Cortical Auditory Evoked Potential Testing in Children With Auditory Neuropathy Spectrum Disorder.

PURPOSE: In the present report, we reviewed the role of cortical auditory evoked potentials (CAEPs) as an objective measure during the evaluation and management process in children with auditory neuropathy spectrum disorder (ANSD). METHOD: We reviewed the results of CAEP recordings in 66 patients with ANSD aged between 2 months and 12 years and assessed the relationship between their characteristics (prevalence, morphology, latencies, and amplitudes) and various clinical features, including the mode of medical management. RESULTS: Overall, the CAEPs were present in 85.2% of the ears tested. Factors such as prematurity, medical complexity, neuronal issues, or presence of syndromes did not have an effect on the presence or absence of CAEPs. CAEP latencies were significantly shorter in ears with cochlear nerve deficiency than in ears with a normal caliber nerve. Three different patterns of CAEP responses were observed in patients with bilateral ANSD and present cochlear nerves: (a) responses with normal morphology and presence of both P1-P2complex and N2 components, (b) responses with abnormal morphology and presence of the N2 component but undefined P1-P2complex peak, and (c) entirely absent responses. None of the patients with normal, mild, or moderate degree of hearing loss had a complete absence of CAEP responses. No significant differences were uncovered when comparing the latencies across unaided and aided children and children who later received cochlear implants. CONCLUSIONS: The CAEP protocol used in our ANSD program did inform about the presence or absence of central auditory stimulation. Absent responses typically fit into an overall picture of complete auditory deprivation and all of these children were ultimately offered cochlear implants after failing to develop oral language. Present responses, on the other hand, were acknowledged as a sign of some degree of auditory stimulation but always interpreted with caution given that prognostic implications remain unclear.

A globally synthesised and flagged bee occurrence dataset and cleaning workflow.

Species occurrence data are foundational for research, conservation, and science communication, but the limited availability and accessibility of reliable data represents a major obstacle, particularly for insects, which face mounting pressures. We present BeeBDC, a new R package, and a global bee occurrence dataset to address this issue. We combined >18.3 million bee occurrence records from multiple public repositories (GBIF, SCAN, iDigBio, USGS, ALA) and smaller datasets, then standardised, flagged, deduplicated, and cleaned the data using the reproducible BeeBDC R-workflow. Specifically, we harmonised species names (following established global taxonomy), country names, and collection dates and, we added record-level flags for a series of potential quality issues. These data are provided in two formats, "cleaned" and "flagged-but-uncleaned". The BeeBDC package with online documentation provides end users the ability to modify filtering parameters to address their research questions. By publishing reproducible R workflows and globally cleaned datasets, we can increase the accessibility and reliability of downstream analyses. This workflow can be implemented for other taxa to support research and conservation.

The influence of substituents in governing the strength of the P-X bonds of substituted halophosphines R1R2P-X (X = F and Cl).

In this study, the gas-phase homolytic P-F and P-Cl bond dissociation energies (BDEs) of a set of thirty fluorophosphine (R1R2P-F) and thirty chlorophosphine-type (R1R2P-Cl) molecules have been obtained using the high-level W2 thermochemical protocol. For the R1R2P-F species, the P-F BDEs (at 298 K) differ by up to 117.0 kJ mol-1, with (H3Si)2P-F having the lowest BDE (439.5 kJ mol-1) and F2P-F having the largest BDE (556.5 kJ mol-1). In the case of the chlorophosphine-type molecules, the difference in BDEs is considerably smaller (i.e., 72.6 kJ mol-1), with (NC)2P-Cl having the lowest P-Cl BDE (299.8 kJ mol-1) and (HO)2P-Cl having the largest (372.4 kJ mol-1). We have further analyzed the effect of substituents in governing the P-F and P-Cl BDEs by considering the effect of substituents in the parent halogenated precursors (using molecule stabilization enthalpies) and the effect of substituents in the product radicals (using radical stabilization enthalpies). Finally, we have also assessed the performance of a wide range of DFT methods for their ability to compute the gas-phase P-F and P-Cl BDEs contained in this dataset. We find that, overall, the double hybrid functional DSD-PBEB95 offers the best performance for both bond types, with mean absolute deviations of just 2.1 (P-F BDEs) and 2.2 (P-Cl BDEs) kJ mol-1.

A Systematic Exploration of B-F Bond Dissociation Enthalpies of Fluoroborane-Type Molecules at the CCSD(T)/CBS Level.

