Rosenfeld Richard M, Kay David
Dept. of Otolaryngology, State University of New York Downstate Medical Center, 340 Henry Street, Brooklyn, NY 11201, USA.
Laryngoscope. 2003 Oct;113(10):1645-57. doi: 10.1097/00005537-200310000-00004.
OBJECTIVE/HYPOTHESIS: Data from cohort studies and untreated groups in randomized controlled trials can be identified through systematic literature review and synthesized with meta-analysis to estimate natural history of acute otitis media (AOM) and otitis media with effusion (OME).
Systematic literature review and meta-analysis.
Source articles were identified by MEDLINE search through August 2002 plus manual crosschecks of bibliographies and published meta-analyses. Data were abstracted independently by two investigators and combined with random effects meta-analysis to estimate spontaneous resolution, 95% confidence intervals (CI), and heterogeneity. Sensitivity analysis was performed.
Sixty-three articles met inclusion criteria. AOM symptoms improved within 24 hours without antibiotics in 61% of children (95% CI, 50-72%), rising to 80% by 2 to 3 days (95% CI, 69-90%). Suppurative complications were comparable if antibiotics were withheld (0.12%) or provided (0.24%). Children entered recurrent AOM trials with a mean rate of 5.5 or more annual episodes but averaged only 2.8 annual episodes while on placebo (95% CI, 2.2-3.4). No AOM episodes occurred in 41%, and only 17% remained otitis prone (3 or more episodes). OME after untreated AOM had 59% resolution by 1 month (95% CI, 50-68%) and 74% resolution by 3 months (95% CI, 68-80%). OME of unknown duration had 28% spontaneous resolution by 3 months (95%, CI 14-41%), rising to 42% by 6 months (95% CI, 35-49%). In contrast, chronic OME had only 26% resolution by 6 months and 33% resolution by 1 year.
The natural history of otitis media is very favorable. Combined estimates of spontaneous resolution provide a benchmark against which to judge new or established interventions. The need for surgery in children with recurrent AOM or chronic OME should be balanced against the likelihood of timely spontaneous resolution and the potential risk of learning, language, or other adverse sequelae from persistent middle ear effusion. Further research is needed to identify prognostic factors that can target children unlikely to improve spontaneously for earlier intervention.
目的/假设：队列研究数据以及随机对照试验中未治疗组的数据可通过系统文献回顾来识别，并与荟萃分析相结合，以估计急性中耳炎（AOM）和中耳积液（OME）的自然病程。
系统文献回顾和荟萃分析。
通过检索截至2002年8月的MEDLINE数据库确定原始文章，并对手稿参考文献和已发表的荟萃分析进行人工交叉核对。由两名研究人员独立提取数据，并采用随机效应荟萃分析合并数据，以估计自然缓解率、95%置信区间（CI）和异质性。进行了敏感性分析。
63篇文章符合纳入标准。61%的儿童在24小时内未使用抗生素时AOM症状改善（95%CI，50 - 72%），2至3天时升至80%（95%CI，69 - 90%）。如果不使用抗生素（0.12%）或使用抗生素（0.24%），化脓性并发症相当。进入复发性AOM试验的儿童年发作率平均为5.5次或更多，但服用安慰剂时年平均发作次数仅为2.8次（95%CI，2.2 - 3.4）。41%的儿童未发生AOM发作，仅17%仍易患中耳炎（3次或更多发作）。未经治疗的AOM后发生的OME在1个月时59%缓解（95%CI，50 - 68%），3个月时74%缓解（95%CI，68 - 80%）。病程不明的OME在3个月时28%自然缓解（95%CI，14 - 41%），6个月时升至42%（95%CI，35 - 49%）。相比之下，慢性OME在6个月时仅26%缓解，1年时33%缓解。
中耳炎的自然病程非常良好。自然缓解的综合估计提供了一个基准，可据此判断新的或已有的干预措施。对于复发性AOM或慢性OME儿童的手术需求，应与及时自然缓解的可能性以及持续性中耳积液对学习、语言或其他不良后遗症的潜在风险相权衡。需要进一步研究以确定预后因素，从而针对不太可能自然改善的儿童进行早期干预。
