Download Ch07: Diagnosis - Society For Middle Ear Disease

7
Diagnosis
OUTLINE
Signs and Symptoms of Otitis Media
Physical Examination
Otoscopy
Positioning the patient for examination
Removal of cerumen
Otoscope
Examination
Position of the tympanic membrane
Appearance of the tympanic membrane
Mobility of the tympanic membrane
Otoscopy in the newborn infant
COMPLETES: a mnemonic for otoscopic examination
Accuracy and validation
Other teaching tools
Clinical Description
Acute otitis media
`Otitis media with effusion
Eustachian tube dysfunction
Atelectasis of the tympanic membrane-middle ear and
high negative pressure
Aural Acoustic Immitance Measurements, Including
Tympanometry
Instrumentation
Tympanometry with impedance instruments
Tympanometry with admittance instruments
Validation of tympanometry
Tympanometric patterns
Acoustic middle-ear muscle reflex
Equivalent ear canal volume
Screening for middle-ear disease with acoustic immittance measurements
Tympanometric screening for middle-ear effusion
Recommendations
Immittance Instrumentation
Acoustic Reflectometry
Assessment of Hearing
Methods
Behavioral tests
Nonbehavioral tests
Indications
Screening for hearing loss
Recommended audiometers
Otoacoustic emissions
Special populations
Vestibular Testing
High-Risk Populations
Cleft palate
Hearing loss
Aural pathology
Infants
Older children and adults
Other high-risk populations
The deaf
Microbiologic Diagnosis
Tympanocentesis
Nasopharyngeal culture
Fluorescence emmision spectrophotometry
Blood culture
White blood cell count
Sedimentation rate
Allergy testing
Radiologic imaging
Eustachian Tube Function Testing in the Clinical Setting
Otoscopy
Nasopharyngoscopy and endoscopy of the eustachian
tube
Tympanometry
Manometry
Methods of assessing eustachian tube function in the
clinical setting
Classic tests of tubal patency
Toynbee test
Patulous eustachian tube test
Nine-step inflation-deflation tympanometric test
Modified inflation-deflation test (nonintact tympanic
membrane)
Other methods available for laboratory use
Clinical Indications for Testing Eustachian Tube
Function
Diagnosis
Eustachian tube function tests related to management
Since there is an ever-increasing rise in the
prevalence of antibiotic-resistant bacteria causing
otitis media, there is a need to accurately diagnose
147
148
OTITIS MEDIA IN INFANTS AND CHILDREN
otitis media to avoid unnecessary treatment.1
Diagnosis of otitis media in children is determined
from medical history and physical examination.
For more than a century, clinicians have used the
otoscope, but it is only relatively recently that a
pneumatic attachment to it has been advocated.
When used appropriately, the otoscope with the
pneumatic attachment is the most feasible and
cost-effective method for diagnosis of otitis media
and many of its associated complications and
sequelae.2,3 In the 1970s, the acoustic admittance
(immittance) audiometer (formerly called the
electroacoustic impedance bridge) became available, with which a tympanogram can be obtained.
This is now the most accurate objective method to
diagnose middle-ear effusion.4–6 Also, a handheld
spectral gradient acoustic reflectometer has
become available for diagnosis of middle-ear
effusion.7,8 Audiometry is of limited value as a
diagnostic method for identifying otitis media, but
it can be helpful in evaluating the effect of middleear disease on hearing. It can also help in the
selection of management options.
SIGNS AND SYMPTOMS OF OTITIS MEDIA
Children with acute otitis media (AOM) may
have nonspecific signs and symptoms, including
fever, irritability, headache, apathy, anorexia,
vomiting, and diarrhea. Fever occurs in one-third
to two-thirds of children with otitis media,9,10
and high fever (temperature above 40uC) is
unusual unless it is accompanied by bacteremia
or a significant focus elsewhere.
Nine specific signs and symptoms are associated with otitis media and its complications and
sequelae.
Otalgia, or ear pain, is by far the most
common complaint in children with AOM and is
the best predictor of AOM.11 In infants, however,
pulling at the ear or irritability, especially when it is
associated with fever, may be the only sign of ear
pain. Otalgia may also result from inflammation of
the external canal or may originate outside the ear
(eg, from the temporomandibular joint, teeth, or
pharynx).12 In most cases, otalgia not associated
with otitis media can be identified as referred pain
due to discomfort with swallowing (tonsillitis),
nasal obstruction, or pain in the throat (pharyngitis). However, any lesion in the areas of the
trigeminal, facial, glossopharyngeal, vagus, great
auricular, or lesser occipital nerve supply can result
in earache.13 On the other hand, earache does not
occur in some children with AOM; approximately
one-fifth of 335 consecutively diagnosed episodes
in a pediatric practice were without earache
(usually among children older than 2 years).14
Otorrhea, a discharge from the ear, may be
from one or more of the following sites: the
external auditory canal, middle ear, mastoid,
inner ear, or intracranial cavity.
Hearing loss is a frequent symptom associated with otitis media when it is elicited from
older children. In infants and younger children
who are not able to verbalize this loss of
function, the only sign of disease in the middle
ear may be the parents’ suspicion of hearing loss.
Vertigo is not a common complaint in children,
but otitis media and eustachian tube dysfunction
are the most common causes of this disorder. The
vestibular system is more commonly affected by
unilateral middle-ear effusion than it is by bilateral
disease. Vertigo may also be due to labyrinthitis.
Older children describe a feeling of spinning or
turning, whereas younger children may not be able
to describe these symptoms but manifest dysequilibrium by falling, stumbling, or ‘‘clumsiness.’’
Nystagmus, which is usually associated with
vertigo of labyrinthine origin, is of the unidirectional, horizontal, jerk type in otitis media.
Tinnitus is another symptom that children
describe infrequently, but like vertigo, it is
commonly due to otitis media and eustachian
tube dysfunction.
Swelling about the ear, especially in the
postauricular area, may indicate disease of the
mastoid (eg, periostitis or subperiosteal abscess)
but must be differentiated from diffuse external
otitis, adenopathy, or adenitis.
Facial paralysis in children, when it is due
to disease within the temporal bone, most
commonly occurs as a complication of AOM,
chronic otitis media with perforation and discharge, or cholesteatoma.
Diagnosis
149
Purulent conjunctivitis can be associated
with AOM. The conjunctivae are injected
with pain; there is tearing or purulent discharge and, in some children, concurrent ear
pain.16 Simultaneous cultures of conjunctivae
and middle-ear exudates reveal nontypeable
Haemophilus influenzae in almost all cases.16 It
has been suggested that AOM caused by
Streptococcus pneumoniae can present as a more
severe disease than when the bacterial etiology is
either H. influenzae or Moraxella catarrhalis, but
this was not found to be correct in a study in
which tympanocentesis confirmed the offending
bacterial organism.17
PHYSICAL EXAMINATION
Aside from the history, the most useful method for
diagnosis of otitis media is a physical examination
that includes pneumatic otoscopy.18 Adequate
examination of the head and neck can lead to
identification of a condition that may predispose
the patient to, or be associated with, otitis media.
The appearance of the child’s face may be an
important clue to susceptibility to middle-ear
disease. Many craniofacial anomalies, such as
mandibulofacial dysostosis (Treacher Collins syndrome) and trisomy 21 (Down syndrome), are
associated with increased incidence of ear disease.19
The character of speech may be altered.
Mouth breathing and hyponasality may indicate
intranasal or postnasal obstruction. Hypernasality is a sign of velopharyngeal insufficiency.
Examination of the oropharyngeal cavity
may uncover an overt cleft palate or a submucous cleft palate (Figure 1), both of which
predispose an infant to otitis media with effusion.20,21 A bifid uvula is also associated with an
increased incidence of middle-ear disease.22
Posterior nasal or pharyngeal inflammation and
discharge may be present.
Pathologic conditions of the nose, such as
polyposis, severe deviation of the nasal septum,
or a nasopharyngeal tumor, may be associated
with otitis media.
Examination of the ear is the most critical part
of the clinician’s assessment of the patient, but it
Figure 1. Bifid uvula, widening and attenuation of the median raphe
of the soft palate, and a V-shaped midline notch (rather than a
smooth curve) are diagnostic of a submucous cleft palate.
must be performed systematically. The auricle and
external auditory meatus should be examined first.
Although not common, congenital aural atresia
can be associated with otitis media and even
cholesteatoma, which is more common when the
ear canal is stenotic.23 Too frequently, these areas
are overlooked in the physician’s haste to make a
diagnosis by otoscopic examination. The presence
or absence of signs of infection in these areas may
later help in the differential diagnosis or evaluation
of complications of otitis media. For instance,
eczematoid external otitis may result from AOM
with discharge, or inflammation of the postauricular area may indicate a periostitis or subperiosteal abscess that has extended from the mastoid
air cells. Palpation of these areas determines
whether tenderness is present; exquisite pain on
palpation of the tragus indicates the presence of
acute, diffuse external otitis.
After examining the external ear and canal,
the clinician may proceed to the most important
part of the physical assessment, the otoscopic
examination.
OTOSCOPY
Positioning the Patient for Examination
The position of the patient for otoscopy depends
on the patient’s age, his or her ability to cooperate,
150
OTITIS MEDIA IN INFANTS AND CHILDREN
the clinical setting, and the examiner’s preference.
Otoscopic evaluation of an infant is best performed on an examining table, and a parent or
assistant is necessary to restrain the baby because
undue movement usually prevents an adequate
evaluation (Figure 2). Some clinicians prefer to
place the infant prone on the table, whereas others
prefer the patient to be supine. Use of the
examining table is also desirable for older infants
who are uncooperative or when a tympanocentesis
or myringotomy is performed without general
anesthesia.
Figure 3 shows that infants and young
children who are just apprehensive and not
actively struggling can be evaluated adequately
while sitting on the parent’s lap. When necessary,
the child may be restrained firmly on an adult’s
lap; the child’s wrists are held over the abdomen
with one of the parent’s hands, and the child’s
head is held against the parent’s chest with the
other hand. If necessary, the child’s legs can be
held between the adult’s thighs. Some infants can
be examined by placing the child’s head on the
parent’s knee (Figure 4). Cooperative children
sitting in a chair or on the edge of an examination table can usually be evaluated successfully.
The otoscope should be held with the hand or
finger placed firmly against the child’s head or
face so the otoscope will move with the head
rather than cause trauma (pain) to the ear canal
if the child moves suddenly (Figure 7-5). Pulling
up and out on the pinna usually straightens the
ear canal enough to allow exposure of the
Figure 3. Mother assisting in restraining a child for examination of
the ear.
tympanic membrane. In the young infant, the
tragus must be moved forward and out of the
way.
Removal of Cerumen
Figure 2. Methods of restraining an infant for examination and for
procedures such as tympanocentesis and myringotomy.
Before the clinician can adequately visualize the
external canal and tympanic membrane, all
obstructing cerumen must be removed from the
canal. Many children with AOM have moderate
to large accumulations of cerumen in the ear
canal. Cerumen in the external auditory canal
even causes chronic cough probably due to
Diagnosis
151
Figure 5. The pneumatic otoscope should be used with the largest
speculum that fits comfortably into the patient’s external auditory
meatus; insertion too deeply will elicit pain. Gentle pressure should
be used initially to determine if the tympanic membrane moves freely
in and out. If it does not, then more pressure can be applied as
described later in Figure 19. Reproduced with permission from
Bluestone CD. Conquering otitis media. Hamilton (ON): BC Decker
Inc; 1999.
Figure 4. Mother using lap position of infant for examination of the
infant’s ear.
stimulation of Arnold’s nerve reflex.24 For
optimal visualization of the tympanic membrane,
mechanical removal was necessary in approximately one-third of 279 patients observed by
Schwartz and colleagues25; cerumen removal was
inversely proportional to age, with more than
half of these infants younger than 1 year.
Removal of cerumen can usually be accomplished by using an otoscope with a surgical head
and a wire loop or a blunt cerumen curet (Figure
6) or by irrigating the ear canal gently with warm
water delivered through a dental irrigator (Water
Pik) (Figure 7). Carbamide peroxide in glycerol
(Debrox, GlaxoSmithKline, Research Triangle
Park, NC) can be used by the patient for a few
days before irrigation. Reported use of other
commercial preparations (eg, triethanolamine
polypeptide oleate-condensate) may cause severe
eczematoid allergic reactions of the external
canal. Also, these agents do not seem to have
any beneficial effect compared with saline irrigation alone.26 Recently, a new product, OtoClear
Safe Irrigation System (Bionix Development
Corporation, Toledo, OH) was used with success
in clearing ear wax in children in a clinical study
conducted at the Children’s Hospital of
Pittsburgh.27
Otoscope
To properly assess the tympanic membrane and
its mobility, the clinician should use a pneumatic
otoscope with a diagnostic head having an
adequate seal.28 Currently, the quality of the
otoscopic examination is limited by deficiencies
in the designs of commercially available otoscopes. The speculum used should have the
largest lumen that can comfortably fit in the
152
OTITIS MEDIA IN INFANTS AND CHILDREN
the bony canal, which can be painful. In most
models, an airtight seal is usually not possible
because of a leak of air within the otoscope head
or between the stiff ear speculum and the external
auditory canal, although leaks in the external
auditory canal can be stopped by cutting off a
small section of rubber tubing and slipping it
over the tip of the ear speculum (Figure 8).
The otoscope should have sufficient brightness for adequate visualization of the tympanic
membrane and external auditory canal. Barriga
and colleagues evaluated the output of lights in
221 otoscopes in various clinical settings and
reported that one-quarter of the lights failed to
meet the minimum recommended standards.29 A
halogen bulb with 100 foot-candles or more is
currently recommended.30 Batteries should be
Figure 6. Method for removing cerumen from the external ear canal
by employing the surgical head attached to the otoscope.
Instruments that can be used are also illustrated.
child’s cartilaginous external auditory meatus. If
the speculum is too small, adequate visualization
may be impaired, and the speculum may touch
Figure 7. Irrigation of the external canal with a dental irrigator to
remove cerumen.
Figure 8. Pneumatic otoscope, with rubber tip on the end of the ear
speculum to give a better seal in the external auditory canal.
Diagnosis
153
replaced frequently, or if the instrument is
rechargeable, it should have recently been
recharged before use to ensure optimal light.
Examination
Inspection of the tympanic membrane should
include evaluation of its position, color, degree of
translucency, and mobility. Assessing the light
reflex is of limited value because it does not
reflect the status of the middle ear in evaluation
of tympanic-membrane–middle-ear disorders.
Clinical otoscopic examinations compare favorably with histologic temporal bone specimens.31
Position of the Tympanic Membrane
Figure 9 illustrates the positions of the tympanic
membrane when the middle ear is aerated and
when effusion is present.
The normal eardrum should be in the neutral
position, with the short process of the malleus
visible, but not prominent, through the membrane.
Mild retraction of the tympanic membrane
usually indicates the presence of negative middleear pressure or an effusion, or both. The short
process of the malleus and posterior mallear fold
are prominent, and the manubrium of the
malleus appears to be foreshortened.
Severe retraction of the tympanic membrane
is characterized by a prominent posterior mallear
fold and short process of the malleus and a
severely foreshortened manubrium. The tympanic membrane may be severely retracted, presumably owing to high negative pressure
associated with a middle-ear effusion.
Fullness of the tympanic membrane is initially apparent in the posterosuperior portion of
the pars tensa and the pars flaccida, because
these two areas are the most highly compliant
parts of the tympanic membrane.32 The short
process of the malleus is commonly obscured.
The fullness is caused by increased air pressure or
effusion, or both, within the middle ear. When
bulging of the entire tympanic membrane occurs,
the malleus is usually obscured; this occurs when
Figure 9. Otoscopic views and corresponding lateral sections
through the tympanic membrane and middle ear demonstrate the
various positions of the eardrum with their respective anatomic
landmarks.
the middle-ear–mastoid system is filled with an
effusion.
Appearance of the Tympanic Membrane
The normal tympanic membrane has a groundglass appearance; a blue or yellow color usually
indicates a middle-ear effusion seen through a
translucent tympanic membrane (Figures 10 to
17 [see CD-ROM for otoscopic appearance of
common tympanic membranes shown in color
and animation]). A red tympanic membrane
alone may not indicate a pathologic condition,
because the blood vessels of the eardrum head
may be engorged as the result of the patient’s
crying, sneezing, or nose blowing. A ‘‘red eardrum’’ has been described as one that is bulging,
154
OTITIS MEDIA IN INFANTS AND CHILDREN
Figure 10. Normal right tympanic membrane and middle ear. (See
color figure on accompanying CD-ROM.)
fiery red, or dark red-purple hemorrhagic, which
has been sometimes associated with AOM caused
by group A streptococci infection or highly
virulent pneumococcal disease.33
It is critical to distinguish between translucency and opacification of the eardrum to
identify a middle-ear effusion. The normal
Figure 11. Bulging right tympanic membrane in acute otitis media.
(See color figure on accompanying CD-ROM.)
Figure 12. Air-fluid level and bubbles visible through right retracted,
translucent tympanic membrane in otitis media with effusion. (See
color figure on accompanying CD-ROM.)
tympanic membrane should be translucent, and
the observer should be able to look through the
eardrum and visualize the middle-ear landmarks
(the incudostapedial joint, promontory, round
window niche, and, frequently, chorda tympani
Figure 13. Severely retracted, opaque right tympanic membrane in
otitis media with effusion. (See color figure on accompanying CDROM.)
Diagnosis
155
Figure 14. Retraction pocket in the posterosuperior quadrant of
right tympanic membrane and middle ear effusion. (See color figure
on accompanying CD-ROM.)
Figure 16. Middle ear cholesteatoma visualized through perforation
of right tympanic membrane. (See color figure on accompanying CDROM.)
nerve) (Figure 18). If a middle-ear effusion is
present medial to a translucent eardrum, an airfluid level or bubbles of air admixed with the
liquid may be visible. Inability to visualize the
middle-ear structures indicates opacification of
the eardrum, which is usually the result of
thickening of the tympanic membrane or the
presence of an effusion, or both. Vesicles on the
tympanic membrane are most likely a sign of
myringitis bullosa.34 The presence of an aural
polyp35 or a white mass, or both, could be
associated with a cholesteatoma and should
Figure 15. Large ‘‘dry’’ central perforation of right tympanic
membrane. (See color figure on accompanying CD-ROM.)
Figure 17. Cholesteatoma within right tympanic membrane. (See
color figure on accompanying CD-ROM.)
156
OTITIS MEDIA IN INFANTS AND CHILDREN
Figure 18. Important landmarks of the tympanic membrane that
can usually be visualized with the otoscope.
prompt an otologic referral (see Chapter 9,
‘‘Complications and Sequelae: Intratemporal’’).
The light reflex is due to the light from the
otoscope reflecting off the tympanic membrane,
usually in the anteroinferior quadrant, but is of
little diagnostic significance, and thus, can
essentially be ignored.36 Scarring of the tympanic
membrane is common in children who have had
recurrent and chronic middle-ear disease (with or
without tympanostomy tube placement), and is
even more common in teenagers and adults who
have many years of eustachian tube dysfunction
and otitis media.37
Mobility of the Tympanic Membrane
Abnormalities of the tympanic membrane and
middle ear are reflected in the pattern of
tympanic membrane mobility when first positive
and then negative pressure is applied to the
external auditory canal with the pneumatic
otoscope.38,39 As shown in Figure 19, this is
achieved by first applying slight pressure on the
rubber bulb (positive pressure) and then, after
momentarily breaking the seal, releasing the bulb
(negative pressure). It is important to start with
slight positive pressure by gently pressing on the
rubber bulb, because the child will experience ear
pain if the bulb is completely depressed vigorously and the tympanic membrane–middle ear is
normal. Excessive pressure applied to a normal
tympanic membrane–middle ear will result in an
unhappy patient who is likely to be frightened by
future attempts to perform otoscopy with a
pneumatic attachment. If the tympanic mem-
Figure 19. Pressure applied to the rubber bulb attached to the
pneumatic otoscope will deflect the normal tympanic membrane
inward with applied positive pressure and outward with applied
negative pressure if the middle-ear air pressure is ambient. The
movement of the eardrum is proportionate to the degree of pressure
exerted on the bulb until the tympanic membrane has reached its limit
of compliance.
brane does not move when slight positive
pressure is applied, progressively more pressure,
as described later, can be used to determine the
mobility. Indeed, one study revealed that a
normal eardrum moves with as little as 10 to 15
millimeters of water (mm H2O) pressure, whereas
fluid-filled ears require a great deal more
pressure to move, and many have little or no
mobility to maximal applied pressure; pneumatic
otoscopes can deliver 1,000 mm H2O or more
when the rubber bulb is fully depressed.40,41 The
Diagnosis
Figure 20. The four quadrants of the pars tensa of a right tympanic
membrane.
same cautious approach should be used in
evaluating the response to applied negative
pressure (releasing the depressed rubber bulb),
because excessive negative pressure applied
initially can also result in moderate to severe
otalgia when the tympanic membrane–middle ear
is normal or when only slight middle-ear negative
pressure is present.
Effusion or high negative pressure within the
middle ear can markedly dampen the movements
of the eardrum. It is important to diagnose high
157
negative pressure because it may be a sign of
eustachian tube dysfunction.42 When middle-ear
pressure is ambient, the normal tympanic membrane moves inward with slight positive pressure
in the ear canal and outward toward the
examiner with slight negative pressure. The
motion observed is proportionate to the applied
pressure and is best visualized in the posterosuperior quadrant of the tympanic membrane
(Figure 20). If a dimeric membrane is present—
that is, two-layered membrane or atrophic scar
(‘‘monomeric’’ membrane is a misnomer)—
which is usually secondary to a healed perforation, mobility of the tympanic membrane can
also be assessed more readily by observing the
movement of the flaccid area.
The movement of the tympanic membrane to
the applied pressure from the rubber bulb
attached to the otoscope can generally determine
whether there is relatively normal pressure within
the middle ear, whether there is negative or
positive pressure, or whether there is a possible
effusion. Figure 21 shows a simple relationship
between the pressure applied by the pneumatic
otoscope and the response of that applied
positive and negative pressure to the medial (in)
and lateral (out) movement of the tympanic
membrane. Figure 22 shows a more specific
relationship between mobility of the tympanic
Figure 21. Middle-ear pressure as
determined by response of the tympanic membrane when positive and
negative pressures are applied with
the pneumatic otoscope. If the tympanic membrane moves medial (in) to
applied positive pressure and lateral
(out) to applied negative pressure,
middle-ear pressure is within relatively normal limits. If the eardrum
moves on applied positive pressure
but not when negative pressure is
applied, positive pressure is within the
middle ear (with or without effusion). If
the eardrum moves on applied negative pressure but not when positive
pressure is applied, negative pressure
is within the middle ear (with or
without effusion). If the tympanic
membrane fails to move after application of positive and negative pressures, effusion in the middle ear, or
very high negative middle-ear pressure, or both, are present.
158
OTITIS MEDIA IN INFANTS AND CHILDREN
Figure 22. Pneumatic otoscopic
findings related to middle-ear contents and pressure.
membrane, as measured by pneumatic otoscopy,
and the middle-ear contents and pressure. In
Figure 22, Frame 1 shows the normal tympanic
membrane when the middle ear contains only air
at ambient pressure. A hypermobile eardrum
(Frame 2) is seen most frequently in children
whose membranes are atrophic or flaccid. The
mobility of the tympanic membrane is greater
than normal (the eardrum is said to be highly
compliant) if the eardrum moves when even
slight positive or negative external canal pressure
is applied. If the eardrum moves equally well to
both applied positive and negative pressures, the
middle-ear pressure is approximately ambient.
However, if the tympanic membrane is hypermobile to applied negative pressure but is
immobile when positive pressure is applied, the
tympanic membrane is flaccid, and negative
pressure is present within the middle ear. A
middle-ear effusion is rarely present when the
tympanic membrane is hypermobile, even though
high negative middle-ear pressure is present. A
thickened tympanic membrane (secondary to
inflammation or scarring) or a partly effusionfilled middle ear (in which the middle-ear air
pressure is ambient) shows decreased mobility to
applied pressures, both positive and negative
(Frame 3).
Normal middle-ear pressure is reflected by
the neutral position of the tympanic membrane
as well as by its response to both positive and
negative pressures in each of the previous
examples (Frames 1 through 3). In other cases,
the eardrum may be retracted—usually because
Diagnosis
negative middle-ear pressure is present (Frames 4
through 6). The compliant membrane is maximally retracted by even moderate negative
middle-ear pressure, and hence cannot visibly
be deflected farther inward with applied positive
pressure in the ear canal. Negative pressure
produced by releasing the rubber bulb of the
otoscope will, however, cause a return of the
eardrum toward the neutral position if a negative
pressure equivalent to that in the middle ear
can be created by releasing the rubber bulb, a
condition (Frame 4) that occurs when air, with or
without an effusion, is present in the middle ear.
When the middle-ear pressure is even lower, there
may be only slight outward mobility of the
tympanic membrane (Frame 5) because of the
limited negative pressure that can be exerted
through the otoscopes currently available. If the
eardrum is severely retracted with extremely high
negative middle-ear pressure or in the presence of
a middle-ear effusion, the examiner is not able to
produce significant outward movement (Frame
6).
The tympanic membrane that exhibits fullness (Frame 7) will move to applied positive
pressure but not to applied negative pressure if
the pressure within the middle ear is positive and
air, with or without an effusion, is present. In
such an instance, the tympanic membrane is
stretched laterally to the point of maximal
compliance and will not visibly move outward
any farther to the applied negative pressure but
will move inward to applied positive pressure as
long as some air is present within the middle-ear–
mastoid-air-cell system. When this system is filled
with an effusion and little or no air is present, the
mobility of the bulging tympanic membrane
(Frame 8) to both applied positive and negative
pressure is severely decreased or absent.
