The paediatric otological caseload resulting from improved screening in the first year of life.

Improved test technique by health visitors has been shown to lead to higher accuracy in the screen of hearing aimed traditionally at prelingual sensorineural deafness. However, it gives greatly increased referrals of children having otitis media with effusion (OME) around the end of the first year of life. Two samples of children (n = 29 and 61) were tested in a children's hearing assessment clinic with properly documented testing techniques and trained personnel. The samples were each formed on a fixed population base, one before and one after screen improvements. This enabled characterization of two outcome groups within each sample (severe/persistent enough to refer to ENT vs discharged, despite slight hearing impairment). The average audiometric criterion for onward referral to ENT rose only very little, despite the increased assessment caseload resulting from more detections by the screen. This usefully permitted the conclusion that the number of true cases found due to the screen and assessed as lying beyond a specifiable degree of severity (average cut-off approximately 47 dB(A) or 35 dBHTL) had increased not through lower criteria for referral to ENT, but through the improvements to the screen. The increase was from approximately 0.4% to 1.3% of the base population screened. Thus a change materially enhancing the sensitivity and positive predictive value of a screen considerably enlarges the eventual otological caseload of children with middle-ear disease thought to justify concern at around the end of their first year. If done properly, screening is hence in practical terms about OME, not about prelingual sensorineural hearing impairment. This conclusion presses the urgency of evaluation and consensus on the otological management of the young child with OME.     

The otological profile of a cohort of Dutch 7.5–8-year-olds

The otological characteristics of a birth cohort of 7.5–8-year-old Dutch children are reported. Questionnaire information was available for 1004 children, while otomicroscopic, tympanometric and pure-tone audiometric data were available for 946 children. Twenty-nine per cent of the children had been treated surgically for various ENT diseases. Fifty-five per cent of the children had normal tympanic membranes, 19% mild abnormalities, and 26% moderate to severe abnormalities. At this age the prevalence of bilateral otitis media with effusion (OME), as shown by a type B tympanogram was 2.5%, while that of unilateral OME was 7%. A pure-tone average hearing level of ≥ 15 dB in the better-hearing ear was found in 4% of the children. The presence of OME was associated with a mean hearing loss of 20 dB. This study shows that structural and functional middle-ear abnormalities are highly prevalent in Dutch school children.     

Prognostic factors for persistent otitis media with effusion in infants.

OBJECTIVE: To study prognostic factors for persistent otitis media with effusion (OME) in a birth cohort of 30,099 children born in the eastern part of The Netherlands between January 1, 1996, and April 1, 1997. DESIGN: Case-referent study. SUBJECTS: Children who failed a triple hearing test before their first birthday and were subsequently diagnosed with bilateral OME during 3 of the 4 bimonthly visits to an ear, nose, and throat (ENT) department (n = 372). The persistent cases were compared with 3 referent groups: (1) all the children who attended the first of 3 hearing tests; (2) all the children of the birth cohort who were referred to an ENT department after the third hearing test; and (3) all the children who were diagnosed with bilateral OME during the first visit to an ENT department. RESULTS: When all the children who participated in the first hearing test were taken as referents, persistent OME was associated with upper respiratory tract infections, attending a day-care center, having older siblings, and a family history of otitis media. When all the children who were referred to an ENT department were taken as referents, only attending a day-care center was associated with persistent OME. When the children diagnosed with bilateral OME during the first visit to an ENT department were taken as referents, no prognostic factors were found for OME persistence. CONCLUSION: When a child is referred early, an otolaryngologist can ask the parent about the presence of prognostic factors to decide which policy to follow.     

Otitis media with effusion in children with congenital or early-onset hearing impairment

OBJECTIVE: The purpose of this study was to examine the incidence of otitis media with effusion (OME) among children with bilateral congenital or early-onset hearing impairment (CEHI) and to assess whether the diagnosis of OME had any effect on the detection of CEHI. METHODS: The study population consisted of all patients diagnosed in a Finnish university hospital between 1976 and 1995 as having CEHI (> 25 dB, 0.5-4 kHz, in the better hearing ear). Early-onset hearing impairments were defined as losses attributed to perinatal or neonatal complications. Otitis media with effusion was assigned when asymptomatic middle ear effusion had lasted at least 2 months and tympanocentesis had yielded mucous effusion. RESULTS: A total of 184 child patients with CEHI were identified. Of these, OME was diagnosed and treated in 28 (15%) patients. Of the patients with OME, diagnosis of CEHI was made before the occurrence of OME in 7 (25%) and at the same time in 10 (36%) but was delayed at least 6 months after the treatment of OME in 11 (39%) patients. CONCLUSION: It is suggested that all children undergoing ventilation tube placement should have age-appropriate hearing examination to exclude coexisting sensorineural hearing loss.     

