Acta Oto-Laryngologica. 2015; Early Online, 1–6

ORIGINAL ARTICLE

Clinical and audiological findings in children with acute otitis media

Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 04/21/15 For personal use only.

 1, KSENIJA RIBARIC  JANKES2, ROBERT TROTIC  3, MIRJANA KOSTIC  4 & VLADIMIR BEDEKOVIC 3 MIHAEL RIES3, BRANKA LEDIC 1

University of Zagreb, School of Medicine, Croatian Institute for Health Insurance, Zagreb, Croatia, 2University of Zagreb, School of Medicine, Zagreb, Croatia, 3University of Zagreb, School of Medicine, Department of ENT Head and Neck Surgery University Hospital Center “Sestre milosrdnice”, Zagreb, Croatia and 4University of Zagreb, School of Dental Medicine, Private praxis, Zagreb, Croatia

Abstract Conclusion: It is recommended to perform follow-up tympanometry and if necessary tonal audiometry in children who have normal plain otoscopy findings after recovering from acute otitis media (AOM). Children with Type B tympanogram, 3 months following the onset of AOM, are very likely to have a conductive hearing loss. Type B tympanogram is a much better indicator of effusion in the middle ear compared to plain otoscopy. Objective: This study was undertaken to investigate the frequency and duration of middle ear effusion in children following an episode of acute otitis media, to track changes in tonal audiometry and tympanometry findings in the post-AOM period, and recognize the optimal timing for performing both tests. Methods: In this study, 125 children aged 5–7 years with bilateral AOM were randomly selected and separately followed up for 3 months. The children underwent six ear, nose, and throat (ENT 1–6) examinations, six tympanometries (TM 1–6), and three tonal audiometries (TA 1–3). Evaluation of nasopharynx was done at the ENT 1 examination. Children who received ventilation tubes were followed for 21 month altogether. Results: At the first otoscopy, pathological findings were recorded in 250 ears/125 children (100.0%). The number of pathological otoscopy findings decreased at each subsequent examination. At ENT 6 all children had normal otoscopy findings. Type B tympanogram was detected in 49/250 (19.6%) ears at TM 6, performed 3 months following the onset of the disease. At the TA 1 conductive hearing impairment was recorded in 158/ 250 (63.2%) ears, at TA 2 in 66/250 (26.4%), and at TA 3 in 39/250 (15.6%). Most of them were associated with Type B tympanogram.

Keywords: Acute otitis media, middle ear effusion

Introduction Acute otitis media (AOM) is one of the most common diseases in childhood. The leading causative pathogens responsible for AOM are Streptococcus pneumoniae, nontypeable Haemophilus influenzae (NTHi), and Moraxella catarrhalis [1–7]. Only ~20% of AOM are caused by viral infection. The viruses that most commonly cause AOM are respiratory syncytial virus (RSV), rhinoviruses, influenza viruses, enteroviruses, and adenoviruses [3,6–8]. Many children have a combination of bacterial and viral infection. Symptoms and signs of AOM caused

by bacteria, viruses, or a combination of both are the same [1,3,8–10]. The standard treatment of AOM is antibiotic therapy. Antimicrobial-resistant pathogens, such as penicillin-resistant S. pneumoniae (PRSP), and ampicillin-resistant strains of H. influenza, have become the major cause of intractable otitis media [2–6,9,11–13]. After adequate use of antibiotics, otoscopy findings are usually normal, but inflammatory or noninflammatory fluid may persist within the tympanic cavity. This transformation of AOM to otitis media with effusion (OME) is a frequent and expected

Correspondence: M. Kostic, Croatian Institute for Health Insurance, Branimirova 37, 10 000, Zagreb, Croatia. E-mail: [email protected]

(Received 2 December 2014; accepted 31 January 2015) ISSN 0001-6489 print/ISSN 1651-2251 online  2015 Informa Healthcare DOI: 10.3109/00016489.2015.1017887

Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 04/21/15 For personal use only.

