Indian J Pediatr 1992; 59 : 341-345







Guest Editor : Y.N. Mehra

Otitis Media of Childhood Satish Mehta and Y.N. Mehra

Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh

Otitis media, a common disease of infants and children is characterised by frequent multiple symptomatic recurrences and the persistence of middle ear effusion for weeks to months after the acute episode2 ~ EPIDEMIOLOGY

The peak prevalence age of otitis media is 6-36 months? In one study of 2,565 children followed for the first three years of life, 7!% had one or more attacks of otids media. ~ In addition, the study showed that after the first episode, 40% of children had a middle ear effusion that persisted for four weeks and 10% had an effusion that was still present at three months. The over all prevalence of the disease in children has been estimated to be between 15-20%. 4 Various authors have reported different figures of incidence of chronic suppurative otitis media i.e. 11.89% in patients attending ENT OPD by Sachdev and Bhatia, 4 2.84%, 3.44% and 8.02% in children attending three different schools by Kapur et al s and 2.55% in general population by Mann et ai. 6 The incidence is higher in males, lower socio-economie group, children with cleft palate and other craniofacial anomalies, immunocompromised children etc. Reprint requests : Dr. Y.N. Mehra, Head, Department of E.N.T., Post Graduate Institute of Medical Education & Research, Chandigarh160012.

Recently, another entity which is called as "Silent Otitis Media" has been considered as one of the stages of otitis media. PapareUa et al a defined the term as histo-pathological evidence of otitis media in the absence of clinical symptoms and signs. Incidence of silent otitis media in neonates and infants has been mentioned varying from 23% to 68%. TM Majority of studies had been post-mortem in regard to diagnosis of silent otitis media. But in life, tympanometry can give an idea of this disease by reflecting change in the impedance status of middle ear, while biopsy confirm the diagnosis. The pathogenesis of otitis media appears to be related to abnormal functions of eustachian tube. Eustachian tube has atleast three physiological functions to perform; equilibration of air pressure (ventilation) in the middle ear with atmospheric pressure, protection from nasopharyngeal secretions (reflux of aspiration) and clearance of secretions from middle ear to nasopharynx. Both, blocked or abnormally patient eustachian tube can result in the pathogenesis of otitis media. The horizontal position of eustachian tube and its wide nasopharyngcal opening makes neonates and infants more prone to develop otitis media. The causative organisms which have been cultured in cases of acute otitis media are streptococcus pneumonia, haemophilus




influenza, fl-hemolytic streptococcus, staphylococcus aureus etc. Anaerobic bacteria have bcen cultured from patients having chronic suppurative otitis media. In a study of 116 ears having otitis media, staph, aureus, pseudomonas hyocynanea were commonest organism cultured while /3-streptococcus haemolyticus was rare. n MANAGEMENT OF ACUTE OTITIS MEDIA The rapid short onset of signs and symptoms of infections in the middle ear is termed Acute Otitis Media. Patient may present with otalgia, fever or recent onset of irritability. The tympanic membrane is full or bulging, opaque and has limited or no mobility to pneumatic otoscopy, all of which are indicative of a middle ear effusion. It is important to note that position of tympanic membrane is horizontal in neonates and infants. Hence, examiner has to pull pinna downwards, backwards and outwards to see the drum head. One must not confuse slight redness or tense tympanic membrane as an evidence for otitis media, especially if the infant is crying. Regarding treatment, majority of authors agree that infants and children who have signs and symptoms of acute otitis media must receive antimicrobial therapy. In a clinical trial by Howie and Plussard, ~s antimicrobial agents were shown to be superior to placebo in sterilising the middle car effusion. Amoxycillin or ampicillin is the currently preferred drug for initial empiric therapy as it is active both in vitro and in vivo against streptococcus pneumonia and most strains of haemophilus influenza. If a child is allergic to penicillin, either er)ethromycin or sulphadiazene or sulfamoxole is recommended. In case of resistant