Is it necessary to screen for hearing loss in the paediatric population with osteogenesis imperfecta?

Is it necessary to screen for hearing loss in the paediatric population with osteogenesis imperfecta? The aim of the study was to assess the necessity of a screening service to detect early hearing loss in the paediatric population with osteogenesis imperfecta. Twenty‐two children were assessed over a 5‐year period. Five children (22.7%) had normal hearing. Fourteen (63.6%) had conductive hearing loss, with 12 children in this group having otitis media with effusion (OME); all had resolution of hearing loss with appropriate therapy. Two children had persistent conductive losses unrelated to OME. Three children (13.6%) had sensorineural hearing loss, with one being detected at the age of 1 year. Existing evidence suggests that hearing loss associated with osteogenesis imperfecta has its onset in the second to third decade of life. Contrary to this, hearing loss was detected in 77.3% (17) of this population with a median and mean age of 9 years. This study would suggest that routine screening is worthwhile in children with osteogenesis imperfecta.     

Snoring,apnoea and ENT symptoms in the paediatric community

This study was designed to determine the prevalence of snoring and assess the extent of associated ENT symptoms in children up to 10 years of age. A questionnaire was presented to the parents of 245 children chosen at random from the General Practice list of the town of Frome, Somerset, UK. The prevalence of snoring was found to be 27%. This increased to 47% in the presence of an upper respiratory infection. Snoring was found to be significantly (P < 0.001) associated with a history of poor hearing, restless sleep, and having a cold. Less significant (P < 0.01) associations occurred with parental smoking, eczema, sleep talking, moving around the bed at night, sore throats, having a runny nose and mouth breathing. Snoring is a common symptom in children up to 10 years of age. Without evidence of other ENT disease the snoring child does not require referral to an ENT department for further investigation.     

Evaluation of the use of a questionnaire to detect hearing loss in Kenyan pre-school children

In developing countries, there is a lack of trained personnel and testing equipment to facilitate the early detection of hearing impairment in children. A questionnaire offers a low cost option and the value of this for detecting hearing impairment in pre-school children was determined in several districts in Kenya. The questionnaire was completed by either teachers, parents/carers or community nurses. The children were subsequently tested using pure tone audiometry and visual examination of the ear by ENT Clinical Officers, who were not given prior access to the results of the questionnaire. A total of 757 (88%) questionnaires were completed. Of the 735 children, who could be tested using pure tone audiometry, four were found to have a unilateral hearing impairment and one was detected by the questionnaire. A total of 13 children had a bilateral hearing impairment >40 dB HL. All were detected using the questionnaire. There were eight males and five females with ages ranging from 4.2 to 6.9 years, mean age 5.7 years and median age 5.8 years. Eight had a sensorineural hearing impairment and two a mixed hearing impairment. Three of the children with a sensorineural hearing loss had a family history of hearing impairment. No question detected all children with a hearing impairment and some questions were more discerning than others. There was 100% sensitivity for the questionnaire when a hearing loss of >40 dB was considered, but specificity was lower at 75%. Negative predictive value was 100%, but the positive predictive value was low, 6.75%. It was concluded that a questionnaire of this nature could be usefully applied at Primary Health Care level for detecting hearing impairment at the pre-school stage. There would be need for services available for diagnosis, treatment and habilitation before a screening programme was introduced.     

A conservative approach to the management of otitis media with effusion in cleft palate children.

