Otitis Media: Implications of Fluctuating, Conductive Hearing Loss on

Learning and Behaviour in High School Age Students.

Paper by Jan Stenton

Definition of Otitis Media:

Otitis media (inflammation of the middle ear) is a general term used

for a number of conditions that affect the middle ear. They range from

acute to chronic, with and without symptoms. Over the last thirty

years there has been a great deal of discussion regarding the terms

used to described the various conditions associated with otitis media.

Consistent, internationally accepted terminology has been established

at four symposia (Klein, Tos, Hussl, Naunton, Ohyama & van Cauwenberge,

1989).

Frequently, the terms otitis media and middle ear infections are used

interchangeably but this is not an accurate procedure. Middle ear

inflammation with progressive tissue damage may proceed without middle

ear infection being present. This process may be acute, subacute or

chronic (Giebink & Daly, 1990).

Acute otitis media is generally defined as the first three weeks of

middle ear infection and is usually accompanied by ear pain, decreased

hearing and possibly fever. Subacute otitis media is defined as middle

ear inflammation lasting for three to eight weeks without symptoms

except for a mild, conductive hearing loss associated with the middle

ear fluid. Chronic otitis media is regarded as middle ear inflammation

lasting longer than eight weeks and it may exist with or without middle

ear fluid being present.

Otitis media is further classified on the basis of middle ear fluid

characteristics and middle ear tissue pathology. The fluid may be thin

and clear (serous), thin and cloudy (purulent), or thick and gluelike

(mucoid). In one third of otitis media with effusion cases there is

little or no effusion (Giebink et al, 1990).

When middle ear fluid is present for at least eight weeks without the

presence of otorrhea (a discharge from the ear) and without clinically

apparent tissue damage, the condition is referred as chronic otitis

media with effusion (OME).

Otitis media with effusion is characterised by the presence of fluid in

the middle ear space without signs or symptoms of infection. Otitis

media with effusion has also been referred to in the literature as:

serous otitis media mucoid otitis media tympanic hydrops

secretory otitis media secondary otitis media glue ear

allergic otitis media hydrotubotympanum fluid ear

catarrhal otitis media exudative catarrh middle ear effusion

nonsupporative otitis media tubotympanitis tubotympanic catarrh

noninfected middle ear effusion

The major symptoms associated with otitis media with effusion include

discomfort and behaviour changes. (Agency for Health Care Policy and

Research, Publication No 94-0623, 1994).

It is frequently difficult to decide by history and visual inspection

of the tympanic membrane the specific stage and type of otitis media

(Bluestone & Klein, 1988). Often, uncertainty remains as to the

content of the fluid and the presence or absence of infectious agents

but the signs and symptoms of acute infection are lacking. According

to Scheidt & Kavanagh (1986) reports of pathogenic organisms cultured

from serous fluid previously thought to be infection-free have added to

this uncertainty. The term otitis media with effusion was introduced

in the later 1970s to allow for the uncertainty in the actual

composition of the middle ear fluid and whether or not infection is

present. The term otitis media with effusion avoids specifying any

distinctions in the type of fluid present and is limited to the

observation that fluid of a non-specific nature is present in the

middle ear space.

After the onset of acute otitis media, fluid may persist in the middle

ear space for varying periods of time. Whatever the cause of the acute

otitis media, an unresolved condition where the fluid remains in the

middle ear space for a period of time from 2 weeks or longer is known

as persistent otitis media with effusion. However, when infections of

the middle ear occur repetitively such as four to five times over a

defined period of six month or a year the condition is referred to as

recurrent otitis media. It is important that a clear distinction

between recurrent, separate episodes of otitis media and persistent

otitis media with effusion be made as their impact on conductive

hearing loss differs.

What is already known regarding the medium and long term effects of

Otitis Media with Effusion:

The problem with otitis media with effusion is that the effusion causes

a conductive hearing loss. This hearing loss can last for six months

and it can fluctuate depending on the type of otitis media with

effusion. The hearing loss associated with otitis media with effusion

is usually mild ie 10 dB - 30 dB and is not always evident to parents

and teachers. The Australian Conductive Deafness Association Inc.

maintains that on any given day one out of three primary school age

children will have some degree of conductive hearing loss as a result

of otitis media with effusion (Teachers! Can Your Pupils Hear You?,

1994).

