Severe Otitis Media Research Articles

SPECTRUM AND MANAGEMENT OF OTITIS MEDIA IN AUSTRALIAN INDIGENOUS AND NON-INDIGENOUS CHILDREN: A NATIONAL STUDY

INTRODUCTION: The reported prevalence and severity of otitis media are highest among the world's Indigenous children, but whether their clinical management varies accordingly is unknown. OBJECTIVE: Our aim was to study the spectrum and management of otitis media in Indigenous and non-Indigenous children in Australia. METHODS: From a representative Australian cluster survey of consecutive primary health care consultations, we analyzed all consultations with children (aged 0–18 years). We compared the practitioners' investigation, treatment, and referral practices for Indigenous and non-Indigenous children with otitis media after adjusting for clustering. RESULTS: Over 8 years (1998–2006), 7991 practitioners managed 141 693 problems in 119 503 consultations with children, including 2856 (2.4%) with Indigenous children. Ear problems were the fourth most common problems managed. Otitis media was managed slightly more commonly in Indigenous than non-Indigenous children (9.8% vs 7.3% consultations; P < .05). When otitis media was diagnosed, Indigenous children were significantly more likely to have severe otitis media (chronic and/or suppurative and/or perforation: 7.9% vs 1.7%; P < .001), discharging ears (3.9% vs 0.1%; P < .001), ear swabs (3.9% [95% confidence interval (CI): 1.6–6.2] vs 0.8% [95% CI: 0.6–0.9]), and topical eardrops administered (10.7% [95% CI: 6.8–14.6] vs 4.5% [95% CI: 4.1–5.0]) but not more likely to receive oral antibiotics (71.8% vs 75.9%), have ear syringing (1.1% vs 0.2%), or be referred to an otolaryngologist (6.1% vs 3.4%) or audiologist (1.8% vs 1.1%) (all P > .05). CONCLUSIONS: In the Australian primary health care setting, Indigenous children are 5 times more likely to be diagnosed with severe otitis media than non-Indigenous children, but reported management is not substantially different, which is inconsistent with established national guidelines. This spectrum-management discordance may contribute to continued worse outcomes for Indigenous children with otitis media.

RANDOMIZED, CONTROLLED TRIAL EFFICACY OF PNEUMOCOCCAL CONJUGATE VACCINE AGAINST OTITIS MEDIA AMONG NAVAJO AND WHITE MOUNTAIN APACHE INFANTS

We report the phase III trial efficacy of 7-valent pneumococcal conjugate vaccine against clinical and culture proven otitis media (OM) among Navajo and White Mountain Apache infants. Efficacy was -0.4% (95% CI: -19.4 to 15.6) for clinically-diagnosed OM, 5.1% (95% CI: -51.5 to 40.6) for severe OM, and 64% (95% CI: -34% to 90%) for vaccine serotype pneumococcal OM suggesting that this vaccine is efficacious for pneumococcal OM in this high risk population.

The Spectrum and Management of Otitis Media in Australian Indigenous and Nonindigenous Children: A National Study

Indigenous children have the highest reported prevalence and severity of otitis media in the world, but whether their clinical management varies accordingly is unknown. Using a representative Australia-wide cluster survey of consecutive primary healthcare consultations, we compared practitioners' investigation, treatment, and referral practices for otitis media in indigenous and nonindigenous children (0-18 years), after adjusting for clustering. Over 8 years (1998-2006), 7991 practitioners managed 141,693 problems during 119,503 consultations with children, including 2856 (2%) with indigenous children. Ear problems were the fourth most common problems managed overall, with otitis media seen more commonly in indigenous than in nonindigenous children (10% versus 7% consultations, P < 0.001). Indigenous children were significantly more likely to have severe otitis media (chronic and/or suppurative and/or perforation, 8% versus 2%, P < 0.001); discharging ears (4% versus 0.1%, P < 0.001); ear swabs [4%, 95% confidence interval (CI): 2%-6% versus 0.8%, 95% CI: 0.6%-0.9%]; and topical eardrops administered (11%, 95% CI: 7%-15% versus 5%, 95% CI: 4%-5%); but not more likely to receive oral antibiotics (72% versus 76%); have ear syringing (1% versus 0.2%); be referred to an otolaryngologist (6% versus 3%) or audiologist (2% versus 1%); all P > 0.05. In the Australian primary healthcare setting, indigenous children are 5 times more likely to be diagnosed with severe otitis media than nonindigenous children, but reported management is not substantially different, which is inconsistent with established national guidelines. This spectrum-management discordance may contribute to continued worse outcomes for indigenous children with otitis media.

