Acute otitis media (AOM) and its sequelae are common in infancy and early childhood. Clinical concerns related to otitis accounted for 26% of total physician visits in one series of children under 2 years of age.1 The complications of otitis media fall into at least three categories: local suppurative complications, otitis media with effusion (OME), and hearing loss.
The first category, local suppurative complications, can occur if AOM is left untreated. Before antibiotics, AOM and mastoiditis were listed as causes of death as frequently as meningitis.2 Such complications are rarely seen today because antibiotics are widely used in managing AOM and in prophylaxis against recurrent disease.
The second complication, persistent fluid in the middle ear cavity (serous otitis media or otitis media with effusion [OME]) is often a sequela of recurrent AOM. The management of this disease and the relative virtues of various interventions including adenoidectomy and tympanostomy tubes are subjects of continued debate.3,4
The third complication, hearing loss, is a direct result of OME. Hearing loss is recognized as the most common sequela of otitis media.5 The impairment is usually conductive (although sensorineural involvement can also occur) and averages about 30 dB through the frequencies 500 Hz to 2000 Hz. The degree of hearing loss varies and can range from minimal to hearing losses as great as 50 dB. About 50%, however, will exhibit less than a 23 dB hearing loss and another 20% less than a 35 dB hearing loss. Children with bilateral disease have greater hearing losses ( 10 dB to 15 dB) than children with unilateral disease.6 If it can be demonstrated that hearing loss associated with otitis leads to language delay and !earning disability, the gravity and long-term implications of childhood otitis are even further amplified.7 This article explores the complicated association of otitis media and hearing loss and their effects on language acquisition.
EVALUATING THE CHILD WITH OME
Childhood otitis media is virtually ubiquitous. In a representative series, 77% of normal children had experienced otitis at least once by 2 years of age and 38% had three or more episodes.1 The frequency of otitis peaks as early as 7 to 9 months of age, and by 2 years of age, otitis is occurring with less than one half the frequency seen in infancy. In older children referred for otolaryngological consultation because of suspected middle ear effusion, many will prove to have normal ears, or the effusion will resolve over a short period. Gates et al found that of 3350 4- to 8-year'old children referred for possible surgical intervention for suspected OME, 1300 did not have effusions when seen and an additional 1000 of the children cleared spontaneously during the 60-day waiting period - leaving less than one third with true persistent OME.3
Four critical questions should be asked to determine how to approach the child in whom one suspects OME and deficits in hearing and language:
* How is otitis media with effusion diagnosed and with what intensity should unsuspected disease, such as clinically silent effusions, be looked for?
* What are the options in treating OME, and how effective are they?
* How are hearing and language problems screened for?
* What interventions are available and effective in treating hearing and language problems attributable to otitis media?
The diagnosis of OME rests largely on the skill of the otoscopist to discern characteristics of the tympanic membrane that correlate with fluid in the middle ear cavity. Tympanometry and other approaches to the mechanical compliance of the tympanic membrane are useful tools, but require considerable training and patience, and their accuracy diminishes in the very young child. Incorporating endoscopie techniques for examining the middle ear, including videotapes of the normal and abnormal ear with insufflation, may prove to be an excellent teaching tool,8 but more practical instruments for diagnosing otitis and middle ear effusion are needed. As the child gets older, the possibilities of mass screening by hearing tests or tympanometry are greater; but this approach has not received formal endorsement. Therefore, the diagnosis of OME presently depends on careful otoscopie examination of the young child at each pediatrie visit.
The options for treating recurrent AOM and OME have become better defined by recent research. Decongestants have not been shown to alter the course of AOM9 or affect the resolution rate of OME.10 Myringotomy appears to have no role in AOM8 or in hastening the resolution of OME.3 However, antibiotics do improve the resolution of AOM8 and have a role to play in resolving OME.11
The greatest controversy surrounds tympanostomy tubes and adenoidectomy. Two major studies examined the role of tympanostomy tubes in older children. 3>1Z The first study established that while tubes were in place, effusions were not seen, but as the tubes fell out after a mean of 181 days, effusions reoccurred. By 2 years after placement, less than 20% of the children were effusion free. In the second study, Maw indicated considerable scarring of the tympanic membrane and persistent perforations after tubes fell out, adding further caution to tympanostomy tube insertion.
The insertion of tubes unquestionably improves hearing while the tubes are in place. This is a major argument for their liberal use and would be consistent with the goals of prevention of language delay. However, the question of whether tube insertion leads to more rapid acquisition of language skills has not been addressed in a clinical study, nor has any study yet addressed the outcome in the young iniant under 2 years of age with recurrent otitis in whom tubes are inserted. Nevertheless, the insertion of tympanostomy tubes remains one of the most common otolaryngological procedures performed in children.
