The term "speech discrimination score" is often used todescribe the results of clinical speech audiometry, though the task is actually an identification task, not a discrimination task, where the listeners would be asked to say whether

Objectives: To determine the adjuvant effects of adenoidectomy with short-stay ventilation tubes to hearing and revision surgery in children over 3.5 years with persistent otitis media with effusion. Design: Randomised controlled three armed trial: observation, short-stay ventilation tube or ventilation tubes with adjuvant adenoidectomy. Five follow-up visits over 2 years. Setting: Eleven UK Otorhinolaryngology Departments. Participants: Children with bilateral otitis media with effusion and better ear hearing level (HL) ≥20 dB persistent for 3 months. Of the 425 eligible children, 376 (88%) accepted randomisation. Main outcome measures: Pure-tone hearing thresholds, eligibility for and actual revision surgery rates, otoscopic sequelae and complications of adenoidectomy. Results: Loss to follow-up at 3, 12 and 24 months was 2%, 6% and 5% respectively. Of the 376 randomised children, 253 (67%) had complete data for all five follow-up visits. Adenoidectomy did not add to the benefit to hearing thresholds of ventilation tubes of 8.8 dB (CI: 7.1–10.5) averaged over 3–6 months postoperatively. Averaged over 12, 18 and 24 months, adenoidectomy provided 4.2 dB of benefit (CI: 2.6–5.7) whilst ventilation tubes gave no benefit. Standardised effect sizes through two years showed equal benefit from ventilation tubes (0.50 sd) and adenoidectomy (0.61 sd) which are additive (1.11 sd). Adenoidectomy halved the numbers meeting a 25 dB HL bilateral cut-off for eligibility for repeat tube surgery from 31% to 14% at 12 months and from 33% to 15% at 18 months. The actual reduction in re-insertion surgery (absolute risk difference) was 21%. In tubed ears, tympanosclerosis occurred in 27%, but otorrhoea in only <2% and permanent perforations in <1%. These events did not occur in control ears. In children that had adenoidectomy, one of 165 (0.6%) had haemorrhage that required return to theatre. Conclusions: Adjuvant adenoidectomy doubles benefit from short-stay ventilation tubes by extending better hearing through the second year in children aged 3.25–6.75 years with persistent otitis media with effusion with at least a 20 dB HL in both ears. The duration of benefit of adenoidectomy is related to the duration of function of the type of the ventilation tubes used. Adenoidectomy also substantially reduces eligibility for revision surgery.

Acute otitis media (AOM) is a leading cause of visits to physicians and of antibiotic prescriptions for young children. We systematically reviewed studies on all-cause AOM episodes and physician visits in which impact was attributed to pneumococcal conjugate vaccines, either as efficacy or effectiveness. Of 18 relevant publications found, most used the 7-valent pneumococcal conjugate vaccine (7vCRM). The efficacy of 7vCRM against all-cause AOM episodes or visits was 0%-9% in randomized trials and 17%-23% in nonrandomized trials. In observational database studies, physician visits for AOM were already declining in the 3-5 years before 7vCRM introduction (mean change, -15%; range, +14% to -24%) and continued to decline afterward (mean, -19%; range, +7% to -48%). This vaccine provides some protection against OM, but other factors have also contributed to the recent decline in OM incidence. Future effectiveness studies should thus use better-controlled methods to estimate the true impact of vaccination on AOM.

Objective: In the Netherlands, many children are surgically treated for OM. Recent publications question the need for surgical treatment in common uncomplicated OM, although there is certainly a subgroup of infants that do need further assessment and possible treatment. The present study explores the possibility of using known and presumed risk factors for OM as an instrument for selecting and routing an infant with OM to further care.Methods: Two questionnaires were used. A questionnaire embracing a wide range of OM-related factors was sent to 6531 children aged nine months that were routinely invited for the hearing screen at nine months. In a second stage, a structured history questionnaire regarding ear and/or hearing problems, subsequent referral and/or treatment, was sent to all parents of children at age 21 months, responding to the first questionnaire. Univariate analysis was performed for identification of potential predictors for surgical treatment of OM for the whole sample as well as for 4 different subsets. Multivariable regression analysis with stepwise backward deletion was applied to arrive at a model for optimal prediction of tube insertion. A ROC (receiver operating characteristic) curve and the accompanying sensitivity and specificity values were analyzed to determine cut off values.Results: Univariate analysis found 10 items predicting surgical treatment for OM. Multivariable regression analysis resulted in a model with a ROC curve having an area of 0.801 and estimated coefficients for risk factors which were used to calculate a OM-score for each case.Conclusion: The developed scoring sheet, e.g., to be used in combination with physical examinations and/or tympanometry looks promising as a predictor for those children that might benefit from further assessment and eventually surgically treatment for OM. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

