Prevalence of and factors affecting otitis media with effusion in children in the region from Balkans to Caspian basin; A multicentric cross-sectional study.

OBJECTIVE: The aim of our study was to contribute to the literature about the prevalence of OME by conducting a research in a wide geography examining most of the associating factors together with a questionnaire. Additionally, possible effects of altitudes and latitudes, concordance between the otoscopic examination findings and tympanometric and acoustic reflex test results were evaluated in 4-7 years old children in the same season in different countries. METHODS: In the randomly sampled schools from different regions of different cities where people of different scoioecomonic statuses live, 4-7 year-old children were included in the study. The results of the questionnaire covering the potential factors in OME etiology were evaluated together with the results of the otoscopic examination and tympanometry findings, and also the acoustic reflex findings to direct the interpretation in cases of low amplitude - blunted peak tympanograms which can be interpreted as a "Type B" or "Type As". All the results were gathered in the same season. RESULTS: Ten centers from nine countries participated in the study. A total of 4768 children were evaluated. The frequency of OME diagnosed by otosopic examination was 22.48% (n=1072) and the diagnosis rate when otoscopic examination plus type B tympanometry were taken into account was found as 11.3% (n=539) in general population. Factors increasing the prevalence of OME were found as; mother's educational level (p=0.02), child's age (p=0.006), history of upper respiratory tract infection (p=0.001), smoking father (p=0.01), mother being a housewife or laborer (p=0.01), history of allergy (p=0.001), asthma (p=0.04), or allergy symptoms (p=0.02). No direct relationship was found between altitudes or latitudes and prevalence of OME. CONCLUSION: The important affecting factors found after analyzing all of the potential risk factors in the same model are secondhand smoke exposure, low level of mother's education, mother's occupation, positive history of URTI, and age of the child being less than 7. By paying attention to the factors that increase the prevalence of OME, putting particular emphasis on the preventable ones such as smoking, education, and fighting with allergies could decrease the prevalence of this public health issue.

Inner Ear Malformations in Congenital Deafness Are Not Associated with Increased Risk of Breech Presentation.

BackgroundThere is speculation that an immature vestibular system may be associated with breech presentation at delivery. Our aim was to determine whether syndromes with congenital inner ear malformations were accompanied by a higher frequency of breech presentation/malpresentations than in the general population (2%-3%). Methods: A review was conducted for published literature using PubMed/MEDLINE (1936-2016), to determine frequency of breech presentation and transverse lie in cases with congenital deafness (Michel aplasia, Wildervanck syndrome, Mondini-Alexander dysplasia, Waardenburg syndrome, CHARGE syndrome, Large vestibular aqueductal syndrome, Pendred syndrome, Oculo-aurico-vertebral spectrum, Jervel and Lange-Nielsen syndrome, Usher syndrome, and Scheibe dysplasia) and vestibular nerve aplasia. Results: Identified were total of 122 cases. The frequency of breech presentation was 1.64%, and of transverse lie 1.64%, giving a total of 3.28% malpresentations. Conclusion: The results of the study suggest that congenital malformations of the vestibular apparatus are not associated with the increased risk of breech presentation at delivery.

COMPARISON OF HEARING THRESHOLD ESTIMATION USING AUDITORY STEADY STATE RESPONSES AND BRAINSTEM AUDITORY EVOKED POTENTIALS IN CHILDREN.

Current recommendations proposed by pediatric audiologists are to commence with hearing amplification in children aged 6 months and above, after previous determination of the type and degree of hearing impairment and audiometric configuration. The goal of this study was to compare results obtained by click-evoked auditory brainstem response (c-ABR) and auditory steady state response (ASSR) in a group of children. This study included 68 children with different degrees of hearing impairment evaluated by c-ABR and ASSR. It is well-known that the c-ABR threshold highly correlates with behavioral hearing level at 2 kHz. In our study, the correlation between the c-ABR and ASSR thresholds in the whole sample was 0.58, 0.73, 0.97, 0.96, 0.95, 0.97; in the group of children with c-ABR thresholds up to 40 dBHL, it was 0.42, 0.73, 0.86, 0.74, 0.81, 0.81; and in the group with c-ABR thresholds worse than 40 dBHL, it was 0.46, 0.56, 0.89, 0.83, 0.85, 0.89 at 0.5, 1, 2, 4, 1-4, 2-4 kHz, respectively. Individual differences between the c-ABR and ASSR thresholds in the whole sample were up to 95, 90, 20, 25 dB at 0.5, 1, 2, 4 kHz, respectively. Study results indicated that there was strong correlation between the c-ABR and ASSR thresholds at 2, 4, 1-4, 2-4 kHz. The ASSR can be used as a valuable clinical tool and an excellent complementary method which, along with other audiologic techniques, provides more accurate hearing threshold estimation at an early age in children.

