Lisa L. Hunter

Effects of Otitis Media on Extended High-Frequency Hearing in Children:

Extended high-frequency (EHF) hearing was studied in children with and without histories of chronic or recurrent otitis media (OM). The EHF thresholds were found to have good test-retest repeatability. Children with OM histories had poorer EHF hearing than children without OM histories. The EHF hearing in OM children appeared to be related to OM severity. Children with residual tympanometric abnormalities had poorer EHF hearing than OM children with normal middle ear function. The results suggest evidence for middle ear and inner ear components of EHF hearing losses in children with OM.

Otitis media, hearing loss, and language learning: Controversies and current research

ABSTRACT. This article reviews research on the possible linkage of otitis media with effusion (OME) to childrens hearing and development, identifies gaps, and directions for research, and discusses implications for healthcare practices. About half of children with an episode of OME experience a mild hearing loss while about 5-10% of children have moderate hearing loss. Recent prospective and randomized clinical trials suggest none to very small negative associations of OME to childrens later language development. Based on both retrospective and prospective longitudinal studies, associations between OME and perceiving speech in noise and tasks that require equal binaural hearing have been reported but have not been adequately studied with regard to functional outcomes. Thus, on average, for typically developing children, OME may not be a substantial risk factor for later speech and language development or academic achievement. However, these conclusions should be interpreted cautiously, since most of these studies used OME rather than hearing loss as the independent variable (although hearing loss rather than OME is hypothesized to affect language development) and many studies did not control for important confounding variables such as socioeconomic status (SES).

High frequency hearing loss associated with otitis media.

Objective: Long‐term effects of otitis media (OM) on hearing in both conventional and high frequency (HF) regions in children were studied. Design: Children with OM were enrolled in a prospective study of sequelae after tympanostomy tube insertion (intubation) and were examined serially at 6‐mo intervals with audiometry and multifrequency tympanometry, and every 3 mo with tympanometry and otoscopy for at least 3, and up to 5 yr. Hearing thresholds in conventional and HF regions were compared with those of an age‐matched control group of children who had 2 or fewer documented episodes of any type of OM since birth. Frequency of OM during follow‐up, number of intubations, use of ototopical eardrops, age, and sex along with several other factors were analyzed for a relationship to HF hearing loss. Results: Otitis media history was associated with poorer HF hearing, but the presence of subtle residual middle ear dysfunction was not associated with an additional effect on HF hearing. Active middle ear disease significantly affected both conventional and HF thresholds. The number of intubations and frequency of OM during follow‐up were significantly and positively associated with poorer HF thresholds. Several other factors, including middle ear appearance at intubation, presence of tympanosclerosis, age, male gender, and use of ototopical eardrops, were also associated with poorer HF hearing but failed to reach significance after their intercorrelation with number of intubations and frequency of OM was considered. Conclusions: High frequency hearing loss was associated with OM after middle ear disease resolved and after middle ear dysfunction was excluded. Relatively poorer HF hearing thresholds found for older children with OM histories appeared to be attributable to time spent with ear disease. Children at greatest risk for HF hearing loss were those who required multiple intubations. Older children tended to have poorer hearing in both conventional and HF regions, suggesting that the effects of OM on hearing thresholds may be progressive.

Multifrequency Tympanometry: Current Clinical Application

Multifrequency tympanometry has emerged as a clinically feasible test with the advent of computer-controlled systems that can store and analyze complex immittance components at multiple probe tone frequencies. The theoretical basis for understanding multifrequency tympanometry has existed for years, but the diagnostic utility of data obtained at frequencies higher than 660 Hz needs further clarification. In this short course, the Vanhuyse model for the analysis of multifrequency tympanograms is discussed and clinical examples illustrating the usefulness of the model are presented. Normative data are provided for adults and children, and various methods for data acquisition and measurement of resonant frequency are presented.

