Pediatric Annals

OTITIS MEDIA 

Otitis Media: The Otolaryngologist's Perspective

Margaret A Kenna, MD

Abstract

Otitis media is an inflammation of the middle ear without reference to a specific etiology or pathogenesis.1 It is the second most common disease of childhood after upper respiratory tract infections and one of the most frequent reasons for a child to visit the pediatrician's office.1"3 Although both the diagnosis and the treatment of otitis media have improved significantly, serious complications, although infrequent, still occur. However, non-life-threatening complications such as conductive hearing loss are common, causing difficulty for many children and generating controversy about the importance and management of such complications.

EPIDEMIOLOGY

The incidence of otitis media seems to be increasing.3 This may be due to an actual increase in the disease, increased vigilance on the part of pediatricians and other care providers, or a combination of the two. Longitudinal studies suggest that children with otitis media fall into one of several basic categories: (!) those who remain free from otitis media; (2) those who occasionally have acute otitis media (AOM); (3) those who frequently have AOM (otitis prone); (4) those who have asymptomatic otitis media with effusion (OME) (here asymptomatic means no clinical symptoms; these children usually have some degree of conductive hearing loss when tested); and (5) those who have persistent OME with recurrent AOM symptoms.

The epidemiology of otitis media has been well studied.1-4"6 The incidence of otitis media increases after the newborn period (first 28 days of life). In one study, 13% of children had at least one episode of otitis media by age 3 months.4 By 12 months old, nearly two-thirds of all children have had at least one episode of AOM, and by 3 years old, 46% of children have had three or more episodes.4 In the study by Teele et al., the highest incidence of AOM for both sexes was found in children 6 to 11 months old, with a second, lower peak noted between 4 and 5 years.4

In many studies, episodes of AOM are equally distributed among boys and girls. However, in others, boys have significantly more episodes than do girls.1,4'6 There appears to be a strong genetic predisposition, with a higher incidence in children who have siblings or parents with a significant history of otitis media.7 Past studies have suggested that white and Hispanic American children have a higher incidence of middle ear infections than do black American children.1 However, recent studies by Casselbrant et al. and Paradise et al. have found that black children who received care equivalent to that of white children have at least as much otitis media as do white children.5-6 Native Americans and Eskimos have an extremely high incidence of middle ear infections, even when there is excellent access to medical care.1-8

Large numbers of children in both die United States and other developed countries attend day care, and many studies document an increased incidence of otitis media in these children. Wald et al. found that young children (birth to 3 years) in group care and day care, compared with those in home care, were more likely to have otitis media as a complication of an upper respiratory tract infection.9 However, by 3 years old, the risk of otitis media was similar in all child care situations. Other investigators have substantiated these results. Contributing factors include exposure to other children, decreased breastfeeding, and exposure to secondhand smoke. Earlier examinations, in an effort to decrease parental leave time from work, have also contributed to the increase in otitis media among children in day care.10"12

Several investigators have shown a high incidence of persistent middle ear effusion (MEE) after an episode of AOM.4-13'15 The mean duration of…

Otitis media is an inflammation of the middle ear without reference to a specific etiology or pathogenesis.1 It is the second most common disease of childhood after upper respiratory tract infections and one of the most frequent reasons for a child to visit the pediatrician's office.1"3 Although both the diagnosis and the treatment of otitis media have improved significantly, serious complications, although infrequent, still occur. However, non-life-threatening complications such as conductive hearing loss are common, causing difficulty for many children and generating controversy about the importance and management of such complications.

EPIDEMIOLOGY

The incidence of otitis media seems to be increasing.3 This may be due to an actual increase in the disease, increased vigilance on the part of pediatricians and other care providers, or a combination of the two. Longitudinal studies suggest that children with otitis media fall into one of several basic categories: (!) those who remain free from otitis media; (2) those who occasionally have acute otitis media (AOM); (3) those who frequently have AOM (otitis prone); (4) those who have asymptomatic otitis media with effusion (OME) (here asymptomatic means no clinical symptoms; these children usually have some degree of conductive hearing loss when tested); and (5) those who have persistent OME with recurrent AOM symptoms.

