Presence Of Middle Ear Effusion Research Articles

Correlation between tympanometric findings and adenoid hypertrophy among children without hearing loss in tertiary care hospital

Adenoid hyperplasia is a common cause of nasal obstruction in children. Chronic infection and hypertrophy result in mouth breathing, snoring, sleep apnoea, hyponasality, sinusitis, and otitis media with effusion (OME). Some children with adenoid hypertrophy have OME in spite of having no complaints of hearing loss. Untreated OME may adversely affect the speech and intellectual development of the child.Aim To determine whether there is a correlation between tympanometric findings and various radiological and endoscopic grades of adenoid hypertrophy.To propose a combination of radiological and/or endoscopic assessment of adenoids and tympanometry as a screening program in patients with suspicion of adenoid hypertrophy.Materials and methods One hundred children, presenting with one or more complaints of upper airway obstruction (UAO), suggestive of adenoid hypertrophy, without a history of hearing loss, to the OPD, were chosen for the study. X-ray nasopharynx soft tissue lateral view was done for all patients. Rigid diagnostic nasal endoscopy with 0° endoscope was conducted in only children who were cooperative and with parental consent. Tympanometry was carried out for all patients and plotted on tympanograms.Results In our study, the mean age of children is 9.43 ± 2.430 years with gender distribution being 57% males and 43% females. The majority of children tend to present with nasal obstruction (100%), mouth breathing (83%), and snoring (56%). On both radiological and endoscopic evaluation of adenoids and correlation with tympanogram, a significantly higher number of patients with Grade 1 adenoids have a type A curve, while a significantly higher number of grade 3 adenoids patients have a type B curve and type C is significantly more prevalent in grade 2 and grade 4 adenoids (p < 0.05).Conclusion In our study, adenoid size as measured from both adenoid X-ray and adenoid endoscopy, showed a significant association with the presence of middle ear effusion and also with eustachian tube dysfunction. This helps in early detection, prior to the development of hearing loss, making it easy to plan early intervention, and curbing the possibility of aggravation of the condition and occurrence of complications.

Machine Learning for Accurate Intraoperative Pediatric Middle Ear Effusion Diagnosis.

Misdiagnosis of acute and chronic otitis media in children can result in significant consequences from either undertreatment or overtreatment. Our objective was to develop and train an artificial intelligence algorithm to accurately predict the presence of middle ear effusion in pediatric patients presenting to the operating room for myringotomy and tube placement. We trained a neural network to classify images as " normal" (no effusion) or "abnormal" (effusion present) using tympanic membrane images from children taken to the operating room with the intent of performing myringotomy and possible tube placement for recurrent acute otitis media or otitis media with effusion. Model performance was tested on held-out cases and fivefold cross-validation. The mean training time for the neural network model was 76.0 (SD ± 0.01) seconds. Our model approach achieved a mean image classification accuracy of 83.8% (95% confidence interval [CI]: 82.7-84.8). In support of this classification accuracy, the model produced an area under the receiver operating characteristic curve performance of 0.93 (95% CI: 0.91-0.94) and F1-score of 0.80 (95% CI: 0.77-0.82). Artificial intelligence-assisted diagnosis of acute or chronic otitis media in children may generate value for patients, families, and the health care system by improving point-of-care diagnostic accuracy. With a small training data set composed of intraoperative images obtained at time of tympanostomy tube insertion, our neural network was accurate in predicting the presence of a middle ear effusion in pediatric ear cases. This diagnostic accuracy performance is considerably higher than human-expert otoscopy-based diagnostic performance reported in previous studies.

Developmental Outcomes in Early-treated Congenital Hypothyroidism: Specific Concern in Tc99m Thyroid Scan Role

