Recent research reports on otitis media range from the expected to the surprising, leaving health care providers with much to "chew" over. So, pop in a piece of gum and read on.

Otitis Media Linked to Colds
Otitis media, or inflammation of the middle ear, is second only to colds in affecting infants and young children. The condition ranges from acute to recurrent to chronic, often with the buildup of fluid, called effusion. Although it seems obvious to many providers as well as concerned parents, research conducted at the University of Texas Medical Branch at Galveston and published in the March 15, 2008, issue of Clinical Infectious Diseases confirms the suspected close link between these two most common diseases.¹

"Understanding how viruses and ear infections are linked will definitely help us find new ways to prevent ear infections," said Tasnee Chronmaitree, MD, a pediatric disease specialist and the study's principal investigator. "To break the link you must first understand it."

Chronmaitree said parents could best protect their children by avoiding exposure to sick children and to have their children vaccinated against influenza. She also suggested children in day care might face reduced exposure to viruses if enrolled in smaller day care facilities with fewer children.

The Texas researchers followed 294 children ages 6 months to 3 years for up to 1 year each and documented 1,300 cold episodes with a 61% rate of ear infections, some with asymptomatic fluid in the middle ear which can cause hearing loss. 

Chronmaitree and colleagues will continue to look at the role of viruses in ear infection, aiming to find a way to prevent the disease by studying children born with genetic variations who are prone to having ear infections and the interaction between genes and the environment.

Antibiotics Fail to Prevent Fluid Buildup
Prevention of ear infections may be a better alternative to treatment than are antibiotics, which do not appear helpful in preventing fluid buildup in the middle ear, according to a meta-analysis of previously published studies by researchers at the University Medical Center Utrecht, the Netherlands.²

In the 2008 study published in the Archives of Otolaryngology Head & Neck Surgery, Laura Koopman and colleagues analyzed data from 1,328 children ages 6 months to 12 years with acute middle ear infections who participated in five randomized controlled trials comparing antibiotics to placebo or to no treatment.

Overall, 44% of the children were younger than age 2 and 51.8% had recurrent ear infections. The risk of developing middle ear effusion was highest for children in these youngest groups. Children taking antibiotics were 90% as likely to develop fluid as those who did not take antibiotics, a difference which was not statistically significant.

"Because of marginal effect of antibiotic therapy on the development of asymptomatic middle ear effusion and the known negative effects of prescribing antibiotics, including the development of antibiotic resistance and adverse effects, we do not recommend prescribing antibiotics to prevent middle ear effusion," the authors write.

Ear Tubes Overused
Avoiding antibiotics in cases of fluid buildup may also apply to placement of tympanostomy or ear tubes. Such tubes are small implants inserted through the tympanic membrane to ventilate the middle ear space during recurrent episodes of acute otitis media or persistent otitis media with effusion. Tubal insertion is the most common procedure that requires general anaesthesia for children in the United States, with 500,000 or more surgeries done each year.

Children who typically receive an operation to insert ear tubes because of ear infections or fluid in the ear may not need it, according to research conducted by Salomeh Keyhani, MD, assistant professor in the department of Health Policy at Mount Sinai School of Medicine and colleagues and published in the January 2008 issue of Pediatrics.³ 

The researchers found that most children who had tubal operations in the New York City area in 2002 had mild disease for which experts recommend medical treatment or watchful waiting, not ear tube implantations. These findings suggest overuse of ear tubes and update a similar finding made in the United States in l990 and 1991.

For the study, Keyhani and colleagues examined the clinical data for 682 children who received ear tubes from any of five New York metropolitan area hospitals in 2002. Data were collected from the pediatrician, otolaryngologist and hospital chart for each child for the year prior to surgery.

Clinical practice guidelines endorsed by the American Academics of Pediatrics, Family Physicians, and Otolaryngology-Head and Neck Surgery recommend that, in general, children with fluid in their ear not receive ear tubes unless fluid has been persistent for at least 3 to 4 months consecutively.

The study's key finding is that more than 75% of the children who received ear tubes had fluid for less than a month and a half. "If the study findings could be applied to the rest of the country," said Keyhani, "it would be particularly troubling." According to the author, further research needs to explore both the optimal course of treatment and why clinical practice so frequently deviates from the accepted guidelines.

Chewing Gum Reduces Otitis Media With Effusion
One low-cost alternative to reducing otitis media with effusion (OME) in younger children, according to Dutch researchers, is chewing gum. In a study published in the August 2007 issue of Ear and Hearing, researchers studied 1,756 children ages 2 to 6 years attending child health centers and diagnosed the presence of fluid through combined tympanometry and otoscopy.⁴ 

Three factors were related to the prevalence of OME, including age, season and the premise that "children consuming daily or at least weekly chewing gum show significantly less chance for OME than a child who seldom consumes or consumes no chewing gum." In cases of regular use of chewing gum, the probability of OME is reduced by 40%.

According to the researchers, "Chewing obviously activates jaw movements, increases salivary flow and, by the way, the rate of swallowing and the rate of activations of peritubal muscles and tubal openings. Chewing also requires nasal respiration, thus preventing mouth breathing." 

For children too young to chew gum, xylitol sugar in syrup form, which inhibits the growth and attachment of bacteria on nasopharyngeal cells, reduced the development of acute otitis media by 30% in two clinical trials conducted by Finnish researchers and reported in a 2000 issue of Vaccine.⁵ Xylitol syrup administered five times daily "appears to be an attractive alternative to prevent acute otitis media; however, "a more practical frequency of doses should be found before its use can be widely recommended."

Jess Dancer is professor emeritus of audiology at the University of Arkansas at Little Rock. Contact him at jedancer@ualr.edu with your personal or professional experiences with otitis media.

References
1. University of Texas Medical Branch at Galveston (2008, March 14). Common cold linked to ear infections, researchers confirm. ScienceDaily. Accessed online at www.sciencedaily.com/releases/2008/03/080313103101.htm.
2. JAMA and Archives Journals (2008, February 20). Antibiotics do not appear helpful in preventing fluid buildup in children with ear infections. ScienceDaily. Accessed online at www.sciencedaily.com/releases/2008/02/080218161743.htm.
3. Mount Sinai Medical Center (2008, January 10). Use of ear tubes for ear infections not consistent with expert guidelines, study says. ScienceDaily. Accessed online at www.sciencedaily.com/releases/2008/01/080109194353.htm.
4.  Kouwen HB, DeJonckere PH. (2007). Prevalence of OME is reduced in young children by using chewing gum. Ear and Hearing, 28(4): 451-5.
5.  Uhari M, Tapiainen T, Kontiokari T. (2000). Vaccine, 19 Suppl l: S144-7.