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OBJECTIVE. We examined relationships between tympanometric findings and the presence or absence of middle-ear effusion in a population-based sample of children under the age of 3 years. METHODS. In a study of children's development in relation to early-life otitis media, we enrolled 6350 infants soon after birth and evaluated them regularly for the presence of middle-ear effusion. In 3686 of the children, we compared tympanometric findings with otoscopic diagnoses. We categorized tympanograms according to varying combinations of tympanometric peak height, peak pressure, and width, and calculated for each resulting category the percentage of the associated ears diagnosed as having effusion. Using these findings we developed algorithms for estimating the probability of middle-ear effusion associated with tympanograms of any configuration. RESULTS. For tympanograms generally, the lower their height and the greater their width, the greater was the probability of associated middle-ear effusion; the probability also was greater when peak pressure was negative rather than positive. Among children [greater than or equal to] 6 months of age, effusion was diagnosed in only 2.7% of ears with tympanometric height [greater than or equal to] 0.6 mL, but in 80.2% of ears with flat tympanograms. Relationships among younger infants were similar but less consistent. In both age groups, the tympanographic configurations most commonly encountered were associated with either a relatively low probability (70%) of the presence of middle-ear effusion. The receiver operating characteristic curve we generated using the algorithm we developed for children [greater than or equal to] 6 months of age gave an area under the curve of 0.84. The algorithm performed equally well when applied to a separate group of children, suggesting that it is generalizable to other unselected populations. CONCLUSIONS. The present report offers two alternative methods for estimating the probability of middle-ear effusion in children aged 6 through 35 months, given any combination of tympanometric values. www.pediatrics.org/cgi/doi/10.1542/peds.2005-t 879 doi:10.1542/peds.2005-1879 Key Words tympanometry, middle ear effusion, otitis media, otoscopic diagnosis, aural acoustic immittance testing, tympanometric-otoscopic relationships, receiver operating characteristic curve Abbreviations MEE--middle ear effusion ASHA--American Speech Language-Hearing Association ROC--receiver operating characteristic CI--confidence interval, OTOSCOPIC DIAGNOSIS OF middle-ear effusion (MEE) in infants and young children is often problematic, (1) and clinicians' skills in that regard are notably variable. (2,3) Tympanometry, on the other hand, [...]

