eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Middle Ear & Mastoid
Middle Ear, Eustachian Tube, Inflammation/Infection: Treatment & Medication
Updated: May 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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).
- 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.
Surgical Care
The primary surgical treatment of all types of otitis media (OM) is myringotomy with tube placement.4 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).
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.
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).
Medication
Antimicrobials are frequently chosen for the treatment of acute otitis media (AOM) and OME.
Topical nasal decongestants, oral decongestants, nasal steroids, and antihistamines can be used to treat ETD.
Antimicrobials
These agents are used to eradicate middle ear bacteria and prevent mastoiditis in acute otitis media (AOM) and to help speed the resolution of inflammation and effusion in COME.
Amoxicillin (Trimox, Biomox)
DOC for first-line OM in patients not allergic to penicillin. Administered for a total of 7-10 d for AOM.
Adult
500 mg PO for 10 d
Pediatric
90 mg/kg/d PO in divided doses bid for 10d
Reduces efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; may enhance chance of candidiasis
Trimethoprim-Sulfamethoxazole DS (Bactrim DS, Septra DS)
Useful in penicillin-allergic patients. Administered q12h for 10d to treat OM. High incidence of resistance.
Adult
160 mg TMP/800 mg SMZ PO bid
Pediatric
<2 months: Do not administer
>2 months: 15-20 mg/kg/d, based on TMP, PO tid/ qid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation
Amoxicillin/clavulanate (Augmentin)
Drug combination treats bacteria resistant to beta-lactam antibiotics. Useful in patients who have failed first-line treatment of OM.
Adult
875 mg PO bid for 10d
Pediatric
90/6.4 mg/kg/d PO divided bid
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Prescribe for a minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of streptococci
Cefuroxime (Ceftin, Kefurox, Zinacef)
Second-line antimicrobial agent for OM. Also for non type I penicillin allergic patients
Adult
250 mg PO bid
Pediatric
20-30 mg/kg/d PO divided bid
Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer half dose if creatinine clearance is 10-30 mL/min and one-quarter dose if less than 10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy
Oral decongestants
These agents are used to decrease swelling of eustachian tube and sinus mucosa.
Pseudoephedrine (Actifed, Sudafed, Afrin)
Used in patients with ETD. Not helpful in OME.
Adult
60 mg PO q4-6h; 120 mg PO bid (sustained release)
Pediatric
<3 months: Not established
3-12 months: 3 gtt/kg/dose
>1 year: 7 gtt/kg PO q4-6h up to 4 doses/d
Propranolol, MAOIs, and sympathomimetic agents may increase toxicity; methyldopa and reserpine may reduce effects
Documented hypersensitivity; severe anemia; postural hypertension or hypotension; closed angle glaucoma; head trauma; cerebral hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, diabetes mellitus, prostatic hypertrophy, and increased intraocular pressure
Nasal corticosteroids
These agents are used to decrease perieustachian tube inflammation.
Mometasone (Nasonex)
Nasal spray; may decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation. Demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. Decreases rhinovirus-induced up-regulation in respiratory epithelial cells and modulate pretranscriptional mechanisms. Reduces intraepithelial eosinophilia and inflammatory cell infiltration (eg, eosinophils, lymphocytes, monocytes, neutrophils, plasma cells).
Adult
2 sprays (50 mcg/spray) each nostril qd
Pediatric
<2 years: Not established
2-12 years: 1 spray (50 mcg/spray) each nostril qd
>12 years: Administer as in adults
None reported
Documented hypersensitivity; nasal septal perforation; nasal surgery; nasal trauma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use with caution in patients with active or quiescent tuberculosis of the respiratory tract; untreated fungal, bacterial, systemic viral infections; or ocular herpes; rare instances of decreased growth velocity in pediatric patients have been reported; also, rare instances of nasal septum perforation and increased IOP have been reported; nasal and inhaled corticosteroids have been associated with development of glaucoma and/or cataracts
Budesonide (Pulmicort Turbuhaler, Rhinocort)
This nasal steroid is useful in ETD especially in patients who are also diagnosed with allergic rhinitis.
