- Email: [email protected]
Evaluation of balance disturbances in children with middle ear effusion
International Journal of Pediatric Otorhinolaryngology 43 (1998) 21 – 26
Evaluation of balance disturbances in children with middle ear effusion A. Golz a,*, B. Angel-Yeger a, S. Parush b a Department of Otorhinolarynogology-Head and Neck Surgery, Rambam Medical Center and Faculty of Medicine, Technion-Israel Institute of Technology, POB 9602, Haifa 31096, Israel b Department of Occupational Therapy, The Hebrew Uni6ersity School of Medicine, Jerusalem, Israel
Received 23 June 1997; accepted 12 October 1997
Abstract Objecti6es: Vertigo and dizziness are not common complaints in childhood, but are present more often than formerly thought. These symptoms are usually caused by otitis media (OM) and middle ear effusion (MEE), two of the most common disorders in children, but were not studied until recently. The purpose of this study was to determine objectively the incidence of balance-related symptoms occurring in children with long lasting MEE and to determine if these symptoms resolve following the insertion of ventilation tubes (VT). Methods: In total 64 children, aged between 4.5 and 7.5 years, were studied using the Bruininks-Oseretsky tests for motor proficiency, before and after insertion of VT. They were compared to 57 healthy children with no history of middle ear diseases. Results: Pathological findings were identified in 39 children with chronic MEE, as compared to only four children of the controls. Following VT insertion the symptoms and signs of balance disturbances resolved in mostly all the operated children. Conclusions: The results of this study indicate that balance-related symptoms often encountered in young children may result from chronic MEE and that these symptoms resolve following ventilation of the middle ear. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Otitis media; Middle ear effusion; Vestibular system; Vertigo; Dizziness
* Corresponding author. Tel.: +972 4 8380645; fax: + 972 4 8515710. 0165-5876/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 1 6 5 - 5 8 7 6 ( 9 7 ) 0 0 1 5 0 - X
22
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
1. Introduction Although not a common complaint, dizziness occurs in childhood [4,5,8], but has been a long-neglected symptom [13]. Dizziness is a non-specific complaint and can be the manifestation of different medical conditions [14]. It is commonly believed that otitis media (OM) is the most common cause of vestibular disturbances in children [4,5,10]. The occurrence of acute labyrinthitis secondary to acute or chronic OM is well recognized and documented. What is less commonly noted, however, is the occurrence of dizziness in children related to Eustachian tube dysfunction and middle ear effusion (MEE) [3]. Busis [8], Balkany and Finkel [1] consider MEE as the most common cause of balance disturbances in children. Most children with abnormal middle ear ventilation or MEE do not complain of balance disturbance or vertigo, but their parents may describe excessive clumsiness, awkwardness and sometimes frequent falling [7,8]. Merica [22] in a clinical study based on 135 children, found that vertigo caused by obstruction of the Eustachian tubes was a distinct clinical entity. Since this pioneer study, dizziness due to Eustachian tube dysfunction has received but scant attention both in literature and in practice. Snashall [25] noted that in her experience 50% of children with serous otitis may have some balance disturbance. Casselbrant et al. [9] pointed out that there was no documentation on the effect of OM with effusion on the vestibular system. Denning and Mayberry [12] found that pre-school children with history of OM had a significantly decreased percentile rank scores on stepping and vertical writing which measure vestibulo-spinal function. Grace and Pfleiderer [20] found that nearly one quarter of the children with non supportive OM had some degree of dysequilibrium or vestibular like disturbance. Jones et al. [21], in a study on 34 children with chronic secretory OM, using a fixed force plate body-sway platform, showed that balance was significantly worse in these children, as compared to the control group. Golz et al. [19] studied 97 children with chronic MEE using electronystagmography (ENG). Overall abnormal findings were found in 71% of the children, compared to only 4% in the control group. Ben-David et al. [2], who investigated vestibular function using the rotating chair oscillation test and craniocorpography, found no differences between children with MEE and children without MEE, regarding their balance performance. Polak et al. [23] in a study presented at the third International Conference on Pediatric Otorhinolaryngology, in 1993 in Israel, found a positional and/or a spontaneous nystagmus in 45.5% of the children with chronic effusions in the middle ear. Casselbrant et al. [10] evaluated 41 children with OM using moving platform posturography and found that episodes of OM affect balance, leaving the children more clumsy and possibly impairing motor development. At the 1995 meeting of the American Academy of Otolaryngology-Head and Neck Surgery in New Orleans, Louisiana Friedman et al. [17] reported their results on balance in children with OM with effusion, using the Peabody Developmental Motor Scales. In balance tasks 40% of the children with bilateral effusions performed significantly below the norm for their age group.