Clinical Practice Guideline Otitis Media with Effusion (Update)

Objective This update of a 2004 guideline codeveloped by the American Academy of Otolaryngology—Head and Neck Surgery Foundation, the American Academy of Pediatrics, and the American Academy of Family Physicians, provides evidence-based recommendations to manage otitis media with effusion (OME), defined as the presence of fluid in the middle ear without signs or symptoms of acute ear infection. Changes from the prior guideline include consumer advocates added to the update group, evidence from 4 new clinical practice guidelines, 20 new systematic reviews, and 49 randomized control trials, enhanced emphasis on patient education and shared decision making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of OME. Purpose The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing OME and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy, identify children who are most susceptible to developmental sequelae from OME, and educate clinicians and patients regarding the favorable natural history of most OME and the clinical benefits for medical therapy (eg, steroids, antihistamines, decongestants). Additional goals relate to OME surveillance, hearing and language evaluation, and management of OME detected by newborn screening. The target patient for the guideline is a child aged 2 months through 12 years with OME, with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for all clinicians who are likely to diagnose and manage children with OME, and it applies to any setting in which OME would be identified, monitored, or managed. This guideline, however, does not apply to patients <2 months or >12 years old. Action Statements The update group made strong recommendations that clinicians (1) should document the presence of middle ear effusion with pneumatic otoscopy when diagnosing OME in a child; (2) should perform pneumatic otoscopy to assess for OME in a child with otalgia, hearing loss, or both; (3) should obtain tympanometry in children with suspected OME for whom the diagnosis is uncertain after performing (or attempting) pneumatic otoscopy; (4) should manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or 3 months from the date of diagnosis (if onset is unknown); (5) should recommend against using intranasal or systemic steroids for treating OME; (6) should recommend against using systemic antibiotics for treating OME; and (7) should recommend against using antihistamines, decongestants, or both for treating OME. The update group made recommendations that clinicians (1) should document in the medical record counseling of parents of infants with OME who fail a newborn screening regarding the importance of follow-up to ensure that hearing is normal when OME resolves and to exclude an underlying sensorineural hearing loss; (2) should determine if a child with OME is at increased risk for speech, language, or learning problems from middle ear effusion because of baseline sensory, physical, cognitive, or behavioral factors; (3) should evaluate at-risk children for OME at the time of diagnosis of an at-risk condition and at 12 to 18 months of age (if diagnosed as being at risk prior to this time); (4) should not routinely screen children for OME who are not at risk and do not have symptoms that may be attributable to OME, such as hearing difficulties, balance (vestibular) problems, poor school performance, behavioral problems, or ear discomfort; (5) should educate children with OME and their families regarding the natural history of OME, need for follow-up, and the possible sequelae; (6) should obtain an age-appropriate hearing test if OME persists for 3 months or longer OR for OME of any duration in an at-risk child; (7) should counsel families of children with bilateral OME and documented hearing loss about the potential impact on speech and language development; (8) should reevaluate, at 3- to 6-month intervals, children with chronic OME until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; (9) should recommend tympanostomy tubes when surgery is performed for OME in a child <4 years old; adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); (10) should recommend tympanostomy tubes, adenoidectomy, or both when surgery is performed for OME in a child ≥4 years old; and (11) should document resolution of OME, improved hearing, or improved quality of life when managing a child with OME.

High-frequency hearing loss and wideband middle ear impedance in children with otitis media histories.

Objective: This study was undertaken to determine the relationship between extended‐high‐frequency (EHF) hearing losses and wideband middle ear impedance in children with chronic otitis media (OM) histories. Design: Children with OM histories were selected from a prospective study cohort if they had normal tympanograms, no air‐bone gaps, and no otoscopic evidence of active OM at the time of testing. OM subjects were divided into two groups, those with Better Hearing in the EHF range and those with Worse Hearing in the EHF range. The OM groups were compared with an age‐matched, healthy Control group that had no more than five documented episodes of OM and no more than two in any 1 yr. All children were 9 to 16 yr of age. Subjects were tested by standard audiometric methods in the conventional audiometric range (0.25 to 8.0 kHz) and the EHF range (8 to 20 kHz). Middle ear impedance and reflectance were measured with an experimental system over the frequency range 0.25 to 10.08 kHz. Results: The Worse Hearing OM group had slightly poorer hearing in the conventional audiometric frequency range compared with the other two groups. The Better Hearing OM group and the Control group had nearly identical EHF hearing. The Worse Hearing OM group had significantly poorer EHF hearing compared with the other two groups, the difference increasing exponentially with frequency. Middle ear impedance differences among groups were confined to low frequencies (<2 kHz). The Control group had significantly higher negative reactance than the two OM groups. There were no significant group differences in impedance or reflectance in the high frequencies (2 to 10 kHz). Conclusions: The results of this study confirm those of previous reports that children who have recovered from chronic OM have significantly poorer hearing in the EHF range compared with children without significant OM histories. The EHF hearing losses that occur in children with OM histories are strongly frequency dependent, suggesting a preferential effect on the base of the cochlea. Middle ear impedance and reflectance differences do not account for the EHF hearing losses observed in children with OM histories. The results support the hypothesis that OM‐related EHF hearing losses are cochlear in origin.

