Management of the draining ear in children

Draining ears and tympanostomy tubes: a survey of pediatric otolaryngologists and pediatric emergency medicine physicians

INTRODUCTION

Posttympanostomy tube otorrhea also known as acute otitis media with tympanostomy tubes (AOMT) occurs in 15% to 80% of children with tympanostomy tubes. Its management is fairly standardized among pediatric ear, nose, and throat (ENT) physicians owing to recommendations published by the American Academy of Otolaryngology-Head and Neck Surgery. Pediatric emergency medicine (EM) physicians have no such guidelines.

OBJECTIVE

This study aimed to compare management of AOMT by pediatric ENT and EM physicians.

METHODS

A 27-question online survey was disseminated via SurveyMonkey.com using e-mail addresses of ENT and EM physicians via organization directories and professional listserves.

RESULTS

A total of 175 and 174 responses were received from EM and ENT physicians, respectively. Higher proportion of EM physicians used oral antibiotics to treat AOMT (54% [n = 94] vs 9% [n = 16], P < 0.001). Virtually all ENT physicians used topical antibiotics, compared with 87% of EM physicians. Only 6% (n = 10) of EM physicians used suction to clean ear canals (aural toilet) before instilling topical antibiotics, compared with 81% (n = 138) of ENT physicians. Most ENT physicians (80% [n = 138]) instructed patients to keep the treated ear up for 10 to 60 seconds after instilling the drops and to use the tragal pump technique to direct the medication down the ear canal and through the tube (92% [n = 157]). Only 56% (n = 98) and 24% (n = 41) of EM physicians did the same.

CONCLUSIONS

There are large differences between ENT and EM physicians with respect to: the use of systemic antibiotics, techniques of using ototopical antibiotics, methods of aural toilet in treating AOMT, and directions given to patients.

Management of granular myringitis: A systematic review

Introduction:

Granular myringitis is a chronic disorder characterised by lateral squamous de-epithelialisation and granulation of the tympanic membrane. Untreated, granular myringitis can lead to post-inflammatory medial external auditory canal fibrosis, acquired canal atresia and inflammatory infiltration of the deep canal.

Aim:

This study aimed to establish optimal management strategies which could be applied to clinical practice, through systematic review of the current literature.

Methods:

Current literature was obtained by searching evidence-based medical databases, the Cochrane database, the Database of Abstracts of Reviews of Effects, the Cochrane controlled trials register, Ovid Medline, the variousBritish Medical Journalimprint journals, individual journal websites and citation indexes, and by hand-searching current journals. Detailed inclusion criteria were set. Data were retrieved from the selected studies and checked for accuracy and consistency. The primary outcome measured was the effect of the proposed intervention on recurrence of granular myringitis, compared with empirical antibiotic therapy.

Results:

Fifty-eight publications were identified, dating from 1964 to 2005; 46 of these were potentially relevant. After assessment using the preset inclusion criteria, only two studies remained. El-Seifi and Fouad (2000) found that surgical excision of granulation tissue resulted in an 80 per cent reduction in recurrence of granular myringitis when compared with conventional antibiotic therapy. However, Junget al.(2002) demonstrated a 96 per cent reduction in granular myringitis recurrence when managed with dilute vinegar solution.

Conclusions:

There was a reduced recurrence of granular myringitis in both studies' intervention groups, although neither study was randomised or blinded, making it difficult to assess the clinical relevance of the results. However, the following conclusions can be inferred. (1) Conventional topical antibiotic and steroid drops appear to be less efficacious and more likely to lead to recurrence of symptoms, compared with other proposed treatment modalities. (2) Treatment with dilute vinegar solution presents a logical, unharmful alternative to conventional antibiotic drops. Further research of high value is needed.

Grommets in otitis media with effusion: the most frequent operation in children. But is it associated with significant complications?

INTRODUCTION

Otitis media with effusion is one of the most frequent diseases in children, and its management requires the attention of general practitioners, pediatricians and ear, nose and throat (ENT) surgeons. The main complications associated with tympanostomy tube insertion, are: (1) purulent otorrhea (10-26% of cases), in which local otic preparations might be effective, and biofilm-resistant tubes may decrease this complication in the future; (2) myringosclerosis (39-65% of operated ears), with usually no serious sequelae; (3) segmental atrophy (16-75% of cases); (4) atrophic scars and pars flaccida retraction pockets (28 and 21% of operated ears, respectively); (5) tympanic membrane perforations (3% of cases, although with T-tubes, the incidence may be as high as 24%); (6) cholesteatoma (1% of cases), although tympanostomy tubes may sometimes prevent, rather than contribute to its development; (7) granulation tissue (5-40% of instances), when the duration of tube retention is prolonged.

CONCLUSION

It would appear that the complications associated with tympanostomy tube insertion are more frequent than anticipated, reaching 80% of operated ears under specific circumstances and in certain subgroups of children. These complications may resolve with conservative management, but in persistent cases surgical removal of the tubes is mandatory.

Acute unilateral hearing loss as an unusual presentation of cholesteatoma

Background

Cholesteatomas are epithelial cysts that contain desquamated keratin. Patients commonly present with progressive hearing loss and a chronically discharging ear. We report an unusual presentation of the disease with an acute hearing loss suffered immediately after prolonged use of a pneumatic drill.

Case presentation

A 41 year old man with no previous history of ear problems presented with a sudden loss of hearing in his right ear immediately following the prolonged use of a pneumatic drill on concrete.

The cause was found to be a fractured long process of incus which had been eroded by the presence of an attic cholesteatoma.

A tympanomastoidectomy and ossiculoplasty was performed with good result.

Conclusion

Cholesteatomas may be asymptomatic and insidious in their onset. This case illustrates the point that an indolent disease such as this may present in unusual ways and the clinician must always have a high index of suspicion combined with thorough assessment and examination of every patient.