Aims: To identify subgroups of children with otitis media with effusion (OME) that might benefit more than others from treatment with ventilation tubes. Methods: An individual patient data (IPD) meta-analysis on seven randomised controlled trials (n = 1234 children in all), focusing on interactions between treatment and baseline characteristics—hearing level (HL), history of acute otitis media, common colds, attending day-care, gender, age, socioeconomic status, siblings, season, passive smoking, and history of breast feeding. Outcome measures that could be studied were mean time spent with effusion (n = 557), mean hearing levels (n = 557 in studies that randomised children, and n = 180 in studies that randomised ears), and language development (n = 381). Results: In the trials that treated both ears the only significant interaction was between day-care and surgery, occurring where mean hearing level was the outcome measure. None of the other baseline variables showed an interaction effect with treatment that would justify subgrouping. In the trials that treated only one ear, the baseline hearing level showed a significant but not pervasive interaction with treatment—that is, only with a cut-off of 25 dB HL. Conclusions: The effects of conventional ventilation tubes in children studied so far are small and limited in duration. Observation (watchful waiting) therefore seems to be an adequate management strategy for most children with OME. Ventilation tubes might be used in young children that grow up in an environment with a high infection load (for example, children attending day-care), or in older children with a hearing level of 25 dB HL or greater in both ears persisting for at least 12 weeks.

BACKGROUND:Several aspects of children's health and development are known from empirical studies to be associated with otitis media with effusion (OME; 'glue ear'). The 'diffuse image' has been an obstacle to defining a core set of impacts about which inter-profession and parent-professional communication can be effective. AIMS:The study quantifies similarities and differences in how the signs, symptoms, and developmental impact of OME are attributed and construed, between teachers, parents, and ear, nose, and throat (ENT)surgeons. SAMPLE:Convenience samples were achieved of 118 teachers and 154 parents of affected children; 178 ENT surgeons from a professional sampling frame (association membership) responded. METHOD:Questionnaires elicited the perceived frequency and concern-value of over 30 manifestations of OME--the various signs, symptoms, and behaviours suggested by the literature. Factor scores derived on the combined sample were compared between respondent groups. RESULTS:Teachers assign high importance to education and language problems but, relative to parents, they accord lower importance to continuing hearing problems. Teachers and parents weighted behaviour and balance problems similarly, placing behaviour higher, but balance lower, than the ENT specialists did. CONCLUSIONS:(1) A four-factor reduction of simple questionnaire items well defines the domains of impact of OME, and can express the ways in which views of impact differ between teachers, ENT specialists and parents.(2) Considerable differences of perspective exist between the groups examined. (3) In valuing a set of measured outcomes on actual children, or for other policy research, sets of weights are now available to represent the differing perspectives of parents and professionals (e.g. in testing robustness of a conclusion across differing stakeholder perspectives). (4) The research and development need in respect of teachers' involvement with OME could profitably play to existing strengths. This implies the systematic and structured acquisition and evaluation of teacher-provided impact information.

To determine possible selection criteria for ventilation tubes (VTs - grommets), in otitis media with effusion (OME), a randomized trial on 68 children was undertaken. To provide both a baseline predictor and outcome measure in auditory disability, speech-in-noise thresholds were obtained with the IHR-McCormick Automated Toy Test (SiN ATT). Children allocated to surgery (n = 32) and control (n = 36) were followed-up at 3 and 12 months postintervention. Baseline SiN ATT score provided a significant by-treatment interaction in predicting the performance at +3 months, establishing it as an evidence-based indicator. Although average benefits on hearing level score (HL) were also shown, baseline HL was not a valid indicator (no significant interaction). The 40% of the sample with worst baseline SiN experienced high benefit from VTs. In children over 3 years of age, baseline SiN performance can indicate those with OME most likely to benefit from VTs.