Vol, 59, No. 3

organisms, ccphalosporins (lst generation) are recommended. The duration of treatment is for 10 days) 4 With appropriate antimicrobial therapy, most children of acute bacterial otitis media show significant improvement within 48 to 72 hours. If signs and symptoms of infection progress, despite antimicrobial therapy, the patient might develop mastoiditis, meningitis and intracranial complication. This often necessitates a change in antibiotic and or tympanocentesis/mastoidectomy. Additional symptomatic treatment in the form of antipyretics, oral and local decongestants is helpful at the onset of disease. Persistent Middle Ear Refusion

Re-evaluation of patient of acute otitis media after 10--14 days of antimicrobial therapy shows persistent middle ear effusion in approximately 50% of cases. The managcment of these cases is controversial. The different modalities advised are simple follow-up, another course of antimicrobial agents for 10 days, tympanocentcsis or systemic steroids and oral decongestants. Cantekin el a115 negated the role of oral decongestants and antihistamines in eliminating persistent middle ear cffusion. At present, many clinicians do not treat childrcn who have asmptomatic middle car effusion still present after 2 weeks of treatment. They advise follow-up and re-evaluation 2 months later. At this time majority of patients wilt be effusion free, but those having still, require tympanostomy tube/ grommet insertion with or without a course of antimicrobial agents. Recurrent Otitis Media

The treatment for recurrent acute otitis media remains same as previously outlined.

MEHTA AND MEHRA : O'I]TIS MEDIA OF CHILDtlOOD But if episodes of acute otitis media are frequent, then patient requires detailed evaluation and prevention of recurrent attacks is desirable. Patient is examined and investigated thoroughly to find the focus of infection, respiratory allergy, immunodeficiency, submucous cleft, nasopharyngeal tumour etc. If none of the preceding conditions is present, then one of the following treatment is suggested to prevent further attacks:


Otitis Media with Effusion

There are many synonyms to this condition like secretory otitis media, non-suppurative otitis media or serous otitis media. The duration of the effusion can be classified as acute (less than 3 weeks ), subacute (3 weeks-3 months) or chronic (more than 3 months). The most important distinction between this type of disease and acute otitis media is that symptoms and signs of acute inflammation are lacking in otitis media (a) Chemoprophylaxis with antibiotics, with effusion, for example otalgia or fever, like injections of benzathcne, penicillin or but hearing loss is usually present in both low dosage oral antibiotic for long time. conditions. (b) Myringotomy with insertion of tymInfants and children who have otitis mepanostomy tube dia with effusion most likely have condition (c) Adenoidectomy with or without tonthat is an extension of upper respiratory sillectomy tract infection. Casselbrant et a119 reported (d) Administration of polyvalent pneuthat in 80% of pre-school children, who demococcal vaccine may be an effective preveloped otitis media with effusion, the conventive measure in children, but is not efdition resolves without treatment in 2 fective for infants. months. Regarding chemoprophylaxis there had Hearing loss of some degree is usually been many cffective clinical trials. ~6-ts associated with this condition. 2~ Although Amoxycillin in the dosage of 20 mg/kg in significance of this hearing loss is still unone dose or sufisoxazole 50 mg/kg as one certain, such a loss may impair cognitive dose (in case child is sensitive to penicillin) and language functions resulting in disturis recommended during respiratory seasons bances of psycho-social adjustments? ~ Imatleast. The advantage with injectable ben- portant facts which need due consideration zathene penicillin is the surety of going into in addition to hearing loss for treatment of body tissue while oral medication is likely to such cases are: (i) occurrence in young inbe missed when taken for long time. The fants because they arc unable to communichild should be examined at frequent inter- cate about their symptoms and may have vals, to be certain that inapparent middle suppurative disease. (ii) an associated acute car effusion does not occur. If long standing purulent upper respiratory tract infection. persistent middle ear effusion is present, (//i) concurrent permanent conductive senwhile child is on chemorophylaxis, it is bet- sorineural hearing loss. (iv) vertigo or tinniter to do myringotomy and tympanostomy tus. (v) alterations of tympanic membrane, tube insertion with or without adenoidec- such as severe atelectasis, especially a deep tomy. There is no evidence in support of retraction pocket in the posterior-superior use of systemic antihistamines or deconges- quadrant, pars flacida or both. (vi) middle tants for prophylaxis of acute otitis media. ear changes, such as adhesive otitis or