Figure 23 shows examples of common conditions of the middle ear as assessed with the
otoscope. Position, color, degree of translucency,
and mobility of the tympanic membrane are
diagnostic aids.
Figure 24 depicts the pneumotoscopic
method used to determine whether a line that is
visualized on the lower portion of the tympanic
159
Figure 23. Common conditions of the middle ear, as assessed with
the otoscope.
membrane is the tympanic membrane touching
the promontory, an effusion level, or a scar
within the tympanic membrane. When the
tympanic membrane is severely retracted and
no middle-ear effusion is present, the tympanic
membrane may touch the promontory, and a line
can be seen through the membrane. However, if
the tympanic membrane can be pulled laterally
when negative pressure is applied with the
pneumatic otoscope, the line disappears because
the membrane is no longer touching the promontory (Figure 24A). A line that is due to a
fluid level moves up when positive pressure is
applied because the middle-ear cavity is made
smaller, and down when negative pressure is
160
OTITIS MEDIA IN INFANTS AND CHILDREN
Figure 24. Diagnostic significance of changing relative pressure and marks on the tympanic membrane. Reproduced with permission from
Bluestone CD. Otitis media. Kalamazoo (MI): The Upjohn Company; 1993. Current Concepts.
applied because the middle-ear cavity is made
larger (Figure 24B). If the line is a scar, it stays in
the same place on the tympanic membrane when
positive or negative pressure is applied (Figure
24C).
Otoscopy in the Newborn Infant
The position of the tympanic membrane in the
neonate is different from that in the older infant
and child.43 If this is not kept in mind, the
examiner may perceive the eardrum to be smaller
and retracted because in the neonate, the
tympanic membrane appears to be as wide as it
is in older children but not as high (Figure 25).
Figure 26 shows that this perception is due to the
more horizontal position of the neonatal eardrum, which frequently makes it difficult for the
examiner to distinguish the pars flaccida of the
tympanic membrane from the skin of the wall of
the deep superior external canal.
In the first few days of life, the ear canal is
filled with vernix caseosa, but this material is
easily removed with a small curet or suction tube.
Diagnosis
161
Figure 25. Otoscopic view of the
tympanic membrane of the neonate,
compared with that seen in the older
infant and child.
The canal walls of the young infant are pliable
and tend to expand and collapse with insufflation
during pneumatic otoscopy. Because of the
pliability of the canal walls, it is necessary to
advance the speculum farther into the canal than
Figure 26. Position of the tympanic membrane in the child is more
vertical than it is in the neonate.
for the older child. The tympanic membrane
often appears thickened and opaque during the
first few days. In many infants, the membrane is
in an extreme oblique position, with the superior
aspect proximal to the observer (see Figure 25).
The tympanic membrane and the superior canal
wall may appear to lie almost in the same plane,
so that it is often difficult to distinguish the point
where the canal ends and the pars flaccida begins.
The inferior canal wall bulges loosely over the
inferior position of the tympanic membrane and
moves with positive pressure, simulating the
movement of the tympanic membrane. The
examiner must distinguish between the movement of the canal walls and the movement of the
membrane. The following should be considered
to distinguish the movement of these structures:
vessels are seen within the tympanic membrane
but not in the skin of the ear canal; the tympanic
membrane moves during crying or respiration;
and inferiorly, the wall of the external canal and
the tympanic membrane lie at an acute angle. By
1 month of age, the tympanic membrane has
assumed an oblique position, as in the older
162
OTITIS MEDIA IN INFANTS AND CHILDREN
child. During the first few weeks of life, however,
examination of the ear requires patience and
careful appraisal of the structures of the external
canal and the tympanic membrane.
COMPLETES: A Mnemonic for Otoscopic
Examination
Kaleida has proposed a mnemonic that clinicians
can use when examining the tympanic membrane
for the presence or absence of otitis media (Table
1).44
Accuracy and Validation
Otoscopy is subjective and is thus usually an
imprecise method of assessing the condition of
the tympanic membrane and middle ear. Many
clinicians do not use a pneumatic otoscope,
and few have been adequately trained to make
a correct diagnosis. The primary reason for this
lack of proper education is the method of
teaching. Because otoscopy is a monocular
assessment of the tympanic membrane, the
teacher cannot verify that the student actually
saw the anatomic features that led to the
diagnosis. A new otoscope with a second viewing
port is available (Figure 27). Teacher and student
can make observations together, and student
Table 1. COMPLETES: A MNEMONIC FOR THE
OTOSCOPIC EXAMINATION
Color
Other conditions
Mobility
Position
Lighting
Entire surface
Translucency
External auditory canal
and auricle
Seal
Gray, white, yellow, amber, pink, red,
blue
Fluid level, bubbles, perforation,
retraction pocket, atrophic area,
otorrhea, bullae, tympanosclerosis,
cholesteatoma
4+, 3+, 2+, 1+
Neutral, bulging, retracted
Battery charged, halogen or bulb
Visualize all quadrants: anterosuperior,
posterosuperior, anteroinferior,
posteroinferior
Translucent or opaque
Inflammation, foreign body,
displacement, deformed
Appropriate-sized speculum, airtight
pneumatic system
Reproduced with permission from Kaleida PH.44
Figure 27. Teaching otoscope with sidearm viewer. Photo courtesy
of Welch-Allyn Inc., Skaneateles Falls, NY.
errors can be corrected immediately. One of the
most effective means of education currently
available is the correlation of otoscopic findings
with those of the otomicroscope, which has an
observer tube for the student. In this manner, the
instructor can point out critical landmarks and
demonstrate tympanic mobility.
Assessment techniques can also be improved
by correlating otoscopy findings with a tympanogram taken immediately after the otoscopic
examination.45 If the otoscopic findings and
tympanometry do not agree, a second otoscopic
examination is usually performed because tympanometry is generally accurate in distinguishing
between normal and abnormal tympanic membranes and middle ears (specifically, in identifying middle-ear effusions). The presence or
absence (and degree) of negative pressure within
the middle ear measured by pneumatic otoscopy
can be verified only by similar results on the
tympanogram.
Validation of otoscopic skills is important for
educating individuals and for documenting the
adequacy of participants in research programs.
Diagnosis
To validate the presence or absence of effusion as
observed by otoscopy, a tympanocentesis or
myringotomy should be performed immediately
after the examination. When surgical opening of
the tympanic membrane is indicated, preliminary
otoscopy by the examiner is an effective way of
validating the otoscopist. When otoscopists, who
ranged from house officers to pediatric otolaryngologists, were tested against myringotomy
findings in their ability to diagnose middle-ear
effusion, sensitivity ranged from 84 to 91, and
specificity was between 74 and 93.46–48 This
method has been described for research purposes,2,38,46,49 but it should be part of every
clinician-otoscopist’s method to improve the
accuracy of diagnosis of otitis media.
In a report from Australia, Eikelboom and
coworkers used digitized still images of the
eardrum, along with the clinical history, audiometry and tympanometry from patients’ primary
care providers in remote communities for the ear
specialist to provide an expert opinion using
television at a central site.50 This method holds
promise for improved diagnostic capabilities in
areas around the world where otologists are not
readily available.
Other Teaching Tools. In addition to the
color animated (movement of the tympanic
membrane with pneumatic otoscopy) figures in
the enclosed CD-ROM, Phillip H. Kaleida, MD,
and his colleagues at the Children’s Hospital of
Pittsburgh have developed a teaching tool and
self-assessment test on the web: the DxEar 50-ear
online self-assessment test and the Enhancing the
Proficiency of Residents in Otitis Media
(ePROM) modules. Individuals should register
on the Pitt Med Navigator site: ,http://
navigator.medschool.pitt.edu.. The URL for
ePROM is ,http://www.eprom.pitt.edu.. This
type of self-teaching and assessment tool is
especially beneficial for pediatric residents, since
one study revealed problematic diagnostic capabilities in these trainees.51 But other trainees,
such as those in family medicine and otolaryngology, as well as medical students, could benefit
from this innovative teaching method.
163
CLINICAL DESCRIPTION
Acute otitis media
The usual picture of AOM is seen in a child who
has had an upper respiratory tract infection for
several days and suddenly develops otalgia, fever,
and hearing loss. Examination with the pneumatic otoscope reveals a hyperemic, opaque,
bulging tympanic membrane that has poor
mobility (see Figure 23C).18 Purulent otorrhea
is usually also a reliable sign. In addition to fever, other systemic signs and symptoms
may include irritability, lethargy, anorexia,
vomiting, and diarrhea. Sore throat and night
restlessness have also been shown to be associated with AOM.52 However, none of these may
be present, and even earache and fever are
unreliable guides and may frequently be absent.53
Likewise, otoscopic findings may consist of only
a bulging or full, opaque, poorly mobile eardrum
without evidence of erythema. Hearing loss will
not be a complaint of the very young and may
not even be noted by parents.
Because of the variability of symptoms, infants
and young children presenting with diminished or
absent mobility and opacification of the tympanic
membrane should be suspected of having AOM.
Certainty in making the diagnosis has been
advocated in an effort to reduce the amount of
unnecessary prescriptions for antibiotics.1,54
The clinical practice guideline of the American
Academy of Pediatrics and American Academy of
Family Physicians was an attempt to provide a
uniform definition of AOM consistent with the
above discussion: acute onset; identification of
signs of middle-ear effusion; and signs and
symptoms of middle-ear inflammation.1 The
guideline identified the following elements:
1. Abrupt onset of signs and symptoms of
middle ear inflammation;
2. Presence of middle-ear effusion identified
by any of the following:
a. Bulging of the tympanic membrane;
b. Limited or absent mobility of the
tympanic membrane;
c. Otorrhea.
164
OTITIS MEDIA IN INFANTS AND CHILDREN
3. Signs of symptoms of middle-ear inflammation identified by either;
a. Erythema of the tympanic membrane or
b. Otalgia.
Otitis Media with Effusion
Most children with otitis media with effusion for
prolonged periods are asymptomatic. Some may
complain of hearing loss and, less commonly,
tinnitus and vertigo. In children, the attention of
an alert parent or teacher may be drawn to a
suspected hearing loss. Sometimes, the child
presents with a behavioral disorder that is due to
the hearing deficit and consequent inability to
communicate adequately. More often, the reason
for referral is the detection of a hearing loss during
a school hearing screening test or when AOM fails
to resolve completely. On occasion, the first
evidence of the disease is discovered during a
routine examination or in high-risk cases, such as
in children with a cleft palate.
Older children will describe a frank hearing
loss or, more commonly, a ‘‘plugged’’ feeling or
‘‘popping’’ in their ears. The symptoms are usually
bilateral. Unilateral signs and symptoms of
chronic middle-ear effusion may uncommonly be
secondary to a nasopharyngeal neoplasm, such as
an angiofibroma, or even a malignant neoplasm.
Pneumatic otoscopy frequently reveals either
a retracted or full tympanic membrane that is
usually opaque (see Figure 23E). However, when
the membrane is translucent, an air-fluid level
or air bubbles may be visualized, and a blue or
amber color is present. The mobility of the eardrum is almost always altered (see Figure 23D).
It is evident from the preceding clinical
description of AOM and otitis media with
effusion that there is considerable overlap, and
it is often difficult for the clinician to distinguish
between acute and chronic forms unless the child
has been observed for a time before the onset of
disease or there are associated specific (otalgia)
or systemic (fever) symptoms. It may not be
possible to distinguish between them even when
the middle-ear effusion is aspirated (tympanocentesis) because in both acute and chronic otitis
Table 2. DIAGNOSIS OF ACUTE OTITIS MEDIA VERSUS
OTITIS MEDIA WITH EFFUSION
Signs and Symptoms
Otalgia, fever, irritability
Middle-ear effusion
Opaque
Bulging tympanic membrane
Retracted tympanic membrane
Decreased mobility of tympanic
membrane
Hearing impairment
Acute
Otitis Media
Otitis Media
with Effusion
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No (air-fluid level)
No (usually)
Yes/No
Yes
Yes
Yes (usually)
media, the effusion may be serous, mucoid, or
purulent. In approximately half of chronic
effusions, bacteria have been cultured that are
frequently found in ears of children with classic
signs and symptoms of AOM.55
Because it is important today in the decision
to treat or not to treat otitis media, especially
with the increasing incidence of antibioticresistant bacteria causing otitis media, the
clinician must appreciate the diagnostic differences between AOM and otitis media with
effusion. Otitis media with effusion is usually
not treated unless it becomes chronic. Table 2
summarizes the important diagnostic differences
between these forms of otitis media.
Eustachian Tube Dysfunction
Some children, especially older ones, complain
of a periodic popping or snapping sound in the
ear that may be preceded or accompanied by a
feeling of fullness in the ear, hearing loss,
tinnitus, or vertigo. Otoscopic examination may
reveal a normal tympanic membrane or possible
slight retraction of the eardrum, but the middleear pressure is within normal limits. These
children have obstruction of the eustachian tube
(ie, the tube is too closed or will not open, or both)
that is not severe enough to cause atelectasis or a
middle-ear effusion but nevertheless may be
disconcerting. This disorder is not uncommon
in girls who are in puberty and may be present
even when there has not been a history of middleear disease in the past. The etiology of this
problem, primarily in young girls, may be related
Diagnosis
to hormonal changes associated with puberty.
When this condition is troublesome, management should be as for the children who have
middle-ear effusion, such as myringotomy and
tympanostomy tube placement.
On occasion, older children may complain of
autophony (hearing one’s own voice in the ear)
and hearing their own breathing. In these cases,
the eustachian tube is most likely patulous
(abnormally patent), and the tympanic membrane will appear normal when it is visualized
through the otoscope. Middle-ear pressure is
normal. However, if the child is asked to breathe
forcefully through one nasal cavity while the
opposite one is occluded with a finger, the
posterosuperior portion of the tympanic membrane is observed to move in and out with
respiration, which confirms the diagnosis.
Tympanometry may also aid in diagnosis.
Atelectasis of the Tympanic Membrane–
Middle Ear and High Negative Pressure
Atelectasis of the tympanic membrane may be
acute or chronic, generalized or localized, and
mild or severe. The tympanic membrane may be
retracted or collapsed. High negative pressure
may be present or absent (see Figure 23B). When
middle-ear effusion is also present, the clinical
description is the same as for cases in which an
acute or chronic otitis media is present. In such
cases, it is not unusual to visualize through the
otoscope a severely retracted malleus associated
with a tympanic membrane that is full or even
bulging in the posterior portion. The malleus is
retracted by concurrent high negative middle-ear
pressure or chronic inflammation of the tensor
tympani muscle or the mallear ligaments, or
both. The hydrostatic pressure of the effusion
(which does not completely fill the middle ear
and mastoid air cell system) results in bulging of
the most compliant (floppy) portion of the pars
tensa (the posterosuperior and posteroinferior
quadrants). An effusion is frequently evident by
the presence of an air-fluid level or bubbles
behind a severely retracted tympanic membrane.
165
Just as when a middle-ear effusion is present,
there may be a lack of specific otologic symptoms
when atelectasis is present with no effusion. The
child may have a severely retracted translucent
tympanic membrane with evidence of high
negative pressure by pneumatic otoscopy (immobile to applied positive pressure and either
decreased or absent mobility to applied negative
pressure) or a high negative middle-ear pressure
tracing on the tympanogram. The otoscopist can
look through the tympanic membrane and see
that no effusion is present. Some children with
such an otoscopic (and tympanometric) examination result may not have any complaint,
whereas others may have a feeling of fullness in
the ear, otalgia, tinnitus, hearing loss, and even
vertigo. The condition may be self-limited and, in
some, physiologic because of temporary eustachian tube obstruction. In others, especially
those with symptoms, the condition is pathologic
and should be managed in a manner similar to
when an effusion is present.
When there is localized atelectasis or a
retraction pocket, especially in the pars flaccida
or posterosuperior portion of the pars tensa of
the tympanic membrane, the condition may be
more serious than when only generalized atelectasis is present. A portion of the tympanic membrane may be atrophic (also termed a dimeric
membrane), which implies only two layers of the
drum when, in reality, there are three layers but
the lamina propria lacks the normal organized
collagenous architecture.56 The child may be
totally asymptomatic, but the retraction pocket
may be associated with a significant conductive
hearing loss, especially if there is erosion of one
or more of the ossicles. Erosion of the long
process of the incus may be present when a deep
posterosuperior retraction pocket is seen (Figure
28). It is extremely important to inspect these
areas of the tympanic membrane to determine
whether a retraction pocket is present and, if it is
present, whether there is destruction of one of the
ossicles.
It is important to distinguish between a
retraction pocket and a cholesteatoma. If the
otoscopic examination is not adequate to make
166
OTITIS MEDIA IN INFANTS AND CHILDREN
one currently used. The function of the aural
acoustic immittance instrument (previously
called an electroacoustic impedance bridge)
depends on the principles of sound in relation
to the physiologic characteristics of the ear. The
most effective transfer of energy occurs when
energy flows from one medium to another
medium of similar impedance (ie, with similar
physical properties of stiffness, mass, and friction). The middle ear facilitates the transfer of
sound from an air medium with low impedance
to a liquid medium with relatively high impedance (cochlea) (Figure 29A). The tympanic
membrane and middle ear, therefore, act as an
impedance-matching transformer. Abnormalities
that interfere with this function impair hearing.
Figure 28. An atelectatic membrane that has a severe retraction
pocket in the posterosuperior quadrant of the pars tensa.
this differential diagnosis, referral to an otolaryngologist for examination with an otomicroscope
should be considered; the otolaryngologist
should not hesitate to perform otomicroscopic
examination under general anesthesia when
indicated. Cholesteatoma, like its precursor, the
deep retraction pocket, may be without signs and
symptoms (other than the otoscopic appearance)
unless conductive hearing loss or otorrhea is
present (see Chapter 9, ‘‘Complications and
Sequelae: Intratemporal’’).
AURAL ACOUSTIC IMMITTANCE
MEASUREMENTS, INCLUDING
TYMPANOMETRY
Acoustic immittance describes the transfer of
acoustic energy. It can be measured in terms of
acoustic impedance (commonly used by clinicians in the past), which is the opposition to the
flow of sound waves, or acoustic admittance,
which expresses the ease of energy flow. Acoustic
admittance is the more appropriate term and the
Figure 29. Examples of normal, increased, and decreased middleear impedance. A, In the normal condition, some sound is transmitted
through the tympanic membrane–middle ear to the cochlea, and
some portion is reflected back into the external canal. B, When there
is increased impedance, such as with an effusion in the middle ear,
less sound is transmitted to the cochlea and more sound is reflected
back into the ear canal than in the normal condition. C, When middleear impedance is decreased, such as with an ossicular chain
discontinuity, sound is stored in the middle ear instead of being
effectively transferred to the cochlea and reflected back into the ear
canal, but at a point in time that is opposite to that when the
tympanic-membrane–middle-ear impedance is increased.
Diagnosis
Three basic observations can be made with
aural acoustic immittance instruments: (1) tympanometric pattern, (2) middle-ear muscle reflex,
and (3) equivalent ear canal volume. The instrument has become increasingly popular and it is
currently used in a wide variety of clinical
settings for both diagnosis and screening. A
tympanic-membrane–middle-ear system that has
an increase in one or more of the components of
impedance (stiffness, mass, or friction) does not
transfer sound energy efficiently to the cochlear
fluids. In such an instance, acoustic impedance is
increased, or stated reciprocally, acoustic admittance is reduced. Therefore, a greater amount of
sound energy is reflected from the tympanicmembrane–middle-ear region and a smaller
amount of sound energy is transmitted to the
cochlea. An excellent example of this type is a
middle ear that contains an effusion (Figure
29B). Conversely, the tympanic membrane and
middle ear may have a decrease in impedance (or
increase in admittance), which may occur with
disarticulation of the ossicular chain. In this case,
an increased amount of sound energy is received
by the middle ear but is not transmitted to the
cochlea (Figure 29C).
Instrumentation
The clinical instrumentation used to perform
acoustic immittance measurements has changed.
Aural acoustic immittance instruments have
replaced the older instruments referred to as
electroacoustic impedance bridges. The design
differs, although both instruments provide an
objective assessment of the mobility of the
tympanic membrane and the dynamics of the
ossicular chain, the intra-aural muscles with their
attachments, and the middle-ear air cushion.
Regardless of which instrumentation is used, the
same principles apply.
The instruments allow a signal to be introduced through an opening in the probe tip, which
is hermetically sealed in the external auditory
canal (Figure 30). A certain amount of the signal
is transmitted into and through the tympanic
membrane and middle ear, and a certain amount
167
Figure 30. Schematic design of aural acoustic immittance instrument (ie, electroacoustic impedance bridge).
is reflected back into the ear canal. The reflected
sound is received by a microphone circuit that
has a certain amplitude and phase related to the
physical properties of the tympanic membrane.
The frequency of the signal is determined by the
frequency of the probe tone, which is commonly
226 Hz.
Another component of the probe assembly is
a connection to an air pump that varies the air
pressure in the closed ear canal. With this
arrangement, immittance can be monitored with
a varying air pressure load or static air pressure
load on the tympanic membrane. The air
pressure can be varied either manually or automatically with most instruments. Measuring
immittance changes at the tympanic membrane
with changes in air pressure is called tympanometry, and when there is a static pressure load,
static immittance can be measured.
Tympanometry with Impedance Instruments
Tympanometry involves varying canal air
pressure in a single sweep from +400 or +200 to
2400 mm H2O (or 2600 decapascals [daPa]),
thereby altering the stiffness of the tympanic
membrane. Changing the stiffness of the tympanic membrane results in an alteration of the
relationship between the probe tone and the
sound pressure level in the canal. The microphone receives the reflected sound and changes it
from an acoustic signal to an electric signal. The
tympanogram, a graphic display of the changing
relationship of the probe tone to the sound
pressure level in the canal, is recorded as
tympanic membrane impedance. The abscissa of
168
OTITIS MEDIA IN INFANTS AND CHILDREN
Figure 31. Tympanogram showing trace (pressure, compliance,
and shape) related diagrammatically to position of the tympanic
membrane during the tympanometry procedure. A, Initially, 200 mm
H2O is applied to the external canal, which stiffens the tympanicmembrane–middle-ear system to produce reduced compliance
(increased impedance). B, The pressure in the external canal is
then progressively lowered to 2400 mm H2O, which also stiffens the
tympanic membrane–middle ear. C, In the normal ear, the peak of
the trace is recorded on the graph at ambient pressure, which is the
point of maximal compliance (lowest impedance) and the pressure
within the middle ear.
the tympanogram records air pressure in millimeters of water (mm H2O), and the ordinate
records compliance, an arbitrary unit. Figure 31
shows an example of a normal tympanogram.
Because tympanic membrane compliance is
maximized when air pressure on both sides of
the eardrum is equal, the peak of the normal
tympanogram tracing occurs at approximately
0 mm H2O. If pressure within the middle ear is
negative, the tympanometric peak is in the
negative pressure zone of the tympanogram
(Figure 32). Thus, the position of the peak of the
trace along the horizontal axis usually indicates the middle-ear pressure.57,58 Also important
is the height of the peak. Normally, the height of
the peak is between half-scale and full-scale on the
ordinate. Conditions that increase the impedance
of the tympanic-membrane–middle-ear system (eg,
middle-ear effusion) can result in a tympanogram
peak that is less than half-scale, showing decreased
or low compliance. Conversely, conditions that
decrease the impedance of the system (eg, a flaccid
Figure 32. Tympanogram showing a trace of an ear with negative
middle-ear pressure. The procedure is the same as illustrated
diagrammatically in Figure 7-31, but in this example, the peak of the
trace, or point of maximal compliance, is in the negative pressure
zone.
tympanic membrane) elevate the peak to exceed
full-scale deflection. Therefore, the position of the
peak along both the ordinate and the abscissa
provides information regarding middle-ear pressure and the acoustic impedance of the system. In
addition, the shape of the peak, or more specifically, the gradient (slope) is also important. A peak
that has a gradual (rounded) slope rather than a
steep one is usually associated with some degree of
tympanic-membrane–middle-ear disorder.
Tympanometry with Admittance
Instruments
Tympanometry with an admittance instrument
uses the same basic techniques as tympanometry
with an impedance instrument. Both vary ear
canal pressure and measure the resulting sound
pressure level in the ear canal. However, there are
some differences.
With admittance instruments, the sound
pressure level of the probe tone is kept constant
with automatic gain control circuitry. The
electrical current required to keep a constant
sound pressure level is directly proportional to
admittance magnitude at the probe tip. The
Diagnosis
tympanogram obtained from an admittance
instrument is measured in absolute units rather
than in the arbitrary units that impedancemeasuring instruments use. The ordinate of the
tympanogram records admittance (Y) of a
volume of air (in cubic centimeters or milliliters)
that has equivalent acoustic admittance, or in
units called millimhos (mmho), and the abscissa
records air pressure in decapascals (1 daPa 5
1.02 mm H2O). The height of the peak varies
with age; values range from a mean of 0.5 (90%
range of 0.22 to 0.8) in children 3 to 5 years
of age to a mean of 0.7 (90% range of 0.3 to 1.4)
in adults.59 The measurement of admittance
allows information regarding the transfer of
acoustic energy to be taken directly from the
tympanogram.
Validation of Tympanometry
Tympanograms obtained from impedance instruments are analyzed qualitatively because of the
use of relative, or arbitrary, units. As a result,
tympanometric patterns are classified and related
to various pathologic conditions involving the
eardrum and middle ear. By assessing the
pressure, compliance, and shape of the tympanometric trace, the normal tympanic-membrane–
middle-ear system can be distinguished from the
abnormal one with a reasonable degree of
certainty. In addition, the types of abnormality
may also be determined.