Fluoroborane-type molecules (R1R2B-F) are of interest in synthetic chemistry, but to date, apart from a handful of small species (such as H2BF, HBF2, and BF3), little is known concerning the effect of substituents in governing the strength of the B-F bonds of such species toward homolytic dissociation in the gas phase. In this study, we have calculated the bond dissociation enthalpies (BDEs) of thirty unique B-F bonds at the CCSD(T)/CBS level using the high-level W1w thermochemical protocol. The B-F bonds in all species considered are very strong, ranging from 545.9 kJ mol-1 in (H2B)2B-F to 729.2 kJ mol-1 HBF2. Nevertheless, these BDEs still vary over a wide range of 183.3 kJ mol-1. The structural properties that affect the BDEs are examined in detail, and the homolytic BDEs are rationalized based on molecule stabilization enthalpies and radical stabilization enthalpies. Since polar B-F bonds may represent a challenging test case for density functional theory (DFT) methods, we proceed to examine the performance of a wide range of DFT methods across the rungs of Jacob's Ladder for their ability to compute B-F BDEs. We find that only a handful of DFT methods can reproduce the CCSD(T)/CBS BDEs with mean absolute deviations (MADs) below the threshold of chemical accuracy (i.e., with average deviations below 4.2 kJ mol-1). The only functionals capable of achieving this feat were (MADs given in parentheses): ωB97M-V (4.0), BMK (3.5), DSD-BLYP (3.8), and DSD-PBEB95 (1.8 kJ mol-1).

Intramolecular Proton-Coupled Hydride Transfers with Relatively Low Activation Barriers.

We report that bifunctional molecules containing hydroxyl and carbonyl functional groups can undergo an effective transfer hydrogenation via an intramolecular proton-coupled hydride transfer (PCHT) mechanism. In this reaction mechanism, a hydride transfer between two carbon atoms is coupled with a proton transfer between two oxygen atoms via a cyclic bond rearrangement transition structure. The coupled transfer of the two hydrogens as Hδ+ and Hδ- is supported by atomic polar tensor charges. The activation energy for the PCHT reaction is strongly dependent on the length of the alkyl chain between the hydroxyl and carbonyl functional groups but relatively weakly dependent on the functional groups attached to the hydroxyl and carbonyl carbons. We investigate the PCHT reaction mechanism using the Gaussian-4 thermochemical protocol and obtain high activation energy barriers (ΔH‡298) of 210.5-228.3 kJ mol-1 for chain lengths of one carbon atom and 160.2-163.9 kJ mol-1 for chain lengths of two carbon atoms. However, for longer chain lengths containing 3-4 carbon atoms, we obtain ΔH‡298 values as low as 101.9 kJ mol-1. Importantly, the hydride transfer between two carbon atoms proceeds without the need for a catalyst or hydride transfer activating agent. These results indicate that the intramolecular PCHT reaction provides an effective avenue for uncatalyzed, metal-free hydride transfers at ambient temperatures.

Asymmetric Ocular Vestibular Evoked Myogenic Potentials in Pediatric Vestibular Migraine.

OBJECTIVE: Although ocular vestibular evoked myogenic potentials (oVEMP) abnormalities have been associated with vestibular migraine (VM) in adults, no studies have evaluated this in pediatric patients with VM. oVEMP asymmetry with normal cervical VEMP (cVEMP) findings may be a reliable VM biomarker in adults. We characterize VEMP results among pediatric patients with VM and benign recurrent vertigo of childhood (BRVC), a migraine precursor, and compare these results with VEMP findings from pediatric patients with nonmigrainous vestibular diagnoses. METHODS: Four hundred seventy-four pediatric patients were evaluated over a 3-year period in a multidisciplinary pediatric vestibular clinic, 139 of whom met the inclusion criteria. Records were reviewed for history, audiometry, and vestibular testing results. VEMP testing was performed with a 500-Hz tone burst. Based on adult normative data, oVEMP asymmetry was defined as greater than 33% interaural difference; cVEMP asymmetry was defined as greater than 41%. RESULTS: Eighty subjects had VM or BRVC (mean [standard deviation] 12.8 [3.8] yr; range, 4.3-18.2 yr). Fifty-nine subjects received vestibular diagnoses other than VM or BRVC (nonmigrainous group; mean [standard deviation] age, 13.0 [3.6] yr; range, 5.14-18.9 yr). A greater proportion of the VM/BRVC group demonstrated oVEMP asymmetry with normal cVEMP as compared with the nonmigrainous group (22.5% versus 10.1%; p < 0.05). Zero subjects in the VM/BRVC group demonstrated cVEMP asymmetry versus three subjects (4.9%) of the nonmigrainous group. CONCLUSIONS: VM and BRVC are notable causes of migraine-related vertigo among pediatric patients. Of VM/BRVC patients, 22.5% had oVEMP asymmetry with normal cVEMP. Similar to the adult VM population, this finding may be a useful biomarker in the right clinical setting for pediatric VM. LEVEL OF EVIDENCE: 4.

