Otitis media across nine countries: disease burden and management.

OBJECTIVE: To assess the perceived disease burden and management of otitis media (OM) among an international cohort of experienced physicians. METHODS: A cross-sectional survey conducted in France, Germany, Spain, Poland, Argentina, Mexico, South Korea, Thailand and Saudi Arabia. Face-to-face interviews conducted with 1800 physicians (95% paediatricians, 5% family practitioners).Main outcome measures were the perceived burden on clinical practice (number of cases, complications and referrals) and first- and second-line management strategies for OM. Results are expressed as mean and range across the nine countries over three continents. RESULTS: Respondents estimated an average annual caseload of 375 (range 128-1003) children under 5 years of age with OM; 54% (range 44-71%) with an initial episode and 38% (range 27-54%) with recurrent OM (ROM). OM with complications was estimated to be approximately 20 (range 7-49) cases per year and an estimated 15% (8-41%) of children with OM was recalled as needing specialist referral. There was high awareness of Streptococcus pneumoniae and Haemophilus influenzae as causative bacterial pathogens: 77% (range 65-91%) and 74% (range 68-83%), respectively, but less recognition of non-typeable H. influenzae (NTHi); 59% (range 45-67%). Although concern over antimicrobial resistance was widespread, empirical treatment with antibiotics was the most common first-line treatment (mean 81%, range 40-96%). The burden of disease is substantial enough that many physicians would consider vaccination to prevent OM (mean score 5.1, range 4.3-6.2 on 1-7 scale). CONCLUSIONS: This large, multinational survey shows that OM remains a significant burden for clinical practice. Despite awareness of shortcomings, antimicrobial therapy remains the most frequent treatment for OM.

Prenatal and postnatal parental smoking and acute otitis media in early childhood.

AIM: To explore the associations between acute otitis media in early childhood and prenatal and postnatal tobacco smoke exposure. METHODS: Subjects were 32 077 children born between 2000 and 2005 in the Norwegian Mother and Child Study with questionnaire data on tobacco smoke exposure and acute otitis media up to 18 months of age. Multivariate regression models were used to obtain adjusted relative risks for acute otitis media. RESULTS: Acute otitis media was slightly more common in children exposed to parental smoking. The incidence from 0 to 6 months was 4.7% in unexposed children and 6.0% in children exposed both prenatally and postnatally. After adjusting for postnatal exposure and covariates, the relative risk for acute otitis media 0-6 months when exposed to maternal smoking in pregnancy was 1.34, 95% confidence interval: 1.06-1.69. Maternal smoking in pregnancy was associated with acute otitis media up to 12 months of age. Compared with non-exposed children, there was a slightly increased risk of recurrent acute otitis media for children exposed both prenatally and postnatally with a relative risk of 1.24, 95% confidence interval: 1.01-1.52. CONCLUSION: Even in a cohort with relatively low exposure levels of parental smoking, maternal smoking in pregnancy was associated with an increased risk of acute otitis media in early childhood.

Chronic rhinosinusitis gives a ninefold increased risk of chronic headache. The Akershus study of chronic headache.

We studied the association of chronic headache and chronic rhinosinusitis in 30,000 persons aged 30-44 years from the general population. They received a mailed questionnaire. Those with possible chronic headache were interviewed by neurological residents. The criteria of the American Academy of Otolaryngology--Head and Neck Surgery were applied to diagnose headache attributed to chronic rhinosinusitis (HACRS), otherwise the International Classification of Headache Disorders was used. The questionnaire response rate was 71%, and the participation rate of the interview was 74%. Compared with the general population, persons with chronic rhinosinusitis have an at least ninefold increased risk of having chronic headache. A 3-year follow-up showed that HACRS symptoms were significantly improved after treatment with nasal surgery, nasal corticosteroids, discontinuation of overused headache medications and discontinuation of nasal decongestants or unspecified reasons. Chronic rhinosinusitis is significantly associated with chronic headache, and HACRS is likely to be a distinct type of headache.

Prevalence of secondary chronic headaches in a population-based sample of 30-44-year-old persons. The Akershus study of chronic headache.

