Inflammatory Diseases of the Middle Ear Treatment & Management

Acute otitis media (AOM) is the most common cause of severe pain in young children. Many infections are viral in origin, especially those that accompany coryza. The most common viruses isolated include respiratory syncytial virus (RSV), influenza viruses, adenovirus, and parainfluenza. Treatment is purely symptomatic and supportive.

The role of antibiotics in the treatment of AOM remains ill defined because studies have shown that antibiotics do not affect the outcome. For instance, studies of children with persistent symptoms of AOM have shown that resistant bacteria account for only approximately 20% of these cases. This has given credence to the theory that the middle ear mucosa is infected with both bacteria and viruses simultaneously, and eradication of the bacteria with antibiotics may not be sufficient to stop the inflammatory cascades in the middle ear.

Therefore, some physician groups advocate observation and withholding antibiotics in children with uncomplicated AOM and no comorbid factors. ^[12] The withholding of antibiotics is based on diagnostic certainty, age, severity of the illness, and means for adequate follow-up. Observation involves monitoring the child for resolution of symptoms within 48-72 hours and reevaluating the patient at this time.

Guidelines from the American Academy of Pediatrics and American Academy of Otolaryngology-Head and Neck Surgery have helped to clarify whom to definitely treat with antibiotics. For infants younger than 6 months, prescribing antibiotics is still recommended because of the increased risk of complications in this age group, even if the diagnosis of AOM is uncertain. If the child is aged 6 months to 2 years and is severely ill (fever ≥ 39°C or moderate-to-severe otalgia) and the diagnosis of AOM is uncertain, antibiotics should be considered.

However, most doctors still universally prescribe antibiotics. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis cause most episodes of acute suppurative otitis media. First-line antimicrobial drugs include beta-lactamase–resistant medications, such as amoxicillin with or without clavulanate and cefuroxime. Adjunctive treatment includes analgesics and antipyretics.

High doses of amoxicillin (90 mg/kg) are recommended by the guidelines; these doses result in middle ear fluid levels that exceed the minimum inhibitory concentration of all S pneumoniae, including those that have intermediate resistance to penicillin and many that are highly resistant. The recommended length of treatment is 10 days for children younger than 6 years and for children with severe symptoms; children older than 6 years can be treated for 5-7 days.

If no clinical response occurs after the first 48-72 hours of therapy, the patient should be reassessed, and further therapy should be chosen based on the most likely pathogens. H influenzae should be suspected as a causative agent in a child who has been immunized with the pneumococcal vaccine and who does not respond to first-line antibiotic therapy. Tympanocentesis should be reserved for patients in whom multiple courses of antibiotics fail in order to determine bacterial etiology.

Pain control is essential to treatment, especially in the first 24 hours after diagnosis, regardless of whether the patient is receiving antibiotics. This is an important recommendation because the pediatric population is often undertreated for pain. In addition to ibuprofen and acetaminophen, topical benzocaine can also be given for pain control. The guidelines also include the use of narcotic analgesia with codeine for severe pain.

The aim of medical treatment in uncomplicated cases of chronic suppurative otitis media (CSOM) is to eliminate infection and to control otorrhea. Treating an ear with chronic discharge requires regular otologic surveillance with microscopic aural toilet. Such treatment is particularly important when a topical medication is used to allow it to reach the middle ear in sufficient concentration.

Topical liquid agents used in the treatment of chronic middle ear disease include a combination of antibiotics, antifungals, antiseptics, solvents, and steroids. The most commonly used topical antibiotics for CSOM include quinolone derivatives, such as ciprofloxacin and ofloxacin (eg, Cipro HC Otic, Floxin), and aminoglycosides. Theoretically, topical aminoglycosides can gain access through a perforated tympanic membrane to the inner ear through the round window membrane and cause cochleovestibular toxicity.

The scientific literature contains sporadic reports of sensorineural hearing loss associated with the use of topical agents; however, clinical studies in humans fail to show significant sensorineural hearing loss attributable to their use. In severe resistant cases of CSOM that involve diffuse mucosal disease, systemic antibiotics have been used in conjunction with topical agents.

