Otitis media with effusion in children

Otitis media with

effusion in children

Dr. Prathyusha PG ENT

Narayana Medical College,Nellore

Introduction • Otitis media with effusion in a child differs

significantly from that of adults in terms of • Presentation• Diagnosis • Management • Follow up• A more comprehensive approach and

judicious management is required in children

DEFINITION• Otitis media with effusion (OME) is

characterized by a nonpurulent effusion of the middle ear that may be either mucoid or serous

• Serous otitis media is a specific type of otitis media with effusion caused by transudate formation due to rapid decrease in middle ear pressure relative to the atmospheric pressure.

• The fluid in this case is watery and clear.

• Otitis media with effusion (OME) can occur during the resolution of acute otitis media (AOM) once the acute inflammation has resolved.

• Among children who have had an episode of acute otitis media, as many as 45% have persistent effusion after 1 month

• but this number decreases to 10% after 3 months

PATHOPHYSIOLOGY OF OME• Eustachian dysfunction theory

• Reflux theory

• Gene regulation theory

• Oxidative stress theory

ET DYSFUNCTION THEORY

• ET has 3 main functions: • Equilibration of pressure between the

middle and external ears, • Clearance of secretions• Protection of the middle ear

ET DYSFUNCTION THEORY

• If ET dysfunction is persistent,

• A negative pressure sets in middle ear due to diffusion of N2 and O2 into the middle ear mucosal cells

• If it persists it elicits a transudate from the mucosa, causing serous effusion.

REFLUX THEORY

• Presence of reflux proven by radiography

• Presence of pepsin A in the middle ear

Bluestone CD, Beery QC, Andrus WS. Mechanics of the eustachian tube as it influences susceptibility to and persistence of middle ear effusions in children. Ann Otol Rhinol Laryngol. 1974 Mar-Apr. 83:Suppl 11:27-34.

Crapko M, Kerschner JE, Syring M, Johnston N. Role of extra-esophageal reflux in chronic otitis media with effusion. Laryngoscope. 2007 Jun 20.

GENE REGULATION THEORY• Upregulation of mucin genes secondary to

bacterial antigen challenge.

• Production of a mucin-rich effusion

OXIDATIVE STRESS THEORY• Significant changes in oxidative stress in patients

with otitis media with effusion• Significantly improved but not normalized level of

oxidants following the placement of ventilation tubes.

• However, the role of antioxidants in the treatment of OME has yet to be fully investigated.

Yilmaz T, Koçan EG, Besler HT, Yilmaz G, Gürsel B. The role of oxidants and antioxidants in otitis media with effusion in children. Otolaryngol Head Neck Surg. 2004 Dec. 131(6):797-803

PREDISPOSING FACTORS

• Infections • Age • Eustachian tube dysfunction• Craniofacial abnormalities• Diet • Racial and sex differences• Seasonal variations• Others

ETIOLOGY AND PREDISPOSING FACTORS FOR OME

• The same flora found in ASOM can be isolated in OME

• In OME the inflammatory process is less and volume of bacteria is less

• S pneumoniae is found in 35% • H influenzae is found in 20% • M catarrhalis is found in 4-13% • Streptococcus pyogenes, Staphylococcus

aureus, gram-negative enteric bacteria, and anaerobes.

• Pseudomonas species predominate.( long standing)

35

206324

30

INFECTIOUS AGENTS IN ASOMpneumococcus

H. Influenzae

moraxella

strep.pyogenes,stah aureus

pseudomonas

RSV, Influenza

Sterile

Kubba H, Pearson JP, Birchall JP. The aetiology of otitis media with effusion: a review. Clin Otolaryngol. 2000 Jun. 25(3):181-94

83 7

1

15

66

INFECTIOUS AGENTS IN OME

pneumococcus H influenzaeBranhamella Strep. PyogenesothersNegative Culture

Jero J, Karma P. Bacteriological findings and persistence of middle ear effusion in otitis media with effusion. Acta Otolaryngologica. 1997; 529: 22-6.