We studied secondary chronic headaches (> or = 15 days/month for at least 3 months) in a random sample of 30 000 persons aged 30-44 years. They received a mailed questionnaire. Those with self-reported chronic headache within the last month and/or year were invited to an interview and examination by a neurological resident. The criteria of the International Classification of Headache Disorders (ICHD-II) were applied. The questionnaire response rate was 71%, and the participation rate of the interview was 74%. Of the 633 participants, 298 had a secondary chronic headache. The 1-year prevalence of secondary chronic headache was 2.14%, i.e. chronic posttraumatic headache 0.21%, chronic headache attributed to whiplash injury 0.17%, post-craniotomy headache 0.02%, medication-overuse headache (MOH) 1.72%, cervicogenic headache 0.17%, headache attributed to chronic rhinosinusitis 0.33% and miscellaneous headaches 0.04%. The majority of those with ICHD-II-defined secondary chronic headache had MOH, while about one-third had other secondary headaches often in combination with MOH.

Respiratory infections in schoolchildren: co-morbidity and risk factors.

AIMS: To assess co-morbidity and risk factors for otitis media, tonsillopharyngitis, and lower respiratory infections in school children. METHODS: Logistic regression analysis of co-morbidity and risk factors for airway infections in a population based sample of 10 year old children living in Oslo, Norway. MAIN OUTCOME MEASURES: otitis media, tonsillopharyngitis, and lower respiratory infections in past 12 months. RESULTS: Airway infections in 10 year old children were common, and significant co-morbidity was found between the various airway infections. Home dampness was a risk factor for all infections, adjusted odds ratios ranging from 1.2 (95% CI 1.0 to 1.5) to 1.4 (95% CI 1.1 to 1.6) for otitis media and tonsillopharyngitis respectively. Atopic disease was a constitutional risk factor, particularly strong for lower airway infections (adjusted odds ratio 2.4, 95% CI 1.8 to 3.1). African or Asian ethnicities were associated with the airway infections, adjusted odds ratios ranging from 1.2 (95% CI 0.9 to 1.7) to 1.7 (95% CI 1.2 to 2.3). CONCLUSIONS: Respiratory tract infections were common in 10 year old children. There was substantial co-morbidity between upper and lower airway infections. Environmental and constitutional factors were identified and positively associated with the infections. Results support the hypothesis of 1957 that the whole respiratory tract is one unit.

Surgery required to verify atypical mycobacterial infections.

To estimate the incidence and distribution of nontuberculuous mycobacterial surgery, a retrospective case record study of 42 children operated for cervicofacial atypical mycobacterial infections in Oslo from 1990 to 2000 was performed. Mean age at diagnosis was 41 months and mean duration of the disease was 40 weeks from symptom onset to remission. All presented with localized and unilateral disease without increased hematological parameters. The majority of children had one lesion localized in the submandibular region characterized by changes in the overlying skin color, but without necrosis or fistula formation. Children below three significantly more often presented with only one lesion and the referring physician more frequently suspected neoplasm and bacterial adenitis than reactive adenopathy in this group. Compared to older children, there was a tendency for shorter symptom duration prior to outpatient treatment (mean 4 and 13 weeks for children up to 3 and above 3 years, respectively, t=-1.6, P=0.11). Furthermore, mycobacterial cultures and histopathology from surgical specimens was needed to diagnose the disease correctly. Fine-needle aspiration biopsy was unsuccessful in 27% (n=8) of the patients, due to non-cooperative patients (n=2) or inconclusive material (n=6), and mycobacterial growth was not obtained in any of the samples. Intradermal mycobacteria skin testing yielded 29% (n=10) false negatives. Although mycobacteria was correctly diagnosed in the remaining patients, correct specimen was found in only 31% (n=11) of the 25 cases.

Labyrinthine fistula detection: the predictive value of vestibular symptoms and computerized tomography.

A retrospective case record study of 20 patients in Oslo operated on for chronic otitis media with labyrinthine fistula between 1986 and 1999 was performed in order to estimate the incidence of, and identify predictors for, labyrinthine fistulas. The incidence of fistula was 0.3 per 100 000, with a median age at diagnosis of 37 years. The median duration of chronic otitis media prior to labyrinthine fistula detection was significantly correlated with age at surgery. Subjective hearing loss (90%), otorrhoea (65%) and dizziness (50%) were presenting symptoms. Modified canal-wall-down mastoidectomy was performed in all patients. Preoperative hearing levels could not predict postoperative hearing outcome. Positive signs of fistula were found in only 4 patients (20%). Correspondingly, computerized tomography (CT) diagnosed the fistula in 11 patients (55%). The seven patients presenting without dizziness and with a negative CT scan and fistula test were characterized by lower age, absence of previous middle ear surgery, lower preoperative pure-tone thresholds for bone conduction and better hearing outcome after surgery. In conclusion, the identification of a younger group of patients presenting with fewer symptoms indicates that fistulas should be suspected in all patients undergoing surgery for chronic middle ear and mastoid disease.

