PUBLIC HEALTH BRIEFS
The Epidemiology of Recurrent Otitis Media DANIEL K. ONION, MD, MPH, AND COLLEEN TAYLOR, RN, PNA
Introduction Otitis media is a very common diagnosis in a primary care practice. The use of antibiotics has markedly diminished complications of the disease. However, one-half the patients experience a temporary hearing deficit after other signs have cleared, and 10 per cent experience a permanent hearing loss of 15 decibels or more. 1 Such hearing losses can diminish school performance significantly.2 Recent evidence indicates that prophylactic antibiotics can decrease the number of acute otitis media episodes in high risk children.3' This new possibility of preventive intervention suggests a potential utility for epidemiologic data on recurrent otitis. Which children with an episode of acute otitis media are at high risk for recurrence and for how long? Adding to our previously published experience with otitis media in children,5 this report includes 165 children each followed for 12 months.
Methods We included all local children with acute otitis media seen by one of us (CT) over a fourteen-month period in the study as index episodes. To make the diagnosis, we required at least an inflamed, dull tympanic membrane with poor pneumatic movement in a compatible clinical setting. We excluded cases with a perforated drum. Recurrent episodes were diagnosed by us or other members of our group practice using the same criteria, in children whose ear(s) had previously returned to normal by pneumatic otoscopic exam. All cases received oral antibiotics for ten days. Children under one year were treated with ampicillin alone (125 mg tid for 10 days); those ages one to four with ampicillin and a decongestant (Pseudoephedrine hydrochloride (Sudafed)). If a possible history of penicillin allergy was elicited, erythromycin was substituted and sulfisoxazole also added if the child was under age four. All cases were re-examined at two weeks. If the inflammation and/or dullness had not resolved, or if the drum's pneumatic movement was poor, then the patient was asked to return in another week. At that time (21 days after initial diagnosis), if the ear was still abnormal, the patient was referred to an ear-nose-throat (ENT) physician. Because the out-of-area otolaryngologist performed follow-up care, 14 children referred to him were dropped from the study. From the Rural Health Associates, Farmington, ME. Address reprint requests to Dr. D. K. Onion, Associate Medical Director, Rural Health Associates, North Main Street, Farmington, ME 04938. This paper, submitted to the Journal September 23, 1976, was revised and accepted for publication January 18, 1977. 472
Screening audiometric testing was performed in children over age four, two weeks after initial diagnosis. If abnormal, these audiograms were repeated at three months and if still abnormal, the child was then referred to an ENT physician. The audiograms were performed by a public health nurse using an Maico Audiometer calibrated in ANSI at frequencies between 1000 and 4000 cps. Children were judged to have an abnormal test and hearing loss if they had a 30 decibels or greater loss at any of the tested frequencies. Patients were asked to bring prescription bottles with them to the two-week follow-up appointment. Compliance in taking the prescribed medicines was estimated from the unused amount. After tabulating data for two years, we have examined the first 12 months experience of each of the 165 children with an index episode. Most patients returned to the same provider (CT) when recurrent illness occurred. However, we reviewed the charts of and telephoned all patients we had not seen. Our recurrence estimates include all medically attended illness. Statistical tests for significant differences in recurrence rates between males and females were performed using a two-tailed binomial test of the difference between two proportions.
Results Most (72 per cent) of the children were under age four (Figure 1). Males outnumbered females in all but the eight to nine age group; the overall male/female ratio was 1.35. Males
10+
0
Li Females
8-9
?A
EL 6-7 x
>
4-5 2-3
4
L
0-1 0
8
.
