Etiologic
Factors in
Secretory Otitis
Mirko Tos, MD; Gert Poulsen, MD;
\s=b\ We investigated the possible etiologic factors of secretory otitis and dysfunction of the Eustachian tube in 278 healthy 2-year-old children based on screening tympanometry and medical history. We found that catarrhalia was the most frequent etiologic factor, with acute otitis being the second most frequent factor. It was demonstrated that secretory otitis may develop without a preceding infection of the middle ear. It is probable that dysfunction of the tube plays a primary role in the development of secretory otitis. Allergy did not seem to be an etiologic factor. Antibiotic treatment does not promote the development of secretory otitis, but is probably unable to prevent it. Parental disposition could not be related to the children's ear diseases.
(Arch Otolaryngol 105:582-588, 1979) it is generally agreed that "ex vacuo" theory is not valid, that the middle ear mucosa changes into a secretory mucosa, and that the effusion is a mixture of exúdate and mucus.11 However, the primary cause of secretory otitis has not yet been clarified. In the literature, three main causes are often mentioned: (1) tubai occlusion; (2) infection; and (3) aller¬
Today, the
gy· TUBAL OCCLUSION
The etiologic role of the tubai occlu¬ sion or dysfunction is especially based on the fact that the tubai function nearly always is reduced in secretory otitis, both before and during tubula-
Accepted
From the
Gentofte mark.
publication Oct 26, 1978. Ear, Nose, and Throat Department,
for
University Hospital, Hellerup,
Den-
Reprint requests to the Ear, Nose, and Throat Department, Gentofte University Hospital, DK\x=req-\ 2900 Hellerup, Denmark (Dr Tos).
Jesper Borch,
MD
tion." In more than 50% of the ears, it is still reduced one to 1% years8 "' and in 33% five to eight years after the tubulation, which is long after cessa¬ tion of secretion from the mucosa." Thorough investigations have shown that children with a cleft palate nearly always have secretory otitis.'-
otitis.' Jordan-- found allergy in 74% of the patients with secretory otitis. Other investigators mention a consid¬ erably lower percentage of allergy.'"' It is extremely difficult to deter¬ mine the primary cause of the secreto¬ ry otitis in a child who probably for a long time has had mucous effusion in the middle ear, a flat tympanogram,
INFECTION
enlarged adenoids, frequent catarrhalia, and recurrent otitis media.
"
Infection by bacteria or viruses, as the cause of secretory otitis" is espe¬ cially based on histopathological find¬ ings. Inflammatory changes such as round cell infiltration, vessel dilation, and metaplasia of the epithelium have been demonstrated in the middle ear mucosa.^"·" Furthermore, children with secretory otitis had one or several periods of acute otitis before they were tubulated. In experimental infection of the middle ear, Fried¬ demonstrated mann' secretory of the middle ear mucosa. changes Furthermore, it has been stated that the tube is never occluded anatomical¬ ly in secretory otitis.'4 Effusion was often found to be sterile, but other investigators have found positive cul¬ tures in 22%' and in 52%'" of the ears, most frequently Haemophilus influenzae, Staphylococcus aureus or S albas, and Pneumococcus. For the high percentage of negative bacterial cul¬ tures, a viral cause was considered. '
ALLERGY
Allergy
as
a
primary etiologic
factor has not been verified histologically. Wright and Kapadia'7 (1969) and Palva et alls (1976) found no ears with eosinophils in the effusion, while others have found a few.'"J" Eosinophilia of the middle ear mucosa has not been demonstrated in secretory
-'
What is cause and what is effect? Advocates of infection as the primary cause find that the tubai dysfunction is a consequence of secretory otitis, but it might be claimed that acute otitis is a consequence of tubai dysfunction or of secretory otitis. In this study, screenings were performed in healthy 2-year-old children in an attempt to analyze the etiologic factors of tubai dysfunction and secre¬ tory otitis. To be able to distinguish reasonably well between cause and effect, it is necessary to analyze the incidence of the possible etiologic factors from birth and during infancy and to correlate these to the incidence of tubai dysfunction and secretory otitis. PATIENTS AND METHODS
early December, performed in 135 healthy 2-year-old boys and 143 girls. They were born between the first and tenth day In late November and
1977, tympanometry
was
in every month in 1976 and live in two communities in the northern part of Copenhagen County, Denmark. They con¬ stitute an equal representation of all 2year-olds in this area, which has a popula¬ tion of 119,270.
Tympanometry was performed using an impedance apparatus with a frequency of 220 Hz; otoscopy was performed with a Siegle's speculum. Bacteria cultivation was performed of a rhinopharyngeal smear
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taken
through the
mouth. A
questionnaire
parents to supply informa¬ tion about the time, the frequency, and the was
sent to the
character of catarrhalia, acute otitis, diseases in the upper respiratory tract, and other febrile diseases, especially tonsillitis, children's diseases, and manifestations of allergy. Furthermore, information was obtained about the disposition of the parents and siblings for ear diseases and allergy; parents were asked to give detailed information about the birth of the child. To establish the exact time for the path¬ ological condition, the questionnaire was divided into periods of six months each. The parents of the children who just turned 1 year of age filled in the form during two periods, and the parents of children approximately 2 years of age filled in during four periods. At the investigation, the questionnaires were examined by a physician and, if necessary, further details were added.
RESULTS
The incidence of tubai dysfunction and secretory otitis has been dis¬ cussed.-1 Of 556 ears investigated, 49.6% had a type A tympanogram, with a middle ear pressure of 0 to -99 mm H.O; 19.4% had a type C, tympa¬ nogram, with a pressure of —100 to -199 mm HX>; 20.1% had type C2, with a pressure of -200 to —350 mm H ,0; and 10.8% had type B, with a flat curve without impedance minimum and with reduced mobility of the eardrum at otoscopy, indicating effusion and secretory otitis. The same classifica¬ tion of tympanogram types will be used herein. There were no significant differences in the distribution of tympanogram types between girls and boys or between left and right ears in general, although only 69.7% of the children had the same type of tympanogram on both ears. Most often, types A and occurred sym¬ metrically. No differences in the distribution of tympanograms were found between children living in private houses and in blocks of flats, or between those from the wealthiest community compared with the poor¬ est. It was concluded that tubai dysfunction and secretory otitis is not a "poor man's disease" in the 2-yearolds. Children nursed in a public day nursery had a significantly higher frequency (P < .001) of secretory oti-
tis and tubai dysfunction than those nursed in home day nurseries or at home. There were no significant differences between the two last mentioned groups. These quite sur¬ prising tympanometry conditions will be related to the possible etiologic factors. Otitis Related to Catarrhalia
Secretory
During the six-month period prior to the investigation, 10.8% of the chil¬ dren had not had catarrhalia, 53.6% had had a few catarrhalia with mucous secretion, 18.3% had mucopurulent secretion, 5.4% had had many catarrh¬ alia with mucous secretion, and 10.8% had mucopurulent secretion from the nose. Table 1 shows the distribution of the tympanogram types for each ear. The tubai function deteriorated grad¬ ually from the slightest affected group without catarrhalia to the most severe group, with many catarrhalia and mucopurulent secretion. The number of type A tympanograms decreased, while types C, and became more frequent. The difference between the two extreme groups is
highly significant ( 2 test, < .001), regardless of whether types , C., and are tested separately or types A, C, and C, and are pooled, respectiveiy.
In the group without catarrhalia during the last six months (Table 1) only the following three children had either a type or a type C_. tympano¬ gram. A boy just under 2 years of age had a type tympanogram on the one ear and a type C, on the other. The child had not had any periods of catarrhalia within the last six months, but had had several colds during the preceding year. The same was the case for a girl of IV2 years who had a type C,, tympanogram on one ear and a type C, on the other. A 1-year-old boy with a type tympanogram on both sides had been nursed in a public nursery for the last three months but had not had colds or other diseases. Otoscopy revealed a pink and re¬ tracted eardrum. The flora of the rhinopharynx was normal. During the following three months, he had had many catarrhalia with mucopurulent secretion and still a type tympano-
Thus, the possibility of a neglected or unnoticed catarrhalia before the first investigation cannot
gram.
be excluded.
