SPECIAL
ARTICLE
Workshop
on Effects
of Otitis
Media
on the
Child*
Charles
D. Bluestone,
MD, Jerome
0. Klein, MD, Jack L. Paradise,
MD,
Heinz Eichenwald,
MD, Fred H. Bess, PhD,
Marion
P. Downs,
MA, DHS, Morris Green,
MD,
Jean Berko-Gleason,
PhD, Ira M. Ventry,
PhD,
Susan W. Gray, PhD, Betty Jane McWilliams,
PhD, and
George
A. Gates,
MD
GOALS, DEFINITIONS, AND CLASSIFICATION
OF OTITIS MEDIA
-Charles D. Bluestone, MD
The goal of this Workshop was to assess current knowledge concerning the effects of otitis media on the child. Experts in pediatrics, infectious disease,
otolaryngology, audiology, speech, linguistics, and
psychology met in Chicago on Aug 25, 1982 to
participate in this Workshop. A summary of the
discussions is presented here.
Otitis media is broadly defined as an inflamma-tion of the middle ear without reference to etiology or pathogenesis.1 Otitis media with effusion is an inflammation ofthe middle ear in which a collection of liquid (i.e., middle ear effusion) is present in the
middle ear space (no perforation of the tympanic membrane is present). Atelectasis of the tympanic membrane, which may or may not be associated with otitis media, is defined as either collapse or retraction of the tympanic membrane. Acute otitis
media implies a rapid and short onset of signs and
symptoms lasting approximately 3 weeks. From 3 weeks to 3 months, the process may be resolving or subacute. If middle ear effusion persists beyond 3 months, the condition is classified as chronic otitis
media with effusion.
Many terms have been used for acute otitis me-dia, such as “suppurative,” “purulent,” or “bacte-rial” otitis media; however, a “serous” effusion may also have an acute onset. Otitis media with effusion unaccompanied by signs and symptoms of acute inflammation has also had a plethora of other names: “serous,” “secretory,” “nonsuppurative,”
and “glue ear” have been the most commonly used.
EPIDEMIOLOGY AND NATURAL HISTORY OF
OTITIS MEDIA
-Jerome
0. Klein, MD
Otitis media is one of the most common infec-tious diseases of
childhood.
By
3 years of age, more than two thirds of Boston children have had at least one episode and one third have had three or moreReceived for publication Nov 11, 1982; accepted Nov 22, 1982.
aThis workshop was convened in Chicago, Aug 25, 1982 and was co-sponsored by the Otitis Media Research Center (grant 5 P01 NS16337), Children’s Hospital of Pittsburgh; and Eli Lilly Co., Indianapolis. Moderator: Charles D. Bluestone, MD, De-partment of Otolaryngology, Children’s Hospital of Pittsburgh, Pittsburgh. Participants: Jerome 0. Klein, MD (co-editor), De-partment of Pediatrics, Boston University, Boston; Jack L. Paradise, MD (co-editor), Departments of Pediatrics and Corn-rnunity Medicine, University of Pittsburgh School of Medicine, Pittsburgh; Heinz F. Eichenwald, MD, Department of Pediat-rics, University of Texas Health Sciences Center at Dallas, Dallas; Fred H. Bess, PhD, Department of Hearing and Speech Sciences, Vanderbilt University School of Medicine, Nashville,
TE; Marion Downs, MA, DHS, Department of Otolaryngology, University of Colorado School of Medicine, Denver; Morris
Green, MD, Department of Pediatrics, University of Indiana
School of Medicine, Indianapolis; Jean Berko-Gleason, PhD, Department of Psychology, Boston University, Boston; Ira M. Ventry, PhD, Department of Audiology, Teacher’s College, Co-lumbia University, New York; Susan W. Gray, PhD, Department of Psychology, Vanderbilt University School of Medicine, Nash-ville; Betty Jane McWilliams, PhD, Cleft Palate Center and Department of Communications, University of Pittsburgh, Pittsburgh; George A. Gates, MD, Department of Otorhinolar-yngology, The University of Texas Health Science Center at San Antonio, San Antonio, TX.
Reprint requests to (C.D.B.) Department of Otolaryngology, Children’s Hospital of Pittsburgh, 125 De Soto St, Pittsburgh, PA 15213.
1 I I I I
. - A
t- BC,N122
.- AC, N=161
episodes of otitis media.2 In the office practices of physicians who provide care to children, otitis me-dia is the most frequent diagnosis for illness and
the most frequent reason, after well baby and child
care, for office visits. In a recent survey in Boston of more than 17,000 office visits during the first year of life, otitis media was responsible for
approx-imately one
third
of visits for illness and approxi-mately one fifth of all office visits.3In the Boston study, some features were associ-ated with increased risk of single or recurrent (three
or more) episodes of otitis media: boys were affected more frequently than were girls; whit children had
a higher incidence of otitis than black children, but the category “other,” including Hispanic children, had the highest incidence; children living in
house-holds with many members were more likely to have otitis media than were children in households with fewer members; and children with siblings or par-ents who had a history of chronic otitis media had a higher incidence of otitis media than did children with siblings or parents without a history of the disease.2
In certain populations, both the incidence and severity of otitis media are great. The disease ap-pears to be particularly severe among American Indians and Alaskan and Canadian Eskimos; otor-rhea occurs in a majority of affected children.4
Among Australian aboriginal children, a form of disease termed necrotizing otitis media occurs, with the rapid development of discharge and a large
permanent eardrum perforation.5
Middie ear effusion persists for weeks to months after an episode of acute otitis media. Appropriate antimicrobial agents sterilize the middle ear effu-sion but do not clear the fluid from the middle ear space. Analysis of the experience of the Boston children after the first episode of otitis media in-dicated that 70% still had middie ear effusion at the conclusion of antimicrobial therapy at 2 weeks,
40% had effusion at 1 month, 20% had effusion at
2 months, and 10% had effusion at 3 months.2 We examined many variables for possible effect on duration of effusion. Only the method of feeding was significantly correlated with duration of
effu-sion. Children who were breast-fed had duration of effusion that was significantly shorter than chil-dren who were bottle-fed; longer periods of breast-feeding were associated with shorter periods of
ef-fusion.
