Spontaneous improvement in ears with middle ear disease

International Journal of Pediatric Otorhinolatyngology, Elsevier Biomedical Press

245

4 ( 1982) 245-250

Spontaneous improvement in ears with middle ear disease Ulf Renvall *, Gunnar ENT-department,

&tra Sjukhuwt,

Aniansson

and Gunnar

Lid&n

416 85 Gijteborg and Audiological department, Sahlgren’s Hospital, 413 45 GBteborg (Sweden) (Received (Accepted

December 4th, 1981) February 22nd, 1982)

Summary The ‘healthy-baby-clinics’ in Goteborg, as in all Sweden, test all 4-year-olds with pure tone screening (failure criterion > 20 dB). Those who fail are referred to an oto-audiological health center. In an effort to prevent over-referrals of false positives as well as under-referrals of false negatives all referred children in this study have been tested with pure tone audiometry supplemented by tympanometry. At the oto-audiological health center a test program including 3 tests with intervals of 6 weeks was initiated. Failure criteria were middle ear pressure -C - 150 mm H,O and hearing loss (HL) in the frequency range 0.125-8 kHz > 20 dB. In Goteborg (430,000 inhabitants) 5928 4-year-olds were tested at the ‘healthybaby-clinics’ during 1980. Of these 498 (8.4%) failed in pure tone screening, 248 of which are included in the present study. At the first check in our test program, which was performed 3-8 weeks after referral, only 45% of the children were abnormal. Of these 60% normalized during the test program. Thus of the ears referred following the pure tone screening at the ‘healthy-baby-clinics’ only 18% remained after 15-20 weeks for referral to an ENT-doctor.

Introduction The most common cause of hearing loss in childhood is the sequel of acute otitis media or serous/mucoid otitis media without a preceding acute otitis media. High negative middle ear pressure and/or middle ear effusion are responsible for the hearing loss which can be of varying degrees. Identification of middle ear pathology

* To whom reprint

requests

0165-5876/82/000&0000/$02.75

should be addressed

0 1982 Elsevier Biomedical

Press

246

by otoscopy may be difficult and many cases may be overlooked especially in young children in which serous/mucoid otitis media is most common. The insidious nature of the disease is demonstrated by a study in which effusion was demonstrated in 4.5% of 1207 symptomless children [13]. This insidious nature of serous/mucoid otitis media, as well as the difficulty in diagnosing this disease by otoscopy, make it important to improve our diagnostic procedures. Previously, pure tone audiometry was the only test available to evaluate middle ear function. Since the introduction of impedance measurements as a screening tool in the late sixties [I] many clinicians have found that the impedance procedure is superior to the pure tone test in identification of middle ear pathology [3,4,6- 10,121. However, pure tone audiometry is still used in most places as the only referral criterion for 4-year-olds. In this study pure tone tests were supplemented by tympanometry in an effort to prevent over-referral as well as under-referral to an ENT-department.

Materials and Methods In Giiteborg 5928 cl-year-olds were tested at the ‘healthy-baby-clinics’ with pure tone screening during 1980. The ‘failure criterion’ was hearing loss (HL) > 20 dB. In this study those who failed were referred to two oto-audiological health centers and a new procedure was introduced within 3-8 weeks after the screening. All ears were investigated by otomicroscopy, tympanometry and pure tone audiometry. The frequency range of pure tone audiometry was 0.125-8.0 kHz. Middle ear air pressure was studied by tympanometric measurements with a probe frequency of 220 Hz. The impedance minimum was checked between -400 and +200 mm H,O. Ears with no demonstrable impedance minimum within this range were classified as ears with a flat tympanogram. Ears with middle ear pressures more positive than - 150 mm H,O, no tympanic membrane retraction and hearing d 20 dB HL were judged as normal and were removed from the study. Children who exhibited a unilateral hearing loss of 2 20 dB HL and/or a retraction pocket and/or middle ear pressure lower than - 150 mm H,O did not get any treatment before approximately 4 months following the first comprehensive test. During this period two repeat audiologic evaluations were performed (see Table I). In some cases with significant bilateral hearing loss treatment was immediately initiated. TABLE TESTING

I SCHEDULE

IN THE PRESENT

STUDY

Test 2

Test 1 (3-6 weeks later)

lest at childrens center

1.1)

