Middle Ear, Eustachian Tube, Inflammation/Infection Treatment & Management

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

Medical Care

In the United States, acute otitis media (AOM) is typically treated with antibiotics. Treatment with amoxicillin for 10 days is the initial antibiotic selection, or Bactrim is substituted if the patient is allergic to penicillin. In Europe, a more conservative approach to treating acute otitis media (AOM) is used. Given the alarming increase in antibiotic resistance, the routine usage of antibiotics in the United States should be reconsidered.

A recent meta-analyses from 30 articles written in English and 3 articles written in a language other than English revealed that acute otitis media (AOM) achieved complete clinical resolution without treatment 81% of the time as compared with resolution 95% of the time with the use of antimicrobials. Criteria for withholding or delaying antibiotic therapy for acute otitis media (AOM) include (1) patient older than 2 years, (2) normal host, (3) intact tympanic membrane, (4) at least 3-6 months since last episode of otitis media (OM), (5) receptive parents, and (6) assurance of medical follow-up care.

In the United States, otitis media with effusion (OME) can be treated with observation, antibiotics, or tympanostomy tube placement. Meta-analysis of controlled studies revealed only a 14% increase in resolution rate when antibiotics are given. Antibiotic suppression is not indicated for otitis media with effusion (OME), and multiple courses of antibiotics have no proven benefit. Consider surgical intervention after 3-4 months of effusion with a 20 dB or greater hearing loss.

Eustachian tube dysfunction (ETD) can be treated primarily with a combination of time, autoinsufflation (eg, an Otovent), and oral and nasal steroids (budesonide, mometasone, prednisone, methylprednisolone). The results of one study suggest that intranasal steroid sprays alone do not help eustachian tube dysfunction.[4]

Decongestants (eg, pseudoephedrine, oxymetazoline, phenylephrine) are also helpful, but not as useful for chronic eustachian tube dysfunction (ETD). Consider the cardiovascular effects of oral decongestants and the early development of tachyphylaxis observed with the use of nasal decongestants; limit the use of the decongestant to short-term symptomatic relief (ie, no more than 3-5 d).

Nasal and oral antihistamines can also be beneficial in patients with allergic rhinitis. Leukotriene antagonists (eg, montelukast sodium [Singulair]) are helpful in some patients when oral steroids are not an option. Adequate control of laryngeal pharyngeal reflux helps to resolve eustachian tube dysfunction (ETD) in patients with an associated peritubal inflammation from reflux. Proton pump inhibitors (esomeprazole magnesium [Nexium], rabeprazole [Aciphex], omeprazole [Prilosec]) administered twice a day are often used. Myringotomy with tube insertion is reserved for the refractory patient with debilitating symptoms.

Next

Surgical Care

The primary surgical treatment of all types of otitis media (OM) is myringotomy with tube placement.[5] The typical ventilation tube stays in place for a period of 8-12 months with closure of the perforation occurring after tube extrusion. In a small percentage of patients with poor eustachian tube function or other complicating factors, the perforation may persist.

  • Adenoidectomy is indicated for refractory OME in children older than 4 years and in younger children when adenoid pathology is present (eg, chronic adenoiditis, adenoid hypertrophy).
  • Tonsillectomy has not been shown to prevent otitis media (OM) either alone or in conjunction with adenoidectomy.
  • Mastoidectomy, both canal wall up and canal wall down, can be used to treat complications of middle ear infection and eustachian tube dysfunction (ETD).
Previous
Next

Consultations

Consult with an otolaryngologist if the patient has any evidence of complications of otitis media (OM), if the effusion persists for longer than 3 months, if a 20 dB or greater hearing loss exists, or if a patient has more than 3 episodes of otitis media (OM) in 4 months or 6 episodes of otitis media (OM) in 1 year.

Neurosurgery consultation may be required for intracranial complications such as a brain abscess.

Previous
Next

Activity

Patients with eustachian tube dysfunction (ETD) must be careful when flying or diving because of the risk of barotrauma. Instruct patients with significant eustachian tube dysfunction (ETD) to use oral and topical decongestants 30 minutes before landing. An Otovent may be used to assist with autoinsufflation in the treatment of eustachian tube dysfunction (ETD).