20 28 40 48 60 68
0%
20%
40%
60%
Percentage of Study Children Number of Children in Study Having an Index Episode
Having One or More Recurrent Episodes Within 12 Months of The Index Episode
FIGURE 1-Distribution of Children with Acute Otitis Media
Recurrent episodes (Table 1) were strikingly frequent in our population; nearly one-half the children with an index episode had at least one recurrence within the one year follow-up period. Males had significantly more recurrent episodes and ENT referrals than females (p < .05). Of the chilAJPH May, 1977, Vol. 67, No.5
PUBLIC HEALTH BRIEFS TABLE 1-Total Recurrent Episodes in Study Group in One Year
Total Males Females Male/Female Ratio
Index Episodes
1 or more Recurrences #/# at risk
2 or more Recurrences #/# at risk
3 or more Recurrences #/# at risk
ENT Referral #/# at risk
165 95 70
76/161 = 47% 48/92 = 52% 28/69 = 41%
29/158 = 18% 23/90 = 26% 6/68 = 9%
8/153 = 5% 7/86 = 8% 1/67 = 1.5%
14/165 = 8% 11/95 = 12% 3/70 = 4%
1.35
1.28
2.89
5.45
2.70
dren who had a recurrent episode within the year, 40 per cent had it within two months and 60 per cent within four months of the index episode. (Figure 2) Hearing was tested in 65 of the 69 episodes of otitis media in children over age four. Five (8 per cent) of these children had a deficit after two weeks of treatment; and four at three months. Only one of these children had normal appearing ears at the time the abnormal hearing test was found. The abnormalities of an acute otitis media episode had cleared in 92 per cent at the two-week re-examination; 97 per cent of episodes had cleared by three weeks. Ninety per cent of the children received over 90 per cent of the prescribed medicine by bottle check at two weeks.
Discussion Our finding that otitis media occurs predominantly in younger children is consistent with other American impressions4 and studies2' 6. 12 but not British data7 in which school
30 4._ U
_ '0-C
Liii:
20
Males Females
o Oe @
C
Q
10
z
100% ,s 4-
X
80%
o- 2 CD
N eA X-
0
60%
C. CJ DK
40%
a) CC-
age children are reported more often afflicted. Likewise the male predominance has frequently been found in surveys of otitis media;4' 8-10 young males are generally reported more susceptible to many infections for unclear reasons.1' The male/female ratio in our practice in those under 14 years is 1.06; thus the practice does not contain more males. Our data suggest that recurrent episodes are very common especially within the first four months after an episode of otitis media. We did not observe a decreasing incidence of recurrence with age as reported by others.4 13 However, our numbers in the older age groups are small. We did not find an increasing incidence of recurrent episodes in children with previous episodes. Instead it appears that with any given episode of otitis one may expect a 30-50 per cent chance of recurrent episodes in that child within the year. Because we did not tap the middle ear we have undoubtedly treated some sterile ears with antibiotics. However, middle ear aspiration is an impractical diagnostic procedure in a primary practice's care of otitis media.6 The data thus pool viral, sterile, and bacterial episodes of otitis. This or more extensive follow-up may explain the greater frequency of recurrence in this study than in others.7' 14 Hearing loss in our patients old enough to test, rarely occurred without associated abnormalities visible in the ear, as reported by others.'5 Since we referred patients with persistently abnormal appearing ears to ENT physicians, our referral rate (8 per cent) probably can be compared to the higher hearing loss rates reported in many studies. " 7. 16. 18 Our patients seem quite similar to those in whom Perrin, et al.4 found prophylactic sulfisoxazole to be an effective way of preventing recurrent otitis media. It is not unreasonable to speculate that a transient hearing loss after acute episodes of otitis media may cause transient learning problems.2' 4 '9 Since our data show that 60 per cent of the recurrent episodes in a year follow-up period occur within four months, we recommend a study to evaluate the efficacy of prophylactic antibiotics for at least four months in children under age seven, and especially boys, who present with an episode of acute otitis media.
> = 4-
,a
._$
L
20%
Summary 0% 0
2
8 10 6 12 Months FIGURE 2-Recurrences versus Time from Index Episode Calendar Months after Index Episode
AJPH May, 1977, Vol. 67, No. 5
4
Nearly one-half of 165 children with episodes of acute otitis media had at least one recurrent acute episode within the year. Males had significantly more recurrences. Most (60 per cent) of the recurrent episodes occurred within four 473
PUBLIC HEALTH BRIEFS
months of the index episdde. Hearing loss persisted beyond two weeks in 8 per cent of testable children. This experience suggests that prophylactic antibiotic use within the first few months after an episode of acute otitis media in young children should be evaluated.
