Factors associated with the development of paediatric chronic otitis media by age nine: a prospective longitudinal cohort study of 6560 children.

OBJECTIVE: This study aimed to analyse social, health and environmental factors associated with the development of chronic otitis media by age nine. METHOD: This was a prospective, longitudinal, birth cohort study of 6560 children, reviewed at age nine. Chronic otitis media defined as previous surgical history or video-otoscopic changes of tympanic membrane retraction, perforation or cholesteatoma. Non-affected children were used as the control group. RESULTS: Univariate analysis demonstrated an association between chronic otitis media and otorrhoea, snoring, grommet insertion, adenoidectomy, tonsillectomy, hearing loss, abnormal tympanograms and preterm birth. Multivariate analysis suggests many of these factors may be interrelated. CONCLUSION: The association between chronic otitis media and otorrhoea, abnormal tympanograms and grommets supports the role of the Eustachian tube and otitis media (with effusion or acute) in the pathogenesis of chronic otitis media. The role of snoring, adenoidectomy and tonsillectomy is unclear. Associations suggested by previous studies (sex, socioeconomic group, parental smoking, maternal education, childcare, crowding and siblings) were not found to be significant predictors in this analysis.

Developmental outcomes in early compared with delayed surgery for glue ear up to age 7 years: a randomised controlled trial.

OBJECTIVES: To investigate whether early versus delayed surgery for children severely affected by otitis media with effusion (OME) results in improved performance on developmental tests up to age 7 years. DESIGN: Follow-up of a randomised controlled trial. SETTING: University of Bristol. PARTICIPANTS: One hundred and eighty-two children (mean age 35 months) with persistent OME, hearing loss and speech, language or behaviour problems who were originally eligible and randomised to either early surgery or delayed surgery after a period of watchful waiting were followed-up as part of the Avon Longitudinal Study of Parents and Children (ALSPAC) at age 4 1/2 and 7-8 years. MAIN OUTCOME MEASURES: Measures included behaviour, language, educational attainment tests, hearing, reading, cognition and coordination. RESULTS: Of the original randomised trial, 88 of 92 of the early surgery and 74 of 90 of the watchful waiting group were still participating in ALSPAC. Analysis was by intention to treat. At age 4 1/2 years there were significant differences in teacher assessment of language (adj OR 3.45, 95% CI: 1.42-8.39) and writing (adj OR 3.74, 95% CI: 1.51-9.27), in favour of early surgery. At age 7-8 years, there was a significant difference on teacher report of emotional problems (adj OR 4.11, 95% CI: 1.15-14.64) in favour of early surgery. There were no other significant differences. CONCLUSIONS: Early surgery for the child severely affected by OME may be associated with subtle benefits at age 4 1/2 years. This may continue to 7-8 years but the small study size makes it difficult to distinguish these effects from chance. A larger study is recommended.

Aural polyps as predictors of underlying cholesteatoma.

In a retrospective study of 96 patients 16 different histological features were examined in 100 aural polyps to see whether some or any could be used to predict the presence or absence of a cholesteatoma underlying the polyp. The patients were divided into those who had cholesteatoma and those who did not, so that discriminatory features were identified. These were combined to make an overall prediction of the probability of a cholesteatoma in the middle ear. The results showed that any polyp that (i) was composed of raw granulation tissue and (ii) contained keratin as flakes or masses had a 70-80% probability of being associated with an underlying cholesteatoma. In contrast, when a polyp (i) was composed of a fibrous core, (ii) had a covering epithelium, and (iii) contained glands and lymphoid aggregates, there was a 70-80% probability of cholesteatoma being absent. This scoring system can be used to help surgeons decide whether surgical exploration of the mastoid should be undertaken.

A longitudinal study of the growth of the nasopharynx and its contents in normal children.

