The value of nasopharyngeal culture in predicting the etiology of acute otitis media in children less than two years of age.

BACKGROUND: In selecting treatment of acute otitis media (AOM), knowledge of its etiology would be valuable. We revisited the possibility to use the nasopharyngeal culture of Streptococcus pneumoniae (Pnc) and Haemophilus influenzae (Hi) for predicting their presence in the middle ear fluid (MEF) during AOM. METHODS: The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of bacterial culture of the nasopharyngeal aspirate (NPA) in predicting the presence of the same pathogen in the MEF were assessed during AOM events among children followed from 2 to 24 months of age. RESULTS: The data comprised 586 AOM events. For Pnc, the sensitivity and NPV were high, 99% (95% confidence interval = 95-100%) and >99% (97-100%), respectively. The specificity and PPV were relatively low, 63% (57-68%) and 50% (43-56%). For Hi, the sensitivity and the NPV were lower (77%, 69-83% and 93%, 90-95%) than for Pnc, but the specificity and the PPV were higher (88%, 85-91% and 64%, 56-71%). The quantity of Pnc and Hi in the NPA was clearly related to their presence in the MEF. If both Pnc and Hi were found in the nasopharynx, Hi was more likely cultured from MEF. CONCLUSION: Together with clinical and epidemiologic features of AOM, the nasopharyngeal culture can be helpful in selecting specific antimicrobial therapy.

The epidemiology of acute bullous myringitis and its relationship to recurrent acute otitis media in children less than 2 years of age.

OBJECTIVE: To evaluate the epidemiological characteristics of acute bullous myringitis (BM), i.e. inflammation of the tympanic membrane with blister(s) in children <2 years and study the relationship between bullous myringitis and recurrent acute otitis media. METHODS: 2028 children aged 7-24 months in a prospective longitudinal cohort study in the Finnish Otitis Media vaccine trial. The main outcome measures were the incidence of bullous myringitis and the incidence of acute otitis media (AOM) before and after the event of bullous myringitis. RESULTS: 82 children had a total of 86 events of acute bullous myringitis. The incidence of bullous myringitis was 5.7 per 100 person years (95% CI, 4.6-7.1 per 100 person years). The number of events with bullous myringitis was 4.6% of the number of all AOM events diagnosed during the follow-up. Recurrent AOM (> or =6 AOM events) occurred in 33% of children with bullous myringitis in comparison with 23% of control children with at least one event of AOM (RR 1.7; 95% CI, 1.01-2.7). The incidence of AOM in children with bullous myringitis was 1.8 per person year (95% CI, 1.4-2.2 per person year) before the event of bullous myringitis and 2.9 per person year (95% CI, 2.3-3.5 per person year) after the event of bullous myringitis. The higher incidence rate of AOM lasted for 2 months after the office visit of bullous myringitis. CONCLUSIONS: Acute bullous myringitis is not a rare disease; it was diagnosed in 5.7% of children <2 years in a 1-year follow-up. It was present in almost 1 of every 20 AOM events. Acute bullous myringitis increases the subsequent risk of recurrent AOM.

The symptoms and clinical course of acute bullous myringitis in children less than two years of age.

OBJECTIVE: the most characteristic symptom of acute bullous myringitis (inflammation of the tympanic membrane) is a sudden onset of severe ear pain. However, in infants and young children a precise symptom history is more difficult to obtain and the symptoms may be less specific. Our objective was to determine the occurrence of different symptoms, signs and the recovery of symptoms during the course of acute bullous myringitis in children less than 2 years. We also evaluated whether there were any specific features in bullous myringitis in comparison with acute otitis media (AOM). METHODS: 2028 children (aged 7-24 months) at primary care level in a prospective longitudinal cohort study in the Finnish Otitis Media Vaccine Trial. RESULTS: during the follow-up there were 86 office visits with bullous myringitis in 92 ears and 1876 office visits with acute otitis media in 2683 ears. Middle ear fluid developed in 97% of cases of bullous myringitis during the course of disease. Earache was present in 58% and fever (>or=38 degrees C) in 62% of cases of bullous myringitis. The symptoms of upper respiratory tract infection (rhinitis in 93% and cough in 73% of events) were present in a majority of cases. Earache, fever, rubbing of the ear, restless sleeping, excessive crying and poor appetite were present more often in bullous myringitis than in acute otitis media. The symptoms were relieved in 1-2 days in a majority of cases. There were no recognized cases of bullous myringitis in ears with patent tympanostomy tubes. CONCLUSIONS: acute bullous myringitis in children represents a special form of AOM with more severe symptoms. Earache and fever were more common in bullous myringitis than in AOM. However, the condition resolved rapidly and the short-term outcome was good.

Prevention of otitis media by adenoidectomy in children younger than 2 years.

