Resolution of Otitis Media With Effusion in Children With Cleft Palate Followed Through Five Years of Age.

OBJECTIVE: To describe the temporal pattern of otitis media with effusion (OME) resolution for a cohort of nonsyndromic cleft palate children enrolled before palatoplasty and followed through 5 years of age. DESIGN: This is a prospective, longitudinal study of the time course for OME resolution in infants and children with palatal clefts. SETTING: Cleft Palate Craniofacial Center of a tertiary care pediatric hospital. PARTICIPANTS: This study included 52 children with cleft palate (29 boys, 45 white, Veau 1 through 4) who had a Furlow-type palatoplasty between 10 and 24 months of age performed by one of six surgeons. INTERVENTIONS: Standard cleft palate management was supplemented with study visits to the research clinic pre- and postpalatoplasty and then yearly to 6 years of age for assessments of middle ear status by interval history, otoscopy, and tympanometry. MAIN OUTCOME MEASURE: The main outcome measure was age at otitis media resolution defined as the age in years at the first in a sequence of "disease-free" diagnoses not interrupted or followed by any other diagnosis. RESULTS: The cumulative percent OME resolution for ears/children at ages <1, 1, 2, 3, 4, 5 years was 4.1/4.4, 14.3/10.9, 31.6/21.7, 45.9/37.0, 56.1/50.0, and 70.4/60.9%. OME resolution followed a simple linear time curve with slopes of 13.5% (confidence interval [CI] = 12.2% to 14.8%, r(2) = .99) and 11.9% (CI = 10.1% to 13.6%, r(2) = .99) resolutions per year for ears and children, respectively. CONCLUSIONS: There is a natural, age-related pattern of resolution for persistent OME that affects most infants and young children with cleft palate that is not affected by palatoplasty.

Postpalatoplasty Eustachian tube function in young children with cleft palate.

OBJECTIVE: To characterize Eustachian tube function using the forced response test in young children with cleft palate with or without cleft lip after palatoplasty with tympanostomy tubes inserted prepalatoplasty and compare these results with those of a 1986 study that evaluated a similar population using identical methods. SETTING: Outpatient research clinic. PATIENTS/PARTICIPANTS: A total of 34 children with cleft palate were tested at an average age of 18.6 ± 4.0 months. MAIN OUTCOME MEASUREs: Passive and active measures for the forced response test. RESULTS: Of the sample, 13 ears could not be tested, and tests on 24 ears were incomplete. The forced response test showed that the passive Eustachian tube function parameters were similar to those of normal adults and children. The percentage of ears that showed tubal dilation with swallowing was 60%. The active resistance and dilatory efficiency were similar to those of a normal adult population. CONCLUSIONS: A 1986 study of Eustachian tube function in postpalatoplasty subjects with cleft palate (37 ears) aged 15 to 26 months documented Eustachian tube dilation with swallowing in 84% of the ears. In the present study, which focused on a similar population, the frequency of tubal dilation was 60%. Nonetheless, both frequencies are significantly greater than the dilation frequency of 27% reported for 56 ears of subjects with cleft palate tested between 3 months and 18 years with tympanostomy tubes inserted for persistent otitis media with effusion. This suggests that dilation during the forced response test may be a prognostic marker for those children with cleft palate who will resolve their ear disease at an early age.

Nasal prostaglandin challenge increases N2O exchange from blood to middle ear.

Nasal inflammation (NI) resulting from allergy or virus infection is causally associated with otitis media. Impaired Eustachian tube (ET) function consequent to NI may mediate this relationship. Moreover, the functional demand placed upon the ET for gas supply may be increased by NI, a hypothesis tested here. A total of five experiments were done at a minimum 2-week interval on four monkeys. For each experiment, the monkey was anesthetized and acclimated for 60 min. Then, the monkey was breathed with a 40% N2O gas mixture for 60 min followed by air breathing for 100 min. Fifteen minutes into air breathing, the nose was challenged with one of the five substances: saline, PGD2, capsaicin, histamine or bradykinin. Throughout, middle ear (ME) pressures were recorded at 5-min intervals. All pressure-time curves had a similar form consisting of a curvilinear decrease during acclimation, a linear increase during N2O breathing and a linear decrease during air breathing. The rates of pressure increase were ear-specific and not different across experiments. Compared to saline, the rate of pressure decrease was greater for challenge with all the substances and significantly greater after PGD2 challenge. Like N2, N2O is an inert gas whose transmucosal exchange is perfusion-limited for the ME. The measured pressure change is linearly related to the volume gas exchange between ME and blood. Therefore, nasal challenge with PGD2 and perhaps the other substances increases transmucosal inert gas exchange. ME to blood N2 transfer rate determines the physiological demand placed upon the ET for gas supply. That demand is increased by nasal exposure to certain inflammatory mediators.