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
23
In all these studies evacuation of the middle ear secretions, followed by the insertion of ventilation tubes (VT), improved hearing and relieved any association balance dysfunction [1,7,10,16,18,19,21]. How do Eustachian tube dysfunction and MEE affect the vestibular system? The answer to this question is still an enigma. Some authors have stated that the negative changes in the middle ear, transmitted through the labyrinthine windows, lead to secondary movement of the inner ear fluids [2,3,8,15,18,20]. Others suggested that the dizziness and vertigo caused by these conditions are due to serous labyrinthitis, secondary to superadded infection in a glue ear [2,3,20]. Jones et al. [21] suggested that ionic transfer through the semipermeable round window membrane alter indirectly the composition of the endolymph via the perilymph, with subsequent changes in ionic channels of the kinocilia and stereocilia which affect balance. The purpose of this study was to objectively determine the incidence of balancerelated symptoms occurring in children with long lasting MEE by the use of a different method and to find out whether these symptoms resolve following VT insertion. 2. Materials and methods Children 4.5 – 7.5 years of age (mean 9 S.D.: 5.8 9 0.8) with unilateral or bilateral persistent MEE (study group) and children of the same age group and sex distribution with no history of ear diseases and with normal ear status who had been scheduled for tonsillectomy operation (controls) were selected for this study from the population at the Rambam Medical Center in Haifa, Israel. Excluded were children with any conductive or sensory-neural hearing loss, except a hearing loss caused by MEE, children who have had acute OM or otalgia during the year prior to the study, children with neurological diseases or any other serious illness and children with an unreliable medical history or whose behavior had been reported as uncooperative. There were 64 children in the study group, 36 boys and 28 girls, 57 controls, 30 boys and 27 girls. Parents were asked to complete a questionnaire relating to their child’s state of balance, clumsiness or tendency to fall. Prior to the study each participant underwent a detailed neurological examination to exclude any central or peripheral, non vestibular disturbance. Assessment of the middle ear status was performed by pneumatic otoscopy, by microscopic examination of the ear-drum, by speech and pure-tone audiometry (for air and bone conduction thresholds) and by tympanometry. Balance was evaluated using two of the eight subtests of the Bruininks-Oseretsky test of Motor Proficiency [6]: those which assess static balance and strength. The tests were administered by an occupational therapist who did not know to which group the tested child belonged. From the study group 55 children underwent myringotomy and VT insertion, of whom 48 (87.3%) were re-evaluated 2–3 months post-operatively using the two subtests of the Bruininks-Oseretsky test.
24
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
The results obtained from the study group were compared with those obtained from the controls and with those obtained from the children post-operatively. We also looked for a correlation between the questionnaires and the results of the Bruininks-Oseretsky tests. The resultant data was analyzed using the Spearman test and the t-test.
