key: cord-298807-67psjrt3
authors: Morris, Peter S.; Leach, Amanda J.
title: Acute and Chronic Otitis Media
date: 2009-12-31
journal: Pediatric Clinics of North America
DOI: 10.1016/j.pcl.2009.09.007
sha: 
doc_id: 298807
cord_uid: 67psjrt3

Otitis media (OM) is a common illness in young children. OM has historically been associated with frequent and severe complications. Nowadays it is usually a mild condition that often resolves without treatment. For most children, progression to tympanic membrane perforation and chronic suppurative OM is unusual (low-risk populations); this has led to reevaluation of many interventions that were used routinely in the past. Evidence from a large number of randomized controlled trials can help when discussing treatment options with families. Indigenous children in the United States, Canada, Northern Europe, Australia, and New Zealand experience more OM than other children. In some places, Indigenous children continue to suffer from the most severe forms of the disease. Communities with more than 4% of the children affected by chronic tympanic membrane perforation have a major public health problem (high-risk populations). Higher rates of invasive pneumococcal disease, pneumonia, and chronic suppurative lung disease (including bronchiectasis) are also seen. These children will often benefit from effective treatment of persistent (or recurrent) bacterial infection.

Peter S. Morris, MBBS, FRACP, PhD a,b,c, *, Amanda J. Leach, PhD a,b Upper respiratory tract infections (including otitis media) are the most common illnesses affecting children. 1 The term ''otitis media'' (OM) covers a wide spectrum of disease, and is used to describe illnesses with predominantly middle ear symptoms (including acute otitis media, otitis media with effusion, and chronic suppurative otitis media). Children can expect to experience around 6 to 8 upper respiratory infections (URTIs) each year. 2 Nearly all children will experience at least one episode of OM during childhood. On average, they experience around one episode of acute otitis media (AOM) per year in the first 3 years of life. 3 The initial cause of respiratory mucosal infections (including OM) is most commonly a viral infection but can be bacterial ( Table 1) . 4 Of importance is that many infections involve both viruses and bacteria. 5 Most commonly, an initial viral infection is complicated by a secondary bacterial infection. In developed countries, both viral and bacterial infections are likely to be self-limited. Persistent symptomatic disease is an indication that the child has an ongoing bacterial infection.

By understanding the evidence available from high quality studies, the clinician is in a position to advise the families on appropriate action. 6 Well designed randomized controlled trials (RCTs) provide the most reliable evidence of effect ( Table 2) . 7 The aim of this article is to support clinicians in answering the following questions:

(i) What happens to children with these conditions when no additional treatment is provided? (ii) Which interventions have been assessed in well-designed studies? (iii) Which interventions have been shown to improve outcomes? (iv) If an intervention is considered appropriate, how large is the overall benefit?

There is a long list of potential interventions for the different forms of OM. Many families have strong personal preferences about their treatment options. The challenge for the clinician is to make an accurate diagnosis and then to match the effective treatment options to the preferences of the family.

In this article, the authors have initially considered the effects of an intervention compared with no intervention. Their focus on trial evidence means that the authors may not review all the relevant information to an individual decision. The overall effects of an intervention may need to be adjusted with this in mind. It is hoped that clinicians using this article should be able to determine which interventions have been rigorously assessed and the overall findings of these assessments.

The GRADE Working Group has described the steps required to review evidence. [8] [9] [10] The GRADE Working Group proposes that a recommendation should indicate a decision that the majority of well-informed individuals would make. For self-limited conditions with low risk of complications, even well-informed individuals may reach different conclusions. Therefore, the authors have tried to provide an evidence summary that will assist discussions with families ( Table 3) . The authors' own approach (informed by the best available evidence) is described in Box 1.

The self-limiting nature of modern OM in developed countries is of the utmost importance in determining which treatments are indicated. In this article, groups of children with low rates of suppurative complications of OM are categorized as low-risk populations. Communities where more than 4% of children experience chronic tympanic membrane perforation secondary to suppurative infection are high-risk populations. 35 In low-risk populations, OM is generally a condition that resolves without treatment or complications. Unfortunately, tympanic membrane perforation remains a common occurrence for many Indigenous groups.