The epidemiology of otitis media has been well studied.1-4"6 The incidence of otitis media increases after the newborn period (first 28 days of life). In one study, 13% of children had at least one episode of otitis media by age 3 months.4 By 12 months old, nearly two-thirds of all children have had at least one episode of AOM, and by 3 years old, 46% of children have had three or more episodes.4 In the study by Teele et al., the highest incidence of AOM for both sexes was found in children 6 to 11 months old, with a second, lower peak noted between 4 and 5 years.4

In many studies, episodes of AOM are equally distributed among boys and girls. However, in others, boys have significantly more episodes than do girls.1,4'6 There appears to be a strong genetic predisposition, with a higher incidence in children who have siblings or parents with a significant history of otitis media.7 Past studies have suggested that white and Hispanic American children have a higher incidence of middle ear infections than do black American children.1 However, recent studies by Casselbrant et al. and Paradise et al. have found that black children who received care equivalent to that of white children have at least as much otitis media as do white children.5-6 Native Americans and Eskimos have an extremely high incidence of middle ear infections, even when there is excellent access to medical care.1-8

Large numbers of children in both die United States and other developed countries attend day care, and many studies document an increased incidence of otitis media in these children. Wald et al. found that young children (birth to 3 years) in group care and day care, compared with those in home care, were more likely to have otitis media as a complication of an upper respiratory tract infection.9 However, by 3 years old, the risk of otitis media was similar in all child care situations. Other investigators have substantiated these results. Contributing factors include exposure to other children, decreased breastfeeding, and exposure to secondhand smoke. Earlier examinations, in an effort to decrease parental leave time from work, have also contributed to the increase in otitis media among children in day care.10"12

Several investigators have shown a high incidence of persistent middle ear effusion (MEE) after an episode of AOM.4-13'15 The mean duration of OME after AOM in several studies is approximately 40 days,13-14 and younger children have slower resolution of MEE following AOM than do older children.4 Investigations reveal that healthy children have a high incidence of asymptomatic OME.15 Its incidence appears to peak during the second year of life, it is most prevalent during the winter, and it is associated with upper respiratory infections.

A study of children 2 to 6 years old found that 53% during the first year of the study and 61% during the second year had OME in at least one ear.15 Teele et al. found that the mean time with fluid in the middle ear was approximately 1 month in each of the first 2 years of life, and a few children had this more than half of the time during the first year.4 More recently, Paradise et al. found a cumulative proportion of days with MEE of 20.4% for the first year of life and 16.6% for the second year.6 During the first 2 years of life, both AOM and OME are more commonly bilateral, becoming more frequently unilateral with increasing age. Most children have resolution of asymptomatic MEE within a few months without medical or surgical intervention.

COMPLICATIONS

The complications of otitis media can be divided into intratemporal and intracranial, with the intratemporal occurring much more frequently. Intratemporal complications include hearing loss (both conductive and sensorineural), chronic suppurative otitis media, tympanic membrane (TM) perforation, cholesteatoma, retraction pocket, adhesive otitis media, tympanosclerosis, ossicular discontinuity, mastoiditis, labyrinthitis, petrositis, facial paralysis, cholesterol granuloma, and eczematoid dermatitis. By far the most common of these is conductive hearing loss, usually due to middle ear fluid.

Even a mild or unilateral hearing loss may have a detrimental effect on speech and language development, school performance, and social interactions in a young child, especially during the early formative language years.16-17 The mild to moderate conductive hearing loss associated with otitis media often fluctuates, making it difficult for the child to develop a "strategy" to deal with the hearing impairment. Children with these types of hearing impairments have greater difficulty when listening conditions are unfavorable (eg, when there is background noise and poor acoustics), such as may occur in the classroom. The studies that have evaluated the effect of otitis media and hearing loss on speech and language are somewhat contradictory. Nonetheless, hearing loss (due to otitis media or not) should be considered in any child with speech and language difficulties, below-par academic performance, poor behavior, or inattention in school.

Intracranial complications include meningitis, epidural abscess, subdural empyema, brain abscess, focal otitic encephalitis, lateral sinus thrombosis, otitic hydrocephalus, and death. Of these, meningitis is the one that occurs most frequently, although all are uncommon. Since the introduction of antimicrobials, the incidence of both suppurative intratemporal and intracranial complications has plummeted. However, complications still do occur, and vigilance is required by pediatricians and other caretakers to recognize them and refer the child to an otolaryngologist in a timely fashion.18·19 The article by Wetmore in this issue discusses these complications in detail.

