Transcript Definition

Updates on Chronic Otitis Media
Block U Interns 2010
Outline
I.
II.
III.
IV.
Background
Management
Clinical Practice Guideline
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
Pathophysiology
It 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 Studies
Prior 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 antibiotics
Oral 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 antibiotics
Topical 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 frequently 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 should
Document 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 should
manage 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 recommendations
when 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 recommendations
 population-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):S95118.