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. 2023 Oct 12;76(1):1464–1469. doi: 10.1007/s12070-023-04256-5

Risk Factors for Chronic and Recurrent Otitis Media in Children: A Review Article

Kholood Assiri 1,✉, Jibril Hudise 2, Ali Obeid 3
PMCID: PMC10908946  PMID: 38440639

Abstract

Otitis media is an inflammation of the mucous membrane of the middle ear, which includes mastoid air cells, the middle ear cavity, the Eustachian tube, and the mastoid antrum. Otitis media can be either acute, less than six weeks, or chronic, which lasts for more than six weeks. Recurrent otitis media refers to three episodes of the disease occurring within six months or four episodes within one year. There are many risk factors for otitis media among children; however, some of such factors may vary based on the type of otitis media. To highlight the risk factors of chronic and recurrent otitis media in pediatrics. Scientific databases were used to search for articles related to our objective. Various terms were used for the search process. The types of articles included in our review were original articles, review articles, meta-analyses, and systematic reviews written in the English language and concerned with our subject. The topic was discussed under four main titles; the first overviewed the prevalence and risk factors of otitis media, the second title discussed chronic otitis media and its risk factors, the third title discussed recurrent otitis media and its risk factors, and the last title discussed the risk factors of both chronic and recurrent otitis media. There are various risk factors for chronic and recurrent otitis media, and they include allergy, passive smoking, male gender, and snoring. Also, genetics may have a common role, but this needs further investigation.

Keywords: COM, ROM, Risk factors, Determinants, Predictors, Children

Introduction

Otitis media (OM) is a severe health problem globally as it has a burden on the patient and family as well as the healthcare system. OM is defined as an inflammation of the middle ear with no specific etiology or pathogenesis. OM refers to the inflammation of the mucous membrane of the middle ear, which includes mastoid air cells, the middle ear cavity, the Eustachian tube, and the mastoid antrum. The infection of the middle ear may cause inflammation and infection in the other three regions of the sinuses because all sinuses of the temporal bone are continuous [1]. The accompanying inflammation with a discharge from a perforation in the tympanic membrane is known as suppurative OM (SOM) [2].

OM can be acute for less than six weeks or chronic that lasts for more than six weeks [2, 3]; acute OM is an inflammation of the middle ear that presents with rapid signs and symptoms onset of up to three weeks duration. Acute OM can be caused by many types of infectious microorganisms, such as viruses and bacteria. Chronic OM (COM) refers to the inflammation that involves middle ear fluid that is present for three months or longer. The term chronic OM also has many synonyms such as glue ear, serous OM, and secretary OM [4]. Recurrent acute OM (AOM) is defined as three episodes of the disease within six months or four episodes within one year [4].

Infants and young children are at an increased risk of developing OT [1], and OT is one of the most frequent disorders of children globally [5]; two out of three children will have at least one episode of OM before their third birthday [6]. Almost 80% of children by the age of three years have at least one episode of acute OM, and nearly one-half have three or more episodes; however, the incidence declines after six years of age [3].

There are many predisposing factors for OM among children and they include the use of pacifiers and digit sucking, parental smoking and exposure to wood smoke, familial tendency, measles, tuberculosis, pertussis, down syndrome, cleft palate, and upper respiratory tract infections such as nasopharyngitis and rhinitis [3].

Both chronic OM (COM) and recurrent OM (ROM) are the most common infectious disorders globally [7]. Although all children can experience at least one episode of OM, morbidity is the highest in children who experience COME/ROM [8]. It was indicated that recurrent OM among children has prolonged impacts on hearing, behavior, speech development, and school performance [9].

Both COM and ROM can cause hearing impairment and speech delay. Additionally, COM can cause both extracranial and intracranial complications [7]. The effective management of a disease is based on the understanding of the risk factors of such disease. The risk factors associated with COM/ROM include genetic factors, ethnicity, breastfeeding, and allergy or atopy [7]. However, there is a lack of reviews overviewed and discussing COM and ROM risk factors; therefore, we conducted the current review to discuss the risk factors of COM and ROM among children.

