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Persistent Otitis Media with Effusion: Can It Be Predicted?

A Family Practice Follow-up Study in Children Aged 6 Months to 6 Years

* BACKGROUND Otitis media with effusion (OME) has a high rate of spontaneous resolution, and a policy of waiting and watching for 3 months is justified. The decision about further treatment should be individualized, depending on duration and symptoms. Knowledge of the determinants for persistent OME would be helpful for identifying patients with a need for active treatment or increased monitoring for complications.

* METHODS A total of 433 children aged 6 months to 6 years were monitored for 3 months in the offices of 57 family physicians. A questionnaire pertaining to determinants was completed. The outcome measures were: presence of unilateral or bilateral OME or bilateral OME after 3 months. The outcome was determined on the basis of tympanometry results. We performed bivariate and multivariate analyses.

* RESULTS The presence of an upper respiratory tract infection (URTI) at the follow-up visit was associated with finding OME at that visit. When a URTI was present, no other determinants for persistent OME were found. When absent, the determinants for persistent bilateral OME were: no history of adenoidectomy, an episode of acute otitis media (AOM) in the first year of life, and month of entry into the study (June-November). For persistent unilateral or bilateral OME, the only significant determinant was an episode of AOM in the first year of life.

* CONCLUSIONS Children with 1 or more of the following factors need special attention for prevention of the sequelae of persistent OME: no history of adenoidectomy, AOM in the first year of life, and the presence of bilateral OME in the period between June and November.

* KEY WORDS Otitis media; otitis media with effusion; child; risk factors; family practice. (J Fam Pract 2000; 49:605-611)

In 1976, Paradise[1] concluded that uncertainty and controversy prevail over the choice and timing of treatment of otitis media with effusion (OME). Now, more than 20 years later, important issues of prognosis and treatment of persistent OME still have not been solved. The costs of medical and surgical treatment for OME are high.[2] There is great concern regarding the worldwide problem of multiply resistant strains of bacteria,[3] and some authors believe that many patients with OME are overtreated with antibiotics.[4,5] Considering the natural course of the disease, the introduction of a waiting period before surgery and restriction of treatment to those cases with sequelae may be cost-effective.[6-8] The duration of this waiting period and the criteria for selecting those cases that should be actively followed up are not yet clear.[9-13] Persistent OME may have functional effects on hearing and cognitive-linguistic development and behavior. The identification of a set of determinants for persistent OME would help physicians identify patients who need further monitoring or treatment. Studies looking at factors associated with persistent OME show conflicting results, and none has been carried out in a family practice population. The only 2 factors on which there is agreement are young age and attendance at a daycare center.[7,14-16] The effect of other factors on the natural course of OME is not known.[15-17] In addition, such studies are difficult to compare because different criteria are used for the diagnosis of OME, and the study populations differ.[7,14,15,17-22]

Most children with OME are initially seen in a primary care setting where a policy of "watchful waiting"[23,24] is feasible. Since there have been no previous studies of factors associated with persistent OME in family practice settings, we addressed the issue.

METHODS

Subjects

Between December 1992 and August 1993, 57 family physicians selected children aged 6 months to 6 years whom they suspected of having middle ear effusion in both ears (bilateral OME) for tympanometry. Only children with bilateral OME were selected, since these are the only cases for which the Dutch College of Family Physicians recommends active treatment.[25] The selection criteria were based on complaints frequently associated in the literature with the occurrence of OME, including: subjective or objective hearing loss, language and speech problems, mouth breathing and snoring, a history of recurrent upper respiratory tract infection (URTI), a family history of otitis media, and acute otitis media (AOM) 6 weeks previously.[16,26,27] Children with a history of the following were excluded: antimicrobial therapy in the preceding 6 weeks, compromised immunity, craniofacial abnormalities, Down syndrome, or cystic fibrosis.

Design

After informed parental consent, a questionnaire covering demographic data and past and present history was completed, and an ear, nose, and throat (ENT) examination, including tympanometry (Welch-Allyn microtymp I), was performed. If the diagnosis of bilateral OME was confirmed, the children were entered into the study and asked to return after 3 months. No treatment for their ear problem was given.