The incidence of symptomatic otitis media de-dines with age. Otitis media is less common in children after 7 years of age. However, point
prey-alence studies in the United States6 and Scandi-navia7’8 indicate that up to 28% of apparently asymptomatic children may be identified by tym-panometry as having middle ear effusion during an
examination period. Repeated examinations re-vealed that effusions cleared spontaneously in most
children within a few months.
HEARING LOSS ASSOCIATED WITH MIDDLE
EAR EFFUSION
-Fred
H. Bess, PhDHearing loss is the most common complication and sequela of middle ear disease. The loss is usu-ally conductive, but sensorineural involvement also occurs. The prevalence of hearing loss depends on
its definition. Although difficulties exist in
deter-mining prevalence from published reports because of limited information about testing conditions, calibration of equipment, definition of hearing loss, and diagnosis of disease, estimates of prevalence
nevertheless can be made by selecting data from
some of the better controlled investigations.
A typical audiometric profile accompanying otitis media with effusion is shown in Fig. 1. The profile for air conduction is relatively flat, with slight peaking at 2,000 Hz.9 The average degree of air
conduction loss through the speech frequency range
(500 Hz, 1 kHz, 2 kHz) is 27.6 dB; the bone
con-duction values averaged 3
dB;
the mean air bone gap was thus 24.6 dB.The hearing loss associated with middle ear ef-fusion is variable in degree. Data from three studies’#{176}12 involving 627 ears indicate the following hearing loss categories: within the speech frequency range, 7.7% showed an average loss of 10 dB or less;
91.5% exhibited losses between 16 and 40 dB; and only 0.8% showed losses of 50 dB or more. If hearing
loss is defined as an average of 21
dB
or more in(I) -J ‘U
U
LU
0
z
.J LU > LU -I 0 1
0
I
(I)
LU
I 0 I
4
100
FREOUENCY IN HERTZ
125 250 500 1000 2000 4000 8000
0
20
40
60
80
-Fig 1. Composite audiogram of subjects diagnosed as having otitis media with effusion. Mean air conduction
(AC) values represent 161 ears, whereas mean bone
con-duction (BC) thresholds constitute 122 ears (adapted
the speech frequency range, the prevalence for these subjects would be 55%, but if hearing loss is defined
as 31
dB
or more, the prevalence would be 26%. It has been a long-standing premise among phy-sicians and audiologists that a correlation exists between the viscosity of the effusion and the degree of hearing loss. It is now understood that hearingloss is dependent on the volume of the effusion rather than the physical properties of the effu-sion.12’13
Hearing loss also may accompany high negative pressure even if effusion is not present.’4’7 Cooper et al17 studied the audiometric status of 1,133 ears and noted that the air bone gap increases as the middle ear pressure decreases. Conductive losses of
10
dB
or greater occurred in more than 50% of the ears with negative middle ear pressure.It is possible that in some instances, hearing loss may result from chronic otitis media.182’ Studies in animals show that toxic products can pass through the round window membrane, damage the cochlea, and produce a high-frequency sensori-neural hearing 1055.2223
COMPLICATIONS AND SEQUELAE OF OTITIS
MEDIA
-Charles D. Bluestone, MD
The complications and sequelae of otitis media predominantly involve the middle ear and adjacent structures within the temporal bone, but in rare instances intracranial complications also may
oc-cur. The aural and intratemporal complications and sequelae include hearing loss (as discussed above), perforation or retraction pocket of the tympanic membrane, tympanoscierosis, adhesive otitis me-dia, ossicular discontinuity and fixation, chronic suppurative otitis media, cholesteatoma, mastoidi-tis, petrositis, labyrinthitis, facial paralysis, and cholesterol granuloma.
In otitis media, perforation of the tympanic mem-brane is usually secondary to acute infection, but may also occur in the course of chronic effusions. Spontaneous perforation has been considered more common in certain population groups such as American Indians and Eskimos, and may be higher in children from whom antimicrobial therapy has been withheld.24 The effect on hearing of a small
perforation, regardless of its location and in the absence of other middle ear abnormalities, is not significant. However, a large perforation can be associated with an appreciable conductive hearing loss, eg, 20 to 30
dB.
Tympanoscierosis is characterized by the pres-ence of white plaques in the tympanic membrane and nodular deposits in the submucosal layers of the middle ear.25 It may be a sequela of chronic
middle
ear
inflammation
or the
result
of trauma,
eg, from a tympanostomy tube. Conductive hearing loss may occur if the ossicles become embedded in the deposits.
Adhesive otitis media is thickening of the mucous
membrane by proliferation of fibrous tissue which frequently causes fixation of ossicles, resulting in a conductive hearing loss. No data on the prevalence
of adhesive otitis media in children exist, but the condition is not uncommon in those who have had recurrent acute or chronic otitis media with effu-sion. Adhesive otitis media also may result in ossi-cular discontinuity due to osteitis, especially of the long process of the incus, which may, in turn, result in conductive hearing loss. When there is a ret
rac-tion pocket (severe localized atelectasis) in the pos-terosuperior portion of the pars tensa of the
tym-panic membrane, adhesive changes may bind the eardrum to the ossicles and cause resorption. Once
this
occurs, the development of a cholesteatoma becomes possible.26Chronic suppurative otitis media is inflammation of the middle ear and mastoid in which chronic perforation and discharge (otorrhea) are present. In a study conducted by the School Health Service
in Great Britain, the proportion of children found
to have chronic otitis media at the periodic medical inspections was approximately 9/1,000.27
Cholesteatoma
is an accumulation
of
desquamat-ing keratinizing stratified squamous epithelium
within the middle ear or other pneumatized por-tions of the temporal bone. The incidence of cho-lesteatoma in Iowa was estimated to be 6/100,000; up to 9 years of age, the incidence was 4.7/100,000; and between 10 and 19 years, 9.2/100,000, the high-est for all age groups. Cholesteatoma is relatively more common in children with cleft palate; in one
study,
9.2% developed cholesteatoma. This seems not unexpected, as chronic otitis media witheffu-sion is universal in infants with unrepaired cleft
palate28 and remains common following repair.29’3#{176}
This progression of the disease may also have
rel-evance to children with chronic otitis media with effusion who do not have a cleft of the palate.