3. Results Pneumatic and microscopic otoscopy confirmed the diagnosis of MEE in the study group and normal ears in the control group. In the study group hearing loss (average air conduction threshold for the frequencies 500 – 2000 Hz in both ears) ranged between 20 and 50 dB (average air-bone gap was 28.393.8 dB) and all had a type B or a type C tympanogram. In the control group hearing threshold did not exceed 20 dB and all had a type A tympanogram. The effusion in the middle ear was bilateral in 59 of the study group, while the remaining five had effusions in one ear only. The degree and severity of the effusion was in some cases different in the two ears. These differences were also observed in the audiograms and in the tympnograms. In the Bruininks-Oseretsky tests 39 (61%) of the study group performed significantly below the expected scores for their age as compared to only four (7%) of the controls. This difference was found to be statistically significant (PB 0.001). Balance disturbances were found to occur as frequently in the children with unilateral effusions as in those with bilateral effusions. No correlation was found between the degree of the hearing loss and the abnormal Bruininks-Oseretsky tests scores. No differences were found between girls and boys for either the children with MEE or the controls. Of the 58 parents of the study group who completed the questionnaires 17 (29.3%) noted that their children had balance disturbances, such as frequent falling, clumsiness or unsteadiness. Of the 40 parents of the controls who completed the questionnaire only two (5%) reported that their child had some balance impairment. Comparing the answers obtained from the questionnaires with the results of the Bruininks-Oseretsky tests, we found a clear-cut correlation between the low scores and the clinical balance disturbances reported by the parents. Of the 17 study group parents who noticed some disturbances in balance and equilibrium, 12 (70.6%) performed significantly below the expected scores on the Bruininks-Oseretsky tests. VT placement was carried out in 55 children. All of the 48 (87.3%) who were re-evaluated had bilateral dry functional tubes and had hearing that returned to normal. With the Bruininks-Oseretsky tests two children (4.2%) still performed below the expected scores for their ages. A statistically significant difference was found between the results obtained before surgery and after VT insertion in the Bruininks-Oseretsky tests (PB 0.001). Following VT placement there was no significant difference in the Bruininks-Os-
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
25
eretsky tests scores between the children with MEE and the controls. Just before their children were re-evaluated 15 parents who preoperatively noticed some balance disturbances in their children completed another questionnaire . They reported that their children became and remained symptom-free following surgery.
4. Discussion Although MEE has been considered the most common cause of vestibular disturbances in children [1,8], this association has not been quantified until recently. In the last 15 years several authors, by the use of different methods for the evaluation of the vestibular system in children, have demonstrated that the anecdotal evidence that children with OM or MEE are more clumsy, stumble more and tend to fall frequently, is supported by distinct clinical findings [9– 12,19 – 21,24]. In our study we used a method for evaluating balance disturbances in children with chronic MEE, that was different from the methods used by the other authors, but our results confirm those of the previously published studies. Balance was significantly worse in children with persistent MEE as compared to healthy children. We found the Bruininks-Oseretsky test for Motor Proficiency useful in the evaluation of dysequilibrium and balance disturbances in young children. It is reliable, can be performed by anyone with minimal training, is inexpensive (in terms of equipment used and time consumption) and is simple and friendly to the child. Thus it can be used routinely for the evaluation of children with chronic persistent MEE. Symptoms of dysequlibrium and imbalance are rarely, if ever, volunteered spontaneously by parents of children with MEE. In this study we have found a clear-cut correlation between the low scores in the Bruininks-Oseretsky tests and the clinical balance disturbances reported by the parents in the questionnaires. Therefore it is important that parents of children with chronic MEE should be asked specifically about balance disturbances occurring in their children. We also demonstrated that insertion of VT is associated with a complete resolution of the imbalance symptoms and the low scores on the Bruininks-Oseretsky tests. These results are similar to those of other authors [3,7,8,10,16,18,19,21] and agree with what a parent will usually report following VT insertion, that the child’s balance, as well as his hearing, have improved immediately following surgery. For many years OM research has focused on auditory sequelae such as hearing loss, language delay and learning difficulties, without considering the role vestibular dysfunction may play in learning disabilities and in a child’s development. Our findings and previous studies suggest that the adverse effects of OM on a child’s development are also attributed to the effect of the effusion on vestibular function.