At the 3-month follow-up visit, any current symptoms were recorded and another ENT examination, including tympanometry, was carried out. All tympanograms were printed out and classified by the first author (FvB).

Outcome Measures

Two outcome measures were studied: the presence of bilateral OME in those children who still had it at the 3-month follow-up examination, and unilateral or bilateral OME in all children with OME, whether unilateral or bilateral, at the follow-up examination.

Definitions

OME was defined as the presence of fluid in the middle ear cavity behind an intact tympanic membrane without signs or symptoms of acute infection. The presence of middle ear effusion was defined by the C2-curve and the B-curve because of their high positive predictive values (88% and 54%, respectively).[28,29] Recurrent URTI was defined as 6 or more episodes of a common cold or nasal catarrh in the past 12 months, each episode not exceeding 4 weeks. Recurrent AOM was defined as 3 or more episodes in the past 12 months. A child failed the Ewing test if he or she did not respond to the sound stimuli in any of the tests. Bottle feeding meant that no breastfeeding had been used at all.

Statistical Analysis

Bivariate analyses were carried out to test the association between determinants and outcome assessed at the 3-month follow-up visit. The strengths of the associations were expressed as odds ratios with 95% confidence interval limits.[30] Associations were also tested by chi-square analysis. All factors showing a P value equal to or less than 0.2, and all factors that were clinically relevant were subjected to logistic regression analysis.[31] The goal of the regression analysis was to find a set of determinants for persistent OME. From those factors that were significant we derived a prediction score by adding the betas (eg, prediction score=[[Beta].sub.factor1]+[[Beta].sub.factor2]+[[Beta].sub.factor3]).[31] The discriminating ability of these predictions was assessed by means of receiver operating characteristic curve analysis. The size of the area under the curve (AUC) is a measure for the discriminating capability, the ability to separate patients into groups classified according to the determinants.[32] A test that does not discriminate will have an AUC of 0.5; a perfect test will have an AUC of 1.0.

RESULTS

A total of 593 children were suspected of having bilateral OME at the initial visit, but the tympanograms were normal for 82 (14%), and no classifiable tympanogram could be obtained for 11 (2%). Sixteen of the remaining 500 children were excluded because they had been given an antibiotic in the preceding 4 weeks, and the parents of 51 children refused consent. Thus a total of 433 children (73%) were included in our study. Eighty children (18%) had more than 3 entry criteria, and 231 (53%) had more than 2. The most common combinations of complaints were subjective hearing loss with recurrent URTI (19%) and subjective hearing loss with mouth breathing and snoring (14%).

Twelve children failed to attend the 3-month follow-up visit, and in 24 no classifiable tympanogram could be obtained (Figure). We excluded these 36 children from the 3-month follow-up as they did not differ significantly from the evaluation group in respect to sex, age, month of entry, presence of URTI at the initial visit, or complaints at entry. Of the remaining 397 children (92%), 223 (56%) still had C2-typanogram and B-tympanogram in both ears, 81 (20%) in one ear, and 93 (24%) had A-tympanogram or C1-tympanogram. Patient characteristics at the initial visit are shown in Table 1 (Please see pages 609 -611 for all tables.)

FIGURE

Eligible

500 patients with bilateral OME

[down arrow]

Excluded

16 patient on exclusion criteria 51 patients' parents refused consent

[down arrow]

Enrolled

433 patients with bilateral OME

[down arrow]

Drop Out

12 patients lost to follow-up 24 patients no interpretable tympanograms

[down arrow]

3 Months' Watchful Waiting

233 patients with bilateral OME 81 patients with unilateral OME 93 patients no OME

OME denotes otitis media with effusion.

TABLE 1 Patients Characteristics
                            INITIAL VISIT   AFTER 3 MONTHS
                               (N=433)          (N=397)

CHARACTERISTIC                 NO. (%)        NO. (%)

Men                          230   (53)      213   (54)
Aged <3 years                104   (24)      104   (26)
URTI at initial visit        196   (45)      173   (44)
Study entry June-November    129   (30)      116   (29)
Hearing loss                 316   (73)      290   (73)
Language/speech problem       49   (11)       41   (10)
Mouth breathing/snoring       96   (22)       88   (22)
Referred hearing loss         36    (8)       32    (8)
Recurrent URTI               166   (38)      150   (38)
AOM previous 6 weeks          45   (10)       40   (10)
Family history positive       57   (13)       45   (11)


URTI denotes upper respiratory tract infection;

AOM, acute otitis media.