Otitis media with effusion (OME) is almost universal in children born with a cleft palate. Early placement of a ventilation tube to alleviate hearing problems is common. A retrospective study has been carried out to assess whether the practice of tube placement only for definite clinical indications is successful in terms of subsequent hearing levels and speech and language development. This was assessed by a case note review, analysis of speech therapy data and by means of a special follow-up clinic. There was no difference in speech development between those treated with tube insertion for OME and those untreated. Audiological thresholds were worse in the treated group. A similar number in each group required regular speech therapy. More abnormal otological findings were present at follow up in those who had tubes inserted, some of these were directly attributable to the presence of tubes. A conservative management of OME in cleft palate children, with tube insertion for only definite clinical indications, is an appropriate management, and will lead to fewer otological complications of tube insertion.     

Evaluation of the use of a questionnaire to detect hearing loss in babies in China.

A questionnaire was used to screen hearing of 1020 babies 6-8 months in China. All babies failing the questionnaire and 10% of those who passed were tested using auditory brainstem audiometry (ABR). Babies with unilateral or bilateral hearing thresholds 30 dBnHL or more were investigated to determine the cause of the hearing impairment. Sixty-seven failing the questionnaire were tested and 23 were confirmed to have a hearing loss, 20 with bilateral hearing impairment. The causes were: 13 otitis media with effusion (OME), one hypoxia, one genetic and five unknown. One child with an OME related hearing loss passed the screen. The sensitivity of the questionnaire was estimated to be 70%, specificity 96%.     

Sensorineural hearing loss in chronic otitis media

Although many studies have demonstrated an association between chronic otitis media (COM) and sensorineural hearing loss (SNHL), there still remains disagreement about the relationship. A retrospective study was conducted to examine the relationship between sensorineural hearing loss and chronic otitis media. Forty-one patients met the following criteria: unilateral COM and no history of head injury, meningitis or previous otological surgery. The differences in preoperative bone conduction threshold between diseased and control (contralateral normal) ear were statistically significant (P < 0.01) and varied from 5.24 to 9.02 dB across the frequency range. The effect of duration of disease on the degree of SNHL was also analysed but no correlation was found. The presence of cholesteatoma and/or ossicular erosion was not associated with a significantly increased risk of sensorineural hearing loss.     

Sensitivity,specificity and predictive value of tympanometry in predicting a hearing impairment in otitis media with effusion

Children with otitis media with effusion (OME) need monitoring over time to identify persistence of disease and to assess their hearing thresholds as a surrogate of auditory disability. It would be useful if tympanometry could be used to predict those with an impairment. This study looked at 1153 children, aged between 3.25 and 6.75 years, referred for suspected OME. The inclusion of type C₂ tympanograms with type B tympanograms versus all other tympanogram types increased the sensitivity of detecting air-conduction thresholds and air-bone gaps of various magnitudes in the better hearing ear but lowered the specificity and the positive predictive value. Extending the pressure range to ?600 daPa and excluding the 30% of children with poor concentration on audiometry made no difference to the sensitivity and specificity. The results were the same for the poorer hearing ear. These findings are of practical help in monitoring children with OME. Thus taking an air-conduction average of 25 dB HL in the better ear as the level needing detection, if all children are audiometrically assessed then 100% of those with an impairment will be identified. Limiting audiometry to those with a bilateral type B tympanogram reduces the workload by 50%, but 90% of impaired children will still be detected. Limiting audiometry to those with type B or C₂ tympanograms reduces the workload to 69% of the sample, and 95% of impaired children will be identified. With such data, decisions as to how to allocate limited audiometric resources for monitoring children with OME are made easier.     

双耳感音神经性聋患儿合并分泌性中耳炎的临床诊治

目的 探讨双耳感音神经性聋并发分泌性中耳炎患儿的症状特点, 为及时诊治此类患者提供临床依据。方法 收集经手术治疗的双耳感音神经性聋并发分泌性中耳炎患儿(A组)17例(34耳)的病历资料, 分析其误诊原因、临床特点及并发症发生率, 并与同期行手术治疗的单纯双耳单纯分泌性中耳炎患儿(B组)17例(34耳)进行鼓室粘连发生率的比较。手术前后应用听性脑干反应(ABR)检查随诊听力变化。结果 A组均以家属发现听力下降为首诊症状, 在当地首诊曾诊断为突发性聋7例, 耳闷塞感、耳鸣、耳痛等症状叙述不清, 均无法采集到确切的分泌性中耳炎发病时间;行双耳鼓膜置管时发现中耳粘连5例(7耳), 手术前后ABR检查Ⅴ波阈值改善0～30 dB nHL, 平均17.3 dB nHL, 手术前后Ⅴ波阈值改善, 差异有统计学意义(P < 0.05)。B组患儿无1例误诊, 首诊诉耳痛或耳鸣、耳闷塞感等耳部不适症状15例, 发病时间明确, 首诊诉听力下降2例, 鼓膜置管时中耳粘连1例(1耳)。A组并发症发生率高于B组, 差异有统计学意义(P < 0.05)。结论 双耳感音神经性聋并发分泌性中耳炎患儿临床病史采集困难, 易误诊, 临床并发症发生率高, 应及时干预;鼓膜置管对听力改善效果明显。     