At the Second National Conference on Childhood Fluctuating, Conductive

Deafness organised by the Australian Conductive Deafness Association

Inc. it was clear that many studies have been done on infants and young

primary age children with a history of otitis media with effusion.

Some of these studies (including Dermody 1995 and Haggard 1995) have

found that children with fluctuating, conductive hearing loss have

speech processing and speech perception difficulties.

The Australian Conductive Deafness Association Inc. maintains that

children with fluctuating, conductive hearing loss are often identified

by their behaviour. This behaviour includes poor concentration and

attention, disobedience, irritability and poor social skills. Howard

(1995) suggests that the consequences of otitis media contribute to

behaviours that fit the diagnostic criteria of Attention Deficit

Disorder.

Bench and Harold (1995) have designed a model to explain how the above

sequelae develop from otitis media with effusion. Their model suggests

there is a progression from the onset of a mild, conductive, hearing

loss through the development of speech and auditory processing

difficulties, metalanguage problems and learning problems to social,

behavioural problems.

It is well established in the research that children who suffer from

fluctuating, conductive hearing loss are at risk of developing learning

and behavioural problems. However, the research to date has been

undertaken with young children ie children from birth to approximately

ten years of age. The purpose of this research is to establish whether

or not the problems identified continue to affect children as they grow

older and possibly no longer suffer from fluctuating, conductive

hearing loss. Does this common childhood problem affect the learning

and behaviour of junior high school students? Rarely have we looked to

improve the educational opportunities of adolescents by exploring

physical factors from early childhood.

Moore & Best (1988), in a study of 1 111 children in Melbourne,

Victoria, found that 33% of the children investigated had an undetected

hearing loss of at least 35 dB. A further 20% had normal hearing

combined with some degree of middle ear dysfunction, demanding careful

follow-up. This unexpectedly high incidence of otitis media with

effusion and abnormal ear dysfunction was of concern because otitis

media with effusion has been described as a precursor of auditory

learning problems in children.

According to Hasenstab (1987) interruption of the language learning

process theoretically interferes with the acquisition of communication

competence. However, it is not clear as to how much interference is

needed before the required skills are not acquired successfully.

Hasenstab (1987) also makes the point that a fluctuating, conductive,

hearing loss may make the acquisition of language skills and more

complex cognitive abilities more difficult than they are for the child

with a sensorineural loss because of the inconsistent auditory input.

In a study with a group of sixty children aged from 5 years 3 months to

6 years 6 months and divided into two groups: an otitis media with

effusion group and a control group Hasenstab (1992) found deficits in

the ability of the experimental group to process and represent auditory

information. Auditory and visual immediate recall for sequential

patterns was below expectations and cognitive abilities exceeded

performance. It takes time to process auditory information and the

children in the experimental group needed more processing time than

those in the control group. Tests which Hasenstab used in this study

to assess auditory tasks were the Nonsense Syllable Test, Pitch Pattern

Perception Test and Backward Masking. Tests to assess learning and

communication included the McCarthy Scales of Children’s Abilities,

Kaufman Assessment Battery for Children, the Assessment of Phonological

Processes and a communication sample analysis (based on a video tape

recording of children’s interactions).

It would be easy to assume that if children with a history of otitis

media with effusion experience the difficulties described by Hasenstab,

then they would present with educational difficulties more frequently

than the non affected population. Dwyer (1992) surveyed the files of

301 primary school children from grades prep to six who presented in a

private practice for educational assessment. The files were examined

for a history of hearing difficulties, including assessment of hearing

and consequent advice or action. The results of this survey must be

evaluated with some caution as all the children presented in a clinical

setting because of learning difficulties and, as such, they represent

a specialised group. However, the reduced phonemic sensitivity of

these children was greater than expected. They had increased

difficulty with tasks requiring phonemic sensitivity and the

application of phonics knowledge. Dwyer suggests that further research

needs to be carried out on the learning difficulties of the otitis

media with effusion population.