Persistent Bilateral OME

Table 2 shows the results of the bivariate analysis of determinants for persistent bilateral OME. Entry into the study between June and November showed a weak association (P=.05). The presence of AOM or URTI during the examination showed a strong association with bilateral OME (P=.005 and P [is less than] .001, respectively).

TABLE 2 Determinants for Persistent Bilateral OME
VARIABLE                   A(*)/NOME+([dagger])

Age < 3 years                     60/223
Male                             114/223
Study entry June to Nov           74/223
Hearing loss, subjective         161/223
Language/speech problem           25/223
Mouth breathing/snoring           51/223
Referred hearing loss             16/223
Recurrent URTI                    85/223
Family history present            28/223
AOM 6 weeks ago                   22/223
AOM in first year (yes)           61/207
AOM at baseline (yes)             12/220
URTI at baseline (yes)            99/215
History of OME (yes)              87/208
Myringotomy (yes)                 21/211
Ewing test (failure)              38/171
No adenoidectomy                 201/220
Recurrent AOM                     60/218
Allergy                           23/211
Bottle feed                       82/213
Breastfeed (>3 months)            65/127
Swimming (>1/week)                40/219
Daycare (attending)               71/220
Parents smoking                  102/219
<3 rooms/house                   104/213
>3 children/household            181/217
Not being first born             117/219
URTI at follow-up visit           82/218
AOM at follow-up visit            16/218

VARIABLE                   B(*)/NOME-([dagger])    OR

Age < 3 years                      44/174         1.09
Male                               99/174         0.79
Study entry June to Nov            42/174         1.56
Hearing loss, subjective          129/174         0.91
Language/speech problem            16/174         1.25
Mouth breathing/snoring            37/174         1.10
Referred hearing loss              16/174         0.76
Recurrent URTI                     65/174         1.03
Family history present             17/174         1.33
AOM 6 weeks ago                    18/174         0.95
AOM in first year (yes)            37/153         1.31
AOM at baseline (yes)              13/169         0.69
URTI at baseline (yes)             74/167         1.07
History of OME (yes)               67/149         0.88
Myringotomy (yes)                  17/157         0.91
Ewing test (failure)               22/137         1.49
No adenoidectomy                  144/166         1.62
Recurrent AOM                      44/267         1.06
Allergy                            15/163         1.21
Bottle feed                        67/162         0.89
Breastfeed (>3 months)              55/93         0.72
Swimming (>1/week)                 27/171         1.19
Daycare (attending)                56/170         0.97
Parents smoking                    72/171         1.20
<3 rooms/house                     67/167         1.42
>3 children/household             139/170         1.12
Not being first born               86/168         1.09
URTI at follow-up visit            26/166         3.25
AOM at follow-up visit              2/168         6.51

VARIABLE                    95% CI     P ([double dagger])

Age < 3 years              0.69-1.71          .72
Male                       0.53-1.18          .25
Study entry June to Nov    0.98-2.50          .05
Hearing loss, subjective   0.58-1.42          .66
Language/speech problem    0.64-2.42          .51
Mouth breathing/snoring    0.68-1.77          .70
Referred hearing loss      0.37-1.57          .46
Recurrent URTI             0.69-1.56          .87
Family history present     0.70-2.57          .38
AOM 6 weeks ago            0.49-1.83          .87
AOM in first year (yes)    0.81-2.11          .26
AOM at baseline (yes)      0.31-1.56          .37
URTI at baseline (yes)     0.71-1.61          .73
History of OME (yes)       0.57-1.35          .55
Myringotomy (yes)          0.46-1.80          .78
Ewing test (failure)       0.83-2.67          .32
No adenoidectomy           0.81-3.25          .15
Recurrent AOM              0.67-1.67          .80
Allergy                    0.61-2.40          .56
Bottle feed                0.58-1.35          .57
Breastfeed (>3 months)     0.42-1.24          .24
Swimming (>1/week)         0.70-2.04          .52
Daycare (attending)        0.63-1.49          .89
Parents smoking            0.80-1.79          .37
<3 rooms/house             0.94-2.15          .09
>3 children/household      0.52-1.51          .95
Not being first born       0.73-1.64          .66
URTI at follow-up visit    1.92-5.53         <.001
AOM at follow-up visit     1.41-41.6          .005


OME denotes odds ratio;

CI, confidence interval;

URTI, upper respiratory infection;

AOM, acute otitis media.

