BACKGROUND: This study aimed to determine predictors for otolaryngology resident success using data available at the time candidates are interviewed (eg, medical school attended, letters of recommendation, test scores) and data that emerge during residency.STUDY DESIGN: We performed a retrospective cohort Study of 36 residents who entered our program between 1983 and 1993.RESULTS: Seventy percent of Alpha Omega Alpha (AOA) members and 13% of nonmembers were in the highest tertile based on faculty ranking (p < 0.01), and candidates with an exceptional trait were more likely than those without an exceptional trait to rank in the highest tertile (57% versus 10%, p < 0.01). AOA membership was also related to current academic appointment (p = 0.02). Significant correlations included United States Medical Licensing Examination (USMLE) I score, year 2 In-training score (0.48, p = 0.03), and years 3 and 4 in-training score and faculty ranking (minus 0.39, minus 0.50, respectively, p <= 0.01). Having more than one peer-reviewed publication was associated with higher USMLE I scores and being favored for selection by > 50% of the interviewers (p < 0.05 for both).CONCLUSIONS: In our program designed to train academic otolaryngologists, postresident success was strongly predicted by having an exceptional trait and AOA membership. Success during residency was predicted by interviewer's impression of the candidate and a USMLE I score > 570. Knowledge of these factors at the time of the resident interview could increase the likelihood of selecting the most appropriate candidates for academic otolaryngology. Resident success is a complex outcome, and other unmeasured and unexamined characteristics can provide additional insight into choosing successful residents.

Otitis media (OM) is the most common childhood disease. Almost all children experience at least one episode, but morbidity is greatest in children who experience chronic/recurrent OM (COME/ROM). There is mounting evidence that COME/ROM clusters in families and exhibits substantial heritability. Subjects who had tympanostomy tube surgery for COME/ROM (probands) and their families were recruited for the present study, and an ear examination was performed, without knowledge of the subject's history, to determine presence of OM sequelae. In addition, tympanometric testing was performed at three frequencies (226, 630 or 710, and 1,400 Hz) to detect abnormal middle-ear mechanics, and hearing was screened at 20 dB for the speech frequencies. Of these families, 121 had at least two individuals who had received the diagnosis of COME/ROM (364 affected and genotyped individuals), of whom 238 affected and informative relative pairs were used for analyses. Single-point nonparametric linkage analysis provided evidence of linkage of COME/ROM to chromosome 10q at marker D10S212 (LOD 3.78; P=3.0 x 10(-5)) and to chromosome 19q at marker D19S254 (LOD 2.61; P=5.3 x 10(-4)). Analyses conditional on support for linkage at chromosomes 10q and 19q resulted in a significant increase in LOD score support on chromosome 3p (between markers D3S4545 and D3S1259). These results suggest that risk of COME/ROM is determined by interactions between genes that reside in several candidate regions of the genome and are probably modulated by other environmental risk factors.

Some methods of temporal statistics are presented and proposed for investigating the date of birth as a disease predictor. A subject's birthday is proposed to be used as a continuous variable with a circular distribution, a special type of interval scale without a true zero point. Three types of endpoints are then considered: a dichotomous endpoint; a continuous endpoint; and time-to-event. A study of otitis media is used for illustration. We found, for example, that children born in late winter to early spring tend to have higher cord blood pneumococcal antibody concentration and lower risk of disease as compared to those born in summer to early fall perhaps due largely to exposure to indoor pollution by pregnant mothers.

Objectives/Hypothesis: Microwave radiation exposure from cellular telephone use has been implicated in the development of intracranial tumors. The intratemporal facial nerve (IFN) is exposed to higher levels of cellular telephone radiation than intracranial tissues. The purpose of the study was to determine whether cellular telephone use is associated with an increased risk of IFN tumors. Study Design: Case-control using a structured telephone survey at an academic, tertiary-care referral center. Methods: Patients with IFN tumors (n = 18) were case-matched with patients treated for acoustic neuroma (n = 51), rhinosinusitis (n = 72), and dysphonia or gastroesophageal reflux disease (n = 69). Risk of facial nerve tumorigenesis was compared by extent of cellular telephone use and other risk factors. Results: The odds ratio of developing an IFN tumor was 0.6 (95% CI, 0.2-1.9) with any handheld cellular telephone use and 0.4 (95% CI,.0.1-2.1) with regular cellular telephone use. No factors were associated with an increased risk for ON tumor development. Conclusions: Regular cellular telephone use does not appear to be associated with a higher risk of IFN tumor development. The short duration of widespread cellular telephone use precludes definite exclusion as a risk for IFN tumor development.

