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0021-7557/03/79-05/391

Jornal de Pediatria
Copyright © 2003 by Sociedade Brasileira de Pediatria

REVIEW ARTICLE

Impact of otitis media


on language acquisition in children
Aracy P.S. Balbani,1 Jair C. Montovani2

Abstract
Objectives: To review the literature concerning the impact of otitis media on language acquisitions in
children.
Method: Medline. The following keywords were used for searching: otitis media, hearing, language
and children.
Results: The hearing loss observed in otitis media may be a result of: 1) structural disorders in the
middle ear; 2) ultrastructural lesions and biochemical anomalies in the cochlea or 3) abnormalities in the
central auditory pathways. About 50% of cases of secretory otitis media, for instance, are accompanied by
mild fluctuating hearing loss. According to the literature, since the first three years of life are critical for
language development, children affected by otitis media in this period are at risk for presenting
disturbances in language acquisition, behavior and later academic achievement.
Conclusion: The main consequences of otitis media and hearing loss on language acquisition are
phonetic and speech articulation problems, as well as impairment of reading comprehension.

J Pediatr (Rio J) 2003;79(5):391-6: Otitis media, language, hearing, child.

“The limits of my language mean the limits of my During the last twenty years, the incidence of acute otitis
world”. media (AOM) increased by 68% in Finland, while that of
Ludwig Wittgenstein, Austrian philosopher (1889-1951) repeat AOM increased by 39% in the United States.3 In
developed countries, the current prevalence of secretory
otitis media (SOM) is 20% in infants.4 In underdeveloped
The shortened period of maternal breastfeeding, the countries, chronic otitis media (COM) - characterized by
early entrance to day car centers and the interaction with a perforated tympanum - remains a significant cause of
large numbers of other children in the same day car hearing loss in childhood. Research performed in the
center/school are some of the factors which have led to Southeast of Brazil showed that the prevalence of COM
an increase in the incidence of childhood otitis media. 1,2 among school age children was 0.94%. 5
The first study to relate otological disease during
childhood with compromised language acquisition was
published in 1969. 6 In 1994, an “Agency for Health Care
1. PhD. Otorhinolaryngologist, School of Medicine, Universidade Estadual
Paulista. Policy” policy in North America stated that otitis media
2. Professor, School of Medicine, Universidade Estadual Paulista. and the resulting hearing loss do not only affect language,
Manuscript received Dec 11 2002, accepted for publication Mar 12 2003. but also behavior and attention.7

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392 Jornal de Pediatria - Vol. 79, Nº5, 2003 Impact of otitis media on language acquisition... – Balbani APS et alii

