William A. Scaldwell

Otitis media (OM) has been recognized as one of the most common early childhood diseases. Studies of various groups throughout the world have noted prevalence rates from eight to 50 percent (Boison, 1986; Howie, Ploussard, & Sloyer, 1975; Kaplan, Fleshman, Bender, Baum, & Clark, 1973; Ling, McCoy, & Levinson, 1969; McShane, 1982; Scaldwell & Frame, 1985; Teele, Klein, & Rosner, 1980).

Otitis media is the inflammation of the middle ear cavity, usually resulting from the closing of the eustachian tube due to swelling, with the resultant loss of ventilation and fluid drainage in the middle ear cavity. Attacks of OM may vary from mild to severe, and may or may not involve bacterial infection. When bacterial infection is involved, the child may have a mild fever, experience severe pain, and have a temporary reduction of hearing acuity. When infection is severe and recurrent, the tympanic membrane (eardrum) usually is perforated by pressure which allows drainage of the purulent effusion through the ear canal, and relief from pain but not infection.

Otitis media is a disease of young children reaching a peak incidence at two to three years of age (Bluestone, 1982). In school-age children the author found that it appears to peak in grades kindergarten to two, or ages four to seven (Scaldwell and Frame, 1985). When young children have frequently recurring or chronic attacks of OM during the first three or four years of life, there is some danger of a diminution of language development due to fluctuating hearing loss. Children learn to speak and use a language largely by imitation and self-feedback and a mild hearing loss during this critical period can be likened to sound deprivation. Welsh, Welsh, and Healy (1983) report auditory, perceptual, and integrative disturbances in some children when sound deprivation due to OM occurs in early childhood.

While it is still unclear whether or not OM is a causative factor in later learning problems, the consensus in the literature supports a strong linkage between severe OM in early childhood and later language difficulties and speech problems (Gdowski, Sanger, & Decker, 1986; Katz, 1978; Lewis, 1976; Needleman, 1977; Silva, Chambers, & Stewart, 1986). It appears that two problem periods result from early, severe, and repeated O.M. attacks. First, the child's normal language development may be delayed or diminished by what Welsh et al. (1983) call sound deprivation. Secondly, the OM child may be faced with a problem in hearing and processing language when he or she enters school and is confronted with formal language learning such as reading and writing.

The incidence of OM among various Indian groups has been consistently reported as high. The rate has been noted as much higher than in other populations (Beery, Doyle, Cantekin, Bluestone, & Wiet, 1980; McShane & Mitchell, 1979; Nimmo, 1980; Wallace, 1973). The reasons for the high incidence of OM in Indian groups are unclear.

McShane (1982) presents a summary of possible relationships including genetic, socio-cultural, environmental, and economic factors. Berry et al. (1980) suggest that the eustachian tubes of Indian people are functionally different than those of Caucasian people, allowing better ventilation of the middle ear cavity but poorer protective function, resulting in invasion of bacteria from the throat. This functional difference may be due to "inherent structural variations in the craniofacial complex."

Whatever the reasons for a high incidence in Indian children, the problem is a severe one not only from the health viewpoint but from the educational one. The author believes OM to be one of the more important factors to influence functional language skills among Indian school children. Indian children, whether in reserve schools or public schools, often have been noted as having low language skills compared to the general population. Tomusiak (1983) noted that Indian children scored lower than the majority population on reading tests. Scaldwell and Frame (1985), in a project report to Indian and Northern Affairs Canada, noted that Indian children in federal schools were consistently lower than the normative group on Spelling, Mathematics, and Reading tests. Menyuk (1980) reported that persistent OM affects general language development and speech reproduction.

Children in each school were examined by a licensed audiologist using an otoscope and an impedance bridge (tympanometer), which assessed the mechanical functioning of the middle ear. Record cards were sorted into three groups--those with normal middle ear functioning, those with present OM in one or both ears, and those who appeared to have signs of past severe OM attacks. This last group exhibited these signs in a variety of ways, such as flaccid eardrums, severe scarring of the eardrum, eroded or fused bones in the middle ear, and reduced response to sound.

All children were given the Gates-MacGinite Reading Test, Canadian Edition. Raw scores were used to compare the results. All children (N = 524) had both tympanometer examination and the Reading Test.

The total group was divided into "northern" and "southern" groups for examination. This was done to see if geographic and environmental factors influenced the prevalence of OM. The difference was not significant (X = .136, p.05). The northern schools exist in small isolated (no roads) communities. The children in these schools usually speak Cree or Qjibway as a first language. Because of isolation, the routine health care is provided at a community health facility. One could say that children in these communities are, as mentioned earlier, ideal subjects for sub-group comparisons because of homogeneity of living conditions. Children in the southern schools live on small reserves which are only 25 miles from two nearby cities. They use health facilities both on and off the reserve. Community members are fairly mobile and integrated into life around their homes. The children in these schools have lives similar in many ways to the non-Indian children in the rural communities near them. It is interesting to note that the rate of OM was similar in both northern and southern schools.

Reading scores of normal, present OM, and past signs groups were compared as total groups, as northern and southern groups, and by grade level.