Maternal pneumococcal immunization may be a strategy for the prevention of pneumococcal disease during the first months of life before infant-administered pneumococcal conjugate vaccine (PCV) becomes protective. Preparatory to a Phase III efficacy trial to investigate this strategy for preventing early infant otitis media (OM), we are conducting a Phase I-II randomized, double-masked trial to determine if maternal 9-valent PCV immunization alters active antibody production in infants who are immunized with PCV-7 and to compare local and systemic adverse events among women immunized with PCV-9 or placebo.A pilot study was conducted in 1997 in a Minneapolis-St. Paul health maintenance organization, HealthPartners (HP), to estimate enrollment rate for the proposed Phase III trial. A total of 154 pregnant women were selected of whom 122 appeared to be eligible from ICD codes in the HP claims database; 76 responded, and 46 of these were eligible for participation. Four of the 46 reported that they would be very likely and 21 somewhat likely to participate; an estimated 20% (25/122) participation rate.The records of 4289 women in their second trimester have been reviewed to date for the Phase I/II trial; 2589 (60%) were found not to be eligible; and an additional 1015 (24%) could not be contacted. Of the 685 remaining, 558 (81%) were not interested in participating when interviewed, and 127 (19%) have consented. Most (46%) of those who declined participation have cited concern about the safety of vaccination during pregnancy. While the overall participation rate of second trimester women is only 3% (127/4289), maternal attrition (2.8%) and infant attrition from the study before age 7 months (3.9%) are lower than projected (25%). Differences in study design could explain the difference in participation rates estimated in the pilot study and experienced in the Phase I/II study. Reports of safety from large-scale studies of maternal PCV immunization in industrialized countries are needed before women are receptive to maternal immunization to protect their infants against pneumococcal disease. (C) 2003 Elsevier Science Ltd. All rights reserved.

Objectives: To determine the rate of otitis media (OM)-associated transient evoked otoacoustic emissions (TEOAE) screening failure in a sample of pre-school children, to evaluate concordance between TEOAE and tympanometry, to investigate risk factors for TEOAE failure, and to determine agreement between TEOAE failure and physician findings at referral. Study Design: Cross-sectional. Methods: Children from birth to 5 years underwent screening by TEOAF, and tympanometry, and those with one or more abnormal test result(s) were referred to their physician for further evaluation. Univariate associations between risk factors and TEOAE failure were determined using chi-square analysis. Multiple logistic regression analysis was done to examine the relationship between specific risk factors and TEOAE failures Results: A total of 664 children aged 2 weeks to 71 months were screened between September 1997 and May 1999. TEOAE and tympanometry failure was found in 25% and 35% of all subjects, respectively. The overall prevalence of OM-associated hearing loss was 20%. Agreement between tympanometry and TEOAE was better for the youngest (<6 mo) and oldest &GE;36 mo) age groups. Of those who failed TEOAE, it physician saw 81% within 3 months, and 80% of these had a diagnosis consistent with hearing loss but only 18% had audiometric testing. Sibling history of OM was the only significant predictor for TEOAE failure. Conclusions: TEOAE screening failure was highly consistent with physician diagnosis at follow-up. Failure of TEOAE in a screening program should be followed with diagnostic audiology testing to determine whether conductive or sensorineural hearing loss is present.

Objective: To determine if cord blood anticapsular polysaccharide pneumococcal IgG antibody concentration was related to the number of otitis media (OM) and acute OM episodes during the first year of life.Design: Prospective study following infants from birth to 24 months.Setting: Health maintenance organization.Patients: The study population consisted of 415 infants whose mothers volunteered for the study during pregnancy. Cord blood samples were collected and infants were followed up for OM in the health maintenance organization. Ninety-seven percent of the infants were white, 49% male, 3% from households with annual incomes of less than $20 000, and 30% from households with annual incomes of more than $60 000.Main Outcome Measure: Number of physician-diagnosed OM episodes, including both OM with effusion and acute OM, and acute OM episodes from birth to 12 months.Results: With univariate analysis, low cord blood antibody concentrations against serotypes 3 and 19F predicted more acute OM episodes (P=.04 and P=.05, respectively), and low antibody concentrations against serotypes 19F and 23F predicted more OM episodes (P=.04 and P=.05, respectively) over the first year of life. With Poisson regression, which adjusted for variables related to the recurrence of OM and having low cord blood antibody concentrations, serotype 19F remained significantly related to the number of OM episodes (relative risk for lowest quartiles vs upper 3 quartiles 1.23; 95% confidence interval, 1.02-1.50; P=.03).Conclusions: Low cord blood antibody concentrations to serotype 19F predicted more OM episodes over the first 12 months of life. These results suggest the potential benefit of maternal immunization to raise neonatalantipolysaccharide pneumococcal antibody concentration and delay the onset and reduce the number of OM episodes.