Background Congenital hypothyroidism (CH) may cause alterations in the child's global development. The current study aimed to screen the global development of children with and without congenital hypothyroidism, focusing on communication, and cognitive abilities and to investigate the influence of illness severity, clinical history, and treatment factors in the evaluated results. Materials and Methods A case control study was conducted on 20 children with early-treated congenital hypothyroidism (CH), and controls without CH (n=100), both groups were matched for age and sex. Patients were subjected to a protocol of assessment applied in Pediatric and Phoniatrics Unit Sohag, Egypt. Assessments included detailed history and medical data, language development testing, intelligence quotient (IQ). According to TSH and T4 levels, case group was divided into controlled group and uncontrolled group. 99m pertechnetate scintigraphy of thyroid (Tc-99m TS) was recommended for all CH children. Results Children’s ages ranged between 3-7 years with a mean age of (4.6 ±1.9year). There were statistically significant differences between study and control group in presence of middle ear effusion, delayed language development, IQ scores (p<0.001). Interestingly, there was a negative correlation between IQ test and total language age with TSH level (r = -0.06, p= 0.004; r =-0.4, p=0.06), respectively. Tc-99m pertechnetate scintigraphy of thyroid confirmed transient CH diagnosis in three cases. Conclusion Despite early treatment in the studied CH children, language and cognitive skills impairments were detected. The magnitude of these impairments significantly related to TSH values and regularity of hormone replacement therapy. TS confirmed transient CH diagnosis in three cases, replacement therapy stopped in those children.

Grommets (ventilation tubes) for recurrent acute otitis media in children.

Acute suppurative otitis media is one of the most common infectious diseases in childhood. Recurrent acute otitis media is defined for the purposes of this review as either three or more acute infections of the middle ear cleft in a six-month period, or at least four episodes in a year. Strategies for managing the condition include the assessment and modification of risk factors where possible, repeated courses of antibiotics for each new infection, antibiotic prophylaxis and the insertion of ventilation tubes (grommets).To establish whether ventilation tube insertion reduces the frequency of episodes of recurrent acute otitis media and the proportion of children with symptoms of ear disease.We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2008), MEDLINE (1950 to 2008), EMBASE (1974 to 2008), CINAHL, mRCT (the metaRegister of Controlled Trials for ongoing/unpublished trials), NRR (National Research Register), LILACs, KoreaMed, IndMed, PakMediNet, Zetoc, ISI Proceedings and Cambridge Scientific Abstracts. Reference lists of articles retrieved from the electronic searches were scanned for further trials. Systematic reviews and other meta-analyses were also searched for and their reference lists scanned. Contact was sought with authors of published trials and other experts in the field. The date of the last search was March 2008.No trials that included a treatment and a control group that met the inclusion criteria were excluded. Abstracts were screened and full text articles of studies that met our inclusion criteria obtained. Two authors independently applied the inclusion criteria. Studies included in the review underwent quality assessment performed independently by all authors adapting the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions.Data were extracted independently by the authors and synthesised descriptively. Five randomised controlled trials were identified, of which two fulfilled the inclusion criteria.Two studies involving 148 children were included in the review. One of these studies, involving 95 children, showed that ventilation tube insertion leads to a mean reduction of 1.5 episodes of acute otitis media in the first six months after treatment. This study also showed a significant increase in the proportion of children with no episodes of AOM (p < 0.001) in the ventilation tube group. The other included study also found a higher proportion of patients in the ventilation tube group had no episodes of AOM in the six months after intervention, but the difference did not reach statistical significance (p = 0.16).Ventilation tubes have a significant role in maintaining a 'disease-free' state in the first six months after insertion. Further research is required to investigate the effect beyond six months. Clinicians should consider the possible adverse effects of grommet insertion before surgery is undertaken.

Otitis media in children

Otitis media is a spectrum of diseases associated with middle ear infection. Acute otitis media is one of the most common acute infections in childhood, with a peak incidence in the second half of infancy. A diagnosis of acute otitis media is often challenging and requires three criteria to be met - acute onset of symptoms, signs of middle ear inflammation, and effusion. Otitis media with effusion is the presence of middle ear effusion without signs or symptoms of ear inflammation such as pain and fever as a result of impaired middle ear ventilation. Features of middle ear effusion in the absence of features of inflammation helps to make the diagnosis of otitis media with effusion. Most cases are self-resolving with 75%–90% showing complete resolution within 3 months.

Twelve years of chiari-like malformation and syringomyelia scanning in Cavalier King Charles Spaniels in the Netherlands: Towards a more precise phenotype.