2

M. Kostic et al.

process. In post-AOM patients, fluid from the middle ear usually clears up spontaneously, but up to 10% of patients may still have OME up to 3 months following a single episode of AOM [1,2,6,7,10,11]. Fluid in the middle ear may be the basis for recurrent acute otitis media (RAOM), and occasionally lead to chronic otitis media and permanent hearing impairment [10,14–16]. During an episode of OME, patients have different degrees of conductive hearing impairment, with no symptoms or signs of acute infection [17]. Otoscopy may appear normal, but tympanometry usually shows a type B tympanogram, while paracentesis reveals fluid in the tympanic cavity. Most clinicians recommend the insertion of ventilation tubes in cases of chronic OME to prevent minor or major hearing loss [4,7,8,12,15,17–19]. The time needed for chronic secretory otitis media (CSOM) to develop has not been accurately defined to date. The viscosity of fluid in the middle ear may vary, but it has been found to be extremely sticky and thick if auditory tube dysfunction persists for over a month. At this stage, the disease becomes chronic [4,10,11,14–16]. Inadequate treatment of AOM, RAOM, and OME may result in minor or major irreversible hearing loss, which has been associated with hyperactivity, behavioral problems, and delayed language development [2,7,10]. Materials and methods In this study, 125 children aged 5–7 years with bilateral AOM were included. The children were randomly selected during the autumn/winter season over a period of 3 years. Each child was followed up for 3 months. The children underwent six ear, nose, and throat (ENT 1–6) examinations, six tympanometries (TM 1–6), and three tonal audiometries (TA 1–3). ENT 1 was performed at the initial presentation with AOM. Otoscopy was recognized as pathologic regarding AOM if redness and bulging of the tympanic membrane was encountered. Later on, signs of secretory otitis and dysfunction of the auditory tube, such as the tympanic membrane retraction, yellowish color of the membrane, absence or shortening of the triangular reflex, or bubbles of air in the middle ear fluid, were looked for. Rhinoscopy and oropharyngoscopy were counted as pathologic if the usual signs of upper respiratory tract inflammation, such as swelling and redness of the mucosa, excessive or colored secretion, and obstruction of the nose were encountered. Evaluation of the nasopharynx was done at ENT 1 by fiberscopy. The adenoid size grading system included was modified and simplified compared to

the original [20]. Adenoids leaning on torus tubarius or larger (touching the vomer and/or soft palate) were categorized as enlarged. TA with the small air bone gap and threshold for air conduction not exceeding 25 dB was marked as a conductive problem. Conductive hearing loss exceeding 25 dB on main speech frequencies was considered as hearing impairment. During the study, 1500 otoscopies, 1500 tympanometries, 750 rhinoscopies, 750 oropharyngoscopies, and 750 tonal audiometries were performed. The first five ENT 1–5 examination and TM 1– 5 measures were performed every 8 days, while the sixth, ENT 6 and TM 6 were performed 40 days following ENT 5 and TM 5. TA 1 was performed at ENT 2 with TM 2, TA 2 was performed at ENT 5 with TM 5, while TA 3 was performed at ENT 6 with TM 6. All children took antibiotics orally for 8–10 days according to treatment guidelines. Children with severe general symptoms or those that did not react to oral antibiotics were submitted to urgent myringotomy with grommets placement. These children received antibiotics parenterally and were not included in this study. Only two received a prolonged antibiotic treatment due to severe ear infection. Antibiotics treatment was not extended in children who had Type B or Type C tympanogram with normal otoscopy findings. However, we monitored the transition of Type B tympanogram to Type C, and Type C to Type A, over time. Paracentesis was performed in 39/250 (15.6%) of ears in which plain otoscopy was normal 3 months following AOM, with no recurrent infection, but with persistent Type B tympanogram and conductive hearing impairment. Children who received ventilation tubes were followed for 21 month altogether. According to our practice, ventilation tubes were removed after 6 month in short inhalatory anesthesia. It usually falls in the summertime, so children get the chance to enjoy some of the swimming season unrestricted, and are not bound to lose tubes amidst the ‘AOM season’, by spontaneous extrusion. Results At the first plain otoscopy all 125 children/250 ears had pathological findings in both ears (100.0%). The number of pathological otoscopy findings decreased at each subsequent examination. The children had the same percentage of pathological findings of rhinoscopy and oropharyngoscopy at ENT 1 and ENT 4. All mentioned findings were normal at ENT 5 (Table I, Figure 1). At ENT 4 the percentages of pathological otoscopy findings and of Type B tympanogram are almost the same (Table II, Figure 2).