AGE • In infants, the eustachian tube has a nearly

horizontal orientation

• Develops the 45° angle (as in adults) after several years.

• Size and shape of the eustachian tube at birth, unlike adults, are unfavourable for ventilation

ET DYSFUNCTION• Respiratory tract has ciliated, pseudostratified columnar

epithelium

• Extends up to ET and anterior part of the middle ear

• Along with goblet cells they produce mucus

• In OME inflammation of this epithelium in the Eustachian tube and hypotympanum.

• Flat cuboidal middle ear and mastoid mucosa is patchily

replaced by thickened pseudostratified mucus-secreting epithelium and goblet cells

ET DYSFUNCTION• The ciliary lining would appear to be less

efficient • The submucosa is oedematous and

inflamed with dilated blood vessels and an increased number of

• Macrophages• Plasma cells• Lymphocytes

CRANIOFACIAL ABNORMALITIES• Cleft palate (even if repaired) have

deficient palatine muscles and resultant poor ET function

• Down syndrome

• Turner syndrome more likely to have OME,

• Bifid uvula do not appear to have a higher incidence of OME

DIET

• high-fat diet proven risk factor • Body mass index category• Protein• Water• Sodium intake• distribution of carbohydrate intake

Choi HG, Sim S, Kim SY, Lee HJ. A high-fat diet is

associated with otitis media with effusion. Int J Pediatr Otorhinolaryngol. 2015 Dec. 79 (12):2327-31

NOT

RACIAL AND SEX DIFFERENCE• OME is higher in Native Americans

• NO difference in prevalence rates between white and black populations exists.

• Males may have a slightly higher preponderence (not statistically significant)

EFFECT OF SEASONAL VARIATION• Twice an amount of children were diagnosed in

winter with OME when compared with summer.• Probable reason could be due to increased URTIs

in winter

Tos M, Holm-Jensen S, Sorensen CH, Mogensen C. Spontaneous course and frequency of secretory otitis in 4-year-old children. Archives of Otolaryngology. 1982; 108: 4-10

OTHER PREDISPOSING FACTORS• bottle feeding, • feeding while supine, • having a sibling with otitis media, • attending day care, • having allergies to common environmental entities,• having a lower socioeconomic status, • living in a home in which people smoke,• having a parental history of otitis media with effusion.

Erdivanli OC, Coskun ZO, Kazikdas KC, Demirci M. Prevalence of Otitis Media with Effusion among Primary School Children in Eastern Black Sea, in Turkey

The Effect of Smoking in the Development of Otitis Media with Effusion. Indian J Otolaryngol Head Neck Surg. 2012 Mar. 64(1):17-21.

Prevalence and Management of Otitis Media with Effusion Amongst the School Going Children of a Rural Area in PuducherrySharath Babu et alBengal Journal of Otolaryngology and Head Neck Surgery Vol. 24 No. 1 April, 2016

HISTORY• very unreliable and cannot be a pointer to OME• decreased hearing• history of ear problems• recurrent upper respiratory infections• mouth breathing and snoring,

• Stewart MG, Friedman EM, Sulek 1\t1, Duncan 1\10, Fernandez AD, Bautista MH. Is parental perception an accurate predictor of childhood hearing loss? A prospective study. Otolaryngology and Head and Neck Surgery. 1999; 120: 340-4

ALL THESE TO BE EXAMINED

OTOSCOPY• Unfortunately the otoscopic appearances of OME are

extremely varied.

• The otoscopic findings in OME are mainly different combinations of retraction of the pars tensa and variations in its colour.

• Retractions may be evident by indrawing of the handle of the malleus

• Fluid levels or air bubbles are relatively uncommon.

OTHER FEATURES• Tonsillar hypertrophy

• Adenoid hypertrophy

• Turbinate bogginess

• Postnasal drip,

• Rhinorrhea

• Watery or erythematous eyes consistent with a concurrent URTI or environmental allergies.

