Updates on Chronic Otitis Media

Block U Interns 2010

Outline

I. BackgroundII. ManagementIII. Clinical Practice GuidelineIV. References

BACKGROUND

Middle Ear

• The middle ear is compossed of tympanum or middle ear cavity, antrum and mastoid cells, and the eustachian tube

Chronic Otitis Media

• Chronic otitis media describe a variety of signs, symptoms, and physical findings that result from the long-term damage to the middle ear by infection and inflammation

Pathophysiology

• usually caused by eustachian tube dysfunction• may also result from a perforation in the

eardrum that failed to heal after trauma or an acute infection of the middle ear

• can also result in a benign growth of cholesteatoma

PathophysiologyIt includes: • Severe retraction or perforation of the eardrum • Scarring or erosion of the small, sound conducting bones of

the middle ear• Chronic or recurring drainage from the ear• Inflammation causing erosion of the bony cover or the

facial nerve, balance canals, or cochlea (hearing organ)• Erosion of the bony borders of the middle ear or mastoid,

resulting in infection spreading to the meninges (the coverings of the brain) or brain

• Presence of cholesteatoma• Persistence of fluid behind an intact eardrum

Clinical Presentation• Persistent blockage of fullness of the ear• Hearing loss• Chronic ear drainage, which may have a very foul

smell• Development of balance problems• Facial weakness/ Facial paralysis• Persistent deep ear pain or headache• Fever• confusion or sleepiness• Drainage or swelling behind the ear

Clinical Presentation

• Some people with chronic otitis media develop a cholesteatoma in the middle ear. – A cholesteatoma, which destroys bone, greatly

increases the likelihood of other serious complications

• In severe conditions, brain infections may develop

Signs and Symptoms

• painless discharge of pus, which may have a very foul smell, from the ear

• inflammation of the inner ear• facial paralysis

MANAGEMENT

Workup

Laboratory StudiesPrior to instituting systemic therapy, a culture should be obtained for sensitivity.

Imaging Studies• CT scanning – Unresponsive to medical treatment, to look for

occult cholesteatoma or foreign body– suspects a neoplasm – intratemporal or intracranial complications.

Imaging Studies• MRI – intratemporal or intracranial complications are

suspected– to reveal dural inflammation, sigmoid sinus

thrombosis, labyrinthitis, and extradural and intracranial abscesses.

Updates on Management of CSOM

Aural toilette• part of standard medical treatment • reduce quantity of infected material from

middle ear • could facilitate middle ear penetration of

topical antimicrobials

Aural toilette• From the Cochrane review, aural toilet alone

was not significantly better in resolving otorrhoea and in healing perforations than no treatment.

Aural toilette• This was based on two field trials among

children in the Solomon Islands (50) and Kenya (155).

• Antimicrobial Treatment, aural toilet must be combined with antibiotics or antiseptics to be effective.

Oral antibioticsOral antibiotics are better than aural toilet

alone• A trial comparing various oral antibiotics with

aural toilet alone reported a higher otorrhoea resolution rate in the antibiotic treated group.

Oral antibiotics• Another trial comparing oral clindamycin with

aural toilet alone found otorrhoea resolution rates of 93% and 29%, respectively

Topical antibioticsTopical antibiotics are better than aural toilet

alone• The addition of topical antibiotics to aural

toilet was associated with a 57% rate of otorrhoea resolution, compared to 27% with aural toilet alone

Topical antibiotics• topical antibiotics: framycetin, gramicidin,

ciprofloxacin, tobramycin, gentamicin and chloramphenicol.

• Podoshin et al. also showed that topical ciprofloxacin or tobramycin was more effective than placebo (clinical response rates were 78.9%, 72.2% and 41.2%, respectively)

Topical antibiotics are better than systemic antibiotics

• The Cochrane review found that topical antibiotics were more effective than systemic antibiotics in resolving otorrhoea and eradicating middle ear bacteria.

• topical antibiotics: gentamicin, chloramphenicol, ofloxacin, and ciprofloxacin

• topical antiseptics: hydrogen peroxide and boric acid with iodine powder as

• systemic antibiotics: cephalexin, flucloxacillin, cloxacillin, amoxycillin, coamoxiclav, erythromycin, metronidazole, piperacillin, ciprofloxacin, azactam, trimethoprim-sulfa, ofloxacin, and intramuscular gentamicin

Combined topical and systemic antibiotics are no better than topical antibiotics alone

• The Cochrane review showed that combined oral-topical antibiotics were no more effective than topical antibiotics alone; the rates of resolution of otorrhoea were 50% and 53%, respectively.

Thus, although combination antibiotics are effective in resolving otorrhoea, adding oral antibiotics to topical antibiotics and aural toilet increases the cost without increasing the success rate.

This confirms the difficulty of systemic drug penetration through the devascularized, fibrotic mucosa of the middle ear and mastoid.

It also emphasizes the critical role of local treatment.

Parenteral antibiotics• Parenteral antibiotics are better than aural

toilet alone• One trial found that intravenous mezlocillin

and ceftazidime were more effective than aural toilet alone in resolving otorrhoea and eradicating middle ear bacteria

• (100% and 8%, respectively).

Surgery• Mastoidectomy and/or tympanoplasty are fre-

quently necessary to permanently cure CSOM. • Mastoidectomy

- removing the mastoid air cells, granulations and debris using bone drills and microsurgical instruments.

• Tympanoplasty - closure of the tympanic perforation by a soft tissue graft with or without reconstruction of the ossicular chain.

CLINICAL PRACTICE GUIDELINE

Clinical Practice Guideline in OME

Otolaryngol Head Neck Surg. 2004 May;130(5 Suppl):S95-118.

UPDATES as compared from 1994 guideline

• Applies to children aged 2 months through 12 years with or without developmental disabilities and or underlying conditions that predispose to OME and its sequelae

• Strongly recommended pneumatic otoscopy as primary diagnostic method and distinguish OME from AOM

UPDATES as compared from 1994 guideline

• Recommended that clinicians shouldDocument laterality, duration of effusion,

presence and severity of associated symptoms at each assessment of the child with OME

distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk

UPDATES as compared from 1994 guideline

• Recommended that clinicians shouldmanage the child with OME who is not at risk

with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown)

UPDATES as compared from 1994 guideline

• Other recommendations hearing testing be conducted when OME persists for 3

months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME

children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected

UPDATES as compared from 1994 guideline

• Other recommendationswhen a child becomes a surgical candidate,

tympanostomy tube insertion is the preferred initial procedure

UPDATES as compared from 1994 guideline

• Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis)

• repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion

• Tonsillectomy alone or myringotomy alone should not be used to treat OME

UPDATES as compared from 1994 guideline

• Negative recommendationspopulation-based screening programs for OME

not be performed in healthy, asymptomatic children

antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management.

UPDATES as compared from 1994 guideline

• Committee gave options that: tympanometry can be used to confirm the diagnosis of

OME when children with OME are referred by the primary

clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery), and provide additional relevant information such as history of AOM and developmental status of the child

UPDATES as compared from 1994 guideline

No recommendations for:complementary and alternative medicine as a

treatment for OME based on a lack of scientific evidence documenting efficacy

allergy management as a treatment for OME based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME

REFERENCES

• Chronic suppurative otitis media, Burden of Illness and Management Options, Child and Adolescent Health and Development, Prevention of Blindness and Deafness, World Health Organization, Geneva, Switzerland, 2004

• Clinical Practice Guideline in OME. Otolaryngol Head Neck Surg. 2004 May;130(5 Suppl):S95-118.