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Epidemiology of otitis media: Problem and research focus for geographers
PROBLEM
EPIDEMIOLOGY AND RESEARCH
OF OTITIS MEDIA: FOCUS FOR GEOGRAPHERS
MARY LOU MILLER Southern
Illinois
University,
Department
of Geography,
Faner Hall, Carbondale, IL 62901, U.S.A.
Abstract-Yearly,
otitis media (inflammation of the middle ear and its extensions) creates fluctuating hearing loss for thousands of children aged ten or younger. The common etiological factor seems to be a dysfunctioning eustachian tube, but there is widespread disagreement as to specific causes contributing to this dysfunction. Certain incidence patterns suggest that season of year, low altitude. high humidity, and variable weather are contributing factors. Geographers could add to an understanding of this medical problem by studying spatial patterns and by attempting to determine the occurrence of otitis media with the interrelationships of such variables as climate, altitude and weather patterns.
INTRODUCTION Otitis media, which is an inflammation of the middle ear and its extensions [l-3], is a serious problem which warrants further research by social scientists. In conducting future research, there are three main reasons for involving geographers: (1) The spatial distribution of increased incidence of otitis media can be specifically pinpointed; (2) this spatial distribution appears to be related to components of the external physical environment; (3) the disease appears to occur because of the interrelationships of multiple interacting variables including those just cited. Because both the spatial distribution of the disease and components of the physical environment appear to play a major role in the etiology of otitis media, it is a problem which needs to be investigated by geographers. IMPORTANCEOF THE PROBLEM
tasks [12-131. It is this impact of fluctuating and permanent hearing loss which concerns health professionals. Since children seldom complain of a hearing loss, the damage is often major before that loss is detected [l&J. If health professionals are to deal effectively with the prevention and management of the problem, more research is needed which would involve geographers. This needed interdisciplinary approach can best be explained by reviewing what is known about the causes of otitis media, who is affected by it, and where and when it occurs. CAUSESOF OTITIS MEDIA Most authors agree that the common etiological factor is the dysfunction of the eustachian tube which no longer is able to drain the excess accumulation of fluid. Yet, there is a widespread difference of opinion as to what causes this fluid to form [IS-17-J. Some of the commonly cited causes include: virus and bacterial infection [ 181; an allergic response [ 19-273 ; air pressure differences [28]; improper antibiotic usage 1291; mechanical obstruction of the tube [30-35-J; or any combination of the previous possible factors. There is a more recent tendency to view otitis media as a complex disease in which many different causal factors may be involved in producing a multiplicity of clinical and histopathological changes [36,37]. Thus, at any time, the causal agent might be any one of a number of possible combinations. It should be noted, however, that several of the listed causes point to the role of the physical environment-viruses, bacteria and allergens. In particular, aeroallergens are repeatedly referred to as major contributors to the fluid accumulation.
Otitis media is more commonly referred to as an earache or an ear infection; and it is a health problem which occurs frequently with well-known symptoms. Since the era of antibiotics, there has been a remarkable reduction of serious and life-threatening complications [4]; however, otitis media is still a major problem for two main reasons. First, in spite of antibiotic usage, otitis media is occurring more frequently [S, 63. Secondly, there are still serious and often unrecognized side effects which are associated with ear infections. An episode of otitis media is characterized by a collection of fluid in the middle ear, and it is this fluid accumulation which contributes to fluctuating hearing loss [7-lo]. It has been estimated that 50% of those patients with otitis media experience a temporary hearing deficit even after other signs have disag peared. It is further estimated that 10% will experiINCIDENCE OF OTITIS MEDIA ence a permanent hearing loss of 15 decibels or more because of damage to the ear drum [ll]. Each year, Although serious, life-threatening complications then, otitis media affects thousands of schoolage have greatly decreased, otitis media is occurring with children. It causes them to miss school and to experigreater frequency. This increase, however, may be a ence a diminished performance. Because otitis media reflection of one or more of the following factors: primarily occurs during a child’s developmental 1. Increased awareness by pediatricians, general period, it may have a major impact upon his lifelong ability to hear, read, speak and perform other practitioners, and otolaryngologists [38,39]. SS.M1.14c+-c 233
MARY
234
Lou MILLER
2. Indiscriminate use and inadequate courses of antibiotics in the treatment of respiratory infections [40-42]. 3. Increase in the number of viral infections. 4. A greater predisposition to allergic reactions. 5. Increased air travel. 6. Change to a conservative attitude in advocating adenotonsillectomy [43]. 7. Improvement of routine screening and development of more effective screening tools [44-45].
