Factors affecting the results of nonsurgical treatment of secretory otitis media in adults

A pilot study to investigate the therapeutic effect of Valsalva maneuver on otitis media with effusion in adults

OBJECTIVE

This pilot study was performed to investigate the therapeutic effect of Valsalva maneuver on otitis media in adults and to evaluate the prognostic factors for the good response.

METHODS

Thirty nine ears of 32 adult patients who were diagnosed as otitis media with effusion and managed by one-week Valsalva maneuver (>20/day) without any other medication were included in this study. Its therapeutic efficacy was evaluated and the prognostic factors which predict the response of Valsalva maneuver were analyzed by comparing various clinical and audiological factors between success and failure groups.

RESULTS

Mean duration of otitis media in the study subjects was 30.9 days (SD 31.6 days). A success rate of 1-week Valsalva maneuver as a single therapeutic modality was up to 64.1% (25/39 ears) and hearing was significantly recovered in success group. No recurrence or side effects were observed. Successful Valsalva maneuver checked and confirmed as bulging of the tympanic membrane by otoendoscopic examination was an excellent indicator of therapeutic response in a week (p<0.05). Age, sex, duration of otitis media, history of previous upper respiratory tract infection, initial hearing levels and type of audiogram were not significant prognostic factors for the therapeutic efficacy of Valsalva maneuver.

CONCLUSION

One-week Valsalva maneuver seems to be considered as a first line therapeutic modality in otitis media with effusion in adult patients who demonstrate the successful maneuver result on oto-endoscopic examination.

An open randomised study of autoinflation in 4- to 11-year-old school children with otitis media with effusion in primary care

BACKGROUND

Otitis media with effusion (OME) is a very common problem in primary care, but one that lacks an evidence-based non-surgical treatment.

OBJECTIVE

To determine the clinical effectiveness of nasal balloon autoinflation for the treatment of OME in children.

DESIGN

A pragmatic, two-arm, open randomised controlled trial.

SETTING

Forty-three general practices from 17 UK primary care trusts recruited between January 2012 and February 2013.

PARTICIPANTS

School children aged 4-11 years with a history of OME symptoms or related concerns in the previous 3 months, and a type B tympanogram, diagnostic of a middle ear effusion, in one or both ears.

INTERVENTION

Three hundred and twenty children were randomised, 160 to each group, using independent web-based computer-generated randomisation (with minimisation based on age, sex and baseline severity of OME) to either nasal balloon autoinflation performed three times per day for 1-3 months plus usual care, or usual care alone.

MAIN OUTCOME MEASURES

The proportion of children demonstrating clearance of middle ear fluid in at least one ear (with normal tympanograms) at 1 and 3 months, assessed blind to treatment. An ear-related measure of quality of life (QoL) [a 14-point questionnaire on the impact of OME (OMQ-14)], weekly diary recorded symptoms, compliance and adverse events were all secondary outcomes.

RESULTS

At 1 month, the proportion of children with normal tympanograms was 47.3% (62/131) in those allocated to autoinflation and 35.6% (47/132) in those receiving usual care [adjusted relative risk (RR) 1.36, 95% confidence interval (CI) 0.99 to 1.88]. At 3 months, the proportions were 49.6% (62/125) and 38.3% (46/120), respectively (adjusted RR 1.37, 95% CI 1.03 to 1.83; number needed to treat = 9). The change in OMQ-14 also favoured the intervention arm (adjusted global score difference -0.42; p = 0.001). Reported compliance was good: 89% in the first month and 80% in months 2 and 3. Adverse events included otalgia in 4% of treated children compared with 1% in the control group. Minor nosebleeds (14% vs. 15%) and respiratory tract infections (18% vs. 13%) were noted.

CONCLUSION

We found the use of autoinflation in young children with OME to be feasible in primary care and effective in both clearing effusions and improving child and parent ear-related QoL and symptoms. This method has scope to be used more widely. Further research is needed for very young children, and to inform prudent use in different health settings.

Normal Mastoid Air Cell System Geometry: Has Surface Area Been Overestimated?