The impact of otitis media (OM) on public health is considerable. OM is the most frequently diagnosed childhood disease in the United States. Between 1993 and 1995 OM was the most common diagnosis during office visits among 1- to 4-year-olds. 1 OM constituted 18% of physician visits, compared with 14% of visits for well child care, 11% of visits for upper respiratory infection, 8% of visits for injury and 5% of visits for sore throat and tonsillitis. Thirty percent of children younger than 24 months in a large managed care organization were treated with tympanostomy tubes in 1994, 2 and cost of OM treatment in the United States was estimated at $3.8 billion in 1995. 3 Additionally OM was one of the most common reasons for deferral of diphtheria, tetanus, pertussis, polio, measles, mumps and rubella vaccines among inner city Baltimore children, 4 which would increase their susceptibility to these vaccine-preventable diseases. INCIDENCE, PREVALENCE, NATURAL HISTORY Recent large prospective studies in the United States have investigated cumulative incidence of OM, using active surveillance and frequent examination. These studies reveal that at least 90% of children have one or more bouts of symptomatic or asymptomatic middle ear effusion (MEE) by the age of 2 years. 5, 6 Peak age-specific incidence in the United States occurs in the first 2 years of life, typically between 6 and 18 months. In European countries, however, children enter child care later, which may delay peak incidence and the cumulative burden of OM (i.e. first OM episode is delayed and recurrent OM correspondingly reduced). Some studies have shown a bimodal distribution, with peak incidence at 1 to 2 years of age and again at 5 years, the latter age corresponding to school entry. About one-half of infants in the United States experience their first OM episode by 6 months of age, and early OM onset is associated with later recurrent OM and chronic otitis media with effusion (OME). The young infants' developing immune system coupled with age-related differences in Eustachian tube anatomy and physiology make them particularly vulnerable to respiratory tract infection and OM. These characteristics increase susceptibility to respiratory pathogens and obstruct drainage of effusion formed during middle ear inflammation that accompanies an OM episode. Added to these liabilities, early exposures to environmental factors (e.g. child care attendance, respiratory viruses, parental smoking) also contribute to early and more frequent OM. Prevalence studies typically document the presence of OME using a variety of methods (i.e. tympanometry, otoscopy, myringotomy and audiometry), and rates vary widely by study. Nevertheless researchers have established that within a study population, OME prevalence declines with age, and rates are higher in the fall and winter than in the spring and summer. The ranges of reported age-specific OME prevalence rates were as follows: children <2 years of age, 6 to 11%; 2- to 4-year-olds, 20 to 39%; 5- to 8-year-olds, 1 to 28%. Inuit children exhibited rates >20%7 and school age children (5 to 18 years) rates of 1 to 12%. 8 Studies that calculated prevalence rates using ears rather than children were not included in these ranges because they underestimate the number of children affected. Differences in age-specific prevalence and incidence rates among studies can be due to a number of factors, including dissimilarities in study groups that affect OM susceptibility (e.g. race or ethnicity, risk factor status, season) or the likelihood of OM diagnosis (e.g. availability and use of health care, diagnostic methods and disease definitions, examination frequency). Prospective studies and randomized antibiotic trials provide insight into the natural history of OM resolution. Among children with OM, about two-thirds resolve their MEE within 1 month after the onset of OM, irrespective of treatment, and 90% resolve it in within 3 months. 8 Younger children are more likely to have persistent effusion than older children; during the first 2 years of life mean proportion of time with MEE is 20%. TRENDS OVER TIME Rates of tympanostomy tube insertion appear to have increased 4-fold between 1970 and 1990. 9 Practice patterns changed substantially during this time period as well, with tube insertions currently being performed predominantly in free-standing surgery centers and infrequently in hospitals. Comparison of tube rates performed in hospitals during this time would vastly underestimate the true tube rate. Therefore two sources of national data, one on hospital discharge diagnoses and another on ambulatory surgery diagnoses, were used for this comparison. Studies from Finland and the United States have reported increasing incidence of acute OM and recurrent OM; both studies also reported an increase in group child care during the study period. 10, 11 Although increased OM incidence would be consistent with the observed increased attendance in group child care, changes in rates of breast-feeding and parental smoking are more complicated. Rates of breast-feeding at 6 months peaked in the United States at 25% in 1982 (up from 5% in 1971), declined to 18% in 1989 and then rose to 22% in 1995. 12 Smoking rates for 20- to 44-year-olds have actually declined since 1974, with male rates dropping more rapidly than female rates. 13 Receiving a diagnosis of OM depends on a number of variables, for example, diagnostic criteria, parent and physician awareness of OM and its risk factors and access to and use of health care. Changes in factors that contribute to the likelihood of OM diagnosis or ascertainment may have occurred over the same time period, resulting in an apparent increase in OM incidence. Demographic factors Difficulties arise when comparing OM rates from studies of a homogenous group to make judgments about differences in OM susceptibility by race or ethnicity. Variability in study design, methodology or other population characteristics (e.g. socioeconomic status, risk factor profiles) may contribute to differences in OM rates that should not be attributed to ethnicity. Previous clinic-based research and survey data from national samples using parental report of children's OM history revealed that African-American children were less likely to experience acute and recurrent OM or OME than white children. 