Materials and Methods

The articles involved in this review were obtained from scientific websites and databases, including PubMed, Science Direct, Scopus, Google Scholar, and Elsevier. Various keywords were used for the search purpose to obtain articles related to the current subject, including "Otitis media, Chronic Otitis media, Recurrent Otitis media, Risk factors, Determinants, Predictors, Children, Pediatric, and Population." These terms were used in different combinations in order to obtain all possible articles. All types of articles were eligible to be incorporated into our review, including original studies, review articles, systematic reviews, and meta-analyses. Therefore, the articles that resulted from the search process were reviewed to involve articles eligible for our subject. Firstly the titles were reviewed for findings, and all articles irrelevant to our subject were excluded. The second step involved reviewing the abstracts of articles, and articles written in non-English language were excluded. Also, articles with unclear findings or incomplete data, duplicate articles, and letters to the editor were also excluded. Due to a lack of studies focusing on chronic otitis media and recurrent otitis media among children, we included not only the recent articles but also the eligible earlier published studies.

Discussion

Prevalence and Risk Factors of Otitis Media Among Children

Many prevalence rates have been reported in the world on OM [1]. Almost 60–70% of all children will experience one or more episodes of OM during childhood and 24% will suffer from more than three episodes of OM during their childhood [10, 11]. In Australia, the prevalence of OM among children aged 5–7 years was found to be 11% for unilateral and 11.5% for bilateral OM [12].

A study from South Africa conducted on children showed that OM was more common among younger children compared to older children, 31.4% Vs. 16.7%, respectively. Also, AOM was diagnosed among younger children aged 2–5 years with a prevalence of 1.7% [13]. A previous review revealed that the prevalence of OM among children less than six years ranged between 6.7% in China to 10% in Egypt [14].

The risk factors of OM involve multiple factors such as host-related factors (gender, age, race, malnutrition, allergy, genetic predisposition, and craniofacial abnormalities, and environmental factors such as breastfeeding, socioeconomic status, tobacco smoking, presence of siblings, daycare, upper respiratory infection and seasonality [13].

Regarding the risk factors of OM, one study was conducted on 300 children patients with OM between the age of three months and 12 years. It was found that the occurrence of OM was significantly associated with many risk factors, including artificial feeding, residence in rural regions, parental smoking, allergic rhinitis, low socioeconomic status, adenoid hypertrophy, the introduction of a foreign body into the ear, and chronic tonsillitis. It was revealed that controlling such risk factors can reduce the incidence of the disease [15]. Another study assessed the risk factors of early OM among children aged six months. There are various identified risk factors for OM, and they include male gender, maternal administration of penicillin during pregnancy, children born before the 38th gestational week, children born for younger age women, and children received breastfeeding less than six months. Furthermore, it was found that parental risk factors were less important regarding early OM before the age of six months [9].

Chronic Otitis Media and Risk Factors

Chronic otitis media (COM) is a term used to illustrate various symptoms and signs as well as physical findings that usually result from long-term damage to the middle ear by inflammation and infections [16]. COM is characterized by more long-term alterations to the function and shape of the eardrum, including [17] retraction pocket in the TM perforation of the TM, atelectasis in which TM is attached to one of the walls of the middle ear, middle ear mucosal disease, chronic or recurring discharge from the middle ear which is known as otorrhea, ossicular erosion in the middle ear and cholesteatoma which refers to the presence of keratinized squamous epithelium in the middle ear [16]. However, COM is relatively rare in childhood [18].

COM is a common childhood disorder, and under treatment or improper treatment may cause severe complications that further affect the quality of life of children [16], as it can cause permanent hearing loss, especially within developing countries [17]. The diagnosis of COM is often difficult as COM comprises a spectrum of pathologies [16].

There are many factors that contribute to COM, and they involve gender (male predominance), genetic predisposition, Down syndrome, congenital midfacial factors, cleft palate, environmental factors such as winter season, perinatal factors such as lack of breastfeeding and precocity, recurrent acute OM, especially when episodes occur early in life, smoking, allergic rhinitis, low socioeconomic status, sinusitis, immunodeficiency, nasopharyngeal diseases, gastroesophageal reflux and barotrauma [19–23].