In a follow up study of the epidemiological Nijmegen Otitis Media study

Grievink, Peters, van Bon & Schilder (1993) examined a total of 946

seven year old children otologically and audiologically. These

children had all taken part in a previous three year study when they

were aged between 2 and 4 years of age. From this group 305 were given

language tests. Tests used included two subtests from the Language

Tests for Children (van Bon, 1982), to establish the children’s general

language ability. The morphological Word Forms Production Test was

also used because it has been demonstrated to be a good indicator of a

general language factor. In this study the researchers came to the

conclusion that parents and teachers need not be overly concerned about

the effects of otitis media with effusion on later language

development, however, they did acknowledge that the results may have

been because they used different language tests at age 3 and age 7 and

that existing differences possibly were missed by the language tests

chosen.

Hall and Grose (1994) investigated the effects of otitis media with

effusion on basic auditory abilities using a control group of 19

children and an experimental group of 42 children who had a history of

otitis media with effusion. Testing involved three masking conditions.

Hall and Grose found that children who have a hearing loss due to

otitis media with effusion are likely to have reduced monotic

Comodulation Masking Release ie they have difficulty in segregating

competing sounds.

Yonowitz, Yonowitz, Nienhuys & Boswell (1995) studied central auditory

processing in the hope of revealing a link between otitis media with

effusion and problems with auditory attention, speech discrimination

and with subsequent language and learning problems. Their experimental

group consisted of 12 Aboriginal children who spike Tiwi as their first

language and English as their school language. Their mean age was 7.9

years. The comparison group was 12 English speaking non Aboriginal

children (mean age =7.7 years) and none of these had a history of

otitis media with effusion or hearing impairment. The results

indicated highly significant differences in the Masked Level Difference

between the two groups.

Dermody (1992) at the First National Conference on Childhood

Fluctuating, Conductive Deafness / Otitis Media addressed issues

related to middle class urban children and focused on the possible

language consequences of middle ear problems. He suggested that there

is evidence for developmental problems associated with otitis media

with effusion including speech perception, attention and behaviour

problems as well as speech production problems. He suggested that the

link between these developmental aspects and otitis media with effusion

requires further investigation.

On the basis of these studies future research in the area of otitis

media with effusion should concentrate on specific areas of language

(eg auditory processing, auditory discrimination, acquisition of

meaning, visual processing etc) rather than on the broad topic of

language. Also it appears that behaviour could very likely be involved

in the sequelae of otitis media with effusion but so far this is mainly

based on theoretical supposition rather than research findings.

The Research Approach to be Used in the Study:

Design

The purpose of this research is to ascertain if there is a relationship

between a history of otitis media with effusion and learning and / or

behaviour. A correlational design is an appropriate approach. Scores

will be obtained related to learning and behaviour from a selected

sample of students with varying histories of otitis media with

effusion. These scores will be analysed so that an interpretation can

be made as to whether or not there is a relationship between a history

of otitis media with effusion and learning and / or behaviour.

Sample

Sixty students from a large, urban, state, high school.

Three groups of students grouped according to their middle ear history

-

Group A: control group - no history of middle ear problems.

Group B: research group 1 - history of middle ear problems - no

Group C: research group 2 - history of middle ear problems - had

All to have English as their first language.

14 years of age ie turning 14 during 1998.

Sample to contain no students with a previously diagnosed condition

such as Down Syndrome, Autism Spectrum Disorder etc which may affect

language, behaviour or both.

Data Collection Techniques:

Learning Area:

School academic results will be collected. Suitable normed instruments

may be used to gather data on students’ language and communication

abilities. The actual tests or testing methods have not yet been

decided upon, however, it is expected that they will include an

analysis of both spoken and written language skills.

Behaviour Area:

School records will be accessed regarding detentions, suspensions etc.

Questionnaires will be used to gather data from parents, students and

school staff.

Procedure:

Permission to undertake the study in a selected state high school

(possibly Cleveland State High School) will be requested from

Education, Queensland. When this permission is received and following

discussions with the school administration regarding the details of

the study a letter (see Appendix A) will be sent home to all Year 9

students requesting permission from their parents for them to take part

in the study.