-

Screening audiometry 2OdB

(6 weeks after

Otomicroscopy Tympanogrom Pure tone audio metry

Test 3 (12 weeks after

t.1)

Tympanogram Pure tone audiometry

Otomicroscopy 1 ympanogram Pure tone audio metry

241

165 ears (33.3%)

Ei

-150 to 400

n

<-LOO mm Hz0

mm HZ0

Fig. 1, 496 ears referred from ‘healthy-baby-clinics’. Failure 0.125-S kHz. Present study performed 3-8 weeks later.

criterion

120

dB HL in the frequency

range

Results At the tone screening tests performed at the ‘healthy-baby-clinics’ 498 (8.4%) out of 5928 4-year-olds failed. Of these 498 children 248 (496 ears) are included in the present study. The first visit at the oto-audiological health center showed (Fig. 1) that 55% of the ears had a middle ear pressure more positive than - 150 mm H,O. These ears also demonstrated otomicroscopically normal tympanic membranes and normal pure tone audiometry. These 55% (273) ears passed our screening procedure and were followed no further. Middle ear pressure in the range of - 150 to - 400 mm H,O was found in 165 (33.3%) of the ears. Flat tympanograms were observed in 58 ears (11.7%). Fig. 2 shows that by Test 2 25% of the 40 ears with flat tympanograms at Test 1 had normal middle ear pressures and 42.5% demonstrated improvement. Fig. 2 also shows that 31% of the ears with flat tympanograms at Test 2 had normal or improved middle ear pressures by Test 3. Fig. 3 shows that out of 104 ears with middle ear pressures between -150 and -400 mm H,O at Test 1 44.2% were

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Fig. 2. Follow-up

of ears with middle ear pressure

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during

12 weeks.

248

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Test 3 [after 12 weeks)

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101ears 161ears been excluded because they didn’t come or were treated) Fig. 3. Twelve weeks follow-up H,O.

of ears with middle ear pressure

between

- 150 mm H,O

and -400

mm

normal, 8.7% were improved, 36.5% were unchanged and 10.6% demonstrated flat tympanograms at Test 2. Fig. 3 also shows that between Tests 2 and 3 an additional 24 ears improved to normal (5 from the Test 2 ‘improved’ group, 14 from the Test 2 ‘unchanged’ group and 5 from the ‘flat tympanogram’ group). Thus a total of 70 ears (67.3%) of ears with middle ear pressures from - 150 to -400 mm H,O had improved to normal pressures during this 1Zweek period. From the group with flat tympanograms at Test 1 16 ears (40%) were normalized during the same period.

Discussion From previous tympanometric studies [2] it is known that middle ear pressure in fluctuates significantly during long observation periods. Brooks demonstrated non-selected material that 50% of the observed ears had normal middle ear pressures during a 2-year period. In 30% of the ears a single episode of reduced middle ear pressure was found and in 20% the middle ear pressure was constantly reduced. However, a follow-up of the latter group showed that only 5% remained abnormal and required treatment. Thus the tendency for spontaneous improvement in ears with reduced middle ear pressure is clear from Brooks’ study. In order to elucidate the degree of spontanous improvement and also to improve the screening procedure in ears with suspected serous/mucoid otitis media the present study was performed. Our results firstly demonstrated that 55% of the ears that failed at pure tone audiometric screening were tympanometrically normal after 3-8 weeks at the first test at an oto-audiological health center. Otoscopy, tympanometry and pure tone

249

TABLE

II

PATHOLOGIC OR NORMAL ING TO OUR CRITERIA Test

Test 1 Pathologic Normal

ears

ILL--

EARS ACCORD-

Test

2

86(61%)

9 58t66”I.I 30(3L%)

