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.

Resistance of Pseudomonas to ciprofloxacin: implications for the treatment of malignant otitis externa.

For fifteen years oral ciprofloxacin has been the standard treatment for malignant otitis externa, a sometimes fatal osteomyelitis of the skull base usually caused by Pseudomonas aeruginosa. Resistance to ciprofloxacin is developing. Over a 16-month period, we saw five cases where malignant otitis externa progressed, with the development of cranial nerve palsies in four cases, despite oral ciprofloxacin. Prolonged intravenous antibiotic therapy became necessary. One case was managed largely as an out-patient, but four patients spent many weeks in hospital. Only two cases had diabetes and this was monitored and controlled. Pseudomonas aeruginosa was isolated in four of the five cases, but antibiotic sensitivity to ciprofloxacin was not determined. In one case a later isolate was tested and found to be ciprofloxacin resistant. Progress was monitored by serial C-reactive protein (CRP) and white cell count. For diagnosis and assessing response to treatment we considered serial magnetic resonance imaging or computed tomography more useful than isotope bone scan. There must be a readiness to use intravenous antibiotics, as a response to ciprofloxacin can no longer be assumed. Bacterial isolates must be tested for sensitivity to antibiotics including ciprofloxacin, and further biopsy and culture are essential if treatment fails.

A multivariate analysis of the factors predicting hearing outcome after surgery for cholesteatoma in children.

OBJECTIVE: To explore factors influencing hearing outcomes in children treated by canal wall up (CWU) and canal wall down (CWD) mastoid surgery. METHODS: Retrospective cohort study including three units in Bristol and Bath, UK. Ninety consecutive children underwent cholesteatoma mastoid surgery, with the first procedure between 1998 and 2001; minimum follow up was three disease-free years. RESULTS: The CWU and CWD cohorts significantly differed in pre-operative stage and hearing. After disease eradication, air conduction (AC) thresholds changed by +4.0 dB (95 per cent confidence intervals (95% CI) -2.0, 10.1) in the CWD group and -5.3 dB (95% CI -9.3, 1.3) in the CWU group (p=0.029). Using multiple linear regression to account for cohort differences, AC thresholds were increased by: pre-operative AC threshold (p<0.0001), initial ossicular stage (p=0.013), and CWD-surgery (p=0.005). CONCLUSION: Disease-free hearing was better with CWU-surgery, less initial ossicular damage, and better pre-operative hearing. Worse initial disease increased the likelihood of CWD surgery. Wider use of ossiculoplasty in the CWU cohort (51 per cent vs 5 per cent) may partially explain the superior results.

Intranasal steroid sprays in the treatment of rhinitis: is one better than another?

The treatment of allergic rhinitis has been revolutionized by the introduction of topical nasal steroids, which are one of the commonest prescriptions from otolaryngology departments. With so many different sprays available on the market, the literature was reviewed for the efficacy, side-effect profile and relative cost of each product and the following conclusions made: (1) A meta-analysis of randomized controlled trials comparing the efficacy of intranasal corticosteroids and oral antihistamines in the treatment of allergic rhinitis showed a clear benefit in favour of intranasal steroids in relieving nasal symptoms. (2) There is no clear evidence to support the suggestion that one steroid spray is more effective than another in the treatment of seasonal or perennial allergic rhinitis. (3) All the sprays have a similar side-effect profile; the commonest being epistaxis with a reported incidence between 17 and 23 per cent. In all the clinical trials, the placebo spray had an appreciable rate of epistaxis of between 10 to 15 per cent. (4) Fluticasone causes a reduction in endogenous cortisol secretion but no significant adrenal suppression was seen with triamcinolone, beclomethasone, budesonide or mometasone. (5) There is little evidence that skeletal growth is restricted by the administration of topical nasal steroid sprays. (6) There is considerable variation in the daily cost of each spray. Beclomethasone, dexamethasone and budesonide are significantly cheaper than fluticasone, mometasone or triamcinolone.

Hearing preservation and facial nerve function in vestibular schwannoma surgery.

The objective of this study was the assessment of hearing preservation in vestibular schwannoma surgery. This study reports a prospective cohort of 40 patients with clinically useful hearing from a consecutive series of 191 patients with unilateral vestibular schwannoma. The patients were managed in a tertiary centre by a combined team of Neurosurgeon, Otologist and Neuro-monitoring Scientist via a neuro-oto-surgical-retrosigmoid approach. Pure tone speech audiometry was conducted preoperatively and 6 months to 9 years following surgery. Using the AA0-HNS classification, useful hearing, i.e. grades A, B and C, was preserved in 47.5% of patients. Thirty-eight per cent achieved grade A or B. Using appropriate surgical and monitoring techniques, it is possible to preserve useful hearing in approximately 50% of patients following removal of a vestibular schwannoma via the retro-sigmoid approach.

