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Otitis Media (middle ear inflammation)
The most frequent primary
diagnosis at visits to US physician offices by children younger than 15 years.
Otitis media particularly affects infants and preschoolers: almost all children
experience one or more episodes of otitis media before age 6.
The American Academy of Pediatrics, the American Academy of Family
Physicians, and the American Academy of Otolaryngology--Head and Neck Surgery,
with the review and approval of the Agency for Health Care Policy and Research
of the US Department of Health and Human Services, convened a panel of experts
to develop a guideline on otitis media for providers and consumers of health
care for young children. Providers include primary care and specialist
physicians, professional nurses and nurse practitioners, physician assistants,
audiologists, speech-language pathologists, and child development specialists.
Because the term otitis media encompasses a range of diseases, from acute to
chronic and with or without symptoms, the Otitis Media Guideline Panel narrowed
the topic. Two types of otitis media often encountered by clinicians were
considered:
 | Acute otitis media--fluid in the middle
ear accompanied by signs or symptoms of ear infection (bulging eardrum usually
accompanied by pain; or perforated eardrum, often with drainage of purulent
material). |
| Otitis media with effusion--fluid in the
middle ear without signs or symptoms of ear infection. |
| The Clinical Practice Guideline, Otitis Media with Effusion in Young
Children, and this reference guide, discuss only otitis media with effusion.
Furthermore, the Guideline and this document narrow their discussion of
the identification and management of otitis media with effusion to a very
specific "target patient": |
| A child age 1 through 3 years; |
| with no craniofacial or neurologic
abnormalities or sensory deficits; |
| and who is healthy except for otitis media with
effusion. |
When the scientific evidence for management permitted, Guideline
recommendations were broadened to include older children.
Highlights Of Patient Management
Congenital or early onset hearing impairment is widely accepted as a risk
factor for impaired speech and language development. In general, the earlier the
hearing problem begins and the more severe it is, the worse its effects on
speech and language development. Because otitis media with effusion is often
associated with a mild to moderate hearing loss, most clinicians have been eager
to treat the condition to restore hearing to normal and thus prevent any
long-term problems.
Studies of the effects of otitis media with effusion on hearing have varied
in design and have examined several aspects of hearing and communication skills.
Because of these differences, the results cannot be combined to provide a clear
picture of the relationship between otitis media with effusion and hearing.
Also, it is uncertain whether changes in hearing due to middle ear fluid have
any long-term effects on development. Evidence of dysfunctions mediated by
otitis media with effusion that have persisted into later childhood, despite
resolution of the middle ear fluid and a return to normal hearing, would provide
a compelling argument for early, decisive intervention. There is, however, no
consistent, reliable evidence that otitis media with effusion has such long-term
effects on language or learning.
The following recommendations for managing otitis media with effusion are
tempered by the failure to find rigorous, methodologically sound research to
support the theory that untreated otitis media with effusion results in
speech/language delays or deficits.
Recommendations and options were developed for the diagnosis and management
of otitis media with effusion in otherwise healthy young children. The following
steps parallel the management algorithm provided at the end of this document.
Diagnosis and Hearing Evaluation
- Suspect otitis media with effusion in young children.
Most children have at least one episode of otitis media with effusion before
entering school. Otitis media with effusion may be identified following an acute
episode of otitis media, or it may be an incidental finding. Symptoms may
include discomfort or behavior changes.
- Use pneumatic otoscopy to assess middle ear status. Pneumatic
otoscopy is recommended for assessment of the middle ear because it combines
visualization of the tympanic membrane (otoscopy) with a test of membrane
mobility (pneumatic otoscopy). When pneumatic otoscopy is performed by an
experienced examiner, the accuracy for diagnosis of otitis media with effusion
may be between 70% and 79%.
- Tympanometry may be performed to confirm suspected otitis media with
effusion. Tympanometry provides an indirect measure of tympanic membrane
compliance and an estimate of middle ear air pressure. The positive predictive
value of an abnormal (type B, flat) tympanogram is between 49% and 99%; that is,
as few as half of ears with abnormal tympanograms may have otitis media with
effusion. The negative predictive value of this test is better--the majority of
middle ears with normal tympanograms will in fact be normal. Because the
strengths of tympanometry (it provides a quantitative measure of tympanic
membrane mobility) and pneumatic otoscopy (many abnormalities of the eardrum and
ear canal that can skew the results of tympanometry are visualized) offset the
weaknesses of each, using the two tests together improves the accuracy of
diagnosis.