Bluestone and colleagues attempted to relate
these patterns (with the Madsen instrument
[Madsen Electronics, Copenhagen, Denmark])
to the presence or absence of effusion at
myringotomy but found a high percentage of
false-positive results (ie, the tympanometric
patterns indicated the presence of an effusion
but none was found at myringotomy).60 In a later
study from Pittsburgh, Paradise and colleagues
proposed a pattern classification with the same
type of instrument to identify middle-ear effusion
based on otoscopy and, in many instances, the
myringotomy findings.61 The accuracy of the
diagnosis of effusion was higher with the
Paradise and colleagues classification than with
169
the previously proposed patterns. The study also
demonstrated that tympanometry in infants
younger than 7 months was not valid because
of their highly compliant external auditory
canals. In a subsequent study conducted in San
Antonio, Gates and colleagues confirmed the
diagnostic accuracy of this pattern classification.62 Beery and coworkers, employing the
Grason-Stadler otoadmittance meter (GrasonStadler Company, Madison, WI), also related
myringotomy findings to the tympanometric
patterns and proposed a pattern classification
for diagnosis of middle-ear effusion.63 The
patterns were 93% accurate. Shurin and colleagues also employed the Grason-Stadler instrument and proposed a pattern classification based
on measurements with a planimeter.64 Cantekin
and colleagues compared the two instruments—
the Madsen electroacoustic impedance bridge
and the Grason-Stadler otoadmittance meter—
by their abilities to identify middle-ear effusions;
the tympanometric findings were validated by
myringotomy, and the same number of falsenegative and false-positive patterns were
recorded for both instruments.
In a Finish study, Palmu and Syrjanen
increased sensitivity and specificity of tympanometry (Grason-Stadler GSI 38 Auto Tymp and
Audiometer) in the diagnosis of otitis media
infants by comparing the child’s sick visits with
ones that were obtained when the child was well.4
Thus, serial examinations in the clinical setting
can aid in an accurate diagnosis.
Unfortunately, the instruments that were
validated for the presence or absence of middleear effusion are no longer available and have
been replaced by admittance-measuring devices.
Few of the instruments currently on the market
have been validated. In addition, quantitative
analysis has replaced classification schemes using
shape. Of the instruments available, the GSI 33
Middle Ear Analyzer (Grason-Stadler) has been
validated by Nozza and coworkers.65 Two
groups of subjects were studied; one was made
up of children undergoing myringotomy and
tube insertion for management of recurrent
AOM or chronic otitis media with effusion, and
170
OTITIS MEDIA IN INFANTS AND CHILDREN
the other was a group of children in an allergy
outpatient setting who were considered to be
more representative of the general population.
The admittance measures were analyzed with
respect to presence or absence of middle-ear
effusion when the myringotomy was performed
and, in the outpatient study, by a validated (ie,
previously validated against myringotomy findings) otoscopist. Calculations of the sensitivity,
specificity, and positive and negative predictive
values were made on different immittance criteria
to determine the presence or absence of effusion
based on findings at the time of myringotomy
(Table 3). The Maico Screening Immittance
Bridge (Model No. 610 [Medical Acousns
Instrument Compaing, MN]) has also been
validated against the findings at myringotomy.45
Fields and coworkers validated the Microtymp
(Welch Allyn, Skaneateies ralls, MN) and the
Amplaid 720 impedance bridge using a modified
Jerger classification, Ovesen and colleagues
validated the Madsen model ZS330 (Medsen
Electronics, Minnetonka, MN),66 and van Balen
and de Melker validated the AR 85 portable Micotymp (Welch Allyn) tympanometer.67
Another method of validating these instruments
is to compare the tympanogram patterns with the
otoscopic assessment of a validated otoscopist.65,68 Other instruments that are currently in
use should have similar validation procedures
performed and published. The American
National Standards Institute has published standards for measurements of acoustic impedance
Table 3. SENSITIVITY AND SPECIFICITY FOR
TYMPANOMETRY RELATED TO PRESENCE OR ABSENCE
OF MIDDLE-EAR EFFUSION AS DETERMINED BY
FINDINGS AT MYRINGOTOMY
Variable
Ytm or Peak Y
(mmho or cm3)
TW (daPa)
Criterion
Sensitivity
Specificity
0.1
0.2
0.3
0.4
. 150
. 200
. 250
67
78
78
78
89
78
78
100
100
98
89
93
99
100
Adapted from Nozza RJ, et al,5 and Nozza RJ, et al.65
Ytm 5 peak admittance; TW 5 tympanometric width; mmho 5 millimho; daPa
5 decapascal.
and admittance (aural acoustic immittance),69
which were used in part by the American SpeechLanguage-Hearing Association updated guidelines.70 Additional information is greatly needed
from large-scale studies using standard measuring techniques to develop normative clinical
data.
Therkildsen and Gaihede assessed a newer
instrument, the MEA 901 tympanometer
(Madsen Electronics, Copenhagen, Denmark)
and found the high rates of pressure change
(common among the newer instruments) can lead
to decreasing accuracy in detecting the middleear pressure, which they attributed to the
intrinsic hysteresis of the middle ear.71
Tympanometric Patterns
From all of these studies, it appears that use of
the acoustic immittance instrument is an accurate
way of identifying middle-ear effusions, but it is
not perfect. The instrument can be an invaluable
aid in diagnosing and, under certain conditions,
screening for middle-ear disease, but there is still
no consensus on the patterns that accurately
identify middle-ear effusion. The first attempt
to classify patterns on the basis of contour
was made by Jerger72; he described types A, B,
C, and D, but these types were not validated
either with myringotomy findings or by a
validated otoscopist. Paradise and coworkers
proposed a classification that was based on
myringotomy findings.61
Figure 33 shows the types of tympanograms
obtained from immittance instruments and their
common variants that relate to expected conditions of the eardrum and middle ear. This chart is
based on myringotomy findings. Tympanograms
that are considered normal are those included in
the first frame of the figure. Ears that yield
variant tympanograms will on occasion (2%) be
found to have an effusion, especially a scant,
thin, serous effusion usually seen as an air-fluid
level or bubbles behind a translucent eardrum.
Variant 1b, even though it has a somewhat low
compliance, is usually not obtained when an
effusion is present. The tympanogram type that
Diagnosis
171
Figure 33. Tympanogram types related to presumptive conditions of the middle ear.
has an open end (peak off graph) at or near the
normal pressure zone (Frame 2) is the result of
high compliance and is most commonly associated with a flaccid tympanic membrane that is
secondary to wide fluctuations in middle-ear
pressure and loss of eardrum elasticity resulting
from eustachian tube dysfunction. However, an
effusion is not present. When this type of
tympanogram is associated with a significant
conductive hearing loss (usually between 40 and
60 decibels [dB]), an ossicular discontinuity
should be suspected.
The negative pressure type of tympanogram
(Frame 3) has many variants, of which the four
most common are shown. Unfortunately, there is
currently no totally reliable way of predicting the
presence or absence of effusion by the variant,
because all may be associated with a middle-ear
effusion. However, the probability that an ear
yielding a tympanogram of variant 3a has an
effusion is less than the probability of effusion in
ears giving the other three variants. An ear from
which a tympanogram of variant 3d (with a
rounded peak) is recorded has the highest probability of having an effusion. When the tympanogram trace is open without a peak and is in the
negative pressure zone (Frame 4), the tympanic
membrane is flaccid, and only rarely will an
effusion be present within the middle ear. The
explanation for the floppy tympanic membrane is
the same as that described for the type of
tympanogram in Frame 2, but in this type,
negative pressure is evident at the time of testing.
Again, as described previously (Frame 2), if a
significant air-bone audiometric gap is found, an
ossicular chain discontinuity should be suspected.
The tympanogram type that shows a high positive
pressure (Frame 5) may be associated with an
effusion, usually AOM with effusion, particularly
with variant b. All of the variants shown for the
types of tympanograms that have low compliance
(Frame 6) are usually associated with a middle-ear
effusion. Ears from which tympanograms of
variants 6a and 6b are recorded may or may not
have an effusion, whereas 90% of ears with
tympanograms of variants c and d will have an
effusion. One study found that the type B
tympanogram (ie, flat) could predict the magnitude of the air-bone gap in otitis media with
effusion.73 Other pathologic conditions that can
result in this type of pattern are conditions that
can increase the acoustic impedance of the system
(eg, thickening of the tympanic membrane,
ossicular chain fixation, or adhesive otitis media).
The most accurate method of determining the
presence or absence of middle-ear effusion is
172
OTITIS MEDIA IN INFANTS AND CHILDREN
tympanometric width (see Table 3).5,74 When
inhalant anesthesia is used, such as when tympanostomy tubes are to be inserted, tympanograms
should be obtained prior to (as opposed to during
or after) the anesthetic for accuracy of the test.75
The shapes of tympanograms recorded from an
immittance device that measures total admittance
(Y) using a low-frequency probe tone are similar to
those recorded from an impedance device. For
example, in conditions that increase the stiffness or
impedance of the middle-ear system, such as
middle-ear effusion, otosclerosis, or ossicular fixation, the tympanograms show a reduced height of
the peak, show a reduced admittance, or may be
flat. However, in certain cases, the admittance (Y) is
within an acceptable range yet the tympanogram is
abnormally wide. Some instruments separate
admittance (Y) into susceptance (B) and conductance (G) components or have the ability to change
the probe tone to higher frequencies. Recording the
separate components and changing the probe tone
to a higher frequency can add diagnostic information and increase the usefulness of tympanometry.
Multiple frequency and multiple component tympanograms are more difficult to classify and
interpret clinically and, until recently, have been
more limited in their use. However, it is important
to have some understanding of the findings with use
of multiple-frequency, multiple-component tympanometry.
If admittance is separated into susceptance
(B) and conductance (G) components or if higher
probe tones are used, variations in tympanometric shape can occur. The overall amplitude of
the tympanogram will be altered, and quantification of admittance becomes important. For most
normal ears, the single-peak tympanogram is
obtained for B, G, and Y for both high- and lowfrequency probe tones, although with highfrequency probes, B and perhaps Y may be
notched. In cases of middle-ear disease that
changes the stiffness of the system, it is easier
to detect the middle-ear abnormality with a
higher frequency probe tone, such as 660 or 667
hertz (Hz), because there is a greater proportional change than with the low-frequency tone.
This is because the 660/667 Hz probe tone is close
to the resonant frequency of the middle ear and is
less dominated by stiffness in the system.
In cases of otosclerosis or ossicular fixation
(also stiffening pathologic processes), tympanograms obtained with multiple components
recorded are different from tympanograms
obtained from normal ears. That is, in most
normal ears, B and G have similar shapes, and G
is greater than B. When there is ossicular fixation,
B is greater than G. In middle-ear conditions that
increase admittance and mass, such as ossicular
discontinuity, there may be a notching in the B and
perhaps G tympanogram when high-frequency
probe tones are used. When low-frequency probe
tones are used, notching usually does not occur.
Multiple-frequency, multiple-component tympanometry yields more useful information for
most middle-ear diseases than single-component,
single-frequency tympanometry. However, even
with multiple-frequency, multiple-component tympanometry, there is no one-to-one correspondence
between specific tympanometric findings and
specific pathologic processes that affect the tympanic membrane. Furthermore, pathologic processes
that affect the tympanic membrane, such as those
that cause high admittance, can obscure middle-ear
pathologic processes of low admittance because
tympanometry is recorded at the plane of the
tympanic membrane and the condition of the
tympanic membrane has primary influence on the
tympanometric pattern. An example is a middle ear
with one of the ossicles fixed (eg, the stapes, with
adhesive otitis media), but a tympanogram is either
normal or reveals high admittance because the
tympanic membrane is flaccid. Therefore, definitive
diagnosis of an ossicular pathologic disorder
usually depends on an audiogram or, ultimately,
an exploratory tympanotomy.
Acoustic Middle-Ear Muscle Reflex
The aural acoustic immittance instrument can
also detect contraction of the middle-ear muscle,
the stapedius, to intense sound stimulation. This
contraction is called the acoustic middle-ear
muscle reflex (or the acoustic stapedial reflex)
or, simply, the acoustic reflex.
Diagnosis
The anatomy of the acoustic reflex arc is
depicted in Figure 34. The afferent portion of the
arc, up to and including the superior olivary
complex, is shared with the hearing mechanism.
The efferent fibers of the acoustic reflex arc arise
from neuronal connections in the brain stem
between the olivary and the facial nerve nucleus
for the stapedius muscle.
The acoustic immittance instrument indicates
the status of the acoustic reflex in two ways.
First, the reflex results in a stiffening of the
ossicular chain and a concomitant increase in
impedance. Second, because the reflex is bilateral
to a unilateral stimulus (the muscles of both sides
contract when one ear is stimulated), delivery of
an intense stimulus to one ear, with the probe tip
of the immittance instrument inserted in the
opposite ear, can detect the immittance change
caused by the reflex.
When the immittance instrument is used to
detect an acoustic reflex elicited by stimulation of
the opposite ear, the response is commonly called
Figure 34. Diagrammatic representation of the acoustic reflex arc.
173
the contralateral, or crossed, acoustic reflex.
Many acoustic immittance instruments marketed
today have probe tips designed to both stimulate
and detect the acoustic reflex in the same ear:
the reflex is elicited and its effect on immittance
is detected in the same ear. Under these conditions, the response is called the ipsilateral, or
uncrossed, acoustic reflex.
The threshold of the acoustic reflex is
operationally defined as the minimal stimulus
intensity required to produce an observable
change in monitored immittance. This minimal
intensity, or acoustic reflex threshold, is typically
specified as a certain number of decibels, referenced to hearing level. Hearing level refers to
normal hearing for a group of young adults (ie,
0 dB on the audiogram).
In adults with normal hearing, the contralateral acoustic reflex threshold for pure tones of
different frequencies is approximately an 85- to
95-dB hearing level. Approximately 20 dB less
intensity is required to elicit a reflex with a
broadband noise stimulus. Ipsilateral reflex
thresholds are approximately 10 dB better than
contralateral thresholds.
The influence of a middle-ear effusion and
attendant conductive hearing loss on the reflex is
not simply a result of the mode of reflex stimulation. Ipsilateral acoustic reflex tests stimulate and
detect the response in the same ear through the
immittance instrument probe tip. In the middle ear
with an effusion, the immittance is already abnormally altered, and further changes in immittance,
due to middle-ear muscle contraction, may not be
observable; to be detectable, these changes may
require elevated stimulus intensity levels.
It follows that ipsilateral acoustic reflex
testing in a middle ear with an effusion will most
probably yield no response. If the response is
present, the threshold of the response will tend to
be elevated.
The influence of a middle-ear effusion on the
contralateral acoustic reflex may be somewhat
more difficult to understand. The contralateral
reflex will probably be absent if the middle
ear with the probe tip has an effusion or if
the effusion-filled middle ear with the stimulus
174
OTITIS MEDIA IN INFANTS AND CHILDREN
earphone has a moderate to moderately severe
conductive hearing loss. The reason for the first
situation was described before. In the second
situation, the conductive hearing loss necessitates
reflex stimulus levels that may be beyond the
instrument’s output capabilities. For these reasons, the contralateral acoustic reflex is generally
absent in cases of bilateral otitis media with
effusion. When the effusion is unilateral, the
contralateral reflex will probably be absent for
both ears if the impaired ear has a moderate to
moderately severe conductive hearing loss.
Equivalent Ear Canal Volume
Estimating the volume of air medial to the probe
tip can be useful, especially when a flat tympanogram is obtained. This measurement can be used
to determine whether the tympanic membrane is
intact or perforated and whether a functioning
tympanostomy tube is present. Clinically, the
volume estimate obtained with a low-frequency
probe tone can detect a microscopic perforation,
even when the tympanic membrane appears to be
mobile when positive or negative pressure is
applied by the pneumatic otoscope (assuming
that the perforation is small enough and the
magnitude of the pressure exerted by the otoscope
is sufficient to move the eardrum). A similar
condition frequently exists when a tympanostomy tube is in the tympanic membrane but the
patency of the tube is questionable.
The volume of the middle ear is measured by
applying +200 or 2400 mm H2O pressure to the
external canal with the immittance instrument. If
the tympanic membrane is intact, the measurement should be approximately 0.5 to 1 mL in a
younger child and between 0.65 and 1.75 mL in
an older child or adult. If the eardrum is not
intact, greater values are found: more than 2 mL
in the child and 2.5 mL in the adult. However,
some children have large ear canal volumes that
may exceed 2 mL when the tympanic membrane
is intact. Therefore, in such a case, an additional
method should be attempted to determine
whether a nonintact tympanic membrane is
present. The external canal pressure should be
Table 4. ASHA GUIDELINE FOR EQUIVALENT EAR
CANAL VOLUME MEASURES FOR CHILDREN 1 TO 7
YEARS OF AGE BEFORE AND AFTER PLACEMENT OF
TYMPANOSTOMY TUBES
90% Range for Ears with and
without Tubes
Before Tube
Placement
After Tube
Placement
5th percentile–95th percentile
0.3–0.9 cm3
1.0–5.5 cm3
Adapted from American Speech-Language-Hearing Association.70
raised to 400 daPa. If the eardrum has an
opening, the eustachian tube will be forced open
in most children, and rapid drops in pressure are
noted. All infants and children from whom a
tympanogram is obtained should also have ear
canal volume recorded because a flat or rounded
tympanogram apparently indicating an effusion
may be found in a child who actually has a nonintact eardrum.
The American Speech-Language-Hearing
Association has published criteria for equivalent
ear canal volume measures in children 1 to 7
years of age (Table 4).70
Screening for Middle-Ear Disease with
Acoustic Immittance Measurements
Emphasis has been placed here on interpreting the
three acoustic immittance measurements—tympanometric pattern, equivalent ear canal volume, and
acoustic reflex—as a whole. This approach provides the best opportunity for accurate diagnostic
assessment. There have been many attempts,
however, to separate certain immittance measurements as screening tools, particularly to detect
middle-ear disease in children.
Several published investigations have evaluated the screening effectiveness of tympanometry, the acoustic reflex, or both.58,59,76–88 Brooks
supported the utility of the acoustic reflex alone
as a screening tool to detect middle-ear disease
in children.89 These investigators commonly
agree that immittance measurements are easy
to perform, noninvasive, reliable, and highly
sensitive to the presence of middle-ear disease.
These factors would favor the use of tympanometry and the acoustic reflex as screening
measurements to detect disease. However, there
Diagnosis
are still no definitive data supporting the validity
of immittance measurements for screening.
Although the measurements are sensitive to
disease when it is present, they are considerably
less accurate in sorting out children without
disease, and the percentage of false-positive
errors is uncomfortably high.90,91 The resulting
over-referral rate argues against the costeffectiveness of mass screening for middle-ear
disease with acoustic immittance measurements.
A review of the state of the art and suggested
guidelines for impedance screening for middle-ear
disease in children were presented at a workshop
on screening by Bluestone and coworkers.92
Tympanometric Screening for Middle-Ear
Effusion
Screening for middle-ear effusion is a process
intended to identify children who may have the
disease but in whom it would otherwise go
undetected. Otitis media is a disease for which
screening appears to be important because it is
highly prevalent, it is associated with varying
degrees of conductive hearing loss, and it may
lead to other more serious complications and
sequelae. Otoscopy performed by an expert is an
excellent method to identify otitis media and
should be employed as a routine part of the
examination by professionals who care for
children. This is especially important in infants
and young children. However, for mass screening, otoscopy is not feasible. Audiometry,
employing the routine audiologic screening
criteria, has been shown to identify only half of
a group of children with middle-ear effusion.60 In
addition, audiometry, employing standard
screening methods, cannot be performed on
young infants, in whom the prevalence of the
disease is the highest. However, immittance
screening employing tympanometry is a highly
sensitive method to screen for middle-ear effusion. The use of the acoustic reflex as the sole
screening measurement is highly sensitive but is
not specific enough to use because too many
children are over-referred to their physicians.65,93
Immittance testing is acceptable to both the child
175
and the health care provider because it is safe,
noninvasive, and simply executed. Studies have
shown immittance measurements to be reliable,
but these studies have not involved subjects of all
age groups or all instruments that are available,
many of which have been designed specifically
for screening purposes.
The validity of referral criteria for specific
diagnoses based on immittance measurements (ie,
their association, singly or combined, with the
presence or absence of middle-ear effusion) has
not been established completely, and further
studies are required. In addition, neither the
epidemiology nor the natural history of the
disease has been adequately studied in the various
age groups affected, which makes most of the
methods of management currently employed
difficult to evaluate. In many instances, middleear effusion spontaneously disappears. Because
of these problems, the referral criteria for
children who are identified with a middle-ear
effusion remain controversial.94
Not only are there no currently agreed upon
criteria for pattern classification related to the
presence or absence of middle-ear effusion, but
the patterns may be interpreted differently by the
tester.95
The detection of middle-ear effusion by
tympanometry is not as accurate during the first
year of life as it is in the second year of life.95
However, in a study from Finland, 58 infants (2
to 11 months of age) who had AOM were
evaluated with use of the GSI 38 Autotymp
(Grason-Stadler), and 74% had a tympanocentesis to validate the presence or absence of
effusion.96 The investigators found tympanometry technically successful in 94% of ears; the
sensitivity of a flat pattern (type B) to detect ears
with effusion was 0.70 and the specificity 0.98
with a positive predictive value of 0.93 and a
negative predictive value of 0.94. The sensitivity
was somewhat lower in infants younger than 7
months (0.61), but specificity and positive and
negative predictive values were good in all infants
in the study. The study showed that AOM can be
detected by use of this instrument, which is
helpful for clinical practice.
176
OTITIS MEDIA IN INFANTS AND CHILDREN
Nevertheless, the most recent American
Speech-Language-Hearing Association panel on
audiologic assessment has proposed guidelines
for screening infants and children with outerand middle-ear disorders when it is needed,
requested, or mandated or when they have
conditions that place them at risk.70 For infants
and children 7 months to 6 years old, screening is
recommended for the following characteristics
(as cited from Bluestone and Klein):97
N
N
N
N
N
N
N
N
N
A first episode of AOM before 6 months of
age.
Infants who have been bottle-fed.
Children with craniofacial anomalies, stigmata, or other findings associated with syndromes known to affect the outer and middle
ear.
Ethnic populations with documented increased
incidence of outer- and middle-ear disease,
such as Native Americans and Eskimo populations.98
A family history of chronic or recurrent otitis
media with effusion.
Those in group day-care settings or crowded
living conditions.
Those exposed to excessive cigarette smoke.
Children diagnosed with sensorineural hearing
loss,99 learning disabilities, behavior disorders,
or developmental delays and disorders.
For children in this age group, it is recommended to conduct the first regularly scheduled
screening program in the fall in conjunction
with screening for hearing impairment. A
second regularly scheduled screening program
is also recommended for those children who
failed or were missed in the fall screening. It is
not necessary to screen children who are under
the care of a physician for middle-ear disease.
Table 5 shows the currently recommended
initial tympanometric screening test criteria.70
Recommendations
The most recent screening protocol recommended by the American Speech-LanguageHearing Association is based on a four-part
Table 5. ASHA RECOMMENDED INITIAL
TYMPANOMETRIC SCREENING TEST CRITERIA
Infants
1 Year to School Age
Ytm , 0.2 mmho
or
TW . 235 daPa
Ytm , 0.3 mmho*
or
TW . 200 daPa
Adapted from American Speech-Language-Hearing Association,70 Roush
et al,259 and Nozza et al.5,65
Ytm 5 peak admittance (in millimhos); TW 5 tympanometric width (in
decapascals).
*For children older than 6 years, when using +400 or 2400 daPa for
compensation or ear canal volume, Ytm of less than 0.4 mmho is the
recommended criterion.
procedure consisting of case history, visual
inspection, pure-tone audiometry, and tympanometry.93 Referral criteria are presented in Table
6. The protocol is presented in flow chart format
in Figure 35. The flow chart is a representation of
the logic used to determine the need for referral.
It does not represent the order in which test
procedures are administered. With the exception
that visual inspection should precede tympanometry, the order of test procedures is unimpor-
Table 6. REFERRAL CRITERIA FOR MEDICAL
EVALUATION
I.
A.
B.
II. Visual
A.
B.
Otalgia
Otorrhea
Inspection of the Ear
Structural defect of the ear, head, or neck
Ear canal abnormalities
1. Blood or effusion
2. Occlusion
3. Inflammation
4. Excessive cerumen, tumor, foreign material
C. Eardrum abnormalities
1. Abnormal color
2. Bulging eardrum
3. Fluid line or bubbles
4. Perforation
5. Retraction
III. Identification Audiometry
Fail air conduction screening at 20 dB HL at 1, 2, or 4
kHz in either ear (ASHA, 1985) (These criteria may
require alteration for various clinical settings and
populations.)
IV. Tympanometry
A. Flat tympanogram and equivalent ear canal volume
(Vec) outside normal range
B. Low static admittance (Peak Y) on two successive
occurrences in a 4- to 6-week interval
C. Abnormally wide tympanometric width (TW) on 2
successive occurrences in a 4- to 6-week interval
Adapted from American Speech-Language-Hearing Association.93
Diagnosis
Figure 35. Flow chart for determining the need for audiologic or
medical referral incorporating case history, visual inspection, puretone audiometry, and tympanometry. Each numbered box is
discussed in the text. The flow chart represents the logic used to
determine the need for referral. It does not indicate the order of test
procedures. Adapted from American Speech-Language-Hearing
Association.93
tant. Each test component, indicated by a
numbered box in Figure 35, is described here.