Compared with the normal group without catarrhalia, the tympanograms of children who had had a few catarrhalia with mucous secretion had already deteriorated significantly with fewer type A (P < .001) and type C, (P < .001) tympanograms, but the differences in type tympanograms were not significant (Table 1). more
In the group with a few catarrhalia but with purulent secretion, signifi¬ cantly more ears had a type tympa¬ nogram (P < .02) than in the preced¬ ing group with mucous secretion (Table 1), but compared with other types there were no significant differ¬ ences. In comparison with the group of children without catarrhalia, there were significantly fewer type A tym¬ panograms {P < .001), and more type ( < .01) C2 (P < .001) and type
tympanograms.
In the group of children with many catarrhalia with mucous secretion (Table 1), there was a slight, though insignificant (P > .05) deterioration of the tubai function compared with the preceding group. However, the percentage of type C2 tympanograms was quite high. Compared with the group without catarrhalia and the group with a few catarrhalia and mucous secretion, the differences were
significant {P < .001).
In the group of children with many catarrhalia with mucopurulent secre¬ tion, the tympanograms were consid¬ erably worse, with significantly fewer type A tympanograms (P < .02) com¬ pared with the preceding group and with an increased number of types C,, C., and tympanograms. Bacterial Flora in
Rhinopharynx
Pathological bacterial flora in the rhinopharynx (Table 2) were found in 30.2% of the children (42 boys and 42 girls). The most frequent types of bacteria were influenzae (12.6%), Pneumococcus (9.4%), and S aureus (4.7%). Furthermore, four children had Streptococcus haemolyticus, three had Meningococcus, two had Esckerichia coli and
one
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had S albus.
Among the 168 ears with pathologi¬ cal flora there were fewer type A (P < .05) and more type ( < .02) tympanograms compared with ears from children with normal flora in the rhinopharynx. However, it was re¬ markable that 43% of the ears with a type A tympanogram were found in children with pathological flora in the rhinopharynx. Only two of the 84 chil¬ dren with pathological flora had not had catarrhalia, 38% had either had many catarrhalia or catarrhalia with purulent secretion. The remaining had had a few catarrhalia with mucous secretion. One third of the children had been nursed in public day nur¬ series. No relationship could be demon¬ strated between the distribution of tympanograms and the type (Table 2) or number of bacteria found at culture. Especially, the frequency of secretory otitis with a type tympa¬ nogram
was
not
Secretory Otitis
Related to Acute Otitis
During the period from birth until the time of the investigation (maxi¬ mum of two years), 26.6% of the chil¬ dren (44 boys and 30 girls) had acute otitis at least once: 14.4% of all 556 ears had been called "red" without secretion by a practitioner, and 9.7% had either had a paracentesis per¬ formed or a spontaneous perforation. Of these, 84 were boys' ears and 50 were from girls. This significant sex difference (P < .001) in the incidence of otitis may be due to the fact that 34.9% of all boys were nursed in public nurseries, in contrast to only 19.6% of the girls. Among all those who had had otitis, 36.7% girls and 40.9% boys had been nursed in public day nurseries. There were no significant differ¬ ences (P > .2) between the tympano¬ grams from the group with red ears and the group with paracentesis or spontaneous perforation. As a rule, the tympanograms were worse in ears
previous acute otitis, with signif¬ icantly fewer type A (P < .001) and
Between Catarrhalia and Tympanogram 2-Year-Old Children*
1.—Relationship
Types
in 278
Catarrhalia, % Few, With
Few,
(N
=
With
With Mucous Secretion
Many,
Purulent Secretion
Mucous Secretion
Tympanogram None Type (N = 64)
300)
(N
=
102)
(N
30)
=
Many,
With
Purulent Secretion
(N
=
60)
Total %
(N
=
556)
A_78_1_51_3_£7_1_43J3_1^3_49.6 C,_14.1_21_3_20_6_10_0_^3_19.4 _C,_3_1_20_3_^6_7_30 _38_3_20.1 4.7
"Including
135
15.7
7.0
16.6
10.8
25.0
boys and 143 girls.
Table
2.—Relationship Between Tympanogram Types in
Bacteria in the Rhinopharynx and 278 2-Year-Old Children*
Bacteria, %
StreptoTympanogram
Type
Haemo-
Pneumo-
philus (N = 70)
(N
coccus =
52)
Staphylococcus aureus
(N
=
26)
coccus
haemoly-
Other
ticus
(N
=
8)
(N
=
Total Abnormal Culture
12) (N
=
Total % Normal Culture
168) (N
=
388)
A_4J_1_36_5_50 _25.0 41.7_42J)_52.6 C,_20 _-\J_5_30_8_25_0_33J3_20^2_19.1
g_17J_308_3J3_50t)_16J_20JJ_19.8 _15.7 21.2_15_4_0_83 16.1_8.5
significantly larger
for specific types of bacteria. One hundred thirty-four ears had had acute otitis. In 32% of these children, pathological bacterial flora were found in the rhinopharynx.
with
Table
"A total of 556
more
type
compared otitis
ears.
(
with
.1 and > .5). Thus, in this group of 2-year-olds, the incidence of tubai dysfunction and secretory otitis was not higher in allergic children than in nonallergic children. As a rule, more boys than girls had a deteriorated tubai function (Table 6). It has earlier been demonstrated-3 that this is due to the coincidence that more boys than girls are nursed in public day nurseries. An investigation of the incidence of tubai dysfunction and secretory otitis among boys and girls nursed at home, in home day nurseries, or in public day nurseries, respectively, showed no differences in
Paracentesis
=
Perforation, %
80)
(N
31.1
25.0 30.0 13.8 *A total of 556
=
A
C,
(N
=
43)
(N
26.9 17.9
18.0 8.5
Table 5.—Tympanogram Types in Ears With Acute Otitis in Various Periods*
=
in One
Periods, % (N = 45)
Period, % (N = 89)
20.0 22.2 40.0 17.8
36.0 25.8 20.2 17.9
Tympanogram Type
Otitis in Two
47)
25.3 4.3 48.9 21.3
6.—Tympanogram Types
•Group with otitis in two or more six-month periods compared with group with one incident of otitis in one period.
in 2-Year-Old Children With
Allergy Compared 278
Tympanogram Allergy Type (N = 18)
Allergy (N = 268)
No
135 Boys, %
Allergy (N = 42)
A_50 _56.3 50.0
Otitis
Nonallergic Children
143 Girls, %
C,
422)
22.2
No Otitis
Otitis
With
It has often been claimed that the
=
55.7 17.7
"Ears divided into group that had otitis and group that never had otitis.
Antibiotic Treatment
(
ears.
20.9 23.3
Table
Total Without Otitis, %
30.6 24.6
24.0
27.9 27.9
C,
in 278
29.6 24.1
Many Catarrhalia, % Tympanogram Type
Otitis, % ( = 134)
54)
Table 4—Tympanogram Types in 90 Ears of Children With Many Catarrhalia Related to Incidence of Otitis*
sex.
increasing frequency of secretory oti¬ tis is due to antibiotic treatment. One hundred thirty-two children (47.5%), 71 girls and 61 boys, had never received antibiotic treatment, and the remaining had received antibiotics, mostly penicillin, at least once. The distribution of tympanograms (Table 7) showed significantly fewer type A (P < .02) tympanograms in the anti¬ biotic group than in the nontreated group. The frequency of other tympa¬ nogram types showed no significant differences; thus, type occurred in 9.1% of ears that had never been treated with antibiotics. Therefore, it cannot be concluded that antibiotics promote the development of secretory otitis. The fact that children were not treated with antibiotics was usually owing to there being no need for this, and generally this group showed good health: only 12 (9.1%) had many catarrhalia, and among these type
Ears, %
(N
Total With
or
Spontaneous
Red
Tympanogram Type
Tympanogram Type
17.5
Allergy (N = 228)
No
Boys and Girls, %
Total
Allergy (N = 60)
Total
No
(N
Allergy 496)
=
33.3_44£_38JJ_51.0 19.0
19.3
28.3
18.3
_0_1_5_3_38J_24J_26J_19.4 0
10.8
occurred in 38% of the ears. In the group treated with antibiotics, 33 chil¬ dren (22.6%) had many catarrhalia, and among these 16.7% of the ears had a
type
tympanogram.
