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.
In 1976, Paradise1 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).