Interview with Jack Paradise M.D., Children's Hospital of Pittsburgh
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AO/Beck: Hi Dr. Paradise. It's an honor to speak with you.
Paradise: Hi Dr. Beck, thanks for inviting me.
AO/Beck: Dr. Paradise, if I may, I'd like to tell the readers a little about your professional history. I know you've published some ground-breaking papers and you've questioned the wisdom of some practices that many accept as the standard of care. Those are bold things to do! I know you've conducted research on the management of middle ear disease and you were the recipient of the 1994 Research Award of the Ambulatory Pediatric Association. In 1995, you were elected a Fellow of the American Association for the Advancement of Science. In 1998, the Pittsburgh Pediatric Society created the Jack Paradise Investigator's Award and you were the first recipient. In 1999, you received the research award of the Society for Ear, Nose and Throat Advances in Children. You've been very involved with otitis media and other aspects of otolaryngologic and audiologic research issues in the pediatric population. Having said all that, Can you please tell me your thoughts on this tremendous body of work?
Paradise: We've been studying these issues for about 30 years. The primary questions we've been addressing have dealt with identifying which children would benefit from the operations and to what degree they would benefit. We conducted a series of randomized clinical trials. Some of the results have been published over the years and others will hopefully be published in the near future. The basic design has been to compare children who have had surgery with children who haven't had surgery, to learn what the outcomes are. Basically, we wanted to know if the operated children are faring significantly better than the children who have not received the operations.
AO/Beck: What have the studies revealed?
Paradise: Regarding ear disease, we randomly assigned children who previously had tubes inserted and who subsequently developed otitis media, to undergo or not undergo adenoidectomy. The children assigned to undergo adenoidectomy who had middle-ear effusion at the time of surgery, also underwent tube insertion . Children in the non-adenoidectomy control group who had effusion that failed to resolve with medical treatment also underwent tube insertion. What we found was that the children who underwent adenoidectomy fared significantly better than the children who did not receive the adenoidectomy.. Therefore, we now recommend, for children who have undergone tube insertion and who subsequently developed recurrent otitis media that has become troublesome enough to warrant a second set of tubes, that adenoidectomy be carried out in conjunction with the second tube operation. The results of that study were reported in JAMA in 1990.
In a more recent study, reported in JAMA in 1999, we studieded children with recurrent acute otitis media who had not previously undergone tube insertion. The children were assigned to one of three treatment groups. The first group underwent adenoidectomy only, the second group underwent tonsillectomy and adenoidectomy (T & A) and the third group received no tonsil or adenoid surgery. The study was designed to avoid, as much as possible, the use of tympanostomy tubes. Accordingly, children who had middle-ear effusion at the time of adenoidectomy or T & A underwent myringotomy only, without tube insertion. Similarly, children in the control group who had middle-ear effusion that persisted despite medical treatment also underwent myringotomy without tubes. Only if a second myringotomy was required in the course of the study did children receive tubes. Analysis indicated that children in each of the two surgical groups fared a little better during the first year of follow-up than did the children who did not undergo surgery, but the effect did not persist thereafter. The results were slightly better in the children who underwent T & A than in those who underwent adenoidectomy alone. However, the between-group differences in this study were not only short-lived but of small magnitude, and even though they were statistically significant, we didn't consider them clinically significant.
Therefore, we concluded that for children with recurrent acute otitis media, nonsurgical management should certainly be attempted first, with tube insertion to be considered as the preferred surgical recourse if the burden of illness becomes unbearable. Relatively few such children should need further surgical treatment.
AO/Beck: At what point do you recommend that a surgical consult be initiated for a child with chronic ear disease?
Paradise: That's a tough question. I really think that every child needs to be evaluated individually by the pediatrician and that guidelines are OK, but too general to be applied across the board to individual children. Whenever the parents or the pediatrician feel that it's the right thing to do, a referral should be made. Many times the decision for or against continuing with conservative management hinges on what the parents' situation is...Are they both working? Are they available to the child? Are they available to bring the child into the office as needed? And, how upset are they by the child's illnesses? All of those factors need to be considered along with the more strictly medical issues.
AO/Beck: Can you offer any insight on the dramatic increase in asthma in the pediatric population over the last 20 to 30 years?
Paradise: I really don't have any expertise concerning asthma. My suspicion is that it may be related to air pollution or other environmental factors.
AO/Beck: I recall reading a few weeks ago that someone was trying to correlate the parents level of stress and anxiety with asthma in their children. Any thoughts on that?