Gates et al examined adenoidectomy as a variable in their trial.3 They found a marginal advantage in long-term outcome over those treated with tympanostomy tubes alone (ie, the median time to first recurrence of effusion was 18 days longer in the group given adenoidectomy).3 Maw's trial indicated more substantial improvement after adenoidectomy but no additional value of concurrent tonsillectomy.12 In another trial, Paradise et al demonstrated that adenoidectomy was of benefit in children who had failed tube placement.'' The role of this procedure as a primary intervention in the young child remains to be defined.
Evaluating Hearing Loss
Several options exist for evaluating children for suspected hearing loss. The use of auditory brainstem response (ABR) has gained widespread acceptance as a technique for estimating hearing sensitivity and for detecting retrocochlear lesions. Limitations to ABR include the cost of the equipment and interpretation of the findings, as well as the fact that ABR is most sensitive to high-frequency hearing loss. This limits its application to more advanced conductive impairments producing low frequency and flat audiometrie configurations.
Sound field screening with visual reinforcement can be carried out with infants as young as 6 to 8 months. The predictive accuracy of this approach, however, has not been determined, especially for young infants under 2 years of age.
The Welch-Allyn Audioscope, a hand-held otoscope with built-in audiometer that delivers pure tones at 25 dB or 40 dB, has been advocated for screening children for hearing loss. This simple, easy-to-use instrument appears to be especially useful for schoolaged children provided that the ambient noise in the test room is not excessive.
Finally, attempts have been made to predict the presence of hearing loss from acoustic reflectometry findings. Pria et al6 reported that hearing levels could not be predicted on the basis of middle ear pressure or from the shape of the tympanogram. Teele and coworkers, however, reported a close association between acoustic reflectometry measurements and the presence of conductive hearing loss.13
When children with recurrent otitis are evaluated with sound field techniques at the age of 2, a striking correlation of hearing loss with increased incidence of otitis media is seen.1 Approximately 30% of children with three or more episodes of otitis will have a ≥25 dB hearing threshold compared with less than 10% of children who have no documented otitis media. Retesting a subset of these children at ages 3 to 4 showed that nine of the children with an elevated hearing threshold at age 2 were all normal at the later testing date with no specific intervention. The dilemma posed by this information is our apparent need to test early during the critical stages of language development (in the first 2 years of life), but our having limited practical ways with which to test at that age and having evidence of a natural tendency toward resolution of hearing loss associated with OME without intervention.
Evaluating Language Deficits
Sometimes delays in speech and language development are the most sensitive and valid indicators of significant hearing impairment among preschool-aged children.14 Asking parents specific questions relative to speech and language development can be helpful in determining the presence of hearing loss. A more formalized screening test of speech and language development commonly used is the Early Language Milestone (ELM) scale. This test is most sensitive for children 24 months of age or older. Unfortunately, strong correlations have not been noted between ELM scores and more formal language measurements.
When a child reaches the age of 2, language can be assessed in a more precise and reproducible way. Formal speech and language tests performed by certified speech pathologists can. be administered at this age. Examples of formal speech and language tests frequently used at this age are the ReceptiveExpressive Emergent Language Scale, the Preschool Language Scale, the Peabody Picture Vocabulary test, and specific articulation tests.
The contribution of recurrent AOM and OME must be assessed in the context of other variables that may influence speech and language development. Some of the best work Jn this area has been done by the Boston Otitis Media Study Group. In 1984, the group published a study of 3 -year-old children given a battery of language tests.15 Children of higher socioeconomic status scored more poorly if they had experienced frequent otitis, particularly during the first 6 to 12 months of life. The same correlation was not seen in lower socioeconomic groups. More recently, this group reported results of tests of intellectual ability, school achievement, speech, and language in 7-year-old children followed prospectively from birth.16 The study indicated that the estimated time spent with middle ear emisión during the first 3 years of life was associated with significantly lower scores on tests of cognitive ability; articulation, speech, and language; school performance; and intellectual ability as tested at the age of 7. The same group also has suggested that there may be attention deficits in the otitis-prone child.