Upper respiratory morbidity in preschool children: a cross-sectional study.

OBJECTIVES: To estimate the occurrence of and associations between upper respiratory tract infections in preschool children, and to assess constitutional and environmental factors as determinants of these infections. DESIGN: Population-based cross-sectional study. SETTING: Oslo, Norway. PARTICIPANTS: Preschool children, aged 4 to 5 years (3853 completed questionnaires). MAIN OUTCOME MEASURES: Acute and recurrent acute otitis media, tonsillopharyngitis, common cold, and rhinitis. RESULTS: Upper respiratory tract infections were common at age 4 years. During the last month, 7.1% of the children had acute otitis media and 7.5% experienced tonsillopharyngitis. Corresponding figures for common cold and rhinitis were 58.3% and 16. 4%, respectively. During the last 12 months, 9.5% of the children experienced more than 1 bout of acute otitis media, 6.9% had more than 1 tonsillopharyngitis episode, 47.7% contracted more than 2 common colds, and 3.2% had rhinitis weekly or monthly. The lifetime prevalence of recurrent acute otitis media (>/=4 episodes in any 12-month period) was 12.7% (n = 473). Bivariate correlations showed small-to-moderate relationships between the infections. Common cold was only weakly related to otitis media, tonsillopharyngitis, and chronic rhinitis. The probability for developing acute otitis media was almost 4-fold increased in children who had tonsillopharyngitis in the last year (adjusted odds ratio = 4.19; 95% confidence interval, 3.09-5.66). In logistic regression analysis, atopic disease was a strong determinant of all upper respiratory tract infections. Low birth weight increased the risk of acute otitis media. Day care attendance and the presence of siblings, which were considered to be indicators of exposure to respiratory pathogens, increased the risk of upper respiratory tract infections. CONCLUSIONS: In preschool children, acute otitis media, tonsillopharyngitis, and common cold were quite common, while chronic rhinitis was less prevalent and strongly associated with atopic disease. Attendance at day care centers increased the risk of upper respiratory tract infections in this age group, although the effect was weaker than that in younger children.

Paediatric otolaryngology--disease profile and characteristics of children in outpatient surgery.

Data were collected from 178 consecutively operated children during a 6-week period at an Oslo hospital in order to study disease profile and routines for referral and treatment in outpatient otorhinolaryngologic surgery. Median time from referral to surgery was less than 4 months. The majority of the children subjected to operation for recurrent acute otitis media, tonsillitis or upper respiratory infections had suffered from the disease for 12 months or less. Obstructive symptoms were registered in 18% of the children. Hospital referrals and controls came mainly from ENT (ear, nose and throat) specialists or paediatricians. Significantly more boys were subjected to surgery. Median age at the time of surgery was 4.2 years, and there was an equal distribution of pharyngeal and middle ear surgery. The numerous combinations of middle ear surgery reflect the non-specific treatment guidelines for otitis media.

Paediatric otolaryngology--a parental satisfaction study in outpatient surgery.

A parental satisfaction survey was administered to obtain information as to exactly how patients and their parents experience essential aspects of their treatment. The parents of 178 children who underwent ear, nose and throat (ENT) surgery completed a questionnaire on various aspects of treatment satisfaction during a 6-week period. Most of the respondents expressed overall satisfaction with the treatment. The factor analysis revealed three parental satisfaction factors. Accordingly, we interpreted the subscales as i) surgical staff and general treatment satisfaction, ii) nursing staff and general information satisfaction and iii) anaesthetic staff satisfaction. The internal consistency values of the subscales, as measured by Cronbach's alpha coefficient, were 0.86, 0.84 and 0.71, respectively. The three scores were mutually correlated; this correlation was significant (0.46-0.67). The duration of general anaesthesia and demographic factors had a small, but significant impact on the satisfaction subscores. In conclusion, the satisfaction study encourages improvement in the evaluation and administration of treatment.

