Clyde G. Smith

Effect of early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at the age of three years.

BACKGROUND A main indication for the insertion of tympanostomy tubes in infants and young children is persistent otitis media with effusion, reflecting concern that this condition may cause lasting impairments of speech, language, cognitive, and psychosocial development. However, evidence of such relations is inconclusive, and evidence is lacking that the insertion of tympanostomy tubes prevents developmental impairment. METHODS We enrolled 6350 healthy infants from 2 to 61 days of age and evaluated them regularly for middle-ear effusion. Before the age of three years 429 children with persistent effusion were randomly assigned to have tympanostomy tubes inserted either as soon as possible or up to nine months later if effusion persisted. In 402 of these children we assessed speech, language, cognition, and psychosocial development at the age of three years. RESULTS By the age of three years, 169 children in the early-treatment group (82 percent) and 66 children in the late-treatment group (34 percent) had received tympanostomy tubes. There were no significant differences between the early-treatment group and the late-treatment group at the age of three years in the mean (+/-SD) scores on the Number of Different Words test, a measure of word diversity (124+/-32 and 126+/-30, respectively); the Percentage of Consonants Correct-Revised test, a measure of speech-sound production (85+/-7 vs. 86+/-7); the General Cognitive Index of McCarthy Scales of Childrens Abilities (99+/-14 vs. 101+/-13); or on measures of receptive language, sentence length, grammatical complexity, parent-child stress, and behavior. CONCLUSIONS In children younger than three years of age who have persistent otitis media, prompt insertion of tympanostomy tubes does not measurably improve developmental outcomes at the age of three years.

Hearing levels in infants and young children in relation to testing technique, age group, and the presence or absence of middle-ear effusion.

Objective As part of a prospective study of possible effects of early-life otitis media on speech, language, cognition, and psychosocial development, we evaluated hearing both during episodes of middle-ear effusion (MEE) and when MEE was not present. The objective of this report is to describe age-specific hearing threshold levels in relation to the presence or absence of MEE in a large sample of young children. Design Participants were 1055 children drawn from a sample of 6350 children who were enrolled in the larger study by 2 mo of age. Otologic evaluation of each child was conducted at least monthly. The protocol of the larger study called for hearing evaluations 1) after 8 wk of continuous unilateral or bilateral MEE and every 4 wk thereafter until one test had been conducted when MEE was no longer present; 2) immediately before developmental testing; and 3) in a sample of children without MEE to obtain age-specific normative data. Results Results are presented by testing technique, age group, and middle-ear condition. In general, hearing threshold levels were highest in the youngest children tested with visual reinforcement audiometry and lowest in the oldest children tested with conventional audiometry. In general also, thresholds were lowest in children with normal middle-ear status, intermediate in children with unilateral MEE, and highest in children with bilateral MEE. On average, the presence of bilateral MEE was associated with hearing threshold levels 10 to 15 dB higher than the normative values for the corresponding age group. Conclusions In infants and young children, audiometric results are influenced by testing technique, age group, and the presence or absence of effusion in each ear.

Early versus delayed insertion of tympanostomy tubes for persistent otitis media: developmental outcomes at the age of three years in relation to prerandomization illness patterns and hearing levels

Background. Whether prompt insertion of tympanostomy tubes in children with persistent early life otitis media prevents or minimizes subsequent developmental impairment has been the subject of conflicting opinions and differing approaches to management. Methods. We randomly assigned 429 children with persistent middle ear effusion (MEE) before the age of 3 years to have tympanostomy tubes inserted either as soon as possible or up to 9 months later if MEE persisted. In 402 of these children, we found no significant differences at age 3 years between the 2 treatment groups in mean scores on any measure of speech, language and cognition and in 401 of the children no significant differences in measures of psychosocial development. We then examined outcomes within subgroups of children who might have been the most severely affected, namely those who had been randomized on the basis of bilateral, continuous MEE rather than unilateral and/or discontinuous MEE and those who had the greatest degrees of hearing loss. Results. In none of the subgroups we considered were scores on any outcome measure significantly more favorable in children in the early treatment group than in children in the late treatment group. Conclusions. In otherwise normal children who have MEE, during the first 3 years of life within the durations we studied, prompt insertion of tympanostomy tubes does not measurably improve developmental outcomes at age 3 years, irrespective of whether MEE has been continuous or discontinuous and unilateral or bilateral and whether or not MEE has been accompanied by mild to moderate hearing loss.