Chiari-like malformation (CM), syringomyelia (SM) and middle ear effusion (also called PSOM) are three conditions that frequently occur in Cavalier King Charles Spaniels (CKCS). Both CM and SM are currently screened in the Netherlands prior to breeding and are graded according to the British Veterinary Association’s Kennel Club (BVA/KC) scheme. This study evaluated the prevalence and estimated genetic parameter of CM, SM and middle ear effusion from 12 years of screening results. For SM, the classical method using the BVA/KC scheme, was compared with exact measuring of the central canal dilation. For CM, the BVA/KC scheme was compared with a more detailed scheme. Next to this the presence of microchip artifacts was assessed. 1249 screening of 1020 dogs were re-evaluated. Results indicated the presence of CM in all dogs, suggesting it has become a breed-specific characteristic. And although different grades of CM were observed, the condition did not deteriorate over time. SM was present in 39% of the dogs and a clear age effect was demonstrated, with SM increasing with age. This emphasizes the importance of screening at appropriate age, since SM can worsen with increasing age. One alternative is to promote repeated measures. The presence of middle ear effusion in this study was 19%–21% for dogs younger than 3 years, and 32%–38% for dogs older than 3 years. In as much as 60%, microchip artifacts were noticed, leading to the recommendation to place microchips in another location in breeds that are susceptible to developing SM. Finally, this study estimated the heritability of CM in this population, due to the lack of phenotypic variance, to be very low at 0.02–0.03. The heritability for SM central canal dilatation to be 0.30, compared to 0.13 for the classical BVA/KC method, using a model including the age effect and the combined effect of veterinary clinic and year of the evaluation. Genetic correlations were rather small, ranging from 0.16–0.33. As a conclusion, screening for SM and CM in the entire population should be maintained, and a selection scheme against SM should be based on estimated breeding values for the exact measurement of the central canal dilatation.

What not to do in acute otitis media: the top five recommendations proposed by the Italian Society of Preventive and Social Pediatrics

ABSTRACTIntroduction: With the aim to reduce inappropriate procedures and antibiotic therapy in the management of acute otitis media (AOM) in children, the Italian Society of Preventive and Social Pediatrics (SIPPS) proposed a top five list of recommendations for clinical practice.Areas covered: AOM is one of the most frequent reasons for antibiotic prescription in pediatric age.The over-estimation of AOM is associated with inappropriate treatment, increased costs, adverse events and spread of antibiotic resistance. Thus, the most recent guidelines provided stringent diagnostic criteria and considered the ‘watchful waiting’ approach, limiting the immediate antibiotic therapy to a well-characterized subgroup of children.Expert commentary: The five recommendations proposed are: 1) Do not diagnose AOM without having documented the presence of middle ear effusion 2) Do not diagnose AOM without examining the entire tympanic membrane; 3) Do not treat immediately all cases of AOM with antibiotics; 4) Do not administer ear analgesic drops until examining the whole tympanic membrane 5) Do not use macrolides in the AOM therapy. This list of top five recommendations could be a novel tool to spread the key messages on the guidelines and to promote the correct diagnostic procedures as well as a rational use of antibiotics in children.

Computed tomographic morphometry of tympanic bulla shape and position in brachycephalic and mesaticephalic dog breeds.

Anatomic variations in skull morphology have been previously described for brachycephalic dogs; however there is little published information on interbreed variations in tympanic bulla morphology. This retrospective observational study aimed to (1) provide detailed descriptions of the computed tomographic (CT) morphology of tympanic bullae in a sample of dogs representing four brachycephalic breeds (Pugs, French Bulldogs, English Bulldog, and Cavalier King Charles Spaniels) versus two mesaticephalic breeds (Labrador retrievers and Jack Russell Terriers); and (2) test associations between tympanic bulla morphology and presence of middle ear effusion. Archived head CT scans for the above dog breeds were retrieved and a single observer measured tympanic bulla shape (width:height ratio), wall thickness, position relative to the temporomandibular joint, and relative volume (volume:body weight ratio). A total of 127 dogs were sampled. Cavalier King Charles Spaniels had significantly flatter tympanic bullae (greater width:height ratios) versus Pugs, English Bulldogs, Labrador retrievers, and Jack Russell terriers. French Bulldogs and Pugs had significantly more overlap between tympanic bullae and temporomandibular joints versus other breeds. All brachycephalic breeds had significantly lower tympanic bulla volume:weight ratios versus Labrador retrievers. Soft tissue attenuating material (middle ear effusion) was present in the middle ear of 48/100 (48%) of brachycephalic breeds, but no significant association was found between tympanic bulla CT measurements and presence of this material. Findings indicated that there are significant interbreed variations in tympanic bulla morphology, however no significant relationship between tympanic bulla morphology and presence of middle ear effusion could be identified.