Objective. In a long-term, prospective study, we set out to determine whether otitis media in the first 3 years of life persisting for periods currently considered developmentally threatening actually results in later impairments of children's cognitive, language, speech, or psychosocial development; whether prompt insertion of tympanostomy tubes prevents or lessens any such impairments; and whether, irrespective of causality, associations exist between persistent early-life otitis media and later developmental impairments. This report describes findings in study participants at the age of 4 years. Methods. We enrolled 6350 healthy infants from 2 to 61 days of age at urban hospitals and 2 small-town/rural and 4 suburban private pediatric practices. We regularly evaluated the children for the presence of middle-ear effusion (MEE) throughout their first 3 years of life by pneumatic otoscopy, supplemented by tympanometry; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated children for otitis media according to specified guidelines. In the clinical trial component of the study, we randomly assigned 429 children who met specified minimum criteria regarding the persistence of MEE to undergo tympanostomy tube insertion either promptly or after a defined extended period if MEE remained present. In the associational component of the study, we selected a representative sample of 241 children who ranged from having no MEE to having MEE the cumulative duration of which fell just short of meeting randomization criteria for the clinical trial. In 397 (92.5%) of the children in the clinical trial and in 234 (97.1%) of the children in the representative sample, we assessed cognitive, language, speech, and psychosocial development at the age of 4 years, using formal tests, conversational samples, and parent questionnaires. Results. In children in the randomized clinical trial, there were no statistically significant differences in mean ([+ or -] standard deviation) scores (higher denotes more favorable) favoring the early-treatment group over the late-treatment group on the General Cognitive Index of the McCarthy Scales of Children's Abilities (97 [+ or -] 14 and 98 [+ or -] 14, respectively); the Peabody Picture Vocabulary Test-Revised, a measure of receptive language (90 [+ or -] 15 vs 92 [+ or -] 16); the Nonword Repetition Test, a measure of phonological memory (66 [+ or -] 12 vs 70 [+ or -] 12); the Number of Different Words, a measure of word diversity (150 [+ or -] 34 vs 150 [+ or -] 31); the Mean Length of Utterance in Morphemes, a measure of sentence length and grammatical complexity (3.4 [+ or -] 0.8 vs 3.4 [+ or -] 0.7); or the Percentage of Consonants Correct-Revised, a measure of speech-sound production (92 [+ or -] 5 vs 93 [+ or -] 5). There were also no significant differences in ratings (higher denotes less favorable) on the Parenting Stress Index-Short Form (Total Stress scores: 68 [+ or -] 18 vs 65 [+ or -] 17) or the Child Behavior Checklist (Total Problem T scores: 50 [+ or -] 10 vs 49 [+ or -] 10). In the associational component of the study, correlations between the children's durations of MEE and their developmental outcomes were generally weak and, in most instances, nonsignificant. Exceptions, after adjustment for sociodemographic variables and for hearing thresholds at the time of developmental testing, consisted of a significant negative correlation between children's cumulative durations of MEE in their first 3 years of life and scores on the McCarthy Verbal subscale, and significant positive correlations between durations of MEE and scores on 2 measures of parent-child stress. The percentage of variance in these scores explained by time with MEE beyond that explained by sociodemographic variables ranged from 1.6% to 3.3%. In both the randomized clinical trial and the associational component, sociodemographic variables seemed to be the most important factors influencing developmental outcomes, and in both components, the results at 4 years of age were consistent with the results that had been obtained at 3 years of age. Conclusions. In otherwise healthy children who are younger than 3 years and have persistent MEE within the duration limits that we studied, prompt insertion of tympanostomy tubes does not measurably improve developmental outcomes at 4 years of age. In such children, persistent MEE within the duration limits that we studied is negligibly associated with and probably does not affect developmental outcomes at 4 years of age. otitis media, middle-ear effusion, tympanostomy tube insertion, language, speech, cognition, parent-child stress, behavior, development., ABBREVIATIONS. OME, otitis media with effusion; MEE, middle-ear effusion; dB HL, decibels hearing level; SD, standard deviation; CBCL, Child Behavior Checklist; PSI-SF, Parenting Stress Index-Short Form. Two important, unresolved questions [...]

Objective. In previous clinical trials involving children severely affected with recurrent throat infection (7 or more well-documented, clinically important, adequately treated episodes of throat infection in the preceding year, or 5 or more such episodes in each of the 2 preceding years, or 3 or more such episodes in each of the 3 preceding years), we found tonsillectomy efficacious in reducing the number and severity of subsequent episodes of throat infection for at least 2 years. The results seemed to warrant the election of tonsillectomy in children meeting the trials' stringent eligibility criteria but also provided support for nonsurgical management. We undertook the present trials to determine 1) whether tonsillectomy would afford equivalent benefit in children who were less severely affected than those in our earlier trials but who nonetheless had indications for tonsillectomy comparable to those in general use, and 2) whether, in such children, the addition of adenoidectomy would confer additional benefit. Methods. We conducted 2 parallel randomized, controlled trials in the Ambulatory Care Center of Children's Hospital of Pittsburgh. To be eligible, children were required to have had a history of recurrent episodes of throat infection that met standards slightly less stringent than the standards used in our earlier trials regarding either the frequency of previous episodes or their clinical features or their degree of documentation, but not regarding >1 of those parameters. These reduced standards were nonetheless more stringent than those in current official guidelines, which list "3 or more infections of tonsils and/or adenoids per year despite adequate medical therapy" as an indication for tonsillectomy or adenotonsillectomy. Of 2174 children referred by physicians or parents, 373 met the current trials' eligibility criteria and 328 were enrolled. Of these, 177 children without obstructing adenoids or recurrent or persistent otitis media were randomized to either a tonsillectomy group, an adenotonsillectomy group, or a control group (the 3-way trial), and 151 children who had 1 or more such conditions were randomized to either an adenotonsillectomy group or a control group (the 2-way trial). Outcome measures were the occurrence of episodes of throat infection during the 3 years of follow-up; other, indirect measures of morbidity; and complications of surgery. Results. By various measures, the incidence of throat infection was significantly lower in surgical groups than in corresponding control groups during each of the 3 follow-up years. However, even among control children, mean rates of moderate or severe episodes were low, ranging from 0.16 to 0.43 per year. Adenotonsillectomy was no more efficacious than tonsillectomy alone. Of 203 children treated with surgery, 16 (7.9%) had surgery-related complications of varying types and severity. Conclusions. The modest benefit conferred by tonsillectomy or adenotonsillectomy in children moderately affected with recurrent throat infection seems not to justify the inherent risks, morbidity, and cost of the operations. We conclude that, under ordinary circumstances, neither eligibility criteria such as those used for the present trials nor the criterion for surgery in current official guidelines are sufficiently stringent for use in clinical practice. Pediatrics 2002;110:7-15; tonsillectomy, adenotonsillectomy, tonsillitis, pharyngitis, streptococcal tonsillopharyngits, throat infection, surgical criteria, randomized clinical trial., Tonsillectomy remains the most commonly performed major surgical operation among United States children; in 1996, the most recent year for which national data are available, an estimated 287 000 children [...]

