47 Otitis Media and Revision Tympanostomy Tubes Otitis media and upper respiratory infection are the two most common conditions seen by pediatricians in the United States.1 Otitis media occurs in children in a bimodal pattern, peaking during infancy and again at grammar school entry. Rates of infection have risen with changing socioeconomic and environmental conditions. Investigators have correlated these increases with rising rates of day care attendance and atopic allergy. Both trends seem likely to continue, thereby maintaining a high rate of otitis media and its sequelae in our patient population. Most children experience the peak of acute ear infections prior to age 2, but a substantial minority will continue to experience recurrent acute infections or chronic effusions. Myringotomy and tube placement have been shown in many studies to be extremely effective for both otitis media with effusion and recurrent acute otitis media.1–4 Patients requiring repeated tube insertions for prolonged otitis, however, represent 22.0 to 35.2% of this overall otitis population.5,6 Evaluation of this more chronic otitis-prone subgroup requires consideration not only of the tube insertion procedure but also of the underlying contributing factors. Persistent otitis media may manifest as recurrent acute infections or chronic middle ear effusion. The nasopharynx may serve as a source of initial infection from upper respiratory tract infection or repeated colonization from bacteria harbored in the adenoid tissue. Nasopharyngeal culture may yield bacteriologic identification to direct antibiotic therapy, as the bacteriology correlates well with middle ear cultures in 62% of patients.7 Negative nasopharyngeal culture results are strongly correlated with sterile middle ear cultures, with negative predictive values ranging from 94 to 100% for the main pathogens Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.7,8 Prophylactic antibiotics have been shown to be effective for prevention of acute infection and increased resolution of middle ear effusion. Polymerase chain reaction techniques have demonstrated bacterial activity in a middle ear considered to be sterile by traditional bacteriologic culture. Thus, initial treatment of acute infection may have to be followed by a more prolonged course of antibiotic treatment at a lower dosage. Although investigators vary somewhat in treatment duration, amoxicillin remains the antibiotic of choice for prophylaxis.9 The increasing rates of antibiotic resistance in multiple pathogens lead researchers to urge for “more selective use of this mode [antibiotics] of prevention.”9,10 Nonantibiotic methods such as antiviral vaccines and environmental changes can impact on prevention, but tympanostomy tubes remain a mainstay of treatment in the current arsenal for otitis media, offering the only substantial option to antibiotic therapy. Oral steroids have not proven efficacious in resolving chronic effusions. The nasopharynx is believed to be a reservoir of potential contamination for the middle ear. Infected secretions may enter into an inflamed or fluid-filled middle ear and cause ongoing infection. Adenoidectomy has been advocated with revision tube placement to remove this tissue as a source of infection. Removal of enlarged adenoid tissue is also felt to decrease obstruction at the nasopharyngeal lumen. Adenoidectomy has been demonstrated in multiple trials to decrease the likelihood of reinsertion of subsequent tubes when performed in association with initial tubes.11,12 However, Paradise et al13 failed to show a clear reduction in otitis media with adenoidectomy or adenotonsillectomy without tube placement. Therefore, these additional surgeries should not replace repeat tube insertion, but rather be done in appropriate patients in conjunction with revision tube placement. Finally, tonsillectomy alone has not been clearly demonstrated to have a direct effect on otitis media; the decision for tonsillectomy should be based on standard criteria for infectious or obstructive indications. Developmental anomalies that affect the palate or skull base are strong indicators for tube placement and replacement. Midline clefting disorders such as Pierre Robin syndrome result in severe eustachian tube dysfunction. Submucous cleft palate and bifid uvula are also associated with poor eustachian tube function, as are other craniofacial disorders that may involve the skull base without frank clefting, including Down, Crouzon, Treacher Collins, Apert, Goldenhar, and Turner syndromes. Patients with such anomalies will likely continue with severe middle ear problems and are thus candidates for rapid tube replacement. Associated sinonasal disease such as polyposis or chronic sinusitis may be associated with chronic otitis media. A detailed history should be obtained and further investigation conducted in appropriate patients. Evaluation of the posterior nasal cavity and nasopharynx is easily accomplished with a flexible endoscope. This may yield important information regarding the underlying etiology of eustachian tube dysfunction, such as an antrochoanal polyp or Tornwaldt cyst. The nasopharynx should be routinely