The incidence of mastoiditis has become low since
the introduction of antimicrobial agents, but the disease still occurs, mainly in untreated cases of acute otitis media.
Labyrinthitis occurs when infection spreads from the middle ear into the inner ear. Acute suppurative labyrinthitis has become rare since the widespread
use of antibiotics.
However,
acute
serous
reviewed the audiograms of patients who had sur-gery for chronic otitis media with perforation and found a significant degree of bone conduction loss in the younger age groups. There was a marked difference in the presence and degree of sensori-neural hearing loss in the affected ear, as compared to the normal ear, in patients of all age groups who had unilateral disease. Fluctuating sensorineural hearing loss has been described in patients with otitis media and has been thought to be due to either endolymphatic hydrops32 or to a perilym-phatic fistula.33
Facial para1ysi may occur in the course of acute otitis media. During the period 1960 to 1980, at least 35 cases of facial paralysis associated with acute otitis media at either the Children’s Hospital or the Eye and Ear Hospital of Pittsburgh were reported.
Suppuration in the middle ear or mastoid, or
both, may extend into the intracranial cavity,
pro-ducing the following suppurative intracranial
corn-plications: meningitis, extradural abscess, subdural empyema, focal encephalitis, brain abscess, lateral (sigmoid) sinus thrombosis, and otitic hydroceph-alus.3436
COMPLICATIONS
AND SEQUELAE
OF
NONSURGICAL
AND SURGICAL
MANAGEMENT
OF OTITIS MEDIA
-Charles D. Bluestone, MD
Complications and sequelae are associated with both nonsurgical and surgical methods of manage-ment of otitis media. It has been estimated that there were approximately 21 million patient visits for otitis media to health professionals last year (National Drug Therapeutic Index, IMS America, New York). Adverse side effects of antimicrobial agents and other drugs occur commonly, but data
concerning the frequency of reactions such as di-arrhea, skin rash, hepatitis, vasculitis, nephritis, serum sickness, anaphylaxis, and even death, are
sparse. Data are also sparse concerning complica-tions of surgical procedures.
Myringotomy and tympanocentesis are simple
and safe procedures. Otorrhea following myringo-tomy for acute otitis media is the desired outcome, but the discharge may become profuse and cause
eczematoid external otitis. Although they occur Un-commonly, the most frequent sequelae of the pro-cedure are persistent perforation, atrophic scar, or tympanosclerosis. Dislocation of the ossicles, 5ev-ering the facial nerve, or puncturing an exposed jugular bulb are dreaded complications but are rare in experienced hands.
Myringotomy with insertion of tympanostomy tubes is currently the most common surgical pro-cedure requiring general anesthesia performed in
children. Common complications of this procedure include scarring of the tympanic membrane (tym-panosclerosis) and localized or diffuse membrane
atrophy and persistent or recurrent otorrhea
(Ta-ble). Much less commonly, a perforation may
re-main at the insertion site following extrusion of the
tube, or more rarely, an implantation
cholestea-toma may develop.
Adenoidectomy performed either separately or in combination with tonsillectomy is the most com-mon major surgical procedure employed to prevent
otitis media.43 In 1979, approximately 634,000
pro-cedures
on the tonsils and adenoids were performed in the United States44; a large but undetermined number were performed for management of otitismedia.
Although
considered
by
many
to be minor
procedures, they carry a significant risk. The death rate has been estimated as between 1 in 3,000 and 1 in 27,000. In the United States, this would result in between 40 and 350 deaths per year. No data are available concerning morbidity rates of tonsil and
adenoid surgery; these rates are obviously many
times greater than the death rates and include permanent neurologic damage following intraoper-ative or postoperative respiratory or cardiac arrest, hemorrhage, injury to the eyes, pharynx, and teeth, velopharyngeal insufficiency, nasopharyngeal
ste-nosis,
and psychological
problems.46
Tympanoplasty -or mastoidectomy, or both, are
TABLE. Incidence of Complications and Sequelae Following Tympanostomy Tube Insertion for Otitis Media with
Effusion in Children
Investigator(s) No. of Subjects (Ears) Follow-up (yr)
mci dence (%)
Tympano- Otorrhea Persistent. Cholesteatoma sclerosis Perforation
Kilby et a137 52 (52) 2 28* NAt 1.9 0
Brown et al 55 (55) 5 42* NA 0 0
Draf and Schulz39 677 (876) NA NA 12.5 0.1 1.6
Muenker#{176} 631 (1,060) NA 50 15.0 2.5 0.9
Barfoed and Rosborg’’ 102 (173) 7 61 34.0 3.0 0
Lildholdt42 150 (150) 5 52* 30.0 0 0
* J contralateral ears in which no tympanostomy tubes had been inserted, incidence was 21%, 0%, and 11.3%.42
Frequency in Cycles per Second
125 250 500 1000 2000 4000 8000
40
\ I MU)
- %,,
0 0
0
z
40
I
(II _
sh ,‘
--Softest Speech Energy
Average Speech Energy
Mean of
ad tosses
Loudest Speech Energy performed infrequently but are the most common major surgical procedures performed on the ears of children.47 The operation involves recognized risks of indeterminate incidence, including facial paral-ysis, sensorineural hearing loss, and risks
associ-ated
with administration of general anesthesia.AUDIOLOGIST’S OVERVIEW OF SEQUELAE OF
EARLY OTITIS MEDIA
-Marion P. Downs, MA, DHS
If hearing loss interferes in any way with norrnal development in young children, it is incumbent upon
the rnanaging physician to identify the develop-rnental delay and to provide intervention.