The outcomes considered important in this article are: (i) persistent disease (short term %14 days, medium term >2 weeks to 6 months, long term >6 months); (ii) time to cure; and (iii) complications arising from progressive disease. The authors considered interventions to have very large effects if they were associated with a relative reduction in the outcome of interest of more than 80%; large effects were associated with a reduction in outcome of at least 50%. 36 Reductions of between 20% and 50% were considered modest and reductions less than 20% were considered slight (or small). Because only a proportion of children with OM experience bad outcomes, even large relative effects may have modest absolute benefits.

The search targeted evidence-based guidelines, evidence-based summaries, systematic reviews, and RCTs of interventions for otitis media (see Box 2) . This simple strategy identified over 1600 hits using PubMed alone. To be included as an evidence-based guideline, summary, or systematic review, one needed to provide an explicit search strategy and criteria for study inclusion. To be included as a clinical trial, randomization needed to be used. Four primary sources to identify relevant information were used: Clinical Evidence (Issue 1 2009), 36 the Cochrane Library (Issue 2 2009), 37 Evidence-Based Otitis Media 27 and Medline (last accessed via PubMed on 26 June, 2009). The evidence-based summaries in Clinical Evidence have links to major guidelines and use the GRADE Working Group approach to assess quality of evidence and strength of recommendations. 36 PubMed was also searched to identify publications specifically addressing OM in Indigenous populations.

The search identified over 50 evidence-based guidelines, evidence summaries, and systematic reviews (and many more additional RCTs) published since 2000. In this the impact of the conjugate pneumococcal vaccine on OM in Navajo and Apache children. 43 Although they were not identified by a search strategy, the authors were also aware of an additional systematic review and evidence-based clinical guidelines developed specifically to assist in the care of Australian Aboriginal children with OM. 44, 45 

Otitis media (OM) is an acute upper respiratory tract infection that affects the respiratory mucosa of the middle ear cleft. OM is a common illness in young children (and occurs much less frequently in children >6 years). 24, 46 In developed countries, OM is the commonest indication for antibiotic prescribing and surgery in young children.

In the United States, annual costs were estimated to be $3 to $5 billion in the 1990s. 46 The costs per capita are likely to be considerably greater in high-risk populations.

Otitis media is best regarded as a spectrum of disease. The most important conditions are OME, acute otitis media without perforation (AOMwoP), acute otitis media with perforation (AOMwiP), and CSOM. OME is usually the mildest form of the disease and CSOM the most severe. Children who end up with CSOM usually progress through the stages of OME, AOM without perforation, AOM with perforation, and finally to CSOM. Unfortunately, there is currently a lack of consistency in definitions of different forms of OM (especially AOM). 47 This can lead to confusion when you need to describe the progress of a child over time. OME is usually defined as the presence of a middle ear effusion without symptoms or signs of an acute infection. OME is by far the most common form of OM in all populations. Brief periods of OME (often in association with upper respiratory tract infections) should be regarded as a normal phenomenon in early childhood.

AOM is usually defined as the presence of a middle ear effusion plus the presence of the symptoms (especially pain) or signs (especially bulging of the tympanic membrane or fresh discharge). The diagnostic criteria used in studies of AOM vary. Some use symptomatic criteria, some use otoscopic criteria, and some require both symptomatic and otoscopic criteria to be met.

CSOM is usually defined as discharge through a perforated tympanic membrane for greater than 2 to 6 weeks. If the duration of the discharge is uncertain, perforations Box 2 A simple PubMed search strategy to identify evidence-based guidelines, evidence-based summaries, systematic reviews, and RCTs on otitis media and additional studies involving Indigenous children that are easily visible (covering >2% of the tympanic membrane) are more likely to be associated with CSOM. Children with immunodeficiency or craniofacial abnormalities (cleft palate, Down syndrome, and so forth) are at increased risk of OM. Other risk factors that have been identified in epidemiologic studies include recent respiratory infection, family history, siblings, child care attendance, lack of breast feeding, passive smoke exposure, and use of a pacifier. 48 

High rates of severe otitis media have been described in Indigenous children for over 40 years. The first publication identified by the authors' search was published in 1960, 49 and publications have appeared regularly from 1965 on. 50 In the recent past, Indigenous children from the United States, Canada, Northern Europe, Australia, and New Zealand have all been affected. [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] The rates of tympanic membrane perforation in these populations remain among the highest ever described in the medical literature. 61 Many investigators have puzzled over the high rates of severe disease and wondered whether ear discharge was a new illness that occurred during the transition from a nomadic lifestyle typical of many of these Indigenous groups. The search reported here did not identify any studies that were able to answer this question.