Antibiotics are often used for treat¬ ment of acute otitis. Among the 87 children who had had acute otitis, only ten (11.5%) had not received any anti¬ biotic treatment. As mentioned, the group of children with acute otitis (Table 3) had deteriorated tubai func¬ tion. Penicillin was given to 85% of the 80 children who had tonsillitis, laryngitis, or bronchitis, and especially to those with recurrent bronchitis. These chil¬ dren were also more catarrhal and had a more deteriorated tubai function than the others. Pathological flora were found in the
9.5
11.8
6.7
11.3
of 46 children (34.8%) who had never been treated with anti¬ biotics and in 38 (26.0%) who had been treated; the difference is not signifi¬
rhinopharynx
cant
(P > .1). Childhood Diseases
Forty-two children (15.1%) had had the following childhood diseases: 5.6%, German measles; 2.5%, morbilli; 1.8%, varicella; 0.7%, tussis convulsiva; and 0.7%, erythema subitum: 1.8% had had two childhood diseases and 0.7% had three. The distribution of tympano¬ grams showed no difference (Table 8) among those who had had childhood diseases and those who had not. Nor did the group with two or three child¬ hood diseases have a more reduced tubai function than the group without childhood diseases.
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Other Febrile Diseases A total of 12.2% of the children had had acute tonsillitis, 3.6% having had it two or three times. The distribution of tympanograms did not differ from the rest of the material (Table 9). However, there seemed to be more
type
Table 7.—Tympanogram Types in 2-Year-Old Children Never Treated With Antibiotics and Those Treated With Antibiotics
ence
Type_(N
was
insignifi¬
chronic coughs during longer peri¬ ods. There were fewer types A (P < .01), C, and when pooled than in the rest of the material, while the differences in frequency of type alone was not significant (P > .2). All 35 children in the bronchitis group had been catarrhal within the last six months: ten many times with mucopu¬ rulent secretion; eight a few times with mucopurulent secretion; and the remaining 17 a few times with mucous secretion. As shown in Table 1, catarrhalia was probably the primary cause of the deteriorated tubai func¬ tion in the bronchitis group. or
parental disposition (Table 10). Espe¬ cially, the group in which there had
been ear diseases in both parents showed the best distribution of tym¬ panograms with the fewest type and the most type A tympanograms. The incidence of acute otitis was the same in the group with predisposition (27.6%) as in the group without a possible disposition (25.6%). The inci¬ dence of frequent catarrhalia was also
264)
A
54.9
C, O,
18.2 17.8 9.1
Table
(N
=
Diseases, %
gram
Type_(N
292)
A
44.9 20.5 22.3 12.3
C,
C,
9.—Tympanogram Types in 2-Year-Old Children Laryngitis, and Bronchitis
=
Tympanogram
Type_(N
68)
(N
=
22)
(N
=
(N
472)
49.6
48.8 20.2 16.7 14.3
19.3 20.8 10.2
Infections,
Total With No Infections,
%
%
70)
=
With Acute Tonsillitis,
%
%
% =
Bronchitis,
Laryngitis,
%
84)
Total
Tonsillitis,
(N
=
160)
(N
=
396)
A_5O0_40_9_32_9_4JL3_53.0 C,_20_6_409_18JS_22J_18.2 C._14J_18^_32_^_23J_18.9 13.1
15.7
14.7
9.8
...
Table
10.—Tympanogram Types
in 2-Year-Old Children Related to Ear Diseases of Parents
Disposition, Tympanogram
Father or
Father and
Mother
Mother
%
Type_(N 196)_(N 36)_(N =
=
Total With No
Disposition, % 232)_(N 324)
Total =
=
A_55^6_6jU_56J_44.8 C,_15J3_194_15JI_21.9 C,_18j)_1X9_18J_21.9 11.7
Disposition One or both parents of 166 2-yearold children (41.7%), 60 boys and 56 girls, had had otitis, recurrent ear pain, or chronic secretory otitis during childhood. A few had had chronic middle ear diseases during adulthood. In 54 children, it was the father who had been affected; in 44, the mother; and in 18, both parents. In the group of children that might be said to have a certain disposition for tubai dys¬ function and secretory otitis, the distribution of tympanograms was even better than in the group without
=
Diseases,
Childhood
Tympano-
Antibi-
otics, %
%
gram
cant. A total of 12.6% of the children had had bronchitis, often recurrent acute bronchitis accompanying colds
Childhood
Antibiotics,
Tympano-
(25%) tympanograms, especial¬
in tympanograms
"
Ño
in children who had had tonsillitis several times, but this is not signifi¬ cant (P > .1). Four percent had had laryngitis stridulosa, but the differ¬
ly
Table 8—Tympanogram Types in 2-Year-Old Children With and Without Childhood Diseases
10.2
the
same
in both groups, 12.1% and
19.1%, respectively (P > .1). COMMENT
Secretory otitis is surprisingly fre¬
quent (10.8%) in 2-year-olds,
9.5
5.6
more
frequent than in any other age group.-' The incidence is especially high at the end of the first year. In this age group, catarrhalia is the most frequent and most dominating etiologic factor in clinical tubai occlu¬ sion and secretory otitis. Catarrhalia is very likely due to viral infection of the upper respiratory tract, combined with bacterial infection of the nose. During catarrhalia, the mucosa of the nose and rhinopharynx is swollen and hypersecretive. Similar mucosal changes probably spread to the pha¬ ryngeal part of the Eustachian tube, which histologically has the same structure as the nasal mucosa. This causes edema and hypersécrétion of
the tubai mucosa and an internal tubai occlusion. Reduced ventilation of rhi¬ nopharynx and internal tubai occlu¬ sion result in a reduced ventilation of the middle ear, which could be demon¬ strated by measurement of the middle ear pressure during prolonged nasotracheal intubation.-' Immediately following tubulation, the pressure became negative but normalized with¬ in a few days after extubation. If intubation was of longer duration, the pressure stayed negative at -200 and -300 mm HO for several days or weeks after the extubation, indicating that internal tubai occlusion had occurred as a consequence of the inflammatory changes in the rhino¬
pharynx. A single short-lasting period of catarrhalia will often reduce ventila¬ tion of the middle ear, which normal¬ izes after cessation of the catarrhalia. In prolonged catarrhalia combined
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with bacterial infection of the nose, more time is needed for normalization of the ventilation. If catarrhalia recurs, ventilation will again deterio¬ rate, resulting in a negative middle ear pressure for weeks or months.
