Efficacy of Pneumococcal Vaccine on Otitis Media: A Systematic Review and Meta-Analysis.

OBJECTIVE: To assess the effect of the pneumococcal vaccine (PCV) toward the surgical management and complications of otitis media. DATA SOURCES: MEDLINE, EMBASE, PubMed, Scopus, and clinicaltrial.gov. REVIEW METHODS: A systematic search was performed using a combination of keywords and standardized terms about PCV and surgical management or complications of otitis media. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies were screened by 3 independent reviewers. Risk of bias assessment, followed by meta-analysis in only randomized-controlled trials was conducted. Vaccine efficacy (VE) and 95% confidence interval (CI) were reported. RESULTS: Of the 2649 abstracts reviewed, 27 studies were included in the qualitative analysis and were categorized into 6 outcomes: tympanostomy tube insertion, otitis media with effusion (OME), mastoiditis, spontaneous tympanic membrane (TM) perforation, recurrent acute otitis media (AOM), and severe AOM. Fifteen studies were included in the meta-analysis to evaluate the rate of tympanostomy tube insertion, OME, and recurrent AOM. PCV was significantly more effective in lowering the rate of tympanostomy tube insertion (VE, 22.2%; 95% CI, 14.6-29.8) and recurrent AOM (VE, 10.06%; 95% CI, 7.46-12.65) when compared with the control group, with no significant difference in reducing the incidence of OME. The qualitative analysis revealed that PCV had efficacy in preventing severe AOM and spontaneous TM perforation but the effect on mastoiditis remained unclear. CONCLUSION: The PCV was effective in reducing the rate of tympanostomy tube insertion and the incidence of recurrent AOM with a nonsignificant effect in preventing OME in children.

Pediatric respiratory tract foreign bodies in children: A systematic review.

OBJECTIVE: Pediatric respiratory emergencies of airway foreign body (FB) are a common cause of visits to the emergency department (ED) and respiratory failure is a major cause of cardiopulmonary arrest. The purpose of this study is to evaluate the literature and update our current understanding of pediatric respiratory tract FBs in children by clearly considering the aspect of the complications and related factors. METHODS: A systematic search of PubMed and Embase yielded a total of 2035 studies related to the respiratory tract FB in children. After screening the abstracts, 118 articles were included for analysis. However, 56 articles were excluded due to the published data more than 10 years. Meanwhile, 6 articles were duplicated and 3 articles were the secondary data. Thus, 53 full text articles were assessed for eligibility. Then, 46 full text articles were excluded due to irrelevant contents. Finally, there were 7 qualitative articles in this systematic review. RESULTS: Most children with FBs in the aerodigestive tract are 1-3 years of age. Most FBs are organic, especially seeds. The most commonly obstructed airway is the right primary bronchus. The most common and severe complications are pneumonia, pulmonary atelectasis, lung consolidation, pneumothorax, bronchiectasis, and death. The main device for the removal of FBs from the airways is a rigid bronchoscope. Duration of diagnosis is major factors that related with severe complication. CONCLUSION: FBs obstructive conditions in respiratory tract of children are serious and life-threatening conditions. The likelihood of death depends on the location of the obstruction, the nature of FB, time to removal, and initial resuscitation. Moreover, even after a FB has been removed, complications can lead to death. Educating parents and immediate treatment is very important. Rapid diagnosis is important factor to prevent complication.

Prevalence of high-risk for obstructive sleep apnea in attention deficit hyperactivity disorder children referred to psychiatry clinic and impact on quality of life.