OBJECTIVES

The aim of this study was to emphasize the necessity of a standard in segmentation threshold and algorithm for measuring volume and surface area of mastoid air cell system (MACS).

METHODS

First, we obtained axial computed tomography scans of 54 normal temporal bones from 27 subjects. Then, we manipulated Hounsfield units (HU) image data in DICOM (digital imaging and communications in medicine) files directly using our program. The volume and surface area of MACS were computed and compared at segmentation thresholds (HU) from -700 to 0 at intervals of 50 using 2 algorithms; square pixel based (SP) algorithm and marching square (MS) algorithm.

RESULTS

No significant difference was found between the volumes computed by SP and MS algorithms at each segmentation threshold. The surface area computed by SP algorithm, however, was significantly larger than that by MS algorithm. We could minimize this significant difference through a modification of the SP algorithm. As the lower HU threshold value was set, the smaller volume was measured. The surface area showed a plateau at a threshold of approximately -200 HU. The segmentation threshold had greater influence on the measured volume of MACS than the algorithm did.

CONCLUSION

A standard method for measuring volume and surface area of MACS is thought to be necessary. We suggest that the MS algorithm and -200 HU of the threshold could be a standard in the measurement of volume and surface area of MACS.

Autoinflation for hearing loss associated with otitis media with effusion

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2006.Otitis media with effusion (OME) or 'glue ear' is an accumulation of fluid in the middle ear, in the absence of acute inflammation or infection. It is the commonest cause of acquired hearing loss in childhood and the usual reason for insertion of 'grommets'. Potential treatments include decongestants, mucolytics, steroids, antihistamines and antibiotics. Autoinflation devices have been proposed as a simple mechanical means of improving 'glue ear'.

OBJECTIVES

To assess the effectiveness of autoinflation compared with no treatment in children and adults with otitis media with effusion.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 12 April 2013.

SELECTION CRITERIA

We selected randomised controlled trials that compared any form of autoinflation to no autoinflation in individuals with 'glue ear'.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, assessed risk of bias and extracted data from included studies.

MAIN RESULTS

Eight studies, with a total of 702 participants, met the inclusion criteria. Overall, the studies were predominantly assessed as being at low or unclear risk of bias; unclear risk was mainly due lack of information. There was no evidence of selective reporting.Pooled estimates favoured the intervention, but did not show a significant effect on tympanometry (type C2 and B) at less than one month, nor at more than one month. Similarly, there were no significant changes for discrete pure-tone audiometry and non-discrete audiometry. Pooled estimates favoured, but not significantly, the intervention for the composite measure of tympanogram or audiometry at less than one month; at more than one month the result became significant (RRI 1.74, 95% CI 1.22 to 2.50). Subgroup analysis based on the type of intervention showed a significant effect using a Politzer device under one month (RRI 7.07, 95% CI 3.70 to 13.51) and over one month (RRI 2.25, 95% CI 1.67 to 3.04).None of the studies demonstrated a significant difference in the incidence of side effects between interventions.

AUTHORS' CONCLUSIONS

All of the studies were small, of limited treatment duration and had short follow-up. However, because of the low cost and absence of adverse effects it is reasonable to consider autoinflation whilst awaiting natural resolution of otitis media with effusion. Primary care could prove a beneficial place to evaluate such interventions and there is ongoing research in this area. Further research should also consider the duration of treatment, the long-term impact on developmental outcomes in children and additional quality of life outcome measures for children and families.

A cross-sectional study of the change in mastoid geometry with age in children without a history of otitis media

OBJECTIVES/HYPOTHESIS

This study assessed the normal growth and development of mastoid air-cell system (MACS) geometry from infancy through adolescence.

STUDY DESIGN

Cross-sectional study.

METHODS

This cross-sectional study evaluated the change with age in MACS volume, surface area, and surface area/volume ratio in 36 (72 ears) individuals aged 1.6 to 18 years with no history of middle ear disease. The three MACS parameters were reconstructed using computed tomography (CT) scans judged by a radiologist to be normal. Linear regression was used to determine the relationship between the left and right values of each parameter, and between those parameters and age for male and female subjects.