Quantitative histological investiga¬
tions"' have shown that children with a chronic clinical tubai occlusion and a middle ear pressure of —200 and -300 mm HoO for several weeks have histo¬ logical changes of the middle ear mucosa, either in the form of vessel dilation, vessel proliferation, round cell infiltration, or slight metaplasia of the flat single-layered to pseudostratified epithelium. Furthermore, there is an increased density of goblet cells. A few of the children also had gland formation. Qualitatively, the histological changes are the same as in incipient and manifest secretory oti¬ tis, but quantitatively they are consid¬ erably less pronounced. We do not know the provoking factor of mucosal changes in chronically reduced venti¬ lation. One possibility is a changed composition of gases, another is dam¬ age of the interepithelial connections, resulting from a negative pressure. Experimentally, Arnold-" was able to demonstrate epithelial damage fol¬ lowed by structural changes of the epithelium shortly after closure of the tube. The previously mentioned changes may be regarded as reparative processes of the mucosa. They resemble an inflammatory reaction, but the mucosa reacts similarly on different pathological stimuli such as trauma-7 and changed air passage in the nose.28·29 Thus, inflammatory changes of the mucosa may be caused by infection. No specific bacteria in the rhino¬ pharynx could be attributed responsi¬ bility for chronic dysfunction of the tube or secretory otitis. More children with a type tympanogram were found in the group with pathological bacterial flora, but by far most of these had been catarrhal. On the other hand, many children (43%) had patho¬ logical flora and a normal tympano¬ gram.
Acute otitis,
especially
recurrent
otitis, may, as chronic tubai occlusion, lead to metaplasia of the mucosa and to secretory otitis. Infecacute
tion of the middle ear mucosa is an etiologic factor, and in children who have had acute otitis the tympano¬ grams are worse, with a higher inci¬ dence of secretory otitis. However, most often, acute otitis will complicate a chronic middle ear disease, especial¬ ly tubai occlusion. Nearly all children had been catarrhal in the six-month period preceding the first otitis, 32% having been catarrhal several times. Therefore, it is probable that many children have been affected by a dete¬ riorated tubai function or secretory otitis before the first acute otitis. The acute otitis aggravates the tubai dysfunction, which prolongs the nor¬ malization process1" and enlarges the risk of recurring otitis. The fact that children with secretory otitis often get acute otitis is considered proof that infection is the primary and only etiologic factor; in our opinion, acute otitis is a consequence rather than a cause of secretory otitis. This study shows that 10.8% of healthy 2-year-old children have secretory otitis even though only a few of them have had recurring acute otitis. When a small number of these children—those who get impaired hearing and recurrent acute otitis—at the age of 4 to 6 will be hospitalized for treatment, the inci¬ dence of acute otitis will be very high. Conversely, in prophylactic treatment of ears with recurrent acute otitis, we were able to demonstrate in a symp¬ tom-free period mucous effusion in 75% of the ears." In our opinion, the demonstration of bacteria in the middle ear effusion in secretory otitis cannot be considered proof of infection being the primary etiologic factor, but merely as an indi¬ cation of one or several previous infec¬ tions, and that the immunological conditions have made the bacteria more or less apatogene. The reason for this tolerance may be that the mucosa has changed into a real mucosa with similar immunological abilities as found in the nose and rhinopharynx, where pathogenic bacteria are quite common; in this material, they were found in 30.2% of the children. The material gave no grounds for assuming that allergy plays any etio¬ logic role in the development of secre¬ tory otitis in the 2-year-olds. Food,
insufficient and low in protein due to potato chips and soft drinks, is said to be an etiologic factor in older children. The children in this study were not malnourished; on the contrary, the food is carefully controlled at obliga¬ tory visits by a health visitor. Children nursed in public day nurseries, where the nourishment was correct, had the highest incidence of secretory otitis.
Childhood diseases, acute tonsillitis, and acute stridulous laryngitis are not etiologic factors in secretory otitis. Children with recurrent bronchitis had also had many catarrhalia, which might explain the poor tympano¬ grams in this group. There seemed to be no hereditary disposition for secretory otitis and dysfunction of the tube in this age group. However, this does not exclude that later, when the tube and the middle ear are fully developed, such a relationship might be found. We" have found a reduced tubai function five to eight years after tubulation in 33% of the children. Two to ten years after tympanoplasty, the tubai func¬ tion was reduced in 77% of adults with cholesteatoma. '- This material demon¬ strates that antibiotic treatment does not promote the development of secre¬ tory otitis, but apparently is unable to prevent it. It is debatable whether or not all children with type tympanograms have had effusion and secretory otitis. On the other hand, some ears with a type C. tympanogram may contain some effusion. Quantitative27' histo¬ logical studies show a gradual change of the mucosa from chronic tubai occlusion to incipient and manifest secretory otitis. Clinically, we are unable to determine the exact time of the onset of the disease, which this study of healthy children clearly illus¬ trates. A deterioration of the tympa¬ nograms will most often show a grad¬ ual shift from types A to C,, C2 and B, and improvement is reversed in the same order. Several subsequent tym¬ panograms in a child with a slight secretory otitis will often show a shift from a type C, to and vice versa. We have attempted to distinguish between cause and effect, but even at this early age this is difficult. Howev¬ er, it is demonstrated that secretory
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otitis may develop without preceding infection of the middle ear. It is rendered probable that dysfunction of the tube due to frequent catarrhalia in this age group is the most frequent etiologic factor, with acute otitis being the second most frequent factor. In this age group, we have not attempted to analyze the significance of the adenoids in the cause of secre¬ tory otitis. These are usually regarded as being small in the first year of life. When ascribing the tubai dysfunction the primary etiologic role, the ade¬ noids must also be considered as an
important etiologic factor, although they very rarely obstruct the pharyn¬ geal orifice. They reduce the ventila¬ tion of the rhinopharynx and promote stagnation of secretion in the rhino¬ pharynx and the internal tubai occluReferences 1. Friedmann I: The pathology of secretory otitis media. Proc R Soc Med 56:695-699, 1963. 2. Sade J: Pathology and pathogenesis of serous otitis media. Arch Otolaryngol 84:297-305, 1966. 3. Lim DJ, Birck H: Ultrastructural pathology of the middle ear mucosa in serous otitis media. Ann Otol 80:838-854, 1971. 4. Tos M, Bak-Pedersen K: The pathogenesis of chronic secretory otitis media. Arch Otolaryn-
gol 95:511-521,
1972.
