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17 Otitis Media withEusion andHearing Loss inChildren
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5. Minovi A, Dazert S.Diseases of the middle ear in childhood. GMS Curr Top Otorhinolaryngol
Head Neck Surg. 2014;13:Doc11.
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cine.medscape.com/article/858990- overview. Accessed 10 Jan 2022.
7. Bluestone CD, Beery QC, Andrus WS.Mechanics of the eustachian tube as it inuences susceptibility to and persistence of middle ear effusions in children. Ann Otol Rhinol Laryngol.
1974;83(Suppl 11):27–34.
8. Crapko M, Kerschner JE, Syring M, Johnston N.Role of extra-esophageal reux in chronic
otitis media with effusion. Laryngoscope. 2007;117:1419.
9. O'Reilly RC, Soundar S, Tonb D, etal. The role of gastric pepsin in the inammatory cascade
of pediatric otitis media. JAMA Otolaryngol Head Neck Surg. 2015;141:350.
10. Harman NL, Bruce IA, Callery P, Tierney S, Sharif MO, O’Brien K, et al. MOMENT—
Management of Otitis Media with Effusion in cleft palate: protocol for a systematic review
of the literature and identication of a core outcome set using a Delphi survey. Trials.
2013;14(1):70.
11. Siddartha, Bhat V, Bhandary SK, Shenoy V, Rashmi. Otitis media with effusion in relation
to socio economic status: a community based study. Indian J Otolaryngol Head Neck Surg.
2012;64(1):56–8.
12. Erdivanli OC, Coskun ZO, Kazikdas KC, Demirci M.Prevalence of otitis media with effusion among primary school children in eastern Black Sea, in Turkey and the effect of smoking in the development of otitis media with effusion. Indian J Otolaryngol Head Neck Surg.
2012;64(1):17–21.
13. Mills R, Hathorn I. Aetiology and pathology of otitis media with effusion in adult life. J
Laryngol Otol. 2016;130(5):418–24.
14. Choi HG, Sim S, Kim SY, Lee HJ.A high-fat diet is associated with otitis media with effusion.
Int J Pediatr Otorhinolaryngol. 2015;79(12):2327–31.
15. Kaya S, Selimoglu E, Cureoglu S, Selimoglu MA.Relationship between chronic otitis media
with effusion and overweight or obesity in children. J Laryngol Otol. 2017;131(10):866–70.
16. Walker RE, Bartley J, Flint D, Thompson JM, Mitchell EA.Determinants of chronic otitis
media with effusion in preschool children: a case-control study. BMC Pediatr. 2017;17(1):4.
17. Gordon MA, Grunstein E, Burton WB.The effect of the season on otitis media with effusion resolution rates in the New York Metropolitan area. Int J Pediatr Otorhinolaryngol.
2004;68:191.
18. van Balen FA, de Melker RA. Persistent otitis media with effusion: can it be predicted? A
family practice follow-up study in children aged 6 months to 6 years. J Fam Pract. 2000;49:
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19. Rosenfeld RM, Schwartz SR, Pynnonen MA, etal. Clinical practice guideline: tympanostomy
tubes in children. Otolaryngol Head Neck Surg. 2013;149:S1.
20. Browning GG, Rovers MM, Williamson I, etal. Grommets (ventilation tubes) for hearing
loss associated with otitis media with effusion in children. Cochrane Database Syst Rev.
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21. Kuo CL, Tsao YH, Cheng HM, etal. Grommets for otitis media with effusion in children with
cleft palate: a systematic review. Pediatrics. 2014;134:983.
22. Davis JM, Elfenbein J, Schum R, Bentler RA.Effects of mild and moderate hearing impairments on language, educational, and psychosocial behavior of children. J Speech Hear Disord.
1986;51:53.
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24. Carney AE, Moeller MP.Treatment efcacy: hearing loss in children. J Speech Lang Hear
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25. Steele DW, Adam GP, Di M, et al. Effectiveness of tympanostomy tubes for otitis media: a
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27. Wallace IF, Berkman ND, Lohr KN, etal. Surgical treatments for otitis media with effusion: a
systematic review. Pediatrics. 2014;133:296.
28. Bluestone CD, Klein JO.Management. In: Otitis media in infants and children. 4th ed. BC
Decker: Hamilton; 2007. p.213.