PNEUMATIC OTOSCOPY AND VIDEO OTOSCOPY• American Clinical Practice Guidelines have

strongly advocated the use of pneumatic otoscopy as the primary diagnostic method for OME

• Video recordings of otoscopy ( video otoscopy), used to monitor changes with time.

Clinical Practice Guideline: Otitis Media with Effusion (Update) Otolaryngology–Head and Neck Surgery 2016, Vol. 154(1S) S1–S41 American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016

TYMPANOMETRY

Type B tympanogram is most of the times associated with OME

Type A is infrequently associated with OME

T type C falls in between

Sensitivity (Sens), specificity (Spec). positive (PPV) and negative predictive values (NPV) of a Type B tympanogram

Sensitivity, specificity , of a Type B+ C2 tympanogram versus Type A + C in the detection of OME with surgical findings as the reference standard

ACOUSTIC REFLECTOMETRY

• Hand-held acoustic otoscope that does not require a seal

• Unfortunately, the sensitivity and specificity of the test is poorer than tympanometry

AUDIOMETRY• Audiometry is mandatory in all children with a

suspected hearing impairment

• Irrespective as to whether OME is diagnosed at the time.

• Routine audiometric testing of the hearing of every child with OME seen at secondary care is recommended

• Hearing impairment can vary enormously from negligible to moderately severe

COMPREHENSIVE ASSESMENT OF CHILD• Needs to be skilfully done with the assistance

of • ENT Surgeon

• Audiologist

• Pediatrician

• Pediatric psychiatrist/psychologist

• Nursing staff/personel trained in developmental pediatrics

COMPREHENSIVE ASSESMENT

• SPEECH AND LANGUAGE

• COGNITION

• BALANCE

• BEHAVIOUR

SPEECH AND LANGUAGE

• Including speech reception

• Speech and sound production

• Expressive language and cognitive understanding.

• Compare with standard mile stones

• Example: Thus, at 18 months they would be expected to have a vocabulary of ten words with meaning.

BALANCE• 30% of children with OME are report by parents that

they are• Clumsy,• imbalanced and can fall.

• May be due to vestibular dysfunction that settles with time

BEHAVIOR• Rutter score (antisocial, neurotic, hyperactive and inattentive

behaviour)

• The MRC Behaviour Questionnaire (aggressive, social immaturity)

• Behaviour scores in children Of 3 to 7 yrs with B/L deafness of 20dB HL are poorer

• At 15 yrs still have poorer behaviour than non-OME children, (inattentive and hyperactive aspects)

Bennett KE, HC1ggard MP, Silva PA, Stewart IA. Behaviour and developmental effect of otitis media with effusion in the teens. Archives of Disease in Childhood. 2001;

MANAGEMENT• Medical

• Surgical

NASAL TOPICAL STEROIDS

• Systematic reviews of the RCT s have found NO ROLE of topical nasal steroids versus placebo

• Another study which gave antibiotics in addition to nasal steroids also found NO difference.

Butler CC, van der Voort JH, Oral or topical nasal steroids for hearing loss associated with otitis media with effusion. Cochrane Database of Systematic Reviews. 2002:

Tracy.lM, Demain JG, Hoffman KM, Goetz OW. Intranasal beclomethasone as an adjunct to treatment of chronic middle ear effusion. Annals of Allergy, Asthma and Immunology. 1998; 80: 198-206.

SYSTEMIC STEROIDS• NO evidence to suggest that oral steroids are

effective for longer or short term with 0r without antibiotics.

• Systemic steroids CANNOT be recommended at present for childhood OME.

Mandel EM, Casselbrant Ml, Rockette HE, Fireman P, KursLasky M, Bluestone CD. Sytemic steroid for chronic otitis media with effusion in children. Pediatrics. 2002; 110: 1071-80.

