Otitis Media: Surgical Expectations

Kavita Dedhia, MD MSHP

Otitis media (OM) is prevalent in the United States, with nearly 2.2 million episodes of otitis media with effusion (OME) yearly and approximately 75% of children <5 years having had at least 1 episode of acute otitis media (AOM). OM is the leading cause of hearing impairment, which can negatively impact a child’s speech and school performance. Predisposing factors include male sex, young age, premature birth, family history of OM, smoke exposure, daycare, formula fed infant, pacifier use, craniofacial abnormalities, obesity, diet, gastroesophageal reflux, and/or food/environmental allergies.

Chronic or recurrent disease may necessitate several courses of antibiotics, prompting consideration of surgical intervention. Children who meet the American Association of Pediatrics guidelines for ear tubes—3 ear infections in 6 months or 4 in one year or children with ear fluid persisting >3 months—should be referred to an otolaryngologist. At the pre-operative visit, children considered at-risk for developmental delay (see Table 1), OM with significant impact on their quality of life, poor tolerance/reactions to antibiotics, and/or have fluid in their ears at the time of surgical consultation are considered surgical candidates.

Pathophysiology/surgical management

In children with frequent ear infections, chronic ear fluid or difficulty with pressure equalization of the middle ear, the eustachian tube is not functioning properly. The eustachian tube is located in the nasopharynx and is responsible for drainage of the middle ear space. Placement of a tympanostomy tube allows for adequate drainage of the middle ear, which is the mainstay surgery for otitis media. This procedure is performed under general anesthesia using an inhaled agent given through a face mask without intubation. The surgical time is approximately 5 to 10 minutes, and no overnight stay is required.

In addition to tympanostomy tubes, children may undergo concurrent adenoidectomy. Adenoidectomy requires removal of the adenoid tissue, which is located adjacent to the eustachian tube orifice. Given this proximity, adenoid tissue can either obstruct the eustachian tube opening or act as a bacterial reservoir for pathogens entering the middle ear. Removing adenoid tissue requires that the patient be intubated, doubles the length of surgery, and may require an overnight stay. Existing otolaryngology guidelines recommend adjuvant adenoidectomy in children >4 years old or cases where children <4 years old present with nasal obstruction or adenoiditis.

Post-operative care

After children have undergone surgical management for otitis media with either tubes alone or tubes with adenoidectomy, we recommend a 4- to 6-week follow-up with an audiogram in the otolaryngology office. After this initial visit, the child should continue follow up until the tubes have extruded to ensure that tubes are functioning appropriately. Tympanostomy tubes are typically in place for 6 to 18 months and fall out on their own. If after the tubes have extruded, the child continues to have recurrent ear infections or fluid, they may require another set of tubes and possibly adenoidectomy, based on their symptoms. In cases where the tube has been in place for approximately 3 years, we recommend removal of the tube to decrease the risk of persistent perforation (a rare complication of tube placement).

One of the most common reasons children return to ENT prior to scheduled visits is due to ear tube drainage (otorrhea). We discuss with families that after tube placement, children may still get ear infections, and instead of fluid being trapped behind the ear drum, it will drain from the ear. In these cases, we recommend treatment with ear drops. Antibiotic drops (Ofloxacin or Ciprofloxacin) drops are first-line treatment, followed by Ciprodex drops (combination of antibiotic and steroids) in refractory cases. When thick drainage is present, we counsel families to make a tissue spear to wick out the drainage prior to placing drops. Cases where drainage persists after 10 days of drops, the child may require suctioning of the ear drainage, along with a culture for directed antibiotic treatment. Copious drainage can block the ear tube, rendering it non-functional. In this instance, we counsel families to use hydrogen peroxide until there is a pain reaction to unblock the tube, with subsequent use of Ofloxacin drops for 5 days. Click to view the figure.

While there is some understanding of patient factors contributing to otitis media, this is less defined for otorrhea. Recent studies have been less supportive of water exposure as a significant cause of otorrhea. We no longer recommend water precautions when swimming in chlorinated water. The literature has identified passive smoke exposure and diet high in fat and sugar as modifiable risk factors associated with increased otorrhea, both of which have also been associated with increasing OM. Counseling families on these modifiable risk factors may play a role in decreasing otorrhea episodes.

Summary

Otitis media is the most common reason for pediatric surgery and third most common reason for pediatric visits. Prevention with ensuring children are up to date on vaccinations, and modifying risk factors may decrease disease burden. Surgical management with tympanostomy tube with or without adenoidectomy can be pursued in the appropriate patients. Otorrhea can commonly occur after tube placement and should be managed with ear drops. Children with ear tubes should have periodic follow-up in the otolaryngology office to ensure tubes are functioning appropriately. (See Figure 1.)