A prominent lactate peak as a potential key magnetic resonance spectroscopy (MRS) feature of progressive multifocal leukoencephalopathy (PML): Spectrum pattern observed in three patients.

Progressive multifocal leukoencephalopathy (PML) is a rare, often fatal, opportunistic infection, associated with demyelinating process. PML is caused by John Cunningham (JC) polyomavirus, and predominantly affects patients with human immunodeficiency virus (HIV) infection or other immunocompromised patients. The purpose of this study was to determine the role of magnetic resonance spectroscopy (MRS) in establishing the diagnosis of PML. MRS with long and short echo time was performed in two patients with PML associated with HIV infection and in one PML patient associated with chronic lymphocytic leukemia. The most prominent peak on the obtained spectra was for lactate; it showed 2-3 times higher concentration of lactate compared to choline, almost 4-6 times higher lactate concentration compared to creatine, and 4-11 times higher lactate in comparison to N-acetylaspartate concentration. Similar spectrum pattern was observed in all patients. To the best of our knowledge, this is a new finding that might be useful in early diagnosis of PML. Nevertheless, further confirmation of our results is needed, since we analyzed the spectrum pattern only in three patients. Overall, our results could help in early detection of PML, especially in non-HIV patients, and thus prevent the fatal outcome of the disease. MRS could also be useful in detecting "tumefactive" demyelinating lesions in PML patients, associated with immune reconstitution inflammatory syndrome, to avoid misdiagnosis of neoplasm.

Comparison between auditory steady-state responses and pure-tone audiometry.

BACKGROUND/AIM: A more recent method, the auditory steady-state response (ASSR), has become more and more important test method due to difference that was found in previous investigations between hearing thresholds determined by the ASSR and the pure-tone audiometry (PTA). The aim of this study was to evaluate the reliability of the ASSR in determining the frequency specific hearing thresholds by establishing a correlation between the thresholds determined by PTA, as well as to evaluate the reliability of ASSR in determining the hearing threshold with respect to the level of hearing loss and the configuration of the PTA findings. METHODS: The prospective study included 46 subjects (92 ears) which were assigned to groups based on their level of hearing loss and audiometric configuration. All the subjects underwent determination of hearing thresholds by PTA and ASSR without insight into their previously obtained PTA results. RESULTS: The overall sample differences between the ASSR and PTA thresholds were 4.1, 2.5, 4.4, and 4.2 dB at 0.5, 1, 2, and 4 kHz, respectively. A high level of correlation was achieved in groups with different configurations of PTA findings. The correlation coefficients between the hearing thresholds determined by ASSR and PTA were significant in subjects with all levels of hearing loss. The differences between hearing thresholds determined by ASSR and PTA were less than 10 dB in 85% of subjects (ranging from 4 dB for moderately severe hearing loss to 7.2 dB for normal hearing). CONCLUSION: The ASSR is an excellent complementary method for the determination of hearing thresholds at the 4 carrier frequencies, as well as determination of the level of hearing loss and the audiometric configuration.

Acute otitis media: to follow-up or treat?