Functional MRI of the Eustachian Tubes in Patients With Nasopharyngeal Carcinoma: Correlation With Middle Ear Effusion and Tumor Invasion.

We sought to combine the Valsalva maneuver with MRI to evaluate eustachian tube function in patients with nasopharyngeal carcinoma (NPC) and to correlate the extent of tumor invasion with the presence of middle ear effusion (MEE) and eustachian tube dysfunction (ETD). We performed MRI along the lengths of the eustachian tubes, before and after the Valsalva maneuver was performed, in 53 patients with untreated NPC. The images were reviewed by two radiologists. A total of 106 eustachian tubes and middle ears were studied. There was dysfunction in 37 eustachian tubes, which was always ipsilateral to the NPC. There was MEE in 26 ears of 22 patients. In all cases of MEE, there was ipsilateral ETD. ETD was correlated with tumor invasion of the ipsilateral pharyngeal recess (p < 0.001), pharyngeal opening of the eustachian tube (p < 0.001), the cartilaginous eustachian tube (p < 0.001), the eustachian cartilage (p < 0.001), Ostmann fat pad (p < 0.001), the levator veli palatine muscle (p < 0.001), and the tensor veli palatine muscle (p < 0.001). There was a strong correlation between the grade of parapharyngeal space invasion and ETD (r = 0.809; p < 0.001) and MEE (r = 0.693; p < 0.001). Combining the Valsalva maneuver with MRI is helpful in assessing the function of the eustachian tube in patients with NPC. The cause of MEE in patients with NPC is dysfunction of the eustachian tube opening, which is associated with tumor invasion around the eustachian tube.

Parental role in the diagnostics of otitis media: can layman parents use spectral gradient acoustic reflectometry reliably?

ObjectiveSpectral gradient acoustic reflectometry (SG-AR) can be used to detect middle ear effusion (MEE). Since both families and primary health care systems carry the burden of otitis media, our aim was to determine whether layman parents could be taught to use the SG-AR reliably. MethodsWe enrolled 359 children (age 6–35 months) whose parents were willing to use SG-AR at home. The parents were asked to perform bilateral SG-AR daily on their child. In this study, we included children who had undergone successful parental home SG-AR examination performed on the same day that a physician had also performed successful SG-AR examination and pneumatic otoscopy at the study clinic. We compared the parental and study physician SG-AR examination results to the study physicians′ pneumatic otoscopy, which served as the diagnostic standard. ResultsWe analyzed 571 successful parental home SG-AR examinations performed on the same day that a study physician had performed a successful SG-AR examination and pneumatic otoscopy at the study clinic. None of the evaluated SG-AR level combinations resulted in both high sensitivity and specificity. For symptomatic visits, the negative predictive value of a parental SG-AR level 1 to detect MEE was 64%. For parental SG-AR levels 4–5, the positive predictive value to detect MEE was 88%. However, for asymptomatic visits, the negative predictive value of a parental SG-AR level 1 to detect MEE was 83%. ConclusionThis study showed that layman parents are able to use the SG-AR technically successfully. In symptomatic children, parentally obtained SG-AR level 1 examination is not adequate to exclude MEE. However, parentally obtained SG-AR levels 4–5 do indicate the presence of MEE. At the same time, in asymptomatic children, parentally obtained SG-AR level 1 examination seems to indicate a healthy middle ear. From the perspective of primary care, the implementation of parental SG-AR examinations in the diagnostic chain of otitis media would be intriguing. This study showed that the possibilities lie in the follow up of the resolution of MEE after an episode of OM in asymptomatic children. However, it seems that currently, the SG-AR technique is an obstacle for wider clinical implementation.

Evaluation of nasopharyngeal microbial flora and antibiogram and its relation to otitis media with effusion.