29. Gravel JS, Wallace IF.Effects of otitis media with effusion on hearing in the rst 3 years of life.
J Speech Lang Hear Res. 2000;43:631.
30. Richards M, Giannoni C.Quality-of-life outcomes after surgical intervention for otitis media.
Arch Otolaryngol Head Neck Surg. 2002;128:776.
31. Rosenfeld RM, Bhaya MH, Bower CM, etal. Impact of tympanostomy tubes on child quality
of life. Arch Otolaryngol Head Neck Surg. 2000;126:585.
32. Brouwer CN, Maillé AR, Rovers MM, etal. Health-related quality of life in children with otitis
media. Int J Pediatr Otorhinolaryngol. 2005;69:1031.
33. Rosenfeld RM, Kay D.Natural history of untreated otitis media. Laryngoscope. 2003;113:1645.
34. Pichichero ME, Poole MD.Assessing diagnostic accuracy and tympanocentesis skills in the
management of otitis media. Arch Pediatr Adolesc Med. 2001;155(10):1137–42.
35. Kaleida PH.Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion. J Pediatr. 2004;145(1):138.
M. Kar et al.
Recurrent Otitis Media andHearing Loss
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inChildren
MehtapKoparal, IbrahimCukurova, VioletaMalinte,
andCodrutSarafoleanu
18.1 Introduction
When acute otitis media (AOM) recurs frequently, clinical management calls for
systemic antimicrobial pharmacotherapy. However, given the rising prevalence of
resistant pathogens, caution is advisable. Antibiotics may be administered prophylactically to prevent the recurrence of AOM.In cases where recurrent AOM leads to
discharge passing out of grommets, ear drops may be used topically. Meanwhile,
conjugated vaccines against Streptococcus pneumoniae appear to somewhat reduce
the incidence of all types of otitis media [1].
The denition of recurrent AOM in paediatric patients is three acute attacks
within the space of 6 months, or four attacks in the space of 1 year. The bacteriological features of recurrent AOM are more complicated than in its sporadic form; however, there are three pathogens that predominate in this disorder, namely
S. pneumoniae, Haemophilus inuenzae and Moraxella catarrhalis. As children
grow and approach their third or fourth birthday, recurrent AOM tends to remit
18
M. Koparal (*)
Section of Otorhinolaryngology, Adıyaman Training and Research Hospital,
Adıyaman, Türkiye
e-mail: drmehtapkoparal@gmail.com
I. Cukurova
Section of Otorhinolaryngology, Tepecik Training and Research Hospital, University of
Health Sciences, İzmir, Türkiye
e-mail: cukurova57@gmail.com
V. Malinte · C. Sarafoleanu
Department of Otorhinolaryngology, Head and Neck Surgery, Carol Davila University of
Medicine and Pharmacy, Sfanta Maria Hospital, Bucharest, Romania
e-mail: violeta_plesa@yahoo.com; csarafoleanu@gmail.com
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. E. Arısoy et al. (eds.), Hearing Loss in Congenital, Neonatal and Childhood
Infections, Comprehensive ENT, https://doi.org/10.1007/978-3-031-38495-0_18
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without intervention. However, recurrent AOM does put families under great pressure, and therefore, carers or parents frequently request prophylactic treatment. The
most frequently utilised treatment to provide both therapeutic benet and prophylaxis is the insertion of grommets [1, 2].
M. Koparal et al.
18.2 Prevalence
The frequency with which recurrent AOM (rAOM) is diagnosed differs between
generalists and specialists. General practitioners diagnosed rAOM in 27% of paediatric patients, whilst the rate amongst ENT practitioners was lower, 14%. Indeed,
when diagnosis was based upon the ndings of tympanocentesis, this rate dropped
even further, to a mere 6%. There is, however, no recommendation that tympanocentesis be performed as a routine diagnostic measure in children with suspected
otitis media [3, 4].
18.3 Risk Factors
In paediatric patients where AOM is the only type of infection to which they are
prone, there is low suspicion of severe immunodeciency. However, if rAOM is just
one infection amongst several or there are other infections from which the patient
takes an unusually long time to recover, there should be a clinical suspicion of
immunodeciency caused by reduced gamma immunoglobulins, defective granulocytic activity, abnormal cell-mediated immune responses or human immunodeciency virus [5].
Another group that are prone to recurrence of AOM are children with cleft palates, such as those with abnormal craniofacial development occurring in association
with a submucous cleft palate, as occurs in micrognathia and glossoptosis. These
abnormalities may be part of the Pierre Robin sequence or related disorders [3].
