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Clinical Review Otitis Media

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Clinical Review Otitis Media Clinical Review Otitis Media Jack Froom, MD Stony Brook, New York The spectrum of otitis media includes acute and chronic forms, each of which can be either suppurative of nonsuppurative. In the usual clinical setting distinctions between these several forms can be difficult. Determination of accurate incidence fig­ ures is impeded by the unavailability of universally accepted diagnostic criteria. Risk factors include season of the year, genetic factors, race, preceding respiratory tract infections, cleft palate, and others. The effect of household size and al­ lergy are uncertain. The most common infecting organisms are Streptococcus pneumoniae and Hemophilus influenzae, al­ though in a significant number of cases either the fluid is non- pathogenic or no organisms can be isolated. The effects of several therapies are reviewed, including antibiotics, myrin­ gotomy, steroids, and middle-ear ventilating tubes. Otitis media is one of the most frequent condi­ Incidence tions treated by family physicians and pediatricians. Otitis media ranks as the ninth most frequently Yet there are no standard criteria for diagnosis, made diagnosis for all ambulatory patient visits. In artd several issues regarding therapy are contro­ 1977 it accounted for approximately 11 million vis­ versial. The use of antihistamines, decongestants, its to physicians in the United States.1 For approx­ myringotomy, and even antibiotics are matters of imately one half of these visits the problem was contention, and the current roles of tympanometry new. Although these data give some indication of and tympanostomy tubes need clarification. The the ubiquitous nature of the problem, they do not purpose of this paper is to provide recommenda­ permit calculation of annual incidence by age and tions for diagnosis and management based on re­ sex. The several studies that do report incidence, ports in the literature, tempered by the author’s unfortunately, are not comparable because the personal experience and judgment. diagnostic criteria used either are not defined or differ among the several investigators. Often the patient population at risk is unknown. Neverthe­ less, a review of these publications permits an es­ timate of incidence. The annual incidence of otitis media varies with From the Department of Family Medicine, State University age, with some investigators reporting peaks in the of New York at Stony Brook, Stony Brook, New York. Re­ quests for reprints should be addressed to Dr. Jack Froom, 0- to 1-year-old group2,3 and others in the 5- to Department of Family Medicine, Health Sciences Center, 6-year-old group.4,5 In the 0- to 1-year-old group State University of New York at Stony Brook, Stony Brook, NY 11794. Continued on page 745 0094-3509/82/080743-10S02.50 c 1982 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 15, NO. 4: 743-770, 1982 743 OTITIS MEDIA Continued from page 743 mer.2,5,9 There are two conflicting reports on the effect of household size in relation to attack rate, attack rates vary between 13.7 percent5 and 47 with one study showing a higher frequency in large percent,6 and in the 6-year-old group an annual households as opposed to smaller ones,6 and the incidence of up to 20.8 percent5 has been reported. other reporting the opposite.7 The relative risk in Although patients aged 15 years and over have a relation to household size is therefore uncertain. much lower annual incidence (0.6 percent5 to 1.1 Both studies, however, found an increased risk in percent7), the age distribution of patients in most siblings or other family members of affected chil­ family practices is such that about 20 percent of all dren. The paucity of investigations on the relation­ cases seen will be from this age group.7 ship between household size and family factors to Boys are affected more often than are girls in otitis media indicates a need for additional studies the younger age groups,7,8 but women predomi­ of these variables. nate among adults.7 Multiple episodes during There is some evidence that race may be a fac­ a one-year period are frequent, affecting from 14 tor. Teele and colleagues6 report a higher inci­ percent5 to 47 percent8 of children who have had dence in Hispanics than in whites, with the lowest at least one attack and 2.1 percent5 to 4 percent7 incidence among blacks. Suppurative otitis media of adult cases. Initial attacks prior to age 12 is a major problem in native American Indians and to 13 months predispose children to subsequent Alaskan and Canadian Eskimos.1012 Whether var­ attacks.2,3 iations in attack rates relate to racial differences Studies from the United Kingdom4,5 report both in the anatomical structure of the middle ear or are a lower incidence and a lower recurrence rate than primarily a manifestation of associated socio­ do United States investigators.2,79 In addition, economic, environmental, and cultural factors is between 20 percent4 and 30 percent5 of patients unknown. in English practices