© Borgis - New Medicine 3/2006, s. 68-70
Mieczysław Chmielik, Eliza Brożek-Mądry, Małgorzata Dębska
Surgical treatment of secretory otitis media in children
Department of Paediatric Otorhinolaryngology, Medical University, Warsaw, Poland
Head of Department: Prof. Mieczysław Chmielik, MD, PhD
The aim of this paper is to review the latest researches on secretory otitis media and its surgical treatment. After a brief summary of diagnostic tools, authors report different approaches in management, focusing on indications for surgical treatment.
Otitis media with effusion (OME) in children and its treatment represents quite a common problem worldwide. The definition of OME covers aseptic fluid accumulation in the tympanic cavity, with preserved tympanic membrane, leading to conductive hearing loss. The pathogenic pattern underlines the role of Eustachian tube obstruction followed by hypotension in the tympanic cavity and subsequently collection of effusion, exudate or mucous gland secretion.
Management of OME can be preservative or surgical. Conservative methods include periodic follow-up and minimization of environmental risk factors, and pharmacological treatment with sympaticomimetics, antihistaminics, steroids, antibacterial agents, or immunostimulating agents. Surgical procedures involve myringotomy with or without ventilation tube, adenoidectomy with or without tonsillotomy (tonsillectomy), either alone or with myringotomy and ventilation tubes optionally, and pressure equalization through Valsalva manoeuvre or application of Politzer balloon. Laser myringotomy has appeared in recent years as an alternative to classic myringotomy.
Establishing diagnosis of otitis media with effusion requires first of all a thorough patient history and scrupulous laryngological assessment. The tympanic membrane on examination is changed and it can be retracted, thickened, opaque, without light reflex or translucent and thin with air bubbles behind the drum or fluid level. Patient´s history shows gradual hearing loss, frequent otitis media and upper respiratory tract infections, and the symptoms of Waldeyer´s ring of lymphoid tissue hypertrophy.
Among available basic diagnostic tools acoustic impedance can be performed in almost all children, while older children can also be assessed by pure tone audiometry. In OME the curve is usually type B and pure tone audiometry shows the bone/air gap approx. 20-30 dB and conductive hearing loss.
Mandel et al. and Rosenfeld et al. report that OME resolves spontaneously in 80-90% of children in three months. Most laryngologists when they do not observe any improvement in preservative treatment decide on ventilation tubes. Still, about 40% of laryngologists think that ear drainage is used too often.
According to the guidelines of the American Academy of Otolaryngologists – Head and Neck Surgeons from 2004, ventilation tubes should be considered in children with OME lasting longer than 4 months and accompanied by hearing loss or other symptoms. Ventilation tubes were described in literature for the first time by Armstrong in 1954. Contemporarily the idea stays the same and indicates myringotomy with evacuation of the fluid from the tympanic cavity, then administration of the steroid and tube insertion in the performed incision.
Recent research on the influence of ventilation tubes and ear drainage on speech and language development, cognitive disorders and psychosocial behaviours has found no difference between a group of children up to three years old who had ear drainage with ventilation tubes performed as soon as OME was diagnosed and children who had the tubes inserted 9 months later.
Another randomized trial showed that ventilation tubes improve hearing only in a short observation period (about 6 months), and follow-up in both groups, i.e. with or without ear drainage performed in 12-18 months, did not find any significant differences in audiometric results.
One of the disadvantages of ear drainage is preterm tube falling out due to gathering of exfoliating cells around the tube and gradual pushing out in approx. 4-7 months. Forty percent of these patients will be again diagnosed with OME and 33-75% will have a further tube inserted.
Complications such as otorrhoea after tube insertion appear three times more often than after myringotomy alone. Otorrhoea may be postoperative and temporary (16%), delayed (26%), recurring (7.4%), or chronic (3.8%).
The next disadvantage is the fact that the patent tube enables bacteria, viruses and allergens to pass into the tympanic cavity. Covering the tubes with different materials having for example anti-adhesive (HSA – human serum albumin) or anti-bacterial properties gradually eliminates this problem.
Other complications of ventilation tubes and ear drainage described in the literature are as follows:
1. retracted tympanic membrane, retraction pockets 3.1%, focal atrophy 25%
2. perioperative inflammation
3. local anti-foreign body reaction
4. granulation 25%
6. tympanosclerosis 32%
7. temporary or constant hearing loss on different levels
8. persistent perforation of the ear drum 16.6 vs 2.2%
9. tube displacement into the tympanic cavity 0.5%
10. tube obturation 7%
11. cholesteatoma 0.7%
Schilder wrote in a review paper on ear drainage that the benefit is immediate hearing improvement. Longer observation does not show an improvement either on otoscopy or in hearing evaluation. Thus the author suggests that more factors should be considered when deciding on insertion of ventilation tubes.
Iino et al. suggested a longer observation period and preservative treatment in patients with chromosome 21 trisomy (Down´s Syndrome) after they observed less benefit of drainage in this group compared to the control group. They propose insertion of ventilation tubes in patients with larger hearing loss and in cases of more pronounced otoscopic findings such as deep retraction pockets or adhesive otitis.
Cholesteatoma was described as a post tube insertion complication, while Rakover et al. suggest that drainage can prevent further cholesteatoma formation.
Additionally, passively smoking children with ventilation tubes more often develop postoperative inflammations, attic retraction, tympanosclerosis and eardrum perforation.
Data on adenoidectomy and adenotonsillotomy together with ear drainage in OME treatment in children show that these patients do not need repeated ventilation tube insertion when compared with children who were treated only with ear drainage. A therapeutic effect was also noticed when adenoidectomy or adenotonsillotomy was performed without myringotomy (50-90%). With the combined method the therapeutic effect was evaluated in 75-85%.
Recent literature also presents a new method of laser myringotomy that enables incision of the tympanic membrane that stays patent longer and heals in 2-3 weeks after surgery. Still this method is described as less effective than drainage.
As an alternative to ventilation tubes some authors describe methods of pressure equalization by forcing air through the Eustachian tube into the tympanic cavity. The most common methods to achieve this are the Valsalva manoeuvre and the Politzer method. The first of them has a disadvantage connected with the difficulty for a child to perform it or to achieve some regularity in performing it. Constant proceedings lead to pressure equalization and symptoms retreat. In a certain group of patients a good solution may be the Politzer method as it does not require as much from the patient as the Valsalva manoeuvre does. Still this method may be connected with a certain amount of discomfort or even pain; thus only a limited group will benefit from it.
1. Watchful waiting as long as possible in children without any accompanying disorders predisposing to OME.
2. Ventilation tubes in patients with:
a. Hearing loss lasting 4-6 months without any perceptible cause or in cases when the cause cannot be treated
b. Tympanic membrane changes such as: atrophy, retraction pockets, adhesions
c. Thick discharge in the tympanic cavity
d. Facial skeleton deformations leading to nasal patency disorders and Eustachian tube dysfunction.
3. Every child with OME should be evaluated as to whether performing adenoidectomy or adenotonsillotomy with accompanying ear drainage may be beneficial for him/her.
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