Objectives: To study the prevalence of high-risk obstructive sleep apnea (OSA) in attention deficit hyperactivity disorder (ADHD) children in a child and adolescent psychiatry clinic using the Thai version of the Pediatric Obstructive Sleep Apnea Screening Tool (POSAST) questionnaire. The secondary objective was to evaluate the quality of life and identify associated factors for high-risk OSA in ADHD children. Study design: Prospective cross-sectional study. Material and method: Caregivers of pediatric patients aged 5-18 years old and diagnosed with ADHD by child and adolescent psychiatrists were surveyed about their child's sleeping habits. Results: Two hundred and seventy-four subjects were included. The patients' mean age was 10.4 ± 2.6 years, and 82.8% were males. There were 30 children (10.9%) diagnosed with obesity, 46 (16.8%) with chronic rhinitis, and 9 (3.3%) with asthma. The median duration of ADHD symptoms was 22.1 months. The prevalence of high-risk OSA was 18.2% and was associated with significantly reduced quality of life (adjusted OR = 4.46, 95% CI: 2.26-8.81, P < 0.001). A significant association between high-risk OSA and obesity also emerged (adjusted OR = 2.84, 95% CI: 1.17-6.88, P = 0.021). Conclusion: An elevated prevalence of high-risk OSA is present among Thai children with ADHD, and significantly impacts quality of life. A significant association between high-risk OSA and obesity is also detected in patients with ADHD. Therefore, screening for high-risk OSA in ADHD patients may likely facilitate early detection and treatment of OSA, and potentially prevent adverse consequences.

Adenoid measurement accuracy: A comparison of lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy (gold standard).

OBJECTIVE: To compare the accuracy of lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy in assessment of adenoid size. METHODS: A cross-sectional study was conducted in 43 pediatric patients undergoing ENT surgery from July 2017 to December 2018. All patients underwent preoperative lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy. RESULTS: The average adenoidal-nasopharyngeal (A/N) ratio obtained from lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy was 72.9, 79.5, and 81.6, respectively. There was a moderate correlation between A/N ratio from lateral skull film and intraoperative rigid endoscopy (Pearson's correlation: 0.567, p˂0.001). Whereas, the A/N ratio from flexible endoscopy compared to intraoperative rigid endoscopy showed a stronger correlation (Pearson's correlation: 0.791, p˂0.001). From linear regression analysis, the intraoperative adenoid measurement was estimated from the results of flexible endoscopy (intraoperative rigid endoscopy: 0.72 [flexible endoscopy] +24.47) and lateral skull film (intraoperative rigid endoscopy = 0.65 [lateral skull film] + 34) CONCLUSION: Flexible endoscopy yields the most accuracy in the assessment of adenoid size and nasopharynx visualization, without radiation exposure or anesthesia. Despite less accuracy, lateral skull film is more availability in every hospital. The correlation of adenoid size measurement in this study can also be applied for the actual size of adenoid.

Validity and reliability of the Thai version of the pediatric obstructive sleep apnea screening tool.

OBJECTIVE: Obstructive sleep apnea (OSA) is highly prevalent in children and requires an expensive and relatively unavailable sleep study for diagnosis. This study was undertaken to translate the previously validated pediatric OSA screening tool (POSAST) to the Thai language and assess its accuracy and test-retest reliability in at-risk symptomatic children. STUDY DESIGN: Prospective cross-sectional cohort study. METHODS: Pediatric patients clinically referred for suspected OSA who underwent overnight polysomnography (PSG) were recruited, and caregivers completed the Thai version of the POSAST. The same questionnaire was completed again after 2-4 weeks. The reliability of the questionnaire was determined by internal consistency and test-retest reliability. The validity of the questionnaire was assessed by constructing receiver operating characteristic (ROC) curves to identify the equation-derived score and total additive score cutoff points that identify high risk for moderate and severe OSA (AHI of ≥ 5 events/h). RESULTS: One hundred and ten subjects completed the study. The mean age was 8.4 ± 2.9 years. The mean apnea-hypopnea index (AHI) was 10.9 ± 11.9 events/h. Test-retest reliability (Pearson correlation coefficient = 0.96, p < .001) and internal consistency between each question (Cronbach's alpha coefficient = 0.82, p < .001) were excellent. An equation-derived score cut-off of 1.9 yielded 78.4% sensitivity, 50.0% specificity, 76.3% positive predictive value (PPV), and 52.9% negative predictive value (NPV), while a total additive score cut-off of 8 corresponded to 81.1% sensitivity, 52.8% specificity, 77.9% PPV, and 57.6% NPV for diagnosing moderate and severe OSA (AHI ≥ 5 events/h). CONCLUSION: The internal consistency and reproducibility of the Thai version of the POSAST are satisfactory, display acceptable validity, and the instrument can be used for screening symptomatic Thai children for OSA.