RESULTS

For all three MACS parameters, the right and left values were highly correlated. MACS volume and surface area for male and female subjects showed an increase between 1 and 18 years. The surface area/volume ratio for males was independent of age but showed a shallow increase for females. When averaged across all ages, the ratio was similar to those previously reported.

CONCLUSIONS

The growth trajectory for MACS volume observed in this study was not consistent with other cross-sectional studies employing planimetry or CT of normal subjects that reported inconsistent results. Because of its potential role as a susceptibility factor for otitis media and other otologic problems, it is important to describe the growth and development of MACS geometry. Additional well-controlled studies of this phenomenon are needed to clarify which of the growth trajectories actually describe the growth process for the three parameters of interest.

Mastoid geometry in a cross-section of humans from infancy through early adulthood with a confirmed history of otitis media

OBJECTIVE

This study describes the changes in mastoid air cell system (MACS) geometry with age in ears with a history of otitis media (OM), without (GR-I) or with (GR-II) middle ear fluid on the CT scan.

METHODS

Thirty-seven (74 MACSs) CT scans were selected to approximate 4 MACSs/year between 1 and 18 years. For each MACS, the volume, surface area and surface area/volume ratio were reconstructed using standard procedures. Correlation analysis was used to define the left-right relatedness for the geometric parameters, and regression analysis was used to determine the effect of age on those parameters for each group.

RESULTS

Twenty scans were from female and 17 from males. Fluid was observed in 12 left, 4 right and 10 bilateral MACSs. The MACS volume and surface area of GR-I increased with age, were significantly greater than those for age-matched MACSs in GR-II, but show large variability. Those measures in GR-II were independent of age and a large percentage of these MACS volumes was <5 ml. The surface-area/volume ratio for MACSs in both groups was independent of age and group assignment. The left-right correlations for the three geometric parameters of the MACS were significant for all MACS in the two groups, and for bilateral MACS concordant for group assignment. The left-right correlations for surface area and volume were not significant for bilateral MACSs discordant for group assignment.

CONCLUSIONS

These results suggest that: the growth of MACS volume and surface area is genetically programmed but that this is disrupted by long-lasting OM; the effect of OM on MACS growth may depend on the duration and timing of the disease, and the MACS surface area/volume ratio does not explain the effect of MACS volume on the rate of gas exchange between middle ear and blood.

Role of the mastoid in middle ear pressure regulation

OBJECTIVES/HYPOTHESIS

Determine the role of mastoid volume in middle ear pressure (MEP) regulation. The hypothesis was that inert gas exchange between blood and middle ear (ME) is slower for larger mastoid volumes.

STUDY DESIGN

Prospective.

METHODS

For 21 enrolled subjects, the bilateral surface areas and volumes of the mastoid and tympanum were measured from computed tomography scans in 20 subjects with a wide range of mastoid volumes. Then, 19 subjects were reclined in a chair, fitted with a non-rebreathing mask and breathed room air for 20 minutes (acclimation), a gas composition of 25% N(2)O, 20% O(2), balance N(2) for 30 minutes (experiment), and room air for 30 minutes (recovery). Bilateral MEPs were recorded by tympanometry every 2 minutes. The slopes of the MEP-time functions during N(2)O breathing were calculated to the first observation of eustachian tube opening and divided by the estimated blood-ME N(2)O gradient to yield a N(2)O time constant. Sufficient data were available for 16 right and 11 left MEs to calculate the time constant.

RESULTS

MEP did not change during the baseline period, but within 10 minutes of breathing the N(2)O mixture showed a progressive increase. The right-left correlation for the time constant was 0.87 (n = 10 ears, P = .001). Regression of the time constants on ME volume showed an inverse relationship (n = 23 ears, r = -41, P = .05). A better data fit was the curvilinear relationship predicted by a mathematical model of the mastoid acting as a ME ear gas reserve.