Concern over the consequences of otitis media in Biochemical and structural alterations of the cochlea
childhood - primarily in relation to language acquisition - In many cases of secretory or chronic otitis media,
has modified the trend of elective otorhinolaryngological conductive hearing loss coexists with sensorineural hearing
surgery, with the result that tympanocentesis with ventilation loss at high frequencies.14-16 In order that this phenomenon
tube insertion is now the most common procedure among could be better analyzed, experimental models of middle
children in a large number of different countries. In the ear infections have been created which permit the
USA, an inquiry revealed that, in 1994, 580,000 operations electrophysiological and pathoanatomical investigation of
were performed to insert ventilation tubes for children and the cochlea.17
adolescents of up to 15 years old. More than 313,000 of the
The majority of experimental studies employ
children who underwent surgery were not yet three years
Streptococcus pneumoniae, since a third of children are
old.8 In 1996, one in every 110 North American children
asymptomatic carriers of pneumococcus in their
received ventilation tubes, almost double the number of
nasopharynx, and its transition to a pathogenic state makes
children undergoing tonsillectomy that year.9 Nevertheless,
it one of the primary etiological agents of otitis media in
Rosenfeld et al.9 point out that ventilation tubes insertion is
humans. The possibility has been raised that pneumococcus
not capable of affecting language development over the
adhere to the epithelial respiratory cells of the middle ear
short term, and Berman.7 adds that significant differences
mucosa by means of the platelet activator factor (PAF)
in terms of language acquisition are not always found
receptor. Starting from this adhesion the inflammatory
between children with SOM treated clinically and those
process of otitis media occurs, triggered by components of
who undergo surgery. As can be observed, the subject is
the bacterial cell wall.18
controversial and merits the attention of pediatricians,
otorhinolaryngologists, phonologists and speech therapist. It has already been demonstrated that there is diffusion
of bacterial toxins and cytokines from the middle ear to the
The objective of this study is to present current knowledge
cochlea by way of the round window membrane (Figure
about hearing loss with severe otitis media and its impact
1),10,17 provoking ultra-structural lesions in the inner ear,
upon children’s language acquisition. We have selected
such as the rupture of the cochlear membranes.18,19
articles catalogued in the Medline database under the
keywords “otitis media”, “language”, “hearing” and “child’. Doubt remains over the irreversible nature of cochlear
On searching the Lilacs database no studies were found of lesions in otitis media. Evaluating children and
the subject. adolescents with antecedents of ventilation tubes insertion
(already free of effusion from the middle ear and with
normal tympanometry), it was shown that alterations
Literature review remain at tonal limits with high-frequency audiometry. 20
Hearing loss with otitis media Nevertheless, Mutlu et al.16 showed that some children
with sensorineural hearing loss at high frequencies
Structural alterations to the middle ear
associated with secretory otitis media presented reversal
The most common structural complications due to of their hearing loss after clinical or surgical treatment.
infections of the middle ear are: perforation of the tympanal
membrane, the formation of tympanosclerosis deposits,
adhesion of the tympanal membrane to the ossicular chain Alterations to the central auditory canals
or the promontory, ossicular chain fusion, the formation of Auditory processing is performed by structures in the
deep retraction pockets and cholesteatoma.10 With chronic brain stem and cerebral cortex, allowing sound stimuli to
otitis media, the following can be observed: hardening/ be analyzed and interpreted (locate the source of a sound,
erosion of the ossicular chain or, mechanical occlusion of memorize verbal sounds, etc.), which is fundamental to
the oval window by granulation tissue, cholesteatoma and the development of speech and language. 13 In order to
purulent secretions.11 All of these alterations can result in assess the possible effect of unilateral SOM on binaural
conductive hypoacusia. auditory processing, a study used plugs to seal the left ear
Around 80% of children have at least one episode of of ferret kits (Mustela putorius furo).21 The plug was
SOM by eight years of age. Of the children affected, fitted at around 29 days and left for between seven and 15
approximately 55% have mild hearing loss at speech months. Unilateral conductive hypoacusia was
frequencies.12 Santos et al.13 show that even mild documented by means of brainstem evoked response
hypoacusia is sufficient to prejudice certain auditory audiometry (BERA). After the kits had been trained to
functions. The fluctuating nature of hearing loss from locate sound stimuli (an ability dependant upon binaural
otitis media (which may alternate with periods of normal hearing), it was perceived that the majority of them
hearing) leads to an inconsistent sound stimulus to the managed to perform the task, despite a higher number of
auditory central nervous system, making it difficult for errors when compared with the animals in the control
the child to perceive the sounds of speech. Furthermore, group (normal hearing). Removal of the plug enabled a
fluid in the middle ear can produce noise at the cochlea, partial re-establishment of function in one to two months.
distorting the perception of sounds. Four to six months later there were no significant
Impact of otitis media on language acquisition... – Balbani APS et alii Jornal de Pediatria - Vol. 79, Nº5, 2003 393

Figure 1 - Schematic representation of the ear anatomy


* oval window

differences between the animals in the control group and Impact on language acquisition
those who had had plugs. The authors point out that long- Language development begins very early on, even during
term unilateral conductive hypoacusia leads to binaural its prenatal phase the child is capable of recognizing voices
auditory processing deficiencies which can take months and the sounds of speech. It is known that there is a universal
to recover after the otitis media has been cured. language acquisition pattern, i.e., phonemes, syllables and
It is accepted that the treatment of secretory otitis prosody (the pronunciation of words) appear to come in the
media in children with mitochondrial diseases can retard same sequence and at the same ages in all languages that
the degeneration of the cochlea and of the nervous fibers have been studied. Slowly, this development becomes more
in the brain stem. 22 One of the primary clinical specific and acquires the characteristics of the mother
manifestations of mitochondrial diseases is progressive tongue of each child.23
sensorineural hearing loss, since the vascular furrow of During the first year of life, communication is based on
the cochlea is one of the tissues which have the highest the syllable. When the child discovers that its voice provokes
metabolic demands.22 Furthermore, when performing reactions by those around it, its vocal behavior becomes
audiological assessment by BERA, lesions are often more varied, incorporating phonemes such as “ba”, “pa”
encountered in the central auditory canals of these and “da”. The first words do not generally sound the same
patients. Mitochondrial diseases are episodic, presenting as the way they are pronounced by adults, but they are
stable periods or periods of slow progression interspersed intelligible.23
with rapid neural degeneration events. Monitoring To the extent that the child practices producing sounds
children with mitochondrial diseases, it was discovered and words, it gradually perceives and incorporates
that infections of the upper airways - including otitis vocabulary, syntax and pronunciation. The level of
media - trigger, in between three and seven days, an understanding is often above the level of production, i.e. the
episode of neural degeneration. This phenomenon is child understands more words and phrases than it can
similar to that observed with the Reye syndrome, in manage to produce.23
which neurological lesions result from a defect in the Correct treatment of otitis media during the first three
oxidization of fatty acids by the mitochondrial. years of life is extremely important, since this is the phase
394 Jornal de Pediatria - Vol. 79, Nº5, 2003 Impact of otitis media on language acquisition... – Balbani APS et alii