14, 15 However, Pittsburgh researchers using passive and active surveillance, monthly study visits and objective diagnostic criteria among biracial study populations demonstrated comparable rates of acute OM, MEE and the proportion of time with MEE in African-American and white children during the first 2 years of life and a strong inverse association between OME duration and socioeconomic status controlling for race. 5, 16 Also, a national population-based study of school age children reported similar rates of OME for whites and African-Americans, whereas Hispanics experienced higher OME prevalence. 17 Inuit, Native American and Native Alaskan children have considerably higher rates of chronic OM than rates reported for similarly aged, predominantly white populations, although only one study included more than one ethnic group. 7 In contrast the few longitudinal studies of Native American or Alaskan Native children in early life describe OM incidence rates similar to those of white and African-American children. Young age clearly increases the risk of OM and OME, a finding established by a preponderance of evidence. Numerous studies have reported that male children are at higher risk of OM than female children, but several others have found no male-female disparity in rates. Socioeconomic status encompasses many independent factors that affect both the risk of OM and the likelihood of OM ascertainment. These include accessibility of medical care, race (often linked to social class), prevalence of risk factors (bottle-feeding, parental smoking), exposure to viruses and bacteria implicated in OM at child care or in crowded living conditions. The complexity of socioeconomic status and failure to adequately control for it in risk factor studies most likely accounts for contradictory findings about the association between socioeconomic status and OM risk. Additionally in studies using passive surveillance, middle and high income groups may appear to have higher OM rates than lower income groups because use of health care increases the likelihood of having OM ascertained. Environmental factors Child care attendance and exposure to other young children (including siblings) has been established by numerous researchers and confirmed with metaanalysis as one of the major risk factors for OM, recurrent OM, OME and tympanostomy tubes. According to one metaanalysis, child care outside the home conferred a 2.5-fold risk of OM. 18 A critical review of studies investigating child care and OM reported odds ratios of 1.1 to 2.6 for family vs. home care and 1.6 to 4.0 for center care vs. home care. 19 Child care brings many children together in close contact, increasing the risk of both respiratory tract infection and OM. Several characteristics of the child care experience are related to increased exposure to other children and provide additional risk. These include center care, number of children in the setting or with whom the child has regular contact, hours spent in child care, age at entry, use of center care for the first placement, changes in care settings and having siblings in child care (this has been reported from Norway, where in contrast to the United States, infants do not enter child care until they are nearly 12 months old). However, recent studies have shown that among children followed prospectively or studied cross-sectionally in child care centers, rates of OM and respiratory disease diminish with age, with older preschoolers appearing to be less prone to respiratory infections and concomitant episodes of OM. Presumably decreasing OM susceptibility with increasing age even among children in center care occurs because of maturing immune systems accompanied by ameliorating changes in the angle and width of the Eustachian tube, which reduces the effects of viral and bacterial infections on the Eustachian tube and middle ear. Infant carriage of bacterial and viral pathogens implicated in OM and upper respiratory tract infection begins in the first few months of life. These pathogens can infect (or colonize) a child, and they are easily spread to others in the child care environment. Proposed mechanisms of viral action include injury to the middle ear and Eustachian tube epithelial cells, enhanced bacterial adhesion to these cells, lessening of middle ear mucociliary clearance, deleterious effects on cellular immune function and phagocytosis, tubal dysfunction resulting in negative pressure and serous transudate in the middle ear (which is an excellent growth medium for invading bacteria) and reduced antibiotic distribution from plasma to the inflamed middle ear. Although those in child care are more likely than other children to acquire active respiratory infections, they are also at higher risk of bacterial and viral colonization of the nasopharynx, which independently increases their OM risk. Scores of researchers have studied the role of infant feeding in OM. Many of these have reported that breast-feeding is protective, but recent studies have found protective effects only for exclusive breast-feeding lasting for 3 to 6 months. A metaanalysis of risk factor studies reported a 13% reduction in OM associated with breast-feeding of this duration. 18 The effect of breast-feeding on OM has been reported to persist 4 to 12 months after breast-feeding cessation, perhaps because it delays the onset of the first OM episode and, thereby, reduces the frequency of OM recurrence. In contrast numerous investigators have failed to find an association between breast-feeding and OM or recurrent OM. Breast-feeding is a complex behavioral variable, which cannot be adequately described with terms such as "breast-feeding" or "bottle-feeding." Researchers' classification of infant feeding should include description of exclusivity of breast (or formula) feeding, duration of each specific feeding practice (exclusive breast, exclusive formula, combination feeding) and timing of introduction of supplemental foods. 20 Another potential design problem is failure to adequately control for smoking and social class. Both are inversely related to breast-feeding but positively related to OM. In addition detection bias may exist if formula-feeding mothers are more likely than breast-feeding mothers to seek medical care for an ill child, thus increasing the likelihood of OM ascertainment. 