The rates of tympanic membrane perforation vary enormously, even with Indigenous groups within the same region. Furthermore, discharging ears as described in Indigenous children (''the running ear are the heritage of the poor'') 62 were common in disadvantaged children living in developed countries in the pre-antibiotic era. 63 For these reasons, the authors believe the most important underlying causes of severe ear infections are likely to be environmental. Indigenous populations at high risk of severe OM also have high rates of rhinosinusitis, bronchitis, pneumonia, invasive pneumococcal disease, and chronic suppurative lung disease (including bronchiectasis). [64] [65] [66] [67] [68] [69] [70] [71] It is likely that the same risk factors contribute to the excessive frequency of all of these conditions. Early exposure to otitis media pathogens has been demonstrated in Australian Aboriginal infants, and this is the most important determinant of subsequent OM (Fig. 1) . [72] [73] [74] Of importance is that in this high-risk population, children usually have multiple pathogens (and often multiple types of each pathogen) and their total bacterial load is high. International comparisons show that a similar early onset of carriage of the pneumococcus is seen in other populations with high rates of invasive pneumococcal disease (Fig. 2) . 75 Although genetic factors are known to contribute to the risk of OM, their importance in high-risk populations has not been determined. Some investigators have proposed that genetic susceptibility is linked to poor Eustachian tube function. 52 However, this does not explain the associated high rates of other bacterial respiratory infection.

Children with OM will usually present with features related to either: (i) pain and fever (AOM); (ii) hearing loss (OME); or (iii) ear discharge (AOM with perforation or CSOM). In some children, OM will be detected as part of a routine examination. Making an accurate diagnosis is not easy. In general it requires a good view of the whole tympanic membrane, and the use of either pneumatic otoscopy or tympanometry (to confirm the presence of a middle ear effusion). 47, 76 Studies of diagnostic accuracy in AOM have found ear pain to be the most useful symptom (but not very reliable on it is own). Presence of bulging, opacity, and immobility of the tympanic membrane are all highly predictive of AOM. Normal (pearly gray) color of the tympanic membrane makes AOM unlikely. 77 

The commonest form of OM is OME. The point prevalence in screening studies is around 20% in young children. 46 OME can occur spontaneously, as part of rhinosinusitis, or following an episode of AOM. The same respiratory bacterial pathogens associated with AOM have been implicated in the pathogenesis. Most children with OME will improve spontaneously within 3 months, and complications from this illness are uncommon. 46 The average hearing loss associated with OME is around 25 dB. 46 Despite large numbers of studies, a causal relationship between OME and speech and language delay has not been proven. 27, 78 

Most children will experience at least one episode of AOM. 46 The peak incidence of infection occurs between 6 and 12 months. Although the pathogenesis of AOM is multifactorial, both viruses and bacteria are implicated. 46 Bacterial infection with the common respiratory pathogens (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) is often preceded by a viral infection. Viruses (especially respiratory syncytial virus and influenza) can cause AOM without coinfection with bacteria. 46 The pain associated with AOM resolves within 24 hours in around 60% and within 3 days in around 80%. 24 Young children with AOM (<2 years) are less likely to experience spontaneous resolution. 22 Complications of AOM include CSOM, mastoiditis, labyrinthitis, facial palsy, meningitis, intracranial abscess, and lateral sinus thrombosis. 27 Mastoiditis was the most common life-threatening complication in the pre-antibiotic era. Mastoiditis occurred in 18% of children admitted to hospital with AOM in one study. 23 Mastoiditis (and all other complications) is now rare in developed countries.

CSOM is the most severe form of OM. 79 Although there is a lack of well-designed longitudinal studies, CSOM is the type of OM most likely to persist without treatment.