CONCLUSIONS

These results support the tested hypothesis that the mastoid could serve as ME gas reserve.

Relationship between surface area and volume of the mastoid air cell system in adult humans

INTRODUCTION

The geometry of the adult human mastoid air cell system has not previously been described over a large range of mastoid air cell volumes.

METHODS

Twenty subjects with a wide range of mastoid air cell pneumatised areas, as determined by X-ray, underwent computed tomography scanning of the middle ear. Mastoid air cell surface areas and volumes were then reconstructed from serial imaging sections, using Image J software.

RESULTS

Mastoid air cell volumes varied from 0.7 to 21.4 ml, and were linearly related to the pneumatised area. Right and left mastoid air cell volumes and surface areas were highly correlated. The mastoid air cell surface area was a linear function of volume.

CONCLUSION

The relationship between mastoid air cell surface area and volume is similar over a wide range of volumes. Given that the rate of gas exchange across the mastoid air cell mucosa is related to the mastoid air cell surface area, that rate will thus also be a direct linear function of the mastoid air cell volume.

Surface area-volume relationships for the mastoid air cell system and tympanum in adult humans: Implications for mastoid function

CONCLUSIONS

The middle ear (ME) surface area/volume ratio (SA/V) is greater than that of the tympanum. The rate of ME pressure decrease is proportional to the ME SA/V. The mastoid air-cell system (MACS) will not function as an ME gas reserve unless the blood perfusion/surface area is much greater for the tympanum than the MACS and decreases as MACS volume increases.

OBJECTIVE

To measure the MACS and tympanum surface areas and volumes and ascertain whether the MACS could function as an ME gas reserve.

METHODS

Twenty adult subjects with a wide range of MACS volumes underwent CT of their MEs. The left and right surface areas and volumes of the tympanum and MACS were reconstructed and entered into a simple perfusion-limited model of transmucosal gas exchange. In this model the MACS would be a gas reserve if ME SA/V was less than the tympanum SA/V or equivalently, if their ratio was less than a critical value of 1.

RESULTS

Both MACS and tympanum SA were linearly related to their volumes. MACS SA/V and the ME SA/V were significantly greater than those for the tympanum. Inputting the measured values into the model yielded a critical value of 1.4, which was significantly greater than 1.

The mastoid as a functional rate-limiter of middle ear pressure change

INTRODUCTION

The physiological function of the mastoid air cell system (MACS) with respect to middle ear (ME) pressure-regulation remains controversial because predictive mathematical models and experimental data to formulate and test hypotheses are lacking.

OBJECTIVE

A mathematical description of MACS volume effects on the rate of ME pressure change is presented; the agreement between published data and model prediction is examined for consistency with the hypothesis that the MACS acts as a functional rate-limiter of ME pressure change, and an explanation for the relationship between MACS volume and otitis media is discussed.

METHODS

The mathematical description shows that the value of a single, free parameter, termed the "MACS buffering efficiency" (M) determines if MACS volume affects the rate of ME pressure change caused by diffusive gas exchange. The MACS serves no rate-limiting function for M=0, acts as a gas sink for M>1 and acts as a gas reserve (rate-limiter) for M<1.

RESULTS

Fitting the model equation to published adult human data yielded an estimate for M of 0.2. This implies that larger MACS volumes are associated with lesser rates of change in ME pressure caused by diffusive gas exchange and lesser required frequencies of effective Eustachian tube openings to maintain near ambient ME pressures.

CONCLUSION

If well-controlled studies confirm M<1 for children and adults, larger MACS volumes will increase the time required to develop sufficient ME underpressures to cause otitis media by hydrops ex vacuo during transient or prolonged periods of Eustachian tube dysfunction.

Autoinflation for hearing loss associated with otitis media with effusion

BACKGROUND

Otitis media with effusion (OME) or 'glue ear' is an accumulation of fluid in the middle ear, in the absence of acute inflammation or infection. It is the commonest cause of acquired hearing loss in childhood and the usual reason for insertion of 'grommets'. Potential treatments include decongestants, mucolytics, steroids, antihistamines and antibiotics. Autoinflation devices have been proposed as a simple mechanical means of improving 'glue ear'.