Differences in mean reading scores were tested by ANOVA. The minimal significance level was set at .05. Results are given below in tabular and graph form.

Because it was expected that the northern and southern groups would differ in reading ability, the means of these groups were compared (Table 1).

TABLE 1
Total Group Reading Scores - Northern and Southern Schools

The children in northern schools live in remote communities isolated except by air travel from outside influences. They usually speak their Native language as a first tongue, and have an experiential background quite different from their peers in southern communities. The difference in mean reading scores reflects this (Table 1).

Comparing the reading scores of the total group of children who had, at time of examination, normal appearing and functioning middle ears, those who on the day of examination had otitis media in one or both ears, and those whose middle ears showed signs of previous severe OM shows quite differing means (Table 2).

TABLE 2
Reading Scores of Total Group - Comparing Normal Ears
to Present OM and Past Signs of OM

It is clear that the reading scores of the present OM group are lower than those with normal ears, but not as low as the group showing signs of previous severe OM attacks. The children in the OM group may or may not have had previous severe attacks over a period of time, and this could not be determined on the day of examination.

It is clear that the group having the lowest reading scores is the "past signs" one. One can speculate that repeated and severe OM results in sequelae that limit reading competence. These sequelae may be retarded language growth, difficulty in relating sound elements to their written forms, lowered hearing acuity, absences from school due to the OM attacks, and others.

When the two OM groups are combined, the mean reading scores are again significantly lower than the normal one (Table 2).

Tables 3 and 4 illustrate similar comparisons when the whole group was divided into northern and southern schools. In Table 3 it is evident that the OM group scores are lower than the normal group's but not significantly, perhaps because the general reading scores were low already in these schools.

TABLE 3
Mean Reading Scores for Northern Schools - Children with Normal Ears,
Otitis Media, and Signs of Past Otitis Media

TABLE 4
Mean Reading Scores for Southern Schools - Children with Normal Ears,
Otitis Media, and Signs of Past Otitis Media

The group revealing earlier signs, however, does demonstrate significantly lower mean scores (p < .01).

Children in southern schools scored consistently higher than their northern peers in reading (Table 1). When comparing the three sub-groups in southern schools it is clear that the children with OM and past signs scored significantly lower than those in the normal ear group (Table 4). The past signs group, again, appears to be the one most at risk for reading success.

When reading score means are examined by grade level, it appears that the OM and past signs mean scores remain consistently low when compared to the mean scores of the normal ear group. This is illustrated in Figure 1. The most at risk for reading development problems were those with signs of repeated and severe OM attacks.

While this study was conducted in reserve schools for Indian children, the results of OM upon later language and reading competence may apply to all children. Many of the studies cited were conducted on non-Indian children. The incidence figures may differ among groups but the results of severe OM are probably similar.

The methodology of this study made no attempt to prove causality of later reading problems, but to investigate a link between OM and later academic performance. It is clear that other factors in the lives of children in the two OM groups, such as familial health patterns, living conditions, nutrition, and others, may play an important role. It is also clear from the reading results that, whatever the causal factors of OM, these children from grades one to eight are consistently behind their peers who have normal middle ears, even when living under very different environmental conditions, in northern and southern communities.

Otitis media has often been noted as a correlate of speech and language problems in young children (Needleman, 1977; Silva et al, 1986). Results in this study suggest a strong link between early OM and reading skills as assessed on the Gates-MacGinite Reading Tests. The group most likely to score lower on this reading test was the one designated as having "past signs" of OM. That is, damage done to the ear drum and middle ear by repeated infections. This has been mentioned as mild conductive hearing loss, flaccid ear drums which may respond to various sound frequencies differently, delayed or diminished ability to relate print symbols with sound elements, and other behavior.

These children may not be as able as their peers to use language in a full sense, and it is vital that school programs and teaching methods be adjusted to fit their needs.

Children entering school for the first time should be screened for signs of previous attacks of otitis media. It is important that this screening employ not only the puretone audiometer but also an impedance bridge (tympanometer), since the puretone audiometer normally used by school health personnel does not identify middle ear deficiencies resulting from OM.

Teachers and educators must be made aware of OM and possible sequelae. It has been the author's experience that school and health personnel view middle ear infection as a medical problem, and are not aware of educational problems which may show up in later years in school.

Teachers should be trained to modify school programs for known OM children. Because of possible auditory inadequacy, language processing, acuity, etc., these modifications should de-emphasize a sound approach (phonetic) to language learning, and emphasize a more visual one in order to avoid reliance upon a weakened sensory channel, and utility of a stronger one.

Extra care should be taken to ensure that OM children hear and perceive sounds accurately so that they are able to self-pronounce correctly and avoid spelling and reading errors and speech problems. These children could be thought of as being similar to those having mild to moderate hearing loss. Seating arrangements and instructional methods should reflect this.

A concerted effort should be made by health and education personnel to alert young parents to the need for immediate medical treatment if infants appear to have ear aches. Toubeh (1986) comments upon the fact that many infants having OM attacks are not seen at clinics. It may be that OM is a "fact of life" and not seen as more than an ear ache. This study indicates a strong relationship between severe OM and reading ability. Further research is needed to investigate certain common speech problems and written and spoken language deficiencies and their relationship to early, severe, and repeated otitis media attacks in young children.