Acute mastoiditis: predictors for surgery.

To estimate the incidence of acute mastoiditis and identify predictors for mastoid surgery, a retrospective case record study of 38 children hospitalised for acute mastoiditis in Oslo from 1989 to 1998 was performed. Median age at diagnosis was 18 months and 13 (34%) of the children received mastoidectomy. Compared to the period 1970-1979, the incidence of mastoidectomy was significantly reduced. Only seven children (18%) had experienced acute otitis media prior to the current episode. Symptom duration of 6 days or more prior to hospitalisation and elevated white blood cell counts and C-reactive Protein were predictive for mastoidectomy ((OR = 5.0 (1.0-22.8), (OR = 24.5 (2.5-240) and OR = 10.5 (1-108.8)). Furthermore, total time from symptom onset to hospital discharge was significantly higher in children who received mastoidectomy. We suggest early referral to an otolaryngologic department in children suspected of acute mastoiditis.

Quality of care in pediatric daycare surgery: a cross-sectional study.

To provide information on how patients and their parents experience essential aspects of daycare otorhinolaryngologic surgery, a cross sectional questionnaire-based study on parental treatment satisfaction at the time of hospital discharge was performed. The main outcome measures were various aspects of treatment satisfaction in 178 consecutively children operated in a community hospital in Oslo, Norway. Overall treatment satisfaction was found. The factor analysis revealed three factors of parental satisfaction. Accordingly, we found the subscales interpreted as: (1) surgical staff and general treatment satisfaction; (2) nursing staff and general information satisfaction; and (3) anaesthetic staff satisfaction. The internal consistency of the subscales measured by the Chronbach's alpha coefficient were 0.86, 0.84 and 0.71, respectively. The three scores were significantly intercorrelated (0. 46-0.67). Parental treatment satisfaction was significantly influenced by demographic and anaesthetic factors. In conclusion, although outpatient pediatric otolaryngologic surgery aim at maximising the efficacy, overall treatment satisfaction was found in our study. Furthermore, the surgical, nursing and anaesthetic staff were identified as three separate quality dimensions.

Female medical leadership: cross sectional study.

OBJECTIVE: To assess the relation between male and female medical leadership. DESIGN: Cross sectional study on predictive factors for female medical leadership with data on sex, age, specialty, and occupational status of Norwegian physicians. SETTING: Oslo, Norway. SUBJECTS: 13 844 non-retired Norwegian physicians. MAIN OUTCOME MEASURE: Medical leaders, defined as physicians holding a leading position in hospital medicine, public health, academic medicine, or private health care. RESULTS: 14.6% (95% confidence interval 14.0% to 15.4%) of the men were leaders compared with 5.1% (4.4% to 5.9%) of the women. Adjusted for age men had a higher estimated probability of leadership in all categories of age and job, the highest being in academic medicine with 0.57 (0.42 to 0.72) for men aged over 54 years compared with 0.39 (0.21 to 0.63) for women in the same category. Among female hospital physicians there was a positive relation between the proportion of women in their specialty and the probability of leadership. CONCLUSION: Women do not reach senior positions as easily as men. Medical specialties with high proportions of women have more female leaders.

[Pediatric day surgery of the respiratory tract--indications and prioritization]. / Dagkirurgi i øvre luftveier hos barn--indikasjoner og prioritering.

Ear, Nose and Throat (ENT) procedures are the most common types of surgery in children and include adenoidectomy, tonsillectomy, myringotomy, ventilation tube insertion or combinations of these. In order to study disease profile and routines for referral and treatment in outpatient otolaryngologic surgery, data were collected from 178 children operated consecutively during a six-week period in 1998. Median time from referral to surgery was less than four months. The majority of children operated for recurrent acute otitis media, tonsillitis or upper respiratory infections had suffered from the disease for 12 months or less. Obstructive symptoms were registered in 18% of these children. Most patients were referred to the hospital by specialists in otolaryngology or paediatric medicine. Surgery was more common in male than female-children, and median age at the time of surgery was 4.2 years. There was an equal distribution of middle ear and pharyngeal surgery.

Distribution and heritability of recurrent ear infections.

