Markku Sipilä

Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media. I. The value of different otoscopic findings

To determine the value of different pneumotoscopic findings in diagnosing the middle ear effusion (MEE) of acute (AOM) and non-acute otitis media, 11,804 ear-related visits of 2,911 unselected children at ages 0.5-2.5 years were analysed. About half of these were examined by an otolaryngologist in one, and half by a pediatrician in another, urban area. Myringotomy was always performed when MEE was suspected, and it confirmed the presence of MEE in 85% (otolaryngologist) and 82% (pediatrician) of altogether 5,462 acute and in 69% (both doctors) of 1,092 non-acute cases suspected. Redness of the tympanic membrane (TM) was found in only 18% and 27% of the visits with AOM, and it predicted MEE with only 60% and 51% probability, if seen in acute visits. Cloudiness of the TM was noticed in 81% and 67% of the visits with AOM; its specificity and the other calculated variables were good in regard to the diagnosing of MEE, especially in acute cases in both groups. Distinctly impaired mobility of the TM was of about the same diagnostic value, but its position reliably indicated MEE only when bulging. In AOM the colour or mobility of the TM was normal very rarely, but the position was normal in a third of the cases. Thus, although there were differences in the incidences of different otoscopic findings in the two study groups, the diagnostic value of certain pneumatic otoscopic findings, especially cloudiness and distinct hypomobility of the TM, seemed to be good in both groups.

Epidemiology and Aetiology of Middle Ear Cholesteatoma

A total of 500 patients with cholesteatoma diagnosed and operated during 1982-91 in the region of Tampere University Hospital and Mikkeli Central Hospital in Finland were analysed retrospectively. The mean annual incidence was 9.2 per 100,000 inhabitants (range 3.7-13.9) and during the study period the annual incidence decreased significantly. The incidence was higher among males under the age of 50 years. There was no accumulation of cholesteatoma diseases in lower social groups. The majority (72.4%) of cholesteatoma patients had suffered from otitis media episodes. Tympanostomy was carried out in 10.2% and adenoidectomy or adenotonsillectomy in 15.9% of all cholesteatoma ears prior to cholesteatoma surgery. Cholesteatoma behind an intact tympanic membrane with no history of otitis media was verified in 0.6% of patients and in cleft palate patients in 8%. In this study, 13.2% of patients had ear trauma or ear operation in anamnes.

Prevention ofotitis media in children by pneumococcal vaccination

A total of 3,340 infants, 95 per cent of them 7 to 9 months old, were randomly vaccinated in a double-blind fashion with either the 14-valent pneumococcal (Pn) polysaccharide vaccine or a saline placebo in three urban areas in Finland. The second dose of the vaccine was given 5 months later. Age and sex distribution, recruitment of infants, and their otitis-related treatment and follow-up were similar in the study areas. Side effects after vaccination were mild and fewer than among older children. Antibody responses to vaccine polysaccharides varied from type to type, but were generally poor, especially to types most prevalent in otitis media. After the first dose of vaccine, the occurrence of otitis visits among the Pn-vaccinated, as compared with controls, showed inter-area differences, but ranged from not more than a 30 per cent reduction at its best to an increase in some areas and in some clinical categories. The respective figures for children with acute otitis media were similar between the vaccination groups and the study areas. The effect of the vaccine on acute otitis media caused by specific Pn types/groups represented in the vaccine was variable but generally poor. Group 6 attacks especially seemed to behave problematically. The second dose of the vaccine did not give additional benefit serologically or clinically. The efficacy of currently available pneumococcal vaccine against otitis media seemed poor in infants.

The bayesian approach to the evaluation of risk factors in acute and recurrent acute otitis media

A multivariant modelling method was used to analyse the risk, associated with 22 different factors, of contracting acute otitis media (AOM) in a prospective cohort of 1294 urban children followed up to the age of 17-32 (mean 25) months. By far the most important risk factor was the caring of the child at a day-care centre. The importance of this factor further increased with increasing recurrence of the attacks. Next in order came the existence of sibling(s) with AOM attacks during the follow-up. Prolongation of breastfeeding increased the protection against AOM during the first year of life. The frequency of AOM attacks was lowest around midsummer and highest in early winter.

Incidence of Acute Otitis Media up to the Age of 1 1/2 Years in Urban Infants

The object of this prospective cohort investigation of 1,642 infants was to study the incidence of acute otitis media (AOM) in urban children during the first 18 months of life. The monthly incidence of AOM was greatest at the age of 10 months, and the largest proportion of children with AOM was also found in this 10-month age group. Before the age of 18 months, 56.7% of the infants had had at least one episode of AOM, while 26.9% had had one or two episodes and 29.8% three or more. The corresponding figures before the age of 12 months were: 45.3%; 26.8%; 18.5%, and before the age of 9 months: 30.5%; 22.1%; 8.4%. The AOM incidence, particularly as regards recurrent AOM, was rather higher in boys than in girls.

OCCURRENCE AND RECURRENCE OF ACUTE OTITIS MEDIA AMONG CHILDREN

The occurrence and recurrence of acute otitis media among 37 570 Finnish children at risk who were under 15 years of age were studied. During a one-year period, 4 337 of the children experienced a total of 6 249 attacks of acute otitis media, giving an annual incidence rate of 16.6%. The highest incidence, 75.5%, was found among infants 6--11 months old. 50% of Finnish children had experienced at least one ear infection before their third birthday and 75% before the age of 10, and among this latter group the total number of otitis attacks per child-year during a lifetime was 0.71. Among children under 10, half of the index attacks were recurrences, and among children under 16, 28% of the index attacks were followed by recurrences during the study year. The highest relative recurrence rate was found during the second year of life. Before the second birthday both incidence and recurrence rates were significantly (p less than 0.001) higher among boys. Acute otitis media was most common in the higher social class families and the lowest incidence and recurrence rates were found among children of farmers.

