Role of Empiric Anti-reflux Therapy in Pediatric Otitis Media With Effusion - a Pilot Study

Otitis media with effusion (OME) is a condition characterized by the accumulation of non-purulent fluid in the middle ear space, in the absence of acute inflammation. OME is diagnosed 2.2 million times annually (U.S. Department of Health & Human Services, 2000). It is a condition in which more then 50% of children will experience in their first year of life (National Institutes of Health, 1993). Although many episodes resolve spontaneously, 30% to 40% persist, and 5% to 10% of episodes last 1 year or longer (Yoshinaga-Itano, 1995). It is particularly more common among children between the ages of one and three years and in seasons where the prevalence of upper respiratory tract infections is high; with an incidence of 10% to 30%. It occurs frequently even up to the age of seven, with a prevalence of 3% to 8%(Fiellau et al, 1997; Fiellau et al, 1983; Lous et al, 1981; Teele et al, 1989).

OME is the most common cause of acquired hearing loss in childhood. Long-term hearing complications from OME are associated with linguistic, developmental, and social consequences; especially if the OME is bilateral and of long duration (Fiellau et al, 1983; Golz et al, 1998; Grace et al, 1990; Lous et al, 1995). The etiology of OME is uncertain; however, low-grade infection, poor eustachian tube function, formation of biofilms, and adenoidal infection or hypertrophy have all been suggested as possible etiologies (Faden et al, 1998; Hall-Stoodley et al, 2006).

Recently, there has been good scientific evidence to suggest that OME is a supraesophageal manifestation of gastroesophageal reflux disease (GERD), and more specifically laryngo-pharyngeal reflux (LPR). Tasker et al (2002) investigated the potential role of gastric reflux in the development of OME in children who underwent myringotomy. Of 65 tested effusion samples, 59 (91%) effusions gave a positive result. The concentrations of pepsin/pepsinogen were roughly estimated to be about 1000 times higher than those found in the serum obtained from a number of controls. They speculated that pepsin found in middle ear effusion (MEE) was most probably due to micro-aspiration of gastric contents passing through the eustachian tube (ET) and reaching the middle ear. Lieu et al (2005) performed a pilot study where they replicated the finding of pepsin/pepsinogen in 17 of 36 (77%) middle ear fluid aspirates, obtained from 22 children who underwent tympanostomy tube placement for chronic or recurrent otitis media (OM).

Based on our literature review, we believe there is sufficient scientific evidence to support the empiric treatment of suspected GERD and LPR in patients with OME. Empiric anti-reflux therapy is a safe, proven, cost-effective diagnostic and treatment strategy used widely in the presence of other signs and symptoms of suspected GERD. This pilot study will be a double-blinded, randomized control trial. It will compare hearing outcomes for children with OME being treated with lansoprazole versus placebo for three months. We believe there is sufficient evidence to support the use of this strategy in patients with suspected GERD and LPR who present with OME.