20 If breast-feeding reduces OM incidence and prevalence, several alternative explanations exist for its benefit. Lying flat during bottle feeding could cause milk to reflux into the middle ear, as first described by Duncan 21 in 1960. A more recent study demonstrated that among bottle-fed infants, 60% fed supine and 15% fed in the upright position had abnormal tympanograms suggestive of MEE after feeding. 22 Alternatively components of breast milk have antimicrobial and immunomodulating properties that could prevent middle ear infections during and subsequent to breast-feeding. However, evidence about specific protective mechanisms is lacking. One study showed that exclusive breast-feeding reduced nasopharyngeal colonization with the three major OM pathogens, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, at 6 months of age, although others have reported no effect of breast-feeding duration or exclusivity on colonization with H. influenzae. Breast-feeding has not been shown to reduce adherence of H. influenzae to respiratory epithelium, and activity of breast milk pneumococcal antibodies was not correlated with colonization or prevention of acute OM. Like breast-feeding, both positive and negative studies have been published on the role of exposure to passive smoke and childhood OM. Several studies have shown a dose-response relationship or increased OM risk only with heavy smoking. Two metaanalyses reported relative risks associated with exposure to passive smoke of 1.2 to 1.7, with an estimated 350 000 to 2 200 000 cases of middle ear disease attributable to this exposure annually in the United States. 18, 23 A possible explanation for discrepancies in studies investigating passive smoke and OM is assessment of child's exposure, which is usually determined by maternal report of parents' current smoking status and number of cigarettes smoked per day. Other important determinants of actual exposure to passive smoke include parent's proximity to child when smoking, child's regular exposure to other smokers and time away from smoking parents (e.g. child care). Furthermore smoking parents may understate the amount they smoke or deny that they are smokers. Therefore quantification of a biomarker for smoke exposure is desirable to assess the child's actual degree of exposure. Studies in which cotinine have been assayed in the child's blood, saliva or urine have demonstrated a significant relationship between the level of this nicotine metabolite and OM risk. Probable mechanisms of the link between passive smoke exposure and childhood OM include inflammation of the mucosal surfaces of the nasopharynx, Eustachian tube and middle ear, rendering them more vulnerable to viral and bacterial infection; goblet cell hyperplasia, resulting in mucoid MEE, which is difficult to clear because it is often accompanied by impaired mucociliary clearance and Eustachian tube obstruction; inflammation of the respiratory tract airways, which increases susceptibility to respiratory infection, an important antecedent of OM; and greater exposure to respiratory infections, which are more common among smoking parents who then pass them on to their children. Genetics Research has demonstrated the familial clustering of OM, and data are emerging on the role of genes in OM susceptibility. Sibling, maternal and paternal OM history has all been shown to be independently related to a child's OM risk. Shared OM history among siblings may be the result of inherited susceptibility and/or exposure to the same environmental factors and cultural practices. But when both parent and child develop OM, the likelihood of shared environmental exposure as the causative factor is not persuasive because parent and child reside in different environments during early childhood, the period of highest risk. To disentangle the role of heredity and environment, recent twin studies have examined the heritability of recurrent OM in 18- to 25-year-olds and total time with MEE in the first 2 years of life. Heritabilities of 72 to 75% were reported, with variability depending on gender and zygosity of the twin pairs. 24, 25 Given the large estimate of heritability and the likelihood that heritability is multigenic, the next logical step is to identify genes linked to OM susceptibility. Knowledge of specific genes involved in OM would provide new insights into pathogenesis. A disease entity may arise from different etiologic pathways (genes at one locus or more, environmental factors or interaction of genes and environment). Subgrouping individuals based on molecular characteristics could elucidate known mechanisms of causation and lead to the discovery of previously unknown mechanisms, suggesting new avenues of treatment. Knowledge of a child's genetic susceptibility would impart more specific, DNA-based estimates of a child's risk to parents (a considerable improvement over knowledge of family history). It could also lead to individualized treatment strategies. Population-based studies would clarify the impact of susceptibility genes on disease burden and allow development and targeting of appropriate prevention activities, for example, eliminating environmental triggers and providing more aggressive surveillance for genetic susceptibles to prevent complications earlier in disease progression. Prenatal and perinatal factors Because OM has its highest incidence in the first few years of life, it is logical to investigate risk factors from the prenatal and perinatal periods. A few studies have shown that lower birth weight and prematurity increased OM risk, although several others have reported no relationship between birth weight, gestational age and OM. However, more recent studies with large numbers of infants with very low birth weight, very preterm birth or intrauterine growth retardation have shown these children to be at higher risk for OME and recurrent OM. 26–28 Our recent study investigating the role of prenatal risk factors for early OM onset demonstrated a significant relationship between low levels of passively transferred maternal pneumococcal antibodies measured in cord blood and early OM. 29 However, no associations were found among maternal prenatal diet, dietary supplements, use of drugs, alcohol, medications and symptoms and illnesses during the last trimester and early OM onset. 