In spite of concern over whether there is a true increase in incidence, otitis media remains a frequent problem. it occurs most often during childhood with the highest incidence rates in children who are ten or younger. Even though there is some discrepancy about the specific age of greatest risk, many cite the 4-7 age range [46-48J. It should be noted, however, that this age range would be one most frequently detected in studies conducted in school systems. It is generally felt that males have a higher rate of incidence than females [49-531. The slight difference, however, remains of questionable significance [54], particularly because there have been no general prevalance and incidence studies and because most reportings have been taken from general practice cases and do not represent the total population at risk. SPATIAL
AND
SEASONAL
OF OTITIS
DISTRIBUTION
MEDlA
The spatial dist~bution of areas with an increase in otitis media incidence is quite distinct and can be linked to five main groups of people and locations. TWO groups, which are located on other continents, include the Maori of New Zealand and the Aborigines of Australia[55]. In North America, the three main groups are quite dispersed. They include native Alaskans, poor Appalachians and American Indians 156-J. McEldowney and Kessner [57] suggest that the common denominator for these groups is more likely poverty than race or genetic influences. They also point out that the poverty relationship may be attributable to a combination of high-risk environmental conditions and to lack of access to medical care [S&-61]. Yet, there have been few studies on the relationship of socioeconomic status to the spatial distribution and severity of middle ear disease[62]. Likewise, no studies appear to have been conducted to isolate additional spatial patterns of incidence. Although certain groups and locations have been identified as having high incidence rates, there are no data from general prevalence and incidence studies to support this [63). Both types of studies are essential. In contrast, the pattern of seasonal variation is firmly established and supported. Even in diverse populations in differing locations, there is a consistent pattern of, seasonal variation. The incidence of otitis media begins to increase in the fall, peaks during the winter and early spring, and drops to a low by summer t64-681, It has been noted that this peaking coincides with an increased level of aeroallergens such as dust, mold and pollen whose counts peak from October through June [69]. It also coincides with a period normally associated with increased upper respiratory tract infections.
250
zoo
130
loo
so 0 J
F
M
AMJJAsOND
Fig. I. Monthly incidence pattern of acute otitis media. Source: McEldowney and Kessner. p. 22. ROLE OF CLIMATOLOGICAL TOPOGRAPHICAL
AND
VARIABLES
At this point, no studies appear to have been conducted which investigate the relationship of climatological and topographical variables with the incidence of otitis media. Instead, what little is known is based upon in~~dual physician reports; however, these reports do designate six factors which warrant further consideration. First, otitis media is reported to be greatest in north temperate climates [70]. Secondly, most otolaryngologists who report an increased incidence of otitis media live in coastal areas and aiong river valleys. In contrast, specialists who reside in non-coastal or non-river valley areas report only a few cases per month or year. Third, common features of coastal areas and river valleys are their high humidity and low altitude. Fourth, femperature is not believed to be an important factor except in the sense that otitis media occurs most frequently in seasons of the year when temperature is the most variable [71]. Fifth, there is a widespread agreement among physicians that periods of variable weather rather than general temperature are predisposing environmental factors in the development of middle ear infections. Sixth, otitis media is believed to occur more frequently in children living in industrial areas [72]. RESEARCH
FOCUSES
FOR GEOGRAPHERS
Ottis media is a disease whose cause, clinical features, physical findings and treatment vary considerably [73]: (Refer to Fig. 2 for a model of this.) Relatively little is positively known about the disease. We do know that otitis media occurs (1) in children aged ten or younger; (2) in boys more than girls; and (3) with greater incidence among American Indians, Alaskan Eskimoes and poor Appalachians. On the other hand, we do not really know what causes the fluid to accumulate in the middle ear thus leading to irritation, inflammation and infection. Nevertheless, we strongly suspect that allergies to components in the physical environment are an important contributing factor, and .discussions of possible causes repeatedly cite allergies as a main precipitator of middle ear fluid. In addition, we know that specific air-borne allergens vary from one area to another and that some areas contain more irritants than others. As a
235
Epidemiology of otitis media
Fig. 2. Epidemiology of otitis media. result of the general practice reports of allergists and otolaryngologists, we also suspect that other environmental factors contribute to the problem: (I ) location in coastal areas or river valleys where there is high humidity and low altitude and (2) location in areas where there is variable weather. At this point, however, these latter suspicions all form untested hypotheses. If we are to deal effectively with the prevention and management of otitis media, studies are needed which will help to explain where the incidence of otitis media is the greatest and what about the location and the people contributes to an increased incidence. Geographers can help to determine the role of several interrelated and interacting variables. They need: 1. To conduct general prevalence and incidence studies to pinpoint the role of spatial, climatological, topographical and socio-economic factors in the occurrence of otitis media. 2. To conduct longitudinal studies to pinpoint the role of variable weather, humidity and altitude.