A questionnaire (see Appendix B) will be sent home with the letter so

that those parents who choose to participate in the study will be able

to give their permission and provide background information on their

student’s middle ear history in the one procedure. The questionnaire

will request details regarding the students’ past history of ear

infections and the presence or not of certain other conditions and

behaviours. From the information received from this questionnaire

sixty students will be selected to participate in the study. The

students will be selected according to their middle ear history

resulting in a cross sample of students who have experienced no ear

infection history, students with a history of severe ear infections

(more than ten episodes) but no grommet insertion and students who were

fitted with grommets at some time. Students who have other,

predetermined, diagnosed conditions will not be included in the study.

Data Analysis:

Multiple correlational measures will be used to indicate the degree of

association between age, gender, history of otitis media with effusion

and learning and behaviour.

A post hoc analysis may be done if there is a cohort of students from

the Australian indigenous population within the overall sample.

Key Issues:

Internal Validity

The sample has been selected so that as many variables as possible have

been controlled, however, there are issues regarding validity which

still need further consideration.

A major difficulty regarding validity in this study will be the

identification of a history of otitis media with effusion within the

sample. As the students are 14 years of age and otitis media with

effusion is generally present during childhood it may be difficult for

parents and students to remember how many episodes of otitis media with

effusion the student had. However, at least the students who had

grommets will remember these and it is likely that if a student had a

high number of episodes of otitis media with effusion they and their

parents will remember them. Doctor’s records may need to be consulted.

A further difficulty will be that those students who report no

incidences of otitis media with effusion may in fact have had episodes

of fluctuating, conductive hearing loss but without infection being

present or without appropriate treatment..

Failure to control for the general state of health or other specific

health problems will predispose to overestimates of the effects of

otitis media with effusion.

By using only one school from which to draw the sample it is expected

that control for socioeconomic factors and linguistic environment will

be achieved.

The use of well developed tests especially in the learning area would

decrease the chance of subjectivity on the part of the researcher being

a validity problem. But it is possible that teacher marked written and

spoken work samples will be used. If possible one experienced English

teacher will be used to mark the samples. The use of questionnaires

will be carefully monitored because it is possible to "find what one is

looking for" and this will invalidate the study.

This study will be using retrospective data and it is possible that a

biased sample will result because parents reading the initial letter

requesting their permission may think that if their student did not

have many or any episodes of otitis media with effusion then there is

no reason for their student to take part in the research. Considerable

consideration must be given to the wording of the initial letter

requesting parental permission in order to avoid having a biased

sample.

External Validity

The extent to which the results of this study can be generalised to

other subjects and situations should be good. The sample will be large

and will include a number of students with and without a history of

otitis media with effusion. Also it is controlled by the elimination

of students with other diagnosed conditions which may lead to the same

type of sequelae as otitis media with effusion.

Conclusion

According to the AHCPR Panel a key issue in research into otitis media

with effusion is the association of this condition with long term

adverse effects on speech and language development, learning and

behaviour. Little is known about the effects that fluctuating,

conductive hearing loss can have on the long term outcomes for

otherwise normal children.

It is the purpose of this research to add to our present knowledge of

the long term effects of fluctuating, conductive hearing loss as a

result of otitis media with effusion.

References:

Agency for Health Care Policy and Research Publication No 94-0623,

(1994), USA. Otitis media with effusion in young children - Topic 12.

http://text.nim.gov/ftrs/tocvi.

Bench, J. & Harrold, E. (1995) How does otitis media lead to the

development of the deemed behavioural sequelae? Proceedings of the

Second National Conference on Childhood Fluctuating, Conductive

Deafness / Otitis Media held in Melbourne, 1995.

Bluestone, C.D., Beery, Q.C. and Paradise, J.L. (1973) Audiometry and

tympanometry in relation to middle ear effusions in children.

Laryngoscope, 83, 594-604.

Bluestone, C. D. & Klein J.O. (1988) Otitis Media In Infants and

Children London: W. B. Saunders Company.

Dermody, P (1992) Assessment of the effects of middle ear problems on

receptive language abilities in young children. Proceedings of the

First National Conference on Childhood Fluctuating, Conductive Deafness

/ Otitis Media held in Melbourne 1992, 115 -121.

Dermody, P. (1995) The consequences of middle ear disease: auditory

receptive language or speech perception problems. Proceedings of the

Second National Conference on Childhood Fluctuating, Conductive

Deafness / Otitis Media held in Melbourne, 1995.