Clinical and audiological findings in children with AOM

had conductive hearing impairment (Table IV). Most cases with conductive hearing impairment were associated with tympanogram type B. The second tonal audiometry, TA 2, was performed at ENT 5 and TM 5 (1 month following the onset of AOM); 126/250 (50.4%) of the ears showed a normal hearing threshold, 58/250 (23.2%) had conductive problems, while conductive hearing impairment was recorded in 66/250 (26.4%) of the ears. The greatest percentage of conductive hearing impairment cases was once again found in ears with Type B tympanogram, and none in ears with Type A tympanogram (Table V). The third tonal audiometry, TA 3, was performed at ENT 6 accompanied with TM 6, 3 months following the onset of AOM. The conductive hearing impairment was detected in 39/250 (15.6%) of ears, all having tympanogram type B (Table VI). Paracentesis was performed in 39 ears with conductive impairment and tympanogram type B, 3 months from the onset of AOM (Table VI). Effusion in the middle ear cavity was found in 36/39 ears. Cytological analysis showed inflammatory cells in 33 ears, and gelatinous effusion without inflammatory cells was found in three ears. Ventilation tubes (VT) were inserted in 36 ears and after 6 months they were removed. No complications associated with VT insertion and no episodes of AOM for the next 12 months were encountered.

Table I. Number of pathological otoscopy, rhinoscopy and oropharyngoscopy findings in all six examinations.

Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 04/21/15 For personal use only.

ENT No. of No. of pathological findings in the examination children/ Ear Nose Oropharynx ears 1

125/250 250 (100.0%) 119 (95.2%) 119 (95.2%)

2

125/250 246 (98.4%)

3

125/250 192 (76.8%)

85 (68.0%)

87 (69.6%)

4

125/250

98 (39.2%)

36 (28.8%)

36 (28.8%)

5

125/250

13 (5.2%)

0 (0.0%)

0 (0.0%)

6

125/250

0 (0.0%)

0 (0.0%)

0 (0.0%)

107 (85.6%) 103 (82.4%)

Enlarged adenoids were found in 37.6% of children, while in 34.4% adenoids were already removed, so roughly one third of our AOM patients populated each of the three groups (adenoids enlarged, nonenlarged, removed). Most children had one or two AOM episodes before our study. Only 17.5% of the children had five or more AOM episodes prior to our study. At TM 1–4, most tympanograms showed Type B, at TM 5 and TM 6 most tympanograms showed Type A. Type B tympanogram was recorded in 103/ 250 (41.2%) of ears at TM 4, more than 3 weeks following the onset of AOM and in 49/250 (19.6%) of ears at TM 6, performed 3 months following the onset of the disease (Table III, Figure 3). The first tonal audiometry, TA 1, was performed at ENT 2 together with TM 2, 1 week following the onset of AOM. Normal hearing threshold was found in 24/250 (9.6%) of ears, 68/250 (27.2%) had minor conductive hearing problems, while 158/250 (63.2%)

Discussion During this 3-month research study, children with bilateral AOM were examined on six occasions.

120.00% 100.00% 80.00%

60.00% 40.00% 20.00%

0.00% 1

2

3 Ear

3

Nose

4

5

6

Oropharynx

Figure 1. Graph showing the percentage of pathological otoscopy, rhinoscopy, and oropharyngoscopy findings in all six examinations.

4

M. Kostic et al.

Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 04/21/15 For personal use only.

Table II. Comparison of pathological findings in the ears and Type B tympanogram in all six examinations. ENT examination

No. of children/ ears

No. of pathological findings in the ear

Tympanogram type B

1

125/250

250 (100.0%)

165 (66.0%)

2

125/250

246 (98.4%)

185 (74.0%)

3

125/250

192 (76.8%)

151 (60.4%)

4

125/250

98 (39.2%)

103 (41.2%)

5

125/250

13 (5.2%)

101 (40.4%)

6

125/250

0 (0.0%)

49 (19.6%)

tympanogram had the highest rate of conductive hearing impairment. Children with a Type B tympanogram had normal hearing thresholds at TA 1 in 4/185 (2.2%) ears, at TA 2 in 9/101 (8.9%) ears, and at TA 3 in 0/49 (0.0%) ears (Tables IV, V, VI). This obvious correlation of hearing impairment to Type B tympanogram promotes tympanometry to a good and simple tool for monitoring post-AOM sequelae. Tympanometry and otoscopy showed that a Type A tympanogram was found in ears with pathological otoscopy findings at ENT 1. The question arises as to whether the presence of Type A tympanogram is associated with earlier/quicker detection of AOM, prior to development of middle ear effusion. The percentage of Type B tympanogram was very high at TM 4 (24 days following the onset of AOM), namely in 103/250 (41.2%) of ears, and then in 101/ 250 (40.4%) of ears at TM 5 (1 month following the onset of AOM), and in 49/250 (19.6%) of ears at TM 6 3 months following the onset of AOM (Table III, Figure 3). We assume that it is not very informative to perform a control tympanometry sooner than 3 months following AOM. It is important to mention the discrepancy between the plain otoscopy and tympanometry findings. At ENT 5, otoscopy findings were interpreted as pathological in 13/250 (5.2%) of ears and as normal in 237/250 (94.8%). At ENT 6, findings in all ears were interpreted as normal (Table I, Figure 1). Tympanometry data indicate a need to monitor changes in the middle ear after AOM for a much longer time than is generally accepted at this time [12,13,15–18]. We can also ask ourselves whether any of the children had secretory otitis media as a result of infections prior to our study.