The most common reason for antimicrobial use in United States children is treatment of otitis media.[1] Of 44.5 million office-based prescriptions for antimicrobials in 1986 for children younger than than [...]

A physical exam may be all that is needed to rule out adenoid obstruction in children if symptoms such as mouth breathing and nasal voice are absent. Researchers compared physician ratings of the degree of obstruction as well as physician evaluations of X-rays of the head in 1,033 children. There was strong agreement among physicians when symptoms were obvious or completely absent. However, intermediate levels of symptoms were harder to diagnose without X-rays. X-rays may not be necessary if the child has no symptoms., Objective. As part of a comprehensive study of indications for tonsillectomy and adenoidectomy, we investigated the reliability of standardized clinical assessments and standardized roentgenographic assessments of adenoidal obstruction of the nasopharynx, and the degree of correlation between clinical assessments and roentgenographic assessments. Methods. We rated the degree of patients' mouth breathing and patients' speech hyponasality on a 4-point scale (none = 1, mild = 2; moderate = 3; marked = 4), we averaged the ratings for each child to obtain a Nasal Obstruction Index, and we determined levels of interobserver agreement concerning the ratings. We classified lateral soft-tissue roentgenograms of the nasopharynx, based on assessments of adenoid size and of nasopharyngeal airway patency, as showing either no obstruction, borderline obstruction, or obstruction, and we determined levels of inter- and intraobserver agreement concerning the classifications. Finally, we determined correlations in individual patients between clinical ratings and roentgenographic ratings of nasal/nasopharyngeal obstruction, and calculated the predictive values of clinical ratings based on roentgenographic ratings as the gold standard. Results. In sets of paired examinations, weighted [Kappa] values for interobserver agreement concerning mouth breathing (total, 235 children) and speech hyponasality (total, 648 children) ranged from 0.84 to 0.91. The value for interobserver agreement concerning roentgenographic assessment of nasopharyngeal airway status (207 children) was 0.92, and for intraobserver agreement (191 children) 0.88. The Kendall's [Tau] b value for concordance between Nasal Obstruction Index values and roentgenographic ratings (1033 children) was 0.51. Nasal Obstruction Index values at the lower and upper extremes--ie, 1.0 and [is greater than or equal to] 3.5, respectively--were highly predictive of concordant roentgenographic ratings. Conclusions. We conclude that standardized clinical ratings of the degree of children's mouth breathing and speech hyponasality provide reliable and reasonably valid assessments of the presence and degree of adenoidal obstruction of the nasopharyngeal airway. These clinical assessments are particularly valid at the extremes of either marked obstruction or no obstruction. Clinical assessment alone may be insufficient to establish the presence of adenoidal obstruction, but clinical assessment alone when findings are unequivocally negative can suffice to rule out adenoidal obstruction with a high degree of confidence. Pediatrics 1998;101:979-986; adenoidal obstruction, nasal obstruction, nasopharyngeal airway, clinical assessment, roentgenographic assessment, mouth breathing, speech hyponasality, diagnostic reliability, diagnostic validity., ABBREVIATION. AN, adenoidal-nasopharyngeal. Chronic nasal obstruction attributable to large adenoids is a common condition of childhood. However, in our experience few children with nasal obstruction complain about or admit to [...]