Ten-year experience using a plastic, disposable curette for the diagnosis of primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD) results in impaired mucociliary clearance. Patients with this disorder develop chronic sinopulmonary disease with recurrent sinusitis, otitis media, nasal polyposis, pneumonia, and, ultimately, bronchiectasis. Other associated findings of dysfunctional ciliary activity include situs inversus, dextrocardia, and infertility. To describe our 10-year experience using a small, plastic, disposable curette to perform a screening procedure for cilia function and to collect samples for electron microscopy. In the past 10 years, we screened infants and children with severe chronic sinusitis and other chronic recurrent upper respiratory tract problems for PCD by using a plastic, disposable curette to collect tissue samples from the nasal mucosa. Samples were placed in sterile saline and examined under light microscopy for the presence of cilia. Failure to note ciliary movement prompted another examination 1 month later. If no functional cilia were noted at the follow-up examination, a specimen was obtained and sent for electron microscopy. We identified 7 patients with PCD; 2 had situs inversus totalis. Average age at diagnosis was 3 years. The most common symptom at presentation was frequent upper respiratory tract infections with severe otitis media (7 patients) and sinusitis (5 patients). Recurrent pneumonia was present in 6 patients. Dynein arm deficiency was the most common electron microscopic diagnosis. Evaluating children for PCD by using a plastic, disposable curette is a relatively simple procedure that could be used by allergists in practice. Primary ciliary dyskinesia occurs frequently enough that physicians should consider it as part of the differential diagnosis in evaluating children with recurrent, severe sinopulmonary infections.

Missed opportunities for a diagnosis of acute otitis media in Aboriginal children.

Severe otitis media and its sequelae are common in rural and remote Aboriginal children. Identification of acute otitis media (AOM) is likely to reduce the number of children who go on to develop chronic suppurative otitis media and associated complications. The aim of this study was to compare the diagnoses made by researchers with that documented in the medical records of children admitted to the paediatric isolation ward of the Royal Darwin Hospital, Darwin, Northern Territory. Children aged <8 years admitted to Royal Darwin Hospital were eligible for assessment by pneumatic otoscopy, video-otoscopy and tympanometry. A diagnosis was made for each child according to the state of their worst ear. Comparisons were made between the researcher diagnoses of ear disease and those documented in the hospital notes by medical staff. Thirty-one children were enrolled during 32 admissions. Most were aged <2 years, Aboriginal, and resided in remote communities. Sixty-one video-otoscopic assessments were attempted and sufficiently good images to allow diagnosis were obtained in 105 of 122 ears. Acute otitis media was diagnosed by the research team in 20 of 32 child admissions. Of 29 children who had ear examinations documented by hospital staff, only seven had a diagnosis of AOM recorded. Overall, the research team were almost three times more likely to make this diagnosis (relative risk 2.9, 95% confidence interval 1.6, 5.2). This difference was unlikely to have occurred by chance (P = 0.0002, McNemar's Chi-squared test). In this small study, young Aboriginal children with clear bulging of their tympanic membrane were not diagnosed with AOM by medical staff. Further training in diagnosis, including cleaning of the ear canal, may lead to more accurate assessment and appropriate recommendations for ongoing management.