(*) Number of children with prognostic factors present.

([dagger]) Total number of children with OME present (+) or absent (-).

([double dagger]) Tested by chi square.

Table 3 shows the results of the logistic regression analysis. Only no adenoidectomy showed any influence on the duration of OME (P [is less than] .05). The presence of AOM or URTI at the follow-up visit was associated with bilateral OME (P [is less than] .05 and P [is less than] .001, respectively). Because of the influence of URTI on OME, logistic regression analysis was carried out both with and without URTI at the follow-up visit. When URTI was present no determinants were found. When it was absent, the following 3 determinants were prognostic of bilateral OME: (1) no adenoidectomy (P [is less than] .05; adjusted odds ratio [OR]=2.75; 95% confidence interval [CI], 1.22-6.20); (2) an episode of AOM in the first year of life (P [is less than] .05; adjusted OR=1.59; 95% CI, 1.03-2.46); and (3) entry into the study between June and November (P [is less than] .05; adjusted OR=2.07; 95% CI, 1.11-3.86). No good set of discrimant factors was found when adding together the [Beta] coefficients for an episode of URTI and AOM on follow-up, no adenoidectomy, and an episode of AOM in the first year of life (AUC=0.61; standard error [SE]=0.029).

TABLE 3 Logistic Regression Analysis of Prevalence of Persistent Bilateral OME
                          ADJUSTED
VARIABLE                     OR        95% CI       P

Age                         1.06     0.59-1.90     .86
Sex                         0.79     0.49-1.25     .31
Study entry June to Nov     1.59     0.94-2.67     .08
AOM at initial visit        0.49     0.19-1.29     .15
URTI at initial visit       1.11     0.68-1.81     .69
Recurrent URTI              0.95     0.56-1.61     .85
Recurrent AOM               0.88     0.55-1.41     .60
Daycare                     1.03     0.63-1.69     .91
<3 rooms/house              1.59     0.97-2.60     .06
Hearing                     1.01     0.57-1.80     .97
AOM at follow-up            5.35     1.10-26.05    .04
URTI at follow-up           2.81     1.61-4.90    <.001
No adenoidectomy            2.01     1.05-3.85     .04
Allergy                     0.90     0.72-1.12     .35
AOM episode in the
  first year of life        1.24     0.89-1.73     .21


OME denotes otitis media with effusion;

OR, odds ratio;

CI, confidence interval;

AOM, acute otitis media;

URTI, upper respiratory tract infection.

Persistent Unilateral or Bilateral OME

Table 4 shows the results of the bivariate analysis of determinants for persistent unilateral or bilateral OME. Absence of AOM at initial visit, attending daycare and less than 3 rooms in the house showed a weak association. The presence of URTI during examination was again associated with the presence of middle ear effusion.

TABLE 4 Determinants for Persistent Bilateral OME
VARIABLE                   A(*)/NOME+([dagger])

Age <3 years                    60/223
Male                           114/223
Study entry June to Nov         74/223
Hearing loss, subjective       161/223
Language/speech problem         25/223
Mouth breathing/snoring         51/223
Referred hearing loss           16/223
Recurrent URTI                  85/223
Family history present          28/223
AOM 6 weeks ago                 22/223
AOM in first year (yes)         61/207
AOM at baseline (yes)           12/220
URTI at baseline (yes)          99/215
History of OME (yes)            87/208
Myringotomy (yes)               21/211
Ewing test (failure)            38/171
No adenoidectomy               201/220
Recurrent AOM                   60/218
Allergy                         23/211
Bottle feed                     82/213
Breastfeed (>3 months)          65/127
Swimming (>1/week)              40/219
Daycare (attending)             71/220
Parents smoking                102/219
<3 rooms/house                 104/213
>3 children/household          181/217
Not being first born           117/219
URTI at follow-up visit         82/218
AOM at follow-up visit          16/218