| Acoustic reflectometry has not been
studied well enough for a recommendation to be made for or against its use to
diagnose otitis media with effusion. |
| Tuning fork tests: No recommendation is
made regarding the use of tuning fork tests to screen for or diagnose otitis
media with effusion, except to note that they are inappropriate in the youngest
children. |
- A child who has had fluid in both middle ears for a total of 3
months should undergo hearing evaluation. Before 3 months of effusion, hearing
evaluation is an option. A change in hearing threshold is both a
clinical outcome and a possible indicator of the presence of otitis media with
effusion. Methods used to determine a child's hearing acuity will vary depending
on the resources available and the child's willingness and ability to
participate in testing. Optimally, air- and bone-conduction thresholds can be
established for 500, 1000, 2000, and 4000 Hz, and an air-conduction pure tone
average can be calculated. This result should be verified by obtaining a measure
of speech sensitivity. Determinations of speech reception threshold or speech
awareness threshold alone may be used if the child cannot cooperate for pure
tone testing. If none of the test techniques is available or tolerated by the
child, the examiner should use his/her best judgment as to adequacy of hearing.
In these cases, the health care provider should be aware of whether the child is
achieving the appropriate developmental milestones for verbal communication.
Although hearing evaluation may be difficult to perform in young children,
evaluation is recommended after otitis media with effusion has been present
bilaterally for 3 months, because of the strong belief that surgery is not
indicated unless otitis media with effusion is causing hearing impairment
(defined as equal to or worse than 20 decibels hearing threshold level in the
better-hearing ear).
Natural History
Longitudinal studies of otitis media with effusion show spontaneous
resolution of the condition in more than half of children within 3 months from
development of the effusion. After 3 months the rate of spontaneous resolution
remains constant, so that only a small percentage of children experience otitis
media with effusion lasting a year or longer. In most children, episodes of
otitis media with effusion do not persist beyond early childhood. The likelihood
that middle ear fluid will resolve by itself underlies the recommendations made
for management of otitis media with effusion.
Environmental Risk Factors
Scientific evidence showed that the following environmental factors may
increase potential risks of getting acute otitis media or otitis media with
effusion:
| Bottle-feeding rather than breast-feeding infants |
| Passive smoking |
| Group child-care facility attendance |
Because the target child for Guideline recommendations is beyond the age when
the choice of breast-feeding versus bottle-feeding is an issue, this risk factor
was not considered at length.
Passive smoking (exposure to another's tobacco smoke) is associated with
higher risk of otitis media with effusion. Although there is no proof that
stopping passive smoking will help prevent middle ear fluid, there are many
health reasons for not exposing persons of any age to tobacco smoke. Therefore,
clinicians should advise parents of the benefits of decreasing children's
exposure to tobacco smoke.
Studies of otitis media with effusion in children cared for at home compared
to those in group child-care facilities found that children in group child-care
facilities have a slightly higher relative risk (less than 2.0) of getting
otitis media with effusion. Research did not show whether removing the child
from the group child-care facility helped prevent otitis media with effusion.
Therapeutic Interventions
Observation OR antibiotic therapy are treatment options for children
with effusion that has been present less than 4 to 6 months and at any time in
children without a 20-decibel hearing threshold level or worse in the
better-hearing ear. Most cases of otitis media with effusion resolve
spontaneously. Meta-analysis of controlled studies showed a 14% increase in the
resolution rate when antibiotics were given. Length of treatment in these
studies was typically 10 days.
The most common adverse effects of antibiotic therapy are gastrointestinal.
Dermatologic reactions may occur in 3% to 5% of cases; severe anaphylactic
reactions are much rarer; severe hematologic, cardiovascular, central nervous
system, endocrine, renal, hepatic, and respiratory adverse effects are rarer
still. The potential for the development of microbial resistance is always
present with antibiotics.
For the child who has had bilateral effusion for a total of 3 months
and who has a bilateral hearing deficiency (defined as a 20-decibel hearing
threshold level or worse in the better-hearing ear), bilateral myringotomy with
tube insertion becomes an additional treatment option. Placement of tympanostomy
tubes is recommended after a total of 4 to 6 months of bilateral effusion with a
bilateral hearing deficit. The principal benefits of myringotomy with
insertion of tympanostomy tubes are the restoration of hearing to the
pre-effusion threshold and clearance of the fluid and possible feeling of
pressure. While patent and in place, tubes may prevent further accumulation of
fluid in the middle ear. Although there is insufficient evidence to prove that
there are long-term deleterious effects of otitis media with effusion, concern
about the possibility of such effects led the panel to recommend surgery, based
on their expert opinion. Tubes are available in a myriad of designs, most
constructed from plastic and/or metal. Data comparing outcomes with tubes of
various designs are sparse, and so there were assumed to be no notable
differences between available tympanostomy tubes.
Insertion of tympanostomy tubes is performed under general anesthesia in
young children. Calculation of the risks for two specific complications of
myringotomy with tympanostomy tube insertion showed that tympanosclerosis might
occur after this procedure in 51%, and postoperative otorrhea in 13%, of
children.
