with bacteria attached were evaluated when specimens were examined under a fluorescence microscope. A distinct difference was noted between young individuals and adult patients regarding bacterial adherence to nasopharyngeal epithelial cells, adherence in young patients being especially remarkable. Bacteria appeared not to attach to ciliated epithelial cells. The high incidence of otitis media infections among young individuals may be due to the remarkable bacterial adherence to nasopharyngeal non-ciliated epithelial cells in this age group.

Occurrence of middle ear pathogens in the nasopharynx of young individuals. A quantitative study in four age groups

Colonization of middle ear pathogens (S. pneumoniae, H. influenzae and B. catarrhalis), potential pathogens (S. aureus and coagulase-negative staphylococci) and non-pathogens was determined quantitatively on the posterior wall of the nasopharynx (NPH) of children (four age groups: under 2 years, 2-5 years, 6-10 years and 11-15 years). None of the 90 individuals examined was suffering at the time of bacterial sampling from acute otitis media (AOM), sinusitis, or tonsillitis. All individuals under 2 years of age harboured middle ear pathogens in the NPH, but only 40% of the individuals of the oldest age group (p less than 0.001). Furthermore, in the youngest group, 57% of the cases had pathogens in the NPH, which completely dominated the bacterial flora, i.e. constituted more than 90% of the total bacterial count when calculated as CFU/cm2. The corresponding count in the oldest age group was only 20% (p less than 0.01). One important reason for the high incidence of AOM among young children in particular seems to be the noticeable accumulation of middle ear pathogens in huge quantities in the NPH in this age group.

Localized middle ear effusions: three unusual acute cases in adults

Three cases of acute, non-suppurative otitis media in adults are described. They are unusual in that the effusion was confined to the upper middle ear, whilst the lower middle ear was aerated. The aetiology of such localized effusions, is probably related to the anatomy of the middle ear compartments, the mucosal folds forming them and the apertures allowing communication between them. The compartments are relatively constant and are a result of the embryological development of the middle ear. The localization of these effusions, demonstrates the segmental anatomy of the middle ear.

The Bayesian approach to the evaluation of risk factors in acute and recurrent acute otitis media

A multivariant modelling method was used to analyse the risk, associated with 22 different factors, of contracting acute otitis media (AOM) in a prospective cohort of 1294 urban children followed up to the age of 17-32 (mean 25) months. By far the most important risk factor was the caring of the child at a day-care centre. The importance of this factor further increased with increasing recurrence of the attacks. Next in order came the existence of sibling(s) with AOM attacks during the follow-up. Prolongation of breastfeeding increased the protection against AOM during the first year of life. The frequency of AOM attacks was lowest around midsummer and highest in early winter.

Middle ear fluid bacteriology of acute otitis media in neonates and very young infants

The middle ear fluid (MEF) bacteriology of 107 attacks of acute otitis media (AOM) in 101 infants less than 3 months old was analyzed. A total of 108 bacteria were isolated from 85 attacks. Major AOM-pathogens, S. pneumoniae (19%), H. influenzae (9%) or B. catarrhalis (7%) were cultured in approximately one-third of all the attacks. S. aureus (17%) and coagulase-negative staphylococci (22%) without the above pathogens were commonly found, whereas gram-negative enteric bacteria were culturable from only 5 attacks. Only 8% of the MEFs were polymicrobial. More than half of all the bacterial strains produced beta-lactamase. The bacteriology of those younger than one month was not different from that of the others. The same was true with attacks of out-patients and in-patients, except for a larger proportion of beta-lactamase producing strains in in-patients. Nasal-nasopharyngeal and MEF samples showed the same bacteriology in only 20% of cases. Two-thirds of AOM attacks were present in infants with perinatal or other concomitant morbidity, but their bacteriology was not different from those without other morbidity. In addition to the examination of ears in infants presenting with any illness before the age of 3 months, the study stresses the importance of bacteriological analysis of MEF in all cases of AOM at this age.

Factors affecting the occurrence of acute otitis media during the first year of life

A regional birth cohort of 5,356 infants was enrolled into a follow-up study in order to investigate the determinants of the development of infectious diseases in children. The infants were examined at three months, six months and twelve months of age by the physicians at the well-baby clinics. At these occasions the number of episodes of acute otitis media in the infants, the duration of breast-feeding, the number of siblings, the type of day care, parental smoking, the presence of animal pets at home and the number and type of other illnesses than otitis were registered. Two thirds of the infants had no episodes of acute otitis media. The median age for the first episode of acute otitis media was eight months. About 10% of the infants had experienced recurrent otitis media (three episodes or more) during their first year of life. Significant associations were found between the occurrence of acute otitis media and the number of siblings, the type of day care, the sex of the infant, the duration of breast feeding, maternal socioeconomic status and prematurity.