A 15-year Review of 260 Children With Auditory Neuropathy Spectrum Disorder: II. Management and Outcomes.

OBJECTIVES: Following a review of the demographic and clinical characteristics of all pediatric patients diagnosed with auditory neuropathy spectrum disorder (ANSD) by a pediatric health care system from 2005 to 2020, the present report highlights the type and timing of intervention and outcomes in the same 260 patients with ANSD. DESIGN: This was a retrospective study reviewing the demographic data, medical history, imaging studies, audiological and speech language data, type of audiological intervention (hearing aids or cochlear implants), and mode of communication in 260 pediatric patients diagnosed with ANSD over a 15-year period. RESULTS: A significant decrease over time in the age at hearing aid fitting was observed. While a similar reduction in the age at implantation occurred over time, cochlear implantation is still rarely performed by 12 months of age in most ANSD patients. Among bilateral ANSD patients fitted with hearing aids, the majority (89.2%) did not benefit from conventional amplification and most received cochlear implants. Some hearing aid benefit for speech and language development was observed in 5.8%, though communication difficulties were persistent and most used a combination of oral and sign language for communication. Only six patients (5%) received significant benefit from their hearing aids for speech and language development. CONCLUSIONS: This review of ANSD management over a 15-year period reveals that hearing aids are not a viable option to develop speech and language for most infants and children with ANSD. This finding confirms previous reports and suggest that while hearing aid trials are warranted, children must be tracked closely so as to avoid delays in decision making. Cochlear implantation constitutes the major (if not only) rehabilitative intervention that allows for speech perception in patients who do not benefit from conventional amplification.

A 15-Year Review of 260 Children With Auditory Neuropathy Spectrum Disorder: I. Demographic and Diagnostic Characteristics.

OBJECTIVES: The aim of the study was to review the demographic and clinical characteristics of all pediatric patients diagnosed with auditory neuropathy spectrum disorder (ANSD) by a pediatric health care system from 2005 to 2020 and examine whether or not our diagnostic capabilities in an ANSD population have evolved as our institutional experience has grown and knowledge in the field has expanded. DESIGN: This was a retrospective study reviewing the demographic data, medical history, imaging studies, audiological and speech-language data, type of audiological intervention and mode of communication in 260 pediatric patients diagnosed with ANSD over a 15-year period. RESULTS: The study revealed that male and female children were equally affected with all levels of hearing detection being represented and that about 40% of affected children were premature and most were admitted to the neonatal intensive care unit. More than a third of our patients presented with a complex medical history and/or neural involvement while about 30% were full-term newborns with normal pregnancy, no prenatal complications or infections, normal birth weight, no neonatal intensive care unit need, no hyperbilirubinemia, no respiratory distress requiring ventilation, and no known syndrome. Review of audiological findings confirms that otoacoustic emissions are not always present in ANSD cases, and that the presence of an abnormal wave V on the auditory brainstem response tracings (only present at high intensities and with an absent intensity/latency function) is not a rare finding and should not immediately be dismissed as not being a case of ANSD. CONCLUSIONS: This review of ANSD diagnosis over a 15-year period clearly reveals the drastic improvements made in the identification of ANSD, with a drastic decrease in the age at diagnosis and a reduction in the percentage of misdiagnosed patients. The study also stresses the need for continued improvement in different areas such as genetic studies and physiological measures to help clinicians distinguish between pre- and postsynaptic ANSD.

Complementary/Integrative Medicine for Pediatric Otitis Media.

Complementary/integrative medicine can be used in treating otitis media, especially during the watchful waiting phase. Elimination of risk factors can be important. Products such as echinacea, xylitol, and probiotics may help in prevention. Herbal eardrop formulations can relieve symptoms in some patients. Other modalities such as homeopathy can lead to faster relief of symptoms in combination with conventional therapy. Chinese, Japanese, and other forms of traditional medicine have varying formulations with unclear safety, but initial results are promising. Most studies are limited by methodological failures and small sample sizes, emphasizing the need for continued research in this area.