In developing countries, CSOM occurs as a complication of AOM with perforation and can be a major health issue. The range of bacterial pathogens associated with CSOM is considerably broader than those seen in AOM. Pseudomonas, Staphylococcus, Proteus, and Klebsiella species are most commonly isolated, and mixed infections are common. 79 Multidrug antibiotic resistance is often seen in Pseudomonas infections. The associated hearing loss is usually more than that seen in OME (and CSOM represents the most important cause of moderate conductive hearing loss [>40dB] in many developing countries). 31 In developed countries, CSOM is now very uncommon. A recent risk factor study in the Netherlands found that most cases of CSOM are now occurring as a complication of tympanostomy tubes insertion. 80 Children with immunodeficiency and some Indigenous populations are also at greatly increased risk. In rural and remote communities in northern Australia, more than 20% of young children are affected. 71 

OME affects all children but is usually asymptomatic. 46 A small proportion of children have persistent OME with associated hearing loss. There is evidence on the effects of screening to identify young children with OME (or hearing loss associated with OME), and this is not effective in developed countries. 81 There is also evidence on treatment effects of antibiotics, insertion of tympanostomy tubes, autoinflation devices, antihistamines and decongestants, and antibiotics plus steroids (see Table 3 ). [14] [15] [16] [17] [18] [19] [20] 22, 23, 82 Of these interventions, early insertion of tympanostomy tubes (compared with watchful waiting and option of insertion later) is proven to improve hearing at 6 and 12 months, but the beneficial effect is modest. [14] [15] [16] This improvement in hearing has not been associated with improvement in language development or cognitive assessment scores. 16 Tympanostomy tubes usually last 6 to 12 months, and there is no evidence that there is any ongoing benefit after they have been extruded. Antibiotics have also been shown to be an effective treatment, but the beneficial effects are slight and do not seem to persist over the long term. 14, 15, 27 There seem to be additional shortterm benefits when antibiotics are combined with steroids, but again the beneficial effect is modest. 14, 20 There is some evidence that autoinflation devices are effective. 14, 19 The benefits are modest and have only been documented to be short term. Antihistamines and decongestants provide no benefit (see Table 3 ). 14, 15, 18 Given the available evidence from RCTs on OME, most well-informed individuals in low-risk populations would choose a course of watchful waiting initially. For those children with persistent OME in both ears associated with hearing loss despite watching and waiting for 6 to 12 months, a trial of antibiotics is reasonable. Insertion of tympanostomy tubes is most appropriate in children for whom the primary concern is the conductive hearing loss and communication difficulties. Children with the most severe conductive hearing loss are most likely to benefit. Families should be informed that a small proportion of children will suffer recurrent persistent OME when the tympanostomy tubes are extruded, and may need a second operation. In these children, tympanostomy tubes plus adenoidectomy is a reasonable option. 14, 82 Children who experience frequent suppurative infections (including those with immunodeficiency or persistent bacterial rhinosinusitis) are at greatest risk of developing CSOM as a complication of tympanostomy tubes. Indigenous children in high-risk populations would fall into this group.

None of the RCTs assessing interventions for OME were conducted with Indigenous children. However, one RCT of prophylactic antibiotics in Australian Aboriginal children enrolled only infants with OME. None of the children in the placebo group had resolution of their OME within 6 months. Around 10% of children in the antibiotic group had resolution of their OME. 40 This result suggests that OME is a persistent condition that does not respond well to established treatment options. Although no reliable evidence from RCTs was found, strategies that aim to improve hearing and communication in those with moderate hearing loss might provide most benefit in high-risk populations.

Although not a primary outcome measure, pneumococcal conjugate vaccine reduced the number of children who received tympanostomy tube insertion by around 20%. It is possible that some of this effect was mediated through a reduction in chronic bilateral OME with hearing loss. Consistent with this, substantial declines in this procedure have been described in the United States in recent years, but not amongst Alaskan Native children. 83 