The forced-response test does not discriminate ears with different otitis media expressions.

OBJECTIVES/HYPOTHESIS: Test the hypothesis that the eustachian tube (ET) function measured using standard manometric test methods is different between groups of ears with tympanostomy tubes inserted for recurrent acute otitis media (RAOM) and for chronic otitis media with effusion (COME). STUDY DESIGN: A cross-sectional study of ET function in populations of young children with different otitis media expressions. METHODS: The results for forced-response testing of ET function were compared using a general linear model between 37 ears of 26 children and 34 ears of 26 children, aged 3 and 4 years, with ventilation tubes inserted for COME and RAOM, respectively. RESULTS: There were no significant between-group differences in either the active measure of ET opening function, dilatory efficiency, or in the passive measures reflecting the magnitude of the forces that tend to hold the ET lumen closed, the opening and closing pressures, and passive trans-ET conductance. CONCLUSIONS: The results do not support the hypothesis that ET closing forces are less in ears with RAOM when compared to ears with COME, and from the results of earlier studies, ears without disease. Both groups were characterized by a low ET opening efficiency (referenced to ears of adults with no disease history). Because both disease expressions present the same pattern of ET dysfunction, other factors are required to explain why a subset of ears with that type of dysfunction develop RAOM, as opposed to the default expression of COME. LEVEL OF EVIDENCE: 2b

Reproducibility of the forced response test in children with chronic otitis media with effusion.

HYPOTHESIS: Eustachian tube function is stable over time in children with ventilation tubes for chronic otitis media with effusion. BACKGROUND: Clinical studies report that Eustachian tube function tests in patients with a persistent tympanic membrane perforation predict the success of myringoplasty, and those in patients with ventilation tubes for chronic otitis media predict disease recurrence after the tubes become nonfunctional. In those studies, Eustachian tube function was usually tested only once, which presumes a semi-stable basal level of function for greatest diagnostic and prognostic usefulness. We investigated the stability of repeated measurements of Eustachian tube function using the forced response test. METHODS: Thirty-nine children aged 36 to 83 months with bilateral ventilation tubes for chronic otitis media with effusion were evaluated using the forced response test 3 times at 3- to 4-month intervals. The variability across test sessions in the Eustachian tube opening pressure, closing pressure, and dilatory efficiency was estimated using regression/correlation analyses. RESULTS: For all test parameters, the between-session and between-ear correlation coefficients were significant, but the shared variance in the parameters among test sessions and between ears at the same test session was relatively low. The average slope for each parameter as a function of the time with a ventilation tube was zero. CONCLUSION: The low between-test shared variance for the test parameters raises questions as to whether a single forced response test captures sufficient information to accurately diagnose the cause of any dysfunction or to predict with high specificity and sensitivity future disease experience or surgical results.

Eustachian tube function as a predictor of the recurrence of middle ear effusion in children.

OBJECTIVES/HYPOTHESIS: In children with ventilation tubes (VTs) inserted for chronic otitis media with effusion (COME), the authors sought to determine whether any parameter of Eustachian tube (ET) function measured by the forced response test (FRT) predicts disease recurrence after the VT becomes nonfunctional. STUDY DESIGN: Prospective study of those factors that predict disease recurrence in children with VTs inserted for COME. METHODS: Forty-nine subjects (73 ears; 28 male, 34 white, aged 5.3 ± 1.2 years) with COME had VTs inserted and were evaluable for disease status after the VT(s) became nonfunctional. The FRT was done when the VTs were patent, and results for the last test before the VT became nonfunctional were used in the analysis. After each VT became nonfunctional, the children were followed for disease recurrence over a 12-month period. Logistic regression was used to determine whether the ET opening pressure, closing pressure, and/or dilatory efficiency predicted disease recurrence. That model was expanded to include age, sex, race, history of adenoidectomy, previous VTs, and duration of VT patency as potential predictive factors. RESULTS: Twenty-nine (40%) ears had recurrence of significant disease within 12 months after the VT became nonfunctional. For the complete logistic regression model, male gender (P = .03), nonwhite race (P = .02), shorter period of VT patency (P = .01), and low dilatory efficiency (P = .01) were significant predictors of disease recurrence. CONCLUSIONS: A measure of active ET function, dilatory efficiency, but not measures of passive function predicted disease recurrence within the 12 months after the VT became nonfunctional in children with COME.