Acute otitis media (AOM) is the most common diagnosis for which antibiotics are prescribed in children. However, due to their widespread use, we are witnesses to increased development of bacterial resistance to antibiotics. The purpose of this study was to evaluate the necessity of antibiotic treatment in patients with AOM. Our study included 314 children, aged between 2 months and 6 years. Children were divided into two groups: the first group included children with less severe forms of AOM, who received symptomatic therapy and "wait-and-see" approach (237 children); the second group presented with purulent ear infection and received antibiotic treatment from the beginning (77 children). After symptomatic therapy, resolution of the disease, without use of any antibiotics, was established in 61% of patients, compared to the overall sample of children with AOM. None of the children developed complications that would require surgical treatment. In the second group of children, receiving antibiotics, almost the same therapeutic effects (80%) were achieved with the use of amoxicillin, amoxicillin-clavulanate and cefixime, while the worst results were obtained after using azithromycin. The wait-and-see approach is recommended in forms of AOM without serious signs and symptoms, because it significantly reduces the use of antibiotics and their potential adverse effects.

[Otitis media in children--a parallelism between the state-of-the-art knowledge and the context of real clinical practice].

INTRODUCTION: Inflammation of the middle ear is the most common illness among children. It is commonly recurrent by its nature, causing transient or long-term hearing reduction. From the clinical aspect, the problem of recrudescence and chronicity of childhood otitis media is enormous. There are controversies and nonuniformities in defining the cause, conservative and surgical treatment, prevention, mostly due to morphofunctional specificities and dynamic developmental features of the tubotympanomastoid complex. Some open questions are as follows: is recurrent otitis media in childhood really recurrent, or we are dealing with clinical manifestations of exacerbation of the chronic process (chronic from the very beginning), which are the factors predisposing and/or reflecting inflammatory processes in the middle ear, which are the potentials of real clinical practice, which are the modalities of prevention of inflammatory processes in the middle ear in children, is there a parallelism between the real clinical, therapeutic practice and current knowledge of the etiopathogenesis of otitis media in children? DISCUSSION: This study reviews current knowledge and identifies potential etiopathogenetic factors in the development of inflammatory processes of the tubotympanomastoid complex. Special attention was given to external predisposing factors, as well as internal factors which include genetic, immunobiochemical, factors of increased adherence of pathogens and Eustachian tube dysfunction. The study also deals with the potentials of diagnostic morphofunctional procedures, as well as modalities of the real clinical practice. CONCLUSION: An open question remains with regard to the parallelism between real clinical therapeutic potentials and state-of-the-art knowledge, as well as the role of preventive procedures in the field of inflammatory processes of the tubotympanic complex in children.

[Analysis of reasons for late diagnosis of hearing impairment in children].

INTRODUCTION: Hearing loss in children will cause cognitive deficits in the central areas which are dependent upon hearing and is therefore responsible for delay in the speech development, poor language skills and disorders in psychological and mental behavior. An early identification of educationally significant hearing loss in infants and young children is an essential prerequisite for effective aural rehabilitation and educational intervention. Maturation of the auditory path takes place within the first 18 months of life and is dependant on the adequate acoustic stimulation. To ensure the optimal therapy a definite diagnosis of the hearing impairment should be made until the sixth month of life. Current health care standards recommend the confirmation of the neonatal hearing loss before the age of three months and the appropriate intervention before the age of six months. MATERIAL AND METHODS: The study consisted of the prospective analysis of data collected for 70 children with suspected hearing loss. According to the hearing level determined by the objective diagnostic methods (Brainstem Evoked Response Audiometry) the whole group was divided into three subgroups. We analyzed the average age when the hearing loss was detected, the reasons for the late identification of the hearing loss, as well as the risk-factors for hearing difficulties. RESULTS AND DISCUSSION: Of 70 children with suspected hearing loss, we found normal hearing or mild hearing loss in 17 cases (group 1), 16 children were suffering from moderate and severe hearing loss (group II), and 37% children were suffering from profound hearing loss (group III). Until the age of 2, the diagnosis was made in 40% of 70 children, most in the group III 58.8%, 25% in the group II and 17.64% of children in the group I. The average age when the hearing loss was suspected was 1.62, 2.38 and 1.41 in the groups I, II and III respectively, whereas the average age when the hearing was examined was 2.83, 3.32 and 2.32 in the groups I, II and III respectively. In 22 children (21.5%) no cause of hearing impairment could be determined Nineteen children (15.7%) had the history of familial hearing loss, 37 (52.8%) children suffered from acquired hearing loss. Risk- factors: the presence of the hearing impaired in the family as well as risk-factors was not the reason for parents to check the hearing status of their child. CONCLUSION: The mean age of children diagnosed to have the hearing impairment is still over 2 years in our region. However, the introduction of a universal screening programme would result in significantly earlier detection of the hearing impairment in children.