Acute otitis media and otitis media with effusion (OME) are the main causes of hearing impairment in children which require proper treatment, mainly antibiotic therapy. Patients whom were appropriate candidates for adenoidectomy were divided into two groups regarding the presence of middle ear effusion. Adenoid tissue specimens were cultured in both groups and the bacterial flora and anti-microbial resistance pattern were determined. 72 patients were studied, 42 % had OME while 58 % did not. The following bacteria were isolated and cultured from both groups with no meaningful difference in prevalence: Streptococcus viridans (p = 0.265), Staphylococcus aureus (p = 0.72), H. influenza (p = 0.806), Entrococcus. spp (0.391), Streptococcus pneumonia (p = 0.391), nonhemolytic Streptococcus (p = 0.230). Bacterial sensitivity was similar for Amoxicillin-clavulanate (p = 0.935), Amoxicillin (p = 0.935), Cephalexin (p = 0.806), Cefixime (p = 0.391) and Azithromycin in both groups. The two groups showed no meaningful difference considering the bacterial flora of nasopharynx and their sensitivity. Bacteria in both groups were sensitive to Amoxicillin and Amoxicillin-clavulanate and resistant to Azithromycin, Cefixime and Cephalexin.

A comparison of tympanometry with 226 Hz and 1000 Hz probe tones in children with Down syndrome

Background For children with Down syndrome, the incidence of hearing loss may be as high as 78% [1], therefore the American Academy of Pediatrics recommends regular screening for the presence of hearing abnormalities. Tympanometry is used as an indication of middle ear pathology. In our experience, Down's patients’ tympanograms do not always correlate with otoscopic findings. Down's patients have joint laxity, small ear canals, anterior tympanic membrane orientation and softer tissue composition, all factors thought to affect tympanogram results in infants. Because the use of the 1000 Hz tympanometry is widely recognized as standard procedure in the evaluation of infants aged 0–6 months, we propose it may have greater reliability in testing patients with Down syndrome. Objective Compare the results of visual inspection of the tympanic membrane by a Pediatric Otolaryngologist to the results of tympanometry at traditional probe tone (226 Hz) and at the infant probe tone (1000 Hz). Methods Institutional Review Board – approved prospective study of 26 subject-ears in patients with Down syndrome aged 6 months–18 years but recent stable middle ear/Eustachian tube function using physical examination and tympanometric probe tones at 226 Hz and 1000 Hz. Subject-ears were examined with record of “clear of effusion,” showed the presence of “fluid,” or were to be “excluded.” Blinded to ear exam results, tympanometry was then completed with record of which Jerger classification tympanogram was found at each frequency. Results Although the sensitivity of each test was 1, the specificity of the 1000 Hz tympanometry (100%) in this study was markedly improved compared to the specificity of the 226 Hz tympanometry (71%) ( p = 0.016). Conclusions This pilot study demonstrated evidence that tympanometry in children with Down syndrome may be more reliable at 1000 Hz than at 226 Hz in detecting the presence of middle ear effusion beyond infancy. Use of the 1000 Hz probe tone yielded fewer false positives for disease (type B tympanograms in the setting of absent middle ear disease). Further studies of a larger patient population are needed to corroborate these results.

An assessment of the validity of tympanometry compared to myringotomy performed under a nitrous oxide-free general anaesthetic

To assess the validity of tympanometry as a test for the presence of middle ear effusion using a 'gold-standard' of myringotomy performed after a nitrous oxide-free general anaesthetic, we performed a prospective validity study comparing tympanometry traces obtained immediately pre-operatively from patients undergoing grommet insertion, with the otomicroscopic findings at myringotomy. Nitrous oxide was omitted from the anaesthetic gaseous mixture as it has been reported to displace middle ear effusions. One hundred and seventy-two patients (aged 1.5-15 years) with a clinically assessed 3 month history of middle ear effusion were included in the study. Sensitivity and specificity of a Jerger classification Type B tympanometric trace for the presence of middle ear effusion were 0.73 and 0.84, respectively. We conclude that tympanometry is a valid test in assessing the presence of middle ear effusion compared to a 'gold standard' of myringotomy performed after a nitrous oxide-free general anaesthetic.

