Childhood socioeconomic status, telomere length, and susceptibility to upper respiratory infection.

Low socioeconomic status (SES) during childhood and adolescence has been found to predict greater susceptibility to common cold viruses in adults. Here, we test whether low childhood SES is associated with shorter leukocyte telomere length in adulthood, and whether telomere length mediates the association between childhood SES and susceptibility to acute upper respiratory disease in adulthood. At baseline, 196 healthy volunteers reported whether they currently owned their home and, for each year of their childhood, whether their parents owned the family home. Volunteers also had blood drawn for assessment of specific antibody to the challenge virus, and for CD8+ CD28- T-lymphocyte telomere length (in a subset, n=135). They were subsequently quarantined in a hotel, exposed to a virus (rhinovirus [RV] 39) that causes a common cold and followed for infection and illness (clinical cold) over five post-exposure days. Lower childhood SES as measured by fewer years of parental home ownership was associated with shorter adult CD8+ CD28- telomere length and with an increased probability of developing infection and clinical illness when exposed to a common cold virus in adulthood. These associations were independent of adult SES, age, sex, race, body mass, neuroticism, and childhood family characteristics. Associations with infections and colds were also independent of pre-challenge viral-specific antibody and season. Further analyses do not support mediating roles for smoking, alcohol consumption or physical activity but suggest that CD8+ CD28- cell telomere length may act as a partial mediator of the associations between childhood SES and infection and childhood SES and colds.

Association between telomere length and experimentally induced upper respiratory viral infection in healthy adults.

IMPORTANCE: Although leukocyte telomere length is associated with mortality and many chronic diseases thought to be manifestations of age-related functional decline, it is not known whether it relates to acute disease in younger healthy populations. OBJECTIVE: To determine whether shorter telomeres in leukocytes, especially CD8CD28- T cells, are associated with decreased resistance to upper respiratory infection and clinical illness in young to midlife adults. DESIGN, SETTING, AND PARTICIPANTS: Between 2008 and 2011, telomere length was assessed in peripheral blood mononuclear cells (PBMCs) and T-cell subsets (CD4, CD8CD28+, CD8CD28-) from 152 healthy 18- to 55-year-old residents of Pittsburgh, Pennsylvania. Participants were subsequently quarantined (single rooms), administered nasal drops containing a common cold virus (rhinovirus 39), and monitored for 5 days for development of infection and clinical illness. MAIN OUTCOME MEASURES: Infection (virus shedding or 4-fold increase in virus-specific antibody titer) and clinical illness (verified infection plus objective signs of illness). RESULTS: Rates of infections and clinical illness were 69% (n = 105) and 22% (n = 33), respectively. Shorter telomeres were associated with greater odds of infection, independent of prechallenge virus-specific antibody, demographics, contraceptive use, season, and body mass index (PBMC: odds ratio [OR] per 1-SD decrease in telomere length, 1.71 [95% CI, 1.08-2.72]; n = 128 [shortest tertile 77% infected; middle, 66%; longest, 57%]; CD4: OR, 1.76 [95% CI, 1.15-2.70]; n = 146 [shortest tertile 80% infected; middle, 71%; longest, 54%]; CD8CD28+: OR, 1.93 [95% CI, 1.21-3.09], n = 132 [shortest tertile 84% infected; middle, 64%; longest, 58%]; CD8CD28-: OR, 2.02 [95% CI, 1.29-3.16]; n = 144 [shortest tertile 77% infected; middle, 75%; longest, 50%]). CD8CD28- was the only cell population in which shorter telomeres were associated with greater risk of clinical illness (OR, 1.69 [95% CI, 1.01-2.84]; n = 144 [shortest tertile, 26%; middle, 22%; longest, 13%]). The association between CD8CD28- telomere length and infection increased with age (CD8CD28- telomere length × age interaction, b = 0.09 [95% CI, 0.02-0.16], P = .01, n = 144). CONCLUSION AND RELEVANCE: In this preliminary study among a cohort of healthy 18- to 55-year-olds, shorter CD8CD28- T-cell telomere length was associated with increased risk for experimentally induced acute upper respiratory infection and clinical illness.

Treatment of acute otitis media in young children.