Tympanometric findings and the probability of middle-ear effusion in 3686 infants and young children.

OBJECTIVE. We examined relationships between tympanometric findings and the presence or absence of middle-ear effusion in a population-based sample of children under the age of 3 years. METHODS. In a study of children’s development in relation to early-life otitis media, we enrolled 6350 infants soon after birth and evaluated them regularly for the presence of middle-ear effusion. In 3686 of the children, we compared tympanometric findings with otoscopic diagnoses. We categorized tympanograms according to varying combinations of tympanometric peak height, peak pressure, and width, and calculated for each resulting category the percentage of the associated ears diagnosed as having effusion. Using these findings we developed algorithms for estimating the probability of middle-ear effusion associated with tympanograms of any configuration. RESULTS. For tympanograms generally, the lower their height and the greater their width, the greater was the probability of associated middle-ear effusion; the probability also was greater when peak pressure was negative rather than positive. Among children ≥6 months of age, effusion was diagnosed in only 2.7% of ears with tympanometric height ≥0.6 mL, but in 80.2% of ears with flat tympanograms. Relationships among younger infants were similar but less consistent. In both age groups, the tympanographic configurations most commonly encountered were associated with either a relatively low probability (<30%) or a relatively high probability (>70%) of the presence of middle-ear effusion. The receiver operating characteristic curve we generated using the algorithm we developed for children ≥6 months of age gave an area under the curve of 0.84. The algorithm performed equally well when applied to a separate group of children, suggesting that it is generalizable to other unselected populations. CONCLUSIONS. The present report offers two alternative methods for estimating the probability of middle-ear effusion in children aged 6 through 35 months, given any combination of tympanometric values.

Impedance Screening for Preschool Children: State of the Art

As a test for detecting middle ear disease among preschool children, tympanometry — as opposed to audiometry — has three advantageous attributes: a high degree of sensitivity, minimal need for subject cooperation, and total objectivity. For these reasons interest has arisen in tympanometry as a method for screening, i.e., identifying children with previously undetected middle ear disease. However, uncertainty persists concerning the importance of detecting apparently asymptomatic middle ear effusions, and concerning optimal methods, or even the advisability, of treating them. Further, the sensitivity and specificity of tympanometry depend on how the pass-fail cutoff point is defined. Defining this cutoff point so as to achieve high sensitivity may result in excessively low specificity, with the production of large numbers of false-positives who then become overreferrals. Data are presented to show how the validity of the test may be increased to some extent by attention to the gradient of “negative-pressure” tympanograms. At the present time, given the various aforementioned uncertainties, and with adequate validation as to the presence or absence of disease often lacking in reported studies of impedance screening in preschool populations, the cumulative results of these studies do not warrant embarking on large-scale screening programs. What is needed instead is additional research to explore the issue further.

EFFICACY OF ADENOIDECTOMY FOR RECURRENT OTITIS MEDIA: RESULTS FROM PARALLEL RANDOM AND NONRANDOM TRIALS

We defined 218 children at high risk for otitis media (OM) in that each had received myringotomy with tympanostomy-tube placement (M & T) and, subsequent to tube extrusion, had developed recurrent acute or secretory OM. 102 children were assigned to an adenoidectomy or control group randomly, and 116 according to parental preference, and all were followed closely. Standardized antimicrobial regimens were used for new episodes of OM, as were specified criteria for repeat MST for persistent middle-ear effusion. Each ear of each subject on each follow-up day was categorized as with or without tube, and with or without OM.Preliminary results in the random trial in subjects largely completing full years of follow-up were as follows:In the nonrandom trial, results also tended to favor surgical subjects, but the differences were not statistically significant.

Language, Speech Sound Production, and Cognition in 3-Year-Old Children in Relation to Otitis Media in Their First 3 Years of Life

Language, Speech Sound Production, and Cognition in 3-Year-Old Children in Relation to Otitis Media in Their First 3 Years of Life

Receptive Vocabulary and Cognition in 3-Year-Old Children in Relation to Otitis Media in Their First 3 Years of Life. ♦ 564

Receptive Vocabulary and Cognition in 3-Year-Old Children in Relation to Otitis Media in Their First 3 Years of Life. ♦ 564

Parent-Rated Behavior in 3-Year-Old Children in Relation to Otitis Media in Their First 3 Years of Life. † 565

Parent-Rated Behavior in 3-Year-Old Children in Relation to Otitis Media in Their First 3 Years of Life. † 565