Previous
Proceed to Medication
 
 
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

References

  1. Doyle WJ, Alper CM, Buchman CA, Moody SA, Skoner DP, Cohen S. Illness and otological changes during upper respiratory virus infection. Laryngoscope. Feb 1999;109(2 Pt 1):324-8. [Medline].

  2. Niemelä M, Pihakari O, Pokka T, Uhari M. Pacifier as a risk factor for acute otitis media: A randomized, controlled trial of parental counseling. Pediatrics. Sep 2000;106(3):483-8. [Medline].

  3. Contencin P, Maurage C, Ployet MJ, Seid AB, Sinaasappel M. Gastroesophageal reflux and ENT disorders in childhood. Int J Pediatr Otorhinolaryngol. Jun 1995;32 Suppl:S135-44. [Medline].

  4. Gluth MB, McDonald DR, Weaver AL, Bauch CD, Beatty CW, Orvidas LJ. Management of eustachian tube dysfunction with nasal steroid spray: a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg. May 2011;137(5):449-55. [Medline].

  5. Haddad J Jr, Saiman L, San Gabriel P, et al. Nonsusceptible Streptococcus pneumoniae in children with chronic otitis media with effusion and recurrent otitis media undergoing ventilating tube placement. Pediatr Infect Dis J. May 2000;19(5):432-7. [Medline].

  6. Black S, Shinefield H, Fireman B, et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group. Pediatr Infect Dis J. Mar 2000;19(3):187-95. [Medline].

  7. Asbjornsen A, Holmefjord A, Reisaeter S, et al. Lasting auditory attention impairment after persistent middle ear infections: a dichotic listening study. Dev Med Child Neurol. Jul 2000;42(7):481-6. [Medline].

  8. Bernstein JM. Immunologic reactivity in the middle ear in otitis media with effusion. Otolaryngol Clin North Am. Aug 1991;24(4):845-58. [Medline].

  9. Block SL, Hedrick J, Harrison CJ, et al. Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiology of acute otitis media. Pediatr Infect Dis J. Sep 2004;23(9):829-33. [Medline].

  10. Bluestone CD. Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment. Int J Pediatr Otorhinolaryngol. Jan 1998;42(3):207-23. [Medline].

  11. Casey JR, Pichichero ME. Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J. Sep 2004;23(9):824-8. [Medline].

  12. Conrad DA. Should acute otitis media ever be treated with antibiotics?. Pediatr Ann. Feb 1998;27(2):66-7, 70-4. [Medline].

  13. Contencin P, Narcy P. Nasopharyngeal pH monitoring in infants and children with chronic rhinopharyngitis. Int J Pediatr Otorhinolaryngol. Oct 1991;22(3):249-56. [Medline].

  14. Daly KA, Giebink GS. Clinical epidemiology of otitis media. Pediatr Infect Dis J. May 2000;19(5 Suppl):S31-6. [Medline].

  15. Ghaffar F, Barton T, Lozano J, et al. Effect of the 7-valent pneumococcal conjugate vaccine on nasopharyngeal colonization by Streptococcus pneumoniae in the first 2 years of life. Clin Infect Dis. Oct 1 2004;39(7):930-8. [Medline].

  16. Heikkinen T. Role of viruses in the pathogenesis of acute otitis media. Pediatr Infect Dis J. May 2000;19(5 Suppl):S17-22; discussion S22-3. [Medline].

  17. Ilicali OC, Keles N, Deger K, Savas I. Relationship of passive cigarette smoking to otitis media. Arch Otolaryngol Head Neck Surg. Jul 1999;125(7):758-62. [Medline].

  18. Meek RB 3rd, McGrew BM, Cuff CF, Berrebi AS, Spirou GA, Wetmore SJ. Immunologic and histologic observations in reovirus-induced otitis media in the mouse. Ann Otol Rhinol Laryngol. Jan 1999;108(1):31-8. [Medline].