evaluated in all adults with otitis media to assess for nasopharyngeal malignancy. Early nasopharyngeal carcinoma or lymphoma may have few other overt findings beyond middle ear fluid, and failure to examine the nasopharynx may cause a delay in diagnosis. In young children, radiologic assessment of obstruction may be substituted for direct endoscopy preoperatively, as appearance of the nasopharynx can be confirmed at the time of tube placement. However, nasopharyngeal films may not fully correlate with potential nasopharyngeal obstruction. The removal of even mildly enlarged adenoids may result in improvement in recurrent otitis that cannot be fully explained, but it presumably reflects removal of the source of contamination.11–13 A history of allergic and immune problems should also be sought. Classic allergic congestion of the sinonasal mucosa can involve the lining of the eustachian tube and middle ear mucosa.14 Elevated levels of eosinophilic cationic protein have been demonstrated in 87.5% of patients sampled with chronic sterile middle ear effusions. Allergic evaluation should be conducted at the time of consideration for revision tubes. This may be done by serologic testing (radioallergosorbent test [RAST] panel) or by skin testing. In some allergic patients, a clinical trial of oral antihistamine therapy may prove effective in resolving middle ear effusion in conjunction with appropriate antibiotic treatment. Longer-term therapy can then be maintained. Nonallergic immune dysfunction should also be evaluated in individuals with no other identifiable risk for recurrent otitis. Immunoglobulin subsets can be evaluated quantitatively. Human immunodeficiency virus (HIV) infection may manifest initially as middle ear effusion and may progress toward further stages of chronic otitis media.15 If not previously treated, some HIV patients may resolve a middle ear effusion with appropriate antiviral therapy. Other disorders affecting local immunity and defenses, such as immotile ciliary disorders and mucopolysacchari-doses, may also contribute to chronic sinusitis and otitis. Patients with suggestive histories should be appropriately evaluated. Prolonged conductive hearing loss in the setting of otitis media with effusion is a common indication for tube placement.2,16 Criteria vary somewhat between reports, ranging from a 10 to 20 dB threshold for the air–bone gap. A conductive loss in the presence of other communication issues such as speech or developmental delay will present a very strong indication for early tube replacement.16–18 Patients with a permanent underlying sensorineural hearing loss will also benefit from surgical resolution of an overlying conductive fluid component. They can then benefit from the maximal appropriate amplification, without the additional conductive overlay. Revision tube placement should be strongly considered for patients who have experienced complications of otitis media, as they may be at risk for recurrence of that complication or for worsening of otologic function. Such complications include otogenic facial nerve paralysis, labyrinthitis, mastoiditis, petrositis, cholesteatoma, meningitis, and intracranial abscess.4,19,20 These sequelae of otitis media are still seen regularly in underdeveloped countries where antibiotics and tube placement are not routinely available.21 Long-term tube replacement should also be strongly considered for ears in which early adhesive changes have begun. Early intervention and maintenance of good middle ear ventilation may prevent further retraction, atelectasis, and ossicular erosion in vulnerable ears. Acute otitis media can cause mastoiditis in a cavity previously opened for cochlear implantation, which may result in labyrinthitis or even meningitis. Gantz et al22 reported an 8-year series of cochlear implant patients in which 5.6% of children developed otitis media, which progressed to mastoiditis in 1%. Three of these five cases lost implant function, and one developed acute labyrinthitis. A trial of prospective tube placement in young cochlear implant candidates showed no cases of progression to mastoiditis and no loss of implant function in otitis-prone children.23 Therefore, tympanostomy tube insertion should be considered prior to or at the time of cochlear implantation in otitis-prone patients. Individuals with special needs for excellent eustachian tube function may require tympanostomy tube placement despite the absence of effusion. Such candidates include persons who suffer from severe barotrauma and patients receiving hyperbaric oxygen therapy.24 Such persons may experience pain, pressure, hearing loss, fluid effusion, and even middle and inner ear hemorrhage from difficulties with pressure equalization during compression and decompression.25
Preoperative Evaluation
Infectious Considerations
Nasopharyngeal Culture
Prophylaxis
Anatomical Considerations
Adenoidectomy
Craniofacial Anomalies
Sinonasal Conditions
Immunologic Considerations
Allergy
Immune Disorders
Otologic and Hearing Issues
Conductive Hearing Loss
Complications of Otitis Media
Cochlear Implant Patients
Special Populations
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