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

Background: Glue ear (otitis media with effusion) is the most common reason for surgical intervention in children.Aim: To determine the yield and predictive value of a set of risk factors that predict persistence of glue ear over the interval from general practice referral to ear nose and throat (ENT) consultation to ensure the appropriateness of referrals.Design of study: Nested case control study.Setting: Sixteen ENT departments in the UK.Method: with the aid of audiometry and tympanometry, diagnostic information was collected on 548 children from 16 ENT departments after referral by their general practitioner (GP), as a lead-in to a clinical trial, the Mal of Alternative Regimens in Glue Ear Treatment (TARGET). Using cases and controls, children were classified as either having or not having persistent glue ear Parental reports on an extensive list of risk factors were also collected.Results: After adjustment for time waiting to he seen from GP referral and age at referral four main significant factors emerged for persistence of glue ear These were referral between July and December (OR [odds ratio] = 1. 73, 95% Cl = 1. 15 to 2.6); having a mother who smokes ten or more cigarettes per day (OR = 1. 7 9596 Cl = 1. 1 to 2.8); multiple upper airway symptoms (OR = 2.2, 9596 Cl = - 1. 5 to 3.2; and siblings with a history of glue ear (OR = 1. 6 for one sibling versus none).Conclusion: For a child who is referred between July and December who has two or more upper airway symptoms, who has a sibling who has had glue ear and who has a mother who smokes ten or more cigarettes per day, the odds of having persistent glue ear are over ten times that of a child without adverse values on these factors.

Objective In children with otitis media with effusion (OME), to investigate the incidence of, and any association, between retractions of the pars tensa and pars flaccida; to assess the effect of pars tensa and pars flaccida retractions on the hearing; to investigate risk factors for retractions; and to document the natural history of such retractions over a 12-week “watchful waiting” period. Study Design Prospective, observational study. Setting Sixteen departments of otolaryngology in hospitals in the U.K. Patients A cohort of 1,267 children aged 3.25 to 6.75 years with confirmed OME. None had previously received surgical intervention. Interventions Follow-up over a “watchful waiting” period of 12 weeks. Main Outcome Measures Otoscopy and pure-tone audiometry. Results Retraction of the pars tensa to the incus or promontory occurred in 8% of the better-hearing ears and 10% of the poorer-hearing ears. Pars flaccida retraction to the malleus or farther occurred in 4.5% of the better-hearing ears and 5.5% of the poorer-hearing ears. Retractions were not associated with a longer history of hearing problems. Pars tensa or pars flaccida retraction in association with OME did not materially affect the hearing. Pars tensa retractions, followed up over a 12-week period, resolved in 69% of the better-hearing ears and 65% of the poorer-hearing ears. In 14% and 10% of ears, respectively, the OME had also resolved. Conclusions There is minimal evidence to support the concept that pars tensa or pars flaccida retractions are a strong or relevant marker for the severity or evolution of OME in children. Prospective studies over a longer period of follow-up are required to confirm this.

OBJECTIVETo examine whether behavioural or cognitive sequelae of otitis media with effusion (OME) continue into late childhood and the early teens (11–18 years).SETTINGData from a large multipurpose birth cohort study: the Dunedin multidisciplinary health and development study.PARTICIPANTSAround 1000 children from the study. The main independent variable of interest was otological status of the child up to age 9.MAIN OUTCOME MEASURESParent and teacher rated behaviour problems, including antisocial, neurotic, hyperactive, and inattentive behaviours, and tests of academic achievement including intelligence quotient (IQ), reading, and spelling were available in a high proportion of the cohort at ages 11 to 18 years.RESULTSAfter adjustments for covariates such as socioeconomic status, hyperactive and inattentive behaviour problems were evident as late as 15 years, and lower IQ associated with OME remained significant to 13 years. The largest effects were observed for deficits in reading ability between 11 and 18 years.CONCLUSIONSNo previous study considering behaviour problems as an outcome has followed children long enough to determine whether some of the early sequelae of OME are still present in the early to late teens. Some developmental sequelae of OME, particularly deficits in reading ability, can persist into late childhood and the early teens.