Pathologie
und Pathogenese der chronischen sekretorischen Otitis im Kindesalter. HNO 24:37-42, 1976. 6. Silverstein H, Miller G, Lindeman R: Eustachian tube dysfunction as a cause for chronic secretory otitis in children. Laryngoscope 76:259\x=req-\ 273, 1966. 7. Renvall U, Holmquist J: Eustachian tube function in secretory otitis media. Scand Audiol 3:87-91, 1974. 8. Bluestone C, Beery Q, Andrus W: Mechanism of the Eustachian tube as it influences susceptibility to and persistence of middle ear effusions in children. Ann Otol 83(suppl 11):27-34, 1974. 9. Poulsen G, Tos M: Tubal function in chronic secretory otitis media in children. ORL 39:57-67, 1977. 10. Renvall U: Tympanometry in secretory otitis media. Scand Audiol 4:83-88, 1975. 11. Tos M, Poulsen G: Secretory otitis media. Late results of treatment with grommets. Arch Otolaryngol 102:672-675, 1976. 12. Paradise JL, Bluestone CD: Diagnosis and management of ear disease in cleft palate infants. Trans Am Acad Ophthalmol Otolaryngol 73:709-714, 1969. 13. Senturia BH, Gessert CF, Carr CD: Middle ear effusions: Causes and treatment. Trans Am Acad Ophthalmol Otolaryngol 64:60-75, 1960. 14. Sade J: Secretory and serous otitis media (SOM). Adv Otorhinolaryngol 23:1-21, 1978. 15. Kokko E: Chronic secretory otitis media in children. Acta Otolaryngol, suppl 327, 1975, pp 1-47. 16. Liu SY, Lang R, Lim DJ, et al: Microorganisms in chronic otitis media with effusion. Ann Otol 85(suppl 25):245-300, 1976. 17. Wright I, Kapadia R: The cytology of "glue ear." J Laryngol 83:367-376, 1969. 18. Palva T, Holopainen E, Karma P: Protein and cellular pattern of glue ear secretions. Ann Otol 85(suppl 25, pt 2):103-109, 1976. 5. Tos M:
19. Suehs OW: Secretory otitis media. Laryngoscope 62:698-1027, 1952. 20. Lim DJ, Liu SY, Schram J, et al: Immunoglobulin E in chronic middle ear effusion. Ann Otol 85(suppl 25):117-124, 1976. 21. Hentzer E, J\l=o/\rgensenMB: The submucous layer of the middle ear in chronic otitis media: II. Chronic suppurative otitis media: A histological and ultrastructural study. Arch Klin Exp Ohrenheilkd 201:119-126, 1972. 22. Jordan R: Chronic secretory otitis. Laryngoscope 59:1002-1015, 1949. 23. Tos M, Poulsen G, Borch J: Tympanometry in two-year-old children. ORL 40:77-85, 1978. 24. Tos M, Bonding P: Middle-ear pressure during and after prolonged nasotracheal and nasogastric intubation. Acta Otolaryngol 83:353\x=req-\ 359, 1977. 25. Tos M: Histopathology of the middle ear mucosa in tubal occlusion in man. Read before Physiology and Pathophysiology of Eustachian Tube and Middle Ear. Freiburg, 1977. 26. Arnold W: Reaktionsformen der Mittelohrschleimhaut. Arch Otorhinolaryngol 216:369\x=req-\ 473, 1977. 27. Burian K: \l=U"\berdie Restitutionsf\l=a"\higheit des Flimmerepithels der Nase nach totaler Zerst\l=o"\rungdes Epithels. Z Laryngol Rhinol 39:387-395, 1960. 28. Hilding A: Experimental surgery of the nose: Changes in the morphology of the epithelium following variations in ventilation. Arch Otolaryngol 16:9-18, 1936. 29. Tos M, Mogensen C: Changes of the nasal mucosa in altered airflow illustrated by blind quantitative histology. J Laryngol 92:667-680, 1978. 30. Leth N, Tos M: Middle ear ventilation after acute otitis media. ORL 39:278-284, 1977. 31. Bonding P, Tos M: Grommets in recurrent acute otitis media. ORL 38:10-13, 1976. 32. Tos M: Tubal function and tympanoplasty. Clin Otolaryngol, to be published.
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Factors in
Secretory Otitis
Mirko Tos, MD; Gert Poulsen, MD;
\s=b\ We investigated the possible etiologic factors of secretory otitis and dysfunction of the Eustachian tube in 278 healthy 2-year-old children based on screening tympanometry and medical history. We found that catarrhalia was the most frequent etiologic factor, with acute otitis being the second most frequent factor. It was demonstrated that secretory otitis may develop without a preceding infection of the middle ear. It is probable that dysfunction of the tube plays a primary role in the development of secretory otitis. Allergy did not seem to be an etiologic factor. Antibiotic treatment does not promote the development of secretory otitis, but is probably unable to prevent it. Parental disposition could not be related to the children's ear diseases.
(Arch Otolaryngol 105:582-588, 1979) it is generally agreed that "ex vacuo" theory is not valid, that the middle ear mucosa changes into a secretory mucosa, and that the effusion is a mixture of exúdate and mucus.11 However, the primary cause of secretory otitis has not yet been clarified. In the literature, three main causes are often mentioned: (1) tubai occlusion; (2) infection; and (3) aller¬
Today, the
gy· TUBAL OCCLUSION
The etiologic role of the tubai occlu¬ sion or dysfunction is especially based on the fact that the tubai function nearly always is reduced in secretory otitis, both before and during tubula-
Accepted
From the
Gentofte mark.
publication Oct 26, 1978. Ear, Nose, and Throat Department,
for
University Hospital, Hellerup,
Den-
Reprint requests to the Ear, Nose, and Throat Department, Gentofte University Hospital, DK\x=req-\ 2900 Hellerup, Denmark (Dr Tos).
Jesper Borch,
MD
tion." In more than 50% of the ears, it is still reduced one to 1% years8 "' and in 33% five to eight years after the tubulation, which is long after cessa¬ tion of secretion from the mucosa." Thorough investigations have shown that children with a cleft palate nearly always have secretory otitis.'-
otitis.' Jordan-- found allergy in 74% of the patients with secretory otitis. Other investigators mention a consid¬ erably lower percentage of allergy.'"' It is extremely difficult to deter¬ mine the primary cause of the secreto¬ ry otitis in a child who probably for a long time has had mucous effusion in the middle ear, a flat tympanogram,
INFECTION
enlarged adenoids, frequent catarrhalia, and recurrent otitis media.
"
Infection by bacteria or viruses, as the cause of secretory otitis" is espe¬ cially based on histopathological find¬ ings. Inflammatory changes such as round cell infiltration, vessel dilation, and metaplasia of the epithelium have been demonstrated in the middle ear mucosa.^"·" Furthermore, children with secretory otitis had one or several periods of acute otitis before they were tubulated. In experimental infection of the middle ear, Fried¬ demonstrated mann' secretory of the middle ear mucosa. changes Furthermore, it has been stated that the tube is never occluded anatomical¬ ly in secretory otitis.'4 Effusion was often found to be sterile, but other investigators have found positive cul¬ tures in 22%' and in 52%'" of the ears, most frequently Haemophilus influenzae, Staphylococcus aureus or S albas, and Pneumococcus. For the high percentage of negative bacterial cul¬ tures, a viral cause was considered. '
ALLERGY
Allergy
as
a
primary etiologic
factor has not been verified histologically. Wright and Kapadia'7 (1969) and Palva et alls (1976) found no ears with eosinophils in the effusion, while others have found a few.'"J" Eosinophilia of the middle ear mucosa has not been demonstrated in secretory
-'
What is cause and what is effect? Advocates of infection as the primary cause find that the tubai dysfunction is a consequence of secretory otitis, but it might be claimed that acute otitis is a consequence of tubai dysfunction or of secretory otitis. In this study, screenings were performed in healthy 2-year-old children in an attempt to analyze the etiologic factors of tubai dysfunction and secre¬ tory otitis. To be able to distinguish reasonably well between cause and effect, it is necessary to analyze the incidence of the possible etiologic factors from birth and during infancy and to correlate these to the incidence of tubai dysfunction and secretory otitis. PATIENTS AND METHODS
early December, performed in 135 healthy 2-year-old boys and 143 girls. They were born between the first and tenth day In late November and
1977, tympanometry
was
in every month in 1976 and live in two communities in the northern part of Copenhagen County, Denmark. They con¬ stitute an equal representation of all 2year-olds in this area, which has a popula¬ tion of 119,270.
Tympanometry was performed using an impedance apparatus with a frequency of 220 Hz; otoscopy was performed with a Siegle's speculum. Bacteria cultivation was performed of a rhinopharyngeal smear
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taken
through the
mouth. A
questionnaire
parents to supply informa¬ tion about the time, the frequency, and the was
sent to the
character of catarrhalia, acute otitis, diseases in the upper respiratory tract, and other febrile diseases, especially tonsillitis, children's diseases, and manifestations of allergy. Furthermore, information was obtained about the disposition of the parents and siblings for ear diseases and allergy; parents were asked to give detailed information about the birth of the child. To establish the exact time for the path¬ ological condition, the questionnaire was divided into periods of six months each. The parents of the children who just turned 1 year of age filled in the form during two periods, and the parents of children approximately 2 years of age filled in during four periods. At the investigation, the questionnaires were examined by a physician and, if necessary, further details were added.