Incidence of acute otitis media up to the age of 1 1/2 years in urban infants

The object of this prospective cohort investigation of 1,642 infants was to study the incidence of acute otitis media (AOM) in urban children during the first 18 months of life. The monthly incidence of AOM was greatest at the age of 10 months, and the largest proportion of children with AOM was also found in this 10-month age group. Before the age of 18 months, 56.7% of the infants had had at least one episode of AOM, while 26.9% had had one or two episodes and 29.8% three or more. The corresponding figures before the age of 12 months were: 45.3%; 26.8%; 18.5%, and before the age of 9 months: 30.5%; 22.1%; 8.4%. The AOM incidence, particularly as regards recurrent AOM, was rather higher in boys than in girls.

Finnish approach to the treatment of acute otitis media. Report of the Finnish Consensus Conference

The theme of the first consensus conference to be held in Finland was the treatment of acute otitis media. The statements and recommendations accepted by the conference, which was organized according to the National Institutes of Health model, are presented in this report. On the basis of scientific knowledge, clinical experience, and conditions in Finland, the conference delegates concluded that penicillin V, in large doses, is still the drug of first choice in this disease. The importance of surgical drainage of the middle ear was stressed, as was the necessity of careful follow-up of the patient until the condition is completely healed. Decongestants were considered rather useless. In the prevention of recurrent attacks, adenoidectomy but not tonsillectomy was regarded as being of help, tympanostomy of probable benefit, antimicrobial (sulfonamide) prophylaxis worth considering in selected cases, but the effect of pneumococcal vaccination poor. The conference delegates agreed that uncomplicated acute otitis media should, as before, usually be treated by physicians taking care of children at the primary health care level.

Acute mastoiditis. Influence of antibiotic treatment on the bacterial spectrum

The work was undertaken to investigate the spectrum of bacteria responsible for acute mastoiditis and to find out whether it is affected by intake of antibiotics prior to surgical treatment. The records were reviewed of 22 children with acute mastoiditis in whom mastoidectomy had been performed and bacterial cultures obtained. Eleven of the patients had had antibiotic treatment prior to admission (9 penicillin V and 2 erythromycin). Streptococcus pneumoniae was found in 8 of the purulent discharges: Haemophilus influenzae, Streptococcus beta-hemolyticus and Staphylococcus aureus in 2 each; Proteus mirabilis, Pseudomonas pyocyaneus and a Bacteroides strain in 1 each, while five discharges-all from patients pretreated with antibiotics-yielded no growth. None of the 9 patients pretreated with penicillin V provided pure cultures of pneumococci or beta-hemolytic streptococci, while one or the other of these species was found in 8 of the 11 untreated patients. Gram-negative bacteria were found both among those with and those without antibiotic pretreatment. The data indicate that pneumococci and beta-hemolytic streptococci are more likely to cause mastoiditis than are the other pathogens found in acute otitis media, and that, when drained at operation, purulent discharges are often found to have been sterilized by the pre-operative antibiotic treatment.

Bacteriological features and chemotherapy of adult acute purulent otitis media

Eighty-eight patients from 16 to 79 years old, with acute purulent otitis media, were bacteriologically examined at the Otorhinolaryngology Department of a primary care hospital in Tokyo from July 1979 to May 1983. Fifty-six patients underwent paracentesis, and 32 patients exhibited otorrhea due to previous spontaneous perforation of the tympanic membrane. Bacteriologic cultures revealed the presence of Streptococcus pneumoniae (62.5 per cent), including S. pneumoniae Type III (28.1 per cent), Haemophilus influenzae (10.5 per cent), Staphylococcus aureus (11.5 per cent), and Streptococcus pyogenes (7.3 per cent). S. pneumoniae Type III had a notably high detection rate in patients from 50 to 79 years old (50-75 per cent). Because Haemophilus influenzae was detected at a relatively high rate in patients of all ages, if can be considered as a major causative pathogen of AOM. In 44 patients, selected mainly from those who underwent paracentesis, a comparative study of bacteria found in middle ear fluid and naso-pharyngeal mucus revealed the same bacteria in 43 out of 44 cases (97.7 per cent), indicating the presence of bacterial infection through the auditory canal. Antibiotics were selected according to an Expected Efficacy Index (EEI), the antibiotic of first choice being Ampicillin or Cefaclor.

The nasopharyngeal microflora of otitis-prone children, with emphasis on H. influenzae

The nasopharyngeal microflora was monitored during a prospective study of 52 otitis-prone children and 33 age-matched controls up to the age of 30 months. The relation between nasopharyngeal culture results and corresponding otoscopic findings was investigated. In contrast to pneumococci, the rate of H. influenzae isolation was correlated to the degree of otologic disease, thus it was found more often in connection with AOM than with a normal otologic status, with OME in an intermediate position. Also in contrast to pneumococci, in children with AOM, H. influenzae was commoner in the otitis-prone group than in the control group. H. influenzae biotype II was found in 77% in association with AOM in the control group. In the otitis-prone group the difference in frequency of biotypes I, II and III causing AOM were less pronounced. Turnover of H. influenzae strains as judged by change in biotype was found to occur more often in connection with treatments with penicillin-V than treatments with amoxicillin.

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.