Sites should include coastal and non-coastal areas and river valley and non-river valley areas as well as other distinctly different regions. 3. To investigate the relationship of the number of and variety of known air-borne allergens in an area with the incidence of otitis media there. To include high-risk and non-high risk groups. 4. TO investigate the relationship between air quality in industrial and non-industrial areas of the same city and incidence of otitis media.
2. Mawson S. R. and Fagan P. Tympanic effusions in children. J. Lar. 0~1. 86, 105, 1972. 3. Recommendations for future goals in improving the management of the otitis media problem: summaries of discussion groups. In Otitis Media (Edited by Glorig A. and Gerwin K. S.), pp. 275-296. Thomas, Springfield, 1972. 4. Onion D. K. and Taylor C. The epidemiology of recurrent otitis media. Am. J. publ. Hlth 67, 472, 1977. 5. Rapp D. J. and Fahey D. Review of chronic secretory otitis media and allergy. J. Asthma Res. 10, 193, 1973. 6. Chan J. C. M., Logan G. B. and McBean J. B. Serous otitis media and allergy. Am. J. Dis. Child. 114, 684. 1967. 7. Mawson S. Op. cit. 8. Phillips M. J. et al. Ig E and secretory otitis media. Lancer 2, 1176. 1974. 9. Tiinder 0. and Gundersen T. Nature of the fluid in serous otitis media. Archs Otolar. 93. 473, 1971. IO. Tuft L. and Mueller H. L. Allergy in Children, pp. 408-413. Saunders, Philadelphia. 1970. Il. Olmsted R. W. et al. The pattern of hearing following acute otitis media. J. Pediat. 65, 252. 1964. 12. Friedman W. H. Serous otitis media in children. J. Commun. Disord. 7, 1I, 1974. 13. Herer G. R. Otitis media and educational achievement. Eye Ear Nose Throat Mon. 53, 17, 1974. 14. Friedman W. H. Op. cit. 15. Draper W. L. Secretory otitis media in children: a study of 540 children. Loryngoscope 77, 636, 1967. 16. Gundersen T. and Gliick E. The middle ear mucosa in serous otitis media. Archs Otoiar. 96, 40, 1972. 17. Chan J. C. M., Logan G. B. and McBean J. M. Op. cit. 18. Kaplan G. J., Fleshman J. K., Bender T. R., Baun C. and Clark P. S. Long-term effects of otitis media: a ten-year cohort study of Alaskan Eskimo children. Pediatrics
1. Mawson S. R.
Diseases
of rhe Ear,
liams & Wilkins, Baltimore, 1974.
52, 577, 1973.
Davison F. W. Middle ear effusion-systemic factors. Laryngoscope 68, 1128, 1958. 20. Davison F. W. Middle ear problems in childhood. J. 19.
REFERENCES pp. 283-348. Wil-
Am. med. Ass. 196, 834. 1966.
MARY Lou
236 21.
22. 23. 24. 2s. 26. 27. 28. 29.