Dwyer, J. (1992) Educational difficulties associated with childhood

fluctuating, conductive hearing loss - a survey of 301 primary school

children. Proceedings of the First National Conference on Childhood

Fluctuating, Conductive Deafness / Otitis Media held in Melbourne 1992,

163 - 169.

Feagans, L., Sanyai, M., Henderson, K., Collier, A., Appelbaum, M.

(1987) Relationship of middle ear disease in early childhood to later

narrative and attention skills. Journal of Paediatric Psychology, 12,

581-594.

Giebink, G. S. & Daley, K. (1990) Epidemiology and management of otitis

media in children. Topics in Language Disorders, 11 1 - 10.

Gravel, J.S. & Wallace, I. F. (1992) Listening and language at 4 years

of age: Effects of early otitis media. Journal of Speech and Hearing

Research, 35, 588 - 595.

Grievink, E. H., Peters, S. A. F., van Bon, W. H. J., Schilder, A. G.

M. (1993) The effects of early bilateral otitis media with effusion on

language ability: A prospective cohort study. Journal of Speech and

Hearing, 36,1004-1012.

Haggard, M. (1995) Sequelae of otitis media - diverse types of impact.

Proceedings of the Second National Conference on Childhood Fluctuating,

Conductive Deafness / Otitis Media held in Melbourne, 1995.

Hall, J. W., Grose, J. H. (1994) Effects of otitis media with effusion

on co-modulation masking release in children. Journal of Speech and

Hearing, 37, 1441-1449.

Hasenstab, S. (1987) Language Learning And Otitis Media. College-Hill

Press, Massachusetts, USA.

Hasenstab, S. (1992) Some effects of ome on auditory processing,

speech, language, learning and cognition. Proceedings of the First

National Conference on Childhood Fluctuating, Conductive Deafness /

Otitis Media held in Melbourne 1992, 95 - 104.

Hawke, M. (1995) Nutrition and its impact on learning, behaviour and

development. Presented at the Australian Council for Educational

Research Limited Council. Brisbane, ANSUA Qld Ltd.

Howard, D. (1995) Conductive hearing loss, communication and school

context. Proceedings of the Second National Conference on Childhood

Fluctuating, Conductive Deafness / Otitis Media held in Melbourne,

1995.

Kokko, E. (1975) Chronic secretory otitis media in children Acta

Otolaryngol. (Stockholm). Suppl. 327

Moore, D. C. & Best, G. F. (1988) Fluctuating, conductive hearing loss

in young children: Incidence and Effects. Report on a study of 1 111

pre-school and young school age children from Melbourne, Victoria.

Funded by the Deafness Foundation of Victoria, and carried out under

the auspices of Monash University, Clayton.

Moore, D. C. & Best, C. (1994) They Can / Can’t Hear When They Want To.

Australian Conductive Deafness Association Inc.

Murphy, E. & Blogg, S. (1995) Guidelines on the management of

paediatric middle ear disease-development, implementation and

evaluation. Proceedings of the Second National Conference on Childhood

Fluctuating, Conductive Deafness / Otitis Media held in Melbourne,

1995.

Nsouli, T., Nsouli, S., Linde, R., O’Mara, F., Scanlon R., Bellanti, J.

(1994) Role of food allergy in serous otitis media. Annals of Allergy

, 73,215-219.

Roberts, J., Rabinowitch, S., Bryant, M., Burchinal,M., Koch, M.,

Ramey, C. (1989) Language skills of children with different pre school

experiences. Journal of Speech and Hearing Research, 32, 773-786.

Scheidt, P.C. & Kavanagh, J.F. (1986) Common terminology for

conditions of the middle ear. In J.F. Kavanagh (ed), Otitis Media and

Child Development (pp xv - xvii).

Teele, D.W., Klein, J.O., Rosner, B.A. and the Greater Boston Otitis

Media Study Group. (1984). Otitis media with effusion during the first

three years of life and development of speech and language.

Paediatrics, 74, 282-287.

Yonowitz, L., Yonowitz, A., Nienhuys, T., Boswell, J., (1995) MLD

evidence of auditory processing factors as a possible barrier to

literacy for Australian aboriginal children. Australian Journal of

Education of the Deaf, 1, 34-42.