56 (39%)

ears

3

screening were all considered normal and thus there had been a 55% over-referral. A simple procedure of pure tone retesting supplemented with tympanometry 4-6 weeks after the screening test would have reduced referrals by 50%. The data suggest that with repeat screening referrals would be further reduced. Ears failing the first oto-audiological test in the present study were retested approximately 6 weeks later. At this point of the study 39% were considered normal according to our criteria (see Table II). At Test 3 in this study a further 34% were found normal. Thus we observed that if screening procedure at the ‘healthy-baby-clinics’ is used 55% of the ears are considered normal within 3-8 weeks at Test 1 (see Fig. 1). Of 144 ears failing at Test 1, 86 ears (60%) became normal during the test period of 12 weeks (see Table III). Of the initially referred ears from the ‘healthy-baby-clinics’ 45% (223 ears) were considered pathologic at Test 1. Of these 223 ears 79 have been excluded because they did not appear or they were treated (see Figs. 2 and 3) and thus 144 ears remained. Of these 144 ears we found that after 12 weeks 86 ears had become normal and 58 were still abnormal. Since 40% of the abnormal 144 ears (see Table III) were still abnormal 12 weeks later it can be expected that 40% (32 ears) of the 79 ears excluded should also have been abnormal after 12 weeks. Thus from the initially referred 496 ears only 18% (58 + 32 ears) remain for referral to the ENT-department. The high degree of spontanous normalization of ears with reduced middle ear pressures or flat tympanograms in this study may also indicate the need for a more conservative treatment philosophy in ears with serous/mucoid otitis media. Forty ears exhibited flat tympanograms (Fig. 2). Without treatment 70% of them improved or normalized. This result is in agreement with findings of Tos et al. [l l] who demonstrated improvement in 53% of ears in 2-year-olds with flat tympanograms

TABLE

III

FOLLOW-UP OF 144 EARS FAILING AT TEST The high degree of normalization is demonstrated. Test Pathologic

1

Test 3 ears

ILL

+

58(40%)

ears

86(60%)

12 weeks Normal

1

250

during a 3-month study. Fiellau-Nikolajsen [5] demonstrated improvement in 65% during a 6-month follow-up of ears with reduced middle ear pressure in 3-year-olds.

Conclusions

(1) The referral rate will diminish by approximately 80% if pure tone screening is supplemented with tympanometry and repeat tests are performed before referral to an ENT-department. (2) The demonstrated high degree of spontanous recovery in ears with suspected serous/mucoid otitis media justifies a period of conservative observation before initiating treatment with for example ventilating tube. It is clear, however, that not all ears improve, and indeed some deteriorate. Follow-up is of critical importance. Hopefully with continued basic and clinical work in this field we will develop appropriate tests and criteria for identifying this group, so that appropriate therapy can be selectively initiated immediately.

References 1 Brooks, D., An objective method of detecting fluid in the middle ear, Int. Audiol., 7 (1968) 563-569. 2 Brooks, D., School screening for middle ear effusions, Ann. Otol., Suppl. 25, 85 (1976) 223-228. 3 Djupesland, G., Use of impedance indicator in diagnosis of middle ear pathology, Int. Audiol., 8 (1969) 570-577. 4 Ferrer, H., Use of impedance audiometry in school screening, Publ. Health, 88 (1974) 153- 163. 5 Fiellau-Nikolajsen, M., Tympanometry in three-year-old children, Ann. Otol., Suppl 68, 89 (1980) 223-227. 6 Harford, E., Fox, J. and Clemis, J., Impedance audiometry for identification of conductive component in school children. In: Impedance Screening for Middle Ear Disease in Children, Grune and Stratton, New York, 1977, pp. 207-217. 7 Harker, L.A. and Van Wagoner, R., Application of impedance audiometry as a screening instrument, Acta Otolaryng., Suppl. 77 (1974) 198-201. 8 Northern, J., Impedance screening and integral part of hearing screening, Ann. Otol., Suppl. 68, 89 (1980) 233-235. 9 Renvall, U., Lid&n, G., Jungert, S. et al., Impedance audiometry as screening method in school children, Stand. Audio]., 2 (1973) 133-137. 10 Renvall, U. and Liden, G., Screening procedure for detection of middle ear and cochlear disease, Ann. Otol., Suppl. 68, 89 (1980) 214-216. 11 Tos, M., Poulsen, G. and Borch, J., Tympanometry in two-year-old children, ORL 40 (1978) 206-215. 12 Urban, B. Impedance in a school screening program. In Grime and Stratton (Eds.). Impedance Screening for Middle Ear Disease in Children, 1977, pp. 18 I- 187. 13 Viroleinen, E., Puhakka, H., Aantaa, E. et al., Prevalence of secretory otitis media in seven to eight year old schoolchildren, Ann. Otol., Suppl 68, 89 (1980) 7- 10.