REFERENCES 1. Olmsted, R. W., Alvarez, M. C., Moroney, J. D., et al. The pattern of hearing following acute Otitis Media. J. Peds. 65:252255, 1964. 2. Kaplan, G. J., Fleshman, J. K., Bender, T. R., et al. Long-term effects of Otitis Media; a ten-year cohort study of Alaskan eskimo children. Peds 52:577-585, 1973. 3. Maynard, J. E., Fleshman, J. K., Tschopp, C. F. Otitis Media in Alaskan eskimo children; Prospective evaluation of chemoprophylaxis. JAMA 219:597-667, 1974. 4. Perrin, J. M., Charney, E., MacWhinney, J. B., Jr. et al. Sulfisoxazole as chemoprophylaxis for recurrent Otitis Media: A double-blind cross-over study in pediatric practice. N. Engl. J. Med. 291:664-667, 1974. 5. Taylor, C., Onion, D. K. The first six months after Otitis Media; a preliminary report. J. ME Med. Assoc. 66:280-281, 1975. 6. Howie, V. M., Ploussard, J. H. Efficacy of fixed combination antibiotics versus separate components in Otitis Media. Clin. Peds. 11:204-205, 1972. 7. Medical Research Council: Acute Otitis Media in General Practice: Report of a survey by the Medical Research Council's working party for research in general practice. Lancet:510-514, 1957. 8. Stickler, G. B., McBean, J. B. The treatment of acute Otitis Media in children: a second clinical trial. JAMA 187:85-89, 1964. 9. Stickler, G. B., Rubenstein, M. M., McBean, J. B., et al. Treatment of acute Otitis Media in children: A fourth clinical trial. Amer. J. Dis. Child 114:123-130, 1967.
I
10. Bass, J. W., Cashman, T. M., Frostad, A. L., et al. Antimicrobials in the treatment of acute otitis media. Amer. J. Dis. Child 125:397-402, 1973. 11. Washburn, T. C., Medearis, D. N., Childs, B. Sex differences in susceptibility to infections. Peds. 35:57-64, 1%5. 12. Howie, V. M., Plossard, J. H., Lester, R. L. Otitis Media: A clinical and bacteriological correlation. Peds. 45:29-35, 1970. 13. Reed, D., Dunn, W. Epidemiologic studies of Otitis Media among Eskimo children. Pub Hlth Report 85:699-706, 1970. 14. Fry, J. Antibiotics in acute tonsillitis and acute Otitis Media. Brit Med J:883-886, 10/11/58. 15. Rubenstein, M. M., McBean, J. B., Hedgecock, L. D., et al. The treatment of acute Otitis Media in children: A third clinical trial. Amer. J. Dis. Child 109:308-313, 1965. 16. Lowe, J. F., Bamforth, J. S., Pracy, R. Acute Otitis Media: One year in a general practice. Lancet: 1129-1132, 1963. 17. Reed, D., Struve, S., Maynard, J. E. Otitis Media and hearing deficiency among Eskimo children: A cohort study. Amer. J. Public Health 57:1657-1662, 1967. 18. Fry, J., Jones, R. F. M., Dillane, J. B., et al. The outcome of acute Otitis Media (a report to the Medical Research Council). Brit. J. Prev. Soc. Med. 23:205-209, 1969. 19. Holm, V. A., Kunze, L. H. Effect of chronic Otitis Media on language and speech development. Peds 43:833-839, 1969.
ACKNOWLEDGMENTS The authors wish to thank Margaret Reed, RN, Public Health Nurse of the town of Farmington, Maine, for performing the screening audiology tests; James Couser, Chairman and Associate Professor of Mathematics at the University of Maine at Farmington, for assistance in performing statistical tests; and Sharon Chiasson for help in tabulation of the data. We are also indebted to Drs. L. George Ray, Martin Myers, Evan Charney, and Loring Pratt for critical review of the manuscript.
Municipal Laboratories
A short article by Dr. Park, Commissioner ofHealth at Rockford, Illinois, deals with the purpose and value of a municipal laboratory. He closes with these words of advice to city governments: "Do not be deceived into thinking that this is a subject that has been overdrawn. Remember that it is war-grim, bloody war-between the armies of Life and those of Death. Cities which yearly spend thousands upon thousands of dollars for such luxuries as parks and libraries, should not turn a wry face when the question of appropriating for a laboratory comes up. "Let not the laboratory be considered merely the study-room ofthe impractical, pedantic savantlet it rather be the battlefield upon which the shining sword ofSciencefightsfor human life and health." Public Health Notes, In Am. J. Public Health 3:837, 1913.