Long-standing hearing losses in children have been classically associated with decreased cognitive skills and lowered school attainment.48’49 Only re-cently have studies appeared suggesting that even mild and fluctuating hearing losses due to otitis
media, when sustained in infancy, may affect later
language functioning of children. Such mild losses
are shown in Fig. 2 in relation to the range of
normal speech.9”1 The speech signal is degraded as a result.50’51
Some 30 studies involving 3,500 children have shown a consistent association of early fluctuant hearing losses with later decreased learning skills.4’50’5277 Although design weaknesses abound, one study made comparisons of children with and without otitis within a circumscribed racial group55; another compared siblings within one
socioeco-
:::-3C
:
ii
::
ii
-:
::::
3,J
60
70
80
-“9
--‘ez
-
-7s
-
---
;7
-::
E
E
E
E
E
Fig 2. Range of speech energy related to standard
au-diogram. Shaded area shows range of sound energy pres-ent in normal speech with dashed line indicating average of speech energy (adapted from Skinner51). Line
con-nected by solid circles shows mean of hearing losses from
otitis media (OM) according to Kokko9. It can be seen that softer speech sounds may not be heard when otitis media is present.
nomic group74; another study contrasted findings
within two disparate socioeconomic groups76;
an-other culled experimental and control groups from
an entire school district’s third grade62; another
looked at groups in
grades
3 to 6 in a schooldis-trict.77 No amount of cavilling over experimental design can obviate the fact that serious attention must be given to these findings.
But what is more relevant to the physician’s
responsibility is the demonstration that language delays due to mild hearing loss from otitis media
can be identified in the first years of life. Friel-Patti et a178 applied language evaluations (Re-ceptive Expressive Emergent Language Scale
[REEL];
Sequenced
Inventory of CommunicationDevelopment [SICD]) at 12, 18, and 24 months to a group of infants who had been in intensive care on low-birth-weight measures and who developed documented recurrent otitis media. A parallel group with documented normal ear history was followed in the same way. Of the 14 infants who had no evidence of otitis media, delayed language of less than 6 months was considered to be present in two subjects and in one child, the delay was greater
than 6 months. By comparison, of the 14 subjects
who were identified as being “otitis-prone,” four
were thought to have a delay in language of less than 6 months, and in six infants, the delay was greater than 6 months. The numbers in this study are small, but the point is made that language delays from otitis can be identified. A tool for such screening has been suggested by Down and Blager.79
When language delay is present, some form of intervention is mandatory, for 75% of children with language problems by 5 years of age can be expected still to be language-delayed at 9 years.#{176}The Con-sortium for Longitudinal Studies81 has shown that early mother-child intervention, from birth to 3 years of age, is efficacious and productive of lasting
effects. Therefore, it is recommended that after 3
months of otitis media without cure, a protocol of
educational intervention concurrent with ongoing
medical or surgical treatment be followed: (1) a home language stimulation program, and (2) con-sideration of hearing aid use in selected cases.79 It has been our experience that such programs result
in marked gains in performance in children with
recurrent otitis media.
Early otitis probably has a complex effect that has not yet been sorted out. As described in the Perry Preschool Project,8’ different environments
influence cognitive ability in different ways, and
different individual reactions to the environment provide another variable. Questions raised by the
presence of other variables include: (1) How is
maternal-infant bonding affected by otitis media?
(3) Are parental communication strategies
af-fected? Are the factors of reciprocal interplay
de-scribed by Schachter broken down? (4) How do
the acoustics of speech affect learning? What
amount of degradation of the speech signal can be
tolerated?5#{176} (5) Are there systemic effects of otitis media? Is this the vital factor in reducing learning?
These questions must be answered before we can
understand
the
dimensions of the problem of mild, recurrent hearing loss associated with otitis media.RESEARCH DESIGN ISSUES IN STUDIES OF
EFFECTS OF MIDDLE EAR EFFUSION
-Ira M. Ventry, PhD
In a 1980 article on the effects of conductive
hearing loss, I made the following statement: “A
careful evaluation of published research on the
relation between conductive hearing impairment
and
language
and learning difficulties suggests that the relationship has been poorly documented, thatmethodologic flaws have contaminated the data and
confounded the reported results, and that there is
a continuing need .
..
for ongoing research in this area.M Although additional studies have beenpub-lished
in the interim, none of these studies hascaused
me to change my opinion. I still maintain that no causal link has been established between early recurrent middle ear effusion and anybehav-ioral phenomenon of interest, such as language
delay, learning problems, or the like.
What I find most distressing in my review of
research in this area is that there is no evidence of
increased research
sophistication
or improved
re-search methodology over the last 10 to 15 years. It
is remarkable, indeed, that in the 13 years since
publication of the work of Holm and Kunze,53 there
have been no refinements in research design, no
innovative statistical treatment of data, no
imagi-native or even state-of-the-art assessments of
lan-guage.
In fact,
there
has been
backsliding.
For
in-stance, Holm and Kunze acknowledged the
limita-tions of their design in a way that is infrequently seen in current research reports.