The age at which the rst attack of AOM occurs also has an effect on proneness
to recurrence. Children who have an initial attack prior to age 6months are prone to
recurrence, and the severity is greater than usual [6, 7]. One potential mechanism by
which this occurs is that an early attach creates abnormality of the auditory tube,
predisposing to future infection. Another possibility is that episodes occur early in
children with abnormal anatomy or genetic risk factors. Both mechanisms may also
be operative simultaneously [8].
The family history is also of importance, since being related to an individual
prone to recurrent or severe AOM is associated with a raised risk of both sporadic
and recurrent AOM [3].
Age also plays a role in how benecial more active interventions, such as prophylactically prescribed antimicrobials or grommet placement are in rAOM.This
increased benet occurs because AOM is more frequent in children before their
second birthday, with attacks becoming rarer as age increases in the majority of
cases [3].
18 Recurrent Otitis Media andHearing Loss inChildren
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One study looked at the frequency of AOM in children at different ages following introduction of the pneumococcal vaccine. Children aged from 6 to 11months
were twofold to threefold more prone to AOM than those aged 25–35 months.
Compared to the latter group, children between the ages of 12 and 23months are
around twice as likely to suffer an episode of AOM [9].
A recent study, by Calatayud-Sáez etal. consider diet to be a risk factor for the
recurrent otitis media. They stipulate that the mucosa covering the entire ENT area is
in a pro-inammatory and hyper-reactive state, as a repercussion of the modications
produced by a decient diet. A total of 42 boys and 48 girls, between 1 and 5years
of age, have received traditional Mediterranean diet for 1 year. The study concluded
that healthy food signicantly reduces occurrence of acute otitis media and may
contribute to the treatment of patients diagnosed with recurrent acute otitis media [10].
Seasonality There are variations in the frequency of infections by particular patho-
gens at different times of year. Having been infected on several occasions prior to
the end of November (i.e. before winter in Europe and North America) puts a child
at increased risk for the rest of the winter. Conversely, recurrent attacks by the end
of May (i.e. prior to summer above the equator) entails a lower risk for the rest of
the warmer months [3].
Siblings If patients have a sibling below the age of 5years or attend childcare, they
have a raised risk of recurrent middle ear infections [11–14].
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Premature Birth Prematurity slightly raises the risk for AOM and is a more potent
predictor of AOM in the rst few years of life than having a lower body mass than
average at birth [15].
Overall Level of Development, Especially Linguistic Children with irreversible
deafness, delay in speaking or using language (whether denitely diagnosed or
thought probable), delayed development, autistic spectrum disorder or irreversible
loss of sight all have a heightened likelihood of problems with speech and language
or intellectual development if AOM recurs [16]. This should be borne in mind when
planning whether to actively intervene.
18.4 Prevention
18.4.1 Socioeconomic Status, Breastfeeding andUse ofTobacco
by theParents
There are numerous accounts in the literature linking otitis media with socioeconomic status and deprivation, in a variety of populations [17–21]. The ndings
relate to otitis media in all its form, rather than specically to rAOM.It is unclear
exactly how greatly young children coming from deprived households with insufcient access to healthcare and where the parents lack educations are at risk of
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rAOM.One study examined a population from the Philippines where otitis media
was especially prevalent [22]. This study concluded that genetic inuences were
stronger on risk than environmental inuences. In particular, possession of a specic genotype raised the risk more than living in deprivation. Meanwhile, a Danish
study [23] has identied epidemiological features indicating a heightened risk of
middle ear infections prior to the age of 6months. Early otitis media is known to
predict the development of recurrence in AOM [24, 25].
Having at least one parent who smokes is also a recognised risk factor for developing respiratory disorders, including URTI and AOM.A study from Norway [26]
showed that mothers who smoked whilst pregnant had children with a heightened
likelihood of developing middle ear infections when very young (RR 1.34) as well
as a somewhat less raised likelihood of suffering rAOM (RR 1.24).
M. Koparal et al.
18.4.2 Genetics
It has long been recognised by clinicians treating rAOM that there is often a denite
family history of AOM.Clinically, a positive family history may be used to anticipate the likely prognosis of children with the condition, particularly the risk of
AOM becoming recurrent. It has also been shown by research that genetic factors
play a major role in middle ear infections [27–29]. Knockout mice in which the tolllike receptor 4 has been silenced are particularly prone to developing otitis media
[30, 31]. This association has now also been demonstrated in humans, from clinical
studies [32].