Continental risk assessment for understudied taxa post-catastrophic wildfire indicates severe impacts on the Australian bee fauna.

The 2019-2020 Australian Black Summer wildfires demonstrated that single events can have widespread and catastrophic impacts on biodiversity, causing a sudden and marked reduction in population size for many species. In such circumstances, there is a need for conservation managers to respond rapidly to implement priority remedial management actions for the most-affected species to help prevent extinctions. To date, priority responses have been biased towards high-profile taxa with substantial information bases. Here, we demonstrate that sufficient data are available to model the extinction risk for many less well-known species, which could inform much broader and more effective ecological disaster responses. Using publicly available collection and GIS datasets, combined with life-history data, we modelled the extinction risk from the 2019-2020 catastrophic Australian wildfires for 553 Australian native bee species (33% of all described Australian bee taxa). We suggest that two species are now eligible for listing as Endangered and nine are eligible for listing as Vulnerable under IUCN criteria, on the basis of fire overlap, intensity, frequency, and life-history traits: this tally far exceeds the three Australian bee species listed as threatened prior to the wildfire. We demonstrate how to undertake a wide-scale assessment of wildfire impact on a poorly understood group to help to focus surveys and recovery efforts. We also provide the methods and the script required to make similar assessments for other taxa or in other regions.

Congenital soft tissue stenosis of the external auditory canal with canal cholesteatoma: Case report and literature review.

Congenital external auditory canal stenosis (EACS) is a spectrum of abnormalities affecting the external and middle ear. We report a 6 year-old patient with EACS affecting the lateral fibrocartilaginous canal that was successfully repaired. This patient highlights a variant of EACS characterized by lateral soft tissue narrowing with normal osseous development. Most previous studies of CAA have described severe forms associated with complete atresia, bony stenosis, and middle ear malformations. Stenosis affecting only the fibrocartilaginous canal is a milder form resulting from premature arrest of the canalization process during embryologic development, and may predispose to cholesteatoma formation.

Cofactors of Pediatric Tinnitus: A Look at the Whole Picture.

Retrospective chart review of 248 children (1-19 years old) with tinnitus who presented to a tertiary pediatric hospital between 2006 and 2011, looking at which cofactors are predictors of pediatric tinnitus. In our review, we extracted demographics, symptoms, historical data, imaging, and laboratory results; we compared with the general population. Eighty-seven percent had normal hearing. Age distribution, noise exposure, and frequency of psychiatric diagnoses in our cohort were consistent with previous reports. We found a lower incidence of otitis media and the same prevalence of dizziness, asthma, and hearing loss as the general population, a lower prevalence of Eustachian tube dysfunction, otitis media, headaches, and higher incidence of rhinosinusitis. Lack of patient reporting and objective testing complicate the ability to detect pediatric tinnitus. We revealed a gap in the literature regarding rhinosinusitis as a cofactor, imaging during diagnosis, and if psychiatric diagnoses are associated with tinnitus in younger children.

Cochlear Nerve Deficiency and Brain Abnormalities in Pediatric Patients.

HYPOTHESIS: To investigate the intracranial abnormalities present in children with cochlear nerve deficiency (CND), including abnormalities of other cranial nerves, and to describe their auditory abilities. BACKGROUND: The prevalence of CND has increased with the development of high resolution magnetic resonance imaging (MRI). There are varying degrees of CND from true aplasia to hypoplasia. The etiology of CND remains unclear and it may be associated with intracranial abnormalities in some instances. CND needs to be identified as early as possible to ensure prompt and adequate management of hearing loss since hearing aids and cochlear implants may not be an option. METHODS: A retrospective chart review of 56 ears of pediatric patients with CND was conducted between August 2006 and November 2014 at a tertiary care pediatric hospital. RESULTS: 27.6% of children had cochlear abnormalities and 48.9.8% had concomitant vestibular anomalies. Five patients had absent or abnormal facial nerves and two patients had aplastic bilateral olfactory nerves. In the 27 ears with an absent nerve that were functionally tested, eight (29.6%) had partial hearing which indicates the presence of an extremely small nerve whose size is below the limits of spatial resolution of the MRI. CONCLUSION: MRI is becoming the initial imaging choice for children with sensorineural hearing loss to identify CND and other brain anomalies. Concomitant vestibular and cochlear abnormalities were observed in respectively half and one-third of the pediatric patients with CND. The incidence of vestibular malformation suggests that balance testing should be recommended for most if not all CND patients.