26
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
References [1] T.J. Balkany, R.S. Finkel, The dizzy child, Ear Hear. 7 (1986) 138 – 142. [2] J. Ben David, L. Podoshin, M. Fradis, D. Faraggi, Is the vestibular system affected by middle ear effusion?, Otolaryngol. Head Neck Surg. 109 (1993) 421 – 426. [3] A.W. Blayney, B.H. Colman, Dizziness in childhood, Clin. Otolaryngol. 9 (1984) 77 – 85. [4] C.D. Blustone, S. Stool (Eds.), Pediatric Otolaryngology, 1st edn., W.B. Saunders, Philadelphia, 1983, pp. 261–270. [5] C.M. Bower, R.T. Cotton, The spectrum of vertigo in children, Arch. Otolaryngol. Head Neck Surg. 121 (1995) 911–915. [6] R.H. Bruininks, Bruininks-Oseretsky test of Motor Proficiency, Examiners manual, American Guidance Service, Minnesota, 1978. [7] S.N. Busis, Vertigo in children, Ear Nose Throat J. 57 (1) (1978) 95 – 100. [8] S.N. Busis, Dizziness in children, Pediat. Ann. 17 (1988) 648 – 655. [9] M.L. Casselbrant, F.O. Black, L. Nashner, R. Panion, Vestibular function assessment in children with otitis media with effusion, Ann. Otol. Rhinol. Laryngol. 92 (1983) 46 – 47. [10] M.L. Casselbrant, J.M. Furman, E. Rubinstein, E.M. Mandel, Effects of otitis media on the vestibular system in children, Ann. Otol. Rhinol. Laryngol. 104 (1995) 620 – 624. [11] D.G. Cyr, P.E. Brookhouser, M. Valente, A. Grossman, Vestibular evaluation of infants and pre-school children, Otolaryngol. Head Neck Surg. 93 (1985) 463 – 468. [12] J. Denning, W. Mayberry, Vestibular dysfunction in pre-school children with a history of otitis media, Occup. Therap. J. Res. 7 (1987) 335 – 348. [13] L. Eviatar, A. Eviatar, Vertigo in children: differential diagnosis and treatment, Pediatrics 59 (1977) 833–838. [14] L. Eviatar, Dizziness in children, Otolaryngol. Clin. North Am. 27 (1994) 557 – 571. [15] K. Flisberg, The effects of vacuum on the tympanic cavity, Otolaryngol. Clin. North Am. 3 (1970) 3–13. [16] M.P. Fried, The evaluation of dizziness in children, Laryngoscope 9 (1980) 1548 – 1560. [17] E.M. Friedman, D.C. Lai, N.O. Duncan, M. Pellicer, Balance in otitis media with effusion: A prospective study, Otolaryngol. Head Neck Surg. 113 (1995) 104. [18] G.A. Gates, Vertigo in children, Ear Nose and Throat J. 59 (1980) 358 – 365. [19] A. Golz, S.T. Westerman, L.M. Gilbert, H.Z. Joachims, A. Netzer, Effects of middle ear effusion on the vesibular labyrinth, J. Laryngol. Otol. 105 (1991) 987 – 989. [20] A.R.H. Grace, A.G. Pfleidere, Dysequilibrium and otitis media with effusion: what is the association, J. Laryngol. Otol. 104 (1990) 682 – 684. [21] N.S. Jones, P. Radomski, A.J.N. Prichard, S.E. Snashall, Imbalance and chronic secretory otitis media in children: effect of myringotomy and insertion of ventilation tubes on body sway, Ann. Otol. Rhinol. Laryngol. 99 (1990) 477 – 481. [22] F.W. Merica, Vertigo due to obstruction of the eustachian tubes, J. Am. Med. Assoc. 118 (1942) 1282–1284. [23] M. Polak, J. Graboowska, A. Piziewicz, J. Mierzwinski, Evaluation of vestibular function in children with secretory otitis media. 3rd International Conference on Pediatric Otorhinolaryngology. Jerusalem, Israel, 1993. [24] R.C. Schaaf, The frequency of vestibular disorders in developmentally delayed pre-schoolers with otitis media, Am. J. Occup. Therap. 39 (1985) 247 – 252. [25] S. Snashall, Vestibular disorders, in: A.G. Kerr, J. Groves (Eds.), Scott-Brrown’s Otolaryngology, 5th edn., Butterworths, London, 1987, pp. 194 – 217.