Adult
2-4 sprays/d in each nostril or 2 sprays bid
Pediatric
1 spray in each nostril qd
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not to be used to abort acute asthmatic episodes
Fluticasone (Flonase, Flovent, Veramyst)
Has extremely potent vasoconstrictive and anti-inflammatory activity. Has a weak hypothalamic-pituitary-adrenocortical axis inhibitory potency when applied topically.
Adult
2 sprays in each nostril qd
Pediatric
1 spray in each nostril qd
None reported
Documented hypersensitivity; viral, fungal, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use, applying over large surface areas, application of potent steroids, and occlusive dressings may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria
Triamcinolone (Azmacort, Nasacort AQ)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
Azmacort: 2 inhalations (150 mcg) tid/qid or 4 inhalations (300 mcg) bid
Nasacort: 220 mcg/day as 2 sprays in each nostril qd
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not for use in the treatment of acute asthma episodes; do not use at higher than recommended doses
Ciclesonide (Omnaris)
Corticosteroid nasal spray indicated for allergic rhinitis. Prodrug that is enzymatically hydrolyzed to pharmacologic active metabolite C21-desisobutyryl-ciclesonide following intranasal application. Corticosteroids have a wide range of effects on multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines, eicosanoids, leukotrienes, cytokines) involved in allergic inflammation. Each spray delivers 50 mcg.
Adult
2 sprays (50 mcg/spray) in each nostril qd (ie, 200 mcg/d)
Pediatric
<6 years: Not established
>6 years: Administer as in adults
Data limited; oral ketoconazole increases desciclesonide AUC by approximately 3.5-fold at steady state
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution when replacing systemic corticosteroids because of risk of adrenal insufficiency; may decrease growth velocity in pediatric patients; caution with active or quiescent tuberculosis infection or with untreated fungal, viral, or bacterial infections; rare instances of wheezing, nasal septum perforation, cataracts, glaucoma, and increased intraocular pressure reported
Anti-inflammatory Agent
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Methylprednisolone (Medrol Dose Pack)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult
Administered PO as follows:
Day 1: 24 mg
Day 2: 20 mg
Day 3: 16 mg
Day 4: 12 mg
Day 5: 8 mg
Day 6: 4 mg
Pediatric
Not established
Coadministration with digoxin, may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics; grapefruit juice increases prednisolone concentrations; methylprednisolone and cyclosporine mutually inhibit one another resulting in increased plasma levels of each drug
Documented hypersensitivity; viral, fungal or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Depo-Medrol contains benzyl alcohol which is potentially toxic when administered locally to neural tissue; administration of Depo-Medrol by other than indicated routes, including the epidural route, has been associated with reports of serious medical events including arachnoiditis, meningitis, paraparesis/paraplegia, sensory disturbances, bowel/bladder dysfunction, seizures, visual impairment including blindness, ocular and periocular inflammation, and residue or slough at injection site
More on Middle Ear, Eustachian Tube, Inflammation/Infection |
| Overview: Middle Ear, Eustachian Tube, Inflammation/Infection |
| Differential Diagnoses & Workup: Middle Ear, Eustachian Tube, Inflammation/Infection |
 Treatment & Medication: Middle Ear, Eustachian Tube, Inflammation/Infection |
| Follow-up: Middle Ear, Eustachian Tube, Inflammation/Infection |
| Multimedia: Middle Ear, Eustachian Tube, Inflammation/Infection |
| References |
| Further Reading |
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References
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Further Reading
Clinical guidelines
Evidence based clinical practice guideline for medical management of acute otitis media in children 2 months to 13 years of age.
Cincinnati Children's Hospital Medical Center; 2004 Oct (reviewed for currency 2006 Aug) 16 pages. NGC:003958
Gastroesophageal reflux disease (GERD).
University of Michigan Health System - Academic Institution. 2002 Mar (revised 2007 Jan). 10 pages. NGC:005568
Keywords
eustachian tube dysfunction, middle ear, eustachian tube inflammation, eustachian tube infection, middle ear infections, otitis media, OM, middle ear infection, acute otitis media, AOM, chronic otitis media, COM, chronic otitis media with effusion, COME, eustachian tube, middle ear inflammation, eustachian tube dysfunction, ETD, mucosal edema of the middle ear, middle ear space, middle ear effusion