The burden of otitis media

Otitis media is the most frequent reason that children go to the doctor for illness. In developing countries, where children have limited access to medical care, suppurative complications of otitis media (OM) are frequent and permanent hearing loss results. In developed countries, the most common morbidity of OM is conductive hearing loss due to middle ear effusion. Infants with severe and recurrent OM and persistent middle ear effusion are at risk for problems in behavior and development of speech, language and cognitive abilities. Parent stress is frequent. The cost of otitis media is large (>$5 billion in the United States). Selection and spread of multi-drug resistant bacterial pathogens arising from extensive use of antimicrobial agents for OM is a problem for management of all diseases due to the pathogens. The incidence and severity of OM may diminish with introduction of new bacterial and viral vaccines.

A systematic review of clinical research addressing the prevalence, aetiology, diagnosis, prognosis and therapy of otitis media in Australian Aboriginal children.

The objective of this review was to systemically identify and summarize all the clinically relevant evidence available from studies addressing the prevalence, aetiology, diagnosis, prognosis and therapy of otitis media in Australian Aboriginal children. Electronic searching of Medline, the Australian Medical Index and the Aboriginal and Torres Strait Islander Health Bibliographic Index was performed. This was supplemented by hand searching the Menzies School of Health Research otitis media collection, the Aboriginal and Torres Strait Islander Health Information Bulletin and Aboriginal Health: an annotated bibliography. Data were extracted and placed in a series of evidence tables relevant to clinical practice. There were 59 studies that met the inclusion criteria. The majority were surveys, and only 19 addressed diagnosis, prognosis or therapy. Severe otitis media in rural Aboriginal children does not occur in isolation but as part of a spectrum of chronic bacterial infections of the respiratory tract. Although the aspects of poverty that result in this condition remain to be clarified, exposure to other young children with chronic nasal discharge is likely to be important. Whilst there is a considerable amount of literature on otitis media in Australian Aboriginal children, the number of studies most relevant to improving health outcomes is small. A systematic approach to disease surveillance, diagnosis, and application of medical interventions is required urgently. Future medical research should be concerned with the evaluation of interventions and the generalisabilty of studies from different populations.

5. Nose X-ray examination on children of severe otitis media with effusion

5. Nose X-ray examination on children of severe otitis media with effusion

Otitis Media in Association with Various Congenital Diseases; Preliminary Study

We studied temporal bone histopathology to obtain clues as to the role of eustachian tube (ET) disease in the pathogenesis of otitis media (OM) in patients with congenital anomalies. Thirteen temporal bones obtained from 13 individuals with various congenital anomalies were used. We looked in particular at severity of inflammation in the middle ear (ME) and ET, and at deformity of the ET cartilage. Evidence of OM was found in all the temporal bones. The ETs consistently showed a moderate degree of inflammation but without any particular correlation with the severity of ME inflammation. Deformity of the ET cartilage was present in six cases (46.2%), representing three cases of cleft palate and three of other congenital anomalies. Because the deformity of ET cartilage tended to be associated with more severe OM, we consider this cartilage deformity to be an important cause of tubal dysfunction, and thus of the high incidence of OM among individuals with congenital ear anomalies.

Speech perception in children with histories of recurrent otitis media.

The present study investigated the ability of 5-year-old children to perceive differences in voice onset time (VOT) in naturally produced speech. Three groups of children whose hearing was within normal limits at the time of the experiment were tested on identification and discrimination tasks: (1) group C, in which the children had normal language abilities and no history of severe, recurrent otitis media (OM), (2) group OM, in which the children had histories of severe, recurrent OM but normal language abilities, and (3) group OM/DL, in which the children had histories of severe OM and delays in the acquisition of linguistic competence. Compared to group C, group OM/DL showed marked differences in their ability to identify and discriminate speech patterns. Their perception was less categorical, as well, in that there was less of a peak in the discrimination function at the region of the phoneme boundary. The performance of group OM fell between the other two groups, with deficits being more pronounced in the discrimination task than in the identification task. The results supported the idea that episodes of OM can produce periods of sensory deprivation that alter perceptual abilities. The relation of a history of OM to later language and academic difficulties was also considered.

