eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Middle Ear & Mastoid

Middle Ear, Acute Otitis Media, Surgical Treatment

Author: John D Donaldson, MD, FRCS(C), FAAP, FACS, Chairman, Board of Directors, Lee Memorial Health System; President-elect, Florida Pediatric Society
Contributor Information and Disclosures

Updated: May 12, 2009

Introduction

In the United States, acute otitis media (AOM) is the most common affliction necessitating medical therapy for children younger than 5 years. The total annual cost to society of this disease and of otitis media with effusion (OME) runs into the billions of dollars. Yet, despite research into prevention and therapy, costs of this disease continue to rise, while incidence remains unabated. The emergence of antimicrobial-resistant bacteria requires reevaluation of the traditional management of this disease.

Surgical management of acute otitis media (AOM) can conveniently be divided into 3 related procedures: tympanocentesis, myringotomy, and myringotomy with insertion of a ventilating tube. This article examines the indications for each and appropriate selection of individual patients.

Tympanocentesis is the aspiration of the contents of the middle ear cleft by piercing the tympanic membrane (TM) with a needle and collecting that material for diagnostic examination. Normally the hole is small enough to permit healing within a day or two.

Myringotomy is the incision and drainage (I&D) procedure for acute otitis media (AOM). In this procedure, the TM is incised with a knife, which allows a fluid-filled middle ear to drain to the ear canal and the exterior. Depending upon the size of the hole and the method used to create it, the TM usually returns to normal within days to a few weeks.

Myringotomy with ventilation tube insertion is performed to maintain the opening to the middle ear to permit longer-term drainage, access for medication, or ventilation for acute otitis media (AOM) prophylaxis.

Drawing of a normal right tympanic membrane. Note...

Drawing of a normal right tympanic membrane. Note the outward curvature of the pars tens (*) of the eardrum. The tympanic annulus is indicated anteriorly (a), inferiorly (i), and posteriorly (P). M = long process of the malleus; I = incus; L = lateral (short) process of the malleus.

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Drawing of a normal right tympanic membrane. Note...

Drawing of a normal right tympanic membrane. Note the outward curvature of the pars tens (*) of the eardrum. The tympanic annulus is indicated anteriorly (a), inferiorly (i), and posteriorly (P). M = long process of the malleus; I = incus; L = lateral (short) process of the malleus.


History of the Procedure

Mastoidectomy predates the extensive use of tympanic membrane incision, primarily because of the severity of the disease and the relatively frequent occurrence of spontaneous perforation in otitis-prone individuals. For example, in Eskimo communities of northern Canada, native Inuit are often found with large central perforations from chronic otitis.

Myringotomy, as a procedure, is a product of technology that allows the illumination of the TM with or without magnification.

Myringotomy and tube placement were attempted in the 19th century using red rubber tubes. This material caused granulation and cholesteatoma formation within the ear, and the procedure was abandoned until the mid 20th century. Tube placement was resurrected in the 1950s by Dr. Beverly Armstrong, who fashioned polyethylene tubes that were relatively nonreactive and were successfully placed. Since then, a host of tube designs and materials have been available to the otolaryngologist, each with its own weaknesses and strengths with respect retention, reactivity, and complications. Selection of any tympanostomy tube design is governed by the length of time the patient is estimated to need ventilation, by the quality of fibrous tissue of the tympanic membrane, and by the incidence any known long-term complication balanced against the benefit derived using that particular tube.

Problem

Acute otitis media (AOM) is defined by convention as the first 3 weeks of a process in which the middle ear experiences the signs and symptoms of acute inflammation. Otitis media with effusion (OME) is defined as the presence of fluid in the middle ear with accompanying conductive hearing loss and without concomitant symptoms or signs of acuity. Otitis media with effusion (OME) is classified as subacute when persisting from 3 weeks to 3 months after acute otitis media (AOM) onset and as chronic thereafter.

Frequency

In the United States
Approximately 70% of all children experience one or more attacks of acute otitis media (AOM) before their second birthday. A recent study in Pittsburgh prospectively monitored urban and rural children for the first 2 years of life. The study indicates that the incidence of middle ear effusion episodes is approximately 48% in infants aged 6 months, 79% in infants aged 1 year, and 91% in children aged 2 years. The peak incidence of acute otitis media (AOM) is in infants aged 3-18 months. Some infants may experience their first attack shortly after birth and are considered otitis prone, ie, at risk for recurrent OM. In the Pittsburgh study, the incidence was highest among the urban poor.1

Internationally
The differences in incidence between nations are influenced by racial, socioeconomic, and climatic factors.