Although acute otitis media (AOM) is one of the most common pediatric problems, the debate over treatment, especially in young children, continues. The 2004 Guideline on treatment of AOM stated that observation without antimicrobial therapy was an option for selected children 6-24 months of age with AOM. Two recent randomized trials sought to determine the necessity of antimicrobial treatment in young children; both studies found modest, statistically significant, positive effects of treatment. However, these studies provoked a flurry of discussion in the literature and the issue remains unsettled. That prevention is preferable to treatment is not controversial. Eliminating or modifying risk factors and use of vaccines, both bacterial and viral, may help decrease the number of AOM episodes. The discussion on treatment of AOM in young children must also take into account side effects of treatment and effect of treatment on possible long-lasting sequelae of AOM, such as developmental outcomes.

The interleukin 6 -174 C/C genotype predicts greater rhinovirus illness.

BACKGROUND: In adults and children with respiratory syncytial virus (RSV) infection, a polymorphism in the interleukin 6 (IL-6) promoter at position -174 predicts illness magnitude. In addition, polymorphisms in the interleukin 10 (IL-10), tumor necrosis factor alpha (TNF-alpha), and interferon gamma (IFN-gamma) genes are associated with immune responsiveness and the frequency of complications. Here, the effect of these polymorphisms on illness and seroconversion during infection with rhinovirus type 39 (RV39) was evaluated. METHODS: Seventy-two adults were genotyped for the selected polymorphisms, experimentally exposed to RV39, and followed to track infection, seroconversion, and symptoms and signs of illness. Regression analysis was used to determine whether these polymorphisms predicted seroconversion and illness magnitude in 57 infected subjects. RESULTS: The low-production IL-6 -174 phenotype (C/C genotype) was associated with greater symptom magnitudes, and the IFN-gamma phenotype +874 predicted the frequency of seroconversion. No relationship between the IL-10 or TNF-alpha polymorphisms and any measured outcome was documented. The concentration of IL-6 protein, as measured in nasal wash fluids from subjects, was positively correlated with symptom magnitude, but it was independent of the IL-6 -174 genotypes representing the high- and low-production phenotypes. CONCLUSIONS: These results document statistically significant associations between the IL-6 -174 and IFN-gamma +874 polymorphisms and specific responses to experimental RV39 infection. For the IL-6 -174 polymorphism, the results replicate those for experimental RSV infection.

Otitis media: a genome-wide linkage scan with evidence of susceptibility loci within the 17q12 and 10q22.3 regions.

BACKGROUND: Otitis media (OM) is a common worldwide pediatric health care problem that is known to be influenced by genetics. The objective of our study was to use linkage analysis to map possible OM susceptibility genes. METHODS: Using a stringent diagnostic model in which only those who underwent tympanostomy tube insertion at least once for recurrent/persistent OM are considered affected, we have carried out a genome-wide linkage scan using the 10K Affymetrix SNP panel. We genotyped 403 Caucasian families containing 1,431 genotyped individuals and 377 genotyped affected sib pairs, and 26 African American families containing 75 genotyped individuals and 27 genotyped affected sib pairs. After careful quality control, non-parametric linkage analysis was carried out using 8,802 SNPs. RESULTS: In the Caucasian-only data set, our most significant linkage peak is on chromosome 17q12 at rs226088 with a p-value of 0.00007. Other peaks of potential interest are on 10q22.3 (0.00181 at rs1878001), 7q33 (0.00105 at rs958408), 6p25.1 (0.00261 at rs554653), and 4p15.2 (0.00301 at rs2133507). In the combined Caucasian and African American dataset, the 10q22.3 peak becomes more significant, with a minimal p-value of 0.00026 at rs719871. Family-based association testing reveals signals near previously implicated genes: 513 kb from SFTPA2 (10q22.3), 48 kb from IFNG (12q14), and 870 kb from TNF (6p21.3). CONCLUSION: Our scan does not provide evidence for linkage in the previously reported regions of 10q26.3 and 19q13.43. Our best-supported linkage regions may contain susceptibility genes that influence the risk for recurrent/persistent OM. Plausible candidates in 17q12 include AP2B1, CCL5, and a cluster of other CCL genes, and in 10q22.3, SFTPA2.

Balance and otitis media with effusion.