Paradise: It's risky to draw conclusions from associations between one phenomenon and another. Association doesn't necessarily imply causality. Parental stress and children's asthma are both more prevalent in poor families than well-to-do families. Poverty, or some of its accompanying difficulties and limitations, may somehow be an important underlying factor for both stress and asthma.
AO/Beck: It's very difficult to truly weigh socio-economic status as some people below the poverty level may come from happy and well adjusted homes, whereas some folks in higher income homes, may come from distressed and broken homes.
Paradise: Very true, but in general, it's probably more advantageous to come from an upper income home!
AO/Beck: I agree. Before I let you go, I'd like to mention the last study of yours that I read. That was the one that looked at speech and language abilities of children as correlated with myringotomy and PE tube placement. Basically, you found that children with and without PE tubes had the same outcomes with regards to speech and language. Is that correct?
Paradise: Yes, that's correct.
AO/Beck: That study really surprised me. My basic belief was that children who do not receive a loud and clear language sample, probably will not develop an accurate lexicon, or foundation of spoken language, or speech articulation ability and knowledge. Nonetheless, I believe your study showed that children with otitis media, with or without tube placement, had about the same outcomes on speech and language measures.
Paradise: Correct. However, keep in mind that the results available to date were from children at age 3 years. We have yet to complete our analysis of results in these children at ages 4 and 6 years. Also, we didn't focus exclusively on children with significant hearing loss;, we included all comers who met our criteria for persistent middle-ear effusion, irrespective of their degree of hearing loss. I think that if a young child has clinically significant hearing loss with his or her OM, and if it remains present for a long enough period of time, it probably would eventually impact the child's speech and language development. Nonetheless, although our children had had middle-ear effusion for relatively long periods, with most hearing tests abnormal in some degree during periods of effusion, their speech and language outcomes were not impacted.
I think it is true that many young children with persistent middle-ear effusion start to speak better immediately after they get tubes, but our study reinforces the proposition that if one waits for the disease to clear on its own, speech and language would eventually reach the same level of proficiency.
AO/Beck: Dr. Paradise I want to thank you for your time and your expertise. Your work is very interesting. The questions you ask and the answers you derive are of paramount importance to all of us involved in hearing healthcare and related fields.
Paradise: Thank you for the opportunity.
Paradise: Hi Dr. Beck, thanks for inviting me.
AO/Beck: Dr. Paradise, if I may, I'd like to tell the readers a little about your professional history. I know you've published some ground-breaking papers and you've questioned the wisdom of some practices that many accept as the standard of care. Those are bold things to do! I know you've conducted research on the management of middle ear disease and you were the recipient of the 1994 Research Award of the Ambulatory Pediatric Association. In 1995, you were elected a Fellow of the American Association for the Advancement of Science. In 1998, the Pittsburgh Pediatric Society created the Jack Paradise Investigator's Award and you were the first recipient. In 1999, you received the research award of the Society for Ear, Nose and Throat Advances in Children. You've been very involved with otitis media and other aspects of otolaryngologic and audiologic research issues in the pediatric population. Having said all that, Can you please tell me your thoughts on this tremendous body of work?
Paradise: We've been studying these issues for about 30 years. The primary questions we've been addressing have dealt with identifying which children would benefit from the operations and to what degree they would benefit. We conducted a series of randomized clinical trials. Some of the results have been published over the years and others will hopefully be published in the near future. The basic design has been to compare children who have had surgery with children who haven't had surgery, to learn what the outcomes are. Basically, we wanted to know if the operated children are faring significantly better than the children who have not received the operations.
AO/Beck: What have the studies revealed?
Paradise: Regarding ear disease, we randomly assigned children who previously had tubes inserted and who subsequently developed otitis media, to undergo or not undergo adenoidectomy. The children assigned to undergo adenoidectomy who had middle-ear effusion at the time of surgery, also underwent tube insertion . Children in the non-adenoidectomy control group who had effusion that failed to resolve with medical treatment also underwent tube insertion. What we found was that the children who underwent adenoidectomy fared significantly better than the children who did not receive the adenoidectomy.. Therefore, we now recommend, for children who have undergone tube insertion and who subsequently developed recurrent otitis media that has become troublesome enough to warrant a second set of tubes, that adenoidectomy be carried out in conjunction with the second tube operation. The results of that study were reported in JAMA in 1990.