The frequency of middle ear infections may be higher than previously thought. Significant risk factors appear to be race, socioeconomic status, and exposure to larger numbers of children. Doctors closely monitored ear infection frequency among 2253 infants from socioeconomically diverse families until they were two years of age. Twenty percent of these children had ear infections before age one and 16.6% had ear infections between age one and two. Children who were black, male, living in cities, on Medicaid, or exposed to a large number of children or family smokers experienced more days with ear infections., Objective. As part of a long-term study of possible effects of early-life otitis media on speech, language, cognitive, and psychosocial development, we set out to delineate the occurrence and course of otitis media during the first 2 years of life in a sociodemographically diverse population of infants, and to identify related risk factors. Methods. We enrolled healthy infants by age 2 months who presented for primary care at one of two urban hospitals or one of two small town/rural and four suburban private pediatric practices. We intensively monitored the infants' middle-ear status by pneumatic otoscopy, supplemented by tympanometry, throughout their first 2 years of life; we monitored the validity of the otoscopic observations on an ongoing basis; and we treated infants for otitis media according to specified guidelines. Results. We followed 2253 infants until age 2 years. The proportions developing [is greater than or equal to] 1 episode of middle-ear effusion (MEE) between age 61 days (the starting point for data analysis) and ages 6, 12, and 24 months, respectively, were 47.8%, 78.9%, and 91.1%. Overall, the mean cumulative proportion of days with MEE was 20.4% in the first year of life and 16.6% in the second year of life. Tympanostomy-tube placement was performed on 1.8% and 4.2% of the infants during the first and second years of life, respectively. By every measure, the occurrence of MEE was highest among urban infants and lowest among suburban infants; these differences were greatest in the earliest months of life. Overall, unadjusted mean cumulative proportions of days with MEE were higher among boys than girls, higher among black than white infants, and higher among Medicaid than private health insurance enrollees. Cumulative proportions of days with MEE varied directly with the number of smokers in the household and with the number of other children to whom infants were exposed, whether at home or in day care, and varied inversely with birth weight, maternal age, level of maternal education, a socioeconomic index, and duration of breastfeeding. After adjustment, using multivariate analysis, the only variables that each remained independently and significantly related to the cumulative proportion of days with MEE were: during the first year of life, study site grouping, sex, the socioeconomic index, breastfeeding for [is greater than or equal to] 4 months, the number of smokers in the household, and an index rating the degree of exposure to other children at home or in day care; and during the second year of life, sex, the socioeconomic index, and the child exposure index. The duration of breastfeeding and the degree of exposure to tobacco smoke contributed little to the explained variance; most was attributable to differences in the socioeconomic index and the child exposure index. Conclusions. Contrary to findings in many previous reports, the prevalence of otitis media during the first 2 years of life among lower-socioeconomic-status black infants appears to be as high as, if not higher than among lower-socioeconomic-status white infants, and certainly higher than among middle-class white infants. Among middle-class white infants the prevalence may also be higher than commonly assumed. The most important sociodemographic risk factors for otitis media appear to be low socioeconomic status and repeated exposure to large numbers of other children, whether at home or in day care. Pediatrics 1997;99:318-333; otitis media, middle-ear effusion, prevalence, risk factors, epidemiology, sociodemographic factors, critical review., ABBREVIATION. MEE, middle-ear effusion. Otitis media is, next to the common cold, the most commonly diagnosed and probably the most prevalent illness in United States children, with its peak incidence [...]

The use of antibiotics to treat middle ear infections should be minimized because it is helping to create a pool of antibiotic resistant Streptococcus pneumoniae. This is particularly concerning because, unlike other penicillin-resistant microbes, there is only one currently known antibiotic that will kill penicillin-resistant S. pneumoniae. For this reason, length of antibiotic treatment for ear infections should be individualized according to the prognosis for the case and in some cases, may be avoided altogether. Antibiotics should not be routinely used to treat fluid in the ears in children who do not have acute infections. Sustained, preventative use of antibiotics in children with repeated ear infections should be avoided in favor of alternative measures wherever possible. These strategies should protect the child's well being while minimizing the potential risk of creating antibiotic resistant strains of S. pneumoniae., ABBREVIATIONS. AOM, acute otitis media; OME, otitis media with effusion; URI, upper respiratory tract infection. Changing circumstances often call for reconsideration of established procedures. Such a circumstance is the increasing [...]