Dizziness can be caused by a variety of peripheral vestibular, central, and systemic disease processes. Eustachian tube dysfunction with and without middle-ear effusion has been considered one of the most common causes of balance disturbances in young children. Several studies have indicated that during an episode of otitis media the child's balance deteriorates and the child may become clumsy and fall more often. Thus, not only the adverse effect on hearing should be considered in the management of a child with otitis media, but also the child's balance.

Contribution of vision to balance in children four to eight years of age.

OBJECTIVES: The use of sensory feedback for postural control develops throughout childhood. The aim of this study was to determine how children use cues from anterior-posterior optic flow for balance from 4 to 8 years of age. METHODS: One hundred forty-eight children were enrolled. The subjects had yearly otologic and posturographic examinations between the ages of 4 and 8 years. Balance was assessed only if the subject had no evidence of middle ear effusion. The subject stood for 30 seconds with eyes open without optic flow and for 30 seconds while viewing 0.1, 0.25, and 0.4 Hz anterior-posterior optic flow. The center of pressure (COP) was recorded from the force platform. The root-mean-square of the COP during the periods of quiet stance and with optic flow was computed. RESULTS: The root-mean-square COP was significantly larger during the optic flow stimulation as compared with during quiet stance. The subjects had a significant decrease in COP during optic flow from year 5 to year 6 of life (p = .005). CONCLUSIONS: A change in the response to optic flow was seen from age 5 to age 6. This change is consistent with transitional changes in postural responses that have been observed during quiet standing.

Prevalence of hearing-loss among HAART-treated children in the Horn of Africa.

OBJECTIVES: The prevalence of hearing loss (HL) in children infected with HIV/AIDS is not well studied. Even fewer studies focus on stable HIV-infected children treated with high-effective antiretroviral therapy (HAART). We aim to compare the prevalence of ear disease and HL in HAART-treated, HIV + children in Addis Ababa, Ethiopia with a well, similarly-aged elementary school population with unknown HIV status (HIVU). METHODS: Children underwent standard head and neck examination and cerumen removal by board certified otolaryngologists. Next, certified audiologists performed hearing screening with pure-tone audiometry using a circumaural headset but without an ambient noise reducing environment. Children failing audiometric screening underwent full behavioral audiometry including air and bone testing. The primary outcome parameter was HL > 25 dB with the audiologist accounting for background noise. A second endpoint was PTA >40 dB (500, 1000, 2000 Hz) without assessment of background noise. RESULTS: 107 HIV+ and 147 HIVU children met inclusion criteria. In the HIV + cohort 17.8% had evidence of TM perforations and 8.4% had otorrhea. In the HIVU group 2.7% had a TM perforation and 0% had otorrhea. Hearing was significantly worse in HIV + children. (Audiologist determination: 38.3% HL HIV+, 12.2% HIVU, Fisher's-Exact-Test OR: 4.5, 95% CI 2.4-8.3, p-value <0.0001; Worse-hearing-ear PTA > 40 dB: 19.6% HL HIV+, 6.1% HIVU, OR: 3.7, 95% CI 1.7-8.4, p-value <0.001). CONCLUSIONS: Chronic OM, conductive and mixed hearing losses are significantly more common in HAART-treated HIV + children than in well, similarly-aged controls. Rates of SNHL are similar.

Prevalence of chronic ear disease among HIV+ children in Sub-Saharan Africa.

