Controversy was generated in the late 1970s regarding a possible link between chronic otitis media and learning disabilities. After several decades, the controversy has not been unequivocally resolved.There remains an interesting hypothesis that "chronic otitis media and its associated transient conductive hearing loss adversely impact on speech/language development, with subsequent impairment in learning skills?" The question is not an issue of pediatricians recommending immediate surgical interventions or to following a particular medical regimen for chronic otitis media --- it is, however, a significant neurodevelopmental challenge which initiates new responsibilities for primary healthcare providers. Can we postulate that chronic otitis media, an organic problem, is in part responsible for a pediatric developmental disorder? If so perceived, the focus is on the need for generating an "awareness;" initiating an early interdisciplinary diagnosis, and designing appropriate management strategies.

The link between chronic otitis media (with associated transient conductive hearing loss and possible central auditory processing deficits) and speech-language delays and disorders has been fairly well documented. However, the cause and effect relationship between recurrent otitis media and subsequent learning impairments, with intermediate pathologies in speech-language and auditory perceptual development, has not been clearly defined.

The first two to three years of life is generally recognized as a "critical period" for the development of speech and language; coinciding with maturation of the central nervous system and its complex functions. It has been hypothesized that even "minor hearing loss" can adversely influence the development of language. Data suggests that if otitis media is undetected for at least six months during infancy, the child will ultimately be handicapped because of a lack of structured auditory stimulation during the critical period of "verbal education." Receptive and expressive language develops concurrently with the neuromaturation of the auditory system.Freeman and Parkins (1979) suggested that "the apparent relationship between audition, language and learning supports the thesis that children with significant auditory deficits may be delayed in linguistic and cognitive development."The incidence of reading impairment among children with a history of recurrent otitis media appears to be significantly greater than among children with no history of middle ear pathology.Howie (1975) suggested that in the classroom, the "otitis-prone" child may become educationally classified as "learning disabled," or as Downs (1977) comments, "an irreversible auditory learning disaster."

Several early studies (Holm & Kunze 1969, Ling 1972) suggested that the fluctuations of hearing acuity during the developmental period when language is being acquired, was enough to produce language problems that later affected academic achievement. Lewis (1976) reported that chronic middle ear disease restricted the development of some auditory processing skills and their integrational pattern. Although a voluminous fund of knowledge documents the severe language, learning and behavioral complications associated with deafness, much less is known about the consequences of fluctuating or transient conductive hearing loss, which accompanies chronic (recurrent) otitis media. Several retrospective studies (Zinkus & Gottlieb, 1980; Gottlieb, Zinkus & Thompson, 1979) suggested a possible predisposition for central auditory processing dysfunction which is manifested under conditions of hearing loss.A provocative speculation is that fluctuating peripheral auditory deprivation, (associated with chronic otitis meia), may adversely influence the maturation of central auditory processing mechanisms required for learning skills.

Various studies concluded that there is only "empirical evidence implicating conductive hearing impairment as a causal agent in learning disability, language dysfunction, and central auditory problems," suggesting that there was little valid data to link conductive hearing impairment with these problems. However, in 1984, an American Academy of Pediatrics Policy Statement on Middle Ear Disease and Language Development acknowledged the mounting evidence "demonstrating a correlation between middle ear disease with hearing impairment and delays in the development of speech, language and cognitive skills." The Statement recommended that "when a child has frequently recurring acute otitis media and/or middle ear effusion persisting for longer than three months, hearing should be assessed and the development of communication skills must be monitored."

The clinical jump from recurrent otitis media to learning impairments continues to permeate the scientific literature, from the 1980s to the present. Validation for or against the "cause and effect" hypothesis would serve to more judiciously provide clinical direction for designing preventive and palliative strategies.Unfortunately, the issues remain scientifically "blurred," and further clarifications remain a research challenge. For many children, there is an obvious urgency in resolving these issues!