1. A recent otologic history of otalgia or
otorrhea is sufficient cause for immediate medical referral.
2. Visual inspection of the ear may produce
sufficient cause for medical referral without the
need for further testing. Referral criteria include
structural defect of the ear, head, or neck;
inflammation, blood, effusion, excessive cerumen, tumors, or foreign body in the ear canal; or
eardrum appearance consistent with active
middle-ear disease. When visual inspection indicates the need for medical referral, tympanometry is not necessary. When visual evidence of
middle-ear infection is present, or when a
pressure-equalization tube is in place, tympano-
177
metry should not be performed unless it is
requested by a physician.
3, 4. Audiometric screening should be performed by the method described in the American
Speech-Language-Hearing Association Guidelines for Identification Audiometry.100 The
guidelines recommend screening with pure-tone
stimuli presented at a 20-dB hearing level (re:
ANSI S3.6-1969) with frequencies of 1,000,
2,000, and 4,000 Hz. Failure to respond to any
frequency constitutes failure of the audiometric
screening. In accordance with the Guidelines for
Identification Audiometry, failure of the audiometric screening should be confirmed by repeated
screening, either on-site or by additional testing
at a later date. If the audiometric screening is
failed on the second administration, a complete
audiologic evaluation should be performed.
5, 6. Low static admittance (Peak Y) associated with an abnormally large volume in front
of the probe is evidence of a tympanic membrane
perforation and warrants immediate referral. The
presence of ear canal volume (estimated at 200
daPa) exceeding the 90% range in the presence of
a flat tympanogram is evidence of a large volume
and should result in a medical referral.
7. Low static admittance (Peak Y) may or may
not be associated with significant middle-ear
disorders. In the absence of other positive findings,
a Peak Y below the 90% range requires observation during an extended period before a medical
referral is warranted. Only after two successive
abnormal findings during an interval of 4 to 6
weeks should a medical referral be made.
8, 9. Abnormal tympanometry width may
occur in the absence of other findings in cases
with otitis media. These cases may represent
transient secretory otitis media, which does not
require medical referral. Like low static admittance, abnormal tympanometry width in the
absence of other signs of middle-ear disorders
requires retesting after 4 to 6 weeks, and only
then should a medical referral be based on this
finding alone.93
Even though tympanometric screening for
middle-ear effusion is not recommended for the
general population of children, screening of special
178
OTITIS MEDIA IN INFANTS AND CHILDREN
populations, as a method to identify effusion for
epidemiologic research, is valuable.101,102
Immittance Instrumentation
During the last 15 years, an increasing number of
instrument companies have introduced immittance
instruments to the market. This has been primarily
because of the widespread acceptance of this
technique of assessment, which is related to the
ever-growing number of studies showing that
immittance testing improves the accuracy of
diagnosis of otitis media and related conditions.
Tympanometry is a reliable, simple procedure that
is easily carried out in a short time by nonprofessional personnel. For all of these reasons, the
instruments have become enormously popular.
With this has come a technologic explosion in
instrumentation that has resulted in confusion
among professionals who wish to purchase new
instruments and concern by those who find their
relatively new instruments outdated in only a few
years. In addition, most of the new or modified
instruments are not field tested and validated
before being marketed; this presents a distinct
problem for the clinician who wishes to use a
validated, reliable instrument. However, some of
the instruments have been validated and are
reliable, as demonstrated during many years of
use by both clinicians and investigators.
The first commercially available instrument
to measure acoustic impedance was developed in
Denmark during the 1950s by Terkildsen and
Nielsen,6 and it was manufactured in 1958 by
Madsen Electronics as their model ZO61. In
1963, Madsen introduced model ZO70, which
rapidly became the prototype for all the impedance bridges that followed and has provided the
latest information on the invaluable diagnostic
capabilities of electroacoustic impedance measurements. In 1971, Madsen introduced the
ZO72, which incorporated an audiometer so that
a contralateral acoustic reflex could be measured.
A later model added the ability to measure the
ipsilateral acoustic reflex. In 1970, the GrasonStadler Company introduced the otoadmittance
meter, which measures the complex components
of acoustic impedance. The measurement as
described by the developers is termed acoustic
admittance, which is divided into acoustic
susceptance (compliance) and acoustic conductance (resistance), and it is expressed in acoustic
milliohms.103 Subsequent to the popularity of the
Madsen model ZO70, many other companies
began manufacturing impedance bridges. Some
are designed for diagnostic use, others are purely
for screening, and still others can be used for both
diagnostic and screening purposes. The clinician
should decide which instrument to purchase on
the basis of need; however, availability of repair
services should also be considered.
The instruments that have been validated by
comparing the patterns obtained by impedance
audiometry with the findings at myringotomy are
the Madsen model ZO7060,61,104; Grason-Stadler
model 172063,64,104; Grason-Stadler model 1722105;
Grason-Stadler GSI 33 Version I Middle Ear
Analyzer65; Maico Screening Impedance Bridge
(model 610),45 Microtymp,47 and the Amplaid 720
impedance bridge47; the Madsen model ZS33066;
and the Grason-Stadler GSI 38 Autotymp.96
ACOUSTIC REFLECTOMETRY
Acoustic reflectometry was introduced by Teele
and Teele in the early 1980s as a method to
accurately and objectively diagnose middle-ear
effusion.106 At that time, a handheld instrument
was developed and used in several studies, with
mixed results.107–111 Then an improved instrument became available with great promise:
handheld a lightweight portable instrument
available for clinical use and a similar device
for home use.112
Acoustic reflectometry, improved with spectral gradient analysis, is available in the
EarCheck-PRO Otitis Media Detector (Innovia
Medical, LLC, Lenexa, KS) (Figure 36).113 The
earlier approach to acoustic reflectometry analyzed only the difference in sound intensity
between incident and reflected waves. Accurate
results depended on operator technique, because
it required a direct line of sight to the tympanic
membrane. Spectral gradient is less technique-
Diagnosis
dependent and does not require a direct line of
sight to the tympanic membrane. Unlike tympanometry, it does not require pressurization of the
ear canal or an ear seal to obtain a reading. The
new device determines the probability of middleear effusion by measuring the response of the
eardrum to a frequency sweep in the audible
range of 1.8 to 4.4 kHz. The instrument emits a
tone into the external auditory canal, and its
microprocessor analyzes the sum of the emitted
Figure 36. Cross-sectional view of spectral gradient acoustic
reflectometry instrument, EarCheck. Photo courtesy of Becton
Dickinson Company, Franklin Lakes, NJ.
179
tone and its reflection. The data from the
instrument can be printed as a curve on a graph.
The slopes of the curve, representing the data
from the incident and reflected sound waves
around the frequency of maximal nullification,
are the spectral gradients. The replaceable plastic
tip of the instrument is inserted into the external
auditory canal of the patient, and a reading is
taken with the push of a button. The spectral
gradient is displayed on the back of the instrument. Results are sorted into five ranges of
spectral gradient angles that indicate the probability of middle-ear effusion. Figure 37 shows
the spectral gradient display for the instrument.
A clinical study of the EarCheck was
reported by Block and coinvestigators that
involved 528 subjects (870 ears) in four centers.114 They compared acoustic reflectometry
with tympanometry and found similar sensitivity,
specificity, and positive and negative predictive
values (Table 7). The percentage of ears with
Figure 37. Display panel of the EarCheck instrument for acoustic
reflectometry showing the five possible outcomes: high, moderatehigh, moderate, low-moderate, and low possibility of presence of
middle-ear effusion.
180
OTITIS MEDIA IN INFANTS AND CHILDREN
Table 7. COMPARISON BETWEEN SPECTRAL GRADIENT
ACOUSTIC REFLECTOMETRY (SG-AR) AND
TYMPANOMETRY DOCUMENTED BY PNEUMATIC
OTOSCOPY IN 528 SUBJECTS
Instrument
Positive Negative
Predictive Predictive
Sensitivity Specificity
Value
Value
SG-AR
Tympanometry
67
61
87
91
57
66
91
89
Adapted from Block SL, et al.114
middle-ear effusion—as documented by pneumatic otoscopy—related to the level of spectral
gradient acoustic reflectometry is shown in Table
8. In a follow-up study by Block and another
group of colleagues, the instrument was found to
be useful in diagnosing middle-ear fluid when the
child had AOM.8 In a study by Barnett and
associates, spectral gradient reflectometry was
compared with the findings at myringotomy,
tympanometry, and pneumatic otoscopy for the
diagnosis of middle-ear effusion.7 They concluded that acoustic reflectometry was comparable to tympanometry for diagnosis of middleear effusion with the presence or absence of
effusion at surgery and pneumatic otoscopy.
It appears from these two studies that
spectral gradient acoustic reflectometry is of
value for clinical use because of its ease of use,
relatively inexpensive, and comparable to the
more expensive tympanometry as an objective
method to diagnose middle-ear effusion. More
studies are recommended.115 The consumer product could be helpful for selected parents whose
children have recurrent or severe ear infections.
Table 8. PERCENTAGE OF EARS WITH MIDDLE-EAR
EFFUSION (MEE) DOCUMENTED BY PNEUMATIC
OTOSCOPY VERSUS LEVEL OF SPECTRAL GRADIENT
ACOUSTIC REFLECTOMETRY IN 870 EARS OF 528
SUBJECTS
Level
Predicted Risk
of MEE
Number of
Ears
Ears with
Documented MEE
(%)
1
2
3
4
5
Low
Low–moderate
Moderate
Moderate–high
High
383
279
82
76
50
3.4
15.8
34.2
57.9
92.0
From Block SL, et al.114
The instrument could reduce the number of
physician office visits if parents who are appropriately counseled monitor their children for the
presence or absence of middle-ear effusion.
ASSESSMENT OF HEARING
The assessment of hearing in infants and children
is not an accurate method for identifying the
presence of a middle-ear effusion. However,
hearing assessment can be valuable in determining the effect of middle-ear disease on hearing
function and is important in making decisions
regarding management.
Hearing loss is by far the most prevalent
complication and morbid outcome of otitis
media, and it may be caused by one or more of
the intra-aural complications or sequelae. To a
varying degree, fluctuating or persistent loss of
hearing is almost always associated with otitis
media. An audiogram usually reveals a mild to
moderate conductive hearing loss; when otitis
media is present, the average loss is 27 dB.116
However, there may be a sensorineural component, generally attributed to the effect of
increased tension and stiffness of the round
window membrane. This hearing loss is usually
reversible when the effusion resolves, but permanent conductive hearing loss can result from
irreversible changes secondary to recurrent acute
or chronic inflammation (eg, adhesive otitis
media, tympanosclerosis, or ossicular discontinuity). Irreparable sensorineural hearing loss
may also occur, presumably when infection
spreads through the round or oval window
membrane117 or labyrinthitis due to perilymphatic fistula occurs.118 Audiometry can be performed reliably in children as young as 6 months.
Children younger than 2 years are the group at
highest risk for effusions and associated hearing
loss, and in these patients, standard audiometric
assessment may be difficult to perform reliably.
Therefore, infants and young children may
require nonbehavioral tests of hearing.
All infants and children should have their
hearing evaluated, if possible, when a chronic
middle-ear effusion is present. The clinician
Diagnosis
considers the type (ie, conductive, sensorineural,
or both) and the degree of hearing loss for the
selection and timing of the various management
options available.
Methods
In general, there are two methods of evaluating
hearing in children: behavioral and nonbehavioral.
The age and the ability of the child to cooperate
usually dictate which tests are selected.119
Behavioral Tests
Neonatal reactions to sudden, intense sound are
predominantly reflexive and include the Moro
reflex, the aural palpebral reflex, and the arousal
and cessation responses.
The Moro reflex is a generalized motor
response that is commonly known as the startle
reflex. Classically, neonates (and most infants)
thrust the head backward and suddenly move the
arms and legs up and outward when a stimulus of
80 to 85 dB sound pressure level is presented. The
aural palpebral reflex, or eyeblink reflex, consists
of a contraction of the musculus orbicularis oculi
and, frequently, closing of the eyelids. A stimulus
of 105 to 115 dB sound pressure level is usually
required. The arousal and cessation reflexes
involve clear contrasts in the neonate’s activity
before and after the stimulus. A stimulus of 90 dB
sound pressure level should awaken or arouse the
sleeping or drowsy neonate; in the cessation reflex,
a decrease or inhibition of activity in the restless or
crying baby is observed. However, these reactions
are primarily reflexive, require intense stimuli, and
are qualitative rather than quantitative.
Behavioral observation audiometry is a technique used for neonates and young infants in
which the examiner presents a stimulus sound
and observes the child’s associated behavioral
response, which does not require conditioning.
Simple noisemakers such as rattles, squeak toys,
and bells are common stimulus devices used in
the office setting. Calibrated stimuli are used in a
test booth in audiology centers.
Visual reinforcement audiometry also involves
the presentation of a stimulus sound and the
181
observation of the child’s conditioned head-turn
response (Figure 38). The response, however, is
rewarded with a visual reinforcement, such as a
blinking light, an illuminated picture or toy, or
an animated toy that is located above the
loudspeaker through which the stimulus is
presented. The test is most successful for assessing infants aged 6 months to 2 years.
Tangible reinforcement audiometry, or tangible reinforcement operant conditioning audiometry, uses candy or sugar-coated cereal to reward
the child for pressing a bar when the sound
stimulus is presented (Figure 39). It is appropriate for assessing children who are difficult to
test, including the mentally retarded and infants.
Figure 38. Visual reinforcement audiometry. Infant sits on mother’s
lap and is observed by the examiner, who presents a sound stimulus
through a speaker to the right or left of the child. The infant’s
response, a head turn toward the sound stimulus, is rewarded by
activation and illumination of the animated toy.
182
OTITIS MEDIA IN INFANTS AND CHILDREN
provide information regarding both speech and
pure-tone stimuli and can determine the degree
of hearing loss for the individual ear. In addition,
play audiometry can provide threshold information on both air and bone conduction and,
therefore, can determine whether a loss is
conductive, sensorineural, or both.
Conventional audiometry is usually reserved
for children 5 years of age and older but can be
used for certain younger children, depending on
the examiner and the cooperation of the child.
The assessment should include pure-tone and
speech audiometry to determine air and bone
conduction thresholds of children with chronic
otitis media with effusion to identify the type and
degree of hearing loss for each ear.
Figure 39. Tangible reinforcement operant conditioning audiometry
(TROCA). Infant or young child sits on mother’s lap and is observed by
the audiologist, who presents the sound stimulus through a speaker to
the right or left of the child. The infant or child responds by pressing the
bar on the TROCA device. Correct responses are rewarded by delivery
of a tangible object, such as cereal, candy, or small toys.
These tests provide some indication of the
degree of hearing loss present but not the type
(conductive or sensorineural). However, in some
children, visual reinforcement audiometry and
tangible reinforcement operant conditioning
audiometry may be able to determine the hearing
level in the individual ear. They are appropriate
for children younger than 3 years.
Play audiometry is similar to conventional
tests given to older children and adults and can
be used to assess the hearing of children 2 years
of age and older. Conventional audiometric
techniques can be used, but they must be modified to be more interesting for the young child,
usually in the form of play. The assessment can
Nonbehavioral Tests
Nonbehavioral techniques to assess hearing
include acoustic impedance measurements, auditory brain stem response recordings, cardiac
audiometry, and respiratory audiometry.
However, of all of these tests, the auditory brain
stem response (ABR) is currently the best
available and most widely used method. It is a
test that is relatively independent of the child’s
behavioral response and is ordinarily used to
evaluate infants and children for whom information on behavioral hearing tests is either unobtainable or unreliable. Figure 40 shows a diagram
of the equipment used for the test procedure.
Three miniature electrodes placed on the scalp
Figure 40. A schematic diagram of the equipment used for auditory
brain stem response audiometry.
Diagnosis
Figure 41. Auditory brain stem response (ABR) to a 60-dB normal
hearing level click stimulus in a patient with normal hearing. Major
wave components are labeled I through VII.
record the responses. The ABR consists of five to
seven vertex-positive waves, labeled I to VII,
occurring in the first 10 milliseconds after the
onset of the stimulus (Figure 41). Waves I
through III presumably reflect activity of the
eighth cranial nerve fibers and auditory centers in
the pons. Waves IV and V apparently reflect
activity of the auditory centers in the mid to
rostral pons and the caudal midbrain, respectively; the neural generators for waves VI and
VII are less certain.
The electrical configuration for the ABR
includes the active electrode on the vertex of
the skull, or mid-forehead at the hairline, and the
reference and ground electrodes, respectively, on
the ipsilateral and contralateral mastoid processes or earlobes. The responses to clicks of
2,000 to 4,000 Hz, filtered clicks, or brief puretone bursts are typically averaged for each
stimulus intensity employed. The stimuli are
presented at a rapid rate (10 to 30 per second),
and a complete run, at a given stimulus intensity,
requires 1.5 minutes; in most cases, the entire
procedure for both ears at several stimulus
intensities averages less than an hour.
183
Because excessive muscle activity can interfere
with the test, the child must be completely relaxed
or, preferably, asleep. Natural sleep can be
facilitated by feeding babies, up to about 6 months
of age, immediately before the test. Children 7
years of age or older can lie quietly for the
procedure. Infants and children between these ages
require sedation or even general anesthesia.
The test can be sensitive in identifying a
conductive hearing loss associated with a chronic
middle-ear effusion, and it is especially valuable in
the young infant. However, the technique does not
assess the perceptual event called hearing. The
ABR reflects auditory neural electric responses
that are adequately correlated to behavioral
hearing thresholds. However, a normal result on
the ABR suggests only that the auditory system up
to the midbrain level is responsive to the stimulus
employed—it does not guarantee normal hearing.
In cases of middle-ear impairment, the entire
series of ABR waves is delayed in time by an
amount commensurate with the degree of attendant conductive hearing loss.120 Latency of wave
I provides a better index of middle-ear impairment (Figure 42). The consistent nature of the
ABR in young infants makes it particularly
useful in evaluating hearing when a chronic
middle-ear effusion is present.
Figure 42. The Auditory brain stem response (ABR) in a 6-monthold infant with otitis media with effusion showing an example of
latency delay. The top trace was recorded immediately before
myringotomy, and the bottom trace immediately thereafter.
Reproduced with permission from Fria TJ, and Sabo DL.120
184
OTITIS MEDIA IN INFANTS AND CHILDREN
Indications
Infants and children who have frequently recurrent otitis media or chronic otitis media with
effusion, or both, should have their hearing
assessed.121 It is important to know the degree
of hearing loss and whether that loss is conductive, sensorineural, or both. Obtaining bone
conduction audiometry is recommended to
determine the presence or absence of a sensorineural loss; there may be a Carhart’s notch (ie, a
false depression of bone conduction thresholds)
in the presence of effusion.122 If the loss is only
conductive and mild, management may consist of
watchful waiting in the hope that the natural
history of the effusion is in favor of spontaneous
resolution. On the other hand, if there is significant
bilateral conductive loss, such as greater than
30 dB, surgical intervention (eg, tympanostomy
tubes) may be an appropriate option, because the
hearing loss may interfere with the child’s development. The degree of conductive loss present in
each ear is more desirable information, because
there may be a sequela or chronic middle-ear
effusion present in one ear and not in the other. An
ossicular chain disarticulation secondary to rarefying osteitis, or ossicular fixation resulting from
adhesive otitis media, may cause a maximal
conductive hearing loss (ie, 50 to 60 dB). In
addition, a cholesteatoma may also be present
even though there is no apparent defect in the
tympanic membrane, and this may cause ossicular
damage and a conductive loss. When the hearing
loss (conductive) appears to be out of proportion
to that expected with chronic otitis media with
effusion, an examination with an otomicroscope is
necessary to exclude the possibility of a retraction
pocket or cholesteatoma, or both, in either the
pars flaccida or the posterosuperior quadrant of
the pars tensa. General anesthesia is required if a
child cannot be examined adequately while awake.
At this time, a myringotomy and aspiration can be
performed and a tympanostomy tube can be
inserted. In addition, if the patient is too young
for assessment of hearing with behavioral methods, is difficult to assess, or is not cooperative, an
ABR can be performed at the time of general
anesthesia. The test should be performed after the
aspiration of the effusion to determine whether a
residual conductive hearing loss is present that
might indicate an ossicular abnormality.
When a conductive hearing loss associated
with a middle-ear effusion is present, and the
effusion either resolves in response to medical
treatment or is removed by myringotomy,
another audiogram should be obtained to verify
that hearing has returned to normal limits. An
audiogram should be obtained for every child
approximately 2 weeks after tympanostomy
tubes are inserted (as long as there is no otorrhea
present). A persistent, marked conductive hearing loss without any effusion is strong evidence
of an acquired ossicular defect or a concurrent
congenital anomaly. The presence of both a
chronic otitis media with effusion and a congenital ossicular deformity is frequent in the child
with Down syndrome.
When a mixed hearing loss (conductive and
sensorineural) is identified after the assessment, the
clinician must suspect a middle-ear effusion that
may be causing a serous (toxic) labyrinthitis
resulting from penetration of the round window
or, possibly, a congenital or acquired defect in
either the oval or round window, or both. In these
cases, the infection spreads directly into the
labyrinth. Progressive or fluctuating sensorineural
hearing loss with or without vertigo may be
present, and if it is documented, the patient should
have further assessment (eg, vestibular testing or
computed tomography of the temporal bone) and
possible exploration (tympanotomy) of the middle
ear to search for a perilymphatic fistula.118,123
If the sensorineural hearing loss is due to a
known cause in children (such as neonatal
asphyxia or meningitis), not to a condition that
can be corrected, as described previously, more
aggressive management of chronic otitis media
with effusion may be required than is needed for
a child who does not have a sensorineural
hearing loss. The conductive hearing loss added
to a permanent sensorineural hearing loss may
be handicapping for the child. This is especially
true for the patient who has a moderate to severe
sensorineural hearing loss and is ‘‘main-
Diagnosis
streamed’’ or is in a school for the deaf.
Myringotomy and tympanostomy tubes are early
treatment options for such children, rather than
prolonged observation. Again, if a mixed hearing
loss is suspected because the degree of loss
appears to be greater than would be expected
from otitis media with effusion, an accurate
assessment of hearing is mandatory, regardless of
the child’s age. High-risk infants and children, in
whom there is a family history of sensorineural
hearing loss, are the greatest concern. For such
an infant, a procedure including examination
under anesthesia, myringotomy, and insertion of
tubes followed by ABR is the best method to
establish a definitive diagnosis and treat the
chronic otitis media with effusion.
185
Figure 43. Audiometric findings in 58 ears with middle-ear effusion.
Approximately half of the ears tested with middle-ear effusion would
have passed hearing screening if 25 dB was the cutoff. Reproduced
with permission from Bluestone CD, et al.60
Screening for Hearing Loss
Identification of hearing loss is an important part
of screening programs for preschool and schoolaged children because such identification must be
followed by more definitive testing, evaluation,
and possibly habilitation or rehabilitation of the
child. However, audiometric screening to identify
a middle-ear effusion does not have high enough
sensitivity and specificity to warrant its use.
Bluestone and coworkers found that only half of
a group of children (58 ears) with chronic middleear effusion would have been identified by an
auditory screening test if 25 dB had been used as
the criterion for failure (Figure 43).60 However,
audiometric screening of children is still necessary to identify those children who have sensorineural or conductive hearing loss.70
traditional hearing screening results and those
obtained from the Audioscope. More experience
in using the Audioscope under office conditions
is required to determine its value for screening
children for hearing loss.
Every otolaryngologist and pediatrician
should have an audiometer available to test
children. For the pediatrician, a soundproof
room and a sophisticated instrument are not
necessary, but a screening audiometer should be
part of pediatric ambulatory clinical facilities.
Those children found to have a hearing loss that
is out of proportion to the disease under
management (eg, otitis media) or those infants
and children who are difficult to treat should be
referred to an otolaryngologist or diagnostic
hearing center, or both.
Recommended Audiometers
Otoacoustic Emissions
A handheld screening instrument that provides
audiometric testing at 500, 1,000, 2,000, and
4,000 Hz at a 25 dB hearing level has been
developed by the Welch-Allyn Company
(Audioscope). Gershel and colleagues compared
the Audioscope with traditional audiologic
screening and pure-tone and speech audiometry.124 There was general agreement between
Otoacoustic emissions are a measure of cochlear
activity and have been used as an objective test to
evaluate hearing. Owens and coworkers have
used this promising test to identify middle-ear
effusion in children,125 but the validity and
feasibility in the clinical setting are currently
being investigated. Dhooge and colleagues have
used click-evoked otoacoustic emissions to eval-
186
OTITIS MEDIA IN INFANTS AND CHILDREN
uate hearing before and after tympanostomy
tube insertion.126 Yeo and colleagues reported
that otoacoustic emissions have a prognostic
value in children with middle-ear effusions.127
The same team of investigators also reported on
the effect on distortion-product otoacoustic
emissions related to clinical and biochemical
factors in children with middle-ear effusion.128
At the Children’s Hospital of Pittsburgh, otoacoustic emission testing has been found to be
very useful in evaluating hearing following
placement of tympanostomy tubes in infants
and other children who are difficult to test using
behavioral methods. Employing both otoacoustic emissions and tympanometry have been found
to be useful in screening infants and young
children for hearing loss and middle-ear effusion,
although follow-up audiologic testing is needed
for those who fail the otoacoustic emissions
testing to determine the type and degree of
hearing loss.129
Special Populations
Because of high risk, serious consequences, or a
known high prevalence of middle-ear disease,
certain populations of children warrant special
consideration, beginning soon after birth, for
early detection of and surveillance for this
disorder. These populations include children with
known sensorineural hearing loss, developmentally delayed and mentally impaired children,
children with cleft palate or other craniofacial
anomalies, and Native American children (First
Nations and Inuit).
