Middle Ear, Eustachian Tube, Inflammation/Infection Follow-up

  • Author: Robert B Meek, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Jun 21, 2011
 

Further Inpatient Care

Inpatient care is seldom required for uncomplicated otitis media (OM). Patients may need admission for IV antibiotics and surgical drainage for extracranial/intracranial complications of acute or chronic otitis media (OM).

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Further Outpatient Care

After 3 months, re-evaluate patients treated conservatively for otitis media with effusion (OME). Ninety percent of effusions that are going to clear without surgical treatment do so by 90 days. If no resolution of effusion occurs, consider myringotomy and ventilation tube insertion.

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Inpatient & Outpatient Medications

  • First-line antimicrobials used for otitis media (OM) include amoxicillin, trimethoprim/sulfamethoxazole, and erythromycin/sulfisoxazole. Despite the prevalence of resistant strains, the low cost and effectiveness in most patients supports continued use of these drugs.
  • Second-line antimicrobials for otitis media (OM) include amoxicillin/clavulanate, cefuroxime, clarithromycin, and azithromycin. These antibiotics and others in their class offer a broader spectrum of coverage. A 2- to 3-week course of a second-line antibiotic has been shown to improve the resolution of OME in 15% more patients compared with no treatment at all. Multiple courses of antibiotics have shown no benefit.
  • Pseudoephedrine is an ingredient found in oral decongestants. Oral decongestants are used in the treatment of eustachian tube dysfunction (ETD) and can help decrease peritubal edema provoked by allergies or URI.
  • Oxymetazoline is an ingredient found in topical decongestants. Topical decongestants can be used acutely for eustachian tube dysfunction (ETD) but must be discontinued after a maximum of 5 days to prevent rebound swelling.
  • Budesonide, fluticasone, beclomethasone, mometasone, triamcinolone, and flunisolide are steroids used in nasal sprays. Steroid nasal sprays are used in the hope of decreasing the peritubal edema on a long-term basis. These agents are most helpful in patients with allergic rhinitis. The results of one study suggest that intranasal steroid sprays alone do not help eustachian tube dysfunction.[4]
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Transfer

Evaluation by an otolaryngologist is recommended for any signs of extracranial/intracranial complications or for chronic effusions with hearing loss.

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Deterrence/Prevention

  • Environmental modification is recommended.
    • Breastfeeding is recommended for at least 3-6 months. A meta-analysis reported a 13% reduction in the frequency of otitis media (OM) associated with breastfeeding for this period of time.
    • Smoking in proximity to the children is not recommended. Two meta-analyses reported the relative risks (1.2-1.7) of passive smoke in the development of otitis media (OM).
    • Limit pacifier use to the moments when the child is falling asleep. A recent study revealed a 29% lower rate of acute otitis media (AOM) in children with limited pacifier usage.
    • Limit daycare exposure when possible; limited exposure can help decrease the frequent development of URTIs. Daycare enrollment is a greater risk factor for otitis media (OM) than parental smoking.
  • Vaccination is the main form of prevention currently available.
    • Haemophilus influenzae type B vaccination is administered to infants for prevention of meningitis and other invasive infections. H influenzae type B causes only approximately 2% of otitis media (OM). Nontypeable H influenzae accounts for a larger percentage of otitis media (OM); however, a common antigen that would cross protect against the various strains of this bacteria has not been developed.
    • Heptavalent pneumococcal conjugate vaccines currently are administered to infants at age 2, 4, and 6 months with a booster dose administered at age 2 years. A significant reduction in otitis media (OM) caused by the serotypes contained in the vaccine was demonstrated in a 2000 Kaiser Permanente vaccine study.[6] Ambulatory visits were reduced by 42.7% for acute otitis media (AOM), and antibiotic prescriptions were reduced 41.9% from 1997-99 to 2004.
    • With the decrease in pneumococcal infections, B-lactamase–producing H influenzae has increased. Luckily, the disease course has been less virulent although more difficult to eradicate with first-line antibiotics.
    • A vaccine for Moraxella catarrhalis is currently being investigated. M catarrhalis has been isolated in approximately 10% of patients with acute otitis media (AOM). URTI is the common denominator in many causes of otitis media (OM).
    • Viral vaccines are currently under investigation including vaccines against adenovirus, respiratory syncytial virus, and influenza. A Finnish study investigating an influenza vaccine showed a reduction in the incidence of URTI and acute otitis media (AOM) in infants who attended daycare during an influenza epidemic.
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Complications

  • Tympanic membrane perforation
  • Hearing loss
  • Cholesteatoma
  • Meningitis
  • Brain abscess
  • Subdural empyema
  • Subperiosteal abscess
  • Petrositis
  • Labyrinthitis
  • Sigmoid sinus thrombophlebitis
  • Otitic hydrocephalus
  • Facial paralysis
  • Death
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Prognosis

Prognosis is excellent if infection is not permitted to spread beyond the middle ear and eustachian tube. Permanent sequelae are usually rare.

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Patient Education

Education of parents in the form of risk factor reduction is useful. Modifiable risk factors include breastfeeding exclusively for at least 3 months, avoidance of parental cigarette smoke, feeding the baby in an upright position, limiting pacifier usage to just when the infant is falling asleep, and avoidance of daycare attendance, if possible.

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Contributor Information and Disclosures
Author

Robert B Meek, MD  Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, Anne Arundel Medical Center

Robert B Meek, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and Association for Research in Otolaryngology

Disclosure: Nothing to disclose.

Specialty Editor Board

Ari J Goldsmith, MD  Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center

Ari J Goldsmith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gregory C Allen, MD  Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

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Anatomy of the external and middle ear.
 
 
 
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