Middle Ear, Acute Otitis Media, Surgical Treatment Treatment & Management

Acute otitis media (AOM) has been described as a self-limiting disease provided the patient does not succumb to a complication. This is an old description, but in the new millennium, practitioners will be forced to observe the lessons of history because these may serve as our models of life without effective antimicrobials. Presently, a chorus of advocates recommends withholding antibiotic therapy for patients with acute otitis media (AOM). Despite these advocates, the overwhelming consensus remains that antibiotics are the initial therapy of choice for acute otitis media (AOM) for 3 very valid reasons, as follows:

• After institution of antibiotic therapy, a marked decline in the suppurative complications of acute otitis media (AOM) has occurred.
• Practitioners cannot predict with certainty which patients will develop complications.
• Studies have demonstrated that use of antibiotics improves patient outcome in both the early and late phases of acute otitis media (AOM).

Recently, some order has been brought to the discussions of antibiotic use under the auspices of the Centers for Disease Control and Prevention (CDC) and by the Agency for Health Care Policy and Research, both agencies of the US government. The CDC has published 6 principles of appropriate antibiotic use in an attempt to bring precepts of good public health and responsible therapy to the discussion, while minimizing selection of resistant strains of bacteria within the community. These principles are listed below.

Antibiotic therapy

Selection of an antibiotic, in the absence of cultures obtained from tympanocentesis, should have 2 objectives, as follows:

• The antibiotic should cover most of the common bacterial pathogens (see Etiology).
• The antibiotic must be individualized for the child with regard to allergy, tolerance, previous exposure to antibiotics, cost, and community resistance levels.

Duration of therapy also is somewhat empiric, and data indicate that significant numbers of children do not receive prescribed antibiotics beyond relief of acute symptoms. Ten to 14 days of therapy has been traditional and is convenient for office scheduling but may not necessarily be more efficacious than 5 days of therapy, or even 2 days.

Studies have demonstrated that short-duration therapy may not be appropriate in children younger than 2 years who appear prone to failure even after 14 days of therapy. Mandel has shown that 20 days of antibiotic therapy gives improved outcome versus 10 days of therapy or placebo, when an effusion-free ear is the prime objective. After 90 days, however, no difference in the groups existed and recurrence was not prevented by the additional therapy.

Administration of prescribed antimicrobials may differ from recommendations for the same antibiotic when used for soft tissue infections.

Pulse-dosing antibiotics, when administered for infections of hollow organs, such as the ear or sinuses, appear to have efficacy because of poorly understood antimicrobial mechanisms, increased compliance on the part of the patient or parent, and slower penetration into and removal from middle ear effusion.

Subminimal serum levels of antibiotics have been shown to disrupt adhesive bonds between bacteria and mucosal cell walls and to provide a postantibiotic effect, in which reproduction of bacteria is disrupted for a period of hours after exposure to antibiotics. Similarly, a leukocyte-enhancing action has been demonstrated at these low concentrations. When used in this manner, a marked variation exists in the effectiveness of individual antibiotics and susceptibility for the various etiologic agents.

Generally, beta-lactam antibiotics are most successful against gram-positive pathogens for both disruption of adhesion and postantibiotic effect.

Amoxicillin (erythromycin/sulfisoxazole in patients who are penicillin allergic) remains the initial treatment of choice in children with acute otitis media (AOM).

With the emergence of resistant strains, the practitioner may need to select an alternative antimicrobial therapy from either a broad-spectrum beta-lactamase-resistant cephalosporin or a combination drug such as amoxicillin/clavulanate or trimethoprim/sulfamethoxazole. Use of combination therapy may help prevent emergence of resistance by mutation, provided the pathogen is initially sensitive to both components. (Efficacy and dosages for selected antimicrobials are provided in the article, Middle Ear, Acute Otitis Media, Medical Treatment.)

With the emergence of multiple drug-resistant S pneumoniae, oral therapy consisting of amoxicillin and amoxicillin/clavulanate may have efficacy when the total amoxicillin dose reaches 80-100 mg/kg/d.