Draper W. L. Allergy in relationship to the eustachian tube and middle ear. In Otolaryngol Clin. North Am.: Symposium in Otorhinolaryngolbgy (Edited by Clemis J. D.), pp. 749-755. Saunders, Philadelphia, 1974. Draper W. L. The otolaryngologist and the allergic child. Sth. med. J. 59, 217. 1966. Fernandez A. A. and McGovern J. P. Secretory otitis media in allergic infants. Sth. med. J. 58. 581. 1965. Freeman M. < and Freeman R. J. Serous otitis media. Am. .I. Dis. Child. 99. 683, 1960. Leeks H. I. Allergic aspects of serous otitis media in childhood. N. Y. St. J. Med. 61, 2737, 1961. Mawson S. R. Op. ci:. Mawson S. R. and Fagan P. Op. cit. Draper W. L. Allergy in relationship to the eustachian tube and middle ear. Op. cir. Friedman W. H. Serous otitis media in children. Op. cit.
30.
Davison F. W. Middle ear problems in childhood. Op. cit.
31.
32. 33.
34. 35. 36.
37. 38. 39. 40. 41.
Divison F. W. Nasal diseases as a cause of otitis media. In Otitis Media (Edited by Glorig A. and Gerwin K. S.), pp. 6278. Thomas, Springfield, 1972. Palva T. and Palva A. Mucosai histochemistry in secretory otitis. Ann. Otol. Rhinol. hr. 84, 112, 1975. Paparella M. M. and Jurgens G. L. Middle ear fluid problems. In Clinical Orology: An International Symoosium (Edited bv- Paoarella M. M.. Michael M.. Hoff. man A. and Huff J. S.), pp. 146156. Mosby, St. Louis, 1971. Rapp D. J. and Fahey D. Op. cit. Chan J. C. M., Logan G. B. and McBean J. B. Op. cit. Ogra P. L., Bernstein J. M.. Yurchak A. M., Co&la P. R. and Tomasi T. B. Characteristics of secretorv immune system in human middle ear: implications in otitis media. J. Immun. 112, 488, 1974. Paparella M. M. and Jurgens G. L. Op. cit. Suehs 0. W. Secretory otitis media. Lclryngoscope 62, 998, 1952. Chan J. C. M., Logan G. B. and McBean J. B. Op. cit. Freeman M. S. and Freeman R. J. Op. cit. Holborow C. Eustachian tubal function: changes in anatomy and function with age and the relationship of these changes to aural .pathology. Arch Otolar. 9L, 624, 1970. Chan J. C. M., Logan G. B. and McBean J. B. Op. cit.
42. 43. ibid.
MILLER
44. Fernandez A. A. and McGovern J. P. Op. cit. 45. Rauo D. J. and Fahev D. OP. cit. 46. Davison F. W. Nasalbiseasd as a cause of otitis media. Op. cir.
47. Holborow C. Op. cit. 48. Chan J. C. M., Logan G. B. and McBean J. B. Op. cir. 49. Davison F. W. Middle-ear problems in childhood. Op. cit.
50. Draper W. L. Secretory otitis media in children: a study of 540 children. Op. cit. 51. Femandez A. A. and McGovern J. P. Op. cit. 52. McEldowney D. and Kessner D. M. Review of the literature: dpidemiology of otitis media. In Oritis Media (Edited by Glorig A. and Gerwin K. S.), pp. I l-25. Thomas, Springfield, 1972. 53. Solow I. A. Is seious otitis media due to allergy or infection? Ann. Allergy 16, 297, 1958. 54. McEldowney D. and Kessner D. M. Op. cit. 55. Manning P., Avery M. E. and Ross A. Purulent otitis media: differences between populations in different environments. Pediatrics 53, 135, 1974. 56. McEldowney D. and Kessner D. M. Op. cit. 57 Ibid. 58 Davison F. W. Nasal disease as a cause of otitis media. Op. cit. 59. Johonnott S. C. Differences in chronic otitis media between rural and urban Eskimo children. C/in. Pediat. 12, 415, 1973. 60. McEldowney D. and Kessner D. M. Op. cit. 61. Manning P., Avery M. E. and Ross A. Op. cit. 62. McEldowney D. and Kessner D. M. Op. cit. 63. Manning P., Avery M. E. and Ross A. Op. cit. 64. Drape.r W. L. Secretory otitis media in children: a study of 540 children. Op. cit. 65. McEldownev D. and Kessner D. M. 00. cit. 66. Pracy R., Siegler J. and Stell P. M. A ‘Short Textbook: Ear Nose and Throat. Lippincott, Philadelphia, 1971. 67. Suehs 0. W. Op. cit. 68. Chan J. C. M., Logan G. 8. and McBean J. 8. Op. cit. 69. Draper W. L. Secretory otitis media in children: a study of 540 children. Op. cit. 70. Davison F. W. Nasal disease as a cause of otitis media. Op. cit.