VESTIBULAR TESTING
Otitis media with effusion and eustachian tube
dysfunction are the most common causes of
dysequilibrium (eg, vertigo, falling, and clumsiness)
in infants and children. The dysequilibrium is
almost invariably resolved when the middle-ear
effusion is absent or the child no longer has
fluctuating middle-ear pressures. Parents will frequently report a dramatic dysappearance of dysequilibrium immediately after tympanostomy tubes
are inserted for recurrent acute or chronic otitis
media with effusion or eustachian tube obstruction
(fluctuating high negative pressure).130–132
For most infants and children with otitis
media and signs and symptoms of dysequilibrium, sophisticated vestibular testing is not
indicated because nonsurgical or surgical management of the eustachian-tube–middle-ear disorder will resolve the problem.133 In addition, the
tests currently available in the usual vestibular
test center are usually not feasible in children,
especially infants and young children. However,
when the dysequilibrium persists, even when the
middle-ear effusion resolves and middle-ear
pressures return to normal levels (especially after
tympanostomy tube insertion), the child should
be referred to an otolaryngologist for assessment
of vestibular function to rule out the possibility
of another cause of imbalance.134 Children who
have frequent attacks of vertigo in association
with otitis media, with or without fluctuating or
progressive sensorineural hearing loss, should
be suspected of having a labyrinthine fistula
(see Chapter 9, ‘‘Complications and Sequelae:
Intratemporal’’).
Casselbrant and colleagues described tests
that can assess vestibular function in infants and
children.130 They evaluate children’s standing
balance with use of a moving posture platform to
assess the velocity of sway before and after
tympanostomy tube insertion. This team
reported use of this method of vestibular testing
in 22 Pittsburgh children with success.135
Casselbrant and colleagues reported that children who had had otitis media in the past had
abnormal balance testing later in life when no
middle-ear effusion was present.136 (The effect of
middle-ear effusion on the balance system is
discussed in more detail in Chapter 9,
‘‘Complications and Sequelae: Intratemporal’’.)
HIGH-RISK POPULATIONS
Cleft Palate
Ear disease and hearing loss have long been
recognized as common problems in patients with
Diagnosis
cleft palate. Alt, in 1878, first reported this
association.137 He noted that hearing improved
when otorrhea associated with cleft palate was
treated. Thorington, in 1892, reported increased
hearing in a patient after artificial correction of a
destroyed palate.138 In 1893, Gutzmann noted
hearing loss in half of his patients with cleft
palate.139 In 1906, Brunck stressed the need for
otologic examination of patients with cleft
palate.140 Since these early descriptions, many
reports have appeared in the literature related to
the incidence, nature, and degree of hearing loss
in patients with cleft palate.
Hearing Loss
The prevalence of hearing loss in the cleft palate
population varies considerably, as reported in the
literature. Of all studies, the average prevalence is
approximately 50%. Even though the criteria of
hearing loss have not been generally agreed on, it
has been identified as conductive and usually
bilateral.
Halfond and Ballenger found that, of 69
patients tested, 37 (54%) had a hearing loss of 20
dB or greater.141 Miller reported that 19 (54%) of
35 children with cleft palate had a hearing loss
greater than 30 dB.142 Walton studied 93 schoolaged children with cleft palate and suggested that
the prevalence may be even greater143; half of
those who would have passed conventional
audiometric screening at the 20 dB level were
found to have air-bone gaps that indicated
conductive hearing loss. Bluestone and colleagues support this contention by having found
high-viscosity middle-ear effusions in children,
including those with cleft palate, who would have
passed a 25 dB screening audiogram.60 One study
revealed that the hearing of children who had
bilateral cleft lip and palate was worse than that
of children who had isolated cleft palate.144 In a
study using ABR testing of 3-month old infants,
the mean thresholds were 53 dB in the left ear
and 49 dB in the right ear; tympanometry at the
time of the hearing testing revealed a flat pattern
in 83%.145 Even though a conductive hearing
impairment would be expected, Bennett and
colleagues reported that 30% of 100 adults with
187
cleft palate had either sensorineural or mixed
hearing loss.146 This finding might be explained
by the work of Paparella and coworkers, who
found sensorineural hearing loss in some patients
with otitis media and ascribed this to directly
associated pathologic changes in the inner
ear, presumably mediated through the round
window.117
When hearing is tested over time in infants
and young children with cleft palate, they
consistently have worse hearing as a group,
compared with children without cleft palate in
the same age group.147 Even though some reports
have indicated that middle-ear disease and its
associated hearing loss decrease after repair of
the palate,148 others have found the need for
placement of ventilation tubes to persist in many
of the children, despite repair.149,150
Aural Pathology
Infants. Variot, in 1904, was the first to
report ear disease in an infant with cleft palate.151
Sataloff and Fraser, in 1952, reported that, in
their experience, ‘‘examination of the ears of very
young children with cleft palate reveals a high
incidence of pathologic changes, despite the
absence of subjective symptoms of otitis
media.’’152 In 1958, Skolnick reported that only
6% of cleft palate patients younger than 1 year,
and only 27% of those between the ages of 1 and
4 years, had aural disorders.153 However,
Linthicum and colleagues in 1959 discovered
pathologic ear changes in 77% of a group of 100
infants and children with cleft palate.154 In 1967,
Stool and Randall reported that middle-ear
effusion was present at myringotomy in 94% of
25 infants with cleft palate.21 In 1969, Paradise
and colleagues, using standard office otoscopy,
diagnosed middle-ear disease in 49 of 50 infants
with cleft palate.20 Most had full or bulging,
opaque, immobile tympanic membranes, but
they also observed spontaneous perforations
and otorrhea. Subsequent studies by the same
team indicate that, throughout the first 2 years of
life in infants with unrepaired cleft palate, otitis
media is a virtually constant complication.155,156
188
OTITIS MEDIA IN INFANTS AND CHILDREN
Older Children and Adults. Although the
criteria for aural disorders in older children and
adults with cleft palate vary considerably, their
prevalence appears to be high. Meissner examined 213 such patients between the ages of 10
and 35 years and found that 83% had abnormal
tympanic membranes.157 Skolnick found that
the prevalence of aural pathologic change was
67% in patients older than 5 years.153 Graham
and Lierle found ear disorders in 44% of 29
patients with cleft palate and in 55% of 146
patients with a cleft of both palate and lip.158 In
a group of 82 patients, Aschan found that 78%
had aural disorders.159 In a retrospective, longitudinal study of 191 patients with cleft palate
between the ages of 5 and 27 years, Severeid
reported that 83% had a middle-ear effusion
confirmed by myringotomy.160 In Bennett’s
study of 100 adults with cleft palate, 30% had
aural pathologic signs consisting of eustachian
tube obstruction (13%), chronic suppurative
otitis media with or without mastoiditis (8%),
dry tympanic membrane perforation (6%), and
chronic adhesive otitis media (3%).161 Ovesen
and Blegvad-Andersen examined 44 11-year-old
children with repaired, complete or unilateral
cleft lip and palate and reported that 24% had
hearing impairment, 44% had abnormal middleear pressures, 23% had retraction of the
tympanic membrane, and 67% had a tympanic
membrane that appeared abnormal.162
Since otitis media is so common in the patient
with a cleft palate, either unrepaired or after
repair, otologic examination and management is
an important part of their health care team’s
program.163
Other High-Risk Populations
Infants and children who have parents or
siblings, or both, with otitis media with effusion
appear to have an increased risk for development
of the disorder compared with those whose
parents or siblings have no evidence of the
disease. Teele and colleagues studied 2,565
infants from birth to their third birthday.164
They found that children who had single or
recurrent episodes of otitis media were more
likely to have parents or siblings with histories
of significant middle-ear infections than were
children who had no episodes of otitis media.
Therefore, children whose siblings have had otitis
media are at higher risk and should have more
frequent otologic examinations than children
whose siblings have not had the disease.
Upper respiratory allergy is thought to be
involved in the development of otitis media and,
therefore, requires close surveillance. Even
though there is no proof that children who have
an upper respiratory allergy have a higher
incidence of otitis media than do children without such an allergy, they should be examined
frequently for possible occurrence of otitis
media.
Any child with a craniofacial malformation
should be suspected of having a middle-ear
effusion. Children with Down syndrome have a
high prevalence and incidence of middle-ear
disease. Sculerati and coworkers evaluated 22
female patients with Turner syndrome and found
that 82% had a history of recurrent or chronic
ear infections; 45% had middle-ear effusion at the
time of the examination.165
Certain racial groups, such as Native
Americans (First Nations and Inuit),166 Maoris
of New Zealand,167 and Aborigines of Australia
are known to have a high prevalence of otitis
media, which in the past, has been characterized
as chronic suppurative otitis media with perforation and discharge. However, as these groups
obtain improved health care, otitis media has
become increasingly less prevalent.
Other possible risk factors warrant consideration for close surveillance, such as prematurity or other reason for being in a neonatal
intensive care unit,168 being in a pediatric
intensive care unit,108 first episode of otitis
media during early infancy,169 malnutrition,
child abuse,170 and being born to human
immunodeficiency virus–infected mothers.171
In addition, day-care center attendance is a
known risk factor for recurrent AOM in infants
and young children, making closer surveillance
necessary.172,173
Diagnosis
The Deaf
Severely deaf to profoundly deaf children
(primarily those whose hearing loss is sensorineural), whether they are enrolled in a special
class in a regular school (mainstreamed) or in
a residential school for the deaf, are of particular concern when middle-ear effusion is present. If a conductive hearing loss secondary to
chronic or recurrent otitis media with effusion or
high negative pressure, or both, is superimposed on the preexisting hearing loss, auditory
input may be severely affected. This may
critically interfere with the education of such
children.174
The incidence of middle-ear problems in deaf
children has not been studied systematically, but
the few studies that have been reported indicate
the incidence to be equal to or possibly higher
than that in non-deaf children. Porter found that
25% of 79 deaf children aged 6 to 10 years had
abnormal tympanograms.175 Brooks reported
that 5-year-old children in a residential school
for the deaf in England had a higher incidence of
abnormal tympanograms than did non-deaf
children.176 Mehta and Erlich found a high
incidence of otitis media with effusion in children
in a school for the deaf.177 Rubin reported the
incidence of middle-ear effusion in children 3 to 6
years of age to be 30%.178 During a period of 1
year, Stool and colleagues conducted otoscopic,
tympanometric, and audiometric evaluations of
446 students at the Western Pennsylvania School
for the Deaf and reported that the incidence of
middle-ear effusion was 8%, whereas that of
high negative middle-ear pressure was 21%.179
However, the incidence of otitis media with
effusion in this study was 26% in the 2- to 5year-old group. In addition, they found that 79%
of the students who were initially identified as
having high negative middle-ear pressure consistently had abnormal negative pressures during
the 1-year observation period.
From these few studies, it is apparent that
surveillance for middle-ear disease and early
treatment should be part of every program or
school for deaf children. This is especially critical
189
for those children with some residual hearing
who benefit from amplification, because even the
slightest conductive hearing loss may decrease or
eliminate the efficacy of amplification. It is
recommended that every school for deaf children
be afforded appropriate health care professionals
who are competent in otoscopy, tympanometry,
audiometry, and treatment of otologic disorders
to carry out this program. Most schools for the
deaf do not have sufficient provisions for such
care.
Because the external auditory canals of deaf
children are often obstructed with cerumen,
frequent examination and removal of the cerumen may be extremely beneficial, especially for
those who wear a hearing aid.180 This finding
alone is reason enough for frequent, periodic
otologic examination, but a schedule for screening for otitis media with effusion and high
negative pressure should also be established.
Until a formal long-term study has been
completed that offers recommendations for a
screening program in schools for the deaf, we
propose the following schedule of examinations
of such children based on the findings of Craig
and colleagues, Findlay and colleagues, Riding
and coworkers, and Stool and colleagues.179–182
All children should have an otoscopic,
tympanometric, and audiometric examination
on entering the school and periodically during
the first school year (Table 9). Because infants
and young children are at highest risk, they
should be examined once a month by otoscopy
(and tympanometry when indicated) during this
first year.
Older children and adolescents can probably
be evaluated on entry and every 3 months during
the first year, because the incidence of middle-ear
disease in this age group is less than in the
younger age group.
All students should be examined during
periods of an upper respiratory tract infection
and whenever there are signs or symptoms
related to the ear, such as otalgia or otorrhea.
In addition, a child should be examined if the
teacher or parent suspects a middle-ear problem
because of a noticeable lack of attention, sudden
190
OTITIS MEDIA IN INFANTS AND CHILDREN
Table 9. SUGGESTED SCREENING FOR MIDDLE-EAR DISEASE IN PROGRAMS AND SCHOOLS FOR DEAF CHILDREN
Population Groups
Infants and Young Children (also multiply
handicapped children of all ages)
First Year on Entry
Frequency of examination
Experience at the end
of the first year
Second Year
(and each succeeding year
until experience changes)
Monthly*
No disease or
Frequently recurrent
infrequent disease
or chronic disease
of short duration
Every 2 to 3 months*
Monthly*
Older Children and Adolescents
No disease
Yearly
Every 3 months*
Infrequent disease
of short duration
Every 3 months*
Frequently recurrent
or chronic disease
Monthly
*And with every upper respiratory tract infection or the appearance of otologic signs and symptoms (eg, otalgia, otorrhea).
or gradual failure to benefit from the amplification, or overt, progressive loss of hearing.
After the first year of follow-up, the children
will usually separate into one of four groups
based on the occurrence of otitis media with
effusion or high negative pressure, or both: (1) no
disease; (2) infrequent disease, of short duration
when it is present; (3) frequently recurrent
disease; and (4) chronic disease.
Infants and young children who fit into either
of the first two categories, based on the
examination of the first year, may be examined
at less frequent intervals, such as every 2 to 3
months during the second year.
Older children who have no evidence of
disease during the first year can probably be
examined once a year, either on entering in the
fall or, more ideally, during the winter months.
Older children with infrequent problems
during the first year should probably be examined every 3 months during the second year.
All infants and children who have frequently
recurrent or chronic middle-ear disease during
the first year must be examined each month and
with each upper respiratory tract infection until
they, too, have a year without significant
problems. Screening during the succeeding years
should be related to the occurrence of middle-ear
disease in the preceding year.
Children who have multiple handicaps in
addition to deafness are considered to be at high
risk for middle-ear disease, which can significantly compound their handicap as a result of the
associated conductive hearing loss. Therefore,
screening for all such students during the first
year should be the same as the program
recommended for infants and young children.
Ideally, every examination should be conducted by a physician who is expert in the
diseases of the middle ear, but this is not always
feasible. Therefore, a nurse should be trained to
perform routine otoscopy, examine the nose and
throat, and remove any cerumen from the
external canal. Tympanometry can be performed
by a nurse, a technician, or an audiologist if one
is available. Even though an otologist cannot
examine every child with the frequency recommended, every school for the deaf must have a
physician, preferably an otologist, assigned to the
school for diagnosis and treatment of those
children found to have middle-ear disease.
All children with severe or profound deafness
must be considered at risk for development of
middle-ear disease. Therefore, they should have
regular periodic ear examinations by competent
health care professionals and appropriate early
treatment so that their educational handicap is
not further compromised by a condition that is
amenable to medical or surgical management.
MICROBIOLOGIC DIAGNOSIS
The correlation between bacterial cultures of the
nasopharynx or the oropharynx and cultures of
middle-ear fluids is poor. In most cases, this poor
correlation occurs because the upper respiratory
tract is frequently colonized with organisms of
known pathogenicity for the middle ear. Less
Diagnosis
191
commonly, it is because cultures of the pathogen
responsible for the middle-ear infection are
absent in the oropharynx or nasopharynx.
Thus, cultures of the upper respiratory tract are
of limited value in specific bacteriologic diagnosis
of otitis media. The consistent results of microbiologic studies of middle-ear fluid of children
with AOM provide an accurate guide to the most
likely pathogens. Thus, in an uncomplicated
case, initial therapy does not require obtaining
specimens for bacterial diagnosis.
A specific microbiologic diagnosis can be
made by culturing middle-ear fluid obtained by
tympanocentesis (needle aspiration through the
intact tympanic membrane). If the patient has
toxic symptoms or a localized infection elsewhere, culture of the blood for the focus of
infection should be performed.
Tympanocentesis
When the diagnosis of AOM is in doubt or
when determination of the etiologic agent is
desirable, aspiration of the middle ear should
be performed. Indications for tympanocentesis
or myringotomy (Figure 44) include the following:
N
N
N
N
N
Otitis media in patients who are seriously ill or
appear toxic (eg, septic).
Unsatisfactory response to antimicrobial
therapy.
Onset of otitis media in a child who is receiving
antimicrobial agents.
Presence of suppurative complications.
Otitis media in the newborn infant or in the
immunologically deficient patient, in whom an
unusual organism may be present.
An example of how valuable tympanocentesis
can be in the management of children with
middle-ear infection is the infant suspected of
having sepsis in which the middle ear may be the
source. Arriaga and colleagues reviewed the
charts of 40 such infants at the Children’s
Hospital of Pittsburgh and reported that, in
80%, the clinical management of these babies was
Figure 44. Tympanocentesis, a needle aspiration of a middle-ear
effusion, is used primarily for diagnosis of the presence or absence of
an effusion and for microbiologic study (upper). Myringotomy is an
incision in the tympanic membrane used primarily for therapeutic
drainage (lower).
directly affected by the results of the tympanocentesis.183 Infants and children who are in
intensive care units have a high frequency of
otitis media, and tympanocentesis has been
shown to be a valuable aid in diagnosis and
identification of the causative organisms.108
Both tympanocentesis and myringotomy can
usually be performed without general anesthesia.184 In certain instances, premedication with a
combination of a short-acting barbiturate and
either morphine or meperidine hydrochloride, or
192
OTITIS MEDIA IN INFANTS AND CHILDREN
Figure 45. Tympanocentesis can be performed by employing a
needle attached to a tuberculin syringe. Reproduced from Bluestone
CD. Conquering otitis media. Hamilton (ON): BC Decker; 1999.
even a general anesthetic, is advisable. The
procedures can be carried out by use of an
otoscope with a surgical head or with an
otomicroscope. Adequate immobilization of the
patient is essential when a general anesthetic is
not used. This procedure can be part of the
pediatrician’s expertise in diagnosing and subsequently effectively treating AOM.
Diagnostic aspiration may be performed
through the inferior portion of the tympanic
membrane by an 18-gauge spinal needle attached
to a syringe or collection trap (Figure 45). The
ear canal should be cultured and cleansed with
alcohol before the procedure (Figure 46). The
canal culture is helpful in determining whether
organisms cultured are contaminants from the
exterior canal or pathogens from the middle ear.
When therapeutic drainage is required, a myringotomy knife should be used and the incision
should be large enough to allow the middle ear to
be adequately drained and aerated.
After tympanocentesis, the effusion caught in
the syringe or collection trap is sent to the
laboratory for culture. A Gram-stained smear
may provide immediate information about the
bacterial pathogens. The smear is of particular
value if cultures are negative because antibiotics
were administered before the culture, or if
infection is due to fastidious organisms such as
anaerobic bacteria. A new antigen test, the Now
test, for S. pneumoniae has been shown to be
rapid, simple and reliable, and relatively inexpensive, and is similar to the urinary antigen test.186
To isolate the likely organisms, the external
ear swab and the fluids aspirated from the middle
ear are inoculated onto appropriate solid media
Figure 46. Method recommended
for tympanocentesis and aspiration
of a middle-ear effusion for microbiologic assessment. A culture of the
external auditory canal is obtained
with a swab, which has been moistened with trypticase soy broth. The
canal is then filled with 70% ethyl
alcohol for 1 minute, after which as
much as possible of the alcohol is
removed from the ear canal by
aspiration. Tympanocentesis is performed in the inferior portion of the
tympanic membrane with an AldenSenturia trap, with a needle attached.
Care is taken not to close the suction
hole in the trap before entering the
middle ear.
Diagnosis
and into broth. Sensitivities of organisms isolated
should be tested by the standard method
described by Bauer and coworkers.187 If available, techniques for assay of pneumococcal
antigens may yield useful information. Future
studies may use rapid diagnostic tests for the
virus.
When spontaneous perforation has occurred,
the exudate will generally be contaminated with a
mixed flora. The ear canal should be carefully
cleaned and cultures taken from the area of the
perforation or, preferably, from within the
middle ear by needle aspiration.
Nasopharyngeal Culture
For identification of the causative organism in a
child with AOM, a nasopharyngeal culture is less
traumatic than a tympanocentesis or myringotomy. The concept is an attractive one, because
the bacteria found in middle-ear aspirates are the
same type found in the nasopharynx of children
with AOM. However, the correlation between
the organisms found in the middle ear and
nasopharynx reported in the past has not proven
to be high enough in the usual clinical setting to
justify its routine use. A possible exception is
when
an
ampicillin-resistant
strain
of
Haemophilus influenzae is suspected. Schwartz
and coworkers and Long and associates reported
a technique that improved the correlation of
organisms isolated by the nasopharyngeal culture
with bacteria identified by the culture of the
middle-ear fluid.188,189 The method involved
immediate plating of the nasopharyngeal swab
on solid media and a semiquantitative estimation
of colonies growing on culture plates. Colonization of the nasopharynx of potential pathogens
is a risk factor for persistent and recurrent AOM,
which would make identification of these organisms important for prevention.190
Fluorescence Emission Spectrophotometry
Fluorescence emission spectrophotometry is an
exciting method that has been reported to be
193
capable of detecting the four common pathogens
that cause AOM. This method works by noninvasively determining the optical fluorescence
through the tympanic membrane.191 The technology and clinical applicability require more
research, but this type of advance may replace
invasive procedures.
Blood Culture
Bacteremia is rarely associated with otitis media
due to nontypeable strains of H. influenzae,
uncommonly associated with otitis media due
to S. pneumoniae, and frequently associated with
otitis media due to type b strains of H.
influenzae.192
House officers at Boston City Hospital
obtained blood for culture from 600 consecutive
children aged 1 to 24 months coming to the walkin clinic with fever. Otitis media was diagnosed in
166 children, and 2 (1.2%) had concomitant
bacteremia.193 Studies of young infants include
information that is selected because those who
had cultures taken of blood showed toxic
symptoms or were hospitalized. In four series of
infants 8 weeks of age or younger194–197 and in
two series of patients 3 months of age or
younger,198,199 five of 136 infants (3.7%) with
otitis media had positive results of blood cultures
(two group B streptococcus, one S. pneumoniae,
one Pseudomonas aeruginosa, and one enterococcus). The yield of cultures of blood is low in
children with uncomplicated otitis media, but it is
likely to be higher in children who have toxic
symptoms, high fever, or concurrent infection at
other foci (eg, pneumonia, meningitis).
White Blood Cell Count
In general, white blood cell counts are too
variable to be helpful in distinguishing the child
with otitis media due to a bacterial pathogen
from the child with otitis media and a sterile
effusion. However, data suggest that mean white
blood cell counts of children with bacterial otitis
media are higher than those of children with
sterile middle-ear effusions.
194
OTITIS MEDIA IN INFANTS AND CHILDREN
Lahikainen noted that the mean white blood
cell count of children with otitis was 13,400/mm3
when it was due to Streptococcus pyogenes,
10,500/mm3 when it was due to S. pneumoniae,
and 11,500/mm3 when it was due to H. influenzae.200 Of children with sterile middle-ear effusion, the mean count was 8,700/mm3. Mortimer
and Watterson found similar results in children
who had a bacterial pathogen in the middle-ear
effusion, in whom the mean white blood cell
count was 10,300/mm3; the mean white blood cell
count was 6,700/mm3 in children with sterile
effusions.10 Feingold and colleagues found an
association of higher white blood cell counts with
isolation of a bacterial pathogen from the
middle-ear effusion201; of 35 children with white
blood cell counts of 15,000/mm3 or more, 27
(77%) had a bacterial pathogen grown from the
middle-ear effusion whereas, of children with a
white blood cell count of 9,000/mm3 or less, 8 of
20 (40%) had a bacterial pathogen grown from
the middle-ear effusion.
Sedimentation Rate
Lahikainen found increases in sedimentation
rate in children with otitis media and differences among the bacterial pathogens isolated
from the middle-ear effusion.200 The mean
sedimentation rate for 104 children with otitis
media due to S. pyogenes was 43.7; for 171
children with otitis media due to S. pneumoniae,
30.2; for 43 children with otitis media due to H.
influenzae, 17.3; and for 85 children with sterile
effusion, 21.3.
Allergy Testing
When children have the signs and symptoms of
nasal allergy and have recurrent otitis media,
allergy testing and possible management seems
reasonable, even though there is no existing
evidence that nasal allergy is involved in the
pathogenesis of middle-ear disease. The methods
of testing for the existence of allergy have been
covered in detail elsewhere.
Radiologic Imaging
For the uncomplicated case of AOM or chronic
otitis media with effusion, radiography or
imaging of the temporal bone is not indicated.
However, computed tomographic scans or more
sensitive magnetic resonance imaging will identify middle-ear and mastoid effusions more
accurately than either otoscopy or tympanometry.203 Caution is advised in over-interpreting
these images. They are so sensitive in detecting middle-ear effusion that fluid may be
identified in the middle ear and mastoid of
an otherwise healthy child who is then
diagnosed with mastoiditis, when the child only
has an asymptomatic effusion (see ‘‘Mastoiditis’’
in Chapter 9,‘‘Complications and Sequelae:
Intratemporal’’).