Mortality/Morbidity
Death from acute otitis media (AOM) is rare in the era of modern medicine.

Race
Definite racial differences occur in the incidence of acute otitis media (AOM). Native Americans and Inuit have very high rates of acute and chronic ear infection, while African Americans appear to have a slightly lower rate than do white children living in the same communities.

Sex
The incidence is slightly higher in boys than in girls.

Age
Children aged 6-11 months appear to be particularly susceptible to acute otitis media (AOM), with frequency declining around age 18-20 months. A small percentage of children begin to experience acute otitis media (AOM) later in life, often in the fourth and early in the fifth year. After the eruption of permanent teeth, incidence drops dramatically, although some otitis-prone individuals continue to have acute episodes into adulthood. Occasionally, an adult with no previous history of ear disease but with an acute viral upper respiratory infection (URI) presents with acute otitis media (AOM).

Etiology

Viral Role in Acute Otitis Media

Viral infection in the nasopharynx with subsequent inflammation of the orifice and mucosa of the eustachian tube has been long understood as part of the pathogenesis of acute otitis media (AOM), although the complete role of the virus is not understood fully. Concurrent or antecedent URIs are identified in at least one quarter of all attacks of acute otitis media (AOM) in children, but the virus itself seldom appears as the pathogen in the middle ear.

Clements has shown that administration of trivalent influenza A vaccine decreases the frequency of acute otitis media (AOM) during the influenza season.2 Viruses have been recovered with increasing frequency as techniques to identify them by direct culture and by indirect means such as enzyme-linked immunosorbent assay (ELISA) testing have improved. On direct culture, the yield is less than 10%, with respiratory syncytial virus (RSV) recovered most frequently; the influenza virus is a distant second. When ELISA testing is performed on middle ear aspirates, the presence of viral antigens is detected in approximately one quarter of samples. RSV is the virus most frequently detected by this method.

The presence of viruses in the middle ear effusion may influence the outcome of therapy for otitis media (OM). Results of outcome studies have been mixed, ranging from no effect to evidence of prolongation of acuity and effusion when viruses are present in acute otitis media (AOM).

Respiratory syncytial virus

Due to RSV's high incidence of association with acute otitis media (AOM), the practitioner must be familiar with this pathogen. Most commonly, RSV is associated with bronchiolitis and pneumonia in the very young, but it may cause acute respiratory disease in persons of any age. In northern climates, RSV is normally identified during annual epidemics in the winter and early spring, but it should be suspected in any neonate with lethargy, irritability, or apnea, with or without otitis media (OM). In older infants and children, respiratory symptoms are usually more prominent, making diagnosis easier to establish.

A large ribonucleic acid (RNA) paramyxovirus, RSV was identified early as a pathogen that appeared to create long-term pulmonary complications, primarily asthma, in up to half of infants with bronchiolitis. RSV may be particularly lethal for children with congenital heart disease, cystic fibrosis, immunodeficiency, bronchopulmonary dysplasia, or prematurity of less than 37 weeks' gestational age. RSV-specific intravenous immunoglobulin prophylaxis is recommended only in children at high-risk for the condition.

When treating a child with concomitant pneumonia or other system disease and otitis media (OM), the practitioner must ensure appropriate diagnosis and management of all aspects of the child's illness. Drainage of the ear by tympanocentesis or myringotomy for culture and therapy may be necessary in some cases. Drainage is mandatory in neonates with sepsis or in children with immunosuppression.

Bacterial Pathogens in Acute Otitis Media

Pathogenic bacteria are recovered from the middle ear effusion in at least half of children with acute otitis media (AOM), and bacterial deoxyribonucleic acid (DNA) or cell wall debris is found in another quarter to third of specimens previously classified as sterile. Four species of bacteria (ie, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes) are responsible for the preponderance of episodes of acute otitis media (AOM) in persons older than 6 weeks. Other bacteria recovered and implicated in acute otitis media (AOM) include Staphylococcus aureus, Streptococcus viridans, and Pseudomonas aeruginosa.

The emergence of resistance to antimicrobial agents is of increasing importance in the management of acute otitis media (AOM) and other bacterial illnesses. The various mechanisms used by bacteria to confer this resistance will be delineated as the common pathologic agents linked to acute otitis media (AOM) are described.