Breast milk may partially protect infants with cleft palate from middle ear infection. Fluid in the middle ear is virtually continuous among formula-fed children with cleft palate. Feeding mode and presence or absence of fluid in the middle ear was evaluated at clinic visits of 315 infants with cleft palate. All infants were bottle fed. Among the 261 infants exclusively fed formula, 2.7% had one or more visits free of middle-ear fluid, whereas 31% of the 54 infants fed breast milk had such visits. Breast milk fed infants were 11.7 times more likely to have a visit clear of middle-ear fluid. The results suggest that protective factors must be in the breast milk itself because all infants were bottle fed., Objective. Most infants with cleft palate suckle unproductively and require feeding by artificial means. Most also have unremitting otitis media accompanied by (usually) nonpurulent middle-ear effusion, a complication generally attributed to impaired eustachian tube ventilatory function. We observed two infants with cleft palate in whom one or both ears appeared effusion-free on more than one occasion, and who also were receiving or previously had received breast milk feedings. This prompted us to analyze the relation between middle-ear status and feeding mode in a large series of infants with cleft palate. Our objective was to determine whether in these infants the receipt of breast milk mitigated the otherwise virtually invariable development and continued presence of otitis media. Methods. We reviewed and analyzed data concerning both feeding mode and the presence or absence of middle-ear effusion in 315 infants with cleft palate, as recorded systematically in the course of prospective studies at our Cleft Palate-Craniofacial Center. Analysis was limited to periods preceding the infants&apos; receipt of tympanostomy-tube placement or palate repair, or their second birthday, whichever occurred first. Results. Freedom from effusion in one or both ears was found at one or more visits in only seven (2.7%) of 261 infants fed cow&apos;s milk or soy formula exclusively, but in 17 (32%) of 54 infants fed breast milk exclusively or in part for varying periods (P < .0001). In virtually all instances, the breast milk had been harvested by the mother and fed to the infant via an artificial feeder. Baseline clinical and sociodemographic characteristics and surveillance in the two groups of infants were comparable. Conclusions. Artificially fed breast milk provides variable protection against the development of otitis media in infants with cleft palate. This finding supports the likelihood of a similarly protective effect of breast milk in noncleft infants. The finding also suggests strongly that in infants with cleft palate, impaired eustachian tube function is not the only pathogenetic factor in the infants&apos; initial development of middle-ear effusion. Pediatrics 1994;94:853-860; cleft palate, otitis media, breast-feeding, breast milk, middle-ear effusion, eustachian tube function, study methodology.

Universal screening for hearing impairment among infants may not be beneficial. The National Institutes of Health (NIH) recommends that all infants be screened for hearing impairment within the first three months of life, preferably before leaving the hospital at birth. Early hearing loss can affect speech and language development, academic achievement, economical potential and self-esteem. However, the validity of diagnostic tests, high numbers of false positive results and cost of treatment make universal screening programs inappropriate. Available diagnostic equipment is difficult to use and test results are hard to interpret. One test cannot detect low frequency hearing loss and the other often generates false positive results in the first 48 hours of life. Universal screening would cost about $200,000,000 per year, which may be an unnecessary expense given the lack of evidence on suitable treatments and early intervention.

Acute otitis media, inflammation of the middle ear, has typically been treated with antibiotics for the last 40 years. However, the optimum treatment and the usefulness of myringotomy (surgery on the tympanic membrane) alone or with antibiotics are unclear. Routine antibiotic therapy is opposed by some who feel that such treatment hampers the body's systemic and immune response to bacterial infection, with recurrent infections possibly resulting. The effectiveness and outcome of treatment with antibiotics with or without myringotomy, or with myringotomy alone, was examined in a study of 536 infants and children. Antibiotic treatment resulted in significantly less treatment failure and development of effusion (escape of fluid into the ear), compared to placebo (inert) treatment for patients with episodes that were not severe. No difference in recurrence rate between amoxicillin and placebo treatments was found. Patients over two years old with severe episodes had more initial treatment failures when given placebo plus myringotomy. Children under two years old had poorer long-term outcomes than older children. Ultimate treatment failure and total duration of effusion were less frequent in children treated with amoxicillin. Children whose initial episodes were severe had similar outcomes regardless of treatment. Depressed hearing acuity in children over two was consistently associated with the presence of middle-ear effusion. The results indicate that amoxicillin should be used to routinely treat acute otitis media due to its effectiveness, and that myringotomy provides no benefit for acute cases of the infection. (Consumer Summary produced by Reliance Medical Information, Inc.)