OBJECTIVES: To determine the prevalence of chronic ear disease in HIV+, highly active anti-retroviral therapy (HAART)-treated children and compare this to the prevalence in healthy children of similar age living in a similar setting. INTRODUCTION: From previous clinical work in Ethiopia, we suspected that chronic middle ear disease was common both in the general pediatric population and especially among children with HIV/AIDS. Few studies have examined the prevalence of chronic ear disease in HIV + children, particularly in those treated with HAART. METHODS: Full examination of the head and neck was performed by otolaryngologists. This including cleaning of cerumen, otoscopy and microscopic otoscopy when needed. Patient's medical records were reviewed. Presence or absence of tympanic membrane (TM) perforation (unilateral or bilateral), tympanosclerosis, TM atrophy, otorrhea and/or cholesteatoma was documented. RESULTS: 112 HIV+ and 162 healthy (HIVU) children were included. Prevalence of TM perforations was 17% in the HIV + infected versus 3% in the HIVU (Fisher's-Exact-Test; OR: 7.2, 95% CI 2.5-20, p-value <0.0001). Presence of unilateral TM perforations was 12% in the HIV + population and 2% in the HIVU population (Fisher's-Exact-Test; OR: 6.8, 95% CI 2.0-22, p-value 0.002). The presence of bilateral perforations was 4% in the HIV + population and 1% in the HIVU population (Fisher's-Exact-Test; OR: 6.8, 95% CI 1.1-42, p-value 0.088). In the HIV + cohort, 2% were diagnosed with cholesteatoma compared to 0% in the HIVU population (95% CI HIV+ 0.002-0.06; HIVU 0.0-0.02) and 8% of HIV + subjects had active middle ear discharge, compared to 0% in the HIVU population (95% CI HIV+ 0.04-0.1; HIVU 0.0-0.02). Neither tympanosclerosis nor tympanic membrane atrophy was more frequent in the HIV + population compared to the HIVU population. Persistent or recurrent TM perforation was not more frequent in children with prior tympanoplasty in the HIV + population compared to the HIVU population. CONCLUSION: TM perforations are significantly more common in HAART-treated HIV + children than in healthy, age-matched HIVU population. Otorrhea and cholesteatoma were found only in the HIV + cohort.

Panel 7: Otitis Media: Treatment and Complications.

Objective We aimed to summarize key articles published between 2011 and 2015 on the treatment of (recurrent) acute otitis media, otitis media with effusion, tympanostomy tube otorrhea, chronic suppurative otitis media and complications of otitis media, and their implications for clinical practice. Data Sources PubMed, Ovid Medline, the Cochrane Library, and Clinical Evidence (BMJ Publishing). Review Methods All types of articles related to otitis media treatment and complications between June 2011 and March 2015 were identified. A total of 1122 potential related articles were reviewed by the panel members; 118 relevant articles were ultimately included in this summary. Conclusions Recent literature and guidelines emphasize accurate diagnosis of acute otitis media and optimal management of ear pain. Watchful waiting is optional in mild to moderate acute otitis media; antibiotics do shorten symptoms and duration of middle ear effusion. The additive benefit of adenoidectomy to tympanostomy tubes in recurrent acute otitis media and otitis media with effusion is controversial and age dependent. Topical antibiotic is the treatment of choice in acute tube otorrhea. Symptomatic hearing loss due to persistent otitis media with effusion is best treated with tympanostomy tubes. Novel molecular and biomaterial treatments as adjuvants to surgical closure of eardrum perforations seem promising. There is insufficient evidence to support the use of complementary and alternative treatments. Implications for Practice Emphasis on accurate diagnosis of otitis media, in its various forms, is important to reduce overdiagnosis, overtreatment, and antibiotic resistance. Children at risk for otitis media and its complications deserve special attention.

Recent developments in the treatment of otitis media with effusion.

The management of otitis media with effusion (OME) has received much attention recently as a result of, among other factors, the development of resistant bacteria and the finding of less long-term impact of middle-ear effusion (MEE) on development than previously believed. Guidelines have recently been published for the management of OME promoting more accurate diagnosis, particularly distinguishing acute otitis media from OME, and recommending the 'judicious' use of antibacterials. Today, more emphasis is being placed on prevention of disease by reducing risk factors and the development of vaccines. The identification of susceptibility genes may lead to better understanding of the pathogenesis of otitis media, which in turn may lead to the development of more innovative and satisfactory methods for prevention and treatment.

Information on co-morbidities collected by history is useful for assigning Otitis Media risk to children.