Antibiotic prophylaxis at one half of the daily therapeutic dose for an acute attack may be used and can be given for up to 6 months. Adverse effects are low. The development of increased drug resistance in upper respiratory tract organisms remains a possibility.

Preventive measures for otitis media are integral in reducing its incidence and complications. This can be accomplished by educating parents about reducing known risk factors for otitis media, including exposure to passive smoke, bottle propping, and pacifier use.

Because S pneumoniae is the most commonly reported bacterial cause of AOM, accounting for 28-55% of cases, counseling parents to the use of pneumococcal vaccines in their children can significantly reduce the incidence of AOM. Multiple studies demonstrate significant population reductions in AOM rates and antibiotic usage after universal introduction of pneumococcal vaccination.

Viral vaccines have also been associated with reducing the incidence of AOM related to viral etiologies. Encouraging children to receive the influenza vaccine can protect against episodes of otitis media during influenza outbreaks. Their exact role in reducing rates of AOM, however, remains to be epidemiologically demonstrated.

Updated guidelines for the evaluation and management of otitis media with effusion were released in 2016 by the American Academy of Otolaryngology-Head and Neck Surgery Foundation and include the following ^{[22, 23]} :

• A recommendation that children at high risk for developing otitis media with effusion—ie, those with an increased likelihood due to developmental issues or a syndrome or condition—be screened for it when the risk factor is diagnosed and again between age 12 and 18 months

• A strengthened recommendation that medical therapy for otitis media with effusion—including systemic antibiotics, systemic steroids, intranasal steroids, antihistamines, and decongestants—be employed only in exceptional circumstances

• A recommendation against using adenoidectomy to treat otitis media with effusion in children under age 4 years unless an indication for adenoid removal, such as nasal obstruction or chronic adenoiditis, is present

When correctly indicated, the surgical procedure on a diseased middle ear and mastoid must be performed meticulously and precisely; such a procedure is often demanding. The aim of surgery is to achieve a dry, pain-free ear, with possible improvement in hearing, freedom from vertigo, and reversal of a facial palsy.

Myringotomy

Myringotomy is a technique in which an incision is made in the tympanic membrane to adequately drain the middle ear.

Myringotomy is reserved for acute otitis media (AOM) associated with severe otalgia or high fever in patients who have had a poor response to antibiotics. Myringotomy is also indicated when a suppurative complication is present, in children who are acutely ill, in cases of AOM that occur during antibiotic treatment, in newborns, and in patients with primary or secondary immunodeficiency in whom an unusual organism may be present. When a myringotomy is performed, the effusion may be cultured, although it is not mandatory.

Myringotomy is performed with a myringotomy knife. The incision is made in the anterior-inferior quadrant of the tympanic membrane in a radial fashion. The incision may be placed in the posteroinferior quadrant but never in the posterosuperior quadrant because the incudostapedial joint could be damaged. Unlike in secretory otitis media (SOM), local anesthesia is inadequate for AOM.

In a retrospective study of 248 pediatric patients who received tympanostomy tubes and postoperative otic drop therapy, Conrad et al found the highest rate of tube occlusion in patients with middle ear fluid and in those with longer time to postsurgical follow-up. The investigators determined that at first follow-up, one or both tubes were occluded in 10.6% of patients. The likelihood of having unobstructed tubes was three times higher in children with no serous fluid than in children with fluid. It was also found that the chance of occlusion increased in relation to the amount of time that existed between surgery and follow-up. ^{[24, 25]}

Other procedures

Recurrent AOM in children may be due to chronic sinus infections, nasopharyngeal obstruction (enlarged and chronically infected adenoids), or cleft palate. Surgically treating these conditions (eg, with adenoidectomy) may decrease the number of ear infections.

Transtympanic ventilation tubes may be used to prevent recurrent AOM, even in the absence of a middle ear effusion, although the reason for this remains unclear.

The removal of discharge from an ear with active CSOM is essential for successful treatment. Regular surveillance and microscopic aural toilet with suction are performed until resolution of discharge. Aural toilet is particularly important when a topical medication is used to allow sufficient application.

If a patient's fitness for general anesthesia permits, cholesteatoma should be surgically treated, regardless of its association with CSOM.