A pearl in the ear: Intracranial complications of pediatric cholesteatomas.

A nine-year-old male had a cholesteatoma of the mastoid and middle ear found incidentally after myringotomy tube placement. Associated asymptomatic sigmoid plate dehiscence with sinus invasion or thrombosis and ossicular chain destruction complicated his case. He had canal wall down tympanomastoidectomy and was followed for 4.5 years. Disease recurrence necessitated revision. Our case highlights an unusual clinical presentation, possible complications, and the aggressive quality of a benign lesion common in the pediatric population. To our knowledge, this is the first report of an asymptomatic lateral sinus obstruction secondary to an invasive cholesteatoma in this population.

Management of First Branchial Cleft Anomalies via a Cartilage-Splitting Technique.

First branchial cleft anomalies are uncommon lesions that often present as periauricular infections. They have high recurrence rates, due in part to scarring secondary to prior infections and their management. These lesions have a close relationship with the facial nerve, and most authors recommend its identification and dissection because of this relationship. Nonetheless, facial nerve palsy has been reported in up to 15% of cases. We describe a novel technique for the management of first branchial cleft anomalies. Such lesions that presented in an infra- or postauricular location were approached via an incision through the cartilage of the pinna, between the tragus and antitragus. This technique affords direct access to the lesion without the need for facial nerve dissection. Six patients were treated. Five had prior surgery, including 3 with previous attempts at excision. There were no complications. The median follow-up was 35 months. One patient developed a recurrence.

The role of gastric pepsin in the inflammatory cascade of pediatric otitis media.

IMPORTANCE: Otitis media is characterized as an ongoing inflammation with accumulation of an effusion in the middle ear cleft. The molecular mechanisms underlying the pathogenesis, particularly the inflammatory response, remain largely unknown. We hypothesize that aspiration of gastric contents into the nasopharynx may be responsible for the initiation of the inflammatory process or aggravate a preexisting condition. OBJECTIVE: To investigate the correlation of gastric pepsin A with inflammatory cytokines, bacterial infection, and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: Prospective study of 129 pediatric patients undergoing myringotomy with tube placement for otitis media at a tertiary care pediatric hospital. MAIN OUTCOMES AND MEASURES: Ear samples were tested for pepsin A; cytokines interleukin (IL)-6, IL-8, and tumor necrosis factor; and bacterial culture inoculation. Data were analyzed by descriptive statistics and regression analysis to identify risk factors for the presence of pepsin A and to correlate pepsin A levels with cytokine levels, infection status, and clinical outcomes. RESULTS: Of the 129 patients, 199 ear samples were obtained; 82 samples (41%) and 64 patients (50%) were positive for pepsin A as measured by immunoassay. Pepsin A positivity correlated with age younger than 3.0 years (mean [SD], 2.3 [2.1] years in the positive group vs 3.3 [3.0] years in the negative group) and with all 3 cytokine levels (mean [SD] tumor necrosis factor, 29.5 [45.9] pg/mL in the positive group vs 13.2 [21.6] pg/mL in the negative group; IL-6, 6791.7 [9389.1] pg/mL in the positive group vs 2849.9 [4066.3] pg/mL in the negative group; and IL-8, 6828.2 [8122.3] pg/mL in the positive group vs 2925.1 [3364.5] pg/mL in the negative group [all P < .05]); however, logistic regression analysis showed that only IL-8 (odds ratio, 3.96; 95% CI, 1.3-12.0; P = .02) and age (odds ratio, 3.83; 95% CI, 1.2-12.7; P = .03) were significant independent variables. No statistically significant association was found with other parameters. Multiple linear regressions revealed that the levels of pepsin A were correlated with IL-8 levels (R2 = 0.248; P < .001) and the need for second or third tubes 6 to 12 months after the first (R2 = 0.102; P = .006). The presence of pepsin A in the middle ear was not associated with increased bacterial infection. Interleukin 8 was independent and significantly associated with both pepsin A levels and bacterial infection (R2 = 0.144 and 0.263, respectively; P = .001 for both). CONCLUSIONS AND RELEVANCE: Extraesophageal reflux as indicated by the presence of pepsin A is closely involved in the middle ear inflammatory process and may worsen the disease in some children; however, a proof of cause and effect between extraesophageal reflux and middle ear inflammation requires further investigation.