Pre- and post-palatoplasty Eustachian tube function in infants with cleft palate.

OBJECTIVE: One past study conducted in 1986 reported Eustachian tube dilation with swallowing during the forced response test (FRT) in a very high percentage (>80%) of cleft palate patients both before and after palatoplasty. The present study was designed to determine the reproducibility of those results. METHODS: The FRT was used to evaluate Eustachian tube function in a cohort of cleft palate children before and after palatoplasty. Pre-palatoplasty FRT data were available for 25 ears and post-palatoplasty data were available for 31 ears; 14 ears had paired pre-post palatoplasty test data. The results for the FRT tests were compared between the pre- and post-palatoplasty groups for the cross-sectional data and for the paired subset of ears. RESULTS: The 3 passive function measures of the FRT, the opening pressure, closing pressure and passive resistance were not different before and after palatoplasty for either data set. Similarly, 2 of the 3 active function measures, active resistance and dilatory efficiency, were not different pre- and post-palatoplasty, but the percent of ears evidencing tubal dilation for the cross-sectional data was 39% and 62% (p=NS) and for the paired subset was 33% and 83% (p=0.04) at the pre- and post-palatoplasty tests. CONCLUSION: Palatoplasty had no effect on most measures of the FRT, but may have had a positive effect on the ability to dilate the Eustachian tube during swallowing. The high frequency of ears with tubal dilation before palatoplasty reported in the 1986 study was not reproduced but that frequency after palatoplasty was similar.

A pilot study of the ability of the forced response test to discriminate between 3-year-old children with chronic otitis media with effusion or with recurrent acute otitis media.

CONCLUSIONS: When used to test 3-year-old children within 3 months of tympanostomy tube placement for recurrent acute otitis media (rAOM) or chronic otitis media with effusion (cOME) the forced response test (FRT) showed relatively minor differences in the active and passive functions of the eustachian tube. While the sample size was small, the high variability in all test parameters suggests that the FRT alone is not capable of distinguishing between children with different expressions of otitis media. OBJECTIVE: The FRT was designed to measure the passive and active properties of the eustachian tube. We evaluated the ability of that test to discriminate groups of children with rAOM or cOME. METHODS: Twenty-two ears (15 children) with a confirmed history of rAOM and 24 ears (17 children) with a confirmed history of cOME were tested at 3 years of age within 3 months of ventilation tube placement. The parameters of the FRT were compared between these groups using a two-tailed Student's t test and the frequencies of ears evidencing eustachian tube dilation with swallowing were compared between groups using a χ(2) test. RESULTS: Passive resistance and one measure of active function were significantly higher in the rAOM group. The frequency of tubal dilation was not significantly different between groups. There were no differences in any of the FRT measures between cOME ears that did and did not have acute otitis media by history.

In vivo measurement of O(2) and CO(2) gas exchange across the human tympanic membrane.

CONCLUSION: The hypothesis that the human tympanic membrane (TM) is permeable to CO(2) and O(2) at physiologic pressure gradients is supported but additional experiments need to be done to validate this methodology. OBJECTIVE: Gas exchange between the middle ear and adjacent compartments determines the trajectory of middle ear pressure change. Little information is available regarding the permeability of the TM to physiological gases. This study aimed to determine in vivo if the human TM is permeable to O(2) and CO(2) at physiologic transTM pressure gradients. SUBJECTS AND METHODS: An ear canal (EC) probe (ECP) constructed from a custom-fitted acrylic body, a glass capillary tube enclosing an oil meniscus to maintain ambient ECP + EC pressure and a silica glass microtube linked to a mass spectrometer (MS) for measuring gas composition was hermetically sealed within one EC in each of 15 adults. ECP + EC volume was measured and gas samples were taken at 10 min intervals for 1 h. Epinephrine (1:100 000) was applied topically to the ipsilateral TM to decrease blood flow and the experiment was repeated. The ECP + EC pressures of O(2) (32 AMU) and CO(2) (44 AMU) were regressed on time and the slope divided by the predicted transTM partial-pressure gradients to yield estimates of transTM O(2) and CO(2) conductance. RESULTS: Consistent with expectations for transTM gas exchange, ECP + EC O(2) decreased and CO(2) increased during the experiments. CO(2) increase was faster after application of epinephrine to the TM. The ratio of O(2)/CO(2) conductances was not consistent with the gas exchange through a primarily water or lipid diffusion barrier.