Objective—To examine whether behavioural or cognitive sequelae of otitis media with eVusion (OME) continue into late childhood and the early teens (11–18 years). Setting—Data from a large multipurpose birth cohort study: the Dunedin multidisciplinary health and development study. Participants—Around 1000 children from the study. The main independent variable of interest was otological status of the child up to age 9. Main outcome measures—Parent and teacher rated behaviour problems, including antisocial, neurotic, hyperactive, and inattentive behaviours, and tests of academic achievement including intelligence quotient (IQ), reading, and spelling were available in a high proportion of the cohort at ages 11 to 18 years. Results—After adjustments for covariates such as socioeconomic status, hyperactive and inattentive behaviour problems were evident as late as 15 years, and lower IQ associated with OME remained significant to 13 years. The largest eVects were observed for deficits in reading ability between 11 and 18 years. Conclusions—No previous study considering behaviour problems as an outcome has followed children long enough to determine whether some of the early sequelae of OME are still present in the early to late teens. Some developmental sequelae of OME, particularly deficits in reading ability, can persist into late childhood and the early teens. (Arch Dis Child 2001;85:91–95)

Otitis media with effusion (OME) is a common, episodic condition in childhood. The subset that has persistent bilateral OME is important to identify so that their management can be targeted. Most guidelines suggest a watchful-waiting period before a decision is made on the appropriateness of surgical intervention. In the UK this usually takes place in a specialist setting (otorhinolaryngology) over a period of 12 weeks. A cohort of children (n = 639), between the ages of 3.25 and 6.75 years with bilateral OME that had no previous ear or throat surgery, was followed up over 12 weeks during the recruitment phase of a multi-centre, randomised controlled study. This allowed multiple factors for persistence to be assessed. The overall spontaneous resolution rate in this cohort was between 26% and 65%, depending on the audiometric cut-off by which a persisting condition was defined. Three significant risk factors-time of year when first seen (July to December); hearing level (greater than or equal to 30 dB HL in the better ear); and a route of referral that included prior audiometry-were identified in the multivariate analysis for persistent OME both in isolation and when accompanied by each of three audiometric cut-offs (greater than or equal to 15, greater than or equal to 20 and greater than or equal to 25dB HL). In this age group, parental report of duration of OME, history of acute otitis media, parental smoking and pars tensa retractions were not significant factors for persistence. These risk factors in combination can increase the odds ratio of persistence more than sixfold. However, the proportion persisting is insufficient to bypass a period of watchful waiting, except perhaps in extreme combinations which apply to less than 7% of the cohort.

Surprisingly little evidence is available in children between the ages of 3 and 7 years on the effect on hearing thresholds of the method of audiometry and of the developmental ability to concentrate and to respond. The Trial of Alternative Regimens in Glue Ear Treatment (TARGET) is a large, national, multi-centre trial of surgical intervention in children with otitis media with effusion (OME) that offers an opportunity to study these effects. Of 1517 children, aged between 3.25 and 6.75 years, reaching the selection stage, 4.5% were unable to give reliable air-conduction thresholds. A further 3% (i.e. 7.5% in all) could not give reliable bone-conduction thresholds. This inability was greatest in the youngest children. During air-conduction testing, a significantly greater proportion (p <0.005) of children were recorded as having only 'fair' or 'poor' concentration on conventional audiometry than with play audiometry. On the other hand, the magnitude of the effect of poor concentration, as rated 'fair/poor' versus 'good', was slightly greater on play as opposed to conventional audiometry (+5 dB versus +3 dB). Although statistically significant, the age of the child had only a very small effect on the air- or bone-conduction thresholds, once the type of audiometry, concentration and the presence of OME had been controlled for. It is concluded that adequately informative thresholds are usually obtainable by conventional audiometry in this age group, even if the concentration is recorded as 'fair' or 'poor'. However, when conventional audiometry is not feasible, play audiometry should be attempted in the 3-5-year-old age group.

