[Overton]The Impact of Otitis Media on Language and Learning

by Valerie Johnston, M.S., CCC-SLP

Otitis media, simply defined, is an inflammatory condition of the middle ear. Acute otitis media (AOM) is the term commonly used to indicate the presence of infected fluid within the middle ear cavity. It is usually of recent onset, accompanied by a myriad of physical symptoms (Kavanagh 1986), and resolves in four to five weeks with or without treatment in 80-90% of the cases (Moller 1985). Historically because of its fairly rapid resolution, the disease has not been of great concern to professionals. However, evidence has begun to accumulate supporting the relationship between otitis media (OM) and later speech, language, and learning problems.

It is well documented that most children have impaired hearing when effusion (fluid) is present (Kavanagh 1986). Since fluid remains in the middle ear for varying amounts of time after the initial diagnosis of AOM, children experience hearing losses associated with the disease for variable periods of time. One study conducted by pediatricians revealed that fluid remained in the middle ear for up to three months after the initial diagnosis in l0% of the cases. This same study revealed that fluid was still present two months post-diagnosis in 20% of the cases, and one month post-diagnosis in 40% (Kavanagh 1986).

The hearing loss which accompanies otitis media with effusion (OME) averages about 25 to 30dB, while the range is from 10 to 40dB (Kavanagh 1986). This loss is not permanent and tends to fluctuate with the stage of the disease. Although the degree of hearing loss associated with OME is considered mild and is only temporary, it poses a threat to children who contract the disease because of the long term affects it can have on speech, language, and learning.

Most cases of OM occur in the first three years of life, with a peak incidence between six and eighteen months (Kavanagh 1986). This is the same time period during which speech and language are first being learned. While developing speech and language skills does not require great concentration for most normally developing children, the hearing loss associated with OME makes it a much more difficult task, requiring extreme levels of concentration. Infants and young children are not capable of exerting this degree of concentration over long periods of time. It is, therefore, critical that children receive a steady auditory signal during these early years.

The studies which follow lend support to the idea that the mild hearing loss associated with OME can cause significant long-term problems in the areas of speech, language, and learning. In fact, it now appears that the frequency, duration and age of onset may be the most significant factors that will enable us to predict who will experience the long-term effects of the disease.

Two studies which support the existence of a relationship between otitis media and language, along with the possibility of long-term effects of the disease, were conducted on the Boston Cohort. This is a group of 2568 consecutively born children who came from lower and middle SES famlies. Both the lower and middle SES groups were divided into three subgroups, depending upon the duration of effusion (29 days or less=low, 30-129 days=mid, 130 days or more=high). The first study conducted on this group (Teele, Klein, and Rosner 1984) was completed on three year olds and tested receptive vocabulary, global receptive and global expressive abilities. Results revealed that for the middle class group there were significant differences between all language scores earned, with respect to duration of OME. These differences were exhibited between each effusion group: low, middle, high. However, no significant differences were found in the lower SES group. One reason hypothesized for the difference in results between the two groups was that the comparatively otitis-free middle class three year olds were showing the typical rapid spurt in language development and leaving their otitis-prone peers behind, whereas, no such general spurt was occurring at this age in the low SES group. The scores on the various tests administered support this conclusion rather well.

However, the second study, conducted on this same group of children (Kavanagh 1986) at seven years of age, revealed significant differences in both the middle and lower SES groups. The areas of language tested included expressive vocabulary, morphology (i.e., verb forms, plurals, possessives), speech production (articulation), speech perception (i.e., discrimination, auditory processing) and syntax (grammar). Since most of the significant differences occurred between the low effusion (< 30 days) and high effusion (> 130 days) groups, it appears that a critical level of disturbance in information processing must occur before there are long-term consequences of OME (Kavanagh 1986).

Feagans (Kavanagh 1986) states that continued bouts of otitis media may produce initial language delays but the critical effect of OME, the effect which produces long-term language delays, is the decreased attention to language caused by intermittent hearing loss. To support this statement, she cites information collected during a study of 44 children who were at risk for otitis media and were followed from birth. These children were studied in terms of language skills at five years and seven years and in terms of attending skills at five years. They were divided into two groups based on the frequency of otitis media in the first three years of life: high group (9 or more episodes) and low group (8 or fewer episodes). Results of the language testing at five years and seven years indicate that the frequency and duration of otitis media in the first three years of life account for the difference between the two groups, both in terms of narrative ability and paraphrasing ability. It is important to note that the differences present are above the variance accounted for simply by I.Q. differences.

In order to determine if inattention to language could be the mediating factor in long-lasting affects of OME, Feagans studied the attending behaviors of the two groups in their kindergarten classrooms. The high otitis media group showed significantly more inattention and distractability, having twice the number of five-second intervals in which they were found to be off-task. This is an important finding since other studies have shown that off-task behaviors may lead to lower achievement and other negative classroom outcomes. (Feagans and McKinney 1981).

In a study on Eskimo children completed by Kaplan and his colleagues (1973), it was found that there was no difference in the acquisition of motor milestones between children with a history of otitis media and those with no history of otitis media. However, significant differences were found in terms of verbal I.Q. and age of acquisition of words and sentences. In addition, it was found that from an overall academic standpoint, children who suffered OME prior to two years of age were worse off than those whose ear disease began after two years. The overall language development of the group who developed chronic OME before age two was 25 months behind the group who developed the disease later than two years of age.

Sak and Ruben (1982) found that children between eight and eleven years with a history of otitis media were significantly poorer in verbal production, auditory decoding, and spelling than their siblings without histories of otitis media. It is interesting to note that the children with a history of otitis media developed strengths in visual sequential memory, as compared to their siblings. It was hypothesized that this strength was developed as a compensation for their poorer auditory and verbal abilities.

The preceding studies indicate that there is a relationship between OME and speech and language development. The reason this relationship exists is because of the hearing loss which usually accompanies the presence of effusion (fluid). In addition, according to these studies, the negative affects of OME on speech, language, and learning can be long-term. It appears that the age of onset (before two), the frequency (9 episodes or more in the first three years of life), and the duration of fluid (>130 days) are among the factors that will assist us in determining which children will experience long-term affects. In addition, it should be noted that any child with a family history of language delay or auditory-based learning disabilities is at an even greater risk of experiencing the long-term language and learning affects associated with OME (Kavanagh 1986).

OME carries with it the risk of speech, language, and learning problems, but it interacts with other factors in the child's life. With appropriate monitoring of speech and language skills in the early years (birth to three years) and intervention, if warranted, the long lasting impact of OME on later academic success can be minimized, or better yet, prevented.


Feagans, L., and McKinney, J.D., The Pattern of Exceptionality Across Domains in Learning Disabled Children. Journal of Applied Developmental Psychology, 1981,1, 313-328.

Kaplan, G., Fleshman, J., Bender, T., Baum, C., and Clark, P., A 10 year cohort study of Alaska Eskimo Children. Pediatrics, 1973, 52, 577-584.

Kavanagh, J. (Ed. - 1982). Otitis Media and Child Development. Parkton, M.D.:York Press, 1986.

Moller, P., Incidence and Time Course of Otitis Media in Children. Audiology in Practice. Amsterdam, Netherlands: Elsevier Science Publishers, 1985.

Sak, R. and Ruben, R, Effects of Middle Ear Effusion in Preschool Years on Language and Learning. Developmental and Behavioral Pediatrics, 1982, 3, 7-11.

Teele, D., Klein, J., and Rosner, B., Otitis Media with Effusion During the First Three Years of Life and Development of Speech and Language. Pediatrics, 1984, 74, 282-287.

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Last revised: February 03, 2001