The areas of the nasopharynx and its contents have been measured on the lateral cephalometric radiographs of 41 normal children who had been examined at yearly intervals for a minimum of 12 years between the ages of three and 19. The means and standard deviations of the areas of the nasopharynx, the soft tissues and the airway have been calculated for each year from three to 11 and for alternate years to age 19. The size and shape of the soft tissues of individual children are shown to vary from year to year, and the anterior convexity changes to a concave shape with maturity. The soft tissues appear to grow more rapidly from three to five than does the nasopharynx, with a consequent decrease in size of the airway at this period. Subsequently the soft tissue area remains relatively constant whilst the nasopharynx increases in size so that the airway progressively enlarges. There is a significant difference between the sexes in nasopharyngeal area from 13 onwards (p less than 0.005).

Chronic otitis media with effusion and adeno-tonsillectomy--a prospective randomized controlled study.

Otitis media with effusion (OME) is one of the commonest, chronic otological conditions of early childhood. There is considerable variation in management in different centres throughout the world. Surgical treatment of the ears, adenoids, tonsils and sinuses is frequently employed and the condition constitutes one of the main indications for adenoidectomy and to a lesser extent for tonsillectomy. To date no randomized prospective, adequately controlled study has demonstrated the effect of these operations on established OME. The present work reports the results at 6 weeks, 3 months, 6 months, 9 months and one year following adenoidectomy and adenotonsillectomy performed randomly and prospectively with a controlled no-surgery group on a cohort of 103 children with established OME, unresponsive to medical treatment. Following adenoidectomy the rate of resolution of OME increases from 39% at 6 weeks, to 72% at one year; and following adeno-tonsillectomy the rate increases from 59% at 6 weeks to 62% at one year. In the no-surgery group the rate increases from 16% at 6 weeks to 26% at one year. Compared with the no-surgery group the effect of adenoidectomy alone at one year is highly significant (P less than or equal to 0.001) and similarly the effect of adenotonsillectomy is significant (P less than or equal to 0.01). However, there is no increased benefit from the addition of tonsillectomy compared with adenoidectomy alone. Thus adenoidectomy resolves established OME in 36-46% of cases for up to 12 months.

Tympanic membrane atrophy, scarring, atelectasis and attic retraction in persistent, untreated otitis media with effusion and following ventilation tube insertion.

Two hundred and twenty two children with persistent bilateral otitis media with effusion (OME) were treated with unilateral ventilation tube insertion and no treatment to the contralateral ear. The tympanic membrane changes in the operated and unoperated ears were compared during a 12 year follow-up. Segmental atrophy resulted from tube insertion whereas minor scarring and thickening of the pars tensa was related to the middle ear condition. Eight three percent of untreated ears and 85% of those treated with tubes did not develop atelectasis. Sixty percent of untreated ears and 64% of treated ears did not develop attic retraction. Very few cases (1.5 and 2%) in untreated and treated ears, respectively developed severe atelectasis. The overall duration of OME was assessed from the pre-operative history of hearing loss, the 3 month period of pre-operative observation and the post-operative time with effusion. There is a relationship between duration of the disease and development of both atelectasis and attic retraction.

Rhinomanometry in the selection for adenoidectomy and its relation to preoperative radiology.

Recent work has shown that resolution of otitis media with effusion (OME) following adenoidectomy may be related to certain preoperative radiographic parameters. This study was performed to investigate the relationship between the total nasal resistance (TNR), adenoid volume and the radiographic palatal airway and adenoid depth in children with OME. Fifty-six children underwent anterior active rhinomanometry and 40 completed the investigation. There was a significant association between the Palatal Airway and the TNR, and in the 27 who subsequently underwent adenoidectomy this was nearly so with respect to adenoid volume and TNR. The relationship demonstrated was not strong enough for TNR to be of use in selection of children for adenoidectomy based on radiographic parameters. Rhinomanometry can be difficult and time-consuming to perform in children. In its present form it is unlikely to be of routine clinical use in this context.

The adenoid as a key factor in upper airway infections.

The adenoids (and the nasopharynx) play a key role in the normal functioning and in various pathologies of the upper respiratory tract. In this paper the role of adenoidal pathology and the beneficial effect of adenoidectomy in some upper respiratory tract and facial anomalies and diseases are discussed; otitis media with effusion, recurrent acute otitis media, sinusitis, snoring and sleep apnea and abnormal patterns in the midface growth and development.

The nasal volume of children as measured by Manometric Rhinometry.