What to do? First, researchers ought to reread
the report of Hanson and Ulvestadm for the many
valuable suggestions and insights made by the
var-ious contributors. Second, researchers should
aban-don the between-subjects retrospective design. The
shortcomings of this design are numerous and the
time spent in handling these shortcomings is
prob-ably better spent in working with other more
pro-ductive research designs. Next, far greater use
should be made of both experimental and
descrip-tive within-subject designs. In the former design,
an independent variable that presumably reflects a
consequence of middle ear effusion can be
manip-ulated to study the effects of that manipulation on
some dependent variable. The latter design can
represent a longitudinal study, a type of study
fre-quently advocated but never used to study the
ef-fects of middle ear effusion. Fourth, there should
be
increased use of correlational designs. Of the many studies that have attempted to explore the behavioral consequences of middle ear effusion, notone has employed even basic, much less advanced,
correlational techniques-this, despite the fact that
statisticians and research methodologists have
sug-gested that certain types of correlational research can lead to cause-and-effect statements. A sophis-ticated extension of correlational research is ex-emplified by path analysis. Duffy et al.87 recently
described
the application of path analysis to speechand language disorders. I would suggest that the
application of path analysis to research on the
effects of middle ear effusion may finally provide
some of the answers we have been seeking. Fifth,
no matter what type of research design is used,
considerable attention must be given to controlling those factors that can threaten the internal validity of the research.m Internal validity is the sine qua
non
of all
research designs. Finally, I believe that research on the effects of middle ear effusion should be in the hands of qualified researchers. The issuesinvolved are of such consequence that they require
the skill, experience, and sophistication of individ-uals who have been trained to do behavioral re-search.
Are there causal links between early and
recur-rent middle ear effusion and delayed speech and
language
development, educational retardation, learning disabilities, or cognitive development? We simply do not have the answers at present. Whetherwe have the answers in the future depends, in large
part, on our commitment to research excellence.
OTITIS MEDIA AND LANGUAGE DEVELOPMENT
-Jean Berko-Gleason, PhD
There are many suggestions in the literature that chronic otitis media with effusion in infants and
young children is associated with, or even causes,
atypical or delayed language development. Inas-much as adequate control of language is a prereq-uisite for attaining many different types of con-cepts, such children are also considered at risk for academic failure once they enter school, especially in reading and other subjects that rely upon lin-guistic skill. Two groups of children are not consid-ered in this paper: those with only occasional acute bouts of otitis media with effusion for whom there
is no evidence of being at risk; and those who have
permanent loss of hearing, for whom there is ample
evidence of frequent linguistic and academic prob-lems.89’9#{176}The children who are considered here are
fluctuating hearing loss during the critical period
of language development because of otitis media
with effusion, with a typical criterion for inclusion in a study being that the child have had at least six episodes before the age of 6 years.’9’
In such children, the rationale for postulating
adverse effects on language development is based
on what we know about the way children acquire
language. For instance, long before they begin to
speak, normal infants are able to make fine
pho-netic discriminations and to distinguish the speech
sounds of the language around them. During early
language acquisition, the child learns the sound
system of the language as well as how to form such
things as plurals or past tenses; this may require
hearing the difference between words like plays and place, or help and helped. An inconsistent auditory
signal resulting from fluctuating hearing loss may
make the stream of speech difficult to segment and
impede the child’s ability to form linguistic cate-gories.
A number of studies attempting to document the
effects of conductive hearing loss on children’s
lin-guistic and academic skills were reviewed by
Rapin89 in 1979. Most of them were retrospective
and dealt with school-aged populations who were
tested with standard instruments, such as the
Illi-nois Test of Psycholinguistic Abilities and the Pea-body Picture Vocabulary Test. General conclusions
were that children with a history of otitis media
with effusion have normal sounding spontaneous speech, with a history of delay rather than deviance
in acquisition, but that they have problems with
reading and limited vocabularies and syntax, as
compared with children without a history of otitis
media with effusion. Caution must be exercised in
interpreting these studies, many of which contain serious design errors. Others dealt with populations
such as Alaskan Eskimos4 or Australian
aborig-ines55 who were not tested in their own language,
and who were already at risk because of
sociocul-tural factors. Results were often contradictory, even
when attempts were made to control for social class
influences.92 Only a study by Needleman56 included
preschool children as subjects, and none of the
studies was developmental and longitudinal in
na-ture.
A more recent paper by Bax93 reported a 5-year
study carried out in London with 870 children who were seen at age 6 weeks, 6 months, 1, 1#{189},2, 3, and
4#{189}years. He reported a highly significant relation-ship between language delay at 2 years and reported
incidence of otitis media with effusion in the
pre-vious 6 months. At age 3 years, the percentage of
children with otitis media with effusion among
those showing language delay was twice as high as
among the group of children that showed normal
language development; the difference was no longer statistically significant. This study relied heavily
on parental report, and unfortunately did not
pro-vide information on the children’s later language
and scholastic performance. Finally, a study by
Bennett and associates adds a new perspective to
previous findings. These authors examined a group
of learning-disabled children and compared their
current and past middle ear status with that of a
group of control children without academic prob-lems. They found that not only
did
thelearning-disabled children have a higher incidence of past
otitis media with effusion, they also had
signifi-cantly more current middle ear malfunction than
control children. They suggest that chronic
unde-tected middle ear problems may be implicated in
some cases of learning disability.
It is clear from even such a brief summary that
the question of the relationship between early otitis
media with effusion and subsequent language
de-velopment has not been adequately addressed. We
know that some young children with otitis media
with effusion later exhibit linguistic difficulties, but
we do not know whether the effects are permanent
or reversible. Nor do we know what factors might
assure normal language development in the
pres-ence of otitis media with effusion. It is likely that the quality of parent-child interaction is an impor-tant factor. Our current view sees language
devel-opment as an interactive process, with much of the
burden falling on the specialized input that adults
provide children who are developing language.