RESULTS
The incidence of tubai dysfunction and secretory otitis has been dis¬ cussed.-1 Of 556 ears investigated, 49.6% had a type A tympanogram, with a middle ear pressure of 0 to -99 mm H.O; 19.4% had a type C, tympa¬ nogram, with a pressure of —100 to -199 mm HX>; 20.1% had type C2, with a pressure of -200 to —350 mm H ,0; and 10.8% had type B, with a flat curve without impedance minimum and with reduced mobility of the eardrum at otoscopy, indicating effusion and secretory otitis. The same classifica¬ tion of tympanogram types will be used herein. There were no significant differences in the distribution of tympanogram types between girls and boys or between left and right ears in general, although only 69.7% of the children had the same type of tympanogram on both ears. Most often, types A and occurred sym¬ metrically. No differences in the distribution of tympanograms were found between children living in private houses and in blocks of flats, or between those from the wealthiest community compared with the poor¬ est. It was concluded that tubai dysfunction and secretory otitis is not a "poor man's disease" in the 2-yearolds. Children nursed in a public day nursery had a significantly higher frequency (P < .001) of secretory oti-
tis and tubai dysfunction than those nursed in home day nurseries or at home. There were no significant differences between the two last mentioned groups. These quite sur¬ prising tympanometry conditions will be related to the possible etiologic factors. Otitis Related to Catarrhalia
Secretory
During the six-month period prior to the investigation, 10.8% of the chil¬ dren had not had catarrhalia, 53.6% had had a few catarrhalia with mucous secretion, 18.3% had mucopurulent secretion, 5.4% had had many catarrh¬ alia with mucous secretion, and 10.8% had mucopurulent secretion from the nose. Table 1 shows the distribution of the tympanogram types for each ear. The tubai function deteriorated grad¬ ually from the slightest affected group without catarrhalia to the most severe group, with many catarrhalia and mucopurulent secretion. The number of type A tympanograms decreased, while types C, and became more frequent. The difference between the two extreme groups is
highly significant ( 2 test, < .001), regardless of whether types , C., and are tested separately or types A, C, and C, and are pooled, respectiveiy.
In the group without catarrhalia during the last six months (Table 1) only the following three children had either a type or a type C_. tympano¬ gram. A boy just under 2 years of age had a type tympanogram on the one ear and a type C, on the other. The child had not had any periods of catarrhalia within the last six months, but had had several colds during the preceding year. The same was the case for a girl of IV2 years who had a type C,, tympanogram on one ear and a type C, on the other. A 1-year-old boy with a type tympanogram on both sides had been nursed in a public nursery for the last three months but had not had colds or other diseases. Otoscopy revealed a pink and re¬ tracted eardrum. The flora of the rhinopharynx was normal. During the following three months, he had had many catarrhalia with mucopurulent secretion and still a type tympano-
Thus, the possibility of a neglected or unnoticed catarrhalia before the first investigation cannot
gram.
be excluded.
Compared with the normal group without catarrhalia, the tympanograms of children who had had a few catarrhalia with mucous secretion had already deteriorated significantly with fewer type A (P < .001) and type C, (P < .001) tympanograms, but the differences in type tympanograms were not significant (Table 1). more
In the group with a few catarrhalia but with purulent secretion, signifi¬ cantly more ears had a type tympa¬ nogram (P < .02) than in the preced¬ ing group with mucous secretion (Table 1), but compared with other types there were no significant differ¬ ences. In comparison with the group of children without catarrhalia, there were significantly fewer type A tym¬ panograms {P < .001), and more type ( < .01) C2 (P < .001) and type
tympanograms.
In the group of children with many catarrhalia with mucous secretion (Table 1), there was a slight, though insignificant (P > .05) deterioration of the tubai function compared with the preceding group. However, the percentage of type C2 tympanograms was quite high. Compared with the group without catarrhalia and the group with a few catarrhalia and mucous secretion, the differences were
significant {P < .001).
In the group of children with many catarrhalia with mucopurulent secre¬ tion, the tympanograms were consid¬ erably worse, with significantly fewer type A tympanograms (P < .02) com¬ pared with the preceding group and with an increased number of types C,, C., and tympanograms. Bacterial Flora in
Rhinopharynx
Pathological bacterial flora in the rhinopharynx (Table 2) were found in 30.2% of the children (42 boys and 42 girls). The most frequent types of bacteria were influenzae (12.6%), Pneumococcus (9.4%), and S aureus (4.7%). Furthermore, four children had Streptococcus haemolyticus, three had Meningococcus, two had Esckerichia coli and
one
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had S albus.
Among the 168 ears with pathologi¬ cal flora there were fewer type A (P < .05) and more type ( < .02) tympanograms compared with ears from children with normal flora in the rhinopharynx. However, it was re¬ markable that 43% of the ears with a type A tympanogram were found in children with pathological flora in the rhinopharynx. Only two of the 84 chil¬ dren with pathological flora had not had catarrhalia, 38% had either had many catarrhalia or catarrhalia with purulent secretion. The remaining had had a few catarrhalia with mucous secretion. One third of the children had been nursed in public day nur¬ series. No relationship could be demon¬ strated between the distribution of tympanograms and the type (Table 2) or number of bacteria found at culture. Especially, the frequency of secretory otitis with a type tympa¬ nogram
was
not
Secretory Otitis
Related to Acute Otitis
During the period from birth until the time of the investigation (maxi¬ mum of two years), 26.6% of the chil¬ dren (44 boys and 30 girls) had acute otitis at least once: 14.4% of all 556 ears had been called "red" without secretion by a practitioner, and 9.7% had either had a paracentesis per¬ formed or a spontaneous perforation. Of these, 84 were boys' ears and 50 were from girls. This significant sex difference (P < .001) in the incidence of otitis may be due to the fact that 34.9% of all boys were nursed in public nurseries, in contrast to only 19.6% of the girls. Among all those who had had otitis, 36.7% girls and 40.9% boys had been nursed in public day nurseries. There were no significant differ¬ ences (P > .2) between the tympano¬ grams from the group with red ears and the group with paracentesis or spontaneous perforation. As a rule, the tympanograms were worse in ears
previous acute otitis, with signif¬ icantly fewer type A (P < .001) and
Between Catarrhalia and Tympanogram 2-Year-Old Children*
1.—Relationship
Types
in 278
Catarrhalia, % Few, With
Few,
(N
=
With
With Mucous Secretion
Many,
Purulent Secretion
Mucous Secretion
Tympanogram None Type (N = 64)
300)
(N
=
102)
(N
30)
=
Many,
With
Purulent Secretion
(N
=
60)
Total %
(N
=
556)
A_78_1_51_3_£7_1_43J3_1^3_49.6 C,_14.1_21_3_20_6_10_0_^3_19.4 _C,_3_1_20_3_^6_7_30 _38_3_20.1 4.7
"Including
135
15.7
7.0
16.6
10.8
25.0
boys and 143 girls.
Table
2.—Relationship Between Tympanogram Types in
Bacteria in the Rhinopharynx and 278 2-Year-Old Children*
Bacteria, %
StreptoTympanogram
Type
Haemo-
Pneumo-
philus (N = 70)
(N
coccus =
52)
Staphylococcus aureus
(N
=
26)
coccus
haemoly-
Other
ticus
(N
=
8)
(N
=
Total Abnormal Culture
12) (N
=
Total % Normal Culture
168) (N
=
388)
A_4J_1_36_5_50 _25.0 41.7_42J)_52.6 C,_20 _-\J_5_30_8_25_0_33J3_20^2_19.1
g_17J_308_3J3_50t)_16J_20JJ_19.8 _15.7 21.2_15_4_0_83 16.1_8.5
significantly larger
for specific types of bacteria. One hundred thirty-four ears had had acute otitis. In 32% of these children, pathological bacterial flora were found in the rhinopharynx.
with
Table
"A total of 556
more
type
compared otitis
ears.