Streptococcus pneumoniae

This bacterium is the most common etiologic agent responsible for acute otitis media (AOM) and for invasive bacterial infections in children of all age groups. S pneumoniae is a gram-positive diplococcus with 90 identified serotypes (classified on the basis of the polysaccharide antigen), the frequency of which varies between age groups and geography. On direct culture, various studies have shown this bacteria to be responsible for 29-40% of isolates, but pneumococcal antigens are recovered from approximately one third of those cultures classified as sterile.

Pneumococcal infections are probably responsible for a minimum of one half of the acute otitis media (AOM) episodes. Serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F are responsible for most invasive pneumococcal disease in America; in ear aspirates from patients with acute otitis media (AOM), serotypes 19 (23%), 23 (12.5%), 6 (12%), 14 (10%), 3 (8.5%), and 18 (6%) are most commonly isolated. Polyvalent pneumococcal vaccine confers immunity to approximately 85% of those serotypes responsible for acute otitis media (AOM).

Until recently, this bacterium was susceptible to almost all common antibiotics, including penicillin G, erythromycin, and even most sulfonamides. Alteration of the cell wall's penicillin binding protein has led to widespread resistance to beta-lactam compounds, macrolides, and sulfonamides by alteration of the antimicrobial target. These mutations are termed multiple drug resistant strains (MDRS). Resistance rates as high as 40% have been reported for these 3 therapeutic antimicrobial groups. Serotypes 6B, 9V, 14, 19A, 19F, and 23F have the highest frequency of resistance to penicillin. Ceftriaxone, cefotaxime, rifampin, and vancomycin still appear to have therapeutic efficacy, as does immunization with polyvalent pneumococcal vaccine for prevention.

Unfortunately, polysaccharide antigens are not immunogenic early in life. To overcome this problem "conjugated" antigens, in which the polysaccharide antigen is attached to a protein carrier, may be administered to induce production of antibodies to these bacterial capsular polysaccharides. Some conjugated antigens (eg, vaccinations to H influenzae type b [Hib]) are in widespread use. A heptavalent vaccine to S pneumoniae is now in widespread use and appears to confer long-term immunity to 7 of the most common and invasive strains.

Haemophilus influenzae

In middle ear aspirates from patients with acute otitis media (AOM), H influenzae is the second most frequently isolated bacterium and is responsible for approximately 20% of episodes in preschool children. The frequency may be higher in otitis-prone children, older children, and adults who have received pneumococcal vaccine. The bacterium is a small, pleomorphic, gram-negative coccobacillus. Those bacteria encapsulated with a polysaccharide coating are classified into 6 distinct types (a-f), while nonencapsulated types are termed nontypeable and are responsible for the great majority of acute otitis media (AOM) episodes. (The nonencapsulated strains have been subtyped biochemically and antigenically, but this classification has limited clinical application to date.)

Traditionally, Hib has been found responsible for most invasive illnesses attributed to these bacteria and for meningitis, epiglottitis, and septicemia. Hib accounts for only 10% of all episodes of acute otitis media (AOM) in which H influenzae is recovered.

In areas of the world where the aforementioned Hib-conjugated vaccine is administered early in life, risks from this potentially lethal strain have diminished greatly. Antimicrobial resistance by these bacteria almost exclusively (95%) is due to formation of a single enzyme, triethylenemelamine 1 (TEM1) lactamase, which is formed by as many as 40% of all nontypeable strains in some series. This resistance is overcome relatively easily by using blocking agents, extended-coverage cephalosporins, broad-spectrum macrolides, or sulfonamides.

Moraxella catarrhalis

In the mid 1970s, this common organism was classified as nonpathogenic in middle ear infections, although, when previously known as Neisseria catarrhalis, it had constituted approximately 10% of all isolates from middle ear aspirates. At that time, M catarrhalis was almost universally susceptible to ampicillin-type penicillins. Twenty years and 2 name changes later (ie, N catarrhalis to Branhamella catarrhalis to M catarrhalis), it is isolated in up to a quarter of children with acute otitis media (AOM), and resistance to the ampicillin-type beta-lactams is almost universal. M catarrhalis is a gram-negative diplococcus and is considered part of the normal flora of the human upper respiratory tract.