OBJECTIVES: To test the effect of adenoidectomy in connection with tympanostomy compared with tympanostomy only in preventing otitis media in children younger than 2 years. DESIGN: Prospective trial with randomized and nonrandomized arms. SETTING: Primary care study clinics. PARTICIPANTS AND INTERVENTIONS: The study participants were selected from 2497 children who had been enrolled in the Finnish Otitis Media Vaccine Trial at the age of 2 months. A total of 306 children, aged 1 to 2 years, who had experienced recurrent episodes of otitis media were randomized into 2 treatment groups: tympanostomy with or without adenoidectomy. Of the 306 children, 137 were operated on according to random basis (randomized trial). The 169 children whose parents declined participation in the randomized trial were operated on according to the parents' preferences (nonrandomized trial). All children were followed up until 2 years of age. The mean follow-up time was 7 months. MAIN OUTCOME MEASURE: The rate of acute otitis media episodes. RESULTS: The average reduction in the rate of all acute otitis media episodes in the adenoidectomy group was 19% (95% confidence interval [CI], -14% to 43%) among children enrolled in the randomized trial and 25% (95% CI, -13% to 50%) in the nonrandomized trial. The reduction in the randomized trial was mainly due to reduction in the rate of pneumococcal otitis media (58%, 95% CI, 16%-79%). CONCLUSION: In children younger than 2 years, concurrent adenoidectomy during the insertion of tympanostomy tubes does not seem to have a major advantage over the insertion of tympanostomy tubes alone in preventing otitis media.

beta-Lactamase-producing Moraxella catarrhalis may prevent the emergence of penicillin-resistant Streptococcus pneumoniae in children with recurrent acute otitis media.

We studied the effect of concomitant nasopharyngeal carriage of beta-lactamase producing Moraxella catarrhalis and Haemophilus influenzae on the occurrence of penicillin resistance of Streptococcus pneumoniae. We took nasopharyngeal samples from 306 children with recurrent otitis media and a history of several antibiotic treatments. We could isolate at least one of the pathogens in 89 subjects. Of these children 13% carried more than one pathogen. Of the isolated M. catarrhalis and H. influenzae strains 93% and 43% produced beta-lactamase, respectively. Of the S. pneumoniae strains 25% were non-susceptible (I/R) to penicillin. However, in patients carrying beta-lactamase-producing M. catarrhalis together with pneumococci all strains were susceptible to penicillin (P=0.0353). This finding suggests that beta-lactamase producing M. catarrhalis may hinder the emergence of penicillin resistance of S. pneumoniae in children with recurrent acute otitis media.

Cytokine gene polymorphism in recurrent acute otitis media.

BACKGROUND: There is increasing evidence that a strong genetic component is involved in the predisposition to recurrent acute otitis media (rAOM). Cytokines play a key role in the pathogenesis of otitis media. Constitutional polymorphisms in cytokine genes may lead to individual variations in cytokine secretion. OBJECTIVE: To elucidate the role of cytokine gene polymorphisms in rAOM. SETTING: University hospital. PARTICIPANTS AND METHODS: Blood samples for genetic analysis were obtained from 63 individuals with rAOM from 20 different families and from 400 healthy blood donors. The medical history of the rAOM group was based on medical records and interview data. We studied the polymorphisms of tumor necrosis factor alpha, interleukin (IL) 1 alpha, IL-1 beta, and IL-1 receptor antagonist genes. RESULTS: The distribution of cytokine alleles in the rAOM group did not differ significantly from that of the control group. However, in patients with rAOM without a history of allergic disorders, allele frequencies of IL-1 alpha-889 differed significantly from those of controls (P =.03). CONCLUSIONS: There is no clear association between the polymorphism of studied cytokine genes and rAOM. However, the IL-1 alpha gene polymorphism may be associated with recurrent middle ear infections in a subgroup of patients without allergic disorders.

Predicting the development and outcome of otitis media by tympanometry.

OBJECTIVE: Identification of children with high risk of development or prolongation of otitis media would be highly useful in clinical practice. In this study, tympanometry was assessed for its capability in predicting development and resolution of acute otitis media (AOM). METHODS: Visits of 329 children followed in the Finnish Otitis Media Cohort Study from 2 to 24 months of age were evaluated for this report. Tympanometry was routinely performed on all children during their visits to a special study clinic. Adjacent consecutive visits were used for analysis of development and resolution of middle ear fluid (MEF) between the visits. Descriptive analysis utilized all data obtained during the longitudinal follow-up; confirmatory statistical analysis was performed on data of one randomly selected visit per subject to ensure independence of observations. Presence of MEF at the second visit was used as the outcome. RESULTS: Negative tympanometric peak pressure (<-100 daPa) was found to predict the development of otitis media when observed during respiratory infection with no concomitant ear disease. Otitis media developed within 20 days to 40% of children with negative pressure compared with 20% of children without negative pressure. The observed association was confirmed statistically (odds ratio 4.8, 95% confidence interval 2.4-9.6). Poor outcome of AOM at the subsequent follow-up visit 3-5 weeks later was found in 9% of ears with negative pressure tympanogram compared with 24% with initial type B or normal pressure tympanogram during AOM. However, we could not confirm the finding in statistical analysis (odds ratio 0.6, 95% confidence interval 0.2-2.0). CONCLUSIONS: Profound negative tympanometric peak pressure is a significant marker of increased risk for development of otitis media. Children with negative pressure have to be thoroughly followed for subsequent progress of the respiratory disease and development of otitis media. For the prediction of resolution of AOM, the findings remained inconclusive.