DIAGNOSIS

Audiometrie Measuiements

Hearing should be evaluated in any child with recurrent or persistent otitis media to (1) document any conductive loss, the most common- type in otitis media; (2) document any underlying sensorineural loss, either preexisting (most common) or secondary to otitis media (uncommon); and (3) obtain baseline hearing results for Later comparison.

Many children have a screening audiogram before they enter school, at age 4 or 5 years. However, children who have recurrent or persistent middle ear disease or in whom there is suspicion of hearing loss for any reason should be evaluated earlier so that treatment, and rehabilitation, can begin as soon as possible. In addition, many states now have newborn hearing screening programs. Although these were set up primarily to detect sensorineural hearing loss, some infants who do not pass the screening have otitis media causing a conductive hearing loss. Because this is correctable, it is important to identify these children early.

The audiometrie examination technique varies with the age and developmental level of the child. Behavioral observation audiometry is used for infants from approximately 6 months to 1 year old. This provides an estimation of hearing, especially in die better-hearing ear. Visual reinforcement audiometry is useful for children 1 to 2 years old and also gives results for the betterhearing ear; in uncooperative children, ear-specific data are sometimes not obtainable.

Neither behavioral observation audiometry nor visual reinforcement audiometry provide indication of the type (conductive or sensorineural) of hearing loss. Play audiometry can be used for cooperative children 2 years and older. Both speech and pure-tone stimuli can be evaluated and ear-specific data obtained. Also, because both air-conduction and bone-conduction thresholds are measurable, a differentiation between a conductive and a sensorineural loss can be made. Conventional audiometry can be used in most children 5 years or older. If a hearing loss is identified and is persistent, is more than mild (greater than 35 dB), or is suggestive of a sensorineural component, auditory brainstem evoked responses may be needed for confirmation and treatment planning.

Additionally, auditory brainstem evoked responses is used to evaluate hearing in children younger than 6 months, to confirm a sensorineural hearing loss for the child who does not cooperate sufficiently for accurate behavioral results, or to further define the laterality of a hearing loss in a child too young to give detailed bilateral behavioral responses. The auditory brainstem evoked responses reflects conduction of the neuronal activity down to the level of the midbrain, and should be correlated with behavioral audiometrie results as soon as the child is old enough or developmentally able to provide reproducible behavioral results. Correlation with behavioral results and otoacoustic emissions see below) is necessary because there is a cognitive component to hearing that cannot be tested by auditory brainstem evoked responses, and, rarely, the auditory brainstem evoked responses may be discrepant with what the child actually perceives as sound. For all techniques, hearing loss is classified as mild (21-40 decibels hearing level [dBHL]), moderate (41-55 dBHL), moderately severe (56-70 dBHL), severe (71-90 dBHL), or profound (> 90 dBHL).

Otoacoustic emissions are sounds that can be recorded in the ear canal that represent the biomechanical response of the cochlea to a sound stimulus. During normal hearing, these emissions originate from the outer hair cells in the cochlea, and are detected by sensitive amplifying processes. They travel from the cochlea through the middle ear to the external auditory canal, where they can be detected using miniature microphones. In the neonatal period, detection of otoacoustic emissions can be accomplished during natural sleep and used as a screening test in infants and children for hearing at or better than the 30- to 35-dBHL level. They are less time consuming and less elaborate than auditory brainstem evoked responses and are more sensitive than behavioral tests in very young children.

Otoacoustic emissions are reduced or absent owing to various types of dysfunction in the inner or the middle ear and are absent in patients with more than 30 to 35 dBHL of hearing loss. Thus, they cannot be used to determine hearing threshold; rather, they really provide a screen for whether the hearing is normal or in the mild hearing loss range versus more severe than that (otoacoustic emissions absent). Diseases such as otitis media or congenitally abnormal middle ear structures reduce the transfer of otoacoustic emissions and may wrongly suggest a cochlear hearing disorder. If a hearing loss is suspected by the absence of otoacoustic emissions, then physical examination of the ear and auditory brainstem evoked responses testing should be used for confirmation and identification of the type, degree, and laterality of hearing loss.

Impedance Measurements

Impedance testing measures the "impedance" or stiffness of the TM and the middle ear system. The article by Hoberman and Paradise in this issue describes two impediance techniques, tympanometry and acoustic reflectometry.