of greatest language development. At around 18 months, for BERA and followed-up until they were nine years old.
the vocabulary of a child has, on average, about 50 words. The majority of children who presented a diagnosis of
By three years, this has already reached 1,000 words. 8 This bilateral AOM at 30% or more of their post-natal
expansion, obviously, does not only depend upon the consultations had altered auditory limits during the first
integrity of the auditory system, but also upon communication year of life, becoming normal in later years. Nevertheless,
with other children and with the adults who live in the same during follow-up, 60% of these children presented some
environment.23 In the USA, a study revealed that poorer language disturbance.26 Another study suggests that children
families tended to use around a third of the vocabulary with otitis media during the first three years of their lives
spoken by families from higher social classes.7 continued to have difficulties with the comprehension of
Children within the age group from one to three years visual language, the articulation of words, with attention
who have hearing loss have greater difficulty in acquiring and reading capacity until they were 11 years old.10
language, less perception of those sounds of speech which Luotonen et al.27 found that children with a history of
contain silent consonants or fricatives such as /s/ and /z/, repeated AOM during the first three years of life were
(24) and frequently make phonetic errors in the pronunciation making unsatisfactory progress at school in reading,
of /l/ and /r/.23 The most common cause of this is mild comprehension of texts and verbal and written expression.
conductive hypoacusia - even though unilateral - provoked In the case of girls, in addition to language difficulties,
by otitis media. During these infections the child receives mathematic ability was also compromised. This finding is
distorted sound stimuli, which explains the phonetic errors.8 attributed to: 1. the strict relationship between cortical
language processing and the performance of mathematical
A hypothesis can be found in the literature that states
operations27 and 2. the differences in metabolism and
that the hearing of the right ear and the auditory processing
functional organization between the language areas of the
of the left temporal lobe are dominant in language functions.
brains of the male and female sexes.27,28
Klausen et al.12 showed that children b eight and ten years
old, with a history of myringotomy and ventilation tube Taking these findings into account, it is believed that
insertion to treat SOM had significantly worse performance otitis media and the resulting hearing loss, during the
in comparison to normal controls in: tests of the articulation first three years of life can have long lasting effects,
of words, discrimination of sounds and auditory attention. prejudicing not only language acquisition during this
According to the authors, children with a history of SOM in crucial period, but also the future scholastic attainments
the right ear were at a disadvantage in the tests. based on of the child.26-30
these results, the authors proposed that early life auditory
deficit in the right ear affects the development of the cortical
language comprehension center. On the other hand, Borg et Discussion
al.23 did not find any significant differences in terms of More than 30 years have passed since the publication
language when comparing children with right-side auditory of the first study into the association between childhood
deficiency with those with left-side deficiencies. otitis media and retarded language development.6 During
There are those that argue that SOM alternates periods this period innumerable works have returned conflicting
of mild conductive hypoacusia with periods of normal results, probably due to different methodologies
hearing, and that a large proportion of cases tend to resolve employed in the diagnosis of otitis media. 4,8 For example,
spontaneously in a few weeks.8 There is controversy based an older study based on pneumatic otoscopy for secretory
on the auditory deficit over the early indication of surgery otitis media diagnosis, 26 while another used
for ventilation tubes insertion when treating SOM. tympanometry.20 On investigating the incidence of acute
otitis media, some authors had recourse to medical
Maw et al.25 evaluated alterations to language, behavior records, 26,30 and others used questionnaires filled out by
and learning in 182 children suffering from bilateral secretory the patients’ parents. 27,28 These differences in
otitis media, with an average age of two years. Half of the methodology make much more difficult the comparison
children were submitted for tympanocentesis and the other of the results obtained and the analysis of the
half received clinical treatment (medication). After nine consequences of otitis media on language acquisition.
months, hearing loss remained significant within the un-
For Paradise,8 problems with the methodology of
operated group, with an average retardation of three months
innumerable studies make pairing between cases and
compared to the level of speech comprehension predicted
controls difficult because they use variables such as
for their age. Both groups had a deficit in verbal expression
socio-economic level, nutritional and cultural factors,
when compared with children without hearing problems.
which are known to influence the language acquisition of
After 18 months’ follow-up, all of the children who had
children. The heterogeneous nature of the groups studied
been treated for SOM (clinically or surgically) presented
does not permit certain confirmation of the disturbances
normal language.
to language resulting from otitis media. To the author,
In a cohort study of otitis and language, 30 one year-old research with reduced samples make the extrapolation of
children were assessed for otitis media incidence, submitted results unviable.
Impact of otitis media on language acquisition... – Balbani APS et alii Jornal de Pediatria - Vol. 79, Nº5, 2003 395

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