ossicular involvement. (vii) Persistence of effusion for 2-3 months or longer, that is chronic otitis media with effusion. (viii) frequent recurrence of the episodes, resulting in an accumulation of an excessive duration of middle ear effusion during a given period of time, such as 6 out of the preceding 12 months. (/x) underlying aetiological factors. The popular method of management using combination of decongestant and antihistamine was shown to be ineffective in the Pittsburgh study of infants and children with acute, sub-acute and chronic otitis media with effusion.~2 The efficacy of topical intranasaI and systemic corticosteriod therapy has been tested, but convincing evidence of efficacy has not been reported. Macknin and Jones z2 reported lack of efficacy in a placebo-controlled study of oral dexamethasone. Even though clinical trials have not been reported that have tested the efficacy of immunotherapy and control of allergy in children who have allergy and middle ear disease, this method of management seems reasonable in children, who have frequently recurrent or chronic otitis media with effusion and evidence of upper respiratory allergy. Inflation of eustachian tube-middle ear, using the method of Politzer of eml~loying the Valsalva manoeuvre has been advocated for more than a century for this condition however, a recently reported randomized controlled trial by Chan and Bluestone z3 reported a lack of efficacy of middle ear inflation for otitis media with effusion, and therefore, it is not recommended. Of all the medical treatment, a trial of an anti-microbial agent would appear to be most appropriate in those children who have not received an antibiotic recently, because bacteria similar to those found in

vol. 59, No. 3

acute otitis media have been isolated from a significant proportion of middle ear aspirates in children with chronic otitis media. If non-surgical methods of management fail, then surgical intervention should bc considered. Tympanostomy tube insertion is advised in such cases. Following spontaneous extubation of tympanostomy tube, reinsertion for recurrence of effusion is indicated after another trial of antimicrobial therapy fails. In some children, reinscrtion of tympanostomy tube may be nceded several times until the child grows oldcr. The efficacy of adenoidectomy in conjunction with myringotomy, and tympanostomy tube insertion for chronic otitis media with effusion can benefit some children, however, others improve without removal of adenoids and still other patients will have persistent disease despite adenoidectomy.~-~ Hence, if a child of otitis media with effusion has upper airway obstruction, recurrent acute-chronic adenoiditis, adenoidectomy should be combined with treatment of otitis media. REFERENCES

1. Telle DW, Klein JO, Rosner BA. Epidcn,.ology of otitis media in children. Aim Otol Rhinol Laryngol 1980; (Supp. 68) 5 : 89. 2. Howie VM, Plous~sard JH, Sloycr J. The otitis prone condition. Am J Dis Child 1975; 129 : 676. 3. Kessner D, Snow CK, Singer T. Assessment of Medical Care for Children : Contrastx h~ ltealth Care Status Vol. 3, Washington DC :

Institute of Medicine, National Academy of Sciences, 1974. 4. Sachdev VP, Bhatia JN. A survey of otitis media in PGI, Chandigarh. Indian J Otolal, yngo/1965; 17 : 134-139. 5. Kapur YP. A study of hearing loss in school