Results of tympanometry can be normal in the presence of serious TM and middle ear pathology (eg, choies tea toma) and so should always be correlated with pneumatic otoscopy. In addition, tympanometry is not a measure of hearing. Abnormal results on tympanometry may suggest the presence of TM or middle ear pathology. If so, it is this pathology that may cause hearing loss. Therefore, if results of tympanograms are persistently abnormal, then audiometry and otoscopy should be performed.

WHEN TO REFER: AN OTOLARYNGOLOGIST S PERSPECTIVE

There are several reasons to refer a child with otitis media to the otolaryngologist. If the child has recurrent AOM, a rough guide for referral is 4 to 6 infections in 1 year or 3 to 4 in 6 months, or a combination of OME and recurrent AOM using these guidelines. Referral should be made if the child has had 3 months of continuous OME, especially bilateral, or 6 months of unilateral OME, even without acute symptoms.20,21 If there is concern about the child's hearing, speech, or language, then referral is appropriate at any time. In either case, the child's hearing will most likely be tested as part of the otolaryngology evaluation. The hearing in a child with OME may be "normal" by audiometrie evaluation. However, because the range of normal is wide (0-20 dB), it is likely that the child with OME hears better without the middle ear fluid than with it. Additionally, if the child's speech and language is of concern, then a formal speech and language evaluation may also be recommended.

Reasons for earlier referral to the otolaryngologist include an underlying sensorineural hearing loss, severe symptoms (pain, not sleeping at night, vertigo, significant hearing loss, substantial weight loss or gastrointestinal symptoms secondary to otitis media [or side effects of antibiotics], or severe disruption of family life due to the child's chronic otitis media [eg, the child is up at night with pain or is irritable during the dayl), or occurrence of otitis media in a young infant (younger than 6 weeks, due to the higher incidence of unusual pathogens, the relative immaturity of the immune system, or both). Physical examination findings such as a deep retraction pocket of the TM, a persistently draining ear, or suspicion of cholesteatoma should also prompt referral. Finally, if the referring physician feels that there is a significant or life-threatening complication in a child with otitis media (eg, facial paralysis, meningitis, or brain abscess), then emergent referral should be made.

SURGICAL INTERVENTION FOR OTITIS MEDIA

With the increase in the percentage of antimicrobially resistant middle ear organisms, placement of tympanostomy tubes has taken on renewed importance.22 Surgical intervention for otitis media should be considered in two situations: (1) when medical management fails; and (2) when a complication is suspected. The two mainstays of the surgical management of otitis media are tympanostomy tubes and adenoidectomy.

Tympanostomy Tubes

Tympanostomy tubes are indicated for recurrent AOM or middle ear fluid that has been documented for 3 months or more and that has been unresponsive to medical therapy. Other factors that are included in the decision to recommend tympanostomy tubes are the presence of conductive hearing loss, speech and language delay, significant clinical symptoms, or the need to obtain middle ear cultures. Occasionally, a tube will be placed urgently as part of the management of a complication of otitis media at the time of tympanocentesis.

Figure. Left tympanic membrane with targe posterior retraction pocket filled with squamous debris. Mucoid middle ear fluid was also present at the time of myringotomy.

Figure. Left tympanic membrane with targe posterior retraction pocket filled with squamous debris. Mucoid middle ear fluid was also present at the time of myringotomy.

The placement of a tympanostomy tube usually requires a brief general anesthetic on an outpatient basis. Occasionally an older child may allow tube placement under local anesthesia. The tubes themselves are made of various materials, including polytetrafluoroethylene, silicon, stainless steel, and titanium. Some are designed for special uses such as longer retention or for insertion through very small ear canals. However, they all function to ventilate the middle ear.

Tympanostomy tubes generally stay in the TM for approximately a year and then extrude spontaneously into the ear canal. Occasionally they have to be removed from the TM due to prolonged retention. While the tympanostomy tubes are in place, the children are unaware that they are there and can pursue their normal activities. Although there has been ongoing concern about keeping water out of the ears, there is little evidence that water precautions during bathing and swimming make a significant difference in the otorrhea rate. One study did suggest that soapy water and water under pressure might be more likely to actually get into the middle ear through a tympanostomy tube, but this was based on a laboratory model and might be difficult to extrapolate to an actual clinical situation.23124