.
Evaluation of balance disturbances in children with middle ear effusion A. Golz a,*, B. Angel-Yeger a, S. Parush b a Department of Otorhinolarynogology-Head and Neck Surgery, Rambam Medical Center and Faculty of Medicine, Technion-Israel Institute of Technology, POB 9602, Haifa 31096, Israel b Department of Occupational Therapy, The Hebrew Uni6ersity School of Medicine, Jerusalem, Israel
Received 23 June 1997; accepted 12 October 1997
Abstract Objecti6es: Vertigo and dizziness are not common complaints in childhood, but are present more often than formerly thought. These symptoms are usually caused by otitis media (OM) and middle ear effusion (MEE), two of the most common disorders in children, but were not studied until recently. The purpose of this study was to determine objectively the incidence of balance-related symptoms occurring in children with long lasting MEE and to determine if these symptoms resolve following the insertion of ventilation tubes (VT). Methods: In total 64 children, aged between 4.5 and 7.5 years, were studied using the Bruininks-Oseretsky tests for motor proficiency, before and after insertion of VT. They were compared to 57 healthy children with no history of middle ear diseases. Results: Pathological findings were identified in 39 children with chronic MEE, as compared to only four children of the controls. Following VT insertion the symptoms and signs of balance disturbances resolved in mostly all the operated children. Conclusions: The results of this study indicate that balance-related symptoms often encountered in young children may result from chronic MEE and that these symptoms resolve following ventilation of the middle ear. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Otitis media; Middle ear effusion; Vestibular system; Vertigo; Dizziness
* Corresponding author. Tel.: +972 4 8380645; fax: + 972 4 8515710. 0165-5876/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 1 6 5 - 5 8 7 6 ( 9 7 ) 0 0 1 5 0 - X
22
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
1. Introduction Although not a common complaint, dizziness occurs in childhood [4,5,8], but has been a long-neglected symptom [13]. Dizziness is a non-specific complaint and can be the manifestation of different medical conditions [14]. It is commonly believed that otitis media (OM) is the most common cause of vestibular disturbances in children [4,5,10]. The occurrence of acute labyrinthitis secondary to acute or chronic OM is well recognized and documented. What is less commonly noted, however, is the occurrence of dizziness in children related to Eustachian tube dysfunction and middle ear effusion (MEE) [3]. Busis [8], Balkany and Finkel [1] consider MEE as the most common cause of balance disturbances in children. Most children with abnormal middle ear ventilation or MEE do not complain of balance disturbance or vertigo, but their parents may describe excessive clumsiness, awkwardness and sometimes frequent falling [7,8]. Merica [22] in a clinical study based on 135 children, found that vertigo caused by obstruction of the Eustachian tubes was a distinct clinical entity. Since this pioneer study, dizziness due to Eustachian tube dysfunction has received but scant attention both in literature and in practice. Snashall [25] noted that in her experience 50% of children with serous otitis may have some balance disturbance. Casselbrant et al. [9] pointed out that there was no documentation on the effect of OM with effusion on the vestibular system. Denning and Mayberry [12] found that pre-school children with history of OM had a significantly decreased percentile rank scores on stepping and vertical writing which measure vestibulo-spinal function. Grace and Pfleiderer [20] found that nearly one quarter of the children with non supportive OM had some degree of dysequilibrium or vestibular like disturbance. Jones et al. [21], in a study on 34 children with chronic secretory OM, using a fixed force plate body-sway platform, showed that balance was significantly worse in these children, as compared to the control group. Golz et al. [19] studied 97 children with chronic MEE using electronystagmography (ENG). Overall abnormal findings were found in 71% of the children, compared to only 4% in the control group. Ben-David et al. [2], who investigated vestibular function using the rotating chair oscillation test and craniocorpography, found no differences between children with MEE and children without MEE, regarding their balance performance. Polak et al. [23] in a study presented at the third International Conference on Pediatric Otorhinolaryngology, in 1993 in Israel, found a positional and/or a spontaneous nystagmus in 45.5% of the children with chronic effusions in the middle ear. Casselbrant et al. [10] evaluated 41 children with OM using moving platform posturography and found that episodes of OM affect balance, leaving the children more clumsy and possibly impairing motor development. At the 1995 meeting of the American Academy of Otolaryngology-Head and Neck Surgery in New Orleans, Louisiana Friedman et al. [17] reported their results on balance in children with OM with effusion, using the Peabody Developmental Motor Scales. In balance tasks 40% of the children with bilateral effusions performed significantly below the norm for their age group.
