EXPERT ROUNDTABLE: Music & Hearing | February 2017 Hearing Review

OME remains the most common infection for which antibiotics are prescribed.

Whenever the topic of hearing, music, and children are discussed, it’s essential to also consider acute otitis media (AOM) and otitis media with effusion (OME). Here is an overview of ear infections through the ages.

Acute otitis media (AOM) continues to be a common health problem, not only in the United States, but worldwide as well. It is predominantly a disease of young children. The highest incidence of otitis media occurs between the ages of 6-24 months and then decreases with advancing age.1 However, the disease does occur in older children, teens, and adults. AOM accounts for approximately 22 million visits to a physician each year in the United States.

Several risk factors have been identified over the years that affect the incidence of developing AOM. First, while it is noted that the vast majority of children who develop AOM do not have an obvious physical defect, there is an increased incidence of the disease in children with conditions that impair either the structure or function of the eustachian tube, including cleft palate, craniofacial abnormalities, and Down’s Syndrome. Impaired immunologic status, as in children with Acquired Immunodeficiency Syndrome (AIDS), can also lead to a greater risk for developing recurring AOM infections.

For reasons unknown, AOM seems to occur more often in males than in females. The age at the time of the first episode of infection (especially before 6-12 months of age) is a strong predictor of recurrent AOM. Breast feeding for 3 months or more is associated with a decreased risk of AOM in infants. Native Americans, First Nation, Alaskan, Canadian Inuit, and other aboriginal groups have a significantly higher incidence and degree of severity of otitis media.2

Placement of children in large daycare groups increases the incidence of AOM presumably from greater exposure to respiratory bacteria. Also, children in daycare not only have tend to have more episodes of AOM but also more severe cases than children in home care. Exposure to tobacco smoke, air pollution, and certain atmospheric conditions has been implicated for an increased risk as well.3

Poverty status has long been recognized as being associated with a higher incidence and severity of recurrent AOM. The likely factors involved include crowding, poor hygiene, and nutritional status, and limited access to medical care and medications. In fact, access to medical care probably accounts for the fact that those with insurance have a higher rate of recurrent AOM than those who are uninsured; the more access to medical care, the more diagnosed and documented cases.4

Although they are actually thought to be different phases of the same disease process, AOM should be distinguished from otitis media with effusion (OME). AOM is characterized by the rapid onset of inflammatory symptoms that can include otalgia, irritability, and fever, whereas there are none of these symptoms with OME.

Exam findings with AOM include middle ear effusion (MEE) associated with bulging and/or erythema of the tympanic membrane or possibly acute tympanic membrane perforation with otorhea. OME findings are that of MEE without evidence of acute inflammation as noted above. However, both share the common symptom of hearing loss directly attributable to the presence of MEE. In fact, MEE is the most common cause of hearing loss in children. It can be mild to moderate in degree, averaging around a 25 dB loss. Hearing loss may persist well after the other symptoms have resolved, as 70% of children with otitis media still have MEE 2 weeks after onset, 40% at 1 month after onset, and 10% at 3 months after onset.5

Complications of AOM can be quite severe and rarely fatal. These include infectious (acute and chronic mastoiditis, petrositis, and intracranial infection), non-infectious (tympanic membrane perforation, ossicular erosion, and tympanosclerosis), and auditory (auditory deprivation leading to delayed language development and learning disabilities, conductive and sensorineural hearing loss) complications.

While the scope of management of otitis media is beyond the scope of this article, suffice to say that the introduction of antibiotics dramatically impacted both the treatment and prognosis of children with otitis media. Before the advent of antibiotics, AOM was considered a serious disease in young children and with limited treatment options. In previous centuries the most common treatment was to apply water from the wells named after various saints.6

In 1932, AOM and its infectious complications accounted for 27% of all pediatric admissions to Bellevue Hospital. Mastoiditis and intracranial complications were common. The appearance of antibiotics markedly reduced the severity and complication rates. While severe AOM and its complications still occur today, they are mostly seen in children who have limited access to medical care.7  Furthermore, even with questions being raised today concerning whether antibiotics are needed in the initial management of uncomplicated cases, AOM remains the most common infection for which antibiotics are prescribed in children.5

References

  1. 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

  2. Klein JO. Otitis externa, otitis media, and mastoiditis. In: Mandell Dl Bennett, eds. Principles and Practice of Infectious Diseases, 8th ed. Philadelphia: Saunders, 2015: 767-773.

  3. Kim PE, Musher DM, Glezen WP, et al. Association of invasive pneumococcal disease with season, atmospheric condition, air pollution, and the isolation of respiratory viruses. Clin Infect Dis. 1996;22:100-106.

  4. Vakharia KT, Shapiro NL, Bhattacharyya N. Demographic disparities among children with frequent ear infections in the United States. Laryngoscope. 2010; 120: pp. 1667

  5. American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery,  American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. Otitis media with effusion. Pediatrics. 2004; 113: pp. 1412-1429

  6. Stephens D. ENT healing traditions of the Celtic saints. In: Pirsig W, Willemot J, Weir N, eds. Ear, Nose and Throat Mirrored in Medicine and Arts. Oostende, Belgium: G. Schmidt;2005:113.

  7. Klein JO. Is acute otitis media a treatable disease? N Engl J Med. 2011; 364:168-169.

EinhornKennethAbout the author: Kenneth Einhorn, MD, is chief of the Division of Otolaryngology at Abington Hospital in Abington, Pa, and also serves as an assistant professor in the Department of Otolaryngology at Jefferson University Hospital in Philadelphia.

CORRESPONDENCE can be addressed to Hearing Review or Dr Einhorn at: drum.ent@verizon.net

Citation for this article: Einhorn K. Ear infections over the ages. Hearing Review. 2017;24(2):18.

 

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