MI~.IITA AND MEI IR,A : OTITIS MEDIA OF CIIII.I)HOOI) children in India. h~dian J Med Res 1965; 53 : 344-370. 6. Mann SBS, Grewal BS, Nahar MS ctal. Incidence of chronic suppurative otitis media in general population-(A rural survey), hrdian j Otolmyngol 1976; ~ : 35-40. 7. Aver" A D ct al. Quality of medical care as-



se.~sment usbtg outcome measures. Eight disease-specific applications. Prepared for the










health resources administration, Departmcnt of Health Education and Welfare by the Rand Corporation, Santa Monica, California 911406, August 1976. Paparella MM, Shea D, Meyerhoff LW et al. Silent otitis media. Laryngoscope 1980; 90 : I089. Mehta S. Silent otitis m e d i a - A n autopsy study in still borns and neonates. Eat" Nose ThroatJ 1990; 69 (5) : 296-317. McLelhm MS, Strong JP, Johnson QR ct al. Otitis media in premature infants--a histopathological study. J Pediatr 196l; 61 : 5375. Balkany T J, Bcrman AS, Simmons AM et :d. Middle ear effusions in neonates. Lao,ngoscope 1978:88 : 398. Baruah PC, Aggam, al SC, Arora MML, Mehra YN. Clinical and microbiological studies in suppurative otitis media in Chandigarh. IJLO 1972, 24 : 157-160. Howie VM, Ploussard JH. Efficacy of fixed combination antibiotics versus separate components in otitis media. Clin Pediatr 1972; 11 : 205-214. Bluestone CD, Connel .IT, Doyle WJ ct al. Symposium questioning the efficacy and safety of antihistantincs in the treatment of upper respiratory infection. Pediatr bff'ect Dis 19S8; 7 : 239-24(I. Cantekin El, Mandcl EM, Bluestone CD et al. Lack of efficacy of a decongestant antihistamine combination for otitis ntedia with effusion (secretory otitis media) in children. New l'ngl J Med 1983; 308 : 297-301. Liston TE, Foshee WS, Person WD. Sul-










fisoxazole chemoprophyh~is for frequent otitis media. Pediauics 1983; 71 : 524-530. Maynard JE, Fleshlrmn JK, Tschopp CF. Otitis media in Alaskan Eskimo Children. Perspective evaluation of chemoprophylaxis. JA3L4 1972; 219:597-599. Perrin 3M, C h a r n ~ ' E, MachWhinncry .113 Jr. ct al. Sulfisoxazole as chcn'~oprophyl~xis for recurrent otitis mcdia. A double-blind crossover study in pediatric practice. :\;e., EnglJ Med 1974; 291 : 664-667. Casselbrant ML, Brostoff LM, Cantckin E1 et al. Otitis media with effusion in preschool children. Laov~goscope 1985; 95 : 428-436. Fria TH, Cantekin El, Cichler JA. tlearing acuity of children with otitis media with cffusion.Alvh Otolaowgol 1985; l 11 : 10-16. Teele DW, Klwin JO, Rosner BA ct al. Otitis media with effusion during the first three years of life and development of speech and language. Pediauics 1984; 74 : 282-287. Macknin ML, Jones PK. Oral dcxamethasone for treatment of persistent middle ear effusion. Pediaoics 1985; 75 : 329-335. Chan KH, Bluestone CD. Lack of cfficac'y of middle ear inflation. Treatment of otitis media with effusion in children. Otolao,ngol llead Neck Sut~ 1989; 100 : 317-327. Gates GA, Avery CA, Prihoda TJ ct al. Effectiveness of adenoidectomy and tympanostomy tubes in the treatment of chronic otitis media with effusion. New EnglJMed 1987; 317 : 1444-1451. Maw AR. Age and adenoid size in relation to adenoidectomy in otitis media with effusion. Ann J Otolao'ngol 1985; 6 : 245248. Paradise JL, Bluestone CD, Rogers KD ct al. Efficacy of adenoidectomv for recurrent otitis media. Results from parallel random and nort-random trials. Pedicmics Rex 1987; 21 : ~q6A.

Otitis media of childhood.

Indian J Pediatr 1992; 59 : 341-345 S Y M P O S I U M : ENT DISORDERS I I III I I i Guest Editor : Y.N. Mehra Otitis Media of Childhood Satish...
330KB Sizes 0 Downloads 0 Views