474
AJPH May, 1977, Vol. 67, No. 5
The Epidemiology of Recurrent Otitis Media DANIEL K. ONION, MD, MPH, AND COLLEEN TAYLOR, RN, PNA
Introduction Otitis media is a very common diagnosis in a primary care practice. The use of antibiotics has markedly diminished complications of the disease. However, one-half the patients experience a temporary hearing deficit after other signs have cleared, and 10 per cent experience a permanent hearing loss of 15 decibels or more. 1 Such hearing losses can diminish school performance significantly.2 Recent evidence indicates that prophylactic antibiotics can decrease the number of acute otitis media episodes in high risk children.3' This new possibility of preventive intervention suggests a potential utility for epidemiologic data on recurrent otitis. Which children with an episode of acute otitis media are at high risk for recurrence and for how long? Adding to our previously published experience with otitis media in children,5 this report includes 165 children each followed for 12 months.
Methods We included all local children with acute otitis media seen by one of us (CT) over a fourteen-month period in the study as index episodes. To make the diagnosis, we required at least an inflamed, dull tympanic membrane with poor pneumatic movement in a compatible clinical setting. We excluded cases with a perforated drum. Recurrent episodes were diagnosed by us or other members of our group practice using the same criteria, in children whose ear(s) had previously returned to normal by pneumatic otoscopic exam. All cases received oral antibiotics for ten days. Children under one year were treated with ampicillin alone (125 mg tid for 10 days); those ages one to four with ampicillin and a decongestant (Pseudoephedrine hydrochloride (Sudafed)). If a possible history of penicillin allergy was elicited, erythromycin was substituted and sulfisoxazole also added if the child was under age four. All cases were re-examined at two weeks. If the inflammation and/or dullness had not resolved, or if the drum's pneumatic movement was poor, then the patient was asked to return in another week. At that time (21 days after initial diagnosis), if the ear was still abnormal, the patient was referred to an ear-nose-throat (ENT) physician. Because the out-of-area otolaryngologist performed follow-up care, 14 children referred to him were dropped from the study. From the Rural Health Associates, Farmington, ME. Address reprint requests to Dr. D. K. Onion, Associate Medical Director, Rural Health Associates, North Main Street, Farmington, ME 04938. This paper, submitted to the Journal September 23, 1976, was revised and accepted for publication January 18, 1977. 472
Screening audiometric testing was performed in children over age four, two weeks after initial diagnosis. If abnormal, these audiograms were repeated at three months and if still abnormal, the child was then referred to an ENT physician. The audiograms were performed by a public health nurse using an Maico Audiometer calibrated in ANSI at frequencies between 1000 and 4000 cps. Children were judged to have an abnormal test and hearing loss if they had a 30 decibels or greater loss at any of the tested frequencies. Patients were asked to bring prescription bottles with them to the two-week follow-up appointment. Compliance in taking the prescribed medicines was estimated from the unused amount. After tabulating data for two years, we have examined the first 12 months experience of each of the 165 children with an index episode. Most patients returned to the same provider (CT) when recurrent illness occurred. However, we reviewed the charts of and telephoned all patients we had not seen. Our recurrence estimates include all medically attended illness. Statistical tests for significant differences in recurrence rates between males and females were performed using a two-tailed binomial test of the difference between two proportions.
Results Most (72 per cent) of the children were under age four (Figure 1). Males outnumbered females in all but the eight to nine age group; the overall male/female ratio was 1.35. Males
10+
0
Li Females
8-9
?A
EL 6-7 x
>
4-5 2-3
4
L
0-1 0
8
.