Resistance is conferred by the secretion of multiple isoenzymes of lactamase, which may be plasmid or chromosomal in origin and which may be inducible (ie, present only in low levels until a substrate is provided). More than 1 isoenzyme may be secreted by a single bacterium. To date, almost all forms are blocked by clavulanic acid, and most are still susceptible to sulfonamides, lactamase-stable cephalosporins, or broad-spectrum macrolides. M catarrhalis often is found to coexist with other airway pathogens. The lactamases (cephalosporinases) that M catarrhalis secretes may protect those other bacteria from antimicrobial agents to which the second target pathogen ordinarily might be susceptible.

Streptococcus pyogenes

This bacterium, group A streptococci (GAS), while still occupying the fourth spot in frequency of isolates from ears with acute otitis media (AOM), has shown a steady decline in frequency of recovery from the ear and in virulence over the past half-century. Similarly, a substantial decline in the major complications of streptococcal infection, rheumatic fever, glomerulonephritis, and scarlet fever, has occurred. GAS may be associated with streptococcal toxic shock syndrome, which may include coagulopathy, soft tissue necrosis or fasciitis, desquamating rash, and liver or renal involvement. GAS, a gram-positive coccus, primarily is a pathogen of the pharynx with more than 80 distinct M-protein strains identified. Now, with the improvement in primary care and the availability of rapid identification tests, early aggressive treatment normally is instituted against this bacterium, which has shown minimal ability to develop resistance to antimicrobial agents.

  • Acute necrotic otitis media
    • In the early 1900s, acute necrotic otitis commonly was associated with scarlet fever, although the condition also was associated with measles, pneumonia, and influenza. Generally, the patient was extremely ill with the systemic component of the disease and presented with a spontaneous perforation shortly after the onset of otalgia. Early inspection of the ear showed the perforation was already of moderate-to-large size; within days, significant evidence of tissue necrosis would be observed, perhaps including the entire tympanic membrane, ossicles, tympanic mucoperiosteum, or the bone of the mastoid air cells. The patient demonstrated a marked conductive hearing loss, although sensorineural loss was not uncommon.
    • Pathologically, the ear showed a marked paucity of the normal vascular proliferation associated with an inflammatory reaction. Instead, a complete loss of the vascularity normally associated with vasculitis or toxin exposure occurred. Healing was never normal; tissue was replaced by epithelial invasion or scar tissue formation. In industrialized societies, acute necrotic otitis media now is primarily of historic interest. The disease still is reported in aboriginal peoples living in areas where modern medicine has not yet penetrated. Thomas Edison appears to have suffered from the sequelae of this condition, according to historical research by Dr Robin Brown.
  • Acute coalescent mastoiditis: GAS also appeared to have been the most prominent organism recovered from patients with acute coalescent mastoiditis in the preantibiotic era. In the 1990s, GAS relinquished this distinction to S pneumoniae but remains a prominent pathogen when this disease is encountered in the very young.

Other aerobic pathogens

Except in neonates and children with chronic disease, few other pathogens have been demonstrated in aspirates from the middle ears of immunologically intact individuals. S aureus is recovered rarely, except in Japan, where studies indicate a somewhat higher incidence (up to 10%) may exist. Mycobacterium tuberculosis is associated most often with chronic otitis media (COM) but should be considered when a patient presents with painless otorrhea as an initial complaint. Consider any patient with a compromised immune system at risk for such an opportunistic infection. Chlamydia pneumoniae has been shown to be an uncommon but significant pathogen in acute otitis media (AOM) and responds only to macrolide therapy.

Anaerobic bacteria

Anaerobic bacteria have been recovered from the middle ears of children with acute otitis media (AOM), but the data do not support a prominent role for these microorganisms in otitis media (OM), at least in the acute form. When recovered from ears of children with acute otitis media (AOM), the anaerobic pathogen most often is not the sole pathogen cultured.

Acute otitis media in the neonatal period

In the perinatal period, the gram-negative bacteria Escherichia coli, enterococci, and group b S pyogenes are the most common etiological agents responsible for sepsis and meningitis. These agents are often recovered from the middle ear, although the total percentage probably is less than 10% of neonates with acute otitis media (AOM).

S pneumoniae remains the most common pathogen responsible for acute otitis media (AOM) in all age groups, including the neonate. The nonencapsulated H influenzae or nontypeable varieties may be invasive in these neonates and constitute the second-most common pathogen recovered from the ear. As bacteremia is common in all neonates with acute otitis media (AOM), tympanocentesis should be undertaken, for both diagnosis and therapy, in any infant with signs of acute otitis media (AOM) or generalized sepsis and any middle ear effusion.

