Margaretha L. Casselbrant

Otitis media with effusion in preschool children.

The incidence, prevalence, and natural history of otitis media with effusion (OME) and middle ear high negative pressure (HNP) were investigated in a group of 2 to 6 year old preschool children. The children were examined monthly over a two year period from September 1981 to August 1983. The middle ear status was assessed using a decision‐tree algorithm which combined the findings of pneumatic otoscopy, tympanometry, and acoustic reflex measurements. Fifty‐three percent of the children in the first year and 61% in the second year developed OME; also during the two years, HNP was documented in 66% of the children. Eighty percent of OME episodes lasted only two months. The prevalence of OME and HNP showed a seasonal variation and a strong association with the presence of upper respiratory infections (URIs). The incidence of OME was independent of age. These data indicate that OME and HNP are prevalent conditions with a high spontaneous recovery in the preschool population.

Head and Neck Space Infections in Infants and Children

A retrospective study was performed in 117 children with head and neck space infections treated at the Childrens Hospital of Pittsburgh from January 1986 through June 1992. Peritonsillar space infections were the most common (49%), followed by retropharyngeal (22%), submandibular (14%), buccal (11%), parapharyngeal (2%), and canine (2%) space infections. The most common pathogens isolated (N = 78) were the aerobes beta-hemolytic streptococcus (18%) and Staphylococcus aureus (18%), the anaerobes Bacteroides melaninogenicus (17%) and Veillonella (14%), and the gram-negative organism Haemophilus parainfluenzae (14%). beta-Lactamase production by aerobic pathogens was detected in 22% of cultures. Computed tomography scans (N = 16) were reviewed in blinded fashion and compared with operative findings. The sensitivity of computed tomography scan in detecting the presence of an abscess vs. cellulitis was high (91%), whereas the specificity was rather low (60%). Treatment of head and neck space infections in children should consist of accurate physical diagnosis aided by imaging studies, empiric antibiotic therapy that covers gram-negative and beta-lactamase--producing organisms as well as gram-positive organisms and anaerobes, and timely surgical intervention, when indicated.

Efficacy of antimicrobial prophylaxis and of tympanostomy tube insertion for prevention of recurrent acute otitis media: results of a randomized clinical trial

To determine the efficacy of amoxicillin prophylaxis and of tympanostomy tube insertion in preventing recurrences of acute otitis media, we randomized 264 children 7 to 35 months of age who had a history of recurrent otitis media but were free of middle ear effusion to receive either amoxicillin prophylaxis, bilateral tympanostomy tube insertion or placebo. The average rate of new episodes per child year of either acute otitis media or otorrhea was 0.60 in the amoxicillin group, 1.08 in the placebo group and 1.02 in the tympanostomy tube group (amoxicillin vs. placebo, P < 0.001; tubes vs. placebo, P = 0.25). The average proportion of time with otitis media of any type was 10.0% in the amoxicillin group, 15.0% in the placebo group and 6.6% in the tympanostomy tube group (amoxicillin vs. placebo, P = 0.03; tubes vs. placebo, P < 0.001). At the 2-year end point, the rate of attrition was 42.2% in the amoxicillin group, 45.5% in the placebo group and 26.7% in the tympanostomy tube group. Adverse drug reactions occurred in 7.0% of the amoxicillin group and persistent tympanic membrane perforations developed in 3.9% of the tympanostomy tube group. The observed degree of efficacy of amoxicillin prophylaxis and of tympanostomy tube insertion must be viewed in light of the fact that study subjects proved not to have been at as high risk for acute otitis media as had been anticipated and in view of the differential attrition rates. We conclude that in the age group we studied, amoxicillin prophylaxis is the preferred first measure in attempting to prevent recurrences of acute otitis media and that tympanostomy tube insertion is a reasonble next alternative.

Treatment of acute maxillary sinusitis in childhood: A comparative study of amoxicillin and cefaclor

Maxillary sinus aspiration and quantitative culture of the aspirate were performed in 50 patients, ranging in age from 1 to 16 years, with clinical and radiographic evidence of acute sinusitis. Of 79 sinuses aspirated, at least one was found to be infected in 35 (70%) children. Streptococcus pneumoniae, Branhamella catarrhalis, and Haemophilus influenzae were the most common organisms recovered. All H. influenzae were nontypeable. Twenty percent of the H. influenzae and 27% of the B. catarrhalis organisms were beta-lactamase positive and amoxicillin resistant. The subjects received either amoxicillin or cefaclor at a dose of 40 mg/kg/day in three doses for 10 days. The clinical cure rate with amoxicillin was 81%, compared to 78% with cefaclor. Radiographic improvement was similar in both treatment groups. Antibiotic therapy failed in four patients; three had been given amoxicillin, and one cefaclor. In three of these, a beta-lactamase-positive antibiotic-resistant bacterial species was recovered from the maxillary sinus aspirate; the fourth aspirate was sterile.

Intratemporal complications of acute otitis media in infants and children

We reviewed our experience with 100 children admitted to Childrens Hospital of Pittsburgh between 1980 and 1995 with an intratemporal complication of acute otitis media. Seventy-two patients were treated for acute mastoiditis. Of these 72 children, 54 (75.0%) were treated conservatively with broad-spectrum intravenous antibiotics and myringotomy. Eighteen (25.0%) required mastoidectomy for treatment of a subperiosteal or Bezolds abscess or cholesteatoma, or because of poor response to conservative therapy. Twenty-two children presented with facial paralysis, complete in 5 (22.7%) and incomplete in 17 (77.3%). Eighteen (81.8%) were treated conservatively, but four required mastoid surgery. Nineteen patients had adequate follow-up; of these, 15 recovered normal facial function but 4 were left with partial paralysis. Three patients presented with serous labyrinthitis and recovered completely with conservative therapy. Of the two patients who presented with suppurative labyrinthitis, one was treated conservatively, but the other required tympanomastoidectomy with cochleotomy; both patients had permanent, profound sensorineural hearing loss in the affected ear. Four patients presented with acute petrositis, and in all four it resolved with mastoidectomy. In the antibiotic era, intratemporal complications of acute otitis media still occur in otherwise healthy children, often after inadequate treatment of acute otitis media.