Association between adenoid bacteriology and clinical characteristics of adenoid-related diseases in children.

INTRODUCTION: The aim of this research is to find the association between the pathogenic bacteria obtained from the adenoid culture and clinical characteristics of adenoid-related diseases in children. METHODS: In this retrospective study, we reviewed the medical records of children who had adenoidectomy for adenoid-related diseases. Demographic data, diagnoses, indications for adenoidectomy and bacterial culture results were collected. The adenoid size was measured in the lateral skull X-ray as adenoid-nasopharyngeal ratio. Associations between the culture results and the demographic data, adenoid size, and the diagnoses were analyzed. RESULTS: There were 407 children who had adenoidectomy for obstructive sleep-disordered breathing (75.2%), otitis media with effusion (19.2%), and chronic sinusitis (5.6%). Median age was 5.9 years. Common pathogenic bacteria in the adenoid were Haemophilus influenzae (26.2%), Staphylococcus aureus (23.5%), Streptococcus pneumoniae (18.2%), and Moraxella catarrhalis (12%). The patient's age had significant association with the prevalence of pathogenic bacteria. S. pneumoniae was most prevalent in young children up to 7 years. S. aureus was more common in children over 7 years. H. influenzae had similar prevalence in all age groups. Size of the adenoid and type of adenoid-related diseases had no association with the outcome of bacterial culture. CONCLUSION: Age of the patients was the significant factor associated with the bacteriological findings of the adenoid while size and types of adenoid-related diseases were not associated with the outcome of bacterial culture.

Watch Peripheral Arterial Tonometry in the Diagnosis of Pediatric Obstructive Sleep Apnea.

Objective To assess the accuracy and clinical reliability of watch peripheral arterial tonometry (PAT) compared with polysomnography (PSG) for the diagnosis of pediatric obstructive sleep apnea (OSA). Study Design Prospective, diagnostic test study. Setting National tertiary referral hospital. Subjects and Methods Patients aged 8 to 15 years with clinically suspected OSA were recruited. All participants underwent PSG and PAT simultaneously in the sleep laboratory. Results Thirty-six patients were included, with a mean age of 10.2 ± 1.8 years. Median (interquartile range) of the apnea hypopnea index (AHI) was 8.0 (5.5-12) and 2.9 (0.5-7.5) events/h, median oxygen desaturation index (ODI) was 2.5 (1.4-8.3) and 1.3 (0.2-3.8) events/h, mean ± standard deviation total sleep time was 398.4 ± 38.3 and 401.9 ± 36.1 minutes, and mean minimum oxygen saturation was 87.1% ± 8.1% and 89.4% ± 7.1% for PSG and PAT sleep parameter results, respectively. Agreement between methods was excellent for the AHI (intraclass correlation coefficient [ICC]: 0.89; 95% CI, 0.40-0.96; P < .001) and ODI (ICC: 0.87; 95% CI, 0.69-0.94; P < .001). Correlation between methods was very good for the ODI ( r = 0.83; 95% CI, 0.67-0.90; P < .001) and moderate for the AHI ( r = 0.64; 95% CI, 0.30-0.85; P < .001). From the receiver operating characteristic curve constructed to assess PAT diagnostic capability, AHI of PAT (W-AHI) at a cutoff of 3.5 events/h provided the highest accuracy (76.9% sensitivity, 78.3% specificity), while W-AHI at 10 events/h yielded 91.3% specificity for diagnosing severe OSA. Conclusion PAT correlated well and had good agreement with PSG. Children with W-AHI ≥10 had high specificity for the diagnosis of severe OSA. Larger studies with PAT designed for children across all age ranges and with a normal control group are still needed.

