RAPA Abstracts
27 May 2009
Abstracts from Recent advances in paediatric audiology (RAPA)
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The global impact of auditory problems in children
Adrian Davis
MRC Hearing and Communication Group, University of Manchester
Katrina Davis, Institute of Psychiatry, Denmark Hill, London
Audiological problems probably affect one in three adults (in terms of hearing, tinnitus and balance) and probably account for over 5% of the burden of disease. An estimate is that the real financial cost of these problems is close to 2% of GDP.
We do not know equivalent data for children! In the UK we know that there are substantial problems with hearing and deafness from birth in about 1 per 1000 children but that the impact of hearing problems is much wider than that figure would suggest. There are another 1 per 1000 who may have unilateral deafness and others who have more mild problems but which are nevertheless a compromise to health development. It is suggested that another 1 per 1000 may acquire deafness in childhood but there are no really definitive data that indicate that the bulk of these problems were not congenital in nature. However recent suggestions are that these conditions could be related to CMV or to mitochondrial genetic induced defects.
We present data that show considerable variation in prevalence of deafness in children world-wide and some of the developmental issues that may underlie these variations. We suggest that a better understanding of the risk factors underlying these problems is needed so we can address prevention and identification more systematically. We will also address the role of screening as a means of access to good quality data and to services that deliver improved outcomes for children with audiological problems. Properly constructed screening services can work to reduce inequalities in access to services as well as improve outcomes for deaf children. However, we now need a clear research infrastructure and network to address the issues of inequality of opportunity for these children and their families and this ought to be done on a national and global basis to make the quickest and most robust progress.
Evidence of improved outcomes with children detected very early
Christine Yoshinaga-Itano
Department of Speech, Language and Hearing Sciences, University of Colorado
A summary of the outcomes from the work of Rosalinda Baca’s dissertation on the longitudinal outcomes of Colorado children with hearing loss in a series of 3 studies will be presented. The work used hierarchical linear modeling to investigate the slope (rate of language growth) and intercept (language development at 36 months and at 84 months of age. The language development of 213 infants and toddlers was measured on the Minnesota Child Development Inventory between birth and 48 months of age. Vocabulary development of the longitudinal development of 135 children between the ages of 48 and 87 months of age was measured by the Expressive One Word Vocabulary Test from 48 to 84 months of age. Understanding of English syntax and grammar was measured by the Test of Auditory Comprehension of Language.
New thinking about appropriately graded clinical response to otitis media
Mark Haggard
MRC Multi-centre Otitis Media Study Group, Cambridge
The growth in the 1970s of interest in and expenditure on the two main forms of child middle ear disease (Recurrent acute otitis media, RAOM, and otitis media with effusion, OME) has left an unimpressive legacy of confusion, ineffectively targeted healthcare expenditure, and bacterial resistance to antibiotics. The public health stance, that otitis media is a non-problem and that treatments are ineffective, is equally sterile. Two main reasons for this systemic failure have been ignoring known adequate evidence about the nature of these conditions, and the delusion of adequacy of a mere diagnosis. Within the most important clinical feature, the total history, these diagnoses overlap, for which biofilms offer a pathogenetic explanation. The important clinical distinction is between children all of whom justify the diagnoses, e.g. between the severe and persistent/recurrent forms that do require intervention, nevertheless quite common, and the very common milder forms that do. Medical thinking has never been good at handling such distributions; where the tail of a distribution is involved, differences for large number of patients are implied by the exact location of boundaries for referral or intervention. This implies large differences in the aggregate balance of benefit to cost and to risk, so new thinking is required. Effort refining diagnostic criteria or improving diagnostic practice is harmless, but not a priority, as the accumulated detailed information that is discarded in a categorical diagnosis decision which needs to accompany a child down the clinical pathway; this aggregate is what determines the ability to benefit from treatment. New biological findings inform a better understanding of OME, but do not have short- even medium-term clinical implications. Evidence supports 4 distinct needs: (1) introduction of a preventive approach to the two main pathogens giving paediatricians and GPs more confidence to reduce antibiotic prescriptions in OM; (2) introduction of better clinical record linkage and a scoring system for length and severity of history; (3) as a safety back up, clinical criteria for the very rare deteriorating cases of AOM which will justify administration of second-line antibiotics and paracentesis to determine exact organism; (4) a more explicit multi-part clinical algorithm for allocating ventilation tubes (aka “grommets”) for OME and super-added RAOM. Current emphases on parent choice, provider competition and speed of access are a distraction from these priorities for optimally converting healthcare resources into population health gain.
Evidence to better define children needing detailed assessment and treatment
Maroeska M. Rovers
University Medical Center, Utrecht
Randomized controlled trials into either 1) the effectiveness of antibiotics in children with acute otitis media or 2) tympanostomy tubes in children with otitis media with effusion showed that the effects of both interventions are limited. Otolaryngologists and general practitioners, however, believe that subgroups of patients might benefit from these interventions. For a long time it was not possible to identify those children that benefit more or less from either intervention. Consequently, over- and under treatment were quite common.
We performed two different Individual Patient Data (IPD) meta-analyses with the raw data of most randomised trials since this method offers the unique opportunity to identify subgroups of children that benefit more or less from an intervention.
The results showed that antibiotics seem to be most beneficial in children younger than 2 years of age with bilateral acute otitis media, and in children with both acute otitis media and otorrhoea. For most other children with mild disease an observational policy seems justified. The effects of conventional ventilation tubes in children with OME were small and limited in duration. Observation (watchful waiting) therefore seems to be an adequate management strategy for most children with OME. Ventilation tubes might, however, 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.
In conclusion, we have shown that IPD meta-analysis indeed offer a unique opportunity to study subgroups based on individual patient and disease characteristics and therefore provide more relevant clinical information than single randomized controlled trials and meta-analysis on published data.
Tinnitus in Children: Diagnosis and Treatment
Richard S. Tyler
Dept of Otolaryngology-Head and Neck Surgery and Speech Pathology and Audiology, University of Iowa
Children have tinnitus, and there are remarkable similarities as well as critical differences between children and adults with tinnitus. First, studies reporting tinnitus in children will be reviewed. Prevalence ratings are about 25% in hearing impaired children, but are heavily influenced by the question. Interestingly, children with congenital tinnitus do not appreciate its abnormality until later in life.
Second, the causes of tinnitus in children are discussed. As in adults, the likely most common cause is noise. Third, the evaluation, treatment and prevention of tinnitus are reviewed. The diagnosis can include input from the parents. In many situations, no treatment is warranted, but otherwise we recommend Tinnitus Narrative Therapy (Kentish and Crocker, 2006) for young children and Tinnitus Activities Therapy (Tyler et al., 2004) for older children.
The “Dizzy” Child
Linda M Luxon
UCL Ear Institute and Great Ormond Street Hospital for Children
Balance presentations are more common in children than previously suspected. Nonetheless, imbalance is relatively rare in children compared with adults and symptoms are frequently dismissed for a number of reasons. Children cannot express their complaints easily, they are often disbelieved, there are other more important symptoms, such as hearing and communication disorders, tests are frequently not available to investigate the disequilibrium and often the complaint is dismissed as trivial. Notwithstanding this, there is clear evidence that otitis media, trauma, migraine and epilepsy are all associated with dizziness/imbalance in childhood, quite apart from vestibular dysfunction in association with congenital inner ear pathologies and rare systemic and otological pathologies.