Immunology in Acute Otitis Media

Immunological activity may play a significant role in the frequency of acute otitis media (AOM) and its outcome. While most research has focused on the immunological aspects of otitis media with effusion (OME), certain relationships between acute otitis media (AOM) and the patient's immune status have been demonstrated, as follows:

  • Production of antibodies may promote the clearance of middle ear effusion following an acute attack.
  • Previous exposure or immunization may have a preventative role by suppressing colonization of the nasopharynx by pathogens.
  • Formation of antibodies during an attack may prevent or modify future attacks. Unfortunately, antibodies to both S pneumoniae and H influenzae are of the polysaccharide type and develop late unless conjugated to proteins.
  • Minor and/or transient immunological defects may give rise to recurrent OM.

Much attention has been focused on the immunoglobulins and the patient's ability to form them. Immunoglobulin G2 (IgG2) and immunoglobulin G4 (IgG4) are responsible for immunity against polysaccharide antigens; deficiencies in formation of these antibodies invariably lead to OM. Research has demonstrated that many patients with Down syndrome have decreased function of immunoglobulin A (IgA), IgG2, and/or IgG4, partially explaining their increased risk for chronic rhinitis and OM.

The immunologic aspects of acute otitis media (AOM) are not confined to the middle ear. The nasopharynx plays an important role in the pathogenesis of acute otitis media (AOM), and immunologic modifications in this lymphoid tissue provide some protection from pathogens by preventing their adherence to mucosal surfaces. The presence of nasopharyngeal IgA antibodies to pneumolysin toxin released by pneumococcal autolysis appears to protect against invasion by healthy pneumococci. Conversely, not all immunoglobulins in the nasopharynx are protective. Bernstein describes effects of immunoglobulin E (IgE) hypersensitivity or hyperimmune effects on the eustachian tube mucosa.3 The allergic response in the nasopharyngeal end of the eustachian tube promotes stasis and subsequent formation of middle ear effusion.

Pathophysiology

Obstruction of the eustachian tube appears to be the most important antecedent event associated with acute otitis media (AOM). The vast majority of acute otitis media (AOM) episodes are triggered by an upper respiratory infection (URI) involving the nasopharynx, usually of viral origin, but allergic and other inflammatory conditions involving the eustachian tube may create a similar outcome. Inflammation in the nasopharynx extends to the medial end of the eustachian tube, creating stasis and inflammation, which, in turn, alters pressure within the middle ear. These changes may be either negative (most common) or positive, relative to ambient pressure.

Stasis also permits pathogenic bacteria to colonize the normally sterile middle ear space by direct extension from the nasopharynx by reflux, aspiration, or active insufflation. The response is the establishment of an acute inflammatory reaction characterized by typical vasodilatation, exudation, leukocyte invasion, phagocytosis, and local immunological responses within the middle ear cleft to give the clinical pattern of acute otitis media (AOM).

In a minority of otitis-prone children, the eustachian tube is patulous or hypotonic. Children with neuromuscular disorders or abnormalities of the first or second arch most likely are "too open" and are predisposed to reflux of nasopharyngeal contents into the middle ear cleft. To become pathogenic in hollow organs, such as the ear or sinus, most bacteria must adhere to the mucosal lining. Viral infections that attack and damage mucosal linings of respiratory tracts may facilitate the ability of the bacteria to become pathogenic in the nasopharynx, eustachian tube, and middle ear cleft. This postulate might explain the recovery of viral antigens from middle ear aspirates in children with acute otitis media (AOM), while only rarely is the actual virus isolated. Data also have been presented indicating that mucosal damage by endotoxins secreted by bacterial invaders similarly may enhance adhesion of pathogens to mucosal surfaces.

Presentation

History
Patient history of acute otitis media (AOM) varies with age, but a number of constant features manifest during the otitis-prone years. Irritability or feeding difficulties may be the only indication of a septic focus in the neonate. Older children begin to demonstrate a consistent presence of fever (with or without a coexistent URI) and otalgia or ear tugging. These latter symptoms are not entirely exclusive to acute otitis media (AOM), as teething pain or pharyngitis (particularly coxsackievirus infection) can mimic these symptoms.