Some of the questions raised can be answered by
prospective studies of young children with otitis
media with effusion; such studies must include
psy-cholinguistically sophisticated testing as well as
careful attention, not only to the child’s emerging language, but to the linguistic environment as well.
COGNITIVE DEVELOPMENT IN RELATION TO
OTITIS MEDIA
-Susan
W. Gray, PhDIn considering the effects of otitis media upon
the child’s cognitive development, the paramount
issues are ones of measurement and of the design
of appropriate research. Measurement over time of hearing loss in relation to otitis media is far from simple. Longitudinal assessment of the cognitive
status of a child even with normal hearing also
presents difficulties. Cognitive development is a
broad term that subsumes the growth of problem
solving, thinking, judgment, and reasoning, or the
so-called higher mental processes.94 I shall limit
most of my remarks to the index of cognitive
de-velopment most closely associated with
Tests of intelligence are highly useful tools but
cover only certain manifestations of cognitive
de-velopment and tell us nothing about underlying
mechanisms or structures. With infants and
tod-dlers, possibly the age groups of most concern here,
intelligence tests generally have little value for
long-range prediction. Most tests are heavily
de-pendent on receptive and expressive language.
Tests designed for special populations such as the
deaf
pose issues of appropriate reference norms.Thus, intelligence tests are hardly comprehensive
instruments with which to attempt to answer the
questions we raise here. Horowitz95 suggested that
other assessment approaches may be more fruitful,
but such forms of assessment are not ready-made;
they require painstaking construction. In addition,
classic experimental design does not lend itself
readily to problems that are developmental and
clinical in nature. Alternative strategies are needed,
but are limited in their applicability and general
acceptance by the research community. If a
re-searcher finds some or no relationship with otitis
media, it may be that the chosen instruments and methodology were inappropriate or inadequate for
the task.
Despite such problems-and they are
considera-ble-it may be possible to pose some questions that
admit of an empirical answer. Anecdotal data,
cer-tam
interesting but flawed studies on hearing loss,Mand extrapolation from other research suggest some
general lines of inquiry. For many questions, suffi-cient resources will not be available for definitive
answers. Perhaps the accumulation of less
ambi-tious studies, if variables are carefully defined, will
gradually make it possible to answer such queries as these:
1. Are there sensitive periods of development
when fluctuating and occasional hearing loss may
have especially negative consequences? An example
might be the period around 18 months, inasmuch
as language acquisition and social interaction are dominant themes in the life of a toddler.
2. Where intellective deficits are observed, do
they indicate delay or permanent damage? Some
recent reports suggest much more reversibility of
early
delay
arising from restricted environmentin-put than was once thought to be the case. It may
not be difficult to compensate for temporary
hear-ing loss.
3. If cognitive deficits occur, are they direct ef-fects of hearing loss, or, rather, are they mediated
by changes in the child’s motivational patterns and
in the perceptions of others? Evidence suggests that undiagnosed hearing loss creates strain in relation-ships with parents and teachers.97 Inconsistencies in the child’s ability to hear and in the reactions of others conceivably might have pervasive and lasting
effects upon the child’s motivation to achieve.
These are only three queries among many of
practical or theoretical interest. The notion that
otitis media has negative effects upon cognitive
development is intuitively appealing, but sound
em-pirical evidence so far appears to be lacking.
EFFECT OF OT1TIS MEDIA ON ARTICULATION
DEVELOPMENT IN CHILDREN
-Betty Jane McWilliams, PhD
The assumption that repeated episodes of otitis
media, with its variably expressed, often fluctuating
hearing losses, are detrimental to articulatory
de-velopment in children finds easy acceptance among
many professional people. It is a hypothesis that
has face validity because everyone knows that
se-vere communicative impairment is invariably
as-sociated with profound hearing losses. Thus, it is
sensible to assume that less serious losses cause
less severe communicative problems and that
artic-ulation is logically an aspect of speech that is ad-versely affected.
Holme and Kunze53 and Needleman56 concluded
that articulation errors were greater in children
with histories of repeated episodes of otitis media than in children who did not present such histories. Consistent with these findings, tentative
observa-tions have been made of children with cleft palate
in whom otitis media is universal.28’98’99 However, Ventry and Paradise1#{176}#{176}have raised serious
ques-tions about the nature of the research leading to
conclusions about otitis media and its effects on
development. The status of our knowledge about
the influences of these mild to moderate conductive
hearing losses on articulatory maturation remains
equally controversial.
There is no doubt about the intimate relationship
between hearing, language, and speech
develop-ment. Northern and Lemme101 highlight this
inter-action when they say that mild hearing losses (HL)
in the range of 15 to 40 dB HL, such as are usually
associated with otitis media, may result in the
child’s missing voiceless consonants. Losses
be-tween 25 and 40 dB HL after the first year of life
may, in their view, be especially detrimental to
articulation.
Clinical evidence suggests that articulation
de-velopment is influenced by conductive hearing loss,
but that the relationship is undoubtedly modified
by many variables that have yet to be identified. These probably include the severity of the loss; the length of time it persists; its consistency; the tim-ing, success, and frequency of treatment; the overall
developmental integrity of the child; the ability of
the family to provide an adequate speech
au-ditory training are provided if they are needed; and countless psychosocial factors not yet specified. In short, it appears that some children with 25 dB losses for specified periods of time may have mild
articulatory impairment, the nature of which
re-mains to be precisely explored, while others may
not, suggesting a multifactorial causation, with hearing loss as one of several causal factors. That
picture may change as the losses become greater or
more persistent or, perhaps, as they fluctuate more
extensively. Clinical experience suggests that such
variations must be studied even though the design problems posed are almost insurmountable.
Until the appropriate research has been carried
out, we suspect but cannot prove, that most of the
articulation disorders that may be related to otitis
media are mild and tend to disappear with
increas-ing age. Otitis media is not usually the explanation for intractable articulatory deficits. However, under certain conditions, still unknown, otitis media may
be responsible for significant alterations in the
pattern of articulation development in younger
children. The age at which the hearing losses are
most influential is another mystery, but it is likely to be within the first 2 to 3 years of life.