OBJECTIVES: Determine if a 2-Step multivariate analysis of historical symptom/sign data for comorbid diseases can abstract high-level constructs useful in assigning a child's "risk" for different Otitis Media expressions. METHODS: Seventeen items related to the symptom/sign expression of hypothesized Otitis Media comorbidities were collected by history on 141 3-year-old children. Using established criteria, the children were assigned to 1 of 3 groups: Control (no significant past Otitis Media, n=45), Chronic Otitis Media with Effusion (n=45) and Recurrent Acute Otitis Media (n=51). Principal Component Analysis was used to identify factors representing the non-redundant shared information among related items and Discriminant Analysis operating on those factors was used to estimate the best predictor equation for pairwise group assignments. RESULTS: Six multivariate factors representing the assignable comorbidities of frequent colds, nasal allergy, gastroesophageal disease (specific and general), nasal congestion and asthma were identified and explained 81% of the variance in the 17 items. Discriminant Analysis showed that, for the Control-Chronic Otitis Media with Effusion comparison, a combination of 3 factors and, for the Control-Recurrent Acute Otitis Media comparison, a combination of 2 factors had assignment accuracies of 74% and 68%, respectively. For the contrast between the two disease expressions, a 2-factor combination had an assignment accuracy of 61%. CONCLUSION: These results show that this analytic methodology can abstract high-level constructs, comorbidities, from low-level data, symptom/sign scores, support a linkage between certain comorbidities and Otitis Media risk and suggest that specific comorbidity combinations contain information relevant to assigning the risk for different Otitis Media expressions.

Craniofacial shape in children with and without a positive otitis media history.

OBJECTIVES: Past studies using traditional morphometric approaches have reported a handful of differences in craniofacial dimensions between individuals with and without otitis media (OM). In this study, a geometric morphometry (GM) approach was used to determine if craniofacial shape is different among children with no history of OM and a history of recurrent acute OM (RAOM) at two different ages. METHODS: Nineteen standard landmarks were identified on lateral cephalometric radiographs from 79 children (41 Control, 38 RAOM) at 4 years and 52 children (27 Control, 25 RAOM) at 6 years of age. Following Procrustes superimposition of the landmark coordinate data, comparisons of group differences in overall size and shape were performed. Discriminant function analysis and principal component analysis were used to determine which, if any, aspects of shape variation distinguished RAOM from Control groups. RESULTS: At 4 years of age, craniofacial size and shape were significantly different between RAOM and Control groups (p<0.05). Shape differences were evident in the relative positions of the mandible, cranial base, external acoustic meatus, sphenoid and palate. Those shape differences were not found in the 6-year old group. CONCLUSIONS: At 4 years of age, the RAOM and Control groups have distinct craniofacial morphologies, but by 6 years of age these differences have largely disappeared. This is consistent with the clinical observation that excess RAOM risk resolves around 6 years of age and the hypothesis that this resolution is partially a result of age-related craniofacial changes.

Meniere's disease.

Meniere's disease (MD) is a disorder of the inner ear that causes vertigo attacks, fluctuating hearing loss, tinnitus and aural fullness. The aetiology of MD is multifactorial. A characteristic sign of MD is endolymphatic hydrops (EH), a disorder in which excessive endolymph accumulates in the inner ear and causes damage to the ganglion cells. In most patients, the clinical symptoms of MD present after considerable accumulation of endolymph has occurred. However, some patients develop symptoms in the early stages of EH. The reason for the variability in the symptomatology is unknown and the relationship between EH and the clinical symptoms of MD requires further study. The diagnosis of MD is based on clinical symptoms but can be complemented with functional inner ear tests, including audiometry, vestibular-evoked myogenic potential testing, caloric testing, electrocochleography or head impulse tests. MRI has been optimized to directly visualize EH in the cochlea, vestibule and semicircular canals, and its use is shifting from the research setting to the clinic. The management of MD is mainly aimed at the relief of acute attacks of vertigo and the prevention of recurrent attacks. Therapeutic options are based on empirical evidence and include the management of risk factors and a conservative approach as the first line of treatment. When medical treatment is unable to suppress vertigo attacks, intratympanic gentamicin therapy or endolymphatic sac decompression surgery is usually considered. This Primer covers the pathophysiology, symptomatology, diagnosis, management, quality of life and prevention of MD.

Eustachian Tube Function in 6-Year-Old Children with and without a History of Middle Ear Disease.