A homozygous SLITRK6 nonsense mutation is associated with progressive auditory neuropathy in humans.

OBJECTIVES/HYPOTHESIS: SLITRK family proteins control neurite outgrowth and regulate synaptic development. In mice, Slitrk6 plays a role in the survival and innervation of sensory neurons in the inner ear, vestibular apparatus, and retina, and also influences axial eye length. We provide the first detailed description of the auditory phenotype in humans with recessive SLITRK6 deficiency. STUDY DESIGN: Prospective observational case study. METHODS: Nine closely related Amish subjects from an endogamous Amish community of Pennsylvania underwent audiologic and vestibular testing. Single nucleotide polymorphism microarrays were used to map the chromosome locus, and Sanger sequencing or high-resolution melt analysis were used to confirm the allelic variant. RESULTS: All nine subjects were homozygous for a novel nonsense variant of SLITRK6 (c.1240C>T, p.Gln414Ter). Adult patients had high myopia. The 4 oldest SLITRK6 c.1240C>T homozygotes had absent ipsilateral middle ear muscle reflexes (MEMRs). Distortion product otoacoustic emissions (DPOAEs) were absent in all ears tested and the cochlear microphonic (CM) was increased in amplitude and duration in young patients and absent in the two oldest subjects. Auditory brainstem responses (ABRs) were dys-synchronised bilaterally with no reproducible waves I, III, or V at high intensities. Hearing loss and speech reception thresholds deteriorated symmetrically with age, which resulted in severe-to-profound hearing impairment by early adulthood. Vestibular evoked myogenic potentials were normal in three ears and absent in one. CONCLUSION: Homozygous SLITRK6 c.1240C>T (p.Gln414Ter) nonsense mutations are associated with high myopia, cochlear dysfunction attributed to outer hair cell disease, and progressive auditory neuropathy.

Complementary and integrative treatments: otitis media.

Acute otitis media is diagnosed frequently in childhood with peak incidence between 6 and 15 months of age. It is the most common reason for physician visits and antibiotic prescriptions in children, with an excess of $100 spent per episode. In this article we discuss current concepts of complementary and alternative medicine as they apply to otitis media. A thorough literature review shows that, whereas many of these modalities are promising, few have been assessed with randomized controlled trials. Finally, we provide an algorithm that may be used in assessing and treating patients with acute otitis media.

Complementary and alternative medicine for pediatric otitis media.

OBJECTIVE: To review the literature involving complementary and alternative medicine (CAM) for pediatric otitis media. Multiple modalities are discussed, including prevention involving breastfeeding, nutrition, and vaccination; symptomatic treatment involving homeopathy, natural health products, and probiotics; manual manipulations involving osteopathy and chiropractics; and traditional Chinese and Japanese medicine. The information presented will assist physicians in advising patients on their decision-making during the early stages of otitis media when antibiotics and surgery are not yet indicated. METHODS: A systematic literature search was conducted through January 2012 in PubMed using MESH term "otitis media" in conjunction with "complementary therapies," "homeopathy," "manipulation, osteopathic," "manipulation, chiropractic," "acupuncture therapy," "probiotics," "naturopathy," and "xylitol." Theses searches yielded 163 unique results. Abstracts and titles were evaluated for relevance. Case reports, case series, randomized controlled trials, and basic science research were included. Publications not relevant to the discussion of alternative medicine in otitis media were excluded. Bibliographies were checked for further publications. Thirty-six unique publications were reviewed. RESULTS: Of all therapies in complementary and alternative medicine, only xylitol has been studied in well-designed, randomized, blinded trials; it is likely effective, but compliance limits its applicability. CONCLUSIONS: Management of acute otitis media begins with watchful waiting. Herbal eardrops may help relieve symptoms. Homeopathic treatments may help decrease pain and lead to faster resolution. Prevention should be emphasized with elimination of risk factors, such as second hand smoke and bottle-feeding, as well as maintaining nutrition and vaccinations. Vitamin supplementation may be helpful. Probiotics and xylitol may be beneficial as well. Traditional Chinese/Japanese therapies show promising results but remain speculative until further research is conducted. Severe cases of otitis media with complications or those that fail to improve with observation or CAM (after 48-72h) should be treated with antibiotics and, in some cases, surgical intervention. It is best to consult a physician when making treatment decisions for full guidance on the risks and benefits of any treatment option.