VARIABLE                   B(*)/NOME-([dagger])   OR

Age <3 years                       44/174         1.09
Male                               99/174         0.79
Study entry June to Nov            42/174         1.56
Hearing loss, subjective          129/174         0.91
Language/speech problem            16/174         1.25
Mouth breathing/snoring            37/174         1.10
Referred hearing loss              16/174         0.76
Recurrent URTI                     65/174         1.03
Family history present             17/174         1.33
AOM 6 weeks ago                    18/174         0.95
AOM in first year (yes)            37/153         1.31
AOM at baseline (yes)              13/169         0.69
URTI at baseline (yes)             74/167         1.07
History of OME (yes)               67/149         0.88
Myringotomy (yes)                  17/157         0.91
Ewing test (failure)               22/137         1.49
No adenoidectomy                  144/166         1.62
Recurrent AOM                      44/267         1.06
Allergy                            15/163         1.21
Bottle feed                        67/162         0.89
Breastfeed (>3 months)              55/93         0.72
Swimming (>1/week)                 27/171         1.19
Daycare (attending)                56/170         0.97
Parents smoking                    72/171         1.20
<3 rooms/house                     67/167         1.42
>3 children/household             139/170         1.12
Not being first born               86/168         1.09
URTI at follow-up visit            26/166         3.25
AOM at follow-up visit              2/168         6.51

VARIABLE                   95% CI      P([double dagger])

Age <3 years               0.69-1.71          .72
Male                       0.53-1.18          .25
Study entry June to Nov    0.98-2.50          .05
Hearing loss, subjective   0.58-1.42          .66
Language/speech problem    0.64-2.42          .51
Mouth breathing/snoring    0.68-1.77          .70
Referred hearing loss      0.37-1.57          .46
Recurrent URTI             0.69-1.56          .87
Family history present     0.70-2.57          .38
AOM 6 weeks ago            0.49-1.83          .87
AOM in first year (yes)    0.81-2.11          .26
AOM at baseline (yes)      0.31-1.56          .37
URTI at baseline (yes)     0.71-1.61          .73
History of OME (yes)       0.57-1.35          .55
Myringotomy (yes)          0.46-1.80          .78
Ewing test (failure)       0.83-2.67          .32
No adenoidectomy           0.81-3.25          .15
Recurrent AOM              0.67-1.67          .80
Allergy                    0.61-2.40          .56
Bottle feed                0.58-1.35          .57
Breastfeed (>3 months)     0.42-1.24          .24
Swimming (>1/week)         0.70-2.04          .52
Daycare (attending)        0.63-1.49          .89
Parents smoking            0.80-1.79          .37
<3 rooms/house             0.94-2.15          .09
>3 children/household      0.52-1.51          .95
Not being first born       0.73-1.64          .66
URTI at follow-up visit    1.92-5.53         <.001
AOM at follow-up visit     1.41-41.6          .005


OME denotes odds ratio;

CI, confidence interval;

URTI, upper respiratory infection;

AOM, acute otitis media.

(*) Number of children with prognostic factors present.

([dagger]) Total number of children with OME present (+) or absent (-).

([double dagger]) Tested by chi square.

Logistic regression analysis (Table 5) showed a significant association with the absence of AOM at the initial visit (P [is less than] .05) and with URTI at the follow-up visit (P=0.001). The analysis was repeated again with and without URTI at the follow-up visit. In the presence of URTI no determinants were found; in the absence of URTI an episode of AOM in the first year of life showed a significant association (P [is less than] .05; adjusted OR=1.69; 95% CI, 1.15-2.49). Again, no good set of discrimant factors was found by adding the [Beta] coefficients of AOM at initial visit, history of AOM in the first year of life, daycare, and URTI at the follow-up visit (AUC=0.65; SE=0.03).