Daily Tympanometry for High‐Resolution Measurement of the Time between Onset Of Cold‐Like Illness and Middle Ear Effusion

Tympanometry is a simple method to assess middle ear pressure (MEP) and the presence of middle ear effusion (MEE), a marker of otitis media (OM). To determine whether daily parental tympanometry and illness sign recording in their children can be used to define the time between onsets of cold-like illness (CLI) and MEE at high resolution. Prospective, longitudinal, 7 month, daily follow-up on 169 children aged 1 through 8.6 years. Tympanograms and illness were recorded daily by a parent. Tympanograms were examined, rejected if artifactual, and MEP data were entered into a database, with "flat tympanograms" coded as -400 mm H2O = MEE. The incidence and burden of CLIs (>2 days) were calculated, and for each CLI, the presence/absence of concurrent MEE (>2 days) was determined. For each child, the average MEP for CLI and nonCLI days was calculated. Paired CLI and tympanometric results were aligned and the days between event onsets determined. Stepwise regression was used to assign risk predictors for the measured outcomes. A total of 566 CLIs were recorded, and the average CLI burden/child was 16%. Age was a significant predictor of CLI incidence/child, and age, history of colds, and daily environment were predictors of CLI-burden/child. Of the 433 evaluable CLI episodes, MEE was a complication in 37%, and MEE with a CLI was predicted by age, OM history, and environment. MEP was significantly more negative during CLI episodes, and the magnitude was predicted by age, race, and OM history. The average difference in MEE-CLI onsets was 1.2 +/- 4.0 days; approximately 32% of MEEs occurred prior to CLI onset and 17% on the same day as CLI onset. CLIs adversely affect the middle ear-ambient pressure balance and are frequently associated with MEE episodes. The distribution in onsets between those events suggests that chemoprophylaxis of a child with a newly identified CLI to prevent MEE would have a low expected efficiency.

Psychometric qualities of questionnaires for the assessment of otitis media impact

The assessment of impact and evaluation of treatment effects in chronic otitis media (OM) calls for a much broader approach than just examining the presence of middle ear effusion or hearing loss. It is increasingly recognised that this condition may result in a comprised quality of life. Several studies have used proxy completed questionnaires to objectify the illness experience associated with chronic OM. To review questionnaires which have been developed to describe the effects of chronic OM on the daily functioning of children. Psychometric properties have been evaluated, in addition to discriminative and evaluative qualities. A systematic review of publications pertaining to developed questionnaires related with chronic OM. Systematic literature searches of PubMed (1966-January 2007) and EMBASE (1989-January 2007) were conducted, supplemented by using free text words to identify publications after January 2005. The included 15 questionnaires were developed for children with recurrent or persistent OM, describing functional health status (FHS), while two questionnaires also evaluate the effect of tympanostomy tubes insertion. The questionnaires generally cover six impact areas (physical symptoms, child development, educational performance, emotional/practical burden and general health status) with physical symptoms being the most prominant. The OM8-30, OMO-22 and OM-6 adequately reflect the multidimensional aspects of FHS in chronic OM. The OMO-22 and OM8-30 show the best psychometric properties for the discrimination of impact severity between children, while the OM-6 was found to have the best qualities for the evaluation of clinical change. Clinical applicability is crucial for the assessment of FHS in chronic OM, but requires a trade-off with necessary psychometric properties.

Middle Ear Effusion Interleukin-6 and Interleukin-8 levels could Differentiate between Bacterial and Non-Bacterial Acute Otitis Media and Help to Identify the Type of Infecting Bacteria