  19. Niemelä M, Uhari M, Möttönen M, Pokka T. Costs arising from otitis media. Acta Paediatr. May 1999;88(5):553-6. [Medline].

  20. Pelton SI. Otitis media: re-evaluation of diagnosis and treatment in the era of antimicrobial resistance, pneumococcal conjugate vaccine, and evolving morbidity. Pediatr Clin North Am. Jun 2005;52(3):711-28, v-vi. [Medline].

  21. Pelton SI, Loughlin AM, Marchant CD. Seven valent pneumococcal conjugate vaccine immunization in two Boston communities: changes in serotypes and antimicrobial susceptibility among Streptococcus pneumoniae isolates. Pediatr Infect Dis J. Nov 2004;23(11):1015-22. [Medline].

  22. Pichichero ME. A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients. Pediatrics. Apr 2005;115(4):1048-57. [Medline].

  23. Pichichero ME, Reiner SA, Brook I, et al. Controversies in the medical management of persistent and recurrent acute otitis media. Recommendations of a clinical advisory committee. Ann Otol Rhinol Laryngol Suppl. Aug 2000;183:1-12. [Medline].

  24. Rinaldo A, Ferlito A. The pathology and clinical features of "glue ear": a review. Eur Arch Otorhinolaryngol. 2000;257(6):300-3. [Medline].

  25. Rovers MM, Straatman H, Ingels K, van der Wilt GJ, van den Broek P, Zielhuis GA. The effect of ventilation tubes on language development in infants with otitis media with effusion: A randomized trial. Pediatrics. Sep 2000;106(3):E42. [Medline].

  26. Rovers MM, Zielhuis GA, Straatman H, Ingels K, van der Wilt GJ, van den Broek P. Prognostic factors for persistent otitis media with effusion in infants. Arch Otolaryngol Head Neck Surg. Nov 1999;125(11):1203-7. [Medline].

  27. Ruuskanen O, Arola M, Putto-Laurila A, et al. Acute otitis media and respiratory virus infections. Pediatr Infect Dis J. Feb 1989;8(2):94-9. [Medline].

  28. Shaw CB, Obermyer N, Wetmore SJ, Spirou GA, Farr RW. Incidence of adenovirus and respiratory syncytial virus in chronic otitis media with effusion using the polymerase chain reaction. Otolaryngol Head Neck Surg. Sep 1995;113(3):234-41. [Medline].

  29. Skull SA, Morris PS, Yonovitz A, et al. Middle ear effusion: rate and risk factors in Australian children attending day care. Epidemiol Infect. Aug 1999;123(1):57-64. [Medline].

  30. Takahashi M, Peppard J, Harris JP. Immunohistochemical study of murine middle ear and Eustachian tube. Acta Otolaryngol. Jan-Feb 1989;107(1-2):97-103. [Medline].

  31. Uhari M, Hietala J, Tuokko H. Risk of acute otitis media in relation to the viral etiology of infections in children. Clin Infect Dis. Mar 1995;20(3):521-4. [Medline].

  32. US Otitis Media Guideline Panel, Stool SE, US Agency for Health Care Policy and Research. Otitis media with effusion in young children/Otitis Media Guideline Panel. Rockville, Md: US Dept. of Health and Human Services, Public Health Service; 1994:Clinic practice gudeline, No. 12.

  33. Wright CG, Meyerhoff WL. Pathology of otitis media. Ann Otol Rhinol Laryngol Suppl. May 1994;163:24-6. [Medline].

  34. Zhou F, Shefer A, Kong Y, Nuorti JP. Trends in acute otitis media-related health care utilization by privately insured young children in the United States, 1997-2004. Pediatrics. Feb 2008;121(2):253-60. [Medline].

  35. Zielhuis GA, Gerritsen AA, Gorissen WH, et al. Hearing deficits at school age; the predictive value of otitis media in infants. Int J Pediatr Otorhinolaryngol. Aug 1 1998;44(3):227-34. [Medline].

 
Previous
Next
 
Anatomy of the external and middle ear.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.