30 CLINICAL IMPLICATIONS OF OM EPIDEMIOLOGY The epidemiologic information on OM gathered to date has led to important avenues for fruitful investigation. Identification of the importance of OM onset in the first few months of life as a strong determinant of subsequent recurrent OM suggested environmental interventions (delayed or small group child care, breast-feeding advocacy) and immunologic strategies (maternal immunization against common infant OM pathogens). Identification of genetic determinants of OM susceptibility will yield a quantum leap in OM prevention through early detection of at risk infants. Racial and socioeconomic factors remain tightly intertwined, and discriminating one from the other factor as OM determinants has been difficult. Clearly respiratory viral infection remains one of the strongest infant and early childhood OM determinants, giving an incentive to develop immunoprophylaxis against these diseases. It is time to expand the clinician's use of this epidemiologic information in patient care while awaiting randomized trials to measure risk factor reduction on decreased OM incidence. In primary OM prevention, breast-feeding and small child care size should be promoted, household tobacco smoking should be discouraged and cleft (and submucous) palate should be identified early in life. A sibling history of early infant or recurrent OM should be known early in life and should lead to careful ear examinations during the first year. Despite a great deal of progress in the development of vaccines to prevent OM, there has been little research on preventive strategies to reduce risk factors as a method of primary prevention. As the Clinical Practice Guideline for OME points out, no randomized intervention studies have been conducted to learn whether reducing traditional risk factors (bottle-feeding, passive smoke exposure, child care size and respiratory infections) would impact OM incidence. However, two recent randomized intervention studies showed that: children of parents who received advice to reduce pacifier use had lower OM rates than controls, 31 and children in child care who were randomly assigned to use xylitol gum or syrup for 3 months had lower acute OM rates than placebo recipients. 32 Many have advocated that physicians advise parents to control environmental risk factors, although the typical physician receives little training on effective strategies to counsel parents about risk factor reduction. In our recent population-based study in Minnesota, only 25% of mothers of 8- to 12-month-old infants received advice from a physician or nurse about OM prevention, and the presence of risk factors was not related to having received this advice. 33 Carefully planned randomized prevention trials are needed. They should be designed to measure risk factor reduction as an intermediate measure of intervention success, with decreased OM incidence as the outcome. There is sufficient knowledge of secondary OM prevention strategies to promote these as well. With the rising prevalence of antibiotic-resistant middle ear bacterial pathogens, judicious use of antibiotics is warranted. In particular the use of antibiotic chemoprophylaxis for recurrent OM has only limited indications today given the marginal impact (∼15% reduction) of this preventive strategy on recurrent OM. The child who clears MEE between recurrent OM episodes, but has three or more episodes in 6 months might be considered for chemoprophylaxis. Polyvalent pneumococcal vaccine [PneumoVax 23 (Merck & Co.); PnuImmune 23 (Lederle Laboratories)] is immunogenic in children older than 24 months and is likely to reduce OM incidence after this age. New pneumococcal conjugate vaccines are likely to have an effect on both infant pneumococcal colonization and OM incidence at a younger age. Surgical intervention (tube insertion, adenoidectomy) is also accepted secondary OM prophylaxis, based on the epidemiologic linkage of abnormal Eustachian tube function with recurrent OM. CONCLUSIONS OM, with its peak incidence in the first 2 years of life, is the most commonly diagnosed pediatric disease. Identified host characteristics are useful in targeting high risk children, and well-defined environmental factors present potential avenues of primary prevention. Advances in understanding the genetics of OM will continue and will dramatically change OM management in the future. Vaccines currently being field-tested offer promise for primary prevention, and strategies for risk factor reduction should be tested and implemented. These strategies are complementary and provide a well-balanced approach to the reduction of OM morbidity into the 21st century. QUESTIONS/ANSWERS Question: In a study of 2000 children from shortly after birth to age 2 years, breast-feeding for 3 months had a carryover effect. Why does this occur? One theory is that the immune system is activated resulting in the long carryover protective effect. Dr. Giebink: My bias is that the carryover effect exists simply because early OM is reduced. Data indicate that early OM is the strongest determinant of recurrent OM. Therefore, if you can delay the first episode 3 to 6 months, the incidence of recurrent OM is dramatically reduced. Question: Why do you think that early OM predicts recurrent OM? Is there any information and what is the mechanism? Dr. Giebink: There are many hypotheses. All studies have shown that there is a very strong, independent risk for recurrent OM with early OM. Question: Is it not true that most OM occurs in the first year of life whether it recurs or not? Dr. Giebink: Most recurrent OM that occurs in the first 6 months goes on. The vast majority of cases are in the first 6 months of life. Studies have shown that if OM was diagnosed at the 2-month office visit, there was over a 50% chance of having three or more episodes before the first birthday vs. a 20% chance if OM was not present at the 2-month visit. Question: Concerning breast-feeding, why is it an effective prevention? Is it because of immunoglobulins in the breast milk? Dr. Giebink: That is a possibility, but other factors may be present. There is a lot of lactoferrin in milk and there are other nonimmunologic mechanisms that may have a role. Let me add that bottle feeding results in a negative pressure in the bottle. Measurements of that pressure plus the pressure in the pharynx suggest that babies struggle to suck the bottle. Also, sucking on pacifiers appears to be related to OM. The negative pressure adversely affects the Eustachian tube (also in supine vs. prone sleeping positions). Breast-feeding is always under positive pressure.