Most children with AOM will improve spontaneously within 14 days, and complications from this illness are uncommon. When considering the onset of the illness, there is evidence on the preventive effects of pneumococcal conjugate vaccine and influenza vaccine (see Table 3 ). [11] [12] [13] 24 Both of these vaccines have been shown to be effective, but the beneficial effects in terms of overall rates of infection are slight. The beneficial effects of the pneumococcal conjugate vaccine are modest in terms of reductions in the insertion of tympanostomy tubes. 84 Most children in low-risk populations will not meet the criteria for tympanostomy tube insertion. There is also evidence on the treatment effects of antihistamines and decongestants, antibiotics, myringotomy, and analgesics (see Table 3 ). 21, [23] [24] [25] 27 Regular analgesics (paracetamol or ibuprofen) provide a benefit (assessment on day 2), and the beneficial effects were large. 24 Antibiotics are also proven to be effective. 22, 23 The short-term beneficial effects are slight in most children. The beneficial effects are modest in children younger than 2 years with bilateral AOM, and large in those with AOM with perforation. Studies of initial treatment with antibiotics have not documented a long-term effect. If antibiotics are to be used, there is evidence that a longer course of treatment (R7 days) is more effective but the beneficial effects are modest (persistent AOM reduced from 22% to 15%). 85 There is no evidence to support the belief that any one of the commonly used antibiotics is more effective than the others. The use of antihistamines and decongestants has not been shown to be beneficial, and myringotomy seems to be harmful compared with no treatment or antibiotics (see Table 3 ). 21, 24, 27 Given the available evidence from RCTs on AOM, most well-informed individuals in low-risk populations would choose symptomatic relief with analgesics and either watchful waiting or antibiotics. Antibiotics would be most appropriate in children younger than 2 years with bilateral AOM, those with AOM with perforation, children with high risk of complications, and those who have already had 48 hours of watchful waiting.

If the child is not in a high-risk group but the family prefers antibiotic treatment, the clinician should discuss ''wait and see prescribing.'' Provision of a script for antibiotic along with advice only to use it if the pain persists 48 hours will reduce antibiotic use by two-thirds (with no negative impact on family satisfaction). [86] [87] [88] A small proportion of children with AOM will experience recurrent AOM (3 episodes in 6 months or 4 episodes within 12 months). 46 There is evidence on the treatment effects of prophylactic antibiotics, adenoidectomy, and tympanostomy tube insertion. 24, [26] [27] [28] [29] [30] Antibiotics are proven to be effective but the beneficial effects are modest. The rates of AOM also reduce spontaneously without treatment so that absolute benefits are less impressive than anticipated. Two of the RCTs assessing prophylactic antibiotics have been conducted in Indigenous children. 39, 40 These studies demonstrate that prophylactic antibiotics will prevent perforation of the tympanic membrane. The size of the benefit is similar to prevention of any AOM. Insertion of tympanostomy tubes also seems to reduce rates of AOM, and the effect is similar to antibiotics. Either of these options could be considered in those children from low-risk populations with very frequent infections (especially if occurring before the peak of respiratory illness in winter). However, children with tympanostomy tubes may develop a discharging ear, so this is not a good option in children at increased risk of suppurative infections (including those with immunodeficiency or persistent bacterial rhinosinusitis). For Indigenous children in high-risk populations, prophylactic antibiotics or prompt antibiotic treatment of infections are probably the more appropriate treatment options. Adenoidectomy does not seem to be an effective treatment. [27] [28] [29] Because Indigenous children in high-risk populations are known to have high rates of pneumococcal diseases, there was hope that introduction of the pneumococcal conjugate vaccine would have a greater impact on OM in these populations. One RCT in Navajo and Apache children assessed the impact on OM and could not demonstrate substantially improved outcomes. 43 Of note, comparison of longitudinal cohorts before and after the introduction of the pneumococcal conjugate vaccine found a reduction in OM visits for American Indian children but not for Alaskan Native children. 83 In Australia, comparison of longitudinal cohorts of Aboriginal infants before and after the introduction of the vaccine did not document substantial reductions in severe OM. 43, 89 