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.

The frequency of otitis media with effusion in British pre-school children: a guide for treatment. ALSPAC Study Team.

Data on the prevalence of otitis media with effusion (OME) as shown by serial tympanometry is presented for young children during the first 5 years of life. The children were participants in the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC); a randomly selected 10% (n = 1400) of whom were selected for examination at ages 8, 12, 18, 25, 31, 37, 43, 49 and 61 months. Whilst sex had no effect, there was a decrease in prevalence of OME with increasing age. There was a marked seasonal effect on the prevalence of OME. Bilateral and unilateral OME were significantly more prevalent in the winter than in the summer months (36.6% in February in children aged 8 months compared with 16% at 61 months and 16.4% in August in children aged 8 months compared with 3.1% at 61 months). The results form an important background against which to assess both the results of screening and also the indications for surgical treatment.

Dry tap at myringotomy: a three-year study of 1688 children undergoing myringotomy.

One thousand six hundred and eighty-eight children undergoing myringotomy were studied to determine the rate of 'dry taps' and factors associated with a dry middle ear at operation. The percentage of bilateral dry taps was 16%. The dry tap rate was significantly higher in the following groups: older children, those with an A, C1 or C2 tympanogram at the time of listing, milder hearing loss, a preceding history of recurrent acute otitis media and operation performed during the summer or autumn. There was no significant relationship between the dry tap rate and the time on the waiting list, the gender of the child or the order in which right or left myringotomies were performed. Careful preoperative reassessment of any child with a type A, C1 or C2 tympanogram should be made to prevent unnecessary surgery. Separating those listed for treatment of recurrent acute otitis media from those with OME would prevent these being included in the overall dry tap rate.

Intraoperative monitoring during surgery for acoustic neuroma: benefits of an extratympanic intrameatal electrode.

OBJECTIVES: To assess the utility of an extratympanic intrameatal electrode for intraoperative monitoring during acoustic neuroma and other cerebellopontine angle tumour surgery and to define the neurophysiological and surgical factors which influence hearing preservation. METHODS: Twenty two patients, 18 with acoustic neuromas and four with other cerebellopontine angle tumours, underwent intraoperative monitoring during tumour excision. The extratympanic intrameatal electrode (IME) was used to record the electrocochleogram (ECoG) and surface electrodes to record the brainstem auditory evoked response (ABR). RESULTS: The compound action potential (CAP) of the ECoG was two and a half times greater in amplitude than wave I of the ABR and was easily monitored. Virtually instant information was available as minimal averaging was required. Continuous monitoring was possible from the commencement of anaesthesia to skin closure. The IME was easy to place, non-invasive, and did not interfere with the operative field. Operative procedures which affected CAP or wave V latency or amplitude were drilling around the internal auditory meatus, tumour dissection, nerve section, and brainstem and cerebellar retraction. Hearing was achieved in 59% of patients. CONCLUSIONS: The IME had significant benefits in comparison with other methods of monitoring. The technique provided information beneficial to preservation of hearing.

Meningiomas involving the internal auditory canal: a diagnostic and surgical challenge.

Meningiomas are the second most common lesion encountered within the cerebello-pontine angle (CPA) and rarely project into or originate from the internal auditory meatus (IAM). It is important to distinguish between meningiomas and acoustic neuromas preoperatively as the choice of surgical approach may differ depending on the tumour type. Fortunately, most lesions can be accurately diagnosed with gadolinium-enhanced magnetic resonunce imaging (MRI). We report six cases of meningioma involving the IAM, often leading to an incorrect preoperative MRI diagnosis. We highlight the challenges these tumors present to radiologists and surgeons.

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%).

A comparison of the sensitivity of manometric rhinometry, acoustic rhinometry, rhinomanometry and nasal peak flow to detect the decongestant effect of xylometazoline.

A study has been undertaken to compare the sensitivity of manometric rhinometry, rhinomanometry, nasal peak flow and acoustic rhinometry to detect the decongestant effect of xylometazoline. Twenty healthy volunteers were investigated before and after decongestion. The sensitivity of all four methods varied from 80 to 95%. These differences were not significant. Manometric rhinometry, a new method of investigating nasal physiology, is as sensitive as more established methods.

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.

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.

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.