Thomas Cl, Simpson S, Butler CC, van der Voort .IH. Oral or topical nasal steroids for hearing loss associated with otitis media with effusion in children. Cochrane

ANTIBIOTICS• Multiple RCT s have shown NO role of antibiotics beyond 2

weeks of antibiotics

• 6 weeks of antibiotics have NO benefit

Rosenfeld RM, Post JC. Meta-analysis of antibiotics for the treatment of otitis media with effusion. Otolaryngology and Head and Neck Surgery. 1992; 106: 378-86

Williams Rl, Chalmers TC, Stange KC, Chalmers FT, Bowlin SJ. Use of antibiotics in

preventing recurrent .otitis media and treating otitis media with effusion. Journal of the American Medical Association. 1993; 270 1344-51

NASAL DECONGESTANTS• meta-analysis of four trials found that

antihistamine/decongestants had NO effect on OME

• Nasal decongestants are NOT recommended for use in childhood OME.

Griffin GH, Flynn C, Bailey RE, Schultz .IK. Antihistamines and/or decongestants for otitis media with effusion (OME) in children. Cochrane Database of Systematic Reviews. 2006;

MUCOLYTICS• Systematic review of six RCT s of S-

Carboxyrnethylcysteine published before 1993 had NO effect.

• Later trials added NO significant effect.

Pignataro 0, Pignataro lD, Gallus G, Calori G, Cordaro CI. Otitis media with effusion and S-carboxymethylcysteine and/or its lysine salt: a critical overview. International Journal of Pediatric Otorhinolaryngology. 1996; 35: 231-41.

AUTO INFLATION• Metanalysis of the three studies indicated that children

with autoinflation were 3.5 times more likely to improve • Ability to autoinflate with the balloon is a particular

problem in younger children (hence NOT recommended)

• During a period of watchful waiting, it has strongest evidence of efficacy for older children.

Williamson I. Otitis media with effusion. Clinical Evidence Concise. 2006; 16: 245-7

HOMEOPATHY

• NO randomized controlled trials have been identified.

• A small, non blinded study DID NOT show homeopathy to be of benefit.

MYRINGOTOMY AND ASPIRATION• From three trials, myringotomy with aspiration

has NOT been shown to be effective in restoring the hearing levels in children with OME.

• Freemantle N, Sheldon TA, Song F, long A. The treatment of persistent glue ear in children. Effective Health Care Bulletin No.4. York: University of York, NHS Centre for Reviews and Dissemination, 1992

VENTILATION TUBES• Introduced in 1954 by Armstrong • Pressure equalization tubes (grommets)are

available in a variety of sizes, shapes,• Teflon,silicone, titanium, gold and be coated with

materials such as silver oxide.

• Permit ventilation of the middle ear and mastoid system.

• Prolonged aeration of the middle ear has been shown to reverse the mucosal hyperplasia and metaplasia that accompany otitis media with effusion.

HOW LONG

• Ventilation tubes are classified as short, or long term,

• Data are lacking on 'duration of tube function'

• Relied upon less relevant 'duration till extrusion

• Self extrude from 6 to 12 months

Shepard Armstrong T tube 0

5

10

15

20

25

30

35

40

45

4540

10

% OF EXTRUSION IN 6 MONTHS

INSERTION SITE• Anterosuperior or anteroinferior outcomes are

SIMILAR

• Posterosuperiorly is NOT done as it can damage the ossicular chain.

• Radial or circumferential, extrusion rates are SIMILAR

Heaton .1M, Bingham BJG, Osbourne J. A comparison of performance of Shepard and Sheehy collar button ventilation tubes. Journal of Laryngology and Otology. 1991; 105: 896-8

Guttenplan MD, Tom WC, DeVito MA, Handler SO, Radial versus circumferential incision in myringotomy and tube placement. International Journal of Pediatric Otorhinolaryngology. 1991 ; 21 : 211-5

PERCENTAGE IN SITU

Antero

inferi

or

Poste

ro inf

erior

0

20

40

60

80

100

120

80

45

30

15

12 Months In Situ6 Months In Situ

ASSOCIATED ASPIRATION• Common practice to aspirate fluid before

inserting a ventilation tube

• NO evidence that this is required.