20 28 40 48 60 68
0%
20%
40%
60%
Percentage of Study Children Number of Children in Study Having an Index Episode
Having One or More Recurrent Episodes Within 12 Months of The Index Episode
FIGURE 1-Distribution of Children with Acute Otitis Media
Recurrent episodes (Table 1) were strikingly frequent in our population; nearly one-half the children with an index episode had at least one recurrence within the one year follow-up period. Males had significantly more recurrent episodes and ENT referrals than females (p < .05). Of the chilAJPH May, 1977, Vol. 67, No.5
PUBLIC HEALTH BRIEFS TABLE 1-Total Recurrent Episodes in Study Group in One Year
Total Males Females Male/Female Ratio
Index Episodes
1 or more Recurrences #/# at risk
2 or more Recurrences #/# at risk
3 or more Recurrences #/# at risk
ENT Referral #/# at risk
165 95 70
76/161 = 47% 48/92 = 52% 28/69 = 41%
29/158 = 18% 23/90 = 26% 6/68 = 9%
8/153 = 5% 7/86 = 8% 1/67 = 1.5%
14/165 = 8% 11/95 = 12% 3/70 = 4%
1.35
1.28
2.89
5.45
2.70
dren who had a recurrent episode within the year, 40 per cent had it within two months and 60 per cent within four months of the index episode. (Figure 2) Hearing was tested in 65 of the 69 episodes of otitis media in children over age four. Five (8 per cent) of these children had a deficit after two weeks of treatment; and four at three months. Only one of these children had normal appearing ears at the time the abnormal hearing test was found. The abnormalities of an acute otitis media episode had cleared in 92 per cent at the two-week re-examination; 97 per cent of episodes had cleared by three weeks. Ninety per cent of the children received over 90 per cent of the prescribed medicine by bottle check at two weeks.
Discussion Our finding that otitis media occurs predominantly in younger children is consistent with other American impressions4 and studies2' 6. 12 but not British data7 in which school
30 4._ U
_ '0-C
Liii:
20
Males Females
o Oe @
C
Q
10
z
100% ,s 4-
X
80%
o- 2 CD
N eA X-
0
60%
C. CJ DK
40%
a) CC-
age children are reported more often afflicted. Likewise the male predominance has frequently been found in surveys of otitis media;4' 8-10 young males are generally reported more susceptible to many infections for unclear reasons.1' The male/female ratio in our practice in those under 14 years is 1.06; thus the practice does not contain more males. Our data suggest that recurrent episodes are very common especially within the first four months after an episode of otitis media. We did not observe a decreasing incidence of recurrence with age as reported by others.4 13 However, our numbers in the older age groups are small. We did not find an increasing incidence of recurrent episodes in children with previous episodes. Instead it appears that with any given episode of otitis one may expect a 30-50 per cent chance of recurrent episodes in that child within the year. Because we did not tap the middle ear we have undoubtedly treated some sterile ears with antibiotics. However, middle ear aspiration is an impractical diagnostic procedure in a primary practice's care of otitis media.6 The data thus pool viral, sterile, and bacterial episodes of otitis. This or more extensive follow-up may explain the greater frequency of recurrence in this study than in others.7' 14 Hearing loss in our patients old enough to test, rarely occurred without associated abnormalities visible in the ear, as reported by others.'5 Since we referred patients with persistently abnormal appearing ears to ENT physicians, our referral rate (8 per cent) probably can be compared to the higher hearing loss rates reported in many studies. " 7. 16. 18 Our patients seem quite similar to those in whom Perrin, et al.4 found prophylactic sulfisoxazole to be an effective way of preventing recurrent otitis media. It is not unreasonable to speculate that a transient hearing loss after acute episodes of otitis media may cause transient learning problems.2' 4 '9 Since our data show that 60 per cent of the recurrent episodes in a year follow-up period occur within four months, we recommend a study to evaluate the efficacy of prophylactic antibiotics for at least four months in children under age seven, and especially boys, who present with an episode of acute otitis media.
> = 4-
,a
._$
L
20%
Summary 0% 0
2
8 10 6 12 Months FIGURE 2-Recurrences versus Time from Index Episode Calendar Months after Index Episode
AJPH May, 1977, Vol. 67, No. 5
4
Nearly one-half of 165 children with episodes of acute otitis media had at least one recurrent acute episode within the year. Males had significantly more recurrences. Most (60 per cent) of the recurrent episodes occurred within four 473
PUBLIC HEALTH BRIEFS
months of the index episdde. Hearing loss persisted beyond two weeks in 8 per cent of testable children. This experience suggests that prophylactic antibiotic use within the first few months after an episode of acute otitis media in young children should be evaluated.