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
23
In all these studies evacuation of the middle ear secretions, followed by the insertion of ventilation tubes (VT), improved hearing and relieved any association balance dysfunction [1,7,10,16,18,19,21]. How do Eustachian tube dysfunction and MEE affect the vestibular system? The answer to this question is still an enigma. Some authors have stated that the negative changes in the middle ear, transmitted through the labyrinthine windows, lead to secondary movement of the inner ear fluids [2,3,8,15,18,20]. Others suggested that the dizziness and vertigo caused by these conditions are due to serous labyrinthitis, secondary to superadded infection in a glue ear [2,3,20]. Jones et al. [21] suggested that ionic transfer through the semipermeable round window membrane alter indirectly the composition of the endolymph via the perilymph, with subsequent changes in ionic channels of the kinocilia and stereocilia which affect balance. The purpose of this study was to objectively determine the incidence of balancerelated symptoms occurring in children with long lasting MEE by the use of a different method and to find out whether these symptoms resolve following VT insertion. 2. Materials and methods Children 4.5 – 7.5 years of age (mean 9 S.D.: 5.8 9 0.8) with unilateral or bilateral persistent MEE (study group) and children of the same age group and sex distribution with no history of ear diseases and with normal ear status who had been scheduled for tonsillectomy operation (controls) were selected for this study from the population at the Rambam Medical Center in Haifa, Israel. Excluded were children with any conductive or sensory-neural hearing loss, except a hearing loss caused by MEE, children who have had acute OM or otalgia during the year prior to the study, children with neurological diseases or any other serious illness and children with an unreliable medical history or whose behavior had been reported as uncooperative. There were 64 children in the study group, 36 boys and 28 girls, 57 controls, 30 boys and 27 girls. Parents were asked to complete a questionnaire relating to their child’s state of balance, clumsiness or tendency to fall. Prior to the study each participant underwent a detailed neurological examination to exclude any central or peripheral, non vestibular disturbance. Assessment of the middle ear status was performed by pneumatic otoscopy, by microscopic examination of the ear-drum, by speech and pure-tone audiometry (for air and bone conduction thresholds) and by tympanometry. Balance was evaluated using two of the eight subtests of the Bruininks-Oseretsky test of Motor Proficiency [6]: those which assess static balance and strength. The tests were administered by an occupational therapist who did not know to which group the tested child belonged. From the study group 55 children underwent myringotomy and VT insertion, of whom 48 (87.3%) were re-evaluated 2–3 months post-operatively using the two subtests of the Bruininks-Oseretsky test.
24
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
The results obtained from the study group were compared with those obtained from the controls and with those obtained from the children post-operatively. We also looked for a correlation between the questionnaires and the results of the Bruininks-Oseretsky tests. The resultant data was analyzed using the Spearman test and the t-test.