Type-specific IgG1 and IgG2 antibodies to Streptococcus pneumoniae capsular polysaccharides 14 and 19F were measured in cord blood samples from 425 neonates, to determine which antibody subclass was most strongly associated with otitis media (OM) during the first 6 months of life (early OM). Early OM was significantly associated with type 14 IgG1 antibody in the lowest antibody quartile (P=.055) but not with type 19F IgG1 antibody or with either IgG2 antibody. IgG1 and IgG2 antibodies were significantly intercorrelated for type 14 (r=.52, P<.001) and type 19F (r=.38, P<.001). Multivariate analysis revealed that having type 14 IgG1 antibody in the lowest quartile, child care attendance, and sibling and maternal OM history were independent risk factors for early OM. Although type-specific pneumococcal IgG2 antibody concentrations were significantly higher than IgG1 concentrations, IgG2 antibodies apparently are not protective against OM during early infancy.

Objective. Although early otitis media (OM) onset predicts later recurrent and chronic OM, little research has been directed at illuminating the role of prenatal exposures in early OM. This prospective study examined prenatal, innate, and early environmental exposures associated with acute otitis media (AOM) onset and recurrent OM (ROM) by age 6 months.Design and Methods. Prospective study of 596 infants from a health maintenance organization followed from birth to 6 months. Mothers completed monthly forms on prenatal exposures (diet, medications, and illnesses) and infant risk factors (eg, smoke exposure and child care) during pregnancy and until infants were 6 months old. Urine samples were collected when infants were 2 months of age and analyzed for cotinine and creatinine. Physicians and nurse practitioners examined infants at each clinic visit and completed standard ear examination forms.Results. Thirty-nine percent had an episode of AOM and 20% had ROM by age 6 months. Using Cox's regression models to control for confounding, respiratory tract infection (relative risk [RR] 7.5), day care (RR 1.7), >1 sibling (RR 1.4), maternal, paternal, and sibling OM history (RR 1.6, 1.5, and 1.7, respectively) were significantly related to early OM onset. ROM was related to respiratory tract infection (RR 9.5), day care (RR 1.9), conjunctivitis (RR 2.0), maternal OM history (RR 1.9), and birth in the fall (RR 2.6). Among prenatal exposures, only high prenatal dietary vitamin C intake was significantly inversely related to early AOM with univariate but not multivariate analysis.Conclusion. Prenatal factors were not linked to early AOM onset with multivariate analysis, but environmental and innate factors play an important role in early AOM onset. Strategies to reduce exposure to environmental variables could reduce rates of early AOM, which could potentially result in declining rates of ROM and chronic OME.

Objective: The diagnosis of Meniere's disease has always been a source of confusion. There is no single test that is definitive for the diagnosis. Recent advances have enabled clinicians to noninvasively test the function of the inner ear and its associated neural pathways. The electrocochleogram (ECOG) has been advocated as a reliable test that is diagnostic for Meniere's disease. This study was undertaken to assess the value of ECOG in establishing the diagnosis of Meniere's disease. Study Design: Patients who were suspected of having Meniere's disease were prospectively entered into a study of the diagnostic value of ECOG. Each patient had a complete evaluation including a detailed history, physical examination, laboratory studies, and audiometric tests. Setting: University otolaryngology clinic. Patients: A group of 199 patients who presented to a neurotology clinic and were suspected to have symptoms consistent with Meniere's disease. Intervention: ECOG testing. Main Outcome Measures: Audiometric thresholds, action potential magnitude (AP), summating potential amplitude (SP), AP latency, and clinical evaluations were assessed. Results: The ECOG was found to correlate with historical and audiometric criteria that are used to diagnose the disease. The percentage of abnormal ECOG did not correlate with stage of disease or duration of time that symptoms were present. Conclusions: The ECOG has limited value in the diagnosis of Meniere's disease. It appears to correlate with the length of time patients experience symptoms and their audiometric findings. It was not correlated with the number of symptoms that the patient experienced at the time that the study was conducted.

Objectives: To explore relationships between age and sequelae in two groups of children treated with tympanostomy tubes for chronic otitis media with effusion (OME). Study Design: Cross-sectional study of sequelae among children, adolescents, and adults at 4 years and 9 to 23 years after tympanostomy tube treatment. Methods: Group I was examined with otomicroscopy, tympanometry, and audiometry two to four times a year as part of a prospective study, and they were evaluated 4 years after initial tube treatment for this study. Group II received tubes while participating in a chronic OME study, but participants were not followed prospectively after treatment. Nine to 23 years after tube treatment, they were examined with otomicroscopy, tympanometry, and hearing screening. Results: Among the 5- to 28- year-old subjects, cholesteatoma (less than or equal to 1%) and perforation (less than or equal to 2%) were rare. In Group I,tympanosclerosis increased with age (P < .01), and OME (flat tympanograms) decreased with age in Group II (P < .01). The older cohort was more likely to have severe retractions (18% vs, 4%, P = .02), hearing loss (21% vs. 10%, P < .01), and severe atrophy (24% vs. 0%, P < .01) than the younger cohort, but they were less likely to have flat tympanograms (2% vs. 12%, P < .01). Conclusions: Although OME became less prevalent with age, important sequelae (severe atrophy, severe tympanic membrane retraction, hearing loss, cholesteatoma, and chronic perforation) may develop in children with chronic OME as they become adolescents and young adults. Long-term prospective studies are important in defining the progression of sequelae in these children.