A small proportion of children with AOM with perforation go on to develop CSOM. In developed countries, CSOM most commonly occurs as a complication of tympanostomy tube placement. There is evidence on the treatment effects of topical antibiotics, topical antiseptics, systemic antibiotics, and ear cleaning. [31] [32] [33] [34] 79 Interpretation of a large number of small studies is challenging, but topical antibiotics are proven to be effective and the beneficial effects vary from large to modest. Most studies have not documented a long-term effect. Topical antibiotics also seem to be more effective than antiseptics and systemic antibiotics. 31 The role of topical antibiotics plus systematic antibiotics is unclear. 90 Cleaning the middle ear discharge has not been proven to be effective in RCTs but is generally regarded as necessary before insertion of topical antibiotics (at least in children with profuse discharge). Although not seen in RCTs, there is also a very small risk of ototoxicity associated with most topical antibiotics (except topical quinolones) and topical antiseptics. 27 For children who fail to respond to prolonged courses of topical antibiotics, 2 small studies (85 participants) have documented high cure rates and large beneficial effects associated with 2 to 3 weeks of intravenous antipseudomonal antibiotics (such as ceftazidime). 91, 92 Given the available evidence from RCTs on CSOM, most well-informed individuals would choose topical antibiotic treatment. However, even though this is an effective treatment, prolonged or repeated courses of treatment are often required. If this is the case, topical quinolones will provide a slight benefit in terms of risk of ototoxicity. Even in high-risk Indigenous populations there is a considerable difference in the likely response to treatment. Two RCTs comparing ciprofloxacin drops with framycetingramycidin-dexamethasone drops in Australian Aboriginal children with CSOM have been conducted. One trial found most children could be effectively treated within 9 days, whereas the other reported most children with persistent CSOM despite 6 weeks of treatment. 41, 42 Although not the subject of RCTs, the outcomes of tympanoplasty in Indigenous children and adults have been described. These studies usually report effective surgical repair of the tympanic membrane in around 50% to 70% and a modest improvement in hearing. 57, 93, 94 These results are not as good as those seen in other populations, where effective repair is usually achieved in 80% to 90%. This operation is probably most appropriate for Indigenous children with bilateral large, dry tympanic membrane perforations associated with a moderate hearing loss or frequent episodes of discharge.

OM is one of the most common illnesses affecting children. In low-risk populations, most illnesses are mild and will resolve completely without specific treatment. Unfortunately, this is not always the case for Indigenous children in high-risk populations. Multiple interventions have been assessed in the treatment of OM. None of the interventions have had substantial absolute benefits for the populations studied. Therefore, for low-risk children symptomatic relief and watchful waiting (including education of the parents about important danger signs) is the most appropriate treatment option. Antibiotics have a role in children with persistent bacterial infection, or those at risk of complications. Even today, many Indigenous children will often fall into these high-risk groups.

Epidemiology of viral respiratory infections

The common cold

Otitis media in infants and children

Textbook of pediatrics

Incidence of acute otitis media and sinusitis complicating upper respiratory tract infection: the effect of age

Smart health choices: making sense of health advice

Statistics notes. Treatment allocation in controlled trials: why randomise?

Grading quality of evidence and strength of recommendations

GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

Systems for grading the quality of evidence and the strength of recommendations II: pilot study of a new system

Pneumococcal vaccines for preventing otitis media

Vaccines for preventing influenza in healthy children

The efficacy of influenza vaccine for healthy children: a meta-analysis evaluating potential sources of variation in efficacy estimates including study quality

Otitis media with effusion

American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. Otitis media with effusion

Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children

Grommets in otitis media with effusion: an individual patient data meta-analysis

Antihistamines and/or decongestants for otitis media with effusion (OME) in children

Autoinflation for hearing loss associated with otitis media with effusion

Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children

Decongestants and antihistamines for acute otitis media in children

Antibiotics for acute otitis media: a meta-analysis with individual patient data

Antibiotics for acute otitis media in children

Otitis media in children (acute)

A randomized, double-blind, multicentre controlled trial of ibuprofen versus acetaminophen and placebo for symptoms of acute otitis media in children

Antibiotics for the prevention of acute and chronic suppurative otitis media in children

Evidence-based otitis media. Hamilton: B.C

Prevention of otitis media by adenoidectomy in children younger than 2 years

Adenoidectomy does not significantly reduce the incidence of otitis media in conjunction with the insertion of tympanostomy tubes in children who are younger than 4 years: a randomized trial

Grommets (ventilation tubes) for recurrent acute otitis media in children

Chronic suppurative otitis media

Topical antibiotics without steroids for chronically discharging ears with underlying eardrum perforations

Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations

Interventions for chronic suppurative otitis media

Report of a WHO/CIBA Foundation Workshop. Prevention of hearing impairment from chronic otitis media. Geneva: World Health Organisation

Oxford: Wiley interScience

A systematic review of clinical research addressing the prevalence, aetiology, diagnosis, prognosis and therapy of otitis media in Australian Aboriginal children