Asthma and bacterial sinusitis in children

Signs, symptoms, and radiographic abnormalities of sinusitis are frequent in children with asthma; it is not known whether sinus inflammation is associated with bacterial infection or other mechanisms. Eight asthmatic patients with exacerbation of asthma despite bronchodilator therapy were studied after maxillary sinusitis was confirmed by radiographs. All had cough, wheezing, nasal stuffiness, rhinorrhea and were afebrile. Four patients had headaches, and two had facial pain. Maxillary sinus aspirates were obtained, and bacterial cultures were positive in five: Branhamella catarrhalis (2), nontypeable Hemophilus influenzae (2), Streptococcus pneumoniae (1). Nose and throat cultures did not correlate with sinus cultures. All patients received bronchodilators, and four of eight patients received steroids. All were treated for 14 to 28 days with antibiotics during which seven of the eight patients improved clinically including all with positive sinus cultures. Asthma-symptoms diary scores were kept by five; all demonstrated improvement. Pulmonary-function tests improved in five of seven patients after the antibiotic and asthma therapy including the four patients with positive cultures. Sinus radiographs cleared in three, improved in three, and were unchanged in two patients after antibiotic therapy.

Acute otorrhea: bacteriology of a common complication of tympanostomy tubes.

We prospectively followed 246 children with tympanostomy tubes and observed acute otorrhea through a functioning tube at least once in 50% of subjects. Pathogens typical of acute otitis media (Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes) were found in 42% of all episodes; Pseudomonas aeruginosa or Staphylococcus aureus was found in 44% of all episodes. Pathogens of acute otitis media were found in 50.0% of subjects under 6 years old versus 4.4% of subjects 6 years or over at the first episode (p < .001). Pseudomonas aeruginosa was found more often in children 6 years or older (43.5% versus 20.5% at the first episode, p = .052). Pathogens typical of acute otitis media were less prevalent in the summer months (14.7% versus 52.2% for the first episode, p = .001), while P aeruginosa was more prevalent in summer (44.1% versus 16.4% for the first episode, p = .006). This suggests that while many younger children with acute otorrhea may respond to treatment with oral antimicrobials alone, outpatient therapy of older children may involve use of topical antipseudomonal agents that may be complicated by the question of the safety of such medications.

Experimental paralysis of tensor veli palatini muscle

In an effort to study the effects of experimental paralysis of tensor veli palatini (TVP) muscle on Eustachian tube (ET) function and middle-ear (ME) status, botulinum toxin A (Oculinum) was injected into the TVP muscles of 8 Rhesus monkeys. Tubal function was tested longitudinally in 2 animals with tympanostomy tubes using the forced-response test, while in the remaining 6 animals; ME condition was documented daily using tympanometry. The postinjection tubal function was characterized by abolished active muscular function and decreased closing pressure. Activity associated with tubal dilations gradually reappeared by the fifth week. The lack of lumen constrictions following injection suggested that the TVP muscle is the cause of constriction as well as normal dilation. In 6 animals with intact tympanic membranes, 10 of the 12 ears developed flat tympanograms associated with otitis media with effusion (OME) within 8-30 days of injection and serous effusions were recovered by tympanocentesis in seven ears. These results show that a non-traumatic reversible functional obstruction of the ET was created by injecting botulinum toxin A into the TVP muscle. This functional obstruction was associated with the development of high negative ME pressure and serous effusion.

Epidemiology, natural history, and risk factors: Panel report from the Ninth International Research Conference on Otitis Media

The 2007 Recent Advances in Otitis Media Research Conference Panel Report provides an update on otitis media (OM) research published from 2003 to 2007. This report summarizes important trends in disease incidence and prevalence, describes established and newly identified risk factors for acute and chronic OM and OM with effusion, and conveys information on newly discovered genetic factors. In this report, researchers have described declining rates of OM diagnosis, antibiotic prescriptions, offices visits for OM, and middle ear surgery since the licensure and routine use of pneumococcal conjugate vaccine in infants. The panel report also recommends short and long term goals for current and future OM research.

Subacute sinusitis in children

The bacteriologic characteristics of subacute maxillary sinusitis have not been delineated in the pediatric age group. Forty children between the ages of 2 and 12 years with respiratory symptoms for at least 30 but less than 120 days were evaluated. Nasal discharge and cough were the most prominent symptoms. Common radiographic findings were diffuse opacification and mucosal thickenings. Sinus aspiration was performed on 52 sinuses of 40 children. Bacterial colony counts greater than or equal to 10(4) colony-forming units per milliliter were found in 30 (58%) of 52 sinus aspirates obtained from 26 (65%) children. The bacterial species most commonly recovered were Streptococcus pneumoniae, Haemophilus influenzae, and Branhamella catarrhalis. Twenty-five percent of the maxillary sinus isolates were beta-lactamase producing; however, many of these were recovered from patients who had recently received antimicrobial therapy. Subacute and acute maxillary sinusitis are similar in regard to causative organism, clinical presentation, and radiographic findings.