Surveillance of Otitis Media With Effusion in Thai Children With Cleft Palate: Cumulative Incidence and Outcome of the Management.

OBJECTIVE: To study the incidence and outcome of management of otitis media with effusion in Thai children with cleft palate. DESIGN: Retrospective cohort study in the tertiary care center. PATIENTS: Ninety-five children with cleft palate were referred for ear evaluation, from June 1997 to January 2015. Fifteen children (15.8%) had associated craniofacial syndromic anomalies. MAIN OUTCOME MEASURES: Cumulative incidence of otitis media with effusion, rate of ventilation tube insertion, duration of indwelling tubes, hearing outcome, and complications of ventilation tubes. RESULTS: Ear examinations were done every 8 to 12 weeks throughout the study. Cumulative incidence of otitis media with effusion was 53.7% in children within 12 months of age and 81.1% within 24 months of age. At the end of the study, all of the patients had at least 1 episode of otitis media with effusion. Eighty-eight children (92.6%) had palatoplasty, and there was no significant difference in the incidence of otitis media before and after palatoplasty. The mean hearing level at recruitment was 40.8 ±18.4 dB. Ventilation tube insertion was done in 76 patients (80%). The median time for indwelling tubes was 11.7 months. Rate of ventilation tube insertion was 0.5/year. The mean hearing level at last follow-up was 23.5 ± 14 dB. Otorrhea through tube was found in 24 cases (31.6%). CONCLUSION: Otitis media with effusion was common in Thai children with cleft palate. Surveillance of middle ear effusion and ventilation tube insertion contributed to a favorable hearing outcome.

Recurrent Acute Rhinosinusitis Prevention by Azithromycin in Children with Nonallergic Rhinitis.

BACKGROUND: Recurrent acute rhinosinusitis (RARS) is characterized by multiple episodes of acute rhinosinusitis between which symptoms and signs resolve completely. The role of antibiotic prophylaxis to prevent RARS in children with nonallergic rhinitis (NAR) has not been investigated. OBJECTIVE: To evaluate the effect of azithromycin to prevent RARS in children with NAR. METHODS: A randomized, double-blind, placebo-controlled study was conducted in NAR children (5-15 years) with RARS. Azithromycin (5 mg/kg/d) 3 d/wk for 12 months or placebo was assigned to the study group and the control group, respectively. Patients with allergic rhinitis were excluded. Number of rhinosinusitis episodes in 12 months, visual analog scale score of nasal symptoms, and adjunctive medication score were recorded. RESULTS: Forty patients were enrolled and 20 patients were assigned randomly to the azithromycin and placebo groups. IgG subclass and specific antibody deficiencies were found in 83% and 2.5% of patients, respectively. After 12 months, the number of rhinosinusitis episodes/y in the azithromycin group reduced significantly from 5 to 0.5 (P < .001) in contrast to the placebo group. Number needed to treat using azithromycin prophylaxis to prevent 1 patient from having RARS was 2. The average visual analog scale score and the average adjunctive medication score in the azithromycin (but not in the placebo) group reduced significantly compared with baseline (2.2 ± 1.4 vs 5.4 ± 1.8) and (3.9 ± 1.7 vs 5.4 ± 1.1), respectively (P < .001). CONCLUSIONS: Azithromycin prophylaxis can reduce the number of rhinosinusitis episodes and medication score, and improve nasal symptoms in NAR children with RARS.

Association of otoscopic findings and hearing level in pediatric patients with otitis media with effusion.