In a prospective longitudinal cohort study that included 6560 children, the risk factors associated with the development of COM among pediatrics by age nine were investigated. The univariate analysis showed that COM was associated with snoring, otorrhoea, adenoidectomy, tonsillectomy, grommet insertion, preterm birth, and tympanogram. Moreover, multivariate analysis revealed that many of such factors were interrelated. However, some factors that were previously reported as risk factors for COM such as sex, parental smoking, maternal education, childcare, crowding, sibling, and socioeconomic status weren't significant factors in that study [17].

Otitis media with effusion (OME) is a childhood condition where the fluid is collected behind the TM [24]. The chronic condition of OME (COME) is an effusion lasting for three or more months, causing hearing loss that may lead to behavioral problems and learning delays [25]. The risk factors of COME were reported to include family history, young age, ethnicity, practices, breastfeeding, upper respiratory tract infection (URI), and exposure to other children [26].

A case-control study conducted on preschool children to assess the determinants of chronic OM with effusion included 209 healthy children aged 3-4 years as a control group and 178 children of the same age diagnosed with chronic OM with effusion. The determinants reported were nasal obstruction (OR = 4.38), always snoring (OR = 3.64), often snoring (OR = 2.45), spending more hours in a week in daycare (OR = 1.03), suffering from a frequent cold (OR = 2.67), having siblings who underwent tympanostomy tube placement (OR = 2.68), long labor of the children (OR = 2.59) and suffering from early introduction of cow‘s milk (OR = 1.76) [24].

In Turkey, there were various factors associated with OME among children, and they included smoking in both parents, the frequency of AOM, URTI in the past year, allergy history, the number of siblings, poor education of parents, and incidence of attending day care centers [27]. In a study conducted on 386 children who had three or more recent episodes of OM with middle ear effusion, it was reported that the risk factors involved bilateral OM with effusion, duration of effusion for more than two weeks, and daycare attendance. Additionally, children who have three of these factors had doubled risk of developing chronic OM with effusion [28]. In a study conducted at the neonatal intensive care unit (NICU) on 83 NICU patients, it was found that disturbed local immunity, nasally-placed tubes for ventilatory assistance, and impaired neuromotor function were associated with COME among neonates in NICU [29].

Another type of COM is chronic supportive otitis media (CSOM) which refers to chronic inflammation of the mucosa of the middle ear with TM perforation and intermittent or persistent otorrhoea with a discharge persisting minimally or 2–6 weeks [30]. This condition involves an infection caused by aerobic and anaerobic bacteria that reach the middle ear either from the Eustachian tube or nasopharynx or from the external ear canal via a perforated TM [31]. CSOM can be complicated by headache, intracranial extension of infection, fever, and nausea-vomiting [31].

In a pilot study included 76 patients younger than 18 years old, it was reported that the significant risk factors of CSOM included recurrent upper respiratory tract infection (URTI) among 88.2%, poor hygiene (86.8%), passive smoking (80.2%), flat position during breast or bottle feeding (77.9%), recurrent acute OM (77%), the recent history of AOM (77.6%), low socioeconomic status (72.4%), low education level of mothers (72.4%) [31].

Recurrent Otitis Media and Risk Factors

Recurrent otitis media (ROM) is a frequent condition in children, and it may affect up to 40% of all young children during the 1–5 years of life. ROM susceptibility is multifactorial and includes genetic factors, host-related factors such as breastfeeding, microbial factors, and environmental factors such as passive smoking and allergy [32].

In one study, it was revealed that habitual snoring was associated with a significant increase in ROM prevalence [32]. A study from the United States (US) was a secondary analysis of cross-sectional data that included data from children less than six years old. The study revealed that there were many independent factors associated with ROM, and they included any allergy (OR = 1.9), black race (OR = 0.6), Hispanic ethnicity (OR = 0.8), daycare (OR = 1.5), and male gender (OR = 1.2) [33].

In Australia, the risk factors of ROM during early childhood were assessed based on parents ‘reports. It was demonstrated that specific risk factors for ROM included the presence of allergies, parity, the introduction of other milk products at four months or younger, and attendance at daycare. Additionally, severe ROM was associated with attendance at daycare and the presence of allergies [34]. On the other hand, an earlier study revealed that atopy was a risk factor for early-onset ROM and daycare outside the home for ROM during the second year, but not the type of feeding [35].