To the Editor.-- Dr Paradise's commentary appearing in the March 1999 issue of Pediatrics raises to my mind 2 questions regarding universal neonatal hearing screening: Is this an appropriate time [...]

Objective. One current practice guideline recommends myringotomy with tympanostomy tube insertion (M&T) for young children in whom middle-ear effusion (MEE) has persisted for 3 months, and another recommends the procedure after MEE has persisted for 4 to 6 months provided that a bilateral hearing loss of [greater than or equal to] 20 dB is present. Sequelae of M&T are not uncommon, but the extent to which these sequelae are attributable to M&T itself or to the middle-ear disease that prompted the procedure or to both has not been clear. Our objective in the present study was to examine the prevalence of various tympanic membrane (TM) abnormalities in otherwise healthy children at the age of 5 years and heating levels at the age of 6 years in relation to persistent MEE and M&T in the children&apos;s first 3 years of life. Methods. In a prospective study of child development in relation to early-life otitis media, we randomly assigned 429 children who met specified criteria regarding the persistence of MEE in their first 3 years of life to undergo M&T either promptly (the "early-treatment" group) or after a defined extended period if MEE remained present (the "late-treatment" group). We also followed a representative sample of 241 children who ranged from having no MEE to having MEE whose cumulative duration fell just short of meeting randomization criteria for the clinical trial (the "nontrial" group). Most of the children in each group underwent both otomicroscopic examination at the age of 5 years and audiometric testing at the age of 6 years, at times when they were free of MEE. Among these children, M&T had been performed in 82.3% of those in the early-treatment group, 38.1% of those in the late-treatment group, and 3.0% of those in the nontrial group. Results. At the age of 5 years, we found 1 or more types of TM abnormality in 1 or both ears in 70.7%, 42.5%, and 9.5% of the children in the early-treatment, late-treatment, and nontrial groups, respectively. Within the 3 groups, however, among children who received tubes, the proportions who had an abnormality of some type were similar, namely, 82.6%, 80.4%, and 83.3%, respectively. The corresponding proportions among children who had not received tubes were 15.4%, 19.3%, and 7.2%, respectively. Segmental atrophy and tympanosclerosis were the most common abnormalities found. At the age of 6 years, mean pure-tone average audiometric thresholds in the early-treatment, late-treatment, and nontrial groups, respectively, were 6.18 dB, 5.49 dB, and 4.63 dB in left ears and 6.17 dB, 6.02 dB, and 4.32 dB in right ears. The thresholds in the early- and late-treatment groups did not differ significantly, but the thresholds in the early- and late-treatment groups were each significantly higher than in the nontrial group. Within the early- and late-treatment groups, we found no significant relation between hearing levels and the presence or type of TM abnormalities. Conclusion. In otherwise healthy children who have persistent MEE during their first 3 years of life, ready resort to M&T results in far more TM abnormalities at age 5 than does selective management in which most children do not receive the procedure. With these differing approaches, however, hearing levels at age 6 do not differ. Regardless of whether children with persistent early-life MEE receive M&T, they have more TM abnormalities at age 5 and negligibly poorer hearing at age 6 than do children who had less or no otitis media. Longer term otologic and audiologic outcomes of persistent early-life MEE and of M&T remain to be determined. In view of 1) the present findings and the remaining uncertainties concerning sequelae, 2) the fact that M&T involves certain immediate risks--albeit minimal--and substantial cost, and 3) previously reported findings in the study&apos;s randomized clinical trial that show no developmental advantage at ages 3 and 4 years accruing from children&apos;s having received prompt M&T, a prolonged period of watchful waiting seems desirable in otherwise healthy children who are younger than 3 years and have persistent, asymptomatic MEE that is not complicated by sensorineural or severe conductive hearing loss, balance dysfunction, or severe TM retraction. Pediatrics 2004;114:e58-e67. URL: http://www.pediatrics.org/cgi/ content/full/114/1/e58; otitis media with effusion, middle-ear effusion, myringotomy, tympanostomy tube insertion, audiometric testing, tympanic membrane abnormality, tympanosclerosis, segmental atrophy, retraction pocket, hearing levels.