When recurrent acute or chronic otitis media
with effusion is present, radiographic evaluation
of the paranasal sinuses may be helpful in
identifying sinusitis that may be causally related
to the otitis media. When signs and symptoms of
sinusitis are present (eg, purulent nasal discharge,
cough, and fetor oris), conventional radiographic
examination of the paranasal sinuses is the
simplest, least expensive, and most practical
examination. The occipitomental (Waters), frontal (Caldwell), basal (submentovertical), and
lateral erect views should be obtained. In
addition, the lateral view is beneficial in assessing
the size of the adenoids in relation to the
nasopharynx. The submentovertical view is helpful in evaluating the ethmoid and sphenoid
sinuses, and both views can reveal a nasopharyngeal tumor, which can mechanically obstruct
the eustachian tube and cause otitis media.
However, computed tomography is the most
definitive method of assessing children with
recurrent or chronic sinusitis who require radiographic studies. Chronic nasal obstruction associated with otitis media, with or without epistaxis
or cervical lymphadenopathy, should prompt the
clinician to suspect a nasopharyngeal tumor. The
A-mode ultrasound examination can also be
useful in determining whether an effusion is in
the maxillary sinuses.204,205
Diagnosis
When certain complications or sequelae of
otitis media are suspected or present, radiologic
evaluation of the temporal bone is indicated.
Plain radiographs (Towne, Law, Stenver) can be
helpful in diagnosing osteitis of the mastoid or a
cholesteatoma, but computed tomography and
magnetic resonance imaging are more precise
and should be obtained if a suppurative intratemporal or intracranial complication is suspected (see Chapter 9, ‘‘Complications and
Sequelae: Intratemporal’’ and Chapter 10,
‘‘Complications and Sequelae: Intracranial’’).206
EUSTACHIAN TUBE FUNCTION TESTING IN
THE CLINICAL SETTING
The radiographic tests developed for assessment
of the protective and clearance functions of the
eustachian-tube–middle-ear system are not feasible in the usual clinical setting. However,
methods for assessment of the ventilatory function of the system are readily available to the
clinician and should be performed when indicated. The ventilatory function is the most
important of the three functions because adequate hearing depends on equal air pressure on
both sides of the tympanic membrane being
maintained. In addition, impairment of the
ventilatory function can result not only in
hearing loss but also in otitis media. This section
provides an overview of these tests, and the
interested reader can find a more comprehensive
description of them in the recently published,
Eustachian Tube: Structure, Function, Role in
Otitis Media.207 The various studies conducted at
the Children’s Hospital of Pittsburgh using these
tests are available elsewhere.208
Before the patient is examined, the presence
of certain signs and symptoms may indicate
eustachian tube dysfunction. Conductive hearing
loss, otalgia, otorrhea, tinnitus, or vertigo may be
present with this disorder.
Otoscopy
Visual inspection of the tympanic membrane is
one of the simplest and oldest ways of assessing
195
how the eustachian tube functions. The appearance of a middle-ear effusion or the presence of
high negative middle-ear pressure, or both,
determined by a pneumatic otoscope,209 is
presumptive evidence of eustachian tube dysfunction, but the type of impairment, such as
functional or mechanical obstruction, and the
degree of abnormality cannot be determined by
this method. Moreover, a normal-appearing
tympanic membrane is not evidence of a normally functioning eustachian tube. For example,
a patulous or semipatulous eustachian tube may
be present when the tympanic membrane appears
to be normal. In addition, the presence of one or
more of the complications or sequelae of otitis
media (such as a perforation or atelectasis that
can be seen through an otoscope) may not
correlate with dysfunction of the eustachian tube
at the time of the examination because eustachian tube function may improve with growth
and development.
Nasopharyngoscopy and Endoscopy of the
Eustachian Tube
Indirect mirror examination of the nasopharyngeal end of the eustachian tube is an old but still
important part of the clinical assessment of a
patient with middle-ear disease. For instance, a
neoplasm in Rosenmüller’s fossa may be diagnosed by this simple technique. The development
of endoscopic instruments has greatly improved
the accuracy of this type of examination. Not
only can certain aspects of the structure of the
eustachian tube be determined with the aid of
currently available instruments, but some investigators have assessed eustachian tube function.210–213
Tympanometry
Using an admittance instrument to obtain a
tympanogram is an excellent way of determining
the status of the tympanic-membrane–middle-ear
system, and it can be helpful in assessing
eustachian tube function (see Figure 33).214 The
presence of a middle-ear effusion or high
196
OTITIS MEDIA IN INFANTS AND CHILDREN
negative middle-ear pressure determined by this
method usually indicates impaired eustachian
tube function.
Unlike the otoscopic evaluation, tympanometry is an objective way of determining the
degree of middle-ear negative pressure.
Unfortunately, assessing the abnormality of
values of negative pressure is not so simple.
High negative pressure may be present in some
patients, especially children, who are asymptomatic and who have relatively good hearing. In
others, symptoms such as hearing loss, otalgia,
vertigo, and tinnitus may be associated with
modest degrees of negative pressure or even with
normal middle-ear pressures. The middle-ear air
pressure may depend on the time of day, season
of the year, or condition of the other parts of the
system, such as the presence of an upper
respiratory tract infection. For instance, a young
child with a common cold may have transitory
high negative middle-ear pressure while he or she
has the cold but may be otherwise otologically
normal.215 Whether high negative pressure is
abnormal or is only a physiologic variation
should be decided by taking into consideration
the presence or absence of signs and symptoms of
middle-ear disease. If severe atelectasis or adhesive otitis media of the tympanic-membrane–
middle-ear system is present, the tympanogram
may not be a reliable indicator of the actual
pressure within the middle ear.
Therefore, a resting pressure that is highly
negative is associated with some degree of
eustachian tube obstruction, but normal middleear pressure does not necessarily indicate normal
eustachian tube function; a normal tympanogram is obtained when the eustachian tube is
patulous.
Manometry
The pump-manometer system of the electroacoustic impedance audiometer is usually adequate for assessing eustachian tube function
clinically when the tympanic membrane is not
intact. However, owing to the limitations of the
manometric systems of all of the commercially
available instruments, a controlled syringe and
manometer (a water manometer will suffice)
should be available when these limitations are
exceeded (eg, when eustachian tube opening
pressure exceeds +400 to +600 mm H2O).
Methods of Assessing Eustachian Tube
Function in the Clinical Setting
Classic Tests of Tubal Patency
Valsalva and Politzer (see Chapter 8,
‘‘Management,’’ Figures 4 and 5) developed
methods to assess eustachian tube patency.
When the tympanic membrane is intact and the
middle ear inflates after one of these methods,
the tube is not totally mechanically obstructed.
Likewise, if the tympanic membrane is not intact,
passage of air into the middle ear indicates
patency of the tube. When the tympanic membrane is intact, the assessment is more objective
with a tympanogram. When the tympanic
membrane is not intact, the assessment is more
objective with a manometric observation on the
impedance instrument. However, inflation of the
eustachian tube and middle ear from the
nasopharynx end of the system by one of these
classic methods is an assessment only of tubal
patency, not of function, and failure to inflate the
middle ear does not necessarily indicate a lack of
patency of the eustachian tube.
Elner and coworkers reported that 86% of
100 otologically normal adults could perform
Valsalva’s maneuver.216 In young children,
Valsalva’s maneuver is usually more difficult to
perform than Politzer’s method. However, in a
study by Bluestone and coworkers, six of seven
children who had a traumatic perforation but
who were otherwise otologically ‘‘normal’’ could
perform Valsalva’s maneuver, but only 11 of 28
children who had a retraction pocket or a
cholesteatoma could do so.217 Valsalva’s maneuver and Politzer’s method may be more beneficial
as management options in selected patients than
as methods of assessment of tubal function,
although there is controversy about the efficacy
of this procedure for treatment of middle-ear
effusion.218,219
Diagnosis
197
Figure 48. Tympanogram obtained before and after the Toynbee
test. Negative middle-ear pressure is objectively demonstrated in the
middle ear; this is considered to be associated with good eustachian
tube function.
Figure 47. The Toynbee test of eustachian tube function. Closednose swallowing results first in positive pressure in the nose and
nasopharynx, followed by a negative pressure phase. When positive
pressure is in the nasopharynx, air may enter the middle ear, creating
positive pressure. During or after the negative pressure phase,
negative pressure may develop in the middle ear, or positive
pressure may still be in the middle ear (no change in middle-ear
pressure during the negative phase), or positive pressure may be
followed by negative middle-ear pressure, or ambient pressure will be
present if equilibration takes place before the tube closes. If the tube
does not open during either the positive or the negative phase, no
change in middle-ear pressure will occur.
Toynbee Test
One of the oldest, and still one of the best, tests
of eustachian tube function is the Toynbee test
(Figure 47). Test responses are usually considered positive when an alteration in middle-ear
pressure results. More specifically, if negative
pressure (even transitory in the absence of a
patulous tube) develops in the middle ear during
closed-nose swallowing, the eustachian tube
function can most likely be considered normal.
When the tympanic membrane is intact, the
presence of negative middle-ear pressure must be
determined by pneumatic otoscopy or, more
accurately, by obtaining a tympanogram before
and immediately after the test (Figure 48). When
the tympanic membrane is not intact, the
manometer of the impedance audiometer can be
observed to determine middle-ear pressure.
In the study by Elner and coworkers, results
of the Toynbee test were positive in 79% of
normal adults.216 Cantekin and colleagues
reported that only 7 of 106 ears (6.6%) of
subjects (mostly children) who had had tympanostomy tubes inserted for otitis media could
show positive results with a modification of the
Toynbee test (closed-nose equilibration attempt
with applied negative middle-ear pressure of 100
or 200 mm H2O).220 Likewise, in a series of
patients, most of whom were older children and
adults with chronic perforations of the tympanic
membrane, only 3 of 21 (14.3%) passed the test.
However, in children with a traumatic perforation of the tympanic membrane but who otherwise had a negative otologic history, 3 of 10
(30%) could pass the test. In the study by
Bluestone and coworkers of normal children
with traumatic perforations, 6 of 7 children could
change the middle-ear pressure, but none of the
198
OTITIS MEDIA IN INFANTS AND CHILDREN
expiration or by performing the Toynbee maneuver. When the tympanic membrane is not intact,
a patulous eustachian tube can be identified by the
free flow of air into and out of the eustachian tube
by using the pump-manometer portion of the
electroacoustic impedance audiometer. These tests
should not be performed while the patient is in a
reclining position because the patulous eustachian
tube will close.221
Figure 49. Diagnosis of a patulous eustachian tube by employing
the tympanogram.
21 ears of children who had a retraction pocket
or a cholesteatoma showed pressure change.217
The test is of greater value in determining
normal or abnormal eustachian tube function in
adults than it is in children. The test is still of
considerable value; regardless of age, if negative
pressure develops in the middle ear during or
after the test, the eustachian tube function is
most likely normal, because the eustachian tube
actively opens and is sufficiently stiff to withstand nasopharyngeal negative pressure (ie, it
does not ‘‘lock’’). If positive pressure is noted or
no change in pressure occurs, the function of the
eustachian tube may still be normal, and other
tests of eustachian tube function should be
performed.
Patulous Eustachian Tube Test
If a patulous eustachian tube is suspected, the
diagnosis can be confirmed by otoscopy or
objectively by tympanometry when the tympanic
membrane is intact.214 One tympanogram is
obtained while the patient is breathing normally,
and a second is obtained while the patient is
holding his or her breath. Fluctuation of the
tympanometric trace that coincides with breathing confirms the diagnosis of a patulous tube
(Figure 49). Fluctuation can be exaggerated by
asking the patient to occlude one nostril with the
mouth closed during forced inspiration and
Nine-Step Inflation-Deflation
Tympanometric Test
Another method of assessing eustachian tube
function when the tympanic membrane is
intact, developed by Bluestone, is the nine-step
inflation-deflation tympanometric test, although
the applied middle-ear pressures are limited in
magnitude.222 The middle ear must be free of
effusion. The nine-step tympanometry procedure
can be summarized as follows (Figure 50):
1. The tympanogram records resting middleear pressure.
2. Ear canal pressure is increased to
+200 mm H2O with medial deflection of
the tympanic membrane and a corresponding increase in middle-ear pressure.
The subject swallows to equilibrate middle-ear overpressure.
3. While the subject refrains from swallowing, ear canal pressure is returned to
normal, thus establishing a slight negative middle-ear pressure (as the tympanic
membrane moves outward). The tympanogram documents the established
middle-ear underpressure.
4. The subject swallows in an attempt to
equilibrate negative middle-ear pressure.
If equilibration is successful, airflow is
from the nasopharynx to the middle ear.
5. The tympanogram records the extent of
equilibration.
6. Ear canal pressure is decreased to
2200 mm H2O, causing a lateral deflection of the tympanic membrane and a
corresponding decrease in middle-ear
pressure. The subject swallows to
Diagnosis
199
Figure 50. Nine-step inflation-deflation tympanometric test. TVP 5 tensor veli palatini muscle; ET 5
eustachian tube; ME 5 middle ear;
TM 5 tympanic membrane; EC 5 ear
canal.
equilibrate negative middle-ear pressure;
airflow is from the nasopharynx to the
middle ear.
7. The subject refrains from swallowing
while external ear canal pressure is
returned to normal, thus establishing a
slight positive pressure in the middle ear
as the tympanic membrane moves medially. The tympanogram records the overpressure established.
8. The subject swallows to reduce overpressure. If equilibration is successful,
200
OTITIS MEDIA IN INFANTS AND CHILDREN
airflow is from the middle ear to the
nasopharynx.
9. The final tympanogram documents the
extent of equilibration.
The test is simple to perform, can give useful
information about eustachian tube function,
and should be part of the clinical evaluation
of patients with suspected eustachian tube
dysfunction. In general, most normal adults
can perform all or some parts of this test,223 but
even normal children have difficulty performing
it. However, if a child can pass some or all of
the steps, eustachian tube function is considered
good.
Modified Inflation-Deflation Test (Nonintact
Tympanic Membrane)
When the tympanic membrane is not intact, the
pump-manometer system of the electroacoustic
impedance audiometer can be used to perform
the modified inflation-deflation eustachian tube
function test (see Figure 30), which assesses
passive as well as active functioning of the
eustachian tube.220,224 With use of this test, the
middle ear should be free of any drainage for an
accurate assessment of eustachian tube function.
The middle ear is inflated (ie, positive
pressure is applied) until the eustachian tube
spontaneously opens (Figure 51). At this time,
Figure 51. Test of passive and
active function of the eustachian tube
after application of positive middleear pressure. A, Analogous ascent in
an airplane. B, Assessment of passive function. C, Closing pressure. D,
Assessment of active function (swallowing). E, Strip chart recording
showing an example of normal pressure tracing. Black circles represent
swallows.
Diagnosis
201
Figure 52. Deflation phase of eustachian tube testing. A, Analogous descent in an airplane. B, Application of
low negative pressure to the middle
ear. C, Equilibration by active tubal
opening. D, Strip chart recording
showing an example of a normal
tracing. Black circles represent swallows.
the pump is manually stopped, and air is
discharged through the eustachian tube until
the tube closes passively. The pressure at which
the eustachian tube is passively forced open is
called the opening pressure, and the pressure at
which it closes passively is called the closing
pressure.225,226 The patient is then instructed to
equilibrate the middle-ear pressure actively by
swallowing. The residual pressure in the middle
ear after swallowing is recorded. The active
function is also recorded by applying overpressure and underpressure to the middle ear,
which the patient then attempts to equilibrate by
swallowing. The residual negative pressure in the
middle ear after the attempt to equilibrate
applied negative pressure of 2200 mm H2O is
also noted (Figure 52).
This procedure is not performed in patients
who cannot equilibrate applied overpressure. If
the eustachian tube does not open after application of positive pressure with use of the
admittance instrument, and if no reduction in
positive pressure occurs during swallowing, the
eustachian tube must be assessed by use of a
manometric system other than that available
with the admittance instrument. The opening
pressure may be higher than 400 to 600 mm H2O
pressure or not present at all (severe mechanical
obstruction).
Figure 53A shows that, after passive opening
and closing of the eustachian tube during the
inflation phase of the study, the patient was able
to completely equilibrate the remaining positive
pressure. Active swallowing also completely
202
OTITIS MEDIA IN INFANTS AND CHILDREN
Figure 53. Examples of results of inflation-deflation ventilation
studies that employed a strip chart recorder. A, Normal adult with a
traumatic perforation. B, Four-year-old boy with a functioning
tympanostomy tube who had a persistent otitis media with effusion.
RP 5 residual pressure; O 5 opening pressure; C 5 closing
pressure; S 5 pressure after swallow. Black circles represent
swallows.
equilibrated applied negative pressure (deflation). This is considered to be characteristic of
normal eustachian tube function. Figure 7-53B
shows the eustachian tube passively opened and
closed after inflation, but subsequent swallowing
failed to equilibrate the residual positive pressure. In the deflation phase of the study, the
patient was unable to equilibrate negative pressure. Inflation to a pressure below the opening
pressure but above the closing pressure could not
be equilibrated by active swallowing. This type of
result is considered abnormal but may be found
in a few subjects who do not have any obvious
otologic disease.
Failure to equilibrate the applied negative
pressure during the test may indicate locking of
the eustachian tube. This type of tube is
considered to have increased compliance or to
be floppy in comparison with a tube with perfect
function.148,227 The musculus tensor veli palatini
is unable to open (dilate) the tube.
Even though the inflation-deflation test
of eustachian tube function does not strictly
duplicate physiologic functions of the tube, the
results are helpful in differentiating normal
from abnormal function. The mean opening
pressure for apparently normal subjects with a
traumatic perforation and negative otologic
history reported by Cantekin and coworkers
was 330 mm H2O (+70 mm H2O).228 If the test
results reveal passive opening and closing within
the normal range, the residual positive pressure
can be equilibrated by swallowing, and the
applied negative pressure can also be equilibrated
completely, the eustachian tube can be considered to have normal function. However, if the
tube does not open to a pressure of 1,000 mm
H2O, one can assume that total mechanical
obstruction is present. This pressure is not
hazardous to the middle ear or inner ear windows
if the pressure is applied slowly. An extremely
high opening pressure (eg, greater than 500 to
600 mm H2O) may indicate partial obstruction,
whereas a low opening pressure (eg, less than 100
mm H2O) indicates a semipatulous eustachian
tube. Inability to maintain even a modest positive
pressure within the middle ear is consistent with a
patulous tube (ie, one that is open at rest).
Complete equilibration of applied negative pressure by swallowing is usually associated with
normal function, but partial equilibration, or
even failure to reduce any applied negative
pressure, may or may not be considered abnormal because even a normal eustachian tube will
lock when negative pressure is rapidly applied.
Therefore, inability to equilibrate applied negative pressure may not indicate poor eustachian
tube function, especially when it is the only
abnormal result of testing.
Other Methods Available for Laboratory
Use
Other methods are available to test the functioning of the eustachian tube, but they are currently
limited to use in the laboratory for investigational purposes. When the tympanic membrane
is intact, the microflow technique229 or an
impedance method230 (both of which require a
pressure chamber), sonotubometry,223,231–235
sequential scintigraphy,236 microendoscopy,212
or direct insertion of a balloon catheter into
the cartilagenous eustachian tube237,238 may be
used. When the tympanic membrane is not
intact, the forced-response test may be used.239
Sonotubometry and the forced-response test are
currently in use in routine research studies but
Diagnosis
are not yet available for clinical use. (A more
detailed description of eustachian tube function
tests may be found in Pediatric Otolaryngology.97
CLINICAL INDICATIONS FOR TESTING
EUSTACHIAN TUBE FUNCTION
Diagnosis
One of the most important reasons for assessing
eustachian tube function is the need to make a
differential diagnosis in a patient who has an
intact tympanic membrane without evidence of
otitis media but who has symptoms that might be
related to eustachian tube dysfunction (such as
otalgia, snapping or popping in the ear, fluctuating hearing loss, tinnitus, or vertigo). An example
of such a case is a child or adolescent who
complains of fullness in the ear without hearing
loss at the time of the examination, a symptom
that could be related to abnormal functioning of
the eustachian tube or caused by an inner-ear
disorder. A tympanogram that reveals high
negative pressure (250 mm H2O or less) is
strong evidence of eustachian tube obstruction,
whereas normal resting middle-ear pressure is
not diagnostically significant. However, when the
resting intratympanic pressure is within normal
limits and the patient can develop negative
middle-ear pressure after the Toynbee test or
can perform all or some of the functions in the
nine-step inflation-deflation tympanometric test,
the eustachian tube is probably functioning
normally. Unfortunately, failure to develop
negative middle-ear pressure during the
Toynbee test or an inability to pass the nine-step
test does not necessarily indicate poor eustachian
tube function; many children who are otologically normal cannot actively open their tubes
during these tests. Tympanometry is not only of
value in determining whether eustachian tube
obstruction is present, it can also identify
abnormality at the other end of the spectrum of
eustachian tube dysfunction, and the presence
of an abnormally patent eustachian tube can be
confirmed by the results of the tympanometric
patulous tube test.
203
Screening for the presence of high negative
pressure in certain high-risk populations (ie,
children with known sensorineural hearing
losses, developmentally delayed and mentally
impaired children, children with cleft palates or
other craniofacial anomalies, Native American
and Inuit children, and children with Down
syndrome) appears to be helpful in identifying
those individuals who may need to be monitored
closely for the occurrence of otitis media.98,240,241
Tympanometry appears to be a reliable
method for detecting the presence of high
negative pressure as well as otitis media with
effusion in children.242,243 The identification of
high negative pressure without effusion in
children indicates some degree of eustachian
tube obstruction. These children and those with
middle-ear effusions should have follow-up serial
tympanograms because they may be at risk for
development of otitis media with effusion.
However, the best methods available to the
clinician today for testing eustachian tube function are the nine-step test when the eardrum is
intact, and the inflation-deflation test when the
eardrum is not intact. A perforation of the
tympanic membrane or a tympanostomy tube
must be present for performance of the inflationdeflation test. The test uses the simple apparatus
described earlier, with or without the impedance
audiometer pump-manometer system. This test
aids in determining the presence or absence of a
dysfunction and the type of dysfunction
(obstruction versus abnormal patency) and its
severity when one is present. No other test
procedures may be needed if the patient has
either functional obstruction of the eustachian
tube or an abnormally patent tube. However, if
there is a mechanical obstruction, especially if the
tube appears to be totally blocked anatomically,
further testing may be indicated. In such
instances, computed tomography of the nasopharynx–eustachian-tube–middle-ear region can
be performed to determine the site and cause of
the blockage, such as a cholesteatoma or tumor.
In most cases in which mechanical obstruction of
the tube is found, inflammation is present at the
middle-ear end of the eustachian tube (osseous
204
OTITIS MEDIA IN INFANTS AND CHILDREN
portion), and this usually resolves with medical
management or middle-ear surgery, or both.
Serial inflation-deflation studies should show
resolution of the mechanical obstruction.
However, if no middle-ear cause is obvious,
other studies should be performed to rule out the
possibility of a neoplasm in the nasopharynx.
Eustachian Tube Function Tests Related to
Management
Ideally, patients with recurrent AOM or chronic
otitis media with effusion, or both, should have
eustachian tube function studies as part of their
otolaryngologic work-up. For most children with
these conditions, one can assume eustachian tube
function to be poor. However, patients in whom
tympanostomy tubes have been inserted may
benefit from serial eustachian tube function
studies.244 Improvement in function as indicated
by inflation-deflation tests might help the
clinician determine the proper time to remove
the tubes. Cleft palate repair,148,156 adenoidectomy,245,246 elimination of nasal and nasopharyngeal inflammation,247 treatment of a nasopharyngeal tumor, or growth and development
of a child248 may be associated with improvement
in eustachian tube function.
Studies of the eustachian tube function of the
patient with a chronic perforation of the tympanic membrane may be helpful preoperatively in
determining the potential results of tympanoplastic surgery. Holmquist studied eustachian
tube function in adults before and after tympanoplasty and reported that the operation had a
high rate of success in patients with good
eustachian tube function (ie, those who could
equilibrate applied negative pressure) but that, in
patients without good tubal function, surgery
frequently failed to close the perforation.249
These results were corroborated,250,251 but other
investigators found no correlation between the
results of the inflation-deflation tests and success
or failure of tympanoplasty.252–255 Most of these
studies failed to define the criteria for success,
and the postoperative follow-up period was too
short. Bluestone and coworkers assessed children
before tympanoplasty and found that, of 51 ears
from 45 children, eight ears could equilibrate an
applied negative pressure (2200 mm H2O) to
some degree.256 In seven of these ears, the graft
took, no middle-ear effusion occurred, and no
recurrence of the perforation developed during a
follow-up period of between 1 and 2 years. A
subsequent study by Manning and coworkers
had a similar outcome.257 However, as in the
studies in adults, failure to equilibrate an applied
negative pressure did not predict failure of the
tympanoplasty.
The conclusion to be drawn from these
studies is that, if the patient is able to equilibrate
an applied negative pressure, regardless of age,
the success of tympanoplasty is likely, but failure
to perform this difficult test will not help the
clinician decide not to operate. However, the
value of testing a patient’s ability to equilibrate
negative pressure lies in the possibility of
determining from the test results whether a
young child is a candidate for tympanoplasty,
when one might decide on the basis of other
findings alone to withhold surgery until the child
is older (see Chapter 9, ‘‘Complications and
Sequelae: Intratemporal’’).