In a more recent study, reported in JAMA in 1999, we studieded children with recurrent acute otitis media who had not previously undergone tube insertion. The children were assigned to one of three treatment groups. The first group underwent adenoidectomy only, the second group underwent tonsillectomy and adenoidectomy (T & A) and the third group received no tonsil or adenoid surgery. The study was designed to avoid, as much as possible, the use of tympanostomy tubes. Accordingly, children who had middle-ear effusion at the time of adenoidectomy or T & A underwent myringotomy only, without tube insertion. Similarly, children in the control group who had middle-ear effusion that persisted despite medical treatment also underwent myringotomy without tubes. Only if a second myringotomy was required in the course of the study did children receive tubes. Analysis indicated that children in each of the two surgical groups fared a little better during the first year of follow-up than did the children who did not undergo surgery, but the effect did not persist thereafter. The results were slightly better in the children who underwent T & A than in those who underwent adenoidectomy alone. However, the between-group differences in this study were not only short-lived but of small magnitude, and even though they were statistically significant, we didn't consider them clinically significant.
Therefore, we concluded that for children with recurrent acute otitis media, nonsurgical management should certainly be attempted first, with tube insertion to be considered as the preferred surgical recourse if the burden of illness becomes unbearable. Relatively few such children should need further surgical treatment.
AO/Beck: At what point do you recommend that a surgical consult be initiated for a child with chronic ear disease?
Paradise: That's a tough question. I really think that every child needs to be evaluated individually by the pediatrician and that guidelines are OK, but too general to be applied across the board to individual children. Whenever the parents or the pediatrician feel that it's the right thing to do, a referral should be made. Many times the decision for or against continuing with conservative management hinges on what the parents' situation is...Are they both working? Are they available to the child? Are they available to bring the child into the office as needed? And, how upset are they by the child's illnesses? All of those factors need to be considered along with the more strictly medical issues.
AO/Beck: Can you offer any insight on the dramatic increase in asthma in the pediatric population over the last 20 to 30 years?
Paradise: I really don't have any expertise concerning asthma. My suspicion is that it may be related to air pollution or other environmental factors.
AO/Beck: I recall reading a few weeks ago that someone was trying to correlate the parents level of stress and anxiety with asthma in their children. Any thoughts on that?
Paradise: It's risky to draw conclusions from associations between one phenomenon and another. Association doesn't necessarily imply causality. Parental stress and children's asthma are both more prevalent in poor families than well-to-do families. Poverty, or some of its accompanying difficulties and limitations, may somehow be an important underlying factor for both stress and asthma.
AO/Beck: It's very difficult to truly weigh socio-economic status as some people below the poverty level may come from happy and well adjusted homes, whereas some folks in higher income homes, may come from distressed and broken homes.
Paradise: Very true, but in general, it's probably more advantageous to come from an upper income home!
AO/Beck: I agree. Before I let you go, I'd like to mention the last study of yours that I read. That was the one that looked at speech and language abilities of children as correlated with myringotomy and PE tube placement. Basically, you found that children with and without PE tubes had the same outcomes with regards to speech and language. Is that correct?
Paradise: Yes, that's correct.
AO/Beck: That study really surprised me. My basic belief was that children who do not receive a loud and clear language sample, probably will not develop an accurate lexicon, or foundation of spoken language, or speech articulation ability and knowledge. Nonetheless, I believe your study showed that children with otitis media, with or without tube placement, had about the same outcomes on speech and language measures.
Paradise: Correct. However, keep in mind that the results available to date were from children at age 3 years. We have yet to complete our analysis of results in these children at ages 4 and 6 years. Also, we didn't focus exclusively on children with significant hearing loss;, we included all comers who met our criteria for persistent middle-ear effusion, irrespective of their degree of hearing loss. I think that if a young child has clinically significant hearing loss with his or her OM, and if it remains present for a long enough period of time, it probably would eventually impact the child's speech and language development. Nonetheless, although our children had had middle-ear effusion for relatively long periods, with most hearing tests abnormal in some degree during periods of effusion, their speech and language outcomes were not impacted.
I think it is true that many young children with persistent middle-ear effusion start to speak better immediately after they get tubes, but our study reinforces the proposition that if one waits for the disease to clear on its own, speech and language would eventually reach the same level of proficiency.
AO/Beck: Dr. Paradise I want to thank you for your time and your expertise. Your work is very interesting. The questions you ask and the answers you derive are of paramount importance to all of us involved in hearing healthcare and related fields.
Paradise: Thank you for the opportunity.