• The hearing levels three months following insertion of a ventilation tube was NO DIFFERENT in ears that were aspirated compared with those that were not aspirated

HEARING FOLLOWING VT INSERTION

• Ventilation tubes alone will improve the hearing level by9dB at 6 months,

6dB at 12 months4 dB at 24 months. (persistent decrease in improvement is due to non functioning VT over a period of time)

• Children randomized to have VT had a marked improvement three months following surgery of 12 dB compared with the nonsurgical group.

• The younger children at day care those with binaural hearing thresholds poorer than 25 dB HL and persistent over at least 12 weeks will benefit most

Rovers MM, Black N, Browning GG, Maw R, Zielhius GA, Haggard MP. Grommets in otitis media with effusion: an individual patient data meta-analysis. Archives of Disease in Childhood. 2005; 90: 480-5.

MEAN IMPROVEMENT IN HEARING WITH TUBE METAANALYSIS

SPEECH AND LANGUAGE

• 3 RCTs assesed speech abd language post VT at different intervals

• VT are not indicated to aid speech and language development in children three years and younger.

COMPLICATIONS OF VT TUBE• Dislodgement • Blockage ( 9% without antibiotics and 1%

with antibiotics)• Otorrohoea • acute otorrhoea 9%

• Recurrent otorhoea 7%

• Chronic otorrhoea 3%

COMPLICATIONS OF VT CONTINUED……….

• Perforation

• Short term incidence 2%

• Long term incidence 17%

TYMPANOSCLEROSIS, PARS TENSA ATROPHY• Localized white patches or plaques of

tympanosclerosis occur with OME • With VT it increases dramatically• Short term 3 dB• Long term ( 18 yrs) 5 to 10 dB• More tubes, more impairment • Pars tensa atrophy occurs with OME and

increases with VT• NOT significant

ADENOIDECTOMY

• Mechanism unclear (? source of infection ?? Physical obstruction to ET )

• Prior to VT Adenoidectomy alone was the surgical management for many years

• Metanalysis showed e overall effect at 6 months on the hearing of adenoidectomy was 8 dB and 12 dB for VT.

• Current practice is to do adenoidectomy as an adjunct to VT

ADENOIDECTOMY

• Blind curettage. ( risk of bleeding)

• Suction diathermy ablation (less risk)

• Selective removal of adenoid tissue and avoiding palatopharyngeal incompetence by leaving an inferior pad of tissue. (preferred)

• Microdebriders have also been advocated as allowing more selective removal of tissue.

ADJUVANT EFFECT OF ADENOIDECTOMY WITH VT

Additional benefit of adenoidectomy during the second year of TARGET trial

HEARING AIDS• Their use as the preferred initial management has not

been extensively reported

• Improvement is at least in the same range as expected of ventilation tubes.

• Main concern is potential noise trauma if the aid continues to be worn after the OME has resolved

• BAHA® (bone anchored hearing aid) offers advantage over hearing aid in a head-band as it avoids noise trauma

• No report has been identified that has looked at the benefit yet

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BIBILIOGRAPHY• Clinical Practice Guideline: Otitis Media with Effusion

(Update) Otolaryngology–Head and Neck Surgery 2016, Vol. 154(1S) S1–S41 American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016

• Scott-Brown's Otorhinolaryngology, Head and Neck Surgery 8th edition 2008 Edward Arnold (Publishers) Ltd

• Ila Upadhya J. Datar Treatment Options in Otitis Media with Effusion Indian J Otolaryngol Head Neck Surg January 2014 66(Suppl 1):S191–S197

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Health & Medicine

Otitis media with effusion in children