In this issue of Pediatrics, Bajorski et al1 performed a prospective observational cohort study of 286 children aged 6 to 36 months, to evaluate the incidence and risk factors for recurrent acute otitis media (AOM), and provide a predictor model clinicians can use to anticipate the recurrence and need for tympanostomy tube placement (TTP).
The burden of AOM in the pediatric population remains substantial; it is the leading cause of health care visits and antibiotic prescriptions, with estimated medical expenditures of $4 billion annually.2 In the United States, 23% of children experience at least 1 AOM by age 1 year, 60% experience an AOM before age 3 years, and up to 24% have 3 or more episodes.3 When a clinician diagnoses an AOM, they must weigh the antibiotics risk (adverse drug events and allergies, cost, microbiome alteration, and Clostridioides difficile infections)4,5 against the risk of watchful waiting (chronic otitis media with effusion, perforation, hearing loss, and rare instances of mastoiditis and intracranial spread).6 Streptococcus pneumoniae has traditionally been the leading cause of AOM and most often associated with perforation7 ; however, with the introduction of pneumococcal vaccinations in 2000, S. pneumoniae has become less prevalent in cultures of middle ear fluid from children with AOM. This decline coincides with an increase in nontypeable Haemophilus influenzae and Moraxella catarrhalis recovery from middle ear fluid3,8 ; organisms that cause less severe disease and are much more likely to resolve without antibiotics.9 Not only have vaccines resulted in a decline in overall cases of AOM, but also, there has been a decline in surgeries performed for AOM.10 However, TTP remains the most commonly performed surgery in pediatrics requiring general anesthesia; a prevalence study using a national health interview survey in 2014 evaluated >73 million children in the United States and estimated the prevalence of TTP at 8.6%.11 Guidelines recommend performing TTP when the child has persistent otitis media with effusion at the time of evaluation, and experiences recurrent AOM, which is defined as 3 or more well-documented episodes of AOM in a 6-month time frame, or at least 4 well-documented AOM in a 12-month time frame.12 This procedure does not come without risks: complications, in addition to the need for general anesthesia, include otorrhea, perforation, occlusion, extrusion, myringosclerosis, and atrophy to name a few.13,14 Additionally, a systematic review of the effect of TTP in children found that 2 to 5 children have to undergo TTP to prevent 1 child from a subsequent case of AOM in 6 months.15 Steele et al evaluated 147 articles and found that TTP improves hearing at 1 to 3 months compared with watchful waiting; however, there was no benefit by 12 to 24 months.14
In the current study, Bajorski et al1 introduce the concept of a window of susceptibility (WOS), referring to a child who has 2 or more closely spaced AOM occurrences during a window of time. They also develop models to predict risk and timing of AOM recurrences. These tools may help clinicians predict the child who is more likely to benefit from a TTP: a young child (aged 6 to 14 months) who attends day care and has had recurrent AOM in proximity. It also allows clinicians to consider watchful waiting and delaying referral for those children who may be at the end of their WOS, and at a lower risk of recurrence using their prediction model.
What is noteworthy in this study is the rigor with which an AOM diagnosis was made: >85% of cases were confirmed by tympanocentesis and culture of the middle ear fluid. This is not what we typically see in the real word, where AOM is commonly overdiagnosed. In fact, diagnostic accuracy for AOM may be as low as 50% to 70%.16–18 Additionally, it does not take into consideration viral AOM, which may account for up to half of AOM cases.19 We suspect many children undergoing TTP in the community may not truly fit the strict diagnostic criteria laid out in the guidelines or followed in this study. The model may therefore overestimate the number of children who may require TTP.
Although this study may help guide clinicians as to which patient may need earlier referral for TTP, many questions remain. Would the data be replicated in a patient population that is not predominantly white, insured, and with very low smoking exposure, a controllable risk factor for AOM? With the decrease in vaccination rates that we are currently witnessing, will the epidemiology of AOM shift yet again?
Until we have more answers, clinicians should remember that pneumococcal and influenza vaccines decrease the risk of AOM. While working to ensure timely adherence with all vaccinations, catchup vaccinations for those children who have fallen behind during the pandemic are essential. Clinicians should support families to modify risk factors like tobacco exposure, follow strict criteria to diagnose AOM, discuss the risks of antibiotics when indicated, and offer watchful waiting when appropriate. Future advances in use of new instruments to view the tympanic membrane and adding in artificial intelligence methodologies may allow for increased accuracy in diagnosis of AOM. The WOS concept may allow us in conjunction with our otolaryngology colleagues to optimize treatment of those with recurrent AOM and to recognize when TTP will improve outcomes.
Dr El Feghaly drafted the commentary and reviewed it critically; Dr Jackson outlined the content and reviewed the commentary critically for clarity of message; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-058556.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLAIMER: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
acute otitis media
tympanostomy tube placement
window of susceptibility