Otitis Media

Otitis media is the most frequently diagnosed illness among children in the United States. Otitis media with effusion (OME) or fluid in the middle ear without evidence of ear infection is one type of otitis media. OME differs from acute otitis media (AOM), where there is middle ear fluid with rapid onset of one or more signs or symptoms of middle ear inflammation. Annual healthcare costs related to the diagnosis and management of otitis media were recently estimated at $4 billion. A major reason for medical management of OME in children, including the use of tympanostomy tubes, is to prevent potential developmental consequences related to persistent OME. However, there is controversy as to whether children experiencing a history of OME in early childhood will have later language and learning difficulties.

Once OME has lasted for longer than 8 weeks, it is called chronic OME. Studies have shown that 70% of children will continue to have OME at 2 weeks, 40% at 1 month, 20% at 2 months, and 10% at 3 months after an initial episode. Risk factors for OME include being less than 2 years old, attending daycare, being exposed to passive smoke, being a member of a special population such as Down syndrome, and having craniofacial differences such as cleft palate. OME generally results in a conductive hearing loss of 25 dB HL, but the loss can range from none to 50 dB. When OME resolves, hearing will generally return to normal. Associations between OME and central auditory processing on functions believed to originate in the lower brainstem and to require equal (binaural) hearing in the two ears have been reported, although these effects resolve over a period of years. Similarly, a few studies have reported an association between OME and central auditory processing skills. However, these studies are retrospective in design and have methodological problems.

OME occurs most often during the first few years of life, a time that is critical for early language development. The mild-to-moderate hearing loss associated with an episode of OME is hypothesized to impede children's ability to process language. Children with prolonged or frequent OME are hypothesized to have delays in their comprehension and production of language, attention problems, and academic difficulties in school. Over 100 studies during the past 3 decades have examined whether children with frequent OME in early childhood score lower on measures of speech, language, and academic achievement than children without such a history.

We are conducting studies at the Frank Porter Graham Child Development Institute at the University of North Carolina. These studies will examine the linkages between OME and hearing loss in early childhood and later auditory processing, language, and academic skills. Innovative experimental studies, conducted at the University of Pittsburgh, are examining whether prompt insertion of tympanostomy tubes improved children's language development as compared to delayed insertion of tubes. These and other studies report that, on average for typically developing children, OME may not be a substantial risk factor for later speech and language development. The results of a recent meta-analysis of several studies examining OME and associated hearing loss on children's speech and language published in Pediatrics in 2004 indicated that the negative association of OME and associated hearing loss with children's later speech and language development varied from none to a very small amount. However, these findings should be interpreted cautiously, given that almost all of these studies used OME rather than hearing loss as the independent variable and many did not control for important confounding variables such as socioeconomic factors.

In May of 2004, new clinical practice guidelines for managing children between 2 months and 12 years with or without developmental disabilities were published in Pediatrics. The committee that worked on these guidelines was selected by the American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery with experts in primary care; otolaryngology; infectious diseases; epidemiology, hearing, speech and language, and advanced practice. Some of these recommendations included: a) testing hearing when OME persists for 3 months or longer, or when language delay, learning problems, or a significant hearing loss is suspected in a child with OME; b) differentiating the children with OME who are at risk for speech, language, or learning problems from other children with OME and providing for these at-risk children a more prompt evaluation of hearing, speech, and language to assess the need for intervention.

In summary, the author believes that, on average, OME may not be a substantial risk factor for later speech and language development for typically developing children. However, for some children (children from special populations and children who have experienced considerable persistent hearing loss caused by OME), a history of hearing loss due to OME may be of concern.

Joanne E. Roberts, PhD
Senior Scientist
Frank Porter Graham Child Development Institute Professor of Pediatrics
and
Speech and Hearing Sciences
Chapel Hill, NC

Bibliography

American Academy of Family Physicians, American Academy of Otolarynogology-Head and Neck Surgery, American Academy of Pediatrics Subcommittee on Otitis Media with Effusion. (2004). Clinical Practice Guideline: Otitis Media with Effusion. Pediatrics, 113(5), 1412-1429.

Paradise, J. L., Dollaghan, C. A., Campbell, T. F., Feldman, M., Bernard, B. S., Colborn, D. K., Rockette, H. E., Janosky, J. E., Pitcairn, D. L., Kurs-Lasky, M., Sabo, D. L., and Smith, C. G. (2003). Otitis Media and tympanpostomy tube insertion during the first three years of life: Developmental outcomes at age four years. Pediatrics, 112, 265-277.

Paradise, J. L., Feldman, H., M., Campbell, T. F., Dollaghan, C. A., Colborn, D. K., Bernard, B. S., Rockette, H. E., Janosky, J. E., Pitcairn, D. L., Sabo, D. L., Kurs-Lasky, M., & Smith, C. G. (2001). Effect of early or delayed insertion of tympanostomy tubes for persistent otitis media on developmental outcomes at the age of three years. New England Journal of Medicine, 344(16), 1179-1187.

Roberts, J., Hunter, L., Gravel, J., Rosenfeld, R., Berman, S., Haggard, M., Hall, J., Lannon, C., Moore, D., Vernon-Feagans, L., & Wallace, I. (2004). Otitis media, hearing loss, and language learning: Controversies and current research. Developmental and Behavioral Pediatrics, 25(2), 1-13.

Roberts, J. E., Burchinal, M. R., & Zeisel, S. A. (2002). Otitis Media in early childhood in relation to children's school-age language and academic skills. Pediatrics(110),4, 1-11.

Roberts, J. E., Rosenfeld, R. M., & Zeisel, S. A. (2004). Otitis media and speech and language: A meta-analysis of prospective studies. Pediatrics, 113(3), 237-247.

Roberts, J. E., & Zeisel, S. A. (2000). Ear infections and language development. American Speech-Language-Hearing Association and the National Center for Early Development and Learning. US Department of Education.

Questions

• Does a history of OME causes later speech, language, leaning, auditory processing, and learning difficulties?
• How do you manage a child with persistent OME?
• When should a child with persistent OME be referred to an otolaryngologist?

This article first appeared in the Vol. 3, No. 6, November/December 2004 issue of Access Audiology.