18.4.3 Vaccination
Whilst there has been a slight reduction in the incidence of AOM following the
introduction of conjugate vaccination against S. pneumoniae and the use of the
inuenza vaccine, a larger effect seems to have occurred in terms of prevention of
recurrence in middle ear infections and the number of procedures undertaken to
insert grommets [33].
18.4.4 The Conjugated Vaccine Against Pneumococcus (PCV)
Routine Anti-Pneumococcal Vaccination In healthcare systems with routine
anti-pneumococcal vaccination, the recommendation is for the vaccine to be administered at age 2months, then 4, 6, and 12–15months. This is the case in the United
States. The World Health Organisation has published suggested vaccination schedules for elsewhere in the world [34, 35]. Not only does the vaccine protect against
invasive infections by S. pneumoniae, it also somewhat reduces the frequency of
AOM, lowers the number of clinic attendances required, diminishes the incidence
of complications, and results in lower numbers of procedures to insert grommets [8].
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Anti-Streptococcal Polysaccharide Vaccine For paediatric patients aged over 2
years and prone to recurrence of AOM, it is recommended that they be vaccinated
with the 23-valent polysaccharide vaccine against S. pneumoniae (PPSV23). This is
in addition to the earlier vaccination with PCV13. The aim is to provide immunity
against the highest number of different serotypes of S. pneumoniae. There should be
an interval between these two vaccines of a minimum 8weeks [35].
Anti-Inuenza Vaccination There is a recommendation to administer yearly anti-
inuenza vaccination to every child aged at least 6months living in the United
States. In healthcare systems where this approach is not adopted, it may be benecial to administer anti-inuenza vaccines yearly to any child whose initial episode
of AOM was prior to the age of 6 months, or who has experienced rAOM in the
previous winter [36].
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18.5 Diagnosis
Otalgia is a common feature of upper respiratory tract infections (URTI) in children.
These are virtually invariably the result of viral infection. Erythema of the eardrum
is frequently noted, but is not pathognomonic of AOM.Unaided otoscopy is often
insufcient to diagnose AOM.A fuller picture can be obtained by pneumatic otoscopy, which tests how mobile the eardrum is. Tympanometry can also conrm
whether uid has built up in the middle ear cavity. The external auditory meatus in
infants is both oppy and narrow, with the result that the meatus must rst be cleared
of cerumen before the eardrum can be visualised. Clinicians know well from experience that cleaning the canal in a distressed baby is highly challenging. Paediatric
patients in whom rAOM has been diagnosed or where this is the likely diagnosis
frequently attend specialist otorhinolaryngological clinics. In such cases, the initial
task is to conrm if the putative diagnosis is correct [1].
In case of nasal obstruction and in case of unilateral otitis media, nasal endoscopy must be undergone, in order to assess the adenoid tissue dimensions [37].
Tonal audiometry is also recommended to be performed for the differential diagnosis (transmission or sensorineural hearing loss). Inner ear damage association
should be considered if a hearing loss greater than 50dB is found [38].
18.6 Treatment
In the majority of children with AOM, penicillin or amoxicillin/co-amoxiclav is
adequate for treatment. Recent research into the ideal treatment duration for coamoxiclav compared a 5day and 10 day course. It concluded that 10 days was
preferable [9]. This study did not comment on subgroups of patients with recurrent
AOM, and indeed, the evidence base in general for how long antimicrobial treatment should continue in middle ear infections is generally decient.
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M. Koparal et al.
Children in whom grommets have been placed frequently have ear discharge
during attacks of AOM.Some studies [39, 40] have shown that ear drops containing
steroid plus antimicrobial are usually adequate to treat AOM in such patients, and
systemic treatment is therefore not required.
Over the years, many studies have been performed regarding the use of corticoids (intranasal or systemic), for their anti-inammatory effect on the Eustachian
tube impairment [41, 42]. Recently, according to Francis etal., who developed a
prospective, double-blind, randomized clinical trial using a cohort of 389 patients
with ages between 2 and 8years, the use of systemic corticoids did not show a signicant hearing gain [43].