Otoscopy, rhinoscopy, and oropharyngoscopy showed that the pharyngeal mucosa findings were consistent with the changes occurring in the nasal mucosa, and that the pathological changes in the ear persisted longer than those in the nose and pharynx (Table I). Most of the paracenteses were positive for effusion and most of the samples contained inflammatory cells. The latter might point to infectious etiology so it could be assumed that most of our patients had OME linked to AOM, and not to other possible causes. All three groups of children according to adenoids size or previous removal were approximately of the same size, which might lead to the conclusion that the size of the adenoids did not have a significant impact on the frequency of AOM. Such a conclusion would, of course, be inappropriate in a study like this. On the first, second, and third audiometric tests, TA 1–3, the group of children with Type B

120.00% 100.00% 80.00% 60.00% 40.00% 20.00% 0.00% 1

2

3

4

PF

Type B

5

6

Figure 2. Graph showing the percentage of pathological findings in the ears in comparison to percentage of tympanograms Type B in all six tympanometries (1–6). PF = pathological findings.

Clinical and audiological findings in children with AOM

5

Table III. Tympanogram types in all six tympanometries (1–6). TT TM

Type A

Type B

Type C

No. of ears

1

29 (11.6%)

165 (66.0%)

56 (22.4%)

250 (100.0%)

2

27 (10.8%)

185 (74.0%)

38 (15.2%)

250 (100.0%)

3

41 (16.4%)

151 (60.4%)

58 (23.2%)

250 (100.0%)

4

79 (31.6%)

103 (41.2%)

68 (27.2%)

250 (100.0%)

5

113 (45.2%)

101 (40.4%)

36 (14.4%)

250 (100.0%)

6

180 (72.0%)

49 (19.6%)

21 (8.4%)

250 (100.0%)

Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 04/21/15 For personal use only.

TT, tympanogram types; TM, tympanometry measurement.

80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 1

2

3 Type A

4 Type B

5

6

Type C

Figure 3. Graph showing the percentage of tympanogram types in all six tympanometries (1–6).

Table IV. Results of tonal audiometry 1 at tympanometry 2. TM2/TA1 TT

Normal hearing threshold

Conductive problems

Type A

11/27 (40.7%)

16/27 (59.3%)

Type B

4/185 (2.2%)

37/185 (20.0%)

Type C Total

9/38 (23.7%) 24/250 (9.6%)

Conductive hearing impairment

0/27 (0.0%) 144/185 (77.8%)

15/38 (39.5%)

14/38 (36.8%)

68/250 (27.2%)

158/250 (63.2%)

No. of ears

27/250 (10.8%) 185/250 (74.0%) 38/250 (15.2%) 250/250 (100.0%)

TT, tympanogram types; TM, tympanometry 2; TA, tonal audiometry 1.

Table V. Results of tonal audiometry 2 at tympanometry 5. TM5/TA2 TT

Normal hearing threshold

Conductive problems

Conductive hearing impairment

Type A

109/113 (96.5%)

4/113 (3.5%)

0/113 (0.0%)

113/250 (45.2%)

Type B

9/101 (8.9%)

Type C Total

No. of ears

33/101 (32.7%)

59/101 (58.4%)

101/250 (40.4%)

8/36 (22.2%)

21/36 (58.3%)

7/36 (19.4%)

36/250 (14.4%)

126/250 (50.4%)

58/250 (23.2%)

66/250 (26.4%)

250/250 (100.0%)

6

M. Kostic et al.

Table VI. Results of tonal audiometry 3 at tympanometry 6. TM6/TA3 TT Type A Type B Type C Total

Normal hearing threshold

Conductive problems

Conductive hearing impairment

176/180 (97.8%)

4/180 (2.2%)

0/180 (0.0%)

180/250 (72.0%)

10/49 (20.4%)

39/49 (79.6%)

49/250 (19.6%)

0/49 (0.0%) 8/21 (38.1%)

13/21 (61.9%)

0/21 (0.0%)

21/250 (8.4%)

184/250 (73.6%)

27/250 (10.8%)

39/250 (15.6%)

250/250 (100.0%)

Conclusion Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 04/21/15 For personal use only.