In older children and adults, hearing loss becomes a constant feature of acute otitis media (AOM) and OME, with complaints of ear stuffiness noted even before the detection of middle ear fluid. Otalgia without hearing loss or fever is observed in adults with external otitis, dental abscess, or pain referred from the temporomandibular joint. Orthodontic appliances often elicit referred pain as the dental occlusion is altered.

Physical
A thorough clinical examination has no substitute. Pneumatic otoscopy is the standard of care in the diagnosis of acute otitis media (AOM) and COM. In acute disease, the tympanic membrane normally demonstrates signs of inflammation, beginning with reddening of the mucosa and progressing to the formation of purulent middle ear effusion and poor tympanic mobility. The tympanic membrane may bulge in the posterior quadrants, and the superficial epithelial layer may exhibit a scalded appearance. Perforation of the tympanic membrane is not unusual as the process advances, most frequently in posterior or inferior quadrants. Prior to or instead of a single perforation, an opaque serumlike exudate oozing through the entire tympanic membrane sometimes is seen.

With perforation and in the absence of a coexistent viral infection, the patient generally obtains rapid relief of pain and fever. The discharge initially is purulent, although it may be thin and watery or bloody; pulsation of the otorrhea is common. Otorrhea from acute perforation normally lasts 1-2 days before spontaneous healing occurs. Otorrhea may persist if the perforation is occupied with mucosal swelling or polypoid changes that can act as a ball valve.

Other considerations include the following:

  • Bullous myringitis
    • Pneumatic otoscopy is an important diagnostic tool when differentiating acute otitis media (AOM) from acute bullous myringitis. The latter, in its purest form, presents 10-14 days following a viral infection and gives severe localized otalgia without middle ear effusion.
    • The bullae or blebs may contain serous or hemorrhagic fluid and may extend onto the adjacent canal wall. Pain is relieved by puncturing the bleb. Similar blebs may occur in association with acute otitis media (AOM).
    • These patients demonstrate more systemic symptoms and continue to have pain associated with purulent middle ear effusion, which persists following rupture of the blebs.
  • Immunosuppressed patients
    • Remember that the descriptions above are for patients who are immunocompetent. Children who are immunosuppressed, particularly those undergoing chemotherapy, may not manifest the typical inflammatory responses described.
    • In these patients, the simultaneous appearance of systemic sepsis and a serous middle ear effusion might be the only indicators of acute otitis media (AOM).
  • Danger signs of possible impending complications
    • Sagging of the posterior canal wall
    • Puckering of the attic
    • Postauricular swelling with loss of the skin crease
  • Systemic examination
    • A finding of acute otitis media (AOM) does not relieve the practitioner of the responsibility to search for coexistent related or unrelated conditions. This responsibility is particularly important when antimicrobial agents are prescribed to ensure appropriate simultaneous coverage of coexistent infections such as acute otitis media (AOM) with streptococcal pharyngitis or mycoplasmal pneumonia.
    • Transtympanic measurements of temperature in children with middle ear effusions have been shown to be inconsistent. Accordingly, measure body temperature using oral, rectal, or axillary means.

Causes
The following are proven risk factors for OM:

  • Patient factors
    • Prematurity and low birth weight
    • Young age
    • Early onset
    • Family history
    • Race (Native American, Inuit, Australian Aborigine)
    • Altered immunity
    • Craniofacial abnormalities
    • Neuromuscular disease
    • Allergy
  • Environmental factors
    • Day care
    • Crowded living conditions
    • Low socioeconomic status
    • Tobacco and pollutant exposure
    • Use of pacifier
    • Prone sleeping position
    • Fall or winter season
    • Not breastfed, prolonged bottle use

Indications

Generally, indications for these 3 procedures can be divided into 3 categories: diagnostic, therapeutic, and prophylactic. More than one indication for selection of the appropriate procedure may need to be considered on a case-by-case basis.

Selection of the appropriate procedure results from evaluation of a number of considerations categorized into patient factors, surgeon factors, available resources, and urgency. Each of these aspects must be examined to select that procedure that gives the optimal predicted outcome.

With increasing antimicrobial resistance, surgical intervention in the form of tympanostomy tube placement can be expected to increase in the coming years, after having fallen into disfavor in the past two decades when resistance was less of a factor. In the author's practice, children younger than 15 months and those in day care centers are most likely to require surgery.