Otitis media in Alaskan Eskimo children. Prospective evaluation of chemoprophylaxis

Compared to placebo, long-term antibiotics resolve otitis media with effusion (OME) and prevent acute otitis media with perforation (AOMwiP) in a high-risk population: a randomized controlled trial

Effectiveness of ototopical antibiotics for chronic suppurative otitis media in Aboriginal children: a community-based, multicentre, double-blind randomised controlled trial

Topical ciprofloxin versus topical framycetingramicidin-dexamethasone in Australian aboriginal children with recently treated chronic suppurative otitis media: a randomized controlled trial

Randomized, controlled trial efficacy of pneumococcal conjugate vaccine against otitis media among Navajo and White Mountain Apache infants

Systematic review of existing evidence and primary care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations. Canberra: Office of Aboriginal and Torres Strait Islander Health

Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Strait Islander populations. Canberra: Office of Aboriginal and Torres Strait Islander Health

Otitis media

American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media

A meta-analytic review of the risk factors for acute otitis media

Prophylaxis for otitis media in an Indian population

Draining ears and deafness among Alaskan Eskimos

Patterns of ear disease in the southwestern American Indian

Eustachian tube function in an American Indian population

Early otitis media among Minnesota American Indians: the little ears study

An overview of twenty years of observation concerning etiology, prevalence, and evolution of otitis media and hearing loss among the Inuit in the eastern Canadian Arctic

High rate of nasopharyngeal carriage of potential pathogens among children in Greenland: results of a clinical survey of middle-ear disease

Prevalence of otitis media in a survey of 591 unselected Greenlandic children

Outcome of mobile ear surgery for chronic otitis media in remote areas

Otitis media in Australian Aboriginal children: an overview

The prevalence of hearing impairment amongst Maori schoolchildren

Prevalence and natural history of otitis media with perforation in Maori school children

Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment

Middle-ear disease in Indians of the Mount Currie Reservation, British Columbia

Childhood morbidity and mortality in Newcastle-Upon-Tyne. Further report on the thousand family study

Bronchiectasis in Alaska Native children

Otitis media in Inuit children in the Eastern Canadian Arctic-an overview 1968 to date

Bronchiectasis in Alaska Native children: causes and clinical courses

Lower respiratory tract infections among American Indian and Alaska Native children and the general population of U.S. children

Invasive pneumococcal disease caused by nonvaccine serotypes among Alaska native children with high levels of 7-valent pneumococcal conjugate vaccine coverage

Invasive pneumococcal disease in central Australia

Bronchiectasis in indigenous children in remote Australian communities

The burden and outcome of respiratory tract infection in Australian and aboriginal children

Bacterial colonization of the nasopharynx predicts very early onset and persistence of otitis media in Australian aboriginal infants

Carriage of multiple ribotypes of nonencapsulated Haemophilus influenzae in aboriginal infants with otitis media

Measuring nasal bacterial load and its association with otitis media

Report from a WHO working group: standard method for detecting upper respiratory carriage of Streptococcus pneumoniae

Evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion

Does this child have acute otitis media?

Otitis media and speech and language: a meta-analysis of prospective studies

Chronic suppurative otitis media: a review

Predictors of chronic suppurative otitis media in children

Identification of children in the first four years of life for early treatment for otitis media with effusion

Surgical prevention of otitis media

Trends in otitis media and myringtomy with tube placement among American Indian/Alaska native children and the US general population of children

Impact of the pneumococcal conjugate vaccine on otitis media

Short course antibiotics for acute otitis media

Delayed antibiotics for respiratory infections

Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial

Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media

Pneumococcal vaccination and otitis media in Australian Aboriginal infants: comparison of two birth cohorts before and after introduction of vaccination

Effectiveness of trimethoprim/sulfamethoxazole for children with chronic active otitis media: a randomized, placebo-controlled trial

Medical treatment of chronic suppurative otitis media without cholesteatoma in children-a two-year follow-up

Outpatient management of chronic suppurative otitis media without cholesteatoma in children

Outcomes of myringoplasty in Australian Aboriginal children and factors associated with success: a prospective case series

Myringoplasty: a post-operative survey of 90 aborigine patients