Until we have more acceptable evidence about
the influence of otitis media in childhood, we should refrain from its simplistic use as an explanation for developmental variations in children.
LONG-TERM EFFECTS OF SHORT-TERM
HEARING LOSS-MENACE OR MYTH?
-Jack L. Paradise, MD
In two recent commnications,1#{176}#{176}”#{176}2I reviewed the then available literature on possible
relation-ships between otitis media during early life and later impairments of intellectual, speech, language,
and psychological development. In those reports, I
concluded, first, that no such associations had been established; second, that should they be established, serious problems would remain in demonstrating
causality; and third, that any developmental
im-pairments that did result from early conductive
losses would probably be reversible if normal hear-ing were restored.
The problems of the studies reported up to that
time were, to an extent, inherent in their retrospec-tive design, but other issues were involved as well. Collectively, the limitations and deficits consisted of the following: uncertain validity of the diagnosis early in life of either the presence of otitis media or its absence; lack of data concerning subjects’ hear-ing levels early in life; persistence of impaired hear-ing at the time of developmental testing; question-ably suitable matching of experimental and control
subjects with regard to variables known to affect
developmental outcome; small numbers of study
subjects, or nonrepresentativeness of subjects, or
both; the use of developmental tests that were
inappropriate or of uncertain reliability and
valid-ity; inadequate blinding; and selective emphasis of
data. Finally, a fundamental obstacle faced by any
study comparing developmental outcomes in chil-dren who had much otitis media with outcomes in children who had little, is the possibility that com-monly underlying factors exist that predispose both
to otitis media morbidity and to developmental
impairments.
More recently, a few additional studies of interest have been reported. Teele et al76 administered tests
of language function to children followed
prospec-tively from birth. Those who had experienced 130
or more days of middle ear effusion, and those who
had experienced fewer than 30 days, were
com-pared. In suburban, private practice subjects, scores were significantly lower in those with persistent than with short-term effusions, but no such
differ-ences were noted among low-income, urban clinic
subjects. Inasmuch as only an abstract was
pub-lished, judgment about the study must await a more
comprehensive report.
Sak and Ruben,74 in an attempt to minimize
possible confounding variables, compared 18 sibling pairs between 8 and 1 1 years of age. One sibling of
each pair had had a documented history of
recur-rent middle ear effusion dating from before 5 years of age, whereas the other sibling had had no middle ear effusion whatever. The subjects were evaluated using a battery of audiologic, psychological, lan-guage, and achievement tests. Both groups tested
in the ‘bright-normal range, without any real
defi-cits, but those who had had otitis media showed, as a group, slightly lower verbal IQs, slightly poorer
auditory reception, and slightly lower spelling
achievement than their matched sibling controls.
Unfortunately, from the standpoint of
interpreta-tion, 72% of the otitis siblings compared with 44%
of the control siblings were boys, a difference that might have contributed to the small differences in
developmental scores between the two groups;
moreover, minor middle ear abnormalities, as
evi-denced by audiometric and tympanometric data,
were more prevalent among the otitis siblings than
among the control siblings. Thus, the so-called
“deficits”-if there were deficits-might
conceiva-bly have been related to recent middle ear disease
rather than to early middle ear disease.
Hoffman-Lawless et al’#{176}3compared 7- and
9-year-old children who had had documented middle
ear disease and surgical placement of
tympanos-tomy tubes prior to 5 years of age, with control
subjects who had had no known middle ear disease.
early otitis and control groups in five tests of
au-ditory processing ability. The findings were thus
inconsistent with those of Sak and Ruben.
Finally, Friel-Patti et al78 examined the relation-ship between frequent episodes of otitis media early
in life and language development as assessed at 12,
18, and 24 months. The infants, who had been
selected from either intensive-care or
low-birth-weight nurseries, and who came from
predomi-nantly low socioeconomic groups, received periodic
otoscopic examinations, auditory brainstem
re-sponse testing, and tympanometric assessment.
Frequent episodes of otitis media were correlated
with a higher prevalence of language delay, but no
correlation was found between hearing impairment
and language delay. This again raises the question
whether early otitis media on the one hand, and
language delay on the other, have predisposing
de-terminants in common without themselves being
causally related.
In summary, no convincing evidence currently
exists that adverse developmental consequences
re-sult from otitis media limited to the first few years
of life. However, because contrary evidence is also
lacking, and because otits media is such a prevalent
disorder, appropriately designed studies are
ur-gently needed to investigate this question further.
SOCIOECONOMIC IMPACT OF OTITIS MEDIA
-George A. Gates, MD
Social and economic consequences of recurrent
or persistent otitis media may be important but
have not often been discussed in the literature.
There may be good reasons for this void. First, such
topics have not been generally regarded as -part of
the sphere of interest or expertise of the biomedical
scientist. It would be desirable to encourage the
social scientist to become involved in this area.
With the rise of consumer activist groups and the
social demystification of the practice of medicine, it is surprising that this has not occurred. Second,
there are limited data that must be culled from a
variety of sources. Third, people perceive problems
differently and what appears as a large problem to
one family may be accepted without a second
thought by another. Much depends upon one’s
at-titude, background, and prior experience in this
regard. Fourth, just as otitis media varies in
sever-ity, so too must the socioeconomic impact upon the
patient and family.
I
divide socioeconomic factors into three groupsaccording to whether they affect primarily the child, the family, or the community.