The distribution of recurrent ear infections was obtained from a population-based sample of 2,750 pairs of Norwegian twins born between 1967 and 1974. The lifetime prevalence of self-reported recurrent ear infections was 8.9%, with a significant predominance of female cases. The mean age of onset was 4.2 years, with a gradual decrease in occurrence from 2 to 7 years of age. Among monozygotic pairs, the rate of tetrachoric correlation between co-twins was almost identical in males (0.73, SE 0.08) and females (0.74, SE 0.06), but among the dizygotic pairs the correlation was clearly higher in males (0.53, SE 0.12) than in females (0.20, SE 0.12). The value in the unlike-sexed dizygotic twins (0.25, SE 0.05) was intermediate to that of the like-sexed male and female dizygotic pairs. The relative contribution of genes and environment to variability in the predisposition to develop otitis media was estimated by means of structural equation modeling. Variation in liability to ear infections was mainly explained by additive genetic and dominance factors in females, for whom heritability was estimated at 74%. The remaining 26% of the variation in liability was explained by individual environmental factors. In males, 45% of the variation could be accounted for by genetic factors, 29% by common familial environment, and the remaining 26% by individual environmental effects.

Recurrent acute otitis media: the significance of age at onset.

In order to assess the relationship between recurrent acute otitis media (rAOM) and age at first acute otitis media (AOM) episode, a prospective cohort of 3754 Norwegian children born in 1992-1993 was followed from birth to 2 years. Recurrent acute otitis media was defined by the criterion of four or more episodes of AOM during a 12-month period. Approximately 5.4% of the children experienced rAOM before the age of 2. Furthermore, children whose first AOM episode occurred before the age of 9 months were at a significantly higher risk for developing rAOM compared to children whose first AOM episode was 10-12 months. In children who had the first ear infection during the first 9 months of life, one-quarter developed rAOM before the age of 2. Multiple logistic regression analysis adjusted for confounding showed that gender and a familial history of atopy were significantly associated with rAOM. In conclusion, the present study found an association between age at first AOM episode and the later subsequent AOM proneness. Additionally, both gender and a family history of atopy seemed to predispose towards otitis-proneness.

Early acute otitis media: determined by exposure to respiratory pathogens.

The purpose of the present study is to assess the relationship between early acute otitis media (AOM) and exposure to respiratory pathogens mediated by siblings and day-care. A prospective cohort of 3,754 Norwegian children born in 1992-93 was followed from birth through 12 months. One or more episodes of AOM had been experienced by 25% of the children before age one. Logistic regression analysis showed that siblings attending day-care is the most important risk factor for early AOM (ORadj = 1.9 (1.4-2.3)). The total number of children in the day-care setting is another determinant for early AOM (ORadj = 2.0 (1.4-2.6) in groups of 4 or more other children and ORadj = 1.3 (1.0-1.7) in groups of 1-3 other children as compared with those who are cared for alone). Siblings who attend day-care and the number of children in the child's own day-care setting are the most important determinants for AOM the first year of life.

[Secretory otitis. Treatment in the light of current knowledge]. / Sekretorisk otitt. Behandling i lys av nyere kunnskap.

Secretory otitis media refers to the presence of middle ear effusion behind an intact tympanic membrane without acute signs or symptoms. 10-20% of all children with acute otitis media subsequently develop secretory otitis media of at least eight weeks duration, but the disease can also be seen without previous existence of acute otitis media. Although spontaneous recovery is common, long-lasting secretory otitis may cause delayed language development. In the light of current knowledge about risk factors and treatment strategies for secretory otitis media, this paper discusses guidelines for the treatment of this condition.

[Acute and recurrent otitis media. Prevention and treatment in the light of current knowledge]. / Akutt og residiverende akutt otitis media. Profylakse og behandling i lys av nyere kunnskap.

Acute otitis media refers to a clinically identifiable infection of the middle ear with sudden onset and of short duration. By two years of age, approximately 40% of children have had at least one attack of acute otitis media. Of these, 5-10% subsequently experience recurrent infections. Evidence suggests that frequent attacks of acute otitis media may adversely affect neurocognitive and language development and necessitate repeated medical and surgical treatment. Efforts have been made to identify early risk factors associated with this proneness to otitis in order to give the affected children optimal medical care and prophylactic treatment. Based on existing literature, guidelines for prophylaxis and treatment of acute and recurrent acute otitis media are discussed in this paper.