OBJECTIVE: To test the hypothesis that eustachian tube opening efficiency, measured as the fractional gradient equilibrated (FGE), is lower in 6-year-old children with no middle ear disease but a well-documented history of recurrent acute otitis media, as compared with children with a negative disease history (control). STUDY DESIGN: Cross-sectional study. SETTING: Tertiary care pediatric hospital. SUBJECTS AND METHODS: Bilateral eustachian tube function was evaluated in 44 healthy 6-year-old children (19 boys, 29 white). None had middle ear disease at the time of testing, but 23 had a history of recurrent acute otitis media. Twenty-one had no significant past otitis media. Eustachian tube function was measured with a pressure chamber protocol that established negative middle ear gauge pressures (referenced to the chamber pressure) and recorded that pressure before and after a swallow. FGE was calculated as the change in middle ear gauge pressure with swallowing divided by the preswallow pressure. Between-group comparisons of the preswallow pressures and FGEs were made with a 2-tailed Student's t test. RESULTS: FGE was independent of the preswallow middle ear gauge pressure. For the 39 and 44 evaluable ears in the control and recurrent acute otitis media groups, the mean preswallow pressures were -194 daPa (95% confidence interval [95% CI] = -211 to -177) versus -203 (95% CI = -216 to -190; P > .40), and FGEs were 0.32 (95% CI = 0.21-0.43) vs 0.16 (95% CI = 0.08-0.24; P = .016), respectively. CONCLUSION: In children with past recurrent acute otitis media, residual eustachian tube opening inefficiency is maintained after they have "outgrown" their middle ear disease.

Otitis media.

Otitis media (OM) or middle ear inflammation is a spectrum of diseases, including acute otitis media (AOM), otitis media with effusion (OME; 'glue ear') and chronic suppurative otitis media (CSOM). OM is among the most common diseases in young children worldwide. Although OM may resolve spontaneously without complications, it can be associated with hearing loss and life-long sequelae. In developing countries, CSOM is a leading cause of hearing loss. OM can be of bacterial or viral origin; during 'colds', viruses can ascend through the Eustachian tube to the middle ear and pave the way for bacterial otopathogens that reside in the nasopharynx. Diagnosis depends on typical signs and symptoms, such as acute ear pain and bulging of the tympanic membrane (eardrum) for AOM and hearing loss for OME; diagnostic modalities include (pneumatic) otoscopy, tympanometry and audiometry. Symptomatic management of ear pain and fever is the mainstay of AOM treatment, reserving antibiotics for children with severe, persistent or recurrent infections. Management of OME largely consists of watchful waiting, with ventilation (tympanostomy) tubes primarily for children with chronic effusions and hearing loss, developmental delays or learning difficulties. The role of hearing aids to alleviate symptoms of hearing loss in the management of OME needs further study. Insertion of ventilation tubes and adenoidectomy are common operations for recurrent AOM to prevent recurrences, but their effectiveness is still debated. Despite reports of a decline in the incidence of OM over the past decade, attributed to the implementation of clinical guidelines that promote accurate diagnosis and judicious use of antibiotics and to pneumococcal conjugate vaccination, OM continues to be a leading cause for medical consultation, antibiotic prescription and surgery in high-income countries.

Genetic susceptibility to otitis media.

PURPOSE OF REVIEW: Otitis media is a disease that is prevalent in the pediatric population, and recent twin and triplet studies have confirmed that there is a strong genetic component to susceptibility. Here, we summarize the status of current efforts to identify the specific genes underlying otitis media susceptibility and presentation. RECENT FINDINGS: Recent studies have focused on identifying candidate genes. For example, IFN-gamma polymorphisms, allotypes of the leukocyte IgG (FcgammaR) receptors and certain haplotypes of surfactant genes were linked in pilot studies to otitis media susceptibility. The pattern of gene expression during an episode of otitis media is also being elucidated with the overall goal of providing clues as to which of these modulated genes are polymorphic and thus potentially capable of affecting otitis media susceptibility. Mucin and cathepsin protease genes were shown to exhibit these characteristics. SUMMARY: In addition to the simple searches for linkages between known genes and otitis media, work is progressing within the context of genome-wide linkage studies. These efforts promise to answer some of the many questions remaining in otitis media susceptibility and pathogenesis.

Water precautions and tympanostomy tubes: a randomized, controlled trial.