  • Diagnostic procedure - Tympanocentesis
    • Consider tympanocentesis in (1) children who are immunosuppressed or immunocompromised, (2) neonates with acute otitis media (AOM), because they are more likely to have an unusual or more invasive pathogen, (3) patients who have exhibited antimicrobial failure and continue to experience local or systemic signs of sepsis, and (4) patients who have had a complication of acute otitis media (AOM) in conjunction with attempts to recover the etiological agent from other sites such as cerebrospinal fluid (CSF) and/or blood.
    • Additionally, tympanocentesis remains a valuable research tool in the evaluation of new antimicrobial agents for efficacy in acute otitis media (AOM) and for identification of host defense mechanisms or flaws in the middle ear immunochemistry.
  • Therapeutic procedure - Myringotomy
    • A myringotomy may be an extension of a tympanocentesis or a separate incision of the tympanic membrane to provide drainage of the middle ear cleft to the ear canal.
    • Any number of instruments from knives to lasers are available to perform this task, but the basic principles remain constant. The hole design, established either by size, by the application of material to retard healing, or by the type of initial tissue damage, is the primary factor in controlling how long the perforation remains open, which, in turn, is determined by patient need.
  • Extended relief - Myringotomy with tube insertion
    • Some patients with acute otitis media (AOM) require ventilation and/or drainage of the middle ear cleft for an extended period of time (eg, patients with mastoiditis), while others may have a history of repetitive attacks. These patients benefit with the placement of a tympanostomy tube at the time of myringotomy.
    • The selection of the design of the tube is governed by the need to ventilate for varying lengths of time. Tube design permits tube placement for 6-9 months, 9-18 months or longer than 2 years, and selection is governed by patient need versus the increasing complication rates associated with prolonged ventilation.

Relevant Anatomy

Incision of the tympanic membrane (TM) is primarily governed by the relationship of the structures behind the tympanic membrane. We divide the TM into quadrants with an imaginary line drawn vertically along the long process of the malleus extending to the inferior annulus and a horizontal line at the umbo. Generally, the TM can safely be incised in all quadrants except the posterior superior section, behind which lie the incus and stapes, which might be injured inadvertently by incision in this area. Two other structures, the facial nerve and the round window, are generally protected from anyone but the clumsiest of surgeons, the former by its high position in the middle ear and the latter by the overhanging niche.

Tubes are generally placed anteriorly, either superiorly or inferiorly. Because the posterior segments are deeper and have more vibratory motion, posterior placement gives a greater dampening effect. Anteriorly, any incision should avoid exposure of the malleus, the malleolar ligament, and the annulus, as this creates a greater tendency for perforations to persist after extrusion of the tube.

Contraindications

Contraindications for incision of the tympanic membrane (TM) are relatively few in the presence of acute disease as discussed under indications. In 25 years of practice, the author has twice managed to tap through "thick TMs" to find himself aspirating CSF from low-hanging and exposed dura (one associated with a porencephalic cyst). Neither resulted in a prolonged complication, but CSF may be obtained with considerably less excitement via a spinal tap.

Patients with patulous eustachian tubes most frequently have persistent otorrhea after placement of tympanostomy tubes. Children with neuromuscular disease, unrepaired cleft palates, or Down syndrome are more prone to this outcome. Otorrhea may be the lesser evil when the child is septic, uncomfortable, or damage to the middle ear cleft is imminent. This contraindication is a relative one and the parent needs to be informed of the risk and participate in the decision to proceed.

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References
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Further Reading

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Keywords

otitis media, otitis media surgery, otitis media treatment, ear infection, ear infections, ear infection treatment, acute suppurative otitis media, acute otitis media, AOM, purulent otitis, otitis media with effusion, OME, tympanocentesis, myringotomy, myringotomy with ventilation, chronic otitis media, COM, ear infection, ear pain, ear ache

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Contributor Information and Disclosures

Author

John D Donaldson, MD, FRCS(C), FAAP, FACS, Chairman, Board of Directors, Lee Memorial Health System; President-elect, Florida Pediatric Society
John D Donaldson, MD, FRCS(C), FAAP, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American College of Surgeons, and American Society of Pediatric Otolaryngology
Disclosure: None None None

Medical Editor

John C Li, MD, Private Practice in Otology and Neurotology; Medical Director, Balance Center
John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Tinnitus Association, Florida Medical Association, and North American Skull Base Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, 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 unstricted gift unknown

 
 
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