REFERENCES 1. Olmsted, R. W., Alvarez, M. C., Moroney, J. D., et al. The pattern of hearing following acute Otitis Media. J. Peds. 65:252255, 1964. 2. Kaplan, G. J., Fleshman, J. K., Bender, T. R., et al. Long-term effects of Otitis Media; a ten-year cohort study of Alaskan eskimo children. Peds 52:577-585, 1973. 3. Maynard, J. E., Fleshman, J. K., Tschopp, C. F. Otitis Media in Alaskan eskimo children; Prospective evaluation of chemoprophylaxis. JAMA 219:597-667, 1974. 4. Perrin, J. M., Charney, E., MacWhinney, J. B., Jr. et al. Sulfisoxazole as chemoprophylaxis for recurrent Otitis Media: A double-blind cross-over study in pediatric practice. N. Engl. J. Med. 291:664-667, 1974. 5. Taylor, C., Onion, D. K. The first six months after Otitis Media; a preliminary report. J. ME Med. Assoc. 66:280-281, 1975. 6. Howie, V. M., Ploussard, J. H. Efficacy of fixed combination antibiotics versus separate components in Otitis Media. Clin. Peds. 11:204-205, 1972. 7. Medical Research Council: Acute Otitis Media in General Practice: Report of a survey by the Medical Research Council's working party for research in general practice. Lancet:510-514, 1957. 8. Stickler, G. B., McBean, J. B. The treatment of acute Otitis Media in children: a second clinical trial. JAMA 187:85-89, 1964. 9. Stickler, G. B., Rubenstein, M. M., McBean, J. B., et al. Treatment of acute Otitis Media in children: A fourth clinical trial. Amer. J. Dis. Child 114:123-130, 1967.
I
10. Bass, J. W., Cashman, T. M., Frostad, A. L., et al. Antimicrobials in the treatment of acute otitis media. Amer. J. Dis. Child 125:397-402, 1973. 11. Washburn, T. C., Medearis, D. N., Childs, B. Sex differences in susceptibility to infections. Peds. 35:57-64, 1%5. 12. Howie, V. M., Plossard, J. H., Lester, R. L. Otitis Media: A clinical and bacteriological correlation. Peds. 45:29-35, 1970. 13. Reed, D., Dunn, W. Epidemiologic studies of Otitis Media among Eskimo children. Pub Hlth Report 85:699-706, 1970. 14. Fry, J. Antibiotics in acute tonsillitis and acute Otitis Media. Brit Med J:883-886, 10/11/58. 15. Rubenstein, M. M., McBean, J. B., Hedgecock, L. D., et al. The treatment of acute Otitis Media in children: A third clinical trial. Amer. J. Dis. Child 109:308-313, 1965. 16. Lowe, J. F., Bamforth, J. S., Pracy, R. Acute Otitis Media: One year in a general practice. Lancet: 1129-1132, 1963. 17. Reed, D., Struve, S., Maynard, J. E. Otitis Media and hearing deficiency among Eskimo children: A cohort study. Amer. J. Public Health 57:1657-1662, 1967. 18. Fry, J., Jones, R. F. M., Dillane, J. B., et al. The outcome of acute Otitis Media (a report to the Medical Research Council). Brit. J. Prev. Soc. Med. 23:205-209, 1969. 19. Holm, V. A., Kunze, L. H. Effect of chronic Otitis Media on language and speech development. Peds 43:833-839, 1969.
ACKNOWLEDGMENTS The authors wish to thank Margaret Reed, RN, Public Health Nurse of the town of Farmington, Maine, for performing the screening audiology tests; James Couser, Chairman and Associate Professor of Mathematics at the University of Maine at Farmington, for assistance in performing statistical tests; and Sharon Chiasson for help in tabulation of the data. We are also indebted to Drs. L. George Ray, Martin Myers, Evan Charney, and Loring Pratt for critical review of the manuscript.
Municipal Laboratories
A short article by Dr. Park, Commissioner ofHealth at Rockford, Illinois, deals with the purpose and value of a municipal laboratory. He closes with these words of advice to city governments: "Do not be deceived into thinking that this is a subject that has been overdrawn. Remember that it is war-grim, bloody war-between the armies of Life and those of Death. Cities which yearly spend thousands upon thousands of dollars for such luxuries as parks and libraries, should not turn a wry face when the question of appropriating for a laboratory comes up. "Let not the laboratory be considered merely the study-room ofthe impractical, pedantic savantlet it rather be the battlefield upon which the shining sword ofSciencefightsfor human life and health." Public Health Notes, In Am. J. Public Health 3:837, 1913.
474
AJPH May, 1977, Vol. 67, No. 5