The easiest, cheapest, and no side effects treatment method is considered to be
the Politzer manoeuvre. Its role is to relieve the dysfunction of the Eustachian tube,
by blowing air up the nostril [44]. Even though the tonal audiometry and tympanometry results after using Politzer manoeuvre were not statistically improved,
patients considered a signicant symptoms improvement [45].
Deciding Whether to Use Watchful Waiting or More Active Management After
assessing the risks versus benets in the individual patient, on some occasions,
watchful waiting will be preferable, whilst on other occasions, a more interventional
approach will be called for [3].
A more conservative approach, including watchful waiting, is often appropriate
for paediatric patients above the age of two, provided there is no immunodeciency,
given that the frequency of AOM precipitously falls after the age of 2 years [46].
A more active approach to management may involve prescription of antimicrobials prophylactically and insertion of grommets. These interventions potentially
make attacks less frequent or at least delay them. A more aggressive approach to
managing the case is needed in children where the following features are
present [3]:
• The child is under the age of 2years. At this stage in life, hearing is especially
vital for normal linguistic development. Children whose rst episode occurs very
early warrant more aggressive management.
• There are several risk factors present, and the risk cannot otherwise be reduced.
For example, the attacks are in the peak season, and the child attends a crowded
nursery.
• There are co-morbid conditions with the potential to increase the risk of rAOM,
such as cleft palate, immotility of the cilia, decient expression of immunoglob-
ulins in general or of a particular class of antibody and craniofacial anomalies
(such as occur in Down Syndrome), or the auditory tube is prone to
dysfunction.
• There is a suspicion or an actual diagnosis of linguistic developmental delay or
any condition causing developmental delay. AOM may result in conductive-type
auditory impairment that persists long after the acute episode has resolved, and
therefore, AOM can cause disproportionate delay if not aggressively managed.
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• The tympanic membrane keeps rupturing, which may be a sign of underlying
chronic suppurative middle ear infection [47].
• The attacks are severe in nature, resulting in moderate or severe otalgia, otalgia
that lasts for more than 2 days or the temperature becomes 39°C or greater [34].
Factors to Consider in Deciding on Prophylactic Antimicrobials or Grommet
Insertion The decision to prescribe prophylactically or to insert grommets depends
on several factors, such as the prevalence of antibiotic resistance in the specic
locale, linguistic competence of the child, anaesthetic or surgical hazards, age of the
child and the priorities and wishes of the child’s family. If a child continues to suffer
from attacks of AOM despite ongoing prophylactic treatment, or is allergic to several antibiotic agents, meaning more interventions are needed, grommet insertion
may be a reasonable strategy to adopt [3].
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18.6.1 Insertion ofGrommets/Ventilatory Tubes
Ventilatory tube insertion may be appropriate in a child who has experienced at least
three separate attacks of AOM in the space of 6months, for which there is clearly
documented evidence, or at least four in the space of a year. However, the decision
to go ahead with this surgical intervention needs to take into account what risks and
advantages are involved [3].
The insertion of grommets is recommended in paediatric patients where a
more aggressive management approach is needed and in cases where
• Antimicrobial prophylaxis has not prevented rAOM.
• The parents do not wish the child to receive antimicrobials prophylactically.
• The child is allergic to more than one antimicrobial agent [3].
Potential Advantages of Grommet Insertion The procedure may make attacks
less common and milder in children prone to rAOM, although there is a lack of
conrmatory evidence for this claim. Paediatric patients with ventilatory tubes in
situ who develop AOM have a discharge from the middle ear into the external
meatus. Since the discharge is infected and can drain away, otalgia may be lessened,
and any further attacks may be milder. Furthermore, grommets may make management easier, since topical otic medications can be utilised. The subject of ear discharge through grommets has been discussed earlier [3].
Accompanying Removal of the Adenoids or Adenoids Plus Tonsils The sole
indication for performing a simultaneous adenoidectomy when inserting ventilatory
tubes is where the nasal cavity is blocked by the adenoids to at least a moderate
degree [48].
Adenoid +/− tonsil removal seems to lack efcacy as an initial treatment for
paediatric cases of rAOM [49–52]. Two RCTs were run concurrently, investigating
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outcomes in children aged between 3 and 15years and prone to recurrent middle ear
infections. The trial subjects had not previously had grommets inserted. These trials
ascertained no benet on AOM from either adenoidectomy or adenotonsillectomy,
regardless of the presence or absence of adenomegaly or tonsillomegaly [49].
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