Epileptiform electroencephalogram abnormality in children with congenital sensorineural hearing loss

Objectives

This work was designed to study electroencephalogram findings in children with congenital sensorineural hearing loss and correlate these findings with the SNHL parameters as duration, etiology, severity, and type.

Methods

Ninety children with bilateral congenital sensorineural hearing loss served as the study group. They were free from any neurological disorders or symptoms that are commonly associated with abnormal electroencephalogram as convulsions or loss of consciousness. Twenty children having normal hearing with no history of otological or neurological disorders served as the control group. All children participating in the study were subjected to full medical and audiological history, otological examination, neurological examination, audiological evaluation and electroencephalogram recording.

Results

Mean age of the children in the control group was 3.56 ± 2.1 years and mean age of the children in the study group was 3.8 ± 2.2 years. While none of the control children had abnormal electroencephalogram, 38 (42.2%) of children with congenital SNHL had epileptiform electroencephalogram abnormality. The epileptiform abnormality was generalized in 14 children (36.8%), focal temporal in 17 children (44.7%) and focal other than temporal in 7 children (18.4%). According to the hemispheric side affected, the abnormality was right in 14 children (36.8%), left in 10 children (26.3%) and bilateral in 14 children (36.8%). No statistically significant predominance of specific site or side of the epileptiform abnormality was found. Similarly, no statistical significant prevalent of the epileptiform abnormality was found in relation to the age or sex of children, duration of hearing loss or etiology of hearing loss (i.e., genetic vs. neonatal insults). On the other hand, the epileptiform abnormality was statistically prevalent in children with moderate degree of hearing loss, and in children with auditory neuropathy spectrum disorder.

Conclusions

The epileptiform electroencephalogram abnormality is a common finding in children with congenital sensorineural hearing loss especially those with auditory neuropathy spectrum disorder, suggesting the affection of the central nervous system despite the absence of neurological symptoms or signs. These findings raise the question of the requirement of medical treatment for those children and the effect of such treatment in their rehabilitation.     

Hypotension and sensorineural hearing loss: a possible correlation

A possible role of hypotension in the genesis of sudden or slowly developing sensorineural hearing loss has been outlined. In order to confirm this hypothesis, and to exclude other vascular risk factors, a prospective study was carried out within the "Brisighella Study", a wide and homogeneous group of subjects thoroughly examined from a metabolic and cardiovascular point of view. Among them, 20 participants aged 50 years or less (18 women, 2 men) with diastolic blood pressure < or = 60 mmHg and/or systolic blood pressure < or = 105 mmHg were selected and underwent otological and audiometric examinations. Patients with previous audiological, vestibular and otological diseases were excluded. The control group was represented by 100 subjects (60 women, 40 men), aged 50 years or less, randomly chosen from within a sample of the normal population in the same region. A statistically significant incidence of sensorineural hearing loss was recorded in the study group (7/20 subjects, all affected by low-frequency hearing loss), while hearing impairment was observed in only 3/100 participants in the control group. The mean values of the main metabolic parameters were normal. An alteration of the vasomotor system associated with a hypotensive condition could be responsible as a possible factor in the origin of a cochlear damage and the consequent sensorineural hearing loss.     