Berry Q., Doyle, W., Cantekin, E., Blueston, C., & Wiet, R. (1980). Eustachian tube function in an American Indian population. The Annals of Otology, Rhinology and Laryngology, 89 suppl 68, 28-33.

Berman, S. (1981). Otitis media with effusion: Its relationship to language, development, intellectual functioning and academic performance. Advances in Behavioral Sciences, 2, 129-140.

Bluestone, C.D. (1982). Current concepts in otolaryngology: Otitis media in children: To treat or not to treat. New England Journal of Medicine, 306, 1399.

Boison, K.W. (1986). The need for hearing conservation in our public schools. International Journal of Rehabilitation Research, 9, 60-63.

Gdowski, R., Sanger, D., & Decker, T.N. (1986). Otitis media: Effect on a child’s learning. Academic Therapy, 21 (3), 283.

Goodwin, M., Shaw, J.R., & Feldman, C.M. (1980). Distribution of otitis media among four Indian populations in Arizona. Public Health Reports, 95 (6), 589.

Howie, V.M., Ploussard, J.H., & Sloyer, J. (1985). The "otitis prone" condition. American Journal of Disease of Children, 129 (6), 676-678.

Hubbard, T., Paradise, J., McWilliams, B.J., Elster, B., & Taylor, F.H. (1985). Consequences of unremitting middle-ear disease in early life. New England Journal of Medicine, 312 (24), 1529-1534.

Kaplan, G.J., Fleshman, J.K., Bender, T.R., Baum, C., & Clark, P.S. (1973). Long term effects of otitis media: A ten-year cohort study of Alaska Eskimo children. Pediatrics, 52, 577-585.

Katz, J. (1978). The effects of conductive hearing loss on auditory function. ASHA, 10, 879.

Lewis, N. (1976). Otitis media and linguistic incompetence. Arch. Otolaryngology, 102, 387-390.

Ling, D., McCoy, R.J., & Levinson, E.D. (1969). The incidence of middle ear disease and its educational implications among Baffin Island Eskimo children. Canadian Journal of Public Health, 60, 385-390.

MacGinite, W. (1978). Gates-MacGinitie Reading Tests. Toronto, Ontario: Thomas Nelson and Sons.

McShane, D. (1982). Otitis media and American Indians: Prevalence, etiology, psychoeducational consequences, prevention and intervention. In S. Manson (Ed.), New directions in prevention among American Indian children and Alaska native communities. Portland, OR: Oregon Health Sciences University.

McShane, D. & Mitchell, J. (1979). Middle ear disease, hearing loss, and educational problems of American Indian children. Journal of American Indian Education, 19(1), 7.

Menyuk, P. (1980). Effect of persistent otitis media on language development. Annals of Otology, Rhinology, and Laryngology, 89 suppl. 68.

Needleman, H. (1977). Effects of hearing loss from early recurrent otitis media on speech and language development. In B.F. Jaffee (Ed.), Hearing loss in children (Ch. 34). Baltimore, MD: University Park Press,

Nimino, V.L. (1980). Incidence of serious otitis media in Native American populations: A need for early detection and treatment. Unpublished thesis, University of Wisconsin at Superior.

Paradise, J. (198 1). Otitis media during early life: How hazardous to development - A critical review of the evidence. Pediatrics, 6 (6), 869.

Scaldwell, W.A. & Frame, J.E. (1985). Prevalence of otitis media in Cree and Ojibway school children in six Ontario communities. Journal of American Indian Education, 25, 1-5.

Scaldwell, W.A. & Frame, J.E. (1985). WESDIAND project report. Toronto, Ontario: Indian and Northern Affairs Canada.

Silva, P.A., Chambers, D., & Stewart, I. (1986). Some audiological, psychological, educational, and behavioral characteristics of children with bilateral otitis media with effusion: A longitudinal study. Journal of Learning Disabilities, 19(3), 63.

Teele, D.W., Klein, J., & Rosner, B.A. (1980). Epidemiology of otitis media in children. Annals of Otology, Rhinology, and Laryngology, 89 suppl 68, 5.

Teele, D.W., Klein, J., & Rosner, B.A. (1984). Otitis media with effusion during the first three years of life and development of speech and language. Pediatrics, 74(2), 282.

Tomusiak, R.F. (1983). Summary report of the northern Saskatchewan norms project (Report No. 96). Regina, Saskatchewan: Saskatchewan School Trustees Association.

Toubeh, J. (1986). Otitis media in the American Indian and Alaska Native populations. Albuquerque, NM: Indian Health Service.

Wallace, H. (1983). The health of American Indian children. American Journal of Disease of Children, 125, 449.

Welsh, L.W., Welsh, J.J., & Healy, M.D. (1983). Effect of sound deprivation on central hearing. Laryngoscope, 93.

Zinkus, P.W., Gottlieb, M., & Schapiro, M. (1978). Developmental and psychoeducational sequelae of chronic otitis media. American Journal of Disease of Children, 132, 1100.