This study aimed to investigate the middle ear effusion (MEE) levels of interleukin-6 (IL-6) and IL-8 inchildren with acute otitis media (AOM) and their relation to its etiology and type of infecting bacteria as a trial to define a faster diagnostic modality than traditional culture and sensitivity testso as to early initiate therapy. The study included 70 children; 44 males and 26 females, with a mean age of 19.3±8 months; 50 patients had unilateral and 20 bilateral AOM (n=90 ears). The diagnosis of AOM was based on presence of fever, irritabilityor earache and signs of inflammation of thetympanic membrane. The presence of MEE was documented by tympanocentesisand MEE sampleswere obtained for culture to define the offending pathogen, cytological examination to grade it according to number of polymophonuclear leucocytes (PNL) and ELISA estimation of the levels of IL-6 and IL-8. Sensitivity and specificity of MEE IL-6 and IL-8 levels for differentiation between bacterial and non-bacterial cases and identification of infecting bacteria were evaluated using the receiver operating characteristic (ROC) curve analysis judged by the area under the curve (AUC). Bacteriological examination identified the infective pathogen in 61 samples (67.7%) and no bacterial infection in 29 samples (32.3%). Combined infection with Haemophilus influenzae (H. inf.) and Streptococcus pneumoniae (S. pn.) was detected in 12 samples. However, single pathogen infection was detected in 49 samples; H. inf in 35 samples, S. pn in 11 samples, Moraxella catarrhalis in 2 samples and S. pyogenes in one sample. Effusion was serous in 52, mucoid in 28 and purulent in 10 effusions. Nine samples weregrade I, 35 were grade II, 29 samples were grade III and 17 samples were grade IV. There was a significant (p 0.05) elevated compared to levels estimated in samples with mixed infection. ROC curve analysis revealed that estimation of MEE levels of both IL-6 and IL-8 are specific for the presence of bacterial AOM with AUC=0.832 & 0.897, respectively. Elevated MEE level of IL-6 could differentiate between H. inf. and S. pn. infection with high specificity with AUC=0.758, while IL-8 was more sensitive indictor of H. inf. infection with AUC=0.363. It may be concluded that AOM is associated with elevated MEE levels ofIL-6 and IL-8 which may suggest a role imposed by these cytokines in pathogenesis of AOM. The elevated levels of both cytokines could differentiate bacterial from non-bacterial cases with high specificity. Elevated MEE level of IL-6 may be specific for S. pn infection, while elevated IL-8 levels may be a sensitive for H. inf. infection

Xylitol to Prevent Acute Otitis Media

To the Editors: We read with interest the clinical trial by Hautalahti, et al “Failure of xylitol given three times a day for preventing acute otitis media.”1 The authors report no effect on the incidence of acute otitis media (AOM) in children treated with xylitol three times daily compared with placebo, in contrast to their two previous clinical trials, which reported 20%–40% reductions in AOM among children treated with a similar total daily dose of xylitol divided five times daily.2,3 The authors explain the disparate findings on the basis of the reduced xylitol frequency, but we find a potentially more compelling explanation. In the current study, the authors’ definition of AOM as the primary outcome of interest required: (1) symptoms of “any respiratory symptoms (fever, cough, rhinitis, blocked nose, sore throat, earache, vomiting, diarrhea, nocturnal restlessness or lack of appetite)”; (2) the presence of middle ear effusion by tympanometry. This definition of AOM is imprecise in that it lacks any requirement for middle ear inflammation and would therefore misclassify episodes of otitis media with effusion (OME) as AOM.4 For example, a child with rhinitis (which could be due to a viral upper respiratory tract infection, environmental allergies, or vasomotor rhinitis) plus a serous middle ear effusion would be classified by the study as having AOM when such a child most likely has OME. Indeed, a child with diarrhea but no respiratory symptoms at all, and an incidental serous middle ear effusion would qualify as having AOM. Such nondifferential misclassification of the outcome biases towards the null and, especially since OME is much more common than AOM, could easily explain the study's null result. What makes this misclassification error all the more puzzling is that the same group of researchers used an appropriate definition of AOM in their 1998 xylitol trial, namely “The diagnosis of AOM required the finding of middle ear effusion in tympanometry (B- or C-curve), verified signs of inflammation in the tympanic membrane (emphasis added), and the presence of symptoms of acute respiratory tract infection (rhinitis, cough, conjunctivitis, sore throat, earache).”3 In summary, the trial by Hautalahti, et al demonstrates that xylitol given three times daily does not prevent OME in children. We believe that the question of whether xylitol given three times daily prevents AOM is still an open one. Louis Vernacchio, MD, MSc Allen A. Mitchell, MD Slone Epidemiology Center at Boston University Boston, MA