A new method of measuring nasal volume has been developed called 'Manometric Rhinometry'. We describe the principle behind its use and present the results of measuring two groups of normal children aged 4-10. The total volume of the nasal cavity, paranasal sinuses and postnasal space in these children averaged 81 ml in 4-year olds and 140 ml in 10-year olds when measured using an open cell foam plug. Where a rigid nasal tip was used the volume averaged 67 ml in 4-year olds rising to 99 ml in 8-year olds. Correlation with age, weight, height and head circumference showed the greatest correlation with height (r = 0.66). Multiple regression analysis did not add further explanatory power.

Tympanometry, stapedius reflex and hearing impairment in children with otitis media with effusion.

The study assessed the relationship between tympanometry, stapedius reflex and pure tone audiometric hearing impairment. A total of 581 audiograms and typanograms from 370 children aged between 3 and 10 years were studied. Only one ear was examined. Measurements of the pure tone air conduction thresholds (PTACT) were made: firstly as an average of the thresholds from 500, 1,000, and 2,000 Hz, secondly as an average of six frequencies from 250 Hz to 8 Hz. The mean PTACT were calculated for each year of age and for each type of tympanogram. Tympanograms were further subdivided by the presence or absence of the stapedius reflex. The sensitivity, specificity and predictive value of a type B tympanogram were investigated for different ages in relation to mean six frequency PTACT at 20, 25 and 30 dB HL. The results were used to show the accuracy of a type B tympanogram in detecting hearing impairment in children of different ages. The results suggest that tympanometry may be used to screen younger children with otitis media with effusion for hearing impairment, without the need for a pure tone audiogram.

Manometric rhinometry: a new method of measuring the volume of the air in the nasal cavity.

Almost all the pathological and physiological process that effect the nose will change the volume of the airspace within it. This volume has previously been difficult to measure but a new method that calculates this space has been developed. A mechanical model was built to test the physical parameters involved in making volume measurements. The model demonstrated that a model sinus could be detected if the ostium was only 0.5 mm in diameter. It also showed that a mathematical model which described the volume of the space could be constructed. In vivo experiments showed that nasal volume can be measured in children as young as 4. In children, nasal volume correlates with age, height, and weight. They had a low coefficient of variation (7.1%) and a high test-retest correlation (r = 0.94). Adult nasal volume averaged 138 ml. The method is sensitive enough to detect the decongestant effect of xylometazoline in a group of 17 healthy volunteers (p < 0.01). There is no significant difference in the sensitivity to detect the decongestant effect of xylometazoline when compared with active anterior rhinometry, nasal peak flow, and acoustic rhinometry (range 80-95%).

Nasal mucociliary clearance and resolution of otitis media with effusion in children following adenoidectomy.

Numerous workers have studied the relationship between nasal mucociliary clearance and adenoid removal in terms of nasal function. This study was performed to investigate the role of preoperative saccharin clearance time and velocity determination in selecting children with established otitis media with effusion (OME) for adenoidectomy. Testing was not found to be particularly reproducible and there was no statistically significant relationship between mucociliary parameters and the otoscopic resolution of effusion.

A comparison of active anterior rhinomanometry and nasometry in the objective assessment of nasal obstruction.

Nasometry is an objective technique that was originally devised for assessing nasality of speech. It is based on a comparison of the acoustic output from the nose and the mouth for a given spoken word or phrase. Subjects with nasal obstruction tend to have "hyponasal" speech and this study compares the standard technique of active anterior rhinomanometry with nasometry in the objective assessment of nasal obstruction. There was a significant association between the Total Nasal Resistance (TNR) and the nasality measurements using nasophonemically enhanced test phrases in 15 adult subjects. This test has obvious advantages over rhinomanometry which can be difficult, time consuming and unreliable particularly in the younger and severely congested patient.

Functional outcome in patients after excision of extracanalicular acoustic neuromas using the suboccipital approach.