3. Results Pneumatic and microscopic otoscopy confirmed the diagnosis of MEE in the study group and normal ears in the control group. In the study group hearing loss (average air conduction threshold for the frequencies 500 – 2000 Hz in both ears) ranged between 20 and 50 dB (average air-bone gap was 28.393.8 dB) and all had a type B or a type C tympanogram. In the control group hearing threshold did not exceed 20 dB and all had a type A tympanogram. The effusion in the middle ear was bilateral in 59 of the study group, while the remaining five had effusions in one ear only. The degree and severity of the effusion was in some cases different in the two ears. These differences were also observed in the audiograms and in the tympnograms. In the Bruininks-Oseretsky tests 39 (61%) of the study group performed significantly below the expected scores for their age as compared to only four (7%) of the controls. This difference was found to be statistically significant (PB 0.001). Balance disturbances were found to occur as frequently in the children with unilateral effusions as in those with bilateral effusions. No correlation was found between the degree of the hearing loss and the abnormal Bruininks-Oseretsky tests scores. No differences were found between girls and boys for either the children with MEE or the controls. Of the 58 parents of the study group who completed the questionnaires 17 (29.3%) noted that their children had balance disturbances, such as frequent falling, clumsiness or unsteadiness. Of the 40 parents of the controls who completed the questionnaire only two (5%) reported that their child had some balance impairment. Comparing the answers obtained from the questionnaires with the results of the Bruininks-Oseretsky tests, we found a clear-cut correlation between the low scores and the clinical balance disturbances reported by the parents. Of the 17 study group parents who noticed some disturbances in balance and equilibrium, 12 (70.6%) performed significantly below the expected scores on the Bruininks-Oseretsky tests. VT placement was carried out in 55 children. All of the 48 (87.3%) who were re-evaluated had bilateral dry functional tubes and had hearing that returned to normal. With the Bruininks-Oseretsky tests two children (4.2%) still performed below the expected scores for their ages. A statistically significant difference was found between the results obtained before surgery and after VT insertion in the Bruininks-Oseretsky tests (PB 0.001). Following VT placement there was no significant difference in the Bruininks-Os-
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
25
eretsky tests scores between the children with MEE and the controls. Just before their children were re-evaluated 15 parents who preoperatively noticed some balance disturbances in their children completed another questionnaire . They reported that their children became and remained symptom-free following surgery.
4. Discussion Although MEE has been considered the most common cause of vestibular disturbances in children [1,8], this association has not been quantified until recently. In the last 15 years several authors, by the use of different methods for the evaluation of the vestibular system in children, have demonstrated that the anecdotal evidence that children with OM or MEE are more clumsy, stumble more and tend to fall frequently, is supported by distinct clinical findings [9– 12,19 – 21,24]. In our study we used a method for evaluating balance disturbances in children with chronic MEE, that was different from the methods used by the other authors, but our results confirm those of the previously published studies. Balance was significantly worse in children with persistent MEE as compared to healthy children. We found the Bruininks-Oseretsky test for Motor Proficiency useful in the evaluation of dysequilibrium and balance disturbances in young children. It is reliable, can be performed by anyone with minimal training, is inexpensive (in terms of equipment used and time consumption) and is simple and friendly to the child. Thus it can be used routinely for the evaluation of children with chronic persistent MEE. Symptoms of dysequlibrium and imbalance are rarely, if ever, volunteered spontaneously by parents of children with MEE. In this study we have found a clear-cut correlation between the low scores in the Bruininks-Oseretsky tests and the clinical balance disturbances reported by the parents in the questionnaires. Therefore it is important that parents of children with chronic MEE should be asked specifically about balance disturbances occurring in their children. We also demonstrated that insertion of VT is associated with a complete resolution of the imbalance symptoms and the low scores on the Bruininks-Oseretsky tests. These results are similar to those of other authors [3,7,8,10,16,18,19,21] and agree with what a parent will usually report following VT insertion, that the child’s balance, as well as his hearing, have improved immediately following surgery. For many years OM research has focused on auditory sequelae such as hearing loss, language delay and learning difficulties, without considering the role vestibular dysfunction may play in learning disabilities and in a child’s development. Our findings and previous studies suggest that the adverse effects of OM on a child’s development are also attributed to the effect of the effusion on vestibular function.