71. Suehs 0. W. Op. cit. 72. Pracy R., Siegler J. and Stell P. M. Op. cit. 73. Chan J. C. M., Logan G. B. and McBean J. 5. Op. cit.
EPIDEMIOLOGY AND RESEARCH
OF OTITIS MEDIA: FOCUS FOR GEOGRAPHERS
MARY LOU MILLER Southern
Illinois
University,
Department
of Geography,
Faner Hall, Carbondale, IL 62901, U.S.A.
Abstract-Yearly,
otitis media (inflammation of the middle ear and its extensions) creates fluctuating hearing loss for thousands of children aged ten or younger. The common etiological factor seems to be a dysfunctioning eustachian tube, but there is widespread disagreement as to specific causes contributing to this dysfunction. Certain incidence patterns suggest that season of year, low altitude. high humidity, and variable weather are contributing factors. Geographers could add to an understanding of this medical problem by studying spatial patterns and by attempting to determine the occurrence of otitis media with the interrelationships of such variables as climate, altitude and weather patterns.
INTRODUCTION Otitis media, which is an inflammation of the middle ear and its extensions [l-3], is a serious problem which warrants further research by social scientists. In conducting future research, there are three main reasons for involving geographers: (1) The spatial distribution of increased incidence of otitis media can be specifically pinpointed; (2) this spatial distribution appears to be related to components of the external physical environment; (3) the disease appears to occur because of the interrelationships of multiple interacting variables including those just cited. Because both the spatial distribution of the disease and components of the physical environment appear to play a major role in the etiology of otitis media, it is a problem which needs to be investigated by geographers. IMPORTANCEOF THE PROBLEM
tasks [12-131. It is this impact of fluctuating and permanent hearing loss which concerns health professionals. Since children seldom complain of a hearing loss, the damage is often major before that loss is detected [l&J. If health professionals are to deal effectively with the prevention and management of the problem, more research is needed which would involve geographers. This needed interdisciplinary approach can best be explained by reviewing what is known about the causes of otitis media, who is affected by it, and where and when it occurs. CAUSESOF OTITIS MEDIA Most authors agree that the common etiological factor is the dysfunction of the eustachian tube which no longer is able to drain the excess accumulation of fluid. Yet, there is a widespread difference of opinion as to what causes this fluid to form [IS-17-J. Some of the commonly cited causes include: virus and bacterial infection [ 181; an allergic response [ 19-273 ; air pressure differences [28]; improper antibiotic usage 1291; mechanical obstruction of the tube [30-35-J; or any combination of the previous possible factors. There is a more recent tendency to view otitis media as a complex disease in which many different causal factors may be involved in producing a multiplicity of clinical and histopathological changes [36,37]. Thus, at any time, the causal agent might be any one of a number of possible combinations. It should be noted, however, that several of the listed causes point to the role of the physical environment-viruses, bacteria and allergens. In particular, aeroallergens are repeatedly referred to as major contributors to the fluid accumulation.
Otitis media is more commonly referred to as an earache or an ear infection; and it is a health problem which occurs frequently with well-known symptoms. Since the era of antibiotics, there has been a remarkable reduction of serious and life-threatening complications [4]; however, otitis media is still a major problem for two main reasons. First, in spite of antibiotic usage, otitis media is occurring more frequently [S, 63. Secondly, there are still serious and often unrecognized side effects which are associated with ear infections. An episode of otitis media is characterized by a collection of fluid in the middle ear, and it is this fluid accumulation which contributes to fluctuating hearing loss [7-lo]. It has been estimated that 50% of those patients with otitis media experience a temporary hearing deficit even after other signs have disag peared. It is further estimated that 10% will experiINCIDENCE OF OTITIS MEDIA ence a permanent hearing loss of 15 decibels or more because of damage to the ear drum [ll]. Each year, Although serious, life-threatening complications then, otitis media affects thousands of schoolage have greatly decreased, otitis media is occurring with children. It causes them to miss school and to experigreater frequency. This increase, however, may be a ence a diminished performance. Because otitis media reflection of one or more of the following factors: primarily occurs during a child’s developmental 1. Increased awareness by pediatricians, general period, it may have a major impact upon his lifelong ability to hear, read, speak and perform other practitioners, and otolaryngologists [38,39]. SS.M1.14c+-c 233
MARY
234
Lou MILLER
2. Indiscriminate use and inadequate courses of antibiotics in the treatment of respiratory infections [40-42]. 3. Increase in the number of viral infections. 4. A greater predisposition to allergic reactions. 5. Increased air travel. 6. Change to a conservative attitude in advocating adenotonsillectomy [43]. 7. Improvement of routine screening and development of more effective screening tools [44-45].