In children who have unilateral perforation
of the tympanic membrane or a tympanostomy
tube in place and a contralateral tympanic
membrane that is intact, the status of the intact
side, observed for at least 1 year, can aid in
determining whether tympanoplasty should be
performed or a tube should be removed. Repair
of the eardrum or removal of the tube is usually
successful if the contralateral intact side has
remained normal (ie, no middle-ear effusion or
high negative pressure). Conversely, if the
opposite ear has developed middle-ear disease
during the previous year, tympanoplasty should
be postponed, or if a tympanostomy tube is in
place, it should not be removed.258
REFERENCES
1. American Academy of Pediatrics, American Academy of
Family Physicians, Subcommittee on Management of
Acute Otitis Media. Clinical practice guideline:
Diagnosis
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
diagnosis and management of acute otitis media.
Pediatrics 2004;113:1451–65.
Kaleida PH, Stool SE. Assessment of otoscopists’
accuracy regarding middle-ear effusion. Am J Dis
Child 1992;146:433–5.
Jones WS, Kaleida PH. How helpful is pneumatic
otoscopy in improving diagnostic accuracy?
Pediatrics 2003;112:510–513.
Palmu AAI, Syrjanen R. Diagnostic value of tympanometry using subject-specific normative values. J
Pediatr Otorhinolaryngol 2005;69:965–71.
Nozza RJ, Bluestone CD, Kardatzke D, Bachman RN.
Identification of middle-ear effusion by aural acoustic
admittance and otoscopy. Ear Hear 1994;15:310–23.
Terkildsen K, Nielsen SS. An electroacoustic impedance
measuring bridge for clinical use. Arch Otolaryngol
Head Neck Surg 1960;72:339–46.
Barnett ED, Klein JO, Hawkins KA, et al. Comparison of
spectral gradient acoustic reflectometry and other
diagnostic techniques for detection of middle-ear
effusion in children with middle-ear disease. Pediatr
Infect Dis J 1998;17:556–9.
Block SL, Pichichero ME, McLinn S, et al. Spectral
gradient acoustic reflectometry: detection of middleear effusion in suppurative otitis media. Pediatr Infect
Dis J 1999;18:741–3.
Schwartz RH, Rodriguez WJ, Brook I, et al. The febrile
response in acute otitis media. JAMA 1981;245:2057–
8.
Mortimer EA Jr, Watterson RL Jr. A bacteriologic
investigation of otitis media in infancy. Pediatrics
1956;17:359–66.
Carlson LH, Carlson RD. Diagnosis. In: Rosenfeld RM,
Bluestone CD, editors. Evidenced-based otitis media.
2nd ed. Hamilton (ON): BC Decker Inc; 2003. p. 136–
46.
Whitaker ME, Hirsch BE. Persistent/recurrent otalgia. In:
Alper CM, Bluestone CD, Casselbrant ML, et al,
editors. Advanced therapy of otitis media. Hamilton
(ON): BC Decker Inc; 2004. p. 496–500.
Ingvarsson L. Acute otalgia in children—findings and
diagnosis. Acta Pediatr Scand 1982;71:705–10.
Hayden GF, Schwartz RH. Characteristics of earache
among children with acute otitis media. Am J Dis
Child 1985;139:721–3.
Bodor FF. Conjunctivitis-otitis syndrome. Pediatrics
1982;69:695–8.
Bodor FF, Marchant CD, Shurin PA, et al. Bacterial
etiology of conjunctivitis–otitis media syndrome.
Pediatrics 1985;76:26–8.
Leibovitz E, Satran R, Piglansky L, et al. Can acute otitis
media caused by Haemophilus influenzae be distinguished from that caused by Streptococcus pneumoniae? Pediatr Infect Dis J 2003;22:509–14.
Rothman R, Owens T, Simel DL. Does this child have
acute otitis media? JAMA 2003;290:1633–9.
Shah UK. Acute otitis media/otitis media with effusion in
craniofacial syndromes. In: Alper CM, Bluestone CD,
Casselbrant ML, et al, editors. Advanced therapy of
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
205
otitis media. Hamilton (ON): BC Decker Inc; 2004.
p. 468–73.
Paradise JL, Bluestone CD, Felder H. The universality of
otitis media in fifty infants with cleft palate. Pediatrics
1969;44:35–42.
Stool SE, Randall P. Unexpected ear disease in infants
with cleft palate. Cleft Palate J 1967;4:99–103.
Taylor GD. The bifid uvula. Laryngoscope 1972;82:
771–8.
Yellon RF. Otitis media and its complications in
congenital aural atresia.
In:
Alper CM,
Bluestone CD, Casselbrant ML, et al, editors.
Advanced therapy of otitis media. Hamilton (ON):
BC Decker Inc; 2004. p. 474–7.
Jegoux F, Legent F, Beauvillain de Montreuil C. Chronic
cough and ear wax. Lancet 2002;360:618.
Schwartz RH, Rodriguez WJ, McAveney W, et al.
Cerumen removal: how necessary is it to diagnose
acute otitis media? Am J Dis Child 1983;137:
1064–5.
Chrisrakis DA, Lehmann HP. Review of a randomized
trial comparing 2 cerumenolytic agents. Arch Pediatr
Adolesc Med 2003;157:1181–3.
Mandel EM, Dohar JE, Casselbrant ML. Aural irrigation
using the OtoClear Safe Irrigation system for children.
Int J Pediatr Otorhinolaryngol 2004;68:1295–9.
Cavanaugh RM Jr. Obtaining a seal with otic specula:
must we rely on an air of uncertainty? Pediatrics 1991;
87:114–6.
Barriga F, Schwartz RH, Hayden GF. Adequate illumination for otoscopy. Am J Dis Child 1986;140:1237–
40.
Pelton SI. Otoscopy for the diagnosis of otitis media.
Pediatr Infect Dis J 1998;17:540–3.
Ruah CB, Barros E, Ruah SB, et al. Paediatric
otoscopy—clinical and histological correlation. J
Laryngol Otol 1992;106:307–12.
Khanna SM, Tonndorf J. Tympanic membrane vibrations
in cats studied by time-averaged holography. J Acoust
Soc Am 1972;51:1904–20.
Schwartz RH. The red eardrum. In: Alper CM,
Bluestone CD, Casselbrant ML, et al, editors.
Advanced therapy of otitis media. Hamilton (ON):
BC Decker Inc; 2004. p. 453–7.
Murray LN. Myringitis bullosa. In: Alper CM,
Bluestone CD, Casselbrant ML, et al, editors.
Advanced therapy of otitis media. Hamilton (ON):
BC Decker Inc; 2004. p. 49–51.
Prasannaraj T, De NS, Narasimhan I. Aural polyps: safe
or unsafe? Amer J Otolaryngol 2003;24:155–8.
Isaacson GC. Examination of the tympanic membranes
for otitis media. In: Alper CM, Bluestone CD,
Casselbrant ML, et al, editors. Advanced therapy of
otitis media. Hamilton (ON): BC Decker Inc; 2004.
p. 14–20.
Hirsch BE. Otitis media in teenagers and adults. In:
Alper CM, Bluestone CD, Casselbrant ML, et al,
editors. Advanced therapy of otitis media. Hamilton
(ON): BC Decker Inc; 2004. p. 483–7.
206
OTITIS MEDIA IN INFANTS AND CHILDREN
38. Bluestone CD, Cantekin EI. Design factors in the
characterization and identification of otitis media
and certain related conditions. Ann Otol Rhinol
Laryngol 1979;88:13–27.
39. Cavanaugh RM Jr. Quantitative pneumatic otoscopy in
pediatric patients with normal and abnormal tympanic membrane mobility. In: Lim DJ, Bluestone CD,
Klein JO, et al, editors. Recent advances in otitis
media: proceedings of the fifth international
symposium. 1991, May 20–24, Ft. Lauderdale, FL.
Hamilton (ON): BC Decker Inc; 1993. p. 1–2.
40. Cavanaugh RM. Pediatricians and the pneumatic otoscope: are we playing it by ear? Pediatrics 1989;84:
362–4.
41. Clarke LR, Wiederhold ME, Gates GA. Quantitation of
pneumatic otoscopy. Otolaryngol Head Neck Surg
1987;96:119–24.
42. Piltcher OB, Alper CM. Persistent/recurrent negative
middle ear pressure. In: Alper CM, Bluestone CD,
Casselbrant ML, et al, editors. Advanced therapy of
otitis media. Hamilton (ON): BC Decker Inc; 2004.
p. 501–507.
43. Barnett. Otitis media in newborn infants. In: Alper CM,
Bluestone CD, Casselbrant ML, et al, editors.
Advanced therapy of otitis media. Hamilton (ON):
BC Decker Inc; 2004. p. 458–61.
44. Kaleida PH. The COMPLETES exam for otitis. Contemp
Pediatr 1997;4:93–101.
45. Finitzo T, Friel-Patti S, Chinn K, et al. Tympanometry
and otoscopy prior to myringotomy: issues in diagnosis of otitis media. In: Lim DJ, Bluestone CD,
Klein JO, et al, editors. Recent advances in otitis
media: proceedings of the fifth international symposium. 1991, May 20–24, Ft. Lauderdale, FL. Hamilton
(ON): BC Decker Inc; 1993. p. 101–10.
46. Cantekin EJ, Bluestone CD, Fria TJ, et al. Identification
of otitis media with effusion in children. Ann Otol
Rhinol Laryngol 1988;68 Suppl:190–5.
47. Fields MJ, Allison RS, Corwin P, et al.
Microtympanometry, microscopy, and tympanometry
in evaluating middle-ear effusion prior to myringotomy. N Z Med J 1993;106:386–7.
48. Mains BT, Toner JC. Pneumatic otoscopy: study of
inter-observer variability. J Laryngol Otol 1989;103:
1134–5.
49. Karma PH, Sipilä MM, Kataja MJ, et al. Pneumatic
otoscopy and otitis media. II. Value of different
tympanic membrane findings and their combinations.
In: Lim DJ, Bluestone CD, Klein JO, et al, editors.
Recent advances in otitis media: proceedings of the
fifth international symposium. 1991, May 20–24, Ft.
Lauderdale, FL. Hamilton (ON): BC Decker Inc;
1993. p. 3–6.
50. Eikelboom RH, Mbao MN, Coates HL, et al. Validation
of tele-otology to diagnose ear disease in children. Int
J Pediatr Otorhinolaryngol 2005;69:739–44.
51. Steinbach WJ, Sectish TC, Benjamin DK, et al. Pediatric
residents’ clinical diagnostic accuracy of otitis media.
Pediatrics 2002;109:993–8.
52. Kontiokari T, Koivunen P, Niemela M, et al. Symptoms
of acute otitis media. Pediatr Infect Dis J 1998;17:676–
9.
53. Niemela M, Uhari M, Jounio-Ervasti K, et al. Lack of
specific symptomatology in children with acute otitis
media. Pediatr Infect Dis J 1994;13:765–8.
54. Rosenfeld RM. Diagnostic certainty for acute otitis
media. Int J Pediatr Otorhinolaryngol 2002;64:89–95.
55. Riding KH, Bluestone CD, Michaels RH, et al.
Microbiology of recurrent and chronic otitis media
with effusion. J Pediatr 1978;93:739–43.
56. Hellstrom S. Dimeric tympanic membrane. In: Alper CM,
Bluestone CD, Casselbrant ML, et al, editors.
Advanced therapy of otitis media. Hamilton (ON):
BC Decker Inc; 2004. p. 392–3.
57. Hergils LG, Magnuson B, Falk B. Different tympanometric procedures compared with direct pressure
measurements in healthy ears. Scand Audiol 1990;
19:183–6.
58. Renvall U, Lidén G, Björkman G. Experimental tympanometry in human temporal bones. Scand Audiol
1975;4:135–47.
59. Margolis R, Heller J. Screening tympanometry: criteria
for medical referral. Audiology 1987;26:197–208.
60. Bluestone CD, Beery QC, Paradise JL. Audiometry and
tympanometry in relation to middle-ear effusions in
children. Laryngoscope 1973;85:594–604.
61. Paradise JL, Smith CG, Bluestone CD. Tympanometric
detection of middle-ear effusion in infants and young
children. Pediatrics 1976;58:198–210.
62. Gates GA, Avery C, Cooper JC, et al. Predictive value of
tympanometry in middle-ear effusion. Ann Otol
Rhinol Laryngol 1986;95:46–50.
63. Beery QC, Bluestone CD, Andrus WS, et al.
Tympanometric pattern classification in relation to
middle-ear effusions. Ann Otol Rhinol Laryngol 1975;
84:56–64.
64. Shurin PA, Pelton SI, Finkelstein BA. Tympanometry in
the diagnosis of middle-ear effusions. N Engl J Med
1977;296:412–7.
65. Nozza RJ, Bluestone CD, Kardatzke D, et al. Toward the
validation of aural acoustic immittance measures for
the diagnosis of middle-ear effusion in children. Ear
Hear 1992;13:442–53.
66. Ovesen T, Paaske PB, Elbrond O. Accuracy of an
automatic impedance apparatus in a population with
secretory otitis media: principles in the evaluation of
tympanometrical findings. Am J Otolaryngol 1993;14:
100–4.
67. van Balen FAM, de Melker RA. Validation of a portable
tympanometer for use in primary care. Int J Pediatr
Otorhinolaryngol 1994;29:219–25.
68. de Melker RA. Diagnostic value of microtympanometry
and pneumatic otoscopy in primary care. In: Lim DJ,
Bluestone CD, Klein JO, et al, editors. Recent
advances in otitis media: proceedings of the fifth
international symposium. 1991, May 20–24, Ft.
Lauderdale, FL. Hamilton (ON): BC Decker Inc;
1993. p. 20–2.
Diagnosis
69. American National Standards Institute. American
national standards specifications for instruments to
measure acoustic impedance and admittance (aural
acoustic immittance). New York: ANSI; 1987.
70. American
Speech-Language-Hearing
Association.
Guidelines for audiologic screening. ASHA 1997;39:
1–60.
71. Therkildsen AG, Gaihede M. Accuracy of tympanometrc middle ear pressure determination: role of
direction and rate of pressure change with fast,
modern tympanometer. Otol Neurotol 2005;26:
252–6.
72. Jerger JF. Clinical experience with impedance audiometry.
Arch Otolaryngol 1970;92:311–24.
73. Sichel J-Y, Priner Y, Weiss S, et al. Characteristics of the
type B tympanogram can predict the magnitude of the
air-bone gap in otitis media with effusion. Ann Otol
Rhinol Larynogol 2003;112:450–4.
74. Nozza RJ. Critical issues in acoustic-immittance screening for middle-ear effusion. Semin Hear 1995;16:86–
98.
75. Chinn K, Brown OE, Manning SC. Effects of inhalant
anesthesia: tympanometry validation. Int J Pediatr
Otorhinolaryngol 2005;69:187–92.
76. Brooks DN. A comparative study of an impedance
method and pure tone screening. Scand Audiol
1973;2:67–72.
77. Brooks DN. School screening for middle-ear effusions.
Ann Otol Rhinol Laryngol 1976;25:223–8.
78. Brooks DN. An objective method of detecting middle ear
fluid in the middle. Int Audiol 1968;7:280–283.
79. Cooper JC, Gates GA, Owen JH, Dickson HD. An
abbreviated impedance bridge technique for school
screening. J Speech Hear Dis 1975;40:260–9.
80. Ferrer H. Use of impedance audiometry in school
screening. Public Health 1974;88:153–63.
81. Fiellau-Nikolajsen M. Tympanometry and secretory otitis
media. Observations on diagnosis, epidemiology,
treatment and prevention in prospective short studies
of three-year-old children. Acta Otolaryngol (Stockh)
1983;394:1–73.
82. Harker LA, Van Wagoner R. Application of impedance
audiometry as a screening instrument. Acta
Otolaryngol (Stockh) 1974;77:198–201.
83. Lewis AN, Barry M, Stuart J. Screening procedures for
the identification of hearing and ear disorders in
Australian Aboriginal children. J Laryngol Otol 1974;
88:335–47.
84. McCandless GA, Thomas GK. Impedance audiometry
as a screening procedure for middle-ear disease.
Trans Am Acad Ophthalmol Otolaryngol 1974;78:
98–102.
85. McCurdy JA, Goldstein JL, Gorski D. Auditory screening of preschool children with impedance audiometry—a comparison with pure tone audiometry. Clin
Pediatr 1976;15:436–41.
86. Orchik DJ, Herdman S. Impedance audiometry as a
screening device with school-age children. J Aud Res
1974;14:283–6.
207
87. Roberts ME. Comparative study of pure tone, impedance,
and otoscopic hearing screening methods. Arch
Otolaryngol Head Neck Surg 1976;102:690–4.
88. Roush J, Tait C. Pure-tone and acoustic impedance
screening of pre-school aged children: an examination
of referral criteria. Ear Hear 1985;6:245–50.
89. Brooks DN. Impedance screening for school children—
state of the art. In: Harford ER, Bess FH,
Bluestone CD, Klein JO, editors. Impedance screening for middle-ear disease in children. New York:
Grune & Stratton; 1978. p. 173–80.
90. Fria T, LeBlanc J, Kristensen R, et al. Ipsilateral acoustic
reflex stimulation in normal and sensorineural
impaired ears: a preliminary report. Can J
Otolaryngol 1975;4:695–703.
91. Paradise JL, Smith CG. Impedance screening for preschool children—state of the art. In: Harford ER,
Bess FH, Bluestone CD, Klein JO, editors. Impedance
screening for middle-ear disease in children. New
York: Grune & Stratton; 1978. p. 113–24.
92. Bluestone CD, Fria TJ, Arjona SK, et al. Controversies in
screening for middle-ear disease and hearing loss in
children. Pediatrics 1986;77:57–60.
93. American Speech-Language-Hearing Association. Guidelines for screening for hearing impairments and
middle-ear disorders. ASHA 1990;32(Suppl 2):17–24.
94. Rockette HE, Casselbrant ML. Methodologic issues in
screening for otitis media. In: Lim DJ, Bluestone CD,
Klein JO, Nelson JD, editors. Recent advances in
otitis media: proceedings of the fourth international
symposium. 1987, June 1–4, Ben Harboter, FL.
Philadelphia: BC Decker Inc; 1988.
p. 42–4.
95. Paradise JL, Smith CG, Sabo DL, et al. Tympanometric
detection of middle-ear effusion in the first versus the
second year of life. In: Lim DJ, Bluestone CD,
Casselbrant ML, et al, editors. Recent advances in
otitis media: proceedings of the sixth international
symposium. 1995, June 4–8, Ft. Lauderdale, FL.
Hamilton (ON): BC Decker Inc; 1996. p. 154–5.
96. Palmu A, Puhakka H, Rahko T, Takala AK. Diagnostic
value of tympanometry in infants in clinical practice.
Int J Pediatr Otorhinolaryngol 1999;49:207–13.
97. Bluestone CD, Klein JO. Otitis media, eustachian tube
dysfunction, and atelectasis. In: Bluestone CD,
Stool SE, Kenna MA, editors. Pediatric otolaryngology. 3rd ed. Philadelphia: W.B. Saunders; 1996.
p. 388–582.
98. Pugh KC, Burke HWK, Brown HM. Tympanometry
measures in native and non-native Hawaiian children.
Int J Pediatr Otorhinolaryngol 2004;68:753–4.
99. Pappas DG, editor. Diagnosis and treatment of hearing
impairment in children. San Diego: College-Hill Press;
1985.
100. American
Speech-Language-Hearing
Association.
Guidelines for identification audiometry. ASHA
1985;27:49–53.
101. Motohashi H, Kobayashi T, Toshima M, et al. A sevenyear school screening for secretory otitis media. In:
208
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
OTITIS MEDIA IN INFANTS AND CHILDREN
Lim DJ, Bluestone CD, Klein JO, et al, editors.
Recent advances in otitis media: proceedings of the
fifth international symposium. 1991, May 20–24, Ft.
Lauderdale, FL. Hamilton (ON): BC Decker Inc;
1993. p. 16–9.
Tos M, Stangerup S, Hvid G, et al. Point prevalence of
secretory otitis at different ages. Ann Otol Rhinol
Laryngol 1990;99(Suppl 49):14–6.
Grason RL. Otoadmittance meters. Proceedings of
impedance symposium. Rochester (MN): GrasonStadler; 1972.
Cantekin EI, Beery QC, Bluestone CD. Tympanometric
patterns found in middle-ear effusions. Ann Otol
Rhinol Laryngol 1977;86:16–20.
Fria TJ, Cantekin EI, Probst G. Validation of an
automatic otoadmittance middle-ear analyzer. Ann
Otol Rhinol Laryngol 1980;89:253–6.
Teele DW, Teele J. Detection of middle-ear effusion
by acoustic reflectometry. J Pediatr 1984;104:832–
8.
Combs JT. Single vs. double acoustic reflectometry
tracings. Pediatr Infect Dis J 1989;8:616–20.
Derkay CS, Bluestone CD, Thompson AE, et al. Otitis
media in the pediatric intensive care unit: a prospective study. Otolaryngol Head Neck Surg 1989;100:
292–9.
Holmes AE, Jones Muir KC, Kemker FJ. Acoustic
reflectometry versus tympanometry in pediatric middle-ear screenings. Lang Speech Hear Serv Schools
1989;20:41–9.
Lampe RM, Schwartz RH. Diagnostic value of acoustic
reflectometry in children with acute otitis media.
Pediatr Infect Dis J 1989;8:59–61.
Macknin MI, Collard ME, Medendorp SV. Acoustic
reflectometry compared to tympanometry and pure
tone thresholds. In: Lim DJ, Bluestone CD, Klein JO,
et al, editors. Recent advances in otitis media:
proceedings of the fifth international symposium.
1991, May 20–24, Ft. Lauderdale, FL. Hamilton
(ON): BC Decker Inc; 1993. p. 22–6.
Combs JT, Combs MK. Acoustic reflectometry:
spectral analysis and the conductive hearing loss
of otitis media. Pediatr Infect Dis J 1996;15:683–
6.
Kimball S. Acoustic reflectometry: spectral gradient
analysis for improved detection of middle-ear
effusion in children. Pediatr Infect Dis J 1998;17:
552–5.
Block SL, Mandel EM, McLinn S, et al. Spectral gradient
acoustic reflectometry for the detection of middle-ear
effusion by pediatricians and parents. Pediatr Infect
Dis J 1998;17:560–4.
Ruuskanen O, Ruohola A. Diagnostic methods. In:
Alper CM, Bluestone CD, Casselbrant ML, et al,
editors. Advanced therapy of otitis media. Hamilton
(ON): BC Decker Inc; 2004. p. 9–13.
Fria TJ, Cantekin EI, Eichler JA. Hearing acuity of
children with otitis media with effusion. Arch
Otolaryngol Head Neck Surg 1985;111:10–6.
117. Paparella MM, Oda M, Hiraide F, et al. Pathology of
sensorineural hearing loss in otitis media. Ann Otol
Rhinol Laryngol 1972;81:632–47.
118. Supance JS, Bluestone CD. Perilymph fistulas in infants
and children. Otolaryngol Head Neck Surg 1983;91:
663–71.
119. Northern JL, Downs MP, editors. Hearing in children.
2nd ed. Baltimore: Williams & Wilkins; 1978.
120. Fria TJ, Sabo DL. Auditory brainstem responses in
children with otitis media with effusion. Ann Otol
Rhinol Laryngol 1980;89:200–6.
121. Downs MP, Northern JL. Instrumentation to identify the
hearing loss from otitis media in the infant. In:
Lim DJ, Bluestone CD, Klein JO, et al, editors.
Recent advances in otitis media: proceedings of the
fifth international symposium. 1991, May 20–24, Ft.
Lauderdale, FL. Hamilton (ON): BC Decker Inc;
1993. p. 30–2.
122. Ahmad I, Pahor AL. Carhart’s notch: a finding in otitis
media with effusion. Int J Pediatr Otorhinolaryngol
2002;64:163–70.
123. Bluestone CD. Prevention of meningitis: cochlear
implants and inner-ear abnormalities. Arch
Otolaryngol Head Neck Surg 2003;129:279–81.
124. Gershel J, Kruger B, Giraudi-Perry D, et al. Accuracy of
the Welch-Allyn audioscope and traditional hearing
screening for children with known hearing loss. J
Pediatr 1985;106:15–20.
125. Owens JJ, McCoy MJ, Lonsbury-Martin BL, et al.
Otoacoustic emissions in children with normal ears,
middle-ear dysfunction, and ventilating tubes. Am J
Otolaryngol 1993;14:34–40.
126. Dhooge I, Vinck BM, van Cauwenberg PB. Clickevoked otoacoustic emissions: a technique for evaluation ventilation of the middle ear after insertion
of tympanostomy tubes. In: Lim DJ, Bluestone CD,
Casselbrant ML, et al, editors. Recent advances
in otitis media: proceedings of the sixth international symposium. 1995, June 4–8, Ft. Lauderdale,
FL. Hamilton (ON): BC Decker Inc; 1996.
p. 156–7.
127. Yeo SW, Park S-N, Park YS. Prognostic value of
otoacoustic emissions in children with middle ear
effusions. In: Lim DJ, Bluestone CD, Casselbrant ML,
et al, editors. Recent advances in otitis media:
proceedings of the eighth international symposium.
2003, June 3–7, Ft. Lauderdale, FL. Hamilton (ON):
BC Decker Inc; 2005. p. 130–1.
128. Park A-N, Yeo SW, Park K-H. Clinical and biochemical
factors that affect expression of distortion-product
otoacoustic emission in children with middle ear
effusion. In: Lim DJ, Bluestone CD, Casselbrant ML,
et al, editors. Recent advances in otitis media:
proceedings of the eighth international symposium.