The child with otitis media may be distracted
from his surroundings because of pain, decreased
hearing, malaise, and the annoying autophony that
accompanies conductive hearing loss. Adjustment
to these symptoms requires differing strategies at
different times because the symptoms usually
fluc-tuate greatly. The anxiety and general
unpleasant-ness associated with hospitals, doctors, office visits,
hearing tests, painful examinations, needles,
bad-tasting medication, awful-smelling anesthetic gases, and separation from parents, home, and friends probably leave remembrances that are, to say the least, discomforting. Undoubtedly, these
traumas can be minimized by guidance, education,
and caring attitudes on the part of all concerned.
Symptoms of otitis media may interfere with
con-centration, a tolerant attitude, and a desire to excel.
I suspect that children with otitis media become
fussy and irritable and find it difficult to
concen-trate on lessons. Most likely they catch up with their school work when they feel better, but un-doubtedly some do not. We all recognize that there
are prime learning experiences that once passed do
not readily present themselves again. It would be
unfortunate, indeed, if one were to miss such an opportunity because of illness.
Most families have direct experience with otitis
media inasmuch as it affects 85% of children at
least once.104 The larger the number of children in the household, the more likely that they will de-velop otitis media, especially as viral upper respi-ratory tract infection that may be a precursor of
most cases’#{176}5 usually passes from sibling to sibling.
The family must contend with earaches in the middle of the night, irritable children who don’t sleep normally, visits to the emergency room and doctor’s office for examination and treatment, con-sultations, hearing tests, and, finally, surgery when
all else fails. Not only is there a strain on the
pocketbook, but also, there is a substantial
emo-tional drain as well. Will my child hear normally?
Will school work be affected? When will the
prob-lem stop? These are but a few of the parental anxieties that have been expressed to all of us who have taken care of these children.
It is impossible to calculate the national bill for
treatment of otitis media for we do not know how
many office and clinic visits are made for treatment
of otitis media, nor do we have any grasp of the
costs involved. However, for purposes of argument,
suppose that 85% of the 3.5 million children born
in 1979 in the United States have one episode of
otitis media, 50% have a second episode, 30% have a third, and 25% have six episodes. By compressing all of these into 1 year, this cohort would then account for 8.4 million episodes. Extrapolating from the report of Teele et al,’#{176}there might be as many
as 12.84 million episodes, however. Given that each
episode might engender one initial visit and one
tympanocenteses ($15), 0.01 myringotomies ($25),
0.5 tympanograms ($10), .01 audiograms ($20), and
0.5 otology consultations ($40), the annual bill
would amount to $454 to 695 million. Of course,
these calculations are hypothetical, but if you were
to fill in the amounts appropriate to your
commu-nity, you would have a general sense as to the fiscal impact of the disorder.
The costs of the surgical procedures must
like-wise be estimated because they vary so widely. I
surveyed a small number of otolaryngologists from
across the country and found that the average sur-gical fee for bilateral myringotomy and insertion of tubes was $277, the anesthesiologist’s fee was $166,
and the hospital charges for an outpatient surgery
amounted to approximately $500. The composite
charge would be about $1,000. The number of such
procedures is not known. The Commission on
Professional Hospital Activities noted that there
were 219,000 procedures coded as myringotomy
done in the 5,764 short-term acute care hospitals
in the United States in 1981.107 The 1979 National
Hospital Discharge Survey conducted by the
Na-tional Center for Health Statistics’#{176}8 indicated that
225,000 myringotomy procedures were done in
8,017 hospitals. That these two surveys produced such disparate results is probably due to the differ-ences in the data base, sample size, and survey
methodology. Both probably greatly underestimate
the actual total due to the number of procedures
performed on outpatients or in ambulatory surgical
centers that are not included. Given that the actual
total might be as high as 400,000 cases annually,
the total bill, including $30 million extra for
ad-enoidectomy, would be in the neighborhood of $430
million. The combined annual cost of treatment of
otitis media could therefore be projected to be as much as $1 billion.
The community ultimately pays for the costs of health care inasmuch as those expenses are met with funds that might have been expended
else-where. The cost of research into prevention and
treatment of otitis media should also be borne by
the community because it is the community that will ultimately benefit from advances.
CONCLUSIONS
Otitis media with effusion is one of the most
common diseases of childhood. Concern about the
disease is based not only on its frequency, but also
on its acute morbidity, its suppurative and
struc-tural complications and sequelae, and its
accom-panying hearing losses of variable degree and
du-ration. Treatments currently used in the
manage-ment of otitis media may, depending on their
na-ture, embody substantial risks as well as
consider-able costs. In general, many of the treatments are
undertaken in the face of inadequate knowledge of
the course of otitis media and its short- and
long-term morbidity and sequelae, and uncertainty
re-garding the relative efficacy and risks of the medical and surgical methods of therapy. In particular, this
is true of the management of middle ear effusion of
prolonged duration in otherwise healthy children;
consensus even is lacking about what specific hear-ing thresholds constitute clinically significant
hear-ing loss at various ages during infancy and child-hood. Little doubt exists that at least temporary
developmental impairments result from hearing
loss of moderate or severe degree that is
long-standing and unremitting, but no convincing
evi-dence exists at present to relate developmental
impairments to single or multiple episodes of short-term hearing loss or to mild hearing loss
irrespec-tive of duration. Future studies directed toward
better understanding of the effects of otitis media, and of the variable hearing loss that accompanies it, will require the participation of investigators from varied disciplines and the application of rig-orous principles of research design.
The Workshop conferees recommend that
chil-dren should receive, as part of every visit to the
health care professional for illness or well-child care, an examination with a pneumatic otoscope to determine the possible existence of otitis media. At present all children who have acute symptomatic otitis media should receive an appropriate
antimi-crobial agent for an adequate period. All children
with middle ear effusion should be reexamined pe-riodically until the condition has cleared. Manage-ment guidelines have been described in recent re-views.102’109
ACKNOWLEDGMENT
The authors thank Sandra Arjona for editorial
prepa-ration of the manuscript.
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