have purulent drainage from Rhinitis appears to be a frequent preceding the ears when first seen, as opposed to 6 percent7 event. Almost 50 percent of attacks follow an in practices in the United States. Data to explain upper respiratory tract infection.5 The effect of these differences are lacking. It is possible, how­ allergy, however, is uncertain. Dees and Lefko- ever, that there are differences in patient behav­ witz13 studied 130 children with recurrent secre­ iors concerning physician visits or in treatments tory otitis media and found that 55.5 percent had given to the two patient populations. Antibiotics allergic rhinitis, 23 percent had asthma, and 6 per­ may be used more liberally by American physi­ cent had other allergic manifestations. In contrast, cians than by their English colleagues (Fry rec­ two recent studies failed to demonstrate a relation­ ommends against their routine use4), and it may be ship between allergies and secretory otitis media.14,15 that English patients wait longer from the onset of Breast feeding may protect against otitis media. ear pain to make a visit to their physician than do When compared with bottle-fed infants, breast-fed their American counterparts. Delay prior to ther­ babies had significantly fewer episodes of all in­ apy and infrequent use of antibiotics could result fectious illnesses, including otitis media.16 In a in an increased frequency of ruptured tympanic study of 536 adult Eskimos, an inverse relation­ membranes. ship between a history of prolonged breast feeding for more than 12 months and chronic middle ear disease was demonstrated.11 The mechanism by which breast feeding protects children from otitis Risk Factors media is not entirely clear. There are several pos­ Several risk factors have been identified, but sible factors. One is the effect of bottle feeding the contribution each makes to producing an in the horizontal position as opposed to the more infection is uncertain. Some reports implicate sea­ upright position maintained during breast feeding. son of year, household size, genetic factors, race, Duncan17 coined the term positional otitis media, allergy, position while feeding, preceding respira­ and studies by him and later by Beauregard18 dem­ tory tract infections, cleft palate, and others. onstrated a relationship between otitis media and The frequency of otitis media attacks is highest during the winter months and lowest in the sum­ Continued on page 750 THE JOURNAL OF FAMILY PRACTICE, VOL. 15, NO. 4, 1982 745 OTITIS MEDIA Continued from page 745 In addition, differences in secretory cells, immuno­ globulins, and chemical indicators of inflammation feeding in the supine position. Swallowing while were noted between these several groups.27 horizontal presumably facilitates the reflux of milk The utility of Senturia’s classification has not into the middle ear. An angled-neck bottle has been demonstrated in clinical settings. Most phy­ been proposed to encourage the upright position sicians make the distinction only between acute during feeding.19 Breast feeding may also be pro­ purulent otitis media and secretory otitis media. tective by the transmission of antibodies. Finally, Acute purulent otitis media is thought to be caused feeding cow’s milk may contribute to infection by by bacteria and precede the development of secre­ the production of milk allergy in the infant. tory otitis. Even these distinctions are not without Additional, but less common, risk factors are problems because ear fluid from purulent otitis cleft palate, in which condition otitis media virtual­ may be sterile and secretions from some cases of ly always occurs,20 and Down’s syndrome, in secretory otitis can contain bacteria. In addition, which 60 percent of children studied were found to secretory otitis media can occur without a docu­ have middle ear effusions.21 mented preceding episode of purulent middle ear infection. Pathogenesis Eustachian tube malfunction is believed to be Infecting Organisms the principle mechanism in the production of mid­ Klein28 compiled several reports of organisms dle ear effusions. Although the obstruction may be isolated from middle ear fluid from a total of 3,583 either functional or mechanical, functional causes children with acute otitis media from the United appear to be more important.22'24 Functional ob­ States, Finland, and Sweden. The distribution of struction can result from either structural abnor­ infecting organisms is given in Table 1. malities of the tube or abnormal tensor tympanic Although Streptococcus pneumoniae continues muscle function, which produces increased com­ to be the most frequently isolated organism, pliance or a “floppy tube.”22 Mechanical obstruc­ Hemophilus influenzae, formerly thought to be tion may be either intrinsic, as from inflammation, mostly limited to children under the age of five or extrinsic, as from hypertrophic adenoid tissue. years, appears to be increasing in frequency in the The viscosity of the effusion is an additional older age groups.29 The etiologic role of Neisseria important factor.
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