Complications of tympanostomy tubes include otorrhea, persistent perforation of the TM when the tube has extruded, scarring or tympanosclerosis involving the TM, formation of granulation tissue around the tube, atrophie or thinned areas of the TM (where the tube was), and cholesteatoma (Figure). Otorrhea is relatively common, occurring in 12% to 30% of children right after tube insertion, especially if the MEE was purulent or mucoid.1 Up to 50% of children have otorrhea at some point during the time the tympanostomy tubes are in place, often secondary to an upper respiratory infection.1 TM perforations that do not close spontaneously occur in up to 3% of ears with tympanostomy tubes, although factors that may be related to a higher persistent perforation rate include tube retention beyond 36 months, multiple sets of tubes, age younger than 5 years, use of "long-lasting" tympanostomy tubes, and frequent postoperative otorrhea.1

Tympanosclerosis or atrophie areas of the TM usually do not affect hearing. Although the etiology of tympanosclerosis is unclear, it may be the result of chronic middle ear inflammation or trauma. Tympanosclerosis can occur without obvious trauma to the TM but is also seen at the site of the tympanostomy tube or perforation (even if a tube has not been placed). Atrophie areas of the TM may occur at old tympanostomy tube sites and usually do not affect hearing. However, if there is ongoing significant eustachian tube dysfunction and the atrophie area becomes significantly retracted and fills with squamous debris, this can lead to a cholesteatoma. Any patient with a TM retraction pocket therefore needs to be observed carefully. If the primary care provider is uncertain about the presence or depth of a retraction pocket, then USe child should be referred to an otolaryngologist.

Cholesteatoma may, uncommonly, occur secondary to placement of a tympanostomy tube. This may happen due to implantation of squamous epithelium during tube placement, or as a result of a persistent perforation or retraction pocket. It is most likely, however, that such cholesteatomas occur as a result of ongoing eustachian tube dysfunction, with development of a retraction pocket that fills with squamous debris. This area then essentially gets "walled off" and may cause erosion or infection of the underlying middle ear structures. If the depths of a retraction pocket cannot be easily seen or if there is a whitish mass, chronic middle ear drainage, or debris or polyps associated with the retraction pocket, the patient should be referred to an otolaryngologist for further evaluation. The only treatment for a cholesteatoma is surgical removal. Careful follow-up by the otolaryngologist is needed because the recurrence or persistence rate is approximately 4O0Xo.1

Recently, the use of the CO2 laser to make a "short-term" myringotomy has been advocated. This has been promoted to provide a few weeks of ventilation of the middle ear without placement of a tympanostomy tube. It can be performed under local anesthesia, and the perforation made by the laser is then supposed to close spontaneously. Although the concept of providing short-term middle ear ventilation is interesting, the indications and long-term complications of the technique need much more research.25

Adenoldaclomy

Adenoidectomy is the other surgical procedure often recommended in the treatment of otitis media. Several studies support its effectiveness to prevent recurrent OME; fewer have examined its effectiveness for AOM. Because the efficacy is consistent (although relatively modest) across most studies, it is reasonable to consider adenoidectomy in the management of otitis media, especially if the patient has had one or more sets of tympanostomy tubes and is still having otitis media refractory to medical therapy. Adenoidectomy for the management of upper airway obstruction, of course, can be considered at any age, regardless of whether otitis media is present.1

The complications of adenoidectomy include bleeding, velopharyngeal incompetence, and nasopharyngeal stenosis. Significant bleeding and velopharyngeal incompetence are uncommon, and nasopharygeal stenosis is rare. For placement of tympanostomy tubes, adenoidectomy, and most other surgical procedures performed in children, general anesthesia is required; this should be performed by an anesthesiologist with much pediatrie experience. Therefore, as with all surgical procedures, the decision to go forward with adenoidectomy must balance any possible positive outcomes with any potential risks.

There is little evidence that tonsillectomy has any significant place in the management of otitis media, and it is not routinely recommended for otitis media alone. Tonsillectomy for recurrent sore throat or upper airway obstruction is still an option, however, regardless of whether otitis media is present, as long as the appropriate clinical indications are met.

CONCLUSION

Recurrent AOM and chronic or recurrent OME are common in the pediatrie population. The management should be primarily medical, with surgical intervention reserved for refractory cases. Although the severe complications of otitis media are now uncommon, they still occur and the primary care provider must be vigilant to recognize them in a timely fashion.