[Cochlear implantation--risk and complications].

As any other medical procedure cochlear implantation could be risky and there are possibilities for the development of complications. Serious and adequate diagnostic as well as preoperative preparation is necessary for cochlear implantation. Omissions in the audiological, radiological or psychological diagnostic procedures could provoke far reaching consequences in rehabilitation process. The commonest intraoperative complications may be divided into major and minor complications. Minor complications are those that resolve without surgical intervention: flap infection, change in taste, transitory balance problems, transitory facial palsy, non excessive intraoperative bleeding and other. Major complications required revision surgery because of flap problems, device extrusion or migration and device failure. CSF leak, meningitis as well as facial palsy. Adequate flap design should insure prevention of the flap necrosis, which is a very unpleasant complication. Principles of prevention, management, and sequelae of complications are given in this paper. Data presented in this paper indicate that cochlear implant surgery in children is a reliable and safe procedure with a low percentage of severe complications. Problems related to ear surgery can occur and should be manageable with standard procedures.

[Psychogenic hearing impairment in differential diagnosis of sudden hearing loss].

INTRODUCTION: Acute hearing impairment or deafhess may manifest as unilateral or bilateral. The etiopathogenetic substrate may be organic, functional and of unknown origin, the so-called idiopathic. The functional causes of impaired hearing and deafness also include psychogenic factors, where the essential dysfunction exists between the conscious simulation of hearing impairment and deafness for benefits versus psychogenic hearing impairment in conversion disorders where physical symptoms result as a symbolic expression of long-term psychological problems or conflicts. Acute hearing impairment, pseudohypacusis, as a symptom of conversion disorder, where hearing impairment is without evidence of organic cause, is a rare pseudosensory form of this disease. Numerous literature data indicate that these disorders are most common among children, whereas in adults only individual cases are reported. In otorhinolaryngological practice, other symptoms of conversion disorders are much more common (psychogenic aphonia and dysphonia, globus pharyngeus, sensation disorder in the head and neck region). CASE REPORT: The paper includes a detailed presentation of the diagnostic procedure, clinical course, differential diagnostic dilemmas and therapeutic procedure in cases of acute bilateral psychogenic hearing impairment in adolescents. CONCLUSION: Acute hearing impairment caused by organic substrate is irreversible in most cases, whereas in psychogenic hearing impairment the prognosis is excellent, particularly among children and adolescents. Identification of the etiologic factors of reversible hearing loss, including psychogenic ones, by the otorhinolaryngologist is of utmost importance in order to provide early differential diagnosis and timely inclusion of a psychiatrist and a clinical psychologist into the diagnostic-therapeutic.

[The role of current audiological tests in the early diagnosis of hearing impairment in children].

INTRODUCTION: Permanent hearing impairment is a significant and relatively common condition in newborns, affecting at least 1 child per 1000 live births. The early identification of hearing loss is very important in order to begin early rehabilitation and for optimizing normal development of language. MATERIAL AND METHODS: We examined 70 children with parental suspicion of a hearing loss. Brainstem Evoked Response Audiometry was performed and the group was divided into three subgroups. The following parameters were analyzed: the average age of hearing loss-identification, the time of parental first suspicion of a hearing loss, as well as risk factors for hearing impairment. RESULTS AND DISCUSSION: Of 70 children with parental suspicion of a hearing loss, in 17 cases normal hearing or mild hearing loss (up to 40 dB HL) was found (group 1), 16 children were suffering from moderate and severe hearing loss (40 to 90 dB HL) (group II), and 37% of children were suffering from profound hearing loss (greater than 90 dB HL) (group III). Up to the age of 2, the diagnosis was made in 17.64% of children in group I, in 25% in group II, and in 58.8% in group III. The average age of hearing loss identification was 2.83, 3.32, 2.32 years in groups I, II, III, respectively, although parents suspected hearing problems at least one year earlier. Presence of hearing impaired family members as well as of risk factors were not sufficient reasons to get a medical check-up. CONCLUSION: The use of otoacoustic emission testing in routine clinical practice, as well as education of parents and pediatricians, was followed by earlier detection of hearing loss in regard to our previous study (10 years ago). The mean age of diagnosis in our region is still over 2 years, but establishment of a universal screening program may help reduce the age of hearing loss detection.

