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
world”.
Ludwig Wittgenstein, Austrian philosopher (1889-1951)
The shortened period of maternal breastfeeding, the
early entrance to day car centers and the interaction with
large numbers of other children in the same day car
center/school are some of the factors which have led to
an increase in the incidence of childhood otitis media. 1,2
1. PhD. Otorhinolaryngologist, School of Medicine, Universidade Estadual
Paulista.
2. Professor, School of Medicine, Universidade Estadual Paulista.
Manuscript received Dec 11 2002, accepted for publication Mar 12 2003.
During the last twenty years, the incidence of acute otitis
media (AOM) increased by 68% in Finland, while that of
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
countries, chronic otitis media (COM) - characterized by
a perforated tympanum - remains a significant cause of
hearing loss in childhood. Research performed in the
Southeast of Brazil showed that the prevalence of COM
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
Policy” policy in North America stated that otitis media
and the resulting hearing loss do not only affect language,
but also behavior and attention.7

391
392 Jornal de Pediatria - Vol. 79, Nº5, 2003
Concern over the consequences of otitis media in
childhood - primarily in relation to language acquisition -
has modified the trend of elective otorhinolaryngological
surgery, with the result that tympanocentesis with ventilation
tube insertion is now the most common procedure among
children in a large number of different countries. In the
USA, an inquiry revealed that, in 1994, 580,000 operations
were performed to insert ventilation tubes for children and
adolescents of up to 15 years old. More than 313,000 of the
children who underwent surgery were not yet three years
old.8 In 1996, one in every 110 North American children
received ventilation tubes, almost double the number of
children undergoing tonsillectomy that year.9 Nevertheless,
Rosenfeld et al.9 point out that ventilation tubes insertion is
not capable of affecting language development over the
short term, and Berman.7 adds that significant differences
in terms of language acquisition are not always found
between children with SOM treated clinically and those
who undergo surgery. As can be observed, the subject is
controversial and merits the attention of pediatricians,
otorhinolaryngologists, phonologists and speech therapist.
The objective of this study is to present current knowledge
about hearing loss with severe otitis media and its impact
upon children’s language acquisition. We have selected
articles catalogued in the Medline database under the
keywords “otitis media”, “language”, “hearing” and “child’.
On searching the Lilacs database no studies were found of
the subject.
Literature review
Hearing loss with otitis media
Structural alterations to the middle ear
The most common structural complications due to
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
or the promontory, ossicular chain fusion, the formation of
deep retraction pockets and cholesteatoma.10 With chronic
otitis media, the following can be observed: hardening/
erosion of the ossicular chain or, mechanical occlusion of
the oval window by granulation tissue, cholesteatoma and
purulent secretions.11 All of these alterations can result in
conductive hypoacusia.
Around 80% of children have at least one episode of
SOM by eight years of age. Of the children affected,
approximately 55% have mild hearing loss at speech
frequencies.12 Santos et al.13 show that even mild
hypoacusia is sufficient to prejudice certain auditory
functions. The fluctuating nature of hearing loss from
otitis media (which may alternate with periods of normal
hearing) leads to an inconsistent sound stimulus to the
auditory central nervous system, making it difficult for
the child to perceive the sounds of speech. Furthermore,
fluid in the middle ear can produce noise at the cochlea,
distorting the perception of sounds.
Impact of otitis media on language acquisition... – Balbani APS et alii
Biochemical and structural alterations of the cochlea
In many cases of secretory or chronic otitis media,
conductive hearing loss coexists with sensorineural hearing
loss at high frequencies.14-16 In order that this phenomenon
could be better analyzed, experimental models of middle
ear infections have been created which permit the
electrophysiological and pathoanatomical investigation of
the cochlea.17
The majority of experimental studies employ
Streptococcus pneumoniae, since a third of children are
asymptomatic carriers of pneumococcus in their
nasopharynx, and its transition to a pathogenic state makes
it one of the primary etiological agents of otitis media in
humans. The possibility has been raised that pneumococcus
adhere to the epithelial respiratory cells of the middle ear
mucosa by means of the platelet activator factor (PAF)
receptor. Starting from this adhesion the inflammatory
process of otitis media occurs, triggered by components of
the bacterial cell wall.18
It has already been demonstrated that there is diffusion
of bacterial toxins and cytokines from the middle ear to the
cochlea by way of the round window membrane (Figure
1),10,17 provoking ultra-structural lesions in the inner ear,
such as the rupture of the cochlear membranes.18,19
Doubt remains over the irreversible nature of cochlear
lesions in otitis media. Evaluating children and
adolescents with antecedents of ventilation tubes insertion
(already free of effusion from the middle ear and with
normal tympanometry), it was shown that alterations
remain at tonal limits with high-frequency audiometry. 20
Nevertheless, Mutlu et al.16 showed that some children
with sensorineural hearing loss at high frequencies
associated with secretory otitis media presented reversal
of their hearing loss after clinical or surgical treatment.