The eardrums of millions of infants and children throughout the world contain foreign bodies, surgically implanted as prostheses. Myringotomy combined with placement of an indwelling tympanostomy tube (or grommet) has gained widespread acceptance among otolaryngologists as the treatment of choice for persistent middle ear effusion(n1) and for certain related otologic conditions. But otolaryngologists by no means stand alone: many if not most of the operations currently performed were initially recommended by pediatricians. It is difficult to determine how many such operations are currently performed on pediatric patients in this country, since most operations take place in outpatient settings and therefore escape systematic reportage. A reasonable estimate, however, would be 1 million procedures per year or, because most of them are bilateral, two million tubes inserted. Among the conditions for which the operation is performed, undoubtedly the most common is chronic secretory otitis media. Here there are three interrelated objectives: to remove the effusion, to relieve any associated hearing loss, and to institute and maintain middle ear ventilation. Less commonly the operation may be undertaken for one of various other reasons: to try to reduce the frequency of episodes of acute otitis media(n2, n3); to relieve persistent underaeration of the middle ear when associated with conductive hearing loss or other symptoms(n2); or to prevent the development of adhesive otitis media or cholesteatoma when atelectasis or, especially, retraction pockets of the eardrum are present.(n2, n4-n6) The idea of using an indwelling tube to artificially ventilate the middle ear dates from 1868, when the great Viennese otologist, Politzer, introduced a ventilating eyelet made of hard rubber.(n7) However, Politzer's eyelet and similar... [ABSTRACT FROM AUTHOR]

Abstract. Tympanometry, a test of middle ear status new to clinical pediatrics, was carried out on 280 subjects, 10 days through 5 years of age. The tympanograms obtained were compared with otoscopic findings and, in 107 of the subjects, with findings at myringotomy. Seven distinct tympanometric curve types were identified and defined, based on their degree of correlation with the presence or absence of middle ear effusion. In subjects 7 months of age and older, curves suggesting normal (high) tympanic membrane compliance in combination with atmospheric or near-atmospheric middle ear air pressure were rarely associated with effusion. Conversely, curves suggesting low tympanic membrane compliance were highly correlated with the presence of effusion. Curves suggesting intermediate compliance or reduced middle ear air pressure were also correlated with effusion, but the degree of correlation was dependent on the shape of the curve. In infants less than 7 months of age, many of the ears with effusion had "normal" tympanograms, presumably because external auditory canal walls in such infants tend to be highly distensible. Tympanometry is a simple, rapid, atraumatic, valid, and objective test, easily administered by paraprofessional personnel. Its use can result in improved detection of middle ear effusion and other middle ear abnormalities, and also appears to promote improvement in diagnostic acumen. [ABSTRACT FROM AUTHOR]

In 138 infants with cleft palate, secretory or suppurative otitis media was a universal complication. Middle ear aeration was instituted by means of myringotomy, aspiration of middle ear liquid, and insertion of tympanostomy tubes, and this procedure was repeated whenever recurrence of middle ear effusion followed blockage or extrusion of the tubes. In infants with either complete or incomplete clefts of the palate, satisfactory middle ear status could usually be maintained. Otorrhea through tympanostomy tubes occurred frequently, but usually responded promptly to treatment. Palate repair resulted in sharp improvement in middle ear status. Early relief of middle ear effusion and establishment and maintenance of middle ear aeration in infants with cleft palate may help maintain normal hearing acuity throughout infancy, with favorable implications for language and intellectual development, and may reduce the risk of permanent middle ear damage and hearing impairment. Further study is necessary to determine the long-term efficacy of this regimen. [ABSTRACT FROM AUTHOR]

Comments on two studies regarding otitis media, child development and tympanostomy tubes. Overview of the studies; Possible bias in the selection of study subjects; Limited characterization of subjects; Possible variability in diagnostic accuracy. INSET: THOMAS SYDENHAM ON SCARLET FEVER AND ITS TREATMENT.