TABLE 5 Logistic Regression Analysis of Prevalence of Persistent Unilateral or Bilateral OME
VARIABLE                                      ADJUSTED OR

Age                                               0.88
Sex                                               0.89
Study entry June to Nov                           1.73
AOM at initial visit                              0.36
URTI at initial visit                             1.56
Recurrent URTI                                    0.78
Recurrent AOM                                     0.77
Daycare                                           1.62
[is greater than or equal to] 3 rooms/house       1.57
Hearing                                           1.44
AOM at follow-up visit                            5.73
URTI at follow-up visit                           3.53
No adenoidectomy                                  1.43
Allergy                                           0.95
AOM episode in first year of life                 1.36

VARIABLE                                       95% CI        P

Age                                           0.45-1.73    .71
Sex                                           0.52-1.53    .68
Study entry June to Nov                       0.92-3.27    .09
AOM at initial visit                          0.13-0.96    .04
URTI at initial visit                         0.88-2.77    .13
Recurrent URTI                                0.42-1.44    .42
Recurrent AOM                                 0.45-1.32    .35
Daycare                                       0.89-2.96    .12
[is greater than or equal to] 3 rooms/house   0.88-2.79    .13
Hearing                                       0.75-2.77    .27
AOM at follow-up visit                        0.61-53.80   .13
URTI at follow-up visit                       1.66-7.49    .001
No adenoidectomy                              0.78-2.61    .25
Allergy                                       0.74-1.23    .69
AOM episode in first year of life             0.93-1.98    .11


OME denotes otitis media with effusion;

OR, odds ratio;

CI, confidence interval;

AOM, acute otitis media;

URTI, upper respiratory tract infection.

DISCUSSION

Our entry criteria detected a high percentage (84%) of patients with bilateral OME. The presence of more than 1 criterion in the same child had no effect on the duration of OME. Our data show a strong association between the presence of AOM or URTI during examination and the finding of middle ear effusion. In the absence of URTI, the following were associated with persistent bilateral OME: no adenoidectomy, an episode of AOM in the first year of life, and entry into the study between June and November. An episode of AOM in the first year of life was associated with persistent unilateral or bilateral OME. It was not possible to construct a discriminant model prognostic of persistent bilateral or unilateral or bilateral OME as the AUCs of 0.61 and 0.65, respectively, were rather low.

A possible weak point in this study is that our results are based on tympanometry outcome after a 3-month interval. The 36 children excluded from the 3-month follow-up did not differ significantly from those included, so their exclusion probably had no influence on the results.

Some of the determinants identified in this study are closely related to URTI. For instance we found a weak association between attending daycare and persistent unilateral or bilateral OME in bivariate analysis, but this association disappeared in the logistic regression analysis. This could be explained by the close relationship between attending daycare and URTI-related factors in the occurrence of OME. This close association between OME and URTI has been reported before.[33] The finding of this relationship suggests that occurrence of middle ear effusion during an URTI episode is a physiologic phenomenon, probably caused by eustachian tube obstruction and needing no further treatment. If this is true, children with URTI-related OME need only close follow up and no active treatment.

The factors of no adenoidectomy, early episodes of AOM, and the prevalence of bilateral OME during the months June to November were found in the absence of URTI and suggest a different, more pathophysiologic relationship with OME than when OME is found with URTI. As adenoid size seems not to be correlated with the pathogenesis of OME,[34] the association with no adenoidectomy supports the viewpoint that the adenoids are an important factor in OME by providing an infectious focus in the nasopharynx or by their influence on the immunological status of the nasopharynx.[34-36]

The association between AOM early in life and persistence of OME has been reported previously.[37] Children with early AOM episodes are frequently known as "otitis-prone."[38] They also have more recurrent AOM episodes and more episodes of URTI than average.

The exact relationship between AOM and OME is not known. AOM may precede OME, but it is also more frequent in patients with OME.[39] Several studies have reported an association between OME and winter or early spring. This is probably the result of the increased incidence of URTI during this Season. The period between June and November (summer and early autumn) is less likely to be associated with frequent episodes of URTI. Contrary to the findings of other studies, we found no association between age younger than 3 years and persistent OME.[40]

