Submerged in the depths of the temporal bone and visible only through the frosted surface of the tympanic membrane, the ear remains an enigmatic organ for many pediatric medical providers. Its anatomy is complex, mastered only through prodigious study and cadaveric laboratory dissection. Its physiology is not yet completely elucidated. Its visualization often is hampered by cerumen impactions, anatomic variations, and poor patient cooperation.
The ear is the product of a marvelous and unique juxtaposition of the respiratory and central nervous systems within a single organ. However, it is precisely this relationship that historically has made the ear so problematic to providers of pediatric medical care. Before the advent of effective antimicrobial therapy, common infections of the middle ear led to complicated infections of the temporal bone and brain. The pediatrician of yore devoted his study of the ear to recognition and treatment of otogenic complications. Little was known about causes and management of children with deafness.
With the development of antibiotics, the pediatrician's focus shifted to management of otitis media and prevention of otogenic infections. Identification of any middle ear disease suggested a potential role for antimicrobial therapy. With more mothers entering the workforce, more children entered daycare environments where such infections flourished. As resistant pathogens developed, parents demanded more effective therapies, and pharmaceutical companies responded with new broad-spectrum medications every few years. At the same time, advances in electron microscopy and electrophysiology provided a more fundamental understanding of the workings of the inner ear. Many of the causes of congenital and acquired deafness were identified, and research provided pediatricians with the tools to recognize children at risk for hearing loss.
Pediatricians in the 21st century are, now more than ever, at the forefront in the management of disorders of the ear in children. In 1983, Teele et al.1 reported that disease of the middle ear accounted for a huge proportion of pediatric office visits made during the first five years of life, rising from 22.7% during the first year to about 40% in years 4 and 5, a trend which has continued. Additionally, treatment paradigms have shifted. The emergence of multidrug-resistant organisms and growing evidence of the self-limited nature of otitis media suggest the need for a more conservative approach to infections of the ear. Asymptomatic middle ear effusion may require no intervention, while acute infection may be treated with judicious use of oral antibiotics or, in some cases, topical agents.
Such an approach demands that the pediatrician be able to hone his diagnostic skills to differentiate those middle ear disorders requiring antibiotic therapy from those that can be watched expectantly. Vaccination against middle ear pathogens, though not yet a huge success, also has become a reality, and the pediatrician must be familiar with the results of such preventive therapy in large-scale trials.
The explosion of technology during the past 50 years also has resulted in a dramatic change in the pediatrician's role in managing childhood hearing loss. Brainstem response audiometry and otoacoustic emissions are now available as screening procedures for hearing loss in newborns, and newborn hearing screening is required by law in some 40 states.2 As a result, the pediatrician in the newborn nursery may be the first medical contact for parents of a hearing-impaired child. In addition, early identification and referral of children with hearing impairment has resulted in more effective use of amplification and cochlear implantation as well as in a savings in healthcare dollars spent on rehabilitation of such individuals. Assistive-Iistening devices themselves have matured in the digital age, providing hearing-impaired patients with a wide selection of amplification options for some hearing losses previously considered unaidable. Advances in research technology also have resulted in the identification of a variety of genetic defects that account for the hearing impairment in many patients for whom no etiology could previously be identified.
IN THIS ISSUE
This issue of Pediatric Annals reviews several of the otologic topics of greatest importance to the general pediatrician. Drs. John and Claire Jacobson address "Evaluation of Hearing Loss in Infants and Young Children." A primer in audiometrie assessment, this article reviews the various behavioral and objective audiometrie tests administered to children and how they are used to differentiate conductive from sensorineural hearing loss. The authors suggest a multidisciplinary approach to the management of such children once they are identified.
In "Medical Management of Childhood Hearing Loss," Dr. Margaret Kenna discusses the myriad causes of hearing impairment in children, focusing on those resulting in sensorineural hearing loss. Dr. Kenna has a research interest in genetic forms of deafness and provides the most current recommendations for medical evaluation of the child with hearing impairment.
Dr. Richard Rosenfeld's article "Appropriate Antibiotic Use for Otitis Media: Oral, Topical, or None?" provides a thorough review of the literature regarding management of pediatric middle ear disease. The literature has Jed to current recommendations for conservative therapies. A leader in the development of management guidelines for otitis media and the author of numerous articles and books on the subject, Dr. Rosenfeld also underscores the importance of a certain diagnosis of acute otitis media prior to initiation of antimicrobial therapy.
In our article, "Management of the Draining Ear in Children," Dr. Ashley Schroeder and I enumerate the many possible causes of otorrhea in children and describe for the pediatrician a general approach to the child with a draining ear. We emphasize the importance of ear debridement in arriving at a correct diagnosis and appropriate interventions, as well as the use of recently developed topical antimicrobiais in the management of pediatric otorrhea.
The Resident's Viewpoint column features Dr. David Skey,who echoes the need for diagnostic accuracy in managing otitis media. Dr. Skey makes a plea for proper use of the pneumatic otoscope and incorporating formal resident training in diagnosis of otitis media into residency programs around the country.
As new approaches to middle ear disease and childhood hearing loss emerge, pediatricians must assume a more critical role in the management of otologic disorders. Through continuing education and training, pediatricians will be prepared to handle the challenges of recurrent and resistant infections and to serve as advocates for their children with hearing loss to ensure their normal development and acceptance in the community.
1. Teele DW. Klein JO, Rosner B, et al. Middle ear disease and the practice of pediatrics. Burden during the first five years of life. JAMA. 1983:249(8): 1026-1029.
2. National Center for Hearing Assessment and Management Utah State University. Available at: http://www.infanthearing. org/legislative. Accessed October 28. 2004.