OBJECTIVES:To investigate maternal knowledge and attitudes about otitis media (OM) risk, to estimate the prevalence of risk factors in the first year of life, and to identify barriers to the reduction of risk factors (eg, formula feeding, day care attendance, and exposure to passive smoke).METHODS:Questionnaires mailed to a systematic sample of 504 Minnesota women >/=18 years old identified through 1994 birth certificates.RESULTS:Eighty percent returned a completed survey. According to maternal report, 29% of infants (age 8 to 13 months) had recurrent OM (>/=3 episodes) and 2% had tympanostomy tubes. Forty-six percent attended day care, 29% had >/=1 smoking parent, and 49% breastfed for </=2 months. Women were more knowledgeable about OM signs and symptoms than about risk factors. Mean OM knowledge score (the sum of correct true-false responses) was 7.0 (standard deviation = 1.6). Using multiple linear regression, knowledge score was significantly related to marital status, education, age, area of residence, breastfeeding (months), and number of cigarettes smoked per day by the mother, but not to infant or sibling OM history or day care attendance (R = .23). Infant history of OM (odds ratio, 1.9; 95% confidence interval, 1.1 to 3.2) and white race (odds ratio, 0.3; 95% confidence interval, 0. 1 to 0.8), but not the presence of risk factors, were significantly related to having received clinicians' advice about OM prevention advice.CONCLUSION:OM education and prevention programs should target pregnant women and new mothers with OM risk factors, and those who are young, single, and less educated.

Low maternally derived serum immunoglobulin G (IgG) antibodies to Streptococcus pneumoniae capsular polysaccharides (PS) combined with the inability of infants to produce anti-PS antibody may explain onset of otitis media in the first 6 months of life. To explore this relation, cord blood samples were assayed for anti-PS IgG antibodies from 414 of 592 infants enrolled in a study of early onset otitis media between 1991 and 1994. Infants' ears were examined at health supervision and illness visits for the first 6 months of life in a large Minneapolis-St. Paul, Minnesota, health maintenance organization. Antibodies to seven common pneumococcal serotypes (3, 4, 6B, 14, 18C, 19F, and 23F) were measured by enzyme-linked immunoabsorbent assay (ELISA). Cox's regression analysis revealed that among infants with a sibling otitis media history, those with low concentrations of type 14 or 19F anti-PS cord blood antibody had earlier otitis media onset than those with higher cord blood antibody concentrations (relative risks (RR) (95% confidence intervals (CI)) = 1.77 (1.05-2.99) and 1.89 (1.11-3.23), respectively). Day care attendance also increased risk (RR = 1.56, 95% CI 0.96-2.52). Breastfeeding, parental smoking, and low anti-PS antibody to pneumococcal serotypes 3, 4, 6B, 18C, and 23F did not significantly affect the risk of early otitis media.

Recurrent acute otitis media (RAOM) and chronic otitis media with effusion (COME) exhibit familial aggregation, but environmental risk factors (day care attendance, cigarette smoke exposure, and bottle feeding) are also important in their development. The Family Study of OM was designed to ascertain the RAOM/COME status of families whose children participated in Otitis Media Research Center studies between 1978 and 1984. Probands were treated with tympanostomy tubes, and had their RAOM/COME status ascertained as criteria for entry into these studies. For the Family Study of OM parents were interviewed about their otitis media and risk factor history; mothers were interviewed about their children's history, and pertinent medical records were obtained. Members of 173 families were examined with otomicroscopy and multifrequency tympanometry; 19% of parents and 32% of siblings were classified as affected, which is substantially higher than RAOM/COME rates from previous reports. Risk factor profiles differed significantly (P < .001) between parents and their children. Younger generation (adjusted odds ratio [OR] = 4.18, 95% confidence interval [CI], 2.74, 6.36), day care attendance (OR = 1.96, 95% CI, 1.32, 2.91) and male gender (OR = 1.42, 95% CI, 1.03, 1.97) were significantly related to RAOM/COME using logistic regression. Analyses confirm 1) higher disease rates in families with an affected member compared to existing studies of the general population, 2) increased risk of RAOM/COME associated with known risk factors, and 3) increased risk for parents irrespective of risk factors. Additional analyses will explore competing models of disease susceptibility using genetic models and known risk factors. (C) 1996 Wiley-Liss, Inc.