Temporal Relationship between Human Parechovirus 1 Infection and Otitis Media in Young Children

BACKGROUND Human parechovirus (HPeV) 1 is a common virus that infects almost everyone during childhood. Because clinical symptoms are poorly documented, we evaluated the symptoms associated with HPeV1 infection in a cohort of children followed prospectively from birth at 3-month intervals. METHODS Symptoms such as fever, cough, those of the common cold, otitis media, and gastroenteritis were determined from hospital records and from questionnaires administered to the parents of 59 children during regular study visits. HPeV1 infections were diagnosed by measuring neutralizing antibodies in follow-up serum samples. Additionally, HPeV RNA was analyzed in middle ear fluid (MEF) and nasopharyngeal aspirate samples from 33 patients with otitis media by reverse-transcription polymerase chain reaction. RESULTS Otitis media showed a clear association with HPeV1 infection-it developed in 50% of the 3-month follow-up periods that yielded evidence for HPeV1 infection but in only 14% of the HPeV1-negative periods (odds ratio [OR], 6.14 [95% confidence interval {CI}, 2.75-13.77]). In children with recurring otitis media, MEF samples were positive for HPeV in 15% of episodes. Cough was also associated with HPeV1 infection, but this association was weaker (OR, 3.67 [95% CI, 1.66-8.09]). Other symptoms were not linked to HPeV1 infection. CONCLUSIONS HPeV1 infections are common in childhood and may cause otitis media and cough.

Haemophilus Influenzae in Acute Otitis Media

We studied the occurrence of Haemophilus influenzae (Hi) in 2625 middle ear fluid (MEF) specimens obtained from 523 children with otitis media, aged 3 months to 6 years, between October 1977 and May 1979. In clinically acute cases 12.3% of the MEFs grew Hi; 6.3% (13/206) of the strains were of type b and 4.9% (10/206) were beta-lactamase producing. In the very first acute case of a child 8.0% (21/263) of the MEFs grew Hi, but in acute recurrences it was cultured in 17.0% (184/1082) (p less than 0.001). In non-acute persistent MEFs obtained during control visits Hi was found in no less than 21.7% (198/913); as many as 12.6% (25/198) of them were beta-lactamase producing. Both of these figures, but not the proportion of type b strains (8.6%), were significantly (p less than 0.001 and p less than 0.01, respectively) greater than in clinically acute MEFs. Hi was grown in 13.1% of the acute MEFs taken from children less than 4 years old, but in only 8.6% of the older children (p less than 0.05). The annual survey of all the 1816 Hi strains isolated from the MEFs of acute or subacute cases of otitis media in one laboratory in 1976-81 showed the proportion of beta-lactamase producing strains of all Hi strains to be gradually increasing from 8.0% (17/212) in 1976 to 15.2% (16/105) in 1981 (p less than 0.05).

Extended High Frequency Hearing and History of Acute Otitis Media in 14-Year-Old Children in Finland

We studied the extended high frequency hearing of 573 white, urban, mean 13.8-year-old unselected children in Tampere, Finland. All their ear-related morbidity had been recorded since their birth and they had been examined at the ages of 7 months, 2 years, and some of them at 5 years. The extended high frequency audiometry was measured from 10 to 18 kHz, with 1 kHz steps, and the results were related to the number of attacks of acute otitis media (AOM) (0, 1-2, 3-7 and > or = 8) they had experienced. The mean pure tone hearing thresholds varied from 10.7 dB at 10 kHz to 37.0 dB at 18 kHz in the right ears and between 11.6 dB at 10 kHz and 37.4 dB at 18 kHz in the left ears. Among those with > or = 8 attacks of AOM the the thresholds were highest, the difference between them and each of the first 3 groups being statistically significant at 13 and 14 kHz. From 11 to 16 kHz the same difference was significant between the last (> or = 8 AOM) and at least 2 of the first 3 AOM groups. Numerous attacks of AOM may have a harmful effect on high frequency hearing in the long term.

Middle ear fluid bacteriology of acute otitis media in neonates and very young infants.

The middle ear fluid (MEF) bacteriology of 107 attacks of acute otitis media (AOM) in 101 infants less than 3 months old was analyzed. A total of 108 bacteria were isolated from 85 attacks. Major AOM-pathogens, S. pneumoniae (19%), H. influenzae (9%) or B. catarrhalis (7%) were cultured in approximately one-third of all the attacks. S. aureus (17%) and coagulase-negative staphylococci (22%) without the above pathogens were commonly found, whereas gram-negative enteric bacteria were culturable from only 5 attacks. Only 8% of the MEFs were polymicrobial. More than half of all the bacterial strains produced beta-lactamase. The bacteriology of those younger than one month was not different from that of the others. The same was true with attacks of out-patients and in-patients, except for a larger proportion of beta-lactamase producing strains in in-patients. Nasal-nasopharyngeal and MEF samples showed the same bacteriology in only 20% of cases. Two-thirds of AOM attacks were present in infants with perinatal or other concomitant morbidity, but their bacteriology was not different from those without other morbidity. In addition to the examination of ears in infants presenting with any illness before the age of 3 months, the study stresses the importance of bacteriological analysis of MEF in all cases of AOM at this age.