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Rate of Concurrent Otitis Media in Upper Respiratory Tract Infections with Specific Viruses

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Rate of Concurrent Otitis Media in Upper Respiratory Tract Infections with Specific Viruses ORIGINAL ARTICLE Rate of Concurrent Otitis Media in Upper Respiratory Tract Infections With Specific Viruses Cuneyt M. Alper, MD; Birgit Winther, MD, PhD; Ellen M. Mandel, MD; J. Owen Hendley, MD; William J. Doyle, PhD Objective: To estimate the coincidence of new otitis me- Results: A total of 176 children (81%) had isolated PCR dia (OM) for first nasopharyngeal detections of the more detection of at least 1 virus. The OM coincidence rates common viruses by polymerase chain reaction (PCR). were 62 of 144 (44%) for rhinovirus, 15 of 27 (56%) for New OM episodes are usually coincident with a viral up- respiratory syncytial virus, 8 of 11 (73%) and 1 of 5 (20%) per respiratory tract infection (vURTI), but there are con- for influenza A and B, respectively, 6 of 12 (50%) for ad- flicting data regarding the association between specific enovirus, 7 of 18 (39%) for coronavirus, and 4 of 11 (36%) viruses and OM. for parainfluenza virus detections (P=.37). For rhinovi- rus, new OM occurred in 50% of children with and 32% Design: Longitudinal (October-March), prospective fol- without a concurrent CLI (P=.15), and OM risk was pre- low-up of children for coldlike illness (CLI) by diary, middle dicted by OM and breastfeeding histories and by daily ear status by pneumatic otoscopy, and vURTI by PCR. environment outside the home. Setting: Academic medical centers. Conclusions: New OM was associated with nasopha- ryngeal detection of all assayed viruses irrespective of Participants: A total of 102 families with at least 2 chil- the presence or absence of a concurrent CLI. Differ- dren aged between 1 and 5 years (213 children; mean [SD] ences among viruses were noted, but statistical signifi- age, 3.7 [1.5] years; 110 male; and 176 white) were recruited cance was not achieved, possibly because of the low from the local communities at 2 study sites by advertisement. power associated with the small number of nonrhinovi- rus detections. Main Outcome Measures: New OM and CLI epi- sodes and nasopharyngeal virus detections. Arch Otolaryngol Head Neck Surg. 2009;135(1):17-21 T IS WELL ACCEPTED THAT MOST versely, that 20% to 40% of CLIs are as- new episodes of otitis media sociated with OM.8-11 Other studies (OM) are temporally coincident reported the recovery of virus, virus pro- with viral upper respiratory tract tein, and viral genomic sequences from the infections (vURTIs),1 and experi- middle ear in subjects with new-onset mental evidence supports causality for this symptomatic OM (acute OM [AOM]) or I 2-4 relationship. vURTIs may or may not persistent OM and related these findings present with a sign-symptom constella- to viral infection of the middle ear mu- tion recognized as a coldlike illness (CLI), cosa as the cause of those episodes.12-16 and the results of some studies show that However, this interpretation can be ques- Author Affiliations: a CLI is not a prerequisite for the devel- tioned based on the results of other stud- Department of Otolaryngology, opment of OM.5,6 Because vURTIs with- ies that reported recovery from the middle Children’s Hospital of out CLI expression do not present clini- ear of genomic sequences for viruses that Pittsburgh and the University of cally, most estimates of the frequency of do not infect the upper respiratory tract Pittsburgh School of Medicine, all OM episodes attributable to vURTIs are but rather establish a persistent infection Pittsburgh, Pennsylvania calculated as the number of OM episodes in other cell types (eg, human immuno- (Drs Alper, Mandel, and Doyle); and Departments of divided by the number of CLI episodes and deficiency virus, Epstein-Barr virus, cyto- Otolaryngology (Dr Winther) therefore are biased. megalovirus, varicella-zoster virus, and 17,18 and Pediatrics (Dr Hendley), Past studies report that more than 50% herpes virus). University of Virginia Health of all new OM episodes in children are tem- Perhaps as a consequence of the wide va- System, Charlottesville. porally associated with a CLI,6,7 and con- riety of study formats used to estimate (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 135 (NO. 1), JAN 2009 WWW.ARCHOTO.COM 17 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 OM-vURTI coincidence in children, the literature is in- servation time, both ears were examined by a validated otoscopist consistent with respect to the relative importance of the and classified as to the presence or absence of OM based on different vURTI viruses.7,8,12,16,19-22 However, because most ratings of the tympanic membrane with respect to visibility, con- interventions that are potentially useful in preventing new dition, position, appearance, color, vascularity, light reflex, and OM during a vURTI are virus specific, unbiased esti- mobility. A positive diagnosis for OM was