In a study at Vanderbilt addressing similar issues, no correlation was found between a history of recurrent otitis and performance on a battery of speech and language tests administered at 2 years of age.1 As suggested by the variability in the above studies, other significant predictors of speech and language performance were noted, including birth order, sex, race, and maternal education.1 Another study from Denmark also has suggested that social variables have a more important impact on speech and language tested at school age than recurrent AOM or OME.17
Treating Hearing and Language Deficits in Children With OME
The American Academy of Pediatrics has recommended that children with OME persisting longer than 3 months need to be screened for hearing sensitivity and communication development.18 If a child foils such screening or if a parent expresses concern about the child's hearing or speech, a referral for a comprehensive speech and language evaluation and audiologic assessment is warranted.
A number of different treatment approaches have been advocated for those who appear to be delayed in speech and language. Sometimes it is sufficient to supply the parents with educational materials on middle ear disease, hearing loss, and language enrichment. The materials should emphasize the importance of parent- infant interaction and communication. Suggestions should be provided to the parents on how they can best communicate with their children. For some children, a more formalized intervention is recommended. Children may need training in speech discrimination, listening, or attending to language. The child also may receive help with strengthening morphological, syntactic or semantic skills. Children who are identified early and receive appropriate management typically exhibit rapid improvement in speech and language skills as well as in educational performance.
1. Wright PF, Sell SH, McConnell KB. et al. Impaccai recurrent otitis media an middle ear function, hearing, and language. J Pe&arr. 1988;! 13:581-587.
2. Vtial Starijiic! of the United States, 1936. Washington. DC: US Depi Health, Education and Welfare, US Public Health Service.
3. Gates OA, Avery CA, Prihoda TJ, Cooper JC. Effectiveness of adenoidectomy and tympanostomy Cubes in the treatment ci chronic otitis media with effusion. N Erigi/ Moi- 1 987:31 7:1444-1451.
4. Paradise JL1 Bluestone CD, Rogers KD, et al. Efficacy of adenoidectomy fat recurrent otitis media in children previously treated with tympanostom>tube placement. JAMA. 1990:263:2066-2073.
5. Bess FH. Audiometrie approaches used in the identification of middle ear diseases in children. In: Kavanaugh JF, ed. Owe Medio and Child Development. Parkton, Md: York Press; 1986:70-82.
6. Fri» TJ, Cantekin El, Eichler JA. Hearing acuity oí children with effusion. AnA OraicBTngol. 1985;111:10-16.
7. Venrry IM. Effects of conductive hearing loas: tact or fiction. Journal of Speech and Hearing Disorders. 1980:45:143-156.
8. Kale ida PH, Hoberman A. Use of otoendoscopy in medical education and clinical education. Presented at the 5th International Recent Advances in Otitis Media Symposium; May 20-24, 1991; ftirt Lauderdale, Fk. Abstract.
9. Kaleida PH. Casselbrant ML. Rockette HE. et al. Amoxicillin at myringotomy or hoth for acute otitis media: results of a randomized clinical trial. Pediatria. I991;87:466-474.
10. Cantekin EI. Mandel EM, Bluestone CD; et al. Lack of efficacy of a decongestantantihistamine combination for otitis media with effusion ( "secretary" otitis media) in children. N Engl J Med- 1933;308:297-301.
11, Mandel EM, Rockette HE, Bluestone CD, Paradise JL. Nona RJ. Efficacy of amoxicilltn with and without decongestant-antihistamine tor oliEis media with effusion in children. N Engl J Med. 1987;3 16:432-437.
12. Maw RA. Chronic otitis media with effusion (glue ear) and adenoroiisillectomy: prospective randomized controlled study. BrMedJ. 1 98 3 ;28 7: 1506- 1588.
13. Teele DW, Srewart MB, Teele JH, Smith DK, Ttegonning SJ. Acoustic reflectomerry for assessment of hearing loss in children with middle ear effusion. Pedían infect Du i. 1990i9:870-872.
14. Bess FH, Humes LE Aadiologj - The Fundamentals. Baltimore, Md: Williams d? Wilkins; 1990.
15. Teele DW, Klein JQ Rosner BA, Greater Boston Otitis Media Study Group. Otitis media with effusion during the first 3 years of life and the development of speech and language. Pediatrics. 1984:74:282-287.
16. Teele DW. Klein JQ Chase C, Menyuk P. Rosner BA, the Greater Boston Otitis Media Study Group. Otitis media in infancy and intellectual ability, school achievement, speech, ami bngua|>e at ag* 1 yean. J \·fa Dis. 1990; 161:685-W4.
17. Lous J. Secretary otitis media and phonology when stalling school. Sound Audiol. 1990:19:215-222.
18. American Academy of Pediatrics. Policy statement on middle ear disease and language development. Acod ftator News & Comment!. 1984:35-9.