2003, June 3–7, Ft. Lauderdale, FL. Hamilton (ON):
BC Decker Inc; 2005. p. 132–3.
129. Ho V, Daly KA, Hunter LL, Davey C. Otoacoustic
emissions and tympanometry screening among 0-5
year olds. Laryngoscope 2002;112:513–9.
Diagnosis
130. Casselbrant ML, Furman JM, Rubenstein E, Mandel EM.
Effect of otitis media on the vestibular system in
children. Ann Otol Rhinol Laryngol 1995;104:
620–4.
131. Golz A, Angel-Yeger B, Parush S. Evaluation of balance
disturbances in children with middle-ear effusion. Int
J Pediatr Otorhinolaryngol 1998;43:21–6.
132. Hart M, Nichols DS, Butler EM, Barin K. Childhood
imbalance and chronic otitis media with effusion:
effect of tympanostomy tube insertion on standardized tests of balance and locomotion. Laryngoscope
1998;108:665–70.
133. Cohen H, Friedman EM, Lai D, et al. Balance in children
with otitis media with effusion. Int J Pediatr
Otorhinolaryngol 1997;42:107–15.
134. Busis S. Vertigo. In: Bluestone CD, Stool SE, Kenna MA,
editors.
Pediatric
otolaryngology.
3rd
ed.
Philadelphia: W.B. Saunders; 1996. p. 261–70.
135. Casselbrant ML, Redfern MS, Furman JM, et al. Visualinduced postural sway in children with and without
otitis media. Ann Otol Rhinol Laryngol 1998;107:
401–5.
136. Casselbrant ML, Furman JM, Mandel EM, et al. Past
history of otitis media and balance in four-year-old
children. Laryngoscope 2000;110:773–8.
137. Alt A. Heilunger Taubstummheit erzielte durch
Beseitigung einer Otorrhea und einer angebornen
Gaumenspalate. Arch Augen Ohrenh 1878;7:21–215.
138. Thorington J. Almost total destruction of the velum palati
corrected by an artificial soft palate, producing not
only greatly improved speech, but an immediate
increase of audition. Med News Phila 1892;61:269–72.
139. Gutzmann H. Zur Prognose und Behandlung der
angeborenen Gaumendefekte. Monatschr Sprachheilk 1893.
140. Brunck W. Die systematische untersuchung des sprachorganes bei angeborenen gaumendefekte in ihrer beziehung zur prognose und therapie. Leipzig 1906.
141. Halfond MM, Ballenger JJ. An audiologic and otorhinologic study of cleft lip and cleft palate cases. Arch
Otolaryngol Head Neck Surg 1956;64:58–62.
142. Miller MH. Hearing losses in cleft palate cases: the
incidence, type, and significance. Laryngoscope 1956;
66:1492–6.
143. Walton WK. Audiometrically ‘‘normal’’ conductive hearing losses among the cleft palate. Cleft Palate J 1973;
10:99–103.
144. Handzic-Cuk J, Cuk V, Risavi R, et al. Hearing levels and
age in cleft palate patients. Int J Pediatr
Otorhinolaryngol 1996;37:227–42.
145. Andrews PJ, Chorbachi R, Sirimanna TJ, et al.
Evaluation of hearing thresholds in 3-month old
children with cleft palate: basis for a selective policy
for ventilation tube insertion at the time of palate
repair. In: Lim DJ, Bluestone CD, Casselbrant ML,
et al, editors. Recent advances in otitis media:
proceedings of the eighth international symposium.
2003, June 3–7, Ft. Lauderdale, FL. Hamilton (ON):
BC Decker Inc; 2005. p. 340–4.
209
146. Bennett M, Ward RH, Tait CA. Otologic-audiologic
study of cleft palate children. Laryngoscope 1968;78:
1011–9.
147. Broen PA, Moller KT, Carlstrom J, et al. Comparison of
the hearing histories of children with and without cleft
palate. Cleft Palate Craniofac J 1996;33:127–33.
148. Bluestone CD, Paradise JL, Beery QC, et al. Certain
effects of cleft palate repair on eustachian tube
function. Cleft Palate J 1972;9:183–93.
149. Nunn DR, Derkay CS, Darrow DH, et al. The effect of
very early cleft palate closure on the need for
ventilation tubes in the first years of life.
Laryngoscope 1995;105:905–8.
150. Robinson PJ, Lodge S, Jones BM, et al. The effect of
palate repair on otitis media with effusion. Plast
Reconstr Surg 1992;89:640–5.
151. Variot G. Ecoulement de lait par l’oreille d’un nourisson
atteint de devision congenitale du voile du palais. Bull
Soc Ped Paris 1904;6:387–91.
152. Sataloff J, Fraser M. Hearing loss in children with cleft
palates. Arch Otolaryngol 1952;55:61–4.
153. Skolnick EM. Otologic evaluation in cleft palate patients.
Laryngoscope 1958;68:1908–49.
154. Linthicum FH, Body H, Keaster J. Incidence of middleear disease in children with cleft palate. Cleft Palate
Bull 1959;9:23–5.
155. Bluestone CD. Eustachian tube obstruction in the infant
with cleft palate. Ann Otol Rhinol Laryngol 1971;80:
1–30.
156. Paradise JL, Bluestone CD. Early treatment of the
universal otitis media of infants with cleft palate.
Pediatrics 1974;53:48–54.
157. Meissner K. Ohrenerkrankungen bei Gaumenspalten.
Hals Nasen Ohrenarzt 1939;30:6–20.
158. Graham MD, Lierle DM. Posterior pharyngeal flap
palatoplasty and its relation to ear disease and hearing
loss: a preliminary report. Laryngoscope 1962;72:
1750–5.
159. Aschan G. Hearing and nasal function correlated to
postoperative speech in cleft palate patients with
velopharyngoplasty. Acta Otolaryngol (Stockh) 1966;
61:371–9.
160. Severeid LR. A longitudinal study of the efficacy of
adenoidectomy in children with cleft palate and
secondary otitis media. Trans Am Acad Ophthalmol
Otolaryngol 1972;76:1319–24.
161. Bennett M. The older cleft palate patient: a clinical
otologic-audiologic study. Laryngoscope 1972;82:
1217–25.
162. Ovesen T, Blegvad-Andersen O. Alterations in tympanic
membrane appearance and middle-ear function in 11year old children with complete unilateral cleft lip and
palate compared with healthy age-matched subjects.
Clin Otolaryngol 1992;17:203–7.
163. Leuwer R. Acute otitis media/otitis media with effusion
in children with cleft palate. In: Alper CM,
Bluestone CD, Casselbrant ML, et al, editors.
Advanced therapy of otitis media. Hamilton (ON):
BC Decker Inc; 2004. p. 465–7.
210
OTITIS MEDIA IN INFANTS AND CHILDREN
164. Teele DW, Klein JO, Rosner BA. Epidemiology of otitis
media in children. Ann Otol Rhinol Laryngol 1980;89:
5–6.
165. Sculerati N, Ledesma-Medina J, Finegold DN, et al.
Otitis media and hearing loss in Turner syndrome. Arch Otolaryngol Head Neck Surg 1990;116:
704–7.
166. Stewart JL. Otitis media in the first year of life in two
Eskimo communities. Ann Otol Rhinol Laryngol
1989;98:200–2.
167. Giles M, Asher I. Prevalence and natural history of otitis
media with perforation in Maori school children. J
Laryngol Otol 1991;105:257–60.
168. Berman SA, Balkany TJ, Simmons MA. Otitis media in
the neonatal intensive care unit. Pediatrics 1978;62:
198–201.
169. Howie VM, Ploussard JH, Sloyer J. The ‘‘otitis prone’’
condition. Am J Dis Child 1975;129:676–8.
170. Downs MP. Identification of children at risk for middleear effusion problems. Ann Otol Rhinol Laryngol
1980;89:168–71.
171. Barnett ED, Klein JO, Pelton SI, et al. Otitis media in
children born to HIV-infected mothers. In: Lim DJ,
Bluestone CD, Klein JO, et al, editors. Recent
advances in otitis media: proceedings of the fifth
international symposium. 1991, May 20–24, Ft.
Lauderdale, FL. Hamilton (ON): BC Decker Inc;
1993. p. 4–5.
172. Teele DW, Klein JO, Rosner BA, the Greater Boston
Otitis Study Group. Day-care and risk for recurrent,
acute otitis media (AOM) in infancy. In: Lim DJ,
Bluestone CD, Klein JO, et al, editors. Recent
advances in otitis media: proceedings of the fifth
international symposium. 1991, May 20–24, Ft.
Lauderdale, FL. Hamilton (ON): BC Decker Inc;
1993. p. 5–6.
173. Wald ER, Dashefsky B, Byers C, et al. Frequency and
severity of infections in day-care. J Pediatr 1988;112:
540–6.
174. Ruben RJ, Math R. Serous otitis media associated with
sensorineural hearing loss in children Laryngoscope
1978;88:1139–54.
175. Porter TA. Otoadmittance measurements in a residential
deaf population. Am Ann Deaf 1974;119:47–52.
176. Brooks DN. Impedance bridge studies on normal and
hearing impaired children. Acta Otorhinolaryngol
(Belg) 1974;28:140–5.
177. Mehta D, Erlich M. Serous otitis media in a school for the
deaf. Volta Rev 1978;80:75–80.
178. Rubin M. Serous otitis media in severely to profoundly
hearing impaired children, ages 0 to 6. Volta Rev
1978;80:81–5.
179. Stool SE, Craig HB, Laird MA. Screening for middle-ear
disease in a school for the deaf. Ann Otol Rhinol
Laryngol 1980;89:172–7.
180. Riding KH, Reichert TJ, Findlay RC, et al.
Tympanometric and otologic evaluation of students
in a school for the deaf. In: Harford ER, Bess FH,
Bluestone CD, Klein JO, editors. Impedance screen-
181.
182.
183.
184.
185.
186.
187.
188.
189.
190.
191.
192.
193.
194.
195.
196.
197.
ing for middle-ear disease in children. New York:
Grune & Stratton; 1978. p. 279–91.
Craig HB, Stool SE, Laird MA. Project ‘‘ears’’: otologic
maintenance in a school for the deaf. Am Ann Deaf
1979;124:458–67.
Findlay RC, Stool SE, Svitko CA. Tympanometric and
otoscopic evaluations of a school-age deaf population:
a longitudinal study. Am Ann Deaf 1977;122:407–13.
Arriaga MA, Bluestone CD, Stool SE. The role of
tympanocentesis in the management of infants with
sepsis. Laryngoscope 1989;99:1048–51.
Belmont MJ. Myringotomy and tympanocentesis. In:
Alper CM, Bluestone CD, Casselbrant ML, et al,
editors. Advanced therapy of otitis media. Hamilton
(ON): BC Decker Inc; 2004. p. 58–62.
Pichichero ME. Diagnostic accuracy, tympanocentesis
performance, and antibiotic selection by pediatric
residents in management of otitis media. Pediatrics
2002;110:1064–70.
Faden J, Poje C, Pizzuto M, et al. A new technique (the
NOW test) for the detection of Streptococcus pneumoniae in the effusions of otitis media. J Laryngol
Otol 2002;116:499–501.
Bauer AW, Kirby WM, Sherris JC, et al. Antibiotic
susceptibility testing by a standardized single disk
method. Am J Clin Pathol 1966;45:493–6.
Schwartz RH, Rodriguez WJ, Mann R, et al. The
nasopharyngeal culture in acute otitis media: a
reappraisal of its usefulness. JAMA 1979;241:2170–3.
Long SS, Henretig FM, Teter MJ, et al. Nasopharyngeal
flora and acute otitis media. Infect Immun 1984;41:
987–91.
Faden J. Role of nasopharyngeal colonization in recurrent
otitis media. In: Alper CM, Bluestone CD,
Casselbrant ML, et al, editors. Advanced therapy of
otitis media. Hamilton (ON): BC Decker Inc; 2004.
p. 125–9.
Werkhaven JA, Reinisch L, Sorrell M, et al. Non-invasive
optical diagnosis of bacteria causing otitis media.
Laryngoscope 1994;104:264–8.
Harding AL, Anderson P, Howie VM, et al. Haemophilus
influenzae isolated from children with otitis media. In:
Sell SHW, Kargon DT, editors. Haemophilus influenzae. Nashville (TN): Vanderbilt University Press;
1973. p. 21–8.
Teele DW, Pelton SI, Grant MJA, et al. Bacteremia in
febrile children under 2 years of age: results of cultures
of blood of 600 consecutive febrile children seen in a
walk-in clinic. J Pediatr 1975;87:227–30.
Crain EF, Shelov SP. Febrile infants: predictors of
bacteremia. J Pediatr 1982;101:686–9.
Greene JW, Hara C, O’Connor S, et al. Management of
febrile outpatient neonates. Clin Pediatr 1981;20:375–
80.
Roberts KB, Borzy MS. Fever in the first eight weeks of
life. Johns Hopkins Med J 1977;11:9–13.
Shurin PA, Howie VM, Pelton SI, et al. Bacteriology of
otitis media during the first six weeks of life. J Pediatr
1978;92:893–6.
Diagnosis
198. Schlesinger PC. The significance of fever in infants less
than three months old: a retrospective review of one
year’s experience at Boston City Hospital’s pediatric
walk-in clinic [dissertation]. New Haven (CT): Yale
University School of Medicine; 1982.
199. Tetzlaff TF, Ashworth C, Nelson JD. Otitis media in
children less than 12 weeks of age. Pediatrics 1977;59:
827–32.
200. Lahikainen EA. Clinico-bacteriologic studies on acute
otitis media: aspiration of tympanum as diagnostic
and therapeutic method. Acta Otolaryngol Suppl
(Stockh) 1953;107:1–82.
201. Feingold M, Klein JO, Haslam GE, et al. Acute otitis
media in children: bacteriological findings in middleear fluid obtained by needle aspiration. Am J Dis
Child 1966;111:361–5.
202. Gentile DA, Skoner DP. Allergy testing/treatment for
otitis media. In: Alper CM, Bluestone CD,
Casselbrant ML, et al, editors. Advanced therapy of
otitis media. Hamilton (ON): BC Decker Inc; 2004.
p. 146–151.
203. Alper CM, Tabari R, Seroky JT, Doyle WJ. Magnetic
resonance imaging of the development of otitis media
with effusion caused by functional obstruction of the
eustachian tube. Ann Otol Rhinol Laryngol 1997;106:
422–31.
204. Edell SL, Isaacson S. A-mode ultrasound evaluation of
the maxillary sinus. Otolaryngol Clin North Am 1978;
11:531–40.
205. Revonta M. A-mode ultrasound of maxillary sinusitis
children [letter]. Lancet 1979;1:320.
206. Weissman JL, Anderson JC. Imaging in otitis media. In:
Alper CM, Bluestone CD, Casselbrant ML, et al,
editors. Advanced therapy of otitis media. Hamilton
(ON): BC Decker Inc; 2004. p. 453–7.
207. Bluestone CD. Eustachian tube: structure, function, role
in otitis media. Hamilton (ON): BC Decker Inc; 2005.
p. 1–219.
208. Bluestone CD, editor. Studies in Otitis Media: Children’s
Hospital of Pittsburgh & University of Pittsburgh
progress report 2004. Laryngoscope 2004;114 Suppl
105:1–26.
209. Bluestone CD, Shurin P. Middle-ear diseases in children:
pathogenesis, diagnosis, and management. Pediatr
Clin North Am 1974;21:379–400.
210. Poe DS, Abou-Halawa A, Abdel-Razek O. Analysis of
the dysfunctional eustachian tube by video endoscopy. Otol Neurol 2001;22:590–5.
211. El-Guindy A. A correlative manometric and endoscopic
study of tubal function in chronic otitis media with
effusion. Acta Otolaryngol (Stockh) 1998;118:692–6.
212. Su C. Microendoscopic findings of the eustachian tube in
patients with otitis media. In: Lim DJ, Bluestone CD,
Casselbrant ML, et al, editors. Recent advances in
otitis media: proceedings of the sixth international
symposium. 1995, June 4–8, Ft. Lauderdale, FL.
Hamilton (ON): BC Decker Inc; 1996. p. 88–9.
213. Takahashi H, Miura A, Honjo I, Fujita A. Cause of
eustachian tube constriction in swallowing in patients
214.
215.
216.
217.
218.
219.
220.
221.
222.
223.
224.
225.
226.
227.
211
with otitis media with effusion. Ann Otol Rhinol
Laryngol 1996;105:724–8.
Bluestone CD. Assessment of eustachian tube function.
In: Jerger J, Northern J, editors. Clinical impedance
audiometry. New York: American Electromedics;
1980. p. 83–108.
Casselbrant ML, Brostoff LM, Cantekin EI, et al. Otitis
media with effusion in preschool children.
Laryngoscope 1985;95:428–36.
Elner A, Ingelstedt S, Ivarsson A. The normal function of
the eustachian tube. Acta Otolaryngol (Stockh) 1971;
72:320–8.
Bluestone CD, Casselbrant ML, Cantekin EI. Functional
obstruction of the eustachian tube in the pathogenesis
of acquired cholesteatoma in children. The
Netherlands: Kugler Publications BV; 1981. p. 211–24.
Chan KH, Bluestone CD. Lack of efficacy of middle-ear
inflation: treatment of otitis media with effusion in
children. Otolaryngol Head Neck Surg 1989;100:317–
23.
Stangerup SE, Sederberg-Olsen J, Balle V. Autoinflation
as a treatment of secretory otitis media: a randomized
controlled study. Arch Otolaryngol Head Neck Surg
1992;118:149–52.
Cantekin EI, Bluestone CD, Parkin LP. Eustachian tube
ventilatory function in children. Ann Otol Rhinol
Laryngol 1976;85 Suppl 25:171–7.
Bluestone CD. Management of the abnormally patulous
eustachian tube. In: Myers EN, Bluestone CD,
Brackmann DE, Krause CJ, editors. Advances in
otolaryngology and head-neck surgery. Vol. 12., St.
Louis: Mosby; 1998. p. 201–29.
Bluestone CD. Assessment of eustachian tube function.
In: Jerger J, editor. Handbook of clinical impedance
audiometry. New York: American Electromedics;
1975. p. 127–48.
McBride TP, Derkay CS, Cunningham MJ, et al.
Evaluation of noninvasive eustachian tube function
tests in normal adults. Laryngoscope 1988;98:655–8.
Ingelstedt S, Ortegren U. Qualitative testing of the
eustachian tube function. Acta Otolaryngol Suppl
(Stockh) 1963;182:7–23.
Bluestone CD, Paradise JL, Beery QC. Symposium on
prophylaxis and treatment of middle-ear effusion; the
physiology of the eustachian tube in the pathogenesis
and
management
of
middle-ear
effusions.
Laryngoscope 1972;82:1654–70.
Iwano T, Hamada E, Kinoshita T, et al. Passive opening
pressure of the eustachian tube. In: Lim DJ,
Bluestone CD, Klein JO, et al, editors. Recent
advances in otitis media: proceedings of the fifth
international symposium. 1991, May 20–24, Ft.
Lauderdale, FL. Hamilton (ON): BC Decker Inc;
1993. p. 6–8.
Sakakihara J, Fujita A, Kurata K, et al. Compliance of
the eustachian tube from the etiologic viewpoint of
middle-ear disease. In: Lim DJ, Bluestone CD,
Klein JO, et al, editors. Recent advances in otitis
media: proceedings of the fifth international sympo-
212
228.
229.
230.
231.
232.
233.
234.
235.
236.
237.
238.
239.
240.
241.
242.
243.
OTITIS MEDIA IN INFANTS AND CHILDREN
sium. 1991, May 20–24, Ft. Lauderdale, FL.
Hamilton (ON): BC Decker Inc; 1993. p. 9–10.
Cantekin EI, Bluestone CD, Saez C, et al. Normal and
abnormal middle-ear ventilation. Ann Otol Rhinol
Laryngol 1977;86 Suppl 41:1–15.
Ingelstedt S, Ivarsson A, Jonson A. Mechanics of the
human middle ear: pressure regulation in aviation and
diving, a nontraumatic method. Acta Otolaryngol
Suppl (Stockh) 1967;228:1–57.
Bylander A. Comparison of eustachian tube function in
children and adults with normal ears. Ann Otol
Rhinol Laryngol 1980;89 Suppl 68:20–4.
van der Avoort SJC, van Heerbeek N, Zielhuis GA,
Cremers CWRJ. Sonotubometry: eustachian tube
ventilatory function test: a state-of-the-art review.
Otol Neurotology 2005;26:538–43.
Murti K, Stern R, Cantekin EI, et al. Sonometric
evaluation of eustachian tube function using broadband stimuli. Ann Otol Rhinol Laryngol 1980;89
Suppl 68:178–84.
Okubo J, Watanabe I, Shibusawa M, et al.
Sonotubometric measurement of the eustachian tube
function by means of band noise. ORL J
Otorhinolaryngol Relat Spec 1987;49:242–52.
Palva T, Marttila T, Jauhiainen T. Comparison of pure
tones and noise stimuli in sonotubometry. Acta
Otolaryngol (Stockh) 1987;103:212–6.
Virtanen H. Sonotubometry: an acoustical method for
objective measurement of auditory tubal opening.
Acta Otolaryngol (Stockh) 1978;96:93–103.
Paludetti G, Di Nardo W, Galli J, et al. Functional
study of the eustachian tube with sequential scintigraphy. ORL J Otorhinolaryngol Relat Spec 1992;54:
76–9.
Kaneko A, Doi T, Hosoda Y, et al. Direct measurement
of eustachian tube compliance. Acta Otolaryngol
(Stockh) 1996;116:594–8.
Morita M, Matsunaga T. Sonotubometry with a tubal
catheter as an index for the use of a ventilation tube in
otitis media with effusion. Acta Otolaryngol Suppl
(Stockh) 1993;501:59–62.
Cantekin EI, Saez CA, Bluestone CD, et al. Airflow
through the eustachian tube. Ann Otol Rhinol
Laryngol 1979;88:603–12.
Handzic-Cuk J, Cuk V, Gluhinic M, et al.
Tympanometric findings in cleft palate patients:
influence of age and cleft type. J Laryngol Otol
2001;115:91–6.
Harford ER, Bess FH, Bluestone CD, Klein JO.
Impedance screening for middle-ear disease in children. New York: Grune & Stratton; 1978.
Beery QC, Bluestone CD, Cantekin EI. Otologic history,
audiometry and tympanometry as a case finding
procedure for school screening. Laryngoscope 1975;
84:1976–85.
Brooks DN. An objective method of detecting fluid in the
middle ear. J Int Audiol 1968;7:280–6.
244. Yamaguchi N, Mizorogi N, Okihisa M, et al. Eustachian
tube function and prognosis of otitis media with
effusion after removal of ventilatory tube. In: Lim DJ,
Bluestone CD, Klein JO, et al, editors. Recent
advances in otitis media: proceedings of the fifth
international symposium. 1991, May 20–24, Ft.
Lauderdale, FL. Hamilton (ON): BC Decker Inc;
1993. p. 25–7.
245. Bluestone CD, Wittel R, Paradise JL, et al. Eustachian
tube function as related to adenoidectomy for otitis
media. Trans Am Acad Ophthalmol Otolaryngol
1972;76:1325–39.
246. Bluestone CD, Cantekin EI, Beery QC. Certain effects of
adenoidectomy on eustachian tube ventilatory function. Laryngoscope 1975;85:113–27.
247. Bluestone CD, Cantekin EI, Beery QC. Effect of
inflammation on the ventilatory function of
the eustachian tube. Laryngoscope 1977;87:493–
507.
248. Holborow C. Eustachian tube function. Arch Otolaryngol
Head Neck Surg 1970;92:624–6.
249. Holmquist J. The role of the eustachian tube in
myringoplasty. Acta Otolaryngol (Stockh) 1968;66:
289–95.
250. Miller GF, Bilodeau R. Preoperative evaluation of
eustachian tubal function in tympanoplasty. South
Med J 1967;60:868–71.
251. Siedentop KH. Eustachian tube dynamics, size of the
mastoid air cell system, and results with tympanoplasty. Otolaryngol Clin North Am 1972;5:33–44.
252. Cohn AM, Schwaber MK, Anthony LS, et al. Eustachian
tube function and tympanoplasty. Ann Otol Rhinol
Laryngol 1979;88:339–47.
253. Ekvall L. Eustachian tube function in tympanoplasty.
Acta Otolaryngol Suppl (Stockh) 1970;263:33–42.
254. Lee K, Schuknecht HF. Results of tympanoplasty and
mastoidectomy at the Massachusetts Eye and Ear
Infirmary. Laryngoscope 1971;81:529–43.
255. Virtanen H, Palva T, Jauhiainen T. The prognostic value
of eustachian tube function measurements in tympanoplastic surgery. Acta Otolaryngol (Stockh) 1980;90:
317–23.
256. Bluestone CD, Cantekin EI, Douglas GS. Eustachian
tube function related to the outcome of tympanoplasty in children. Laryngoscope 1979;89:
450–8.
257. Manning SC, Cantekin EI, Kenna MA, et al. Prognostic
value of eustachian tube function in pediatric
tympanoplasty. Laryngoscope 1987;97:1012–6.
258. Bluestone CD. Otologic surgical procedures. In:
Bluestone CD, Stool SE, editors. Atlas of pediatric
otolaryngology. Philadelphia: W.B. Saunders; 1995.
p. 27–128.
259. Roush J, Bryant K, Mundy M, et al. Developmental
changes in static admittance and tympanometric
width in infants and toddlers. J Am Acad Audiol
1995;6:334–8.