OBJECTIVES/HYPOTHESIS: The objective was to determine whether there is an increased incidence of otorrhea in young children with tympanostomy tubes who swim and bathe without water precautions as compared with children who use water precautions in the form of ear plugs. STUDY DESIGN: Prospective, randomized, investigator-blinded, controlled trial. METHODS: Two hundred one children (age range, 6 mo-6 y) who had undergone bilateral myringotomy and tube insertion were randomly assigned into one of two groups: swimming and bathing with or without ear plugs. Children were seen monthly for 1 year and whenever there was intercurrent otorrhea. RESULTS: Ninety children with and 82 children without ear plugs returned for at least one follow-up visit. Mean (SD) duration of follow-up was 9.4 (4.1) months for the children with ear plugs and 9.1 (4.4) months for the children without ear plugs. Forty-two children (47%) who wore ear plugs developed at least one episode of otorrhea, as compared with 46 (56%) who did not use ear plugs (logistic regression adjusting for stratification variables, P = .21). The mean (SD) rate of otorrhea per month was 0.07 (0.31) for the children who wore ear plugs as compared with 0.10 (0.31) for the children who did not wear ear plugs (Poisson regression adjusting for stratification variables, P = .05). CONCLUSION: There is a small but statistically significant increase in the rate of otorrhea in young children who swim and bathe without the use of ear plugs as compared with children who use ear plugs. Because the clinical impact of using ear plugs is small, their routine use may be unnecessary.

Intralesional cidofovir for pediatric recurrent respiratory papillomatosis.

OBJECTIVE: To compare disease response among children with recurrent respiratory papillomatosis (RRP) who underwent combined surgical debulking and intralesional cidofovir injections vs repeated surgical debulking only. DESIGN: Retrospective medical record review; follow-up range: 16 to 56 months. SETTING: Tertiary care children's hospital. PATIENTS: Seven children with RRP, including 4 subjects treated with cidofovir and 3 controls matched for age and initial papilloma staging score. INTERVENTIONS: Subjects treated with cidofovir underwent combined surgical debulking and intralesional cidofovir injection every 2 months until disease remission. Control subjects underwent repeated surgical debulking at individually determined intervals. MAIN OUTCOME MEASURES: Intraoperative endoscopic photographs were retrospectively assigned papilloma staging scores. Cidofovir and control group comparisons were made using nonparametric 2-sample Wilcoxon rank-sum (Mann-Whitney) testing, and comparisons of initial and final papilloma staging scores were made using nonparametric matched-pair Wilcoxon signed-rank testing. RESULTS: The final cidofovir group scores were significantly lower than the control group scores (P < .05). Within-group differences between initial and final scores were not significant (cidofovir group, P = .07; control group, P = .29). CONCLUSIONS: Four children with RRP were safely and successfully treated with intralesional cidofovir injection. Consideration should be given to using cidofovir more widely for treatment of pediatric RRP. Larger numbers in the cidofovir and control groups are needed in future studies to determine the true impact of cidofovir on management of this disease.

The genetic component of middle ear disease in the first 5 years of life.

OBJECTIVE: To determine the genetic component of time with middle ear effusion (MEE) and episodes of MEE and acute otitis media. DESIGN: Prospective twin/triplet cohort. SETTING: Research center at a tertiary pediatric hospital. PARTICIPANTS: A total of 168 healthy same-sex twin and 7 same-sex triplet sets were recruited by age 2 months. INTERVENTIONS: Longitudinal assessment of middle ear status by pneumatic otoscopy and tympanometry at monthly evaluations, and at examinations during upper respiratory tract infections or symptoms of middle ear disease. OUTCOME MEASURES: Proportion of time with MEE and episodes of acute otitis media and MEE. RESULTS: Of the 140 sets for which zygosity was obtained, 114 were followed up to age 3 years and 83 sets to age 5 years. The heritability estimate for proportion of time with MEE in the first 5 years of life was 0.72 (P<.001). The correlation of proportion of time with MEE between children within a set was significantly higher in monozygotic sets (0.65-0.77) than in dizygotic sets (0.31-0.39) for each year to age 3 years. In the fourth and fifth years of life, the correlations decreased in both monozygotic and dizygotic twin sets. CONCLUSIONS: Findings for the first 2 years of follow-up have been previously published and indicate a strong genetic component to the proportion of time with MEE. In the present report, which details the entire 5-year follow-up, the effect of this component appears to attenuate after the third year but its cumulative effect remains significant after 5 years.