OBJECTIVES

To determine the effects of autoinflation in adults and children with otitis media with effusion.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, CENTRAL (The Cochrane Library Issue 1, 2006), MEDLINE (1951 to 2006), EMBASE (1974 to 2006) and twelve other databases, using the Cochrane Ear, Nose and Throat Disorders Group search strategy.

SELECTION CRITERIA

We selected randomised controlled trials that compared any form of autoinflation to no autoinflation in individuals with 'glue ear'.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, assessed quality and extracted data from included studies.

MAIN RESULTS

Six studies met the inclusion criteria. Improvement occurred for the composite measure of tympanogram or audiometry at less than one month (Relative Risk of Improvement (RRI) 2.47, 95% confidence interval (CI) 0.93 to 6.58) and at more than one month (RRI 2.20, 95% CI 1.71 to 2.82). Subgroup analysis based on the type of intervention showed a significant effect using a Politzer device under one month (RRI 7.07, 95% CI 3.70 to 13.51) and over one month (RRI 2.25, 95% CI 1.67 to 3.04). Pooled estimates showed non-significant change in tympanometry (type C2 and B) at less than one month (RRI 1.65, 95% CI 0.49 to 5.56) and non-significant improvement in tympanometry at greater than one month (RRI 1.89, 95% CI 0.77 to 4.67). Non-significant improvements occurred for discrete pure tone audiometry (RRI 0.80, 95% CI 0.22 to 2.88) and non-discrete audiometry (WMD 6.95 dB, 95% CI 21.03 to 7.13). None of the studies demonstrated a significant difference in the incidence of side effects between interventions.

AUTHORS' CONCLUSIONS

All of the studies were small, of limited treatment duration and short follow up. However, because of the low cost and absence of adverse effects it is reasonable to consider autoinflation whilst awaiting natural resolution of otitis media with effusion. Further research should consider the duration of treatment and the long-term impact of autoinflation on developmental outcomes in children.

[Diagnostics of the cochlear amplifier by means of DPOAE growth functions]

Extrapolated DPOAE growth functions can be applied in ENT diagnostics for a specific assessment of cochlear dysfunction. In screening newborn hearing, they are able to detect transitory sound conductive hearing loss and thus help to reduce the rate of false positive TEOAE responses in the early postnatal period. Since DPOAE growth functions are correlated with loudness functions, DPOAEs offer the potential for basic hearing aid adjustment, especially in children. Extrapolated DPOAE I/O-functions provide a tool for a fast, automated frequency-specific and quantitative evaluation of hearing loss. However, DPOAE diagnostics is limited to a hearing loss of 50 dB HL. Thus, a combined measurement of DPOAE and AMFR would be useful.

Squamous cell metaplasia of the nasopharyngeal epithelium and its association with adult-onset otitis media with effusion

CONCLUSION

The common association between adult-onset otitis media with effusion (AO-OME) and squamous cell metaplasia (SCM) of the epithelium of Rosenmüller's fossa, which is near the Eustachian tube orifice, implies the predictive role of metaplasia, which probably compromises the drainage function of the middle ear.

OBJECTIVE

To determine the effects of nasopharyngeal epithelial changes (SCM) on AO-OME. AO-OME is a multifactorial and insidious disease that may necessitate detailed investigation, i.e. biopsy of the nasopharynx, because of possible underlying nasopharyngeal malignancy.

MATERIAL AND METHODS

Fifty-two patients with AO-OME (study group) and 29 with a unilateral neck mass in the posterior triangle without AO-OME (control group) were enrolled. Nasopharyngeal biopsies taken from all subjects were evaluated with regard to surface epithelial changes of the nasopharynx.

RESULTS

Nasopharyngeal biopsies revealed SCM in 34/52 patients (65%) in the study group and 9/29 (31%) in the control group (p<0.05). During the follow-up period, recurrence of effusion occurred in 56% of the group with SCM and 22% of the group without it.