Wideband reflectance in newborns: Normative regions and relationship to hearing screening results

Objectives: To develop normative data for wideband middle-ear reflectance in a newborn hearing-screening population and to compare test performance with 1-kHz tympanometry for prediction of otoacoustic emission (OAE) screening outcome. Design: Wideband middle-ear reflectance (using both tone and chirp stimuli from 0.2 to 6 kHz), 1-kHz tympanometry, and distortion-product (DP) OAEs were measured in 324 infants at two test sites. Ears were categorized into DP pass and DP refer groups. Results: Normative reflectance values were defined over various frequency regions for both tone and chirp stimuli in ambient pressure conditions, and for reflectance area indices integrated over various frequency ranges. Receiver operating characteristic analyses showed that reflectance provides the best discriminability of DP status in frequency ranges involving 2 kHz and greater discriminability of DP status than 1-kHz tympanometry. Repeated-measures analyses of variance established that (a) there were significant differences in reflectance as a function of DP status and frequency but not sex or ear; (b) tone and chirp stimulus reflectance values are essentially indistinguishable; and (c) newborns from two geographic sites had similar reflectance patterns above 1 kHz. Birth type and weight did not contribute to differences in reflectance. Conclusions: Referrals in OAE-based infant hearing screening were strongly associated with increased wideband reflectance, suggesting middle-ear dysfunction at birth. Reflectance improved significantly during the first 4 days after birth with normalization of middle-ear function. Reflectance scores can be achieved within seconds using the same equipment used for OAE screening. Newborns with high reflectance scores at stage I screening should be rescreened within a few hours to a few days, because most middle-ear problems are transient and resolve spontaneously. If reflectance and OAE are not passed upon stage II screening, referral to an otologist for ear examination is suggested along with diagnostic testing. Newborns with normal reflectance and a refer result for the OAE screen should be referred immediately to an audiologist for diagnostic testing with threshold auditory brainstem response because of higher risk for permanent hearing loss.

Tympanometric evaluation of middle ear function in children with otitis media.

Current tympanometry instruments allow a quantitative approach to the evaluation of middle ear function in children with otitis media. Conventional 226-Hz tympanograms can be characterized by static admittance, tympanometric width (gradient), tympanometric peak pressure, and equivalent volume. Multifrequency tympanograms obtained with probe frequencies ranging from 226 to 2,000 Hz appear to be sensitive to sequelae of otitis media that are not detected by conventional tympanometry or audiometry.

Otoacoustic emissions and tympanometry screening among 0-5 year olds

Objectives To determine the rate of otitis media (OM)‐associated transient evoked otoacoustic emissions (TEOAE) screening failure in a sample of preschool children, to evaluate concordance between TEOAE and tympanometry, to investigate risk factors for TEOAE failure, and to determine agreement between TEOAE failure and physician findings at referral.

Safety and clinical performance of acoustic reflex tests.

OBJECTIVE Safety and effectiveness of acoustic reflex tests are important issues because these tests are widely applied to screen for retrocochlear pathology. Previous studies have reported moderately high sensitivity and specificity for detection of acoustic neuroma. However, there have been reports of possible iatrogenic hearing loss resulting from acoustic reflex threshold (ART) and decay (ARD) tests. This study assessed safety and clinical performance of ART tests for detection of acoustic neuroma. DESIGN We report a case in which ARD testing resulted in a significant bilateral permanent threshold shift. This case was the impetus for us to investigate the clinical utility of ART and ARD tests. We analyzed sensitivity and specificity of ART, as well as asymmetry in pure-tone thresholds (PTT) for detection of acoustic neuroma in 56 tumor and 108 non-tumor ears. RESULTS AND CONCLUSIONS Sensitivity and specificity were higher for PTT asymmetry than for ART. Ipsilateral ART at 1000 Hz had poor sensitivity and specificity for detection of acoustic neuroma, and involves some potential risk to residual hearing for presentation levels higher than 115 dB SPL. Approximately half of the acoustic neuroma group had ipsilateral ARTs that would require administration of ARD tests at levels exceeding 115 dB SPL. Therefore, we conclude that PTT asymmetry is a more effective test for detection of acoustic neuroma, and involves no risk to residual hearing. Future studies of contralateral reflex threshold and ARD in combination with PTT asymmetry are recommended.