Recurrent acute otitis media (RAOM) occurs due to the high rate of relapse; almost 33% of children under three years of age suffer from three or more episodes, and 10–20% of children experience repeated episodes of AOM [36]. It was reported that the presence of siblings enhances the risk of RAOM in the first two years of age [37].

A retrospective study from Egypt was conducted on 340 infants with ROAM. It was revealed that the recurrence of AOM was associated with the use of pacifiers, older age of infants, short duration of breastfeeding, adenoid hypertrophy, and URTI. An understanding of such factors may reduce the recurrence rate [38].

In a systematic review, there were risk factors related to the host, and t risk factors related to the environment were identified as risk factors for RAOM. The risk factors of RAOM and related to the host included gastroesophageal reflux, allergy, craniofacial abnormalities, and the presence of adenoids, whereas the risk factors related to the environment included attendance to the daycare center, upper airway infections, the presence of siblings and family size, breastfeeding and the use of pacifiers as well as passive smoking. However, there are many factors that are modifiable such as the use of pacifiers, passive smoking, and attendance at daycare centers [39].

Recurrent OM with effusion (OME) refers to the recurrence of OME among 30–40% of children [40]. In Egypt, recurrent OME was found to be associated with some factors, as shown by multi-factor logistic regression analysis. Recurrent OME among children was found to be associated with tonsil hypertrophy, adenoid hypertrophy, sinusitis, allergic rhinitis, posterior nostril polyps, recurrent UTRI, and gastroesophageal reflux [41]. One study included 305 aged zero to ten years old and demonstrated that children with recurrent OME were more prevalent among children suffering from allergy in a significant proportion [40].

Eustachian tube dysfunction (ETD) is one of contributing factors to otitis media with or without effusion that results in increased negative pressure in the middle ear, hence improper drainage of secretions out of the Eustachian tube or protection from nasopharyngeal secretions [42]. The dysfunction or anatomical abnormality of Eustachian tube were correlated with COM [43].

Several treatment options are introduced to restore Eustachian tube function, tympanostomy tube placement surgery may be recommended after failure of medical treatment and depending on associated symptoms and risks [44], yet rapid maxillary expansion (RME) can stretch the tubal dilator muscles to open the pharyngeal orifice of the Eustachian tube and can recover its function [45]. In a prospective study to determine if ETD with OME would recover after RME, 68.2% of dysfunctional ears recovered and exhibit normal Eustachian tube function after RME and the observation period [46]. Another study reported an improvement after RME in 83% of the included 54 ears with recurrent otitis media and associated with skeletal development syndrome and adenoid hypertrophy, helping to restore normal Eustachian tube function [47].

COME/ROM Risk Factors

Regarding COME/ROM, it was stated that COME/ROM clusters in families exhibit substantial heritability. A greater risk of COME/ROM has been reported in children with a family history of middle-ear disorders, which suggests a genetic component. However, the development of COME/ROM between siblings may be due to interaction between them, common environmental exposures, or inherited biological susceptibility [8].

Previous prospective studies found that children whose siblings have a history of COME/ROM had an increased risk by 1.6–4.2 folds after controlling the environmental factors [18, 48, 49]. A study conducted on the Norwegian population of 2750 twin pairs revealed ROM heritability for male and female pairs ascertained by self-report of 0.45 and 0.74, respectively [50].

The findings of a study based on a genome scan for susceptibility loci for COME/ROM suggest that the risk of COME/ROM was determined by the interactions between genes that reside in several candidate regions of the genome and likely modulated by other environmental risk factors [8].

In a previous meta-analysis, the risk factors of COM and ROM were investigated and it was found that such risk factors included snoring, previous history of AOM/ROM, allergy/atopy, low social status, and second-hand smoking [7].

Conclusion

There are various risk factors for otitis media; chronic and recurrent otitis media have some common risk factors, such as allergy, passive smoking, male gender, and snoring. Some of the factors were modifiable, and others were modifiable. Additionally, there was a huge heterogeneity of factors between chronic and recurrent otitis media due to variations in the assessed risk factors. Therefore, there is a need for studies reporting the risk factors of chronic and recurrent otitis media together, as there are a few studies reporting the risk factors of both chronic and recurrent otitis media. Additionally, the studies focusing on the risk factors of each category were few.

Footnotes

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