Tympanometry or Reflectometry for Confirming Middle Ear Effusion

Accurate diagnosis of acute otitis media (AOM) or otitis media with effusion depends on the presence of middle ear effusion (MEE). Tympanometry and spectral gradient acoustic reflectometry (SGAR) are noninvasive methods for detecting MEE. To compare the accuracy of the two methods, researchers analyzed data from an AOM vaccine study in …

Otitis Media: The Need for a New Paradigm in Medical Education

Those of us who have been concerned about issues related to the diagnosis of otitis media and its appropriate management have come to an urgent conclusion: that our future doctors need to be better educated about otitis media. Although otitis media in children is one of the most prevalent problems that practitioners face in practice, our medical students and residents leave their training inadequately prepared to correctly diagnose and manage this important and ubiquitous health care issue. Spurred by the alarming rates of bacterial resistance, the New York State Otitis Project (sponsored by the New York State Department of Health; www.health.state.ny.us/nysdoh/antibiotic/antibiotic.htm) has, for the past 8 years, been actively dealing with issues related to diagnostic accuracy, evidence-based judicious use of antibiotics, parental and professional perceptions and myths, and the “observation option.” The observation option for acute otitis media (AOM) is a strategy in which antibiotic treatment of selected children (based on diagnostic certainty, age, illness severity, and assurance of follow-up) is deferred for up to 3 days, during which time management is limited to analgesics and symptomatic relief and after which appropriate follow-up is performed.1–3 Our committee has identified many areas in which educational interventions are needed. There are multiple levels in clinical practice that lend themselves to varied venues for more instruction. However, if we look for ways to have the most widespread effect, the best outcome, and the “biggest bang for the buck,” our focus homes in on our trainees in medical school and residency. AOM is the most commonly treated bacterial infection in children. Treatment of this infection accounts for >50% of pediatric antibiotic prescriptions and as much as $5 billion (US) annually in cost.4 AOM, as defined by the Agency for Healthcare Research and Quality, is the presence of middle-ear effusion plus … Address correspondence to Denia A. Varrasso, MD, Chair, New York State Otitis Project, 1214 Waring Ave, Bronx, NY 10469-5432. E-mail: d.varrasso{at}worldnet.att.net

Pneumococcal capsular polysaccharides conjugated to protein D for prevention of acute otitis media caused by both Streptococcus pneumoniae and non‐typable Haemophilus influenzae: a randomised double‐blind efficacy study

Background Acute otitis media is one of the most commonly-diagnosed childhood infections. This study assessed the efficacy of a novel vaccine that contained polysaccharides from 11 different Streptococcus pneumonias serotypes each conjugated to Haemophilus influenzae-derived protein D in prevention of acute otitis media. Methods 4968 infants were randomly assigned to receive either pneumococcal protein D conjugate or hepatitis A vaccine at the ages of 3, 4, 5, and 12-15 months and were followed-up until the end of the second year of life. Middle-ear fluid was obtained for bacteriological culture and serotyping in children who presented with abnormal tympanic membrane or presence of middle-ear effusion, plus two predefined clinical symptoms. The primary endpoint was protective efficacy against the first episode of acute otitis media caused by vaccine pneumococcal serotypes. Analysis was per protocol. Findings From 2 weeks after the third dose to 24-27 months of age, 333 clinical episodes of acute otitis media were recorded in the protein D conjugate group (n=2455) and 499 in the control group (n=2452), giving a significant (33·6%[95%CI 20·8-44·3]) reduction in the overall incidence of acute otitis media. Vaccine efficacy was shown for episodes of acute otitis media caused by pneumococcal vaccine serotypes (52·6% [35·0-65·5] for the first episode and 57·6% [41·4-69·3] for any episode). Efficacy was also shown against episodes of acute otitis media caused by non-typable H influenzae (35·3% [1·8-57·4]). The vaccine reduced frequency of infection from vaccine-related cross-reactive pneumococcal serotypes by 65·5%, but did not significantly change the number of episodes caused by other non-vaccine serotypes. Interpretation These results confirm that using the H influenzae-derived protein D as a carrier protein for pneumococcal polysaccharides not only allowed protection against pneumococcal otitis, but also against acute otitis media due to non-typable H influenzae. Whether this approach would also allow improved protection against lower respiratory tract infections warrants further investigation.