In our study we found that factors associated with persistent OME differ from those that increase the risk for occurrence of OME (attending daycare, bottle feeding, passive smoking).(*) This is an important finding. First, the absence or presence of the determinants for persistent OME may affect the choice of treatment. A more active attitude is needed if there is a higher chance for sequelae, such as language delay caused by conductive hearing loss, atelectasis of the tympanic membrane, and cholesteatoma, as is the case in persistent OME. In the absence of determinants for persistent OME a more watchful policy may be followed, especially if the child has no severe hearing loss, does not suffer from recurrent AOM episodes, and has no tympanic membrane abnormalities. This would lead to a reduction of overtreatment and to cost reduction. In the presence of determinants for persistent OME, children should be monitored more closely. When sequelae such as language delay or recurrent episodes with AOM are present, active treatment with antibiotics, tympanostomy tub insertion,[5,9] or adenoidectomy[34-36] is needed. We also feel that future research should be focused on the pathophysiological group of otitis-prone children and not on all children with OME. If we are capable in differentiating between those children who need further treatment from those children in whom OME is a physiological reaction on a URTI, overtreatment and costs may be greatly reduced.

ACKNOWLEDGMENTS

We thank Dr F.W.M.M. Touw-Otten who contributed much to this study but passed away in 1997. We also thank Dr H. de Glanville for his critical review of this paper.

(*) Additional tables relating to the factors for persistent OME are available on the Journal's Web site, www.jfampract.com

REFERENCES

[1.] Paradise JL. Pediatrician's view of middle-ear effusions: more questions than answers. Ann Otol Rhinol Laryngol 1976; 85(suppl):20-24.

[2.] Stool SE, Field MJ. The impact of otitis media. Pediatr Infect Dis J 1989; 8:S11-14.

[3.] de Melker RA, van Balen FAM. Antimicrobial treatment of upper respiratory tract infections from the Dutch perspective. Int J Antimicrob Agents 1997; 9:43-48.

[4.] Maw AR. Using tympanometry to detect glue ear in general practice: overreliance will lead to overtreatment. BMJ 1992; 304:67-68.

[5.] Schilder AGM. Long-term effects of otitis media with effusion in children [dissertation]. Nijmegen, the Netherlands: Katholieke Universiteit Nijmegen; 1993.

[6.] ZielLuis GA, Straatman H, Rach GH, van den Broek P. Analysis and presentation of data on the natural course of otitis media with effusion in children. Int J Epidemiol 1990; 19:1037-44.

[7.] Fiellau-Nikolajsen M. Tympanometry and secretory otitis media: observations on diagnosis, epidemiology, treatment and prevention in prospective cohort studies of three-year-old children. Acta Otolaryngol 1983; 394:1-73.

[8.] Berman S, Roark R, Luckey D. Theoretical cost effectiviness of management options for children with persisting middle ear effusions. Pediatrics 1994; 93:353-63.

[9.] Stool SE, Berg AO, Berman S, et al. Otitis media with elfusion in young children. Clinical Practice Guideline No. 12. AHCPR Publication No 94-0622. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; 1994.

[10.] University of Leeds. Effective health care: the treatment of persistent glue ear in children. Bulletin no. 4. Leeds, England: University of Leeds; 1992.

[11.] de Melker RA. Treating persistent glue ear in children. BMJ 1993; 306:5-6.

[12.] Tos M. Epidemiology and natural history of secretory otitis. Am J Otol 1984; 5:459-62.

[13.] Klein JO, Teele DW, Pelton SI. New concepts in otitis media: results of the investigations of the Greater Boston Otitis Media Study Group. Adv Pediatr 1992; 39:127-56.

[14.] Shurin PA, Pelton SI, Donner A, Klein JO. Persistence middle-ear effusion after acute otitis media in children. N Engl J Med 1979; 300:1121-23.

[15.] van Cauwenberge PB. Relevant and irrelevant predisposing factors in secretory otitis media. Acta Otolaryngol 1984; 414 (suppl):147-53.

[16.] Haggard MP, Hughes E. Screening children's hearing: a review of the literature and implications of otitis media. London, England: HMSO Books; 1991.

[17.] Kraemer MJ, Richardson MA, Weiss NS, et al. Risk factors for persistent middle-ear effusions. JAMA 1983; 249:1022-25.

[18.] Black N. The aetiology of glue ear: a case-control study. Int J Pediatr Otorhinolaryngol 1985; 9:121-33.