Alterations to the central auditory canals
Auditory processing is performed by structures in the
brain stem and cerebral cortex, allowing sound stimuli to
be analyzed and interpreted (locate the source of a sound,
memorize verbal sounds, etc.), which is fundamental to
the development of speech and language. 13 In order to
assess the possible effect of unilateral SOM on binaural
auditory processing, a study used plugs to seal the left ear
of ferret kits (Mustela putorius furo).21 The plug was
fitted at around 29 days and left for between seven and 15
months. Unilateral conductive hypoacusia was
documented by means of brainstem evoked response
audiometry (BERA). After the kits had been trained to
locate sound stimuli (an ability dependant upon binaural
hearing), it was perceived that the majority of them
managed to perform the task, despite a higher number of
errors when compared with the animals in the control
group (normal hearing). Removal of the plug enabled a
partial re-establishment of function in one to two months.
Four to six months later there were no significant
Impact of otitis media on language acquisition... – Balbani APS et alii
Figure 1 - Schematic representation of the ear anatomy
* oval window
differences between the animals in the control group and
those who had had plugs. The authors point out that long-
term unilateral conductive hypoacusia leads to binaural
auditory processing deficiencies which can take months
to recover after the otitis media has been cured.
It is accepted that the treatment of secretory otitis
media in children with mitochondrial diseases can retard
the degeneration of the cochlea and of the nervous fibers
in the brain stem. 22 One of the primary clinical
manifestations of mitochondrial diseases is progressive
sensorineural hearing loss, since the vascular furrow of
the cochlea is one of the tissues which have the highest
metabolic demands.22 Furthermore, when performing
audiological assessment by BERA, lesions are often
encountered in the central auditory canals of these
patients. Mitochondrial diseases are episodic, presenting
stable periods or periods of slow progression interspersed
with rapid neural degeneration events. Monitoring
children with mitochondrial diseases, it was discovered
that infections of the upper airways - including otitis
media - trigger, in between three and seven days, an
episode of neural degeneration. This phenomenon is
similar to that observed with the Reye syndrome, in
which neurological lesions result from a defect in the
oxidization of fatty acids by the mitochondrial.
Jornal de Pediatria - Vol. 79, Nº5, 2003 393
Impact on language acquisition
Language development begins very early on, even during
its prenatal phase the child is capable of recognizing voices
and the sounds of speech. It is known that there is a universal
language acquisition pattern, i.e., phonemes, syllables and
prosody (the pronunciation of words) appear to come in the
same sequence and at the same ages in all languages that
have been studied. Slowly, this development becomes more
specific and acquires the characteristics of the mother
tongue of each child.23
During the first year of life, communication is based on
the syllable. When the child discovers that its voice provokes
reactions by those around it, its vocal behavior becomes
more varied, incorporating phonemes such as “ba”, “pa”
and “da”. The first words do not generally sound the same
as the way they are pronounced by adults, but they are
intelligible.23
To the extent that the child practices producing sounds
and words, it gradually perceives and incorporates
vocabulary, syntax and pronunciation. The level of
understanding is often above the level of production, i.e. the
child understands more words and phrases than it can
manage to produce.23
Correct treatment of otitis media during the first three
years of life is extremely important, since this is the phase
394 Jornal de Pediatria - Vol. 79, Nº5, 2003
of greatest language development. At around 18 months,
the vocabulary of a child has, on average, about 50 words.
By three years, this has already reached 1,000 words. 8 This
expansion, obviously, does not only depend upon the
integrity of the auditory system, but also upon communication
with other children and with the adults who live in the same
environment.23 In the USA, a study revealed that poorer
families tended to use around a third of the vocabulary
spoken by families from higher social classes.7
Children within the age group from one to three years
who have hearing loss have greater difficulty in acquiring
language, less perception of those sounds of speech which
contain silent consonants or fricatives such as /s/ and /z/,
(24) and frequently make phonetic errors in the pronunciation
of /l/ and /r/.23 The most common cause of this is mild
conductive hypoacusia - even though unilateral - provoked
by otitis media. During these infections the child receives
distorted sound stimuli, which explains the phonetic errors.8
A hypothesis can be found in the literature that states
that the hearing of the right ear and the auditory processing
of the left temporal lobe are dominant in language functions.
Klausen et al.12 showed that children b eight and ten years
old, with a history of myringotomy and ventilation tube
insertion to treat SOM had significantly worse performance
in comparison to normal controls in: tests of the articulation
of words, discrimination of sounds and auditory attention.
According to the authors, children with a history of SOM in
the right ear were at a disadvantage in the tests. based on
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
al.23 did not find any significant differences in terms of
language when comparing children with right-side auditory
deficiency with those with left-side deficiencies.
There are those that argue that SOM alternates periods
of mild conductive hypoacusia with periods of normal
hearing, and that a large proportion of cases tend to resolve
spontaneously in a few weeks.8 There is controversy based
on the auditory deficit over the early indication of surgery
for ventilation tubes insertion when treating SOM.
Maw et al.25 evaluated alterations to language, behavior
and learning in 182 children suffering from bilateral secretory
otitis media, with an average age of two years. Half of the
children were submitted for tympanocentesis and the other
half received clinical treatment (medication). After nine
months, hearing loss remained significant within the un-
operated group, with an average retardation of three months
compared to the level of speech comprehension predicted
for their age. Both groups had a deficit in verbal expression
when compared with children without hearing problems.