No. of ears

It is recommended to follow-up children following AOM. Tympanometry is a good method for diagnosing OME and Type B tympanogram is usually associated with conductive hearing loss, so it works well in identifying candidates for tonal audiometry. Tympanometry should be performed no sooner than 3 months following an episode of AOM. Tonal audiometry should be performed in children with Type B tympanogram 3 months from AOM. Plain otoscopy is not a good indicator of middle ear content. Adenoids seem to have no impact on OME duration following an AOM episode. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References [1] Leibovitz E. Epidemiologic and microbiologic characteristics of culture-positive spontaneous otorrhea in children with acute otitis media. Pediatr Infect Dis J 2009;28:381–4. [2] Leibovitz E, Dagan R. Antibiotic treatment of acute otitis media. Intern J Antimicrob Agents 2000;15:169–77. [3] Coker TR, Chan LS, Newberry SJ, Limbos MA, Suttorp MJ, Shekelle PG, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children. JAMA 2010;304:2161–9. [4] Brook I. The role of anaerobic bacteria in chronic suppurative otitis media in children: implications for medical therapy. Anaerobe 2008;14:297–300. [5] Sakakura K, Chikamatsu K, Furukawa M, Shibasaki M, Takegoshi T, Takahashi K, et al. Acute otitis media caused by drug-resistant bacteria:correlation with antibiotic treatment. Acta Otolaryngol 2004;124:1008–14. [6] Rovers MM, Schilder AGM, Zielhuis GA, Rosenfeld RM. Otitis media. Lancet 2004;363:465–73. [7] Rovers MM, Schilder AGM, Zielhius GA, Rosenfeld RM. Otitis media. Lancet 2004;363:1325–9.

[8] Yamanaka N, Hotomi M, Billal DS. Clinical bacteriology and immunology in acute titis media in children. J Infect Chemother 2008;14:180–7. [9] Leibovitz E, Greenberg D. Clinical outcome in children with culture-negative acute otitis media. Pediatr Infect Dis J 2009; 28:1105–13. [10] Kim SJ, Chung JH, Kang HM, Yeo SG. Clinical bacteriology of recurrent otitis media with effusion. Acta Otolaryngol 2013;133:1133–41. [11] Leibovitz E. Complicated otitis media and its implications. Vaccine 2008;26:G16–19. [12] Butler CC, van der Linden MK, MacMillan HL, van der Wouden JC. Should children be screened to undergo early treatment for otitis media with effusion? A systematic review of randomized trials. Child Care Health Dev 2003;29: 425–32. [13] Kouwen H, van Balen FAM, Dejonckere PH. Functional tubal therapy for persistent otitis media with effusion in children: myth or evidence? Int J Pediatr Otorhinolaryngol 2005;69:943–51. [14] Lous J, Ryborg CT, Thomsen JL. A systematic review of the effect of tympanostomy tubes in children with recurrent acute otitis media. Int J Pediatr Otorhinolaryngol 2011;75:1058–61. [15] Ryding M, Konradsson K, White P, Kalm O. Hearing loss after “refractory” secretory otitis media. Acta Otolaryngol 2005;125:250–5. [16] Coates H, Thornton R, Langlands J, Filion P, Keil AD, Vijayasekaran et al. The role of chronic infection in children with otitis media with effusion: evidence for intracellular persistence of bacteria. Otolaryngol Head Neck Surg 2008; 138:778–81. [17] Malaty J, Antonelli PJ. Effect of blood and mucus on tympanostomy tube biofilm formation. Laryngoscope 2008;118: 867–70. [18] Saeed K, Coglianese CL, McCormick DP, Chonmaitree T. Otoscopic and tympanometric findings in acute otitis media yielding dry tap at tympanocentesis. Pediatr Infect Dis J 2004;23:1030–4. [19] Vlastaracos PV, Nikolopoulos TP, Korres S, Tavoulari E, Tzagaroulakis A, Ferekidis E. Grommets in otitis media with effusion: the most frequent operation in children. But is it associated with significant complications? Eur J Pediatr 2007; 166:385–91. [20] Parikh SR, Coronel M, Lee JJ, Brown SM. Validation of a new grading system for endoscopic examination of adenoid hypertrophy. Otolaryngol Head Neck Surg 2006;135:684–7.

Clinical and audiological findings in children with acute otitis media.

It is recommended to perform follow-up tympanometry and if necessary tonal audiometry in children who have normal plain otoscopy findings after recove...
372KB Sizes 1 Downloads 11 Views