Abstract. To determine whether nasal obstruction in children results in impaired nasal function, olfactory sensitivity was assessed in 65 children with various degrees of nasal obstruction and in 13 children without nasal obstruction. Overall, olfactory detection thresholds were directly related to clinical ratings of degree of nasal obstruction. Of the subjects with nasal obstruction attributable to adenoid hypertrophy, 28 received adenoidectomy; when retested 2 to 28 months later, 20 of the 28 subjects showed generally commensurate reductions in nasal obstruction ratings and olfactory detection thresholds. In a comparison subgroup of 16 subjects retested after intervals of 5 to 13 months without having received intervening adenoidectomy, both the nasal obstruction ratings and the olfactory detection thresholds remained relatively unchanged. These results suggest that, in children, nasal obstruction of varied degree is associated with commensurate impairment of the ability to smell, and that reduction in the degree of nasal obstruction results in commensurate recovery of the ability to smell. Olfactory function, although hitherto accorded little pediatric attention, deserves consideration both in weighing the importance of nasal obstruction in children and in deciding about therapeutic intervention. [ABSTRACT FROM AUTHOR]

Abstract. Tympanograms with peaks located in the high-positive air pressure range (is greater than or equal to 50 mm H[sub 2]O) are infrequently recorded in clinical practice and have been little discussed in the literature. Such tympanograms accounted for 1.2% of a series of 8,011 tympanograms recorded at various times from 1,556 subjects ranging in age from 7 months through 12 years. Correlations between otoscopic diagnoses and tympanometric findings in the case of 65 of the high-positive air pressure tympanograms form the basis of the present report. Of the 65 high-positive air pressure tympanograms, 51 showed relatively high compliance (less than or equal to 5.5 Madsen units), and of these 46 (90%) were associated with ears considered normal otoscopically. Fourteen of the high-positive air pressure tympanograms showed low compliance (>5.5 Madsen units), and of these, six (43%) were associated with ears considered normal, six (43%) with ears showing signs of acute infection, and two (14%) with ears in which the presence of effusion seemed probable. A previously presented zonal schema for classifying tympanograms has been modified on the basis of these Findings. [ABSTRACT FROM AUTHOR]

Focuses on a study which examined the relationship between otitis media and later developmental impairments and its implication to early life development. Clinical description of acute otitis media; Background of the study; Issues associated with the relationships of the abnormalities.

Presents information on how to evaluate and manage infants and children with otitis media. Epidemiology and pathogenesis; Etiology of acute suppurative otitis; Definition and conceptualization of nonsuppurative otitis media; Diagnosis of otitis media; Management and treatment of otitis media; Prevention of otitis media; Impedance screening of populations for middle-ear disease.

Discusses several issues concerning tonsillectomy and adenoid (T&A) surgery. Implications of the differences in practice; Comparison of the health status of those who had undergone T&A surgery with unoperated people; Arguments concerning the validity of studies on the issue.

Bilateral secretory (serous) or suppurative otitis media was found without exception in 50 infants with cleft palate who were 20 months of age or younger. Middle ear disease probably develops in all cleft palate infants during the first few months of life, and appears to be best managed by myringotomy with insertion of plastic tubes. Unless drainage and aeration of the middle ear are accomplished, irreparable damage to middle ear structures may develop in some patients; and, in all of them, hearing impairment will probably persist throughout infancy or longer, with adverse effects on well-being and function and with serious implications for intellectual, speech, and emotional development. Further studies are required to assess the long-range effectiveness of surgical management. [ABSTRACT FROM AUTHOR]

Describes a feeding bottle designed for infants with cleft palate. Problems in feeding infants with cleft palate; Features of the feeding bottle; Benefits from the feeding bottle.

Reports on an infant with Pierre Robin syndrome who developed glossoptotic obstruction of the airway. Mechanism of airway obstruction in Pierre Robin syndrome; Information on the patient; Nature of its resolution.