In spite of concern over whether there is a true increase in incidence, otitis media remains a frequent problem. it occurs most often during childhood with the highest incidence rates in children who are ten or younger. Even though there is some discrepancy about the specific age of greatest risk, many cite the 4-7 age range [46-48J. It should be noted, however, that this age range would be one most frequently detected in studies conducted in school systems. It is generally felt that males have a higher rate of incidence than females [49-531. The slight difference, however, remains of questionable significance [54], particularly because there have been no general prevalance and incidence studies and because most reportings have been taken from general practice cases and do not represent the total population at risk. SPATIAL
AND
SEASONAL
OF OTITIS
DISTRIBUTION
MEDlA
The spatial dist~bution of areas with an increase in otitis media incidence is quite distinct and can be linked to five main groups of people and locations. TWO groups, which are located on other continents, include the Maori of New Zealand and the Aborigines of Australia[55]. In North America, the three main groups are quite dispersed. They include native Alaskans, poor Appalachians and American Indians 156-J. McEldowney and Kessner [57] suggest that the common denominator for these groups is more likely poverty than race or genetic influences. They also point out that the poverty relationship may be attributable to a combination of high-risk environmental conditions and to lack of access to medical care [S&-61]. Yet, there have been few studies on the relationship of socioeconomic status to the spatial distribution and severity of middle ear disease[62]. Likewise, no studies appear to have been conducted to isolate additional spatial patterns of incidence. Although certain groups and locations have been identified as having high incidence rates, there are no data from general prevalence and incidence studies to support this [63). Both types of studies are essential. In contrast, the pattern of seasonal variation is firmly established and supported. Even in diverse populations in differing locations, there is a consistent pattern of, seasonal variation. The incidence of otitis media begins to increase in the fall, peaks during the winter and early spring, and drops to a low by summer t64-681, It has been noted that this peaking coincides with an increased level of aeroallergens such as dust, mold and pollen whose counts peak from October through June [69]. It also coincides with a period normally associated with increased upper respiratory tract infections.
250
zoo
130
loo
so 0 J
F
M
AMJJAsOND
Fig. I. Monthly incidence pattern of acute otitis media. Source: McEldowney and Kessner. p. 22. ROLE OF CLIMATOLOGICAL TOPOGRAPHICAL
AND
VARIABLES
At this point, no studies appear to have been conducted which investigate the relationship of climatological and topographical variables with the incidence of otitis media. Instead, what little is known is based upon in~~dual physician reports; however, these reports do designate six factors which warrant further consideration. First, otitis media is reported to be greatest in north temperate climates [70]. Secondly, most otolaryngologists who report an increased incidence of otitis media live in coastal areas and aiong river valleys. In contrast, specialists who reside in non-coastal or non-river valley areas report only a few cases per month or year. Third, common features of coastal areas and river valleys are their high humidity and low altitude. Fourth, femperature is not believed to be an important factor except in the sense that otitis media occurs most frequently in seasons of the year when temperature is the most variable [71]. Fifth, there is a widespread agreement among physicians that periods of variable weather rather than general temperature are predisposing environmental factors in the development of middle ear infections. Sixth, otitis media is believed to occur more frequently in children living in industrial areas [72]. RESEARCH
FOCUSES
FOR GEOGRAPHERS