(
with
.1 and > .5). Thus, in this group of 2-year-olds, the incidence of tubai dysfunction and secretory otitis was not higher in allergic children than in nonallergic children. As a rule, more boys than girls had a deteriorated tubai function (Table 6). It has earlier been demonstrated-3 that this is due to the coincidence that more boys than girls are nursed in public day nurseries. An investigation of the incidence of tubai dysfunction and secretory otitis among boys and girls nursed at home, in home day nurseries, or in public day nurseries, respectively, showed no differences in
Paracentesis
=
Perforation, %
80)
(N
31.1
25.0 30.0 13.8 *A total of 556
=
A
C,
(N
=
43)
(N
26.9 17.9
18.0 8.5
Table 5.—Tympanogram Types in Ears With Acute Otitis in Various Periods*
=
in One
Periods, % (N = 45)
Period, % (N = 89)
20.0 22.2 40.0 17.8
36.0 25.8 20.2 17.9
Tympanogram Type
Otitis in Two
47)
25.3 4.3 48.9 21.3
6.—Tympanogram Types
•Group with otitis in two or more six-month periods compared with group with one incident of otitis in one period.
in 2-Year-Old Children With
Allergy Compared 278
Tympanogram Allergy Type (N = 18)
Allergy (N = 268)
No
135 Boys, %
Allergy (N = 42)
A_50 _56.3 50.0
Otitis
Nonallergic Children
143 Girls, %
C,
422)
22.2
No Otitis
Otitis
With
It has often been claimed that the
=
55.7 17.7
"Ears divided into group that had otitis and group that never had otitis.
Antibiotic Treatment
(
ears.
20.9 23.3
Table
Total Without Otitis, %
30.6 24.6
24.0
27.9 27.9
C,
in 278
29.6 24.1
Many Catarrhalia, % Tympanogram Type
Otitis, % ( = 134)
54)
Table 4—Tympanogram Types in 90 Ears of Children With Many Catarrhalia Related to Incidence of Otitis*
sex.
increasing frequency of secretory oti¬ tis is due to antibiotic treatment. One hundred thirty-two children (47.5%), 71 girls and 61 boys, had never received antibiotic treatment, and the remaining had received antibiotics, mostly penicillin, at least once. The distribution of tympanograms (Table 7) showed significantly fewer type A (P < .02) tympanograms in the anti¬ biotic group than in the nontreated group. The frequency of other tympa¬ nogram types showed no significant differences; thus, type occurred in 9.1% of ears that had never been treated with antibiotics. Therefore, it cannot be concluded that antibiotics promote the development of secretory otitis. The fact that children were not treated with antibiotics was usually owing to there being no need for this, and generally this group showed good health: only 12 (9.1%) had many catarrhalia, and among these type
Ears, %
(N
Total With
or
Spontaneous
Red
Tympanogram Type
Tympanogram Type
17.5
Allergy (N = 228)
No
Boys and Girls, %
Total
Allergy (N = 60)
Total
No
(N
Allergy 496)
=
33.3_44£_38JJ_51.0 19.0
19.3
28.3
18.3
_0_1_5_3_38J_24J_26J_19.4 0
10.8
occurred in 38% of the ears. In the group treated with antibiotics, 33 chil¬ dren (22.6%) had many catarrhalia, and among these 16.7% of the ears had a
type
tympanogram.
Antibiotics are often used for treat¬ ment of acute otitis. Among the 87 children who had had acute otitis, only ten (11.5%) had not received any anti¬ biotic treatment. As mentioned, the group of children with acute otitis (Table 3) had deteriorated tubai func¬ tion. Penicillin was given to 85% of the 80 children who had tonsillitis, laryngitis, or bronchitis, and especially to those with recurrent bronchitis. These chil¬ dren were also more catarrhal and had a more deteriorated tubai function than the others. Pathological flora were found in the
9.5
11.8
6.7
11.3
of 46 children (34.8%) who had never been treated with anti¬ biotics and in 38 (26.0%) who had been treated; the difference is not signifi¬
rhinopharynx
cant
(P > .1). Childhood Diseases
Forty-two children (15.1%) had had the following childhood diseases: 5.6%, German measles; 2.5%, morbilli; 1.8%, varicella; 0.7%, tussis convulsiva; and 0.7%, erythema subitum: 1.8% had had two childhood diseases and 0.7% had three. The distribution of tympano¬ grams showed no difference (Table 8) among those who had had childhood diseases and those who had not. Nor did the group with two or three child¬ hood diseases have a more reduced tubai function than the group without childhood diseases.
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Other Febrile Diseases A total of 12.2% of the children had had acute tonsillitis, 3.6% having had it two or three times. The distribution of tympanograms did not differ from the rest of the material (Table 9). However, there seemed to be more
type
Table 7.—Tympanogram Types in 2-Year-Old Children Never Treated With Antibiotics and Those Treated With Antibiotics
ence
Type_(N
was
insignifi¬
chronic coughs during longer peri¬ ods. There were fewer types A (P < .01), C, and when pooled than in the rest of the material, while the differences in frequency of type alone was not significant (P > .2). All 35 children in the bronchitis group had been catarrhal within the last six months: ten many times with mucopu¬ rulent secretion; eight a few times with mucopurulent secretion; and the remaining 17 a few times with mucous secretion. As shown in Table 1, catarrhalia was probably the primary cause of the deteriorated tubai func¬ tion in the bronchitis group. or
parental disposition (Table 10). Espe¬ cially, the group in which there had
been ear diseases in both parents showed the best distribution of tym¬ panograms with the fewest type and the most type A tympanograms. The incidence of acute otitis was the same in the group with predisposition (27.6%) as in the group without a possible disposition (25.6%). The inci¬ dence of frequent catarrhalia was also
264)
A
54.9
C, O,
18.2 17.8 9.1
Table
(N
=
Diseases, %
gram
Type_(N
292)
A
44.9 20.5 22.3 12.3
C,
C,
9.—Tympanogram Types in 2-Year-Old Children Laryngitis, and Bronchitis
=
Tympanogram
Type_(N
68)
(N
=
22)
(N
=
(N
472)
49.6
48.8 20.2 16.7 14.3
19.3 20.8 10.2
Infections,
Total With No Infections,
%
%
70)
=
With Acute Tonsillitis,
%
%
% =
Bronchitis,
Laryngitis,
%
84)
Total
Tonsillitis,
(N
=
160)
(N
=
396)
A_5O0_40_9_32_9_4JL3_53.0 C,_20_6_409_18JS_22J_18.2 C._14J_18^_32_^_23J_18.9 13.1
15.7
14.7
9.8
...
Table
10.—Tympanogram Types
in 2-Year-Old Children Related to Ear Diseases of Parents
Disposition, Tympanogram
Father or
Father and
Mother
Mother
%
Type_(N 196)_(N 36)_(N =
=
Total With No
Disposition, % 232)_(N 324)
Total =
=
A_55^6_6jU_56J_44.8 C,_15J3_194_15JI_21.9 C,_18j)_1X9_18J_21.9 11.7
Disposition One or both parents of 166 2-yearold children (41.7%), 60 boys and 56 girls, had had otitis, recurrent ear pain, or chronic secretory otitis during childhood. A few had had chronic middle ear diseases during adulthood. In 54 children, it was the father who had been affected; in 44, the mother; and in 18, both parents. In the group of children that might be said to have a certain disposition for tubai dys¬ function and secretory otitis, the distribution of tympanograms was even better than in the group without
=
Diseases,
Childhood
Tympano-
Antibi-
otics, %
%
gram
cant. A total of 12.6% of the children had had bronchitis, often recurrent acute bronchitis accompanying colds
Childhood
Antibiotics,
Tympano-
(25%) tympanograms, especial¬
in tympanograms
"
Ño
in children who had had tonsillitis several times, but this is not signifi¬ cant (P > .1). Four percent had had laryngitis stridulosa, but the differ¬
ly
Table 8—Tympanogram Types in 2-Year-Old Children With and Without Childhood Diseases
10.2
the
same
in both groups, 12.1% and
19.1%, respectively (P > .1). COMMENT
Secretory otitis is surprisingly fre¬
quent (10.8%) in 2-year-olds,
9.5
5.6
more
frequent than in any other age group.-' The incidence is especially high at the end of the first year. In this age group, catarrhalia is the most frequent and most dominating etiologic factor in clinical tubai occlu¬ sion and secretory otitis. Catarrhalia is very likely due to viral infection of the upper respiratory tract, combined with bacterial infection of the nose. During catarrhalia, the mucosa of the nose and rhinopharynx is swollen and hypersecretive. Similar mucosal changes probably spread to the pha¬ ryngeal part of the Eustachian tube, which histologically has the same structure as the nasal mucosa. This causes edema and hypersécrétion of
the tubai mucosa and an internal tubai occlusion. Reduced ventilation of rhi¬ nopharynx and internal tubai occlu¬ sion result in a reduced ventilation of the middle ear, which could be demon¬ strated by measurement of the middle ear pressure during prolonged nasotracheal intubation.-' Immediately following tubulation, the pressure became negative but normalized with¬ in a few days after extubation. If intubation was of longer duration, the pressure stayed negative at -200 and -300 mm HO for several days or weeks after the extubation, indicating that internal tubai occlusion had occurred as a consequence of the inflammatory changes in the rhino¬
pharynx. A single short-lasting period of catarrhalia will often reduce ventila¬ tion of the middle ear, which normal¬ izes after cessation of the catarrhalia. In prolonged catarrhalia combined
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with bacterial infection of the nose, more time is needed for normalization of the ventilation. If catarrhalia recurs, ventilation will again deterio¬ rate, resulting in a negative middle ear pressure for weeks or months.