OBJECTIVE: To find the association between the abnormalities of tympanic membrane characteristics and the hearing level in pediatric patients with otitis media with effusion. METHODS: Sixty-three pediatric patients with otitis media with effusion had undergone ear examinations by pneumatic otoscopy to assess the color, transparency, mobility, fluid level and retraction of the tympanic membrane. An audiogram was done in the same setting, average hearing threshold and air-bone gap were measured. Otoscopic findings and the result of the hearing test were analyzed to identify the association between the abnormalities of the tympanic membrane characteristics and elevated hearing threshold. RESULTS: Hearing loss was found in 92.1% of the patients. Mean hearing level was 31.7+/-10.3 dB. From linear regression analysis, the patients with dull or opaque tympanic membrane had a significantly higher hearing threshold of 7.2 dB than the patient with translucent ear drum after adjusting for mobility and retraction. The patients with tympanic membrane retraction had a higher hearing threshold of 5.1 dB than the patient who had no retraction after adjusting for transparency and mobility. Mobility had a significant relationship to elevated hearing threshold in the univariate analysis but not in multivariable analysis. CONCLUSION: Opacity and retraction were the two characteristics of abnormal tympanic membrane that were associated with elevated hearing threshold in the patients with otitis media with effusion. Hearing test is suggested if opacity or retraction of the tympanic membrane is found.

Factors affecting quality of life of pediatric outpatients with symptoms suggestive of sleep-disordered breathing.

OBJECTIVE: To determine the relationship between causative factors of sleep-disordered breathing (SDB) and quality of life (QOL) of children who presented with SDB. METHODS: Prospective cross-sectional study was done. Pediatric outpatients with SDB were recruited. Patients with craniofacial, neurologic or syndromic anomalies and previous adenotonsillectomy were excluded. Data collected were clinical history, physical examination and lateral skull X-ray, along with QOL survey by using obstructive sleep apnea-18 (OSA-18) questionnaires. We assessed the association between clinical signs, the size of the tonsils and the adenoids, overweight/obesity and the OSA-18 scores to see the impact of these factors on QOL. RESULTS: Fifty-one children were enrolled. Mean age was 6.4+/-2.6 years. The most common clinical findings was mouth breathing (41.2%). Tonsillar hypertrophy (> or =3+) was found in 62.7 and 52.9% had adenoid-nasopharyngeal ratio greater than 70%. Overweight/obesity were found in 35.3% of the patients. OSA-18 scores ranged from 22 to 85. Tonsillar hypertrophy was significantly related to QOL (p<0.05). Adenoid hypertrophy had trends towards impact on QOL (p=0.094). Mouth breathing correlated well with QOL (p<0.01). Overweight/obesity and QOL had no statistically significant correlation. CONCLUSION: Tonsillar hypertrophy and mouth breathing were the clinical findings that affected most to the QOL of the children with SDB. Adenoid hypertrophy had trends towards the impact on QOL, although not statistically significant.

Pediatric sinusitis:symptom profiles with associated atopic conditions.

INTRODUCTION: Sinusitis is a very common disease in childhood. Clinical manifestations in childhood sinusitis are different than in adult. Information in childhood sinusitis in Thailand is limited. We performed a prospective descriptive study to determine clinical characteristics of childhood sinusitis in Thailand MATERIAL AND METHOD: One hundred pediatric patients with clinical diagnosis of sinusitis attending pediatric allergy clinic, pediatric outpatient clinic, and pediatric ENT clinic were recruited. Clinical diagnosis was defined by presence of symptoms indicating upper respiratory infections with exudates at middle meatus by anterior rhinoscopy. Thorough history taking and physical examinations were conducted with findings recording into sinusitis questionnaire. Sinus radiographs were taken in 77 patients and were read blindly a single radiologist who was unaware of clinical conditions of patients. Allergy skin prick tests were performed with a panel of common aeroallergens in Thailand. RESULTS: Age range of the 100 patients were between 1.7 to 12.4 years with a mean (+/- SD) of 6 +/- 2.72 years. History of atopic disease among patients and their families was positive in 49% and 47% respectively. Four most common clinical manifestations were rhinorrhea (95%), nocturnal and productive cough (91%), nasal congestion (74%) and posterior nasal dripping (66%). The three most common signs were obstruction of middle meatus (100%), swelling of turbinates (92%) and granular pharynx (48%). All paranasal sinuses X-rays were abnormal with maxillary sinus being the most commonly involved sinus (99%) followed by ethmoid sinus (91%). The majority of patients had involvement of more than one sinus. Skin prick tests were positive in 53.6%. The two most common sensitizing allergens were dust mites (57.7) and cockroaches (18.6%). CONCLUSION: The presence of symptoms of rhinorrhea, cough, nasal congestion and posterior nasal drip should alert physicians for diagnosis of sinusitis in pediatric patients. Maxillary and ethmoid sinus were the most common sinuses involved. Atopic predisposition is present in up to 53.6% in this population.