An audit of surgery for acoustic neuroma was carried out to determine the frequency and nature of postoperative symptoms and their impact upon the patient's quality of life and vocation. Fifty-six patients were interviewed between 6 months and 5 years (mean 26 months) after surgical excision of an acoustic neuroma. The objective surgical results in these patients are good, with normal or near normal functional preservation rates of 80% for the facial nerve (House-Brackmann grade I/II), and 27.3% for a previously functioning acoustic nerve. Despite this there was no significant overall reduction in the reported occurrence of balance problems, tinnitus, headache and other neurological sequelae of the tumour after surgical excision. In 20% of the patients persistent symptoms, including deafness and facial weakness, had prevented the resumption of former social activities. As a result of these symptoms 8.6% of the patients were certified medically unfit for work, but of those employed preoperatively over 70% had returned to their jobs. The success of neuro-otological surgical management of acoustic neuroma is offset by some degree of chronic morbidity. Our patients expressed the need to know whether their symptoms would resolve, but were often too afraid to ask. Patients can be reassured that the majority resume their former social and vocational activities, but should be advised that some symptoms can persist or occur de novo after surgery. Our data suggest that early intervention would reduce the incidence of these troublesome sequelae.

The long term effect of adenoidectomy on established otitis media with effusion in children.

Adenoidectomy is a recommended treatment for otitis media with effusion (OME). This work up-dates a previous report and includes a larger number of 155 cases. Surgery has been allocated at random with a control non-adenoidectomy group. The study is prospective and allows for a wide variety of variables. These include age, sex, adenoid size, seasonal variation, observer accuracy, and spontaneous resolution. Adenoidectomy results in clearance of OME even one year following operation in 31-45% of cases. Clearance is related to the duration of history of hearing loss though this may reflect on age effect. Tonsillectomy provides no additional benefit.

Development of tympanosclerosis in children with otitis media with effusion and ventilation tubes.

Ventilation tube (VT) insertion is an accepted treatment for chronic otitis media with effusion (OME) in children. One hundred and eighty five children with bilateral OME were treated by unilateral myringotomy and VT insertion with no treatment to the contralateral ear. During a 5 year follow-up 95 of the children required only one VT but the remainer required more than one but always treatment was carried out to the same ear. The rate of development of tympanosclerosis was measured and scored. After 2-3 years the extent of the sclerotic changes stabilised and the rate of development reached 37-39 per cent in ears receiving only one VT, compared with 47-49 per cent in ears treated by more than one tube. The extent of the changes was no different whether or not one or more than one tube had been inserted. There was no overall evidence of resolution of sclerotic change with time.

Treatment of glue ear in relation to radiographic palatal airway size: a predictor for outcome following adenoidectomy?

Adenoidectomy performed for 'glue ear' accounts for many of the admissions for surgery in childhood. In spite of this there are no objective guidelines to enable the clinician to select those cases in whom a definite benefit is likely, or in whom such procedures might best be avoided. A total of 147 children with established bilateral glue ear randomized to adenoidectomy (A) or no pharyngeal surgery (NS) treatment groups were examined for clearance of effusion in an unoperated ear after one year. Outcome was analysed with respect to the pre-operative Radiographic Palatal Airway size in three groups in relation to mean measurements obtained from matched populations of normal children and those with established disease. Those with small airways had significantly increased clearance following A when compared with NS between the ages of 3-7 years. Adenoidectomy should probably not be performed in those children with large airway measurements, although the outcome may ultimately be related to the age at which surgery is performed.

Auro-nasopharyngeal polyp and cholesteatoma.

We report the association of an auronasopharyngeal polyp arising in a congenitally abnormal middle ear and Eustachian tube. Subsequently, ten years after removal of the polyp and insertion of a ventilation tube, there was recurrence of the polyp in association with cholesteatoma of the middle ear.

Cholesteatoma causing facial nerve transection.

Cholesteatoma is a well recognized cause of a facial nerve palsy. The usual mechanism for this complication is direct pressure on the nerve. We present a case in which the facial nerve has been transected by cholesteatoma and discuss the possible causes.

Tympanic membrane ossification.

Ossification of the tympanic membrane after myringoplasty is recorded for the first time. Myringoplasty was performed for closure of a perforation which followed the surgical treatment of otitis media with effusion and had included the insertion of a long-term T-tube.