Longitudinal studies of experimental otitis media with Haemophilus influenzae in the gerbil.

Haemophilus influenzae non-typable strain 119 was found to cause severe otitis media with sequellae when inoculated into the middle ear cavities of the Mongolian gerbil, Meriones unguiculatus. Acute inflammation was followed by the development of highly vascular granulation tissue and formation of new bone within the middle ear bulla. These changes persisted throughout the 14-week study in the untreated animals. The gerbil was variably susceptible to otitis media caused by inoculating 30-3000 bacterial cells and 100% susceptible to greater than 3000 cells. The susceptibility of the gerbil to common etiological agents of otitis media allows its use as an appropriate model of the disease.

Tympanostomy tubes: the conservative approach.

The clear advantage accruing from the use of tympanostomy tubes in the treatment of otitis media with effusion is immediate improvement in hearing; there are also disadvantages entailed, such as scarring of the drum risk of continuing otorrhea and interference with the patient's normal physical activities. All possible forms of medical treatment should be exhausted (antihistamine decongestants, politzerization) before resorting to tympanostomy tubes. There is a small group of children with severe chronic nasal obstruction and otitis media with effusion for whom adenoidectomy is likely to be required.

Prolonged Anuria in Wegener's Granulomatosis

IN WEGENER'S granulomatosis with renal involvement, the outcome had been uniformly fatal until cytotoxic therapy was found to dramatically alter the course of the disease. We describe a patient with remarkable recovery of renal function while receiving cyclophosphamide therapy after prolonged anuria. Report of a Case A 24-year-old woman was well until April 1976, when a fistula developed in the scar of a uterotomy performed five years earlier. In May, she had severe otitis media on the left, with hearing loss and perforation of the tympanic membrane. An excision of the abdominal fistula was done in July; the histologic examination showed chronic granulomatous inflammation. In August, polyarthralgia and otitis media on the right and facial nerve palsy on the left developed. A mastoidectomy was performed because of mastoiditis; a histologic examination was not done. On Sept 10, she was admitted to another hospital because of prostration, fever, and ulcerations of

Anaphylactic Reaction To γ-globulin

To the Editor:— A 7-year-old white boy has been under my care for approximately 4 1/2 years, because of repeated upper-respiratory tract infections, and episodes of tonsilitis, somewhat helped by tonsillectomy at the age of 4. Additional complications have been nonspecific croup, bronchopneumonia, and superficial skin abscesses. Frequent and severe otitis media has usually been a consequence of an upper-respiratory tract infection. The boy would complain of pain in one ear in the morning, and, despite immediate administration of decongestants and antibiotics, perforation of the ear drum would take place in six to seven hours. This happened four or five times in four years, in addition to attacks of otitis media without perforation at least once a month. Otologic and other studies have reported only perennial nasopharyngitis of infectious origin. Cultures of nasopharyngeal and ear exudates have yielded Haemophilus influenzae, Staphylococcus aureus , coagulase positive, pneumococci, and streptococci of the viridans

CONJUGATE DEVIATION OF THE EYES WITH MIDDLE EAR SUPPURATION.Read before the Chicago Medical Society, Jan. 8, 1894.

Upon June 13 last, I was called in consultation to see the following case, on account of the serious symptoms which had supervened three days before. The history of the case was given as follows: John W., aged 18, had a discharge from his left ear during childhood. This had ceased and remained well until the present attack. After having influenza seven weeks ago, a severe otitis media on the left side with profuse discharge followed. Under treatment he was progressing favorably until three days ago when he had chills, severe pain in left side of head, dizziness and vomiting, since which time his temperature has ranged from one-half to three-quarters of a degree above normal, but has not exceeded that at any time. It was also noticed that the discharge was less profuse. <i>Condition Present</i>.—Patient very weak, perspiring freely. Temperature 99 degrees. Pulse 120. Dizziness so bad he could