Failure of a child to respond to an antibiotic within 48 hours accompanied by local and systemic signs of toxicity may indicate resistance to the selected drug. Treatment options include an empirical change of antimicrobial agent or a drainage procedure with culture. Failure to improve with antibiotic therapy may indicate coexistent viral infection in children with prolonged acute symptoms.

• Principles for judicious use of antimicrobials in the treatment of acute otitis media (AOM)

  • Episodes of OM should be classified as acute otitis media (AOM) or OME.
  • Antimicrobials are indicated for treatment of acute otitis media (AOM); however, diagnosis requires documented middle ear effusion and signs or symptoms of acute local or systemic illness.
  • Uncomplicated acute otitis media (AOM) may be treated with a 5- to 7-day course of antimicrobials in certain patients older than 2 years.
  • Antimicrobials are not indicated for initial treatment of OME; treatment may be indicated if effusions persist for longer than 3 months.
  • Persistent OME after therapy for acute otitis media (AOM) is expected and does not require re-treatment with antimicrobials.
  • Antimicrobial prophylaxis should be reserved for control of recurrent acute otitis media (AOM), defined by 3 or more distinct well-documented episodes in 6 months or 4 or more episodes in 12 months.
• Other medical therapies

  • Analgesics and antipyretics have a definite role in the symptomatic management of acute otitis media (AOM).
  • Decongestants and antihistamines do not appear to have efficacy either early or late in the acute process, although they may relieve coexistent nasal symptoms.
  • Systemic steroids have no demonstrated role in the acute phase.

Tympanocentesis and myringotomy are the procedures used to treat acute otitis media (AOM). Tympanocentesis, in its purest form, is a diagnostic procedure that gives the clinician access to acute or chronic middle ear effusion for culture and other evaluations. Generally, perform tympanocentesis without anesthesia, after sterilization of the ear canal with isopropyl alcohol or Betadine. Insert a needle through the anterior portion of the tympanic membrane, and aspirate the contents of the middle ear into a sterile trap for identification of microbes and their properties.

A tympanocentesis may be converted to a myringotomy and become therapeutic by enlargement of the hole in the tympanic membrane, often by spreading the edges with a microalligator forceps or suction tip. Instillation of antibiotic drops and suctioning of the middle ear may be performed through the myringotomy. Typically, the patient experiences prompt relief of local symptoms. Cultures must be obtained prior to extension of the incision.

The use of a carbon dioxide laser in myringotomy on children with acute otitis media (AOM) has been promoted widely and directly to the consumer by the manufacturers of these instruments; proponents claim to have ushered in a "new treatment" for acute otitis media (AOM) without the use of antimicrobials. While undoubtedly a boon to the otolaryngologist who is less technically adept, emerging studies demonstrate little or no change in efficacy over standard myringotomy.

If the patient has a suppurative complication of the temporal bone and requisite prolonged drainage seems likely, insertion of a tympanostomy tube may be needed. In most instances, general anesthesia or sedation is necessary in older children, as topical anesthesia is relatively ineffective in acutely inflamed tympanic membranes.

Complications of tympanocentesis and myringotomy are few and rare in appropriately performed procedures in children with otherwise normal anatomy. They include the following:

• Immediate complications

  • Injury to skin of ear canal
  • Injury to ossicular chain
• Intermediate complications

  • Persistent otorrhea
  • Persistent perforation
  • External otitis from persistent drainage
  • Implantation cholesteatoma
• Long-term complications

  • Persistent perforation with or without otorrhea
  • Ear canal stenosis

The complications for myringotomy with tube placements are the same with the addition of those related to the tube and to longer perforation. Medialization of tubes of modern design is now quite rare. Some tube designs have a tendency to collect epithelial debris and inherently have a higher rate of cholesteatoma formation. As a rule, longer ventilation increases the likelihood of persistence of the perforation, the formation of aural polyps, and chronic otorrhea. Most are reversed by removal of the tube with or without repair of the hole with a small myringoplasty.