made when middle ear effusion (with or without air-fluid level) was observed ir- mates of virus-specific OM risk are needed.1,8 This study respective of the presence or absence of concurrent signs of addresses that need using a longitudinal format with high- middle ear infection. Acute OM was diagnosed by the pres- density assessments for detection of OM, CLI, and naso- ence of OM with concurrent signs of middle ear infection in- pharyngeal virus in a large group of unselected children. cluding parental report of ear pulling, otalgia, irritability, and The null hypothesis tested is that the new OM coinci- fussiness and otoscopic signs of erythema and/or white opaci- dence rate of a vURTI is not virus specific. Acceptance or fication (other than from scarring) of the tympanic mem- rejection of this hypothesis is important for developing ra- brane, bulging or fullness of the tympanic membrane, or otor- tional strategies to prevent that complication. rhea from a perforation of a previously intact tympanic membrane. Otitis media with effusion (OME) was assigned to OM episodes without concurrent signs of infection. Episodes METHODS of AOM but not OME were treated empirically with antibiot- ics. Because otoscopy was not necessarily performed at a time The data for this report were abstracted from those available for when the child first presented with otologic symptoms (the chil- the first 4 years of an ongoing, 5-year study designed to charac- dren were seen and treated by their primary care physician for terize the causal relationships among vURTIs, CLIs, and OM in most illnesses), subclassification of OM for this report was bi- young children. The protocol was approved by the institutional ased to OME assignment. review boards at the University of Pittsburgh and the University Otoscopic data were coded for the left and right ears as OME of Virginia. Families at 2 study sites (Pittsburgh, Pennsylvania, present or absent (0=absent; 1=present), and AOM present or and Charlottesville, Virginia) with 2 children aged between 1 and absent (0=absent; 2=present). Between otoscopic assess- 5 years were recruited for participation by advertisement. Ex- ments, daily OM assignment for each ear was made based on clusion criteria included the presence in either child of a seri- that at the preceding visit, to yield a string of observations for ous medical condition, a medical condition that predisposes to each day of the study period. A new OME episode was defined persistent OM, a nonintact or structurally abnormal tympanic as a sequence of 1s preceded and followed by a sequence of 0s, membrane, a preexisting sensorineural hearing loss, or an in- and an episode of AOM was defined as a newly introduced string ability to cooperate sufficiently with the examination and test of 2s, irrespective of preceding and subsequent observations. procedures. After affirmation of willingness to participate and In the analysis, the child was considered to be the unit of mea- acquisition of written informed consent, families were entered sure, and either new unilateral or bilateral OM episodes were into the study in October with an anticipated follow-up through assigned as a new OM episode. April of that year and were reimbursed for participation. The study The technique for collecting nasal secretions from the chil- subjects included the 2 index children and any older siblings dren and the methods and protocols for storage and transport younger than 10 years who provided assent. of the specimens to the virology laboratory were previously de- The data for this report consist of demographic information scribed.24 Samples were assayed in batches for PCR detection of for each child (age, sex, and race), information on selected OM adenovirus, coronavirus, influenza virus A and B, parainflu- risk factors (history of OM, frequent colds, breastfeeding, and enza virus, rhinovirus (picornavirus), and respiratory syncytial exposure to tobacco smoke and the child’s daily environment virus (RSV) using a protocol adapted from the commercially avail- for a subset of children [those enrolled at the Pittsburgh site in able Hexaplex procedure (Prodesse Inc, Waukesha, Wiscon- years 1-4 and at the Charlottesville site in years 2-4]),23 the lon- sin) as described in previous publications.6 Each viral species was gitudinal daily assignments of the presence or absence of a CLI assigned a numeric code, and the temporal distribution for these day as recorded by a parent and weekly assignments of the pres- codes was overlaid onto the sequence strings for CLI and new ence or absence of OM as assessed by bilateral pneumatic otos- OM episodes. Detections of the same virus within a 20-day pe- copy performed by validated study personnel. These data were riod and without an intermittent observation of a different vi- supplemented with virus detections by polymerase chain reac- rus or “no detectable virus” were linked as a single virus detec- tion (PCR) assay of nasal secretions collected from the children tion.
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