[19.] Bartolozzi G, Sacchetti A, Scarane P, Becherucci P. Natural history of otitis media with effusion in children under six years of age. In: Galioto GB, ed. Tonsils: a clinically oriented update. Adv Otorhinolaryngol 1992; 47:281-83.

[20.] Birch L, Elbrond O. Prospective epidemiological study of secretory otitis media in children not attending kindergarten: a prevalence study. Int J Pediatr Otorhinolaryngol 1986; 11:191-97.

[21.] Marchant CD, Shurin PA, Turczyk VA, Wasikowski DE, Tutihasi MA, Kinney SE. Course and outcome of otitis media in early infancy: a prospective study. J Pediatr 1984; 104:826-31.

[22.] Zielhuis GA, Rach GH, van den Broek P. Predisposing factors for otitis media with effusion in young children. Adv Otorhinolaryngol 1988; 40:65-69.

[23.] de Melker RA. Diagnostic value of microtympanometry in primary care. BMJ 1992; 304:96-98.

[24.] van Balen FAM, de Melker RA, Touw-Otten FWMM. Double-blind randomised trial of co-amoxiclav versus placebo for persistent otitis media with effusion in general practice. Lancet 1996; 348:713-16.

[25.] van de Lisdonk EH, Appelman CLM, Bossen PC, Dunk JHM, de Melker RA, van Weert HCPM. NHG-standaard otitis media met effusie bij kinderen. Huisarts en Wet 1991; 34:426-29.

[26.] Tos M, Poulsen G, Borch J. Etiologic factors in secretory otitis. Arch Otolaryngol 1979; 105:582-88.

[27.] Williamson IG, Dunleavey J, Robinson D. Riskfactors in otitis media with effusion. A 1-year case control study in 5-7 year old children. Fam Pract 1994; 11:271-74.

[28.] Balen FAM van, Melker KA de. Validation of a portable tympanometer for use in primary care. Int J Pediatr Otorhinolaryngol 1994; 29:219-26.

[29.] Jerger J. Clinical experience with impedance audiometry. Arch Otolaryngol 1970; 92:311-24.

[30.] Altman DG. Practical statistics for medical research. New York, NY: Chapman and Hall; 1991.

[31.] Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research: principles and quantitative methods. New York, NY: Van Nostrand Reinhold; 1982.

[32.] van der Schouw YT, Verbeek ALM, Ruys JHJ. ROC-curves for the initial assessment of new diagnostic tests. Fam Pract 1992; 9:506-11.

[33.] Daly K, Giebink GS, Le CT, et al. Determining risk for chronic otitis media with effusion. Pediatr Infect Dis J 1988; 7:471-75.

[34.] Gates GA, Muntz HR, Gaylis B. Adenoidectomy and otitis media. Ann Otol Rhinol Laryngol 1992; 101:24-32.

[35.] Sade J, Luntz M. Adenoidectomy in otitis media: a review. Ann Otol Rhinol Laryngol 1991; 100:226-31.

[36.] Linder TE, Marder HP, Munzinger J. Role if adenoids in the pathogenesis of otitis media: abacteriologic and immunohistochemical analysis. Ann Otol Rhinol Laryngol 1997; 106:619-23.

[37.] Appelman CLM, Claessen JPQJ. Recurrent otitis media: a contribution to answering the question how to treat acute otitis media [dissertation]. Utrecht, the Netherlands: University of Utrecht; 1992

[38.] Howie VM, Ploussard JH, Sloyer J. The `otitis-prone' condition. Am J Dis Child 1975; 129:676-78.

[39.] Stangerup SE, Tos M. The etiologic role of acute suppurative otitis media in chronic secretory otitis. Am J Otol 1985; 6:126-31.

[40.] 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: 83-94.

* Submitted, revised, May 18, 2000. From the Department of Family Practice, University of Utrecht. Reprint requests should be addressed to F.A.M. van Balen, MD, PhD, Department of Family Practice, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands. E-mail: F.A.M.VanBalen@med.uu.nl.

F.A.M. VAN BALEN, MD, PHD, AND R.A. DE MELKER, MD, PHD Utrecht, the Netherlands
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Author:VAN BALEN, F.A.M.; DE MELKER, R.A.
Publication:Journal of Family Practice
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Date:Jul 1, 2000
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