[Cochlear implantation at the Ear, Nose and Throat Clinic of the Clinical Center of Vojvodina].

INTRODUCTION: A cochlear implant is a small electronic device that can provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. Cochlear implants bypass the damaged hearing systems and directly stimulate the auditory nerve. Signals generated by the implant are sent by way of the auditory nerve to the brain, which recognizes the signals as sound. Hearing through a cochlear implant differs from normal hearing and takes time to learn or relearn. Cochlear implantations have been performed at the ENT Clinic in Novi Sad since 2002. The aim of this retrospective investigation was to evaluate performance of cochlear implanted patients in regard to the age of hearing loss identification, age at implantation, as well as complications. MATERIAL AND METHODS: During a 5-year period (2002-2007), 45 patients underwent cochlear implantation (46 implants) at the ENT Clinic in Novi Sad. Only four patients were postlingually deaf adults. Forty-one implanted patients were children with a mean age at implantation of 42.2 months (range: 2 to 8 years). Out of these patients, 28 (68.2%) had congenital deafness of unknown cause. The commonest known cause was meningitis, found in 4 (9.7%) patients, followed by use of ototoxic drugs and hereditary deafness. Etiological factors included: postnatal hypoxia, intracranial hemorrhage, pre term birth, cytomegalovirus infection during pregnancy, middle ear cholesteatoma, as well as sudden bilateral deafness. The time span between diagnosis of hearing loss and implantation was 34.6 months in 2002 and only 10 months in 2007. RESULTS: 6 (13%) patients presented with complications. There were 4 major, and two minor complications. The following complications were noted: ossified cochlea which required reoperation, unsuccessful operation in a patient with Down syndrome, facial tics, temporary facial weakness and ataxia. Five out of six complications were successfully resolved CONCLUSION: New, more sophisticated audiological evaluation is essential to shorten the time for diagnosing hearing impairment. The results of the investigation performed at the Cochlear Implantation Center of the ENT Clinic in Novi Sad show that cochlear implantation is an effective procedure which should be continued.

Initial evaluation of vertigo.

Dizziness is one of the most common reasons patients visit their physicians. Balance control depends on receiving afferent sensory information from several sensory systems: vestibular, optical and proprioceptive. Bioelectric signals, generated by body movements in the semicircular canals and in the otolithic apparatus, are transported via the vestibular nerve to the vestibular nucleus. All four vestibular nuclei, located bilaterally in medial longitudinal fasciculus, are linked with central nervous system structures. These central nervous system structures are involved in maintaining visual stability, spatial orientation and balance control. Nystagmus is a result of afferent signals balance disorders. Nystagmus due to peripheral lesions is conjugate nystagmus, because there is a bilateral central connection. Lesions above the vestibular nuclei induce deficits in synchronization and conjugation of eye movements, thus the nystagmus is dissociated. This paper shows that in peripheral vestibular disorders spontaneous nystagmus is rhythmic, associated, horizontal-rotatory or horizontal, with subjective sensation of dizziness which decreases with time and harmonic signs whose direction coincides with the slow phase of nystagmus and it is associated with mild disorders during pendular stimulation with statistically significant vestibular hypofunction. Spontaneous nystagmus in central vestibular lesions is severe, dissociated, horizontal, rotatory or vertical, without changes related to optical suppression; if vestibular symptoms are present, they are non-harmonic. In central disorders, findings after thermal stimulation are either normal or pathological, with dysrhythmias and inhibition in pendular stimulation. This paper deals with differential diagnosis of vertigo based on anamnesis and clinical examination, as well as objective diagnostic tests.