26
A. Golz et al. / Int. J. Pediatr. Otorhinolaryngol. 43 (1998) 21–26
References [1] T.J. Balkany, R.S. Finkel, The dizzy child, Ear Hear. 7 (1986) 138 – 142. [2] J. Ben David, L. Podoshin, M. Fradis, D. Faraggi, Is the vestibular system affected by middle ear effusion?, Otolaryngol. Head Neck Surg. 109 (1993) 421 – 426. [3] A.W. Blayney, B.H. Colman, Dizziness in childhood, Clin. Otolaryngol. 9 (1984) 77 – 85. [4] C.D. Blustone, S. Stool (Eds.), Pediatric Otolaryngology, 1st edn., W.B. Saunders, Philadelphia, 1983, pp. 261–270. [5] C.M. Bower, R.T. Cotton, The spectrum of vertigo in children, Arch. Otolaryngol. Head Neck Surg. 121 (1995) 911–915. [6] R.H. Bruininks, Bruininks-Oseretsky test of Motor Proficiency, Examiners manual, American Guidance Service, Minnesota, 1978. [7] S.N. Busis, Vertigo in children, Ear Nose Throat J. 57 (1) (1978) 95 – 100. [8] S.N. Busis, Dizziness in children, Pediat. Ann. 17 (1988) 648 – 655. [9] M.L. Casselbrant, F.O. Black, L. Nashner, R. Panion, Vestibular function assessment in children with otitis media with effusion, Ann. Otol. Rhinol. Laryngol. 92 (1983) 46 – 47. [10] M.L. Casselbrant, J.M. Furman, E. Rubinstein, E.M. Mandel, Effects of otitis media on the vestibular system in children, Ann. Otol. Rhinol. Laryngol. 104 (1995) 620 – 624. [11] D.G. Cyr, P.E. Brookhouser, M. Valente, A. Grossman, Vestibular evaluation of infants and pre-school children, Otolaryngol. Head Neck Surg. 93 (1985) 463 – 468. [12] J. Denning, W. Mayberry, Vestibular dysfunction in pre-school children with a history of otitis media, Occup. Therap. J. Res. 7 (1987) 335 – 348. [13] L. Eviatar, A. Eviatar, Vertigo in children: differential diagnosis and treatment, Pediatrics 59 (1977) 833–838. [14] L. Eviatar, Dizziness in children, Otolaryngol. Clin. North Am. 27 (1994) 557 – 571. [15] K. Flisberg, The effects of vacuum on the tympanic cavity, Otolaryngol. Clin. North Am. 3 (1970) 3–13. [16] M.P. Fried, The evaluation of dizziness in children, Laryngoscope 9 (1980) 1548 – 1560. [17] E.M. Friedman, D.C. Lai, N.O. Duncan, M. Pellicer, Balance in otitis media with effusion: A prospective study, Otolaryngol. Head Neck Surg. 113 (1995) 104. [18] G.A. Gates, Vertigo in children, Ear Nose and Throat J. 59 (1980) 358 – 365. [19] A. Golz, S.T. Westerman, L.M. Gilbert, H.Z. Joachims, A. Netzer, Effects of middle ear effusion on the vesibular labyrinth, J. Laryngol. Otol. 105 (1991) 987 – 989. [20] A.R.H. Grace, A.G. Pfleidere, Dysequilibrium and otitis media with effusion: what is the association, J. Laryngol. Otol. 104 (1990) 682 – 684. [21] N.S. Jones, P. Radomski, A.J.N. Prichard, S.E. Snashall, Imbalance and chronic secretory otitis media in children: effect of myringotomy and insertion of ventilation tubes on body sway, Ann. Otol. Rhinol. Laryngol. 99 (1990) 477 – 481. [22] F.W. Merica, Vertigo due to obstruction of the eustachian tubes, J. Am. Med. Assoc. 118 (1942) 1282–1284. [23] M. Polak, J. Graboowska, A. Piziewicz, J. Mierzwinski, Evaluation of vestibular function in children with secretory otitis media. 3rd International Conference on Pediatric Otorhinolaryngology. Jerusalem, Israel, 1993. [24] R.C. Schaaf, The frequency of vestibular disorders in developmentally delayed pre-schoolers with otitis media, Am. J. Occup. Therap. 39 (1985) 247 – 252. [25] S. Snashall, Vestibular disorders, in: A.G. Kerr, J. Groves (Eds.), Scott-Brrown’s Otolaryngology, 5th edn., Butterworths, London, 1987, pp. 194 – 217.
.