Ottis media is a disease whose cause, clinical features, physical findings and treatment vary considerably [73]: (Refer to Fig. 2 for a model of this.) Relatively little is positively known about the disease. We do know that otitis media occurs (1) in children aged ten or younger; (2) in boys more than girls; and (3) with greater incidence among American Indians, Alaskan Eskimoes and poor Appalachians. On the other hand, we do not really know what causes the fluid to accumulate in the middle ear thus leading to irritation, inflammation and infection. Nevertheless, we strongly suspect that allergies to components in the physical environment are an important contributing factor, and .discussions of possible causes repeatedly cite allergies as a main precipitator of middle ear fluid. In addition, we know that specific air-borne allergens vary from one area to another and that some areas contain more irritants than others. As a
235
Epidemiology of otitis media
Fig. 2. Epidemiology of otitis media. result of the general practice reports of allergists and otolaryngologists, we also suspect that other environmental factors contribute to the problem: (I ) location in coastal areas or river valleys where there is high humidity and low altitude and (2) location in areas where there is variable weather. At this point, however, these latter suspicions all form untested hypotheses. If we are to deal effectively with the prevention and management of otitis media, studies are needed which will help to explain where the incidence of otitis media is the greatest and what about the location and the people contributes to an increased incidence. Geographers can help to determine the role of several interrelated and interacting variables. They need: 1. To conduct general prevalence and incidence studies to pinpoint the role of spatial, climatological, topographical and socio-economic factors in the occurrence of otitis media. 2. To conduct longitudinal studies to pinpoint the role of variable weather, humidity and altitude.
Sites should include coastal and non-coastal areas and river valley and non-river valley areas as well as other distinctly different regions. 3. To investigate the relationship of the number of and variety of known air-borne allergens in an area with the incidence of otitis media there. To include high-risk and non-high risk groups. 4. TO investigate the relationship between air quality in industrial and non-industrial areas of the same city and incidence of otitis media.
2. Mawson S. R. and Fagan P. Tympanic effusions in children. J. Lar. 0~1. 86, 105, 1972. 3. Recommendations for future goals in improving the management of the otitis media problem: summaries of discussion groups. In Otitis Media (Edited by Glorig A. and Gerwin K. S.), pp. 275-296. Thomas, Springfield, 1972. 4. Onion D. K. and Taylor C. The epidemiology of recurrent otitis media. Am. J. publ. Hlth 67, 472, 1977. 5. Rapp D. J. and Fahey D. Review of chronic secretory otitis media and allergy. J. Asthma Res. 10, 193, 1973. 6. Chan J. C. M., Logan G. B. and McBean J. B. Serous otitis media and allergy. Am. J. Dis. Child. 114, 684. 1967. 7. Mawson S. Op. cit. 8. Phillips M. J. et al. Ig E and secretory otitis media. Lancer 2, 1176. 1974. 9. Tiinder 0. and Gundersen T. Nature of the fluid in serous otitis media. Archs Otolar. 93. 473, 1971. IO. Tuft L. and Mueller H. L. Allergy in Children, pp. 408-413. Saunders, Philadelphia. 1970. Il. Olmsted R. W. et al. The pattern of hearing following acute otitis media. J. Pediat. 65, 252. 1964. 12. Friedman W. H. Serous otitis media in children. J. Commun. Disord. 7, 1I, 1974. 13. Herer G. R. Otitis media and educational achievement. Eye Ear Nose Throat Mon. 53, 17, 1974. 14. Friedman W. H. Op. cit. 15. Draper W. L. Secretory otitis media in children: a study of 540 children. Loryngoscope 77, 636, 1967. 16. Gundersen T. and Gliick E. The middle ear mucosa in serous otitis media. Archs Otoiar. 96, 40, 1972. 17. Chan J. C. M., Logan G. B. and McBean J. M. Op. cit. 18. Kaplan G. J., Fleshman J. K., Bender T. R., Baun C. and Clark P. S. Long-term effects of otitis media: a ten-year cohort study of Alaskan Eskimo children. Pediatrics
1. Mawson S. R.
Diseases
of rhe Ear,
liams & Wilkins, Baltimore, 1974.
52, 577, 1973.
Davison F. W. Middle ear effusion-systemic factors. Laryngoscope 68, 1128, 1958. 20. Davison F. W. Middle ear problems in childhood. J. 19.
REFERENCES pp. 283-348. Wil-
Am. med. Ass. 196, 834. 1966.
MARY Lou
236 21.
22. 23. 24. 2s. 26. 27. 28. 29.
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