Quantitative histological investiga¬
tions"' have shown that children with a chronic clinical tubai occlusion and a middle ear pressure of —200 and -300 mm HoO for several weeks have histo¬ logical changes of the middle ear mucosa, either in the form of vessel dilation, vessel proliferation, round cell infiltration, or slight metaplasia of the flat single-layered to pseudostratified epithelium. Furthermore, there is an increased density of goblet cells. A few of the children also had gland formation. Qualitatively, the histological changes are the same as in incipient and manifest secretory oti¬ tis, but quantitatively they are consid¬ erably less pronounced. We do not know the provoking factor of mucosal changes in chronically reduced venti¬ lation. One possibility is a changed composition of gases, another is dam¬ age of the interepithelial connections, resulting from a negative pressure. Experimentally, Arnold-" was able to demonstrate epithelial damage fol¬ lowed by structural changes of the epithelium shortly after closure of the tube. The previously mentioned changes may be regarded as reparative processes of the mucosa. They resemble an inflammatory reaction, but the mucosa reacts similarly on different pathological stimuli such as trauma-7 and changed air passage in the nose.28·29 Thus, inflammatory changes of the mucosa may be caused by infection. No specific bacteria in the rhino¬ pharynx could be attributed responsi¬ bility for chronic dysfunction of the tube or secretory otitis. More children with a type tympanogram were found in the group with pathological bacterial flora, but by far most of these had been catarrhal. On the other hand, many children (43%) had patho¬ logical flora and a normal tympano¬ gram.
Acute otitis,
especially
recurrent
otitis, may, as chronic tubai occlusion, lead to metaplasia of the mucosa and to secretory otitis. Infecacute
tion of the middle ear mucosa is an etiologic factor, and in children who have had acute otitis the tympano¬ grams are worse, with a higher inci¬ dence of secretory otitis. However, most often, acute otitis will complicate a chronic middle ear disease, especial¬ ly tubai occlusion. Nearly all children had been catarrhal in the six-month period preceding the first otitis, 32% having been catarrhal several times. Therefore, it is probable that many children have been affected by a dete¬ riorated tubai function or secretory otitis before the first acute otitis. The acute otitis aggravates the tubai dysfunction, which prolongs the nor¬ malization process1" and enlarges the risk of recurring otitis. The fact that children with secretory otitis often get acute otitis is considered proof that infection is the primary and only etiologic factor; in our opinion, acute otitis is a consequence rather than a cause of secretory otitis. This study shows that 10.8% of healthy 2-year-old children have secretory otitis even though only a few of them have had recurring acute otitis. When a small number of these children—those who get impaired hearing and recurrent acute otitis—at the age of 4 to 6 will be hospitalized for treatment, the inci¬ dence of acute otitis will be very high. Conversely, in prophylactic treatment of ears with recurrent acute otitis, we were able to demonstrate in a symp¬ tom-free period mucous effusion in 75% of the ears." In our opinion, the demonstration of bacteria in the middle ear effusion in secretory otitis cannot be considered proof of infection being the primary etiologic factor, but merely as an indi¬ cation of one or several previous infec¬ tions, and that the immunological conditions have made the bacteria more or less apatogene. The reason for this tolerance may be that the mucosa has changed into a real mucosa with similar immunological abilities as found in the nose and rhinopharynx, where pathogenic bacteria are quite common; in this material, they were found in 30.2% of the children. The material gave no grounds for assuming that allergy plays any etio¬ logic role in the development of secre¬ tory otitis in the 2-year-olds. Food,
insufficient and low in protein due to potato chips and soft drinks, is said to be an etiologic factor in older children. The children in this study were not malnourished; on the contrary, the food is carefully controlled at obliga¬ tory visits by a health visitor. Children nursed in public day nurseries, where the nourishment was correct, had the highest incidence of secretory otitis.
Childhood diseases, acute tonsillitis, and acute stridulous laryngitis are not etiologic factors in secretory otitis. Children with recurrent bronchitis had also had many catarrhalia, which might explain the poor tympano¬ grams in this group. There seemed to be no hereditary disposition for secretory otitis and dysfunction of the tube in this age group. However, this does not exclude that later, when the tube and the middle ear are fully developed, such a relationship might be found. We" have found a reduced tubai function five to eight years after tubulation in 33% of the children. Two to ten years after tympanoplasty, the tubai func¬ tion was reduced in 77% of adults with cholesteatoma. '- This material demon¬ strates that antibiotic treatment does not promote the development of secre¬ tory otitis, but apparently is unable to prevent it. It is debatable whether or not all children with type tympanograms have had effusion and secretory otitis. On the other hand, some ears with a type C. tympanogram may contain some effusion. Quantitative27' histo¬ logical studies show a gradual change of the mucosa from chronic tubai occlusion to incipient and manifest secretory otitis. Clinically, we are unable to determine the exact time of the onset of the disease, which this study of healthy children clearly illus¬ trates. A deterioration of the tympa¬ nograms will most often show a grad¬ ual shift from types A to C,, C2 and B, and improvement is reversed in the same order. Several subsequent tym¬ panograms in a child with a slight secretory otitis will often show a shift from a type C, to and vice versa. We have attempted to distinguish between cause and effect, but even at this early age this is difficult. Howev¬ er, it is demonstrated that secretory
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otitis may develop without preceding infection of the middle ear. It is rendered probable that dysfunction of the tube due to frequent catarrhalia in this age group is the most frequent etiologic factor, with acute otitis being the second most frequent factor. In this age group, we have not attempted to analyze the significance of the adenoids in the cause of secre¬ tory otitis. These are usually regarded as being small in the first year of life. When ascribing the tubai dysfunction the primary etiologic role, the ade¬ noids must also be considered as an
important etiologic factor, although they very rarely obstruct the pharyn¬ geal orifice. They reduce the ventila¬ tion of the rhinopharynx and promote stagnation of secretion in the rhino¬ pharynx and the internal tubai occluReferences 1. Friedmann I: The pathology of secretory otitis media. Proc R Soc Med 56:695-699, 1963. 2. Sade J: Pathology and pathogenesis of serous otitis media. Arch Otolaryngol 84:297-305, 1966. 3. Lim DJ, Birck H: Ultrastructural pathology of the middle ear mucosa in serous otitis media. Ann Otol 80:838-854, 1971. 4. Tos M, Bak-Pedersen K: The pathogenesis of chronic secretory otitis media. Arch Otolaryn-
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Pathologie
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