La implantación coclear pediátrica en el periodo crítico de la vía auditiva,nuestra experiencia

IntroductionNumerous experimental and clinical studies have suggested a critical or sensitive period in which the auditory pathway develops its greatest potential in terms of plasticity and learning. Early cochlear implantation performed in prelingual deaf children in this period provides a better prognosis for language acquisition. The aim of this study is to show the importance of cochlear implantation before this critical period ends.MethodsWe conducted an observational, longitudinal, retrospective study of 57 children suffering profound prelingual bilateral sensorineural hearing loss who had received Advanced Bionics implants at our ENT department between June, 1998, and November, 2006. Data on their audiometric thresholds, the disyllabic word test adapted to children, open-set sentences recognition test and the Nottingham scale were analyzed.ResultsThe analysis of audiometric thresholds showed no differences between children receiving the implants at different ages. However, statistically significant differences (p<0.05) were found in speech tests between groups of children receiving the implants before and after 4 years of age.ConclusionsOur results are in line with other publications showing differences in auditory performance when comparing children with early implants versus children receiving the implants at a later age. We found the greatest differences at 4 years of age. Nevertheless, these findings should not exclude children over this age from implantation.     

Nonsyndromic 35 delG mutation of the connexin 26 gene associated with deafness in syndromic children: two case reports

OBJECTIVES/HYPOTHESIS: Several genetic diseases, such as velocardiofacial syndrome Del(22q11) and Down syndrome, are associated with hearing impairment. STUDY DESIGN: Case reports. METHODS: The authors reported two cases of hearing-impaired children, one with Del (22q11) and one with Down syndrome, both with bilateral nonevolutive profound sensorineural deafness. Because of unusual features of their deafness and familial history, genetic evaluation was proposed. A homozygous 35delG mutation on the Connexin 26 gene was found in both children (DFNB1 phenotype). RESULTS: A review of the reported otological features of Del (22q11) and Down syndrome showed that sensorineural deafness is rare and seldom profound. The authors found no evidence for a genetic link between Del(22q11) or Down syndrome and 35delG mutation on the Connexin 26 gene. CONCLUSION: The case reports reveal a coincidental association between DFNB1 and a multiple congenital anomaly syndrome. The clinician must be aware of this type of association to manage genetic counseling, appropriate otological care, and suitable treatment.     

儿童分泌性中耳炎相关骨导听力下降的临床分析

目的：分析儿童分泌性中耳炎相关的骨导听力下降的病因、诊断和治疗方法。方法：回顾性分析150例（225耳）分泌性中耳炎儿童中35例（37耳）骨导听力下降的临床资料。结果：35例患儿均给予鼓膜切开置管或（和）鼻内镜下腺样体切除术,术后给予药物治疗。34例患儿骨导听阈恢复正常,1例患儿随访6个月改善不明显。结论：35例（23．3％）患儿的暂时性听阈移位或永久性听阈移位的发病机制与分泌性中耳炎有关。儿童分泌性中耳炎的发病病程中有发展成骨导听力下降的可能,应引起高度重视,及早干预避免病情发展。     

The role of ventilation tube status in the hearing levels in children managed for bilateral persistent otitis media with effusion

The study determined the effects on hearing of the status of ventilation tubes, using a combination of otoscopy and tympanometry to determine function, in children managed for bilateral persistent otitis media with effusion (OME). The subjects were aged between 3.5 and 7 years and had a documented history of bilateral OME over a 12-week watchful waiting period associated with a hearing impairment in both ears of >or= 20 dB HL. The children reported are those randomized to the two surgical arms, both of which had bilateral myringotomy, aspiration of middle ear fluid and insertion of Shepard ventilation tubes. One arm furthermore received adenoidectomy. The data were analysed 'as treated' to document therapeutic progress. Tubes confirmed to be functioning on otoscopy and tympanometry only partially alleviate the conductive impairment associated with childhood OME (AC mean 12 dB HL, SD 4; ABG 13 dB, SD 7, 3 months post operation). Thus, children with a functioning ventilation tube cannot be considered to have 'normal' hearing. Once the tube has extruded, ears that no longer have OME still have a small conductive hearing impairment (at 12 months AC 14 dB HL, SD 6; ABG 16 dB, SD 9) but this improves with time. In children with bilateral tubes, both remain functioning for a median duration of 21 weeks (IQR 10-40) and at least one for a median of 40 weeks (IQR 24-61). Tube blockage significantly (P = 0.001) increases the risk of extrusion (84% versus 44%). When inserted in children between 3.5 and 7 years for OME, the otoscopic incidence of tube infection is low (1%).