REFERENCES

1. Bluestone CD, Klein JO. Otitis media atelectasis and eustachian tube dysfunction. In: Bluestone CD, Stool SE, Renna MA, eds. Pediatrie Otolaryngology, 3rd ed. Philadelphia: W. B. Saunders; 1996:388-582.

2. Freid VM, Makuc DM, Rooks RN. Ambulatory health care visits by children: principal diagnosis and place of visit. Vital and Health Statistics-Series 13: Data from the National Health Survey. 1998;137:l-23.

3. Lanphear BP, Byrd RS, Auinger P, Hall CB. Increasing prevalence of recurrent otitis media among children in the United States. Pediatrics. 1997;99:E1. Available at: www.pediatrics.org/cgi/ content/ full/ 99 /3 /el.

4. Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J infect Dis. 1989;160:83-94.

5. Casselbrant ML, Mandel EM, Kurs-Lasky M, Rockette HE, Bluestone CD. Otitis media in a population of black American and white American infants, 0-2 years of age. Int J Pediatr Otorhinolaryngol. 1995;33:1-16.

6. Paradise JL, Rockette HE, Colborn DK, et al. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics. 1997;99:318-333.

7. Casselbrant ML, Mandel EM, Fall PA, et al. The heritability of otitts media: a twin and triplet study. JAMA. 1999;282:2125-2130.

8. Kramer AH, McCullough DW. The prevalence of otitis media with effusion among lnuit children. Int J Circumpolar Health. 1998;57(suppl l):265-267.

9. WaId ER, Guerra N, Byers C. Upper respiratory tract infections in young children: duration of and frequency of complications. Pediatrics. 1991;87:129-133.

10. Ball TM, Wright AL. Health care costs of formula-feeding in the first year of life. Pediatrics. 1999;103:870-876.

11. Strachan DP, Cook DG. Health effects of passive smoking: 4. Parental smoking, middle ear disease and adenotonsillectomy in children. Thorax. 1998;53:50-56.

12. Hildesheim ME, Huffman HJ, Overpack MD. Frequent ear infections in association with child-care characteristics, based on the 1988 Child Health Supplement to the National Health Interview Survey. Peediatr Perinat Epidemiol. 1999; 13:466-472.

13. Schwartz RH, Rodríguez WJ, Grundfast KM. Duration of middle ear effusion after acute otitis media. Pediatr Infect Dis ). 1984;3:204-207.

14. Shurin PA, Pelton SI, Dormer A, Klein JO. Persistence of middle ear effusion after acute otitis media. N Engl} Med. 1979;300:1121-1123.

15. Casselbrant ML, Brostoff LM, Cantekin EI, et al. Otitis media with effusion in preschool children. Laryngoscope. 1985, 195:428-436.

16. Bess FH, Tharpe AM. Unilateral hearing impairment in children. Pediatrics. 1984;74:206-216.

17. Teele DW, Klein JO, Chase C, Menyuk P, Rosner BA. Otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years. / Infect Dis. 1990;162:685-694.

18. Goldstein N, Casselbrant ML, Bluestone CD, Kurs-Lasky M. Intratemporal complications of acute otitis media in infants and children. Otolaryngol Head Neck Surg. 1998;119:444-154.

19. Albers FW. Complications of otitis media: the importance of early recognition. Am J Otol. 1999;20:9-12.

20. Stool SE, Berg AO, Berman S, et al. Otitis Media With Effusion in Young Children: Clinical Practice Guideline, Number 12. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; July 1994. AHCPR Publication No, 94-0622,

21. Hsu GS, Levine SC, Giebink GS. Management of otitis media using Agency for Health Care Policy and Research Guidelines. Otolaryngol Head Neck Surg, 1998;118:437-443.

22. Bluestone CD. Role of surgery for otitis media in the era of resistant bacteria. Pediatr Infect Dis }. 1998;17: 1090-1098.

23. Lee D, Youk A, Goldstein NA. A meta-analysis of swimming and water precautions. Laryngoscope. 1999;109:536540.

24. Hebert RL 2nd, King GE, Bent JP 3rd. Tympanostomy tubes and water exposure: a practical model. Arch Otolaryngol Head Neck Surg. 1998;124:1118-1121.

25. Szeremeta W, Parameswaran MS, Isaacson G. Adenoidectomy with laser incisional myringotomy for otitis media with effusion. Laryngoscope. 2000;11 0:342-345.

10.3928/0090-4481-20001001-08

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