A number of treatments are not recommended for treatment of otitis media with
effusion in the otherwise healthy child age 1 through 3 years.
| Steroid medications are not recommended
to treat otitis media with effusion in a child of any age because of limited
scientific evidence that this treatment is effective and the opinion of many
experts that the possible adverse effects (agitation, behavior change, and more
serious problems such as disseminated varicella in children exposed to this
virus within the month before therapy) outweighed possible benefits. |
| Antihistamine/decongestant therapy is
not recommended for treatment of otitis media with effusion in a child of any
age, because review of the literature showed that these agents are not effective
for this condition, either separately or together. |
| Adenoidectomy is not an appropriate
treatment for uncomplicated middle ear effusion in the child younger than age 4
years when adenoid pathology is not present (based on the lack of scientific
evidence). Potential harms for children of all ages include the risks of general
anesthesia and the possibility of excessive postoperative bleeding. |
| Tonsillectomy, either alone or with
adenoidectomy, has not been found effective for treatment of otitis media
with effusion. |
| The association between allergy and otitis
media with effusion was not clear from available evidence. Thus, although
close anatomic relationships between the nasopharynx, eustachian tube, and
middle ear have led many experts to suggest a role for allergy management in
treating otitis media with effusion, no recommendation was made for or against
such treatment. |
| Evidence regarding other therapies for the
treatment of otitis media with effusion was sought, but no reports of
chiropractic, holistic, naturopathic, traditional/indigenous, homeopathic, or
other treatments contained information obtained in randomized controlled
studies. Therefore, no recommendation was made regarding such other therapies
for the treatment of otitis media with effusion in children. |
What is Eustachian Tube?
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1 Tympanic Membrane
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2 Maleus Incus Stapes
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3 Semicircular canals
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4 Cochlea
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5 Cochlear Nerve
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6 Oval Window
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7 Eustachian Tube
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8 Orifice
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9 Round Window
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10
Middle Ear Cavity
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The Eustachian tube is only channel of communication between the nasopharynx and
the middle ear for the purpose of equalizing the pressure of the external air
and that contained in the middle ear (see figure).
The natural ventilator of the middle ear is
the eustachian tube. The middle ear is aerated only when the eustachian tube is
opened, which take place during the act of deglutition. The tube is otherwise
closed, so intended by nature to protect the middle ear from unnecessary
exposure from the nasopharynx.
Large pressures in the middle ear cavity can
affect the inner ear by way of the cochlear windows(Round window and Oval
window).
When you travel by plane, you may sometimes
feel ear fullness. But this feeling will disapper by swallowing or chewing. Your
Eustachian Tube is working in this way.
Treatment Outcomes
The Table
summarizes the benefits and harms identified for management interventions in the
target child with otitis media with effusion.
Algorithm
The notes below are an integral part of the algorithm that follows. See
Algorithm
- Otitis media with effusion (OME) is defined as fluid in the middle ear
without signs or symptoms of infection; OME is not to be confused with acute
otitis media (inflammation of the middle ear with signs of infection). The
Guideline and this algorithm apply only to the child with otitis media with
effusion. This algorithm assumes followup intervals of 6 weeks.
- The algorithm applies only to a child age 1 through 3 years with no
craniofacial or neurologic abnormalities or sensory deficits (except as noted)
who is healthy except for otitis media with effusion. The Guideline
recommendations and algorithm do not apply if the child has any craniofacial or
neurologic abnormality (for example, cleft palate or mental retardation) or
sensory deficit (for example, decreased visual acuity or pre-existing hearing
deficit).
- The Panel found some evidence that pneumatic otoscopy is more accurate
than otoscopy performed without the pneumatic test of eardrum mobility.
- Tympanometry may be used as confirmation of pneumatic otoscopy in the
diagnosis of OME. Hearing evaluation is recommended for the otherwise healthy
child who has had bilateral OME for 3 months; before 3 months, hearing
evaluation is a clinical option.
- In most cases, OME resolves spontaneously within 3 months.
- The antibiotic drugs studied for treatment of OME were amoxicillin,
amoxicillin-clavulanate potassium, cefaclor, erythromycin, erythromycin-sulfisoxazole,
sulfisoxazole, and trimethoprim-sulfamethoxazole.
- Exposure to cigarette smoke (passive smoking) has been shown to increase
the risk of OME. For bottle-feeding versus breast-feeding and for child-care
facility placement, associations were found with OME, but evidence available to
the Panel did not show decreased incidence of OME with breast-feeding or with
removal from child-care facilities.
- The recommendation against tonsillectomy is based on the lack of added
benefit from tonsillectomy when combined with adenoidectomy to treat otitis
media with effusion in older children. Tonsillectomy and adenoidectomy may be
appropriate for reasons other than otitis media with effusion.
- The Panel found evidence that decongestants and/or antihistamines are
ineffective treatments for otitis media with effusion.
- Meta-analysis failed to show a significant benefit for steroid
medications without antibiotic medications in treating otitis media with
effusion in children.
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