Development of a health-related quality of life questionnaire for Thai patients with rhinoconjunctivitis.

The objective of this study was to develop a disease-specific questionnaire for patients with rhinoconjunctivitis. All patients were recruited at the Out-Patient Clinic at Siriraj Hospital. Related topics were gathered from several sources, and a list of 63 items was produced. In phase I, the first version of the questionnaire was completed by 363 patients. Forty-eight items were identified by clinical impact analysis during the item removal process, two more questions were then added, giving a total of 50. Two hundred and forty-three patients completed the second version questionnaire in phase II. The average time taken to complete the questionnaire was 6.38 minutes. The item removal process in phase II was achieved by a multi-step process. There were 36 items in the third version questionnaire which consisted of six dimensions and two independent items as follows: symptoms (17 items), physical functioning (3 items), role limitations (3 items), sleep (3 items), social functioning (3 items), emotions (5 items), general health (1 item), and absenteeism (1 item). The scores of each item ranged from 1 to 5; a lower score indicating a better quality of life. Data from the selected 36 items was extracted to test the validity and reliability of the final version. The floor and ceiling effects of the scores for each dimension were low. Multitrait multi-item analysis was conducted to examine construct validity. The scaling success of convergent and divergent validity was 100% and 94%, respectively. Internal consistency determined by Cronbach's alpha coefficient, was satisfactory (0.79-0.87). The study indicates that the questionnaire is suitable for use in clinical settings. While the test results are encouraging, further work needs to be done on the test-retest reliability and on responsiveness.

Effect of adenoidectomy in children with complex problems of rhinosinusitis and associated diseases.

OBJECTIVES: The effectiveness of adenoidectomy in the management of pediatric sinusitis is still a controversial issue. The size of the adenoid and associated diseases are the factors for consideration. The adenoid has been studied and is proved to be a probable source of infection for the paranasal sinus. The purpose of this study is to evaluate the efficacy of adenoidectomy in reducing the frequency of sinusitis in children. METHODS: A prospective study was done in pediatric patients with rhinosinusitis admitted for adenoidectomy from January 2000 to January 2002. Pre-operative frequency of rhinosinusitis, underlying diseases and the diseases caused by the adenoid were recorded. The adenoid size was evaluated by lateral skull X-ray. The patients were followed after surgery and frequency of rhinosinusitis and associated diseases were compared with the pre-operative period. RESULTS: There were 37 patients with mean age of 6+/-2.8 years. Mean duration for pre-operative review was 436.7 days and mean duration for post-operative follow up was 450.2 days. Almost all (92%) of the patients had obstructive sleep disorder and 88.2% had adenoid-nasopharyngeal ratio >0.7. There was a statistically significant reduction of episodes per year of rhinosinusitis and obstructive sleep disorder after surgery (P-value < 0.001 and 0.008, respectively). CONCLUSIONS: Adenoidectomy was proved to be effective in the management of pediatric rhinosinusitis in this series. Adenoidectomy should be most beneficial as a surgical option before endoscopic sinus surgery (ESS), especially in younger children with obstructive symptoms.