Referrals for Recurrent Acute Otitis Media With and Without Spontaneous Tympanic Membrane Perforation Through COVID-19: A Cross-Sectional Comparative Study.

To the Editors: Most children experience at least one episode of acute otitis media (AOM) and approximately one-third of them suffer from recurrent episodes (rAOM) with or without spontaneous tympanic membrane perforation (STMP).1 Data on the epidemiology of rAOM and STMP during the COVID-19 pandemic are scarce. The aim of this report is to evaluate the number and characteristics of children presenting with rAOM with and without STMP before and during the pandemic. This study was conducted at the otitis media pediatric outpatient clinic of the Ospedale Maggiore Policlinico, Milan (Italy), from 2019 to 2022. All consecutive children referring to the outpatient clinic for a first-time visit for rAOM2 were eligible and the following information was extracted: sex, age (≤2 and >2 years), date of first visit and history of STMP. Data were obtained from patient’s online medical records. Four periods were considered for the analysis: the year preceding the pandemic (2019), the 2 years with the strictest measures to limit the spread of COVID-19 (2020 and 2021) and the year in which these measures were progressively relaxed (2022). The Fisher exact test or the χ2 test were used for the analysis, as appropriate. A P value <0.05 was assumed as significant. The study was approved by the Ethical Committee of the Ca’ Granda Ospedale Maggiore, Milan (Comitato Etico Area2). A total of 786 children (53% >2 years of age and 45% females) were included (Table 1). A decreasing trend in the number of children with rAOM was observed in the first 3 years of the study. Furthermore, the percentage of children <2 years of age increased in 2021 and 2022. Similar data were observed for children with rAOM without STMP. No age difference (P = 0.319) was found for children with rAOM and STMP. TABLE 1. - Total Number of Patients and Number of First-Time Visits for rAOM With and Without STMP All 2019 2020 2021 2022 P Value rAOM N 786 300 141 108 237 Male 437 165 71 54 147 0.072 Age ≤2 yr 367 (47%) 120 (40%) 61 (43%) 59 (55%) 127 (53%) 0.004 >2 yr 419 (53%) 180 (60%) 80 (57%) 49 (45%) 110 (47%) rAOM without STMP N 441 143 59 72 167 Male 248 79 30 36 103 0.273 Age ≤2 yr 190 (43%) 44 (31%) 21 (36%) 41 (57%) 84 (50%) 0.0002 >2 yr 251 (57%) 99 (69%) 38 (64%) 31 (43%) 83 (50%) rAOM with STMP N 344 157 81 36 70 Male 189 87 41 18 43 0.544 Age ≤2 yr 177 (51%) 77 (40%) 39 (48%) 18 (51%) 43 (62%) 0.319 >2 yr 167 (49%) 80 (60%) 42 (52%) 18 (49%) 27 (38%) rAOM indicates recurrent acute otitis media; STMP, spontaneous tympanic membrane perforation P values <0.05 are in bold. The changes in rAOM frequency during the study period is consistent with prior research indicating a reduction in AOM cases.3,4 However, the main finding of this investigation pertains to a notable shift in the age distribution of children affected by rAOM. This age bracket presumably comprises children born during the peak of the stringent control measures. As such, the infection control protocols might have limited their exposure to pathogens, creating a cohort of immunologically naive children more susceptible to rAOM once the restrictions were lifted. Contrary to initial expectations, a significant rise in rAOM with STMP cases in 2022 and the decrease in the age of affected children were not observed. Recent data point out a change in antibiotic prescription in children after 2020.5 The early and widespread use of broad-spectrum antibiotics for respiratory infections and AOM may have decreased the incidence of common complications such as STMP. The main limitation of this study relies on its retrospective, monocentric design. In conclusion, this investigation reveals a rise in rAOM cases in 2022 with a noticeable increase in the younger age groups. These data underscore the possible medium to long-term repercussions of infection control measures.