OBJECTIVES:To resolve controversies over associations between a history of middle ear disease and psychosocial or cognitive/educational outcomes.DESIGN:Multipurpose longitudinal birth cohort study. Original cohort comprised all UK births between 5 and 11 April 1970; data were available for approximately 12,000 children at 5 years old and 9000 children at 10 years old.METHODS:For 5 year old children, parent reported data were available on health, social, and behavioural factors, including data on two validated markers of middle ear disease. Cognitive tests were administered at 5 and 10 years of age, and behavioural problems rated at 10 years by the child's teacher.RESULTS:After adjustment for social background and maternal malaise, the developmental sequelae of middle ear disease remained significant even at 10 years. The largest effects were observed in behaviour problems and language test data at age 5, but effect sizes were modest overall.IMPLICATIONS:These results provide an epidemiological basis for policies that aim to minimise the sequelae of middle ear disease by awareness in parents and preschool teachers, early referral, and intervention for more serious or persistent cases.

Children with otitis media with effusion (OME) need monitoring over time to identify persistence of disease and to assess their bearing thresholds as a surrogate of auditory disability. It would be useful if tympanometry could be used to predict those with an impairment. This study looked at 1153 children, aged between 3.25 and 6.75 years, referred for suspected OME. The inclusion of type C-2 tympanograms with type B tympanograms versus all other tympanogram types increased the sensitivity of detecting air-conduction thresholds and air-bone gaps of various magnitudes in the better hearing ear but lowered the specificity and the positive predictive value. Extending the pressure range to -600 daPa and excluding the 30% of children with poor concentration on audiometry made no difference to the sensitivity and specificity. The results were the same for the poorer hearing ear. These findings are of practical help in monitoring children with OME. Thus taking an air-conduction average of 25 dB HL in the better ear as the level needing detection, if all children are audiometrically assessed then 100% of those with an impairment will be identified. Limiting audiometry to those with a bilateral type B tympanogram reduces the workload by 50%, but 90% of impaired children will still be detected. Limiting audiometry to those with type B or C-2 tympanograms reduces the workload to 69% of the sample, and 95% of impaired children will be identified. With such data, decisions as to how to allocate limited audiometric resources for monitoring children with OME are made easier.

Some health authorities in the UK are discontinuing hearing screening at school entry, mainly because the pure tone sweep test is under-specific (i.e. fails too many children) and thus leads to unnecessary and costly, but unproductive, follow-up assessment. A screening method with different properties such as a questionnaire could be a more cost-effective method of mass screening children. The MRC Institute of Hearing Research has developed and evaluated through several stages such a screening questionnaire (the Childhood Middle Ear Disease and Hearing Questionnaire (CMEDHQ), containing 11 scored questions under two broad headings: history and presentation of the disease, and consultation/treatment history. In a service-based evaluation, 2860 mainstream reception-year school children from two consecutive years, attending schools in south west Cumbria in the North-West Regional Health Authority received the sweep test and the CMEDHQ. (Although predominantly designed to detect middle ear problems, the questionnaire also has some potential to detect permanent hearing loss; thus providing a useful backstop for detection of permanent losses either missed or not present in earlier infancy.) The screening CMEDHQ obtained a very high response rate (90%). Follow-up included 235 control cases as well as all pure tone sweep test failures. Analysis, by use of a definition of cases conservative with respect to the sensitivity of the questionnaire, showed that the CMEDHQ has better specificity, but slightly lower sensitivity, than the pure tone sweep test for composite system decision (where 'case' = treated at ENT; 'non-case' = pass at whatever stage was reached before discharge). Follow-up indicated that the limited method available for assessing sensitivity might give an over-favourable view of the pure tone sweep test. Possible improvement of questionnaire sensitivity by further refinements is under examination. The findings show that it is worth conducting a fully parallel multi-district cost-effectiveness comparison of the pure tone sweep test versus the CMEDHQ.