After 18 months’ follow-up, all of the children who had
been treated for SOM (clinically or surgically) presented
normal language.
In a cohort study of otitis and language, 30 one year-old
children were assessed for otitis media incidence, submitted
Impact of otitis media on language acquisition... – Balbani APS et alii
for BERA and followed-up until they were nine years old.
The majority of children who presented a diagnosis of
bilateral AOM at 30% or more of their post-natal
consultations had altered auditory limits during the first
year of life, becoming normal in later years. Nevertheless,
during follow-up, 60% of these children presented some
language disturbance.26 Another study suggests that children
with otitis media during the first three years of their lives
continued to have difficulties with the comprehension of
visual language, the articulation of words, with attention
and reading capacity until they were 11 years old.10
Luotonen et al.27 found that children with a history of
repeated AOM during the first three years of life were
making unsatisfactory progress at school in reading,
comprehension of texts and verbal and written expression.
In the case of girls, in addition to language difficulties,
mathematic ability was also compromised. This finding is
attributed to: 1. the strict relationship between cortical
language processing and the performance of mathematical
operations27 and 2. the differences in metabolism and
functional organization between the language areas of the
brains of the male and female sexes.27,28
Taking these findings into account, it is believed that
otitis media and the resulting hearing loss, during the
first three years of life can have long lasting effects,
prejudicing not only language acquisition during this
crucial period, but also the future scholastic attainments
of the child.26-30
Discussion
More than 30 years have passed since the publication
of the first study into the association between childhood
otitis media and retarded language development.6 During
this period innumerable works have returned conflicting
results, probably due to different methodologies
employed in the diagnosis of otitis media. 4,8 For example,
an older study based on pneumatic otoscopy for secretory
otitis media diagnosis, 26 while another used
tympanometry.20 On investigating the incidence of acute
otitis media, some authors had recourse to medical
records, 26,30 and others used questionnaires filled out by
the patients’ parents. 27,28 These differences in
methodology make much more difficult the comparison
of the results obtained and the analysis of the
consequences of otitis media on language acquisition.
For Paradise,8 problems with the methodology of
innumerable studies make pairing between cases and
controls difficult because they use variables such as
socio-economic level, nutritional and cultural factors,
which are known to influence the language acquisition of
children. The heterogeneous nature of the groups studied
does not permit certain confirmation of the disturbances
to language resulting from otitis media. To the author,
research with reduced samples make the extrapolation of
results unviable.
Impact of otitis media on language acquisition... – Balbani APS et alii
Many children with SOM have normal auditory limits.
Paradise8 believes that this is the reason for some studies
concluding that there is no causal relationship between
middle ear effusion and retarded language acquisition.
As we have seen, the data presented ion literature serve
as a warning to pediatricians, otorhinolaryngologists,
phonologists, speech therapists and educators. Following
up cases of otitis media within the pediatric age group, it is
important to question parents over the child’s progress in
language acquisition, and also enquire of their teachers how
their progress is at school. It is possible that many of these
children will need monitoring both by a pedagogue and a
speech therapist, concurrently with antibiotic and/or surgical
treatment of the middle ear. We are reminded that the
participation of pediatricians is vital to the treatment of
otitis media and the avoidance of its sequelae in sufferers,
and also to bring the issue to the attention of parents and
teachers.
While this study has not approached the subject, the
effects of otitis media on balance31 and behavior h32 have
also been the cause of many clinical and psychological
experiments over the years.
Ever more children are being submitted for surgery to
insert ventilation tubes because of a single milliliter of
liquid in the middle ear. 8,9 This possibly occurs as a
result of concerns on the part of pediatric
otorhinolaryngologists about the sequelae of otitis media.
There is a hypothesis that the privation from sound
stimuli provoked by this milliliter of secretion has a
negative effect upon the auditory cortex which is
equivalent to the effect of congenital blindness on the
visual cortex. 8 This and other fascinating
neurophysiological questions such as the possible
dominance of the right ear in central auditory processing,
the sexual differences in this function, the development
of auditory processes in the children of bilingual families,
and the connection between language, memory and visual
communication merit deeper research.
Finally, it is vital, not just to treat, but also to prevent
otitis media and its sequelae in childhood1: by means of the
fight against malnutrition, the improvement of the social
and hygienic conditions of the public and universal access
to health services, including the application of vaccines
against untypable Haemophilus influenzae and
pneumococcus, since these etiological agents of otitis media
are presenting more and more strains that are resistant to
antibiotics.33 Indirectly, these measures can improve not
just the language acquisition of children, but also their
quality of life, widening their horizons in this world replete
with sound.
Acknowledgements
The authors would like to thank Sra. Sueli Loureiro
Knoll for the illustration.
Jornal de Pediatria - Vol. 79, Nº5, 2003 395
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Corresponding author:
Aracy P.S. Balbani
Rua Maneco Pereira, 365
CEP 18270-400 – Tatuí, SP, Brazil
Fax: +55 (15) 251.3852 / 251.6691
E-mail: a_balbani@hotmail.com