Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4408_Библиотеки_им_академика_М_И_Перельмана

The clinical studies in acute/recurrent otitis media and otitis media with effusion, however, were the rst to bring the evidence-based approach to otolaryngology, with clinical trials published in the 1980s and meta-analyses from the 1990s on. The pioneers in clinical trials of otitis media in children, such as the North Americans from Pittsburgh (Charles Bluestone, Sylvan Stool, and Jack Paradise) and the

There are some articles that point out a great correlation (approximately 70%) between the rhinopharyngeal bacteria

Genetic factors and their inuence on the genesis of otitis media are just beginning to be understood. We already have a few studies that can provide evidence for this. A positive parental story for RAOM remained a signicant predictor for RAOM in children even after the logistic regression was per­formed, as shown by a huge prevalence study in Greenland [26]. The strongest evidence was demonstrated in research with twins and triplets. In a Norwegian retrospective study with 2750 twin pairs, 45% and 74% of heritability were found in boys and girls, respectively. Another retrospective study with a sample of 1373 twin pairs estimated heritability for RAOM in the ages of 2, 3, and 4years, on average, close to 0.57 [27]. In the prospective twins and triplets Pittsburgh study, in which monthly monitoring of the middle ear was done, at the 2-year endpoint, the estimated heritability of oti­tis media was 0.79in girls and 0.64in boys. Of the original 140 pairs of twins and triplets with determined zygosity, 114 were followed up to the age of 3, and 83 were followed up for 5years. The monozygotic twins had a signicantly lon­ger time with MEE (0.65–0.77) than the dizygotic twins (0.31–0.39) for each year until the third. After that, there was a decrease in these rates, probably explained by the lower incidence of otitis media in older children. The discordance estimates for three or more MEE episodes were 0.02 for monozygotic twins and 0.40 for dizygotic twins, both fol­lowed up until the fth year (p=0.07). The estimated herita­bility of the proportion of time spent with MEE in the rst

with the number of companies [5, 6]. Large group childcare centers increase otitis media incidence and have been dened as those in which professional educators provide care for up to 10 groups of 8–12 children in the same setting [42]. Beyond that, children in daycare centers need more ventila­tion tubes than those who receive care at home [41]. The large prevalence of URTI in children exposed to other sub­stances can be one mechanism related to this phenomenon [43]. Alho etal. [44], in a hypothetical cohort, estimated that if 825 children were transferred from daycare centers to home care and followed up for 2years, approximately two out of ve affected would have RAOM.Strong clinical evi­dence from the clinical practice of otolaryngologists con­rms this presumption. During the COVID-19 pandemic, there was a signicant reduction in cases of AOM in children in countries that adopted the strategy of closing daycare cen­ters. In conclusion, daycare attendance is a risk factor for RAOM (evidence level II).

It is one of the most studied risk factors for RAOM.However, the rst studies were controversial, showing both positive [38, 49–51] and negative [48, 52–55] associations between otitis media and second-hand smoke exposure. Posterior studies, however, showed more conclusive results. Mother’s heavy smoking (20 or more cigarettes per day) was a signi­cant risk factor for RAOM, with an RR of 1.78 (95% CI

1.01–3.11) in a multivariate analysis, as demonstrated by Ey etal., who prospectively analyzed 1013 children from birth to 1year [56]. In another prospective cohort with a sample of 918 children, the ones who had heavy-smoker mothers were at signicantly increased risk of having four or more AOM episodes (RR 1.8; 95% CI 1.1–3.0) and made the rst AOM

11.9) after ventilation tube insertion in another prospective cohort [58]. Some studies tried to measure objectively tobacco exposure through cotinine (a nicotine metabolite) concentrations in saliva and urine. One of these studies, using salivary cotinine, was a retrospective cohort of 9years with 132 daycare children [59]. The incidence rate of MEE was 1.39 (95% CI 1.15–1.69) in the rst year of life and 1.38 (95% CI 1.21–1.56) in the rst 3years. Nonetheless, when other variables were included in the logistic regression, the signicance disappeared. Stratchan et al. did not nd an association between salivary cotinine and otitis media. The association between early AOM onset and the rate of cotinine- creatinine in urine was also not able to be demon­strated by Daly et al. [60]. Stratchan and Cook’s meta­analysis demonstrated estimated RRs, if at least one of the parents smoked, of 1.48 (95% CI 1.08–2.04) and 1.38 (95% CI 1.23–1.55) for RAOM and MEE, respectively [49]. Another meta-analysis calculated a risk of 1.92 (95% CI

The treatment of RAOM can be clinical and/or surgical. There are two main approaches: the treatment of repeated episodes and the prophylactic treatment to avoid or reduce the recurrence of acute episodes.

these acute episodes (do not forget that antibiotics do not treat pain acutely, so all approaches must be accompanied by analgesics): (1) immediate treatment of all cases of acute bulging; (2) expectant treatment (advise parents to only return for a new evaluation if the child still has fever or otal­gia after 48h) [99]; or (3) dispensing a delayed prescription, that is, prescribing the antimicrobial and asking that the pre­scription be used only if symptoms persist after 48h [100].

A recent study showed that whereas some clinical charac­teristics were moderate determinants for watchful waiting, clinician antibiotic prescribing volume and specialty were strong determinants. Low-volume antibiotic prescribers (≥80% of AOM episodes managed with watchful waiting) had 11.61 (95% CI 10.66–12.64) higher odds of using watch­ful waiting for the index AOM episode than high-volume antibiotic prescribers (≥80% treated). Otolaryngologists were more likely to adopt watchful waiting (OR 5.45, 95% CI 5.21–5.70) than pediatricians, whereas other specialties deferred more commonly to antibiotics. Among 2,176,617 AOM episodes, 77.8% were treated within 3days [101]. This result reinforces the need to invest in medical education, whether in medical schools or in the form of continuing medical education, in order to achieve more rational levels of antimicrobial prescribing, especially for pediatricians.