Chronic secretory otitis media

Chronic secretory otitis media

International Journal of Pediatric Otorhinolaryngology, @ Elsevier/North-Holland Biomedical Press CHRONIC I.W.S. MAIR, SECRETORY O.K. HAUGETO, 16...

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International Journal of Pediatric Otorhinolaryngology, @ Elsevier/North-Holland Biomedical Press

CHRONIC

I.W.S. MAIR,

SECRETORY

O.K. HAUGETO,

161-170

161

OTITIS MEDIA

H.H. ELVERLAND

Department of Otorhinolaryngology, Tromsd, 9000 Tromsm (Norway) (Received (Accepted

2 (1980)

and K.E. SCHRBDER

Institute of Clinical Medicine,

University of

January 7th, 1980) March 24th, 1980)

SUMMARY

Of 242 children and teenagers treated surgically for chronic secretory otitis media in 1972, 212 presented for evaluation 5 years later. Although the pure-tone audiometric threshold was 20 dB HL or better in 87.7% of the ears, only 40.6% were judged to be otoscopically normal. The findings at the first myringotomy for insertion of tympanostomy tubes were of no prognostic value for the course of the disease, and the presence of characteristics of middle ear fluid at subsequent myringotomies varied unpredictably. Adenoidectomy performed at an early stage, and in the presence of nasal obstruction, resulted in a significant reduction in the need for re-insertion of tympanostomy tubes.

INTRODUCTION

Secretory otitis media (SOM) is characterized by the presence of non-suppurative effusion in the middle ear cleft, and is the most common cause of hearing loss in children [35,38]. The condition in adults is not infrequently unilateral and causally related to acute respiratory infection, barotrauma or progressive nasopharyngeal disease. SOM in children usually affects both ears [16,40], and has been seen with increasing frequency in the past 2-3 decades, although this can probably be ascribed to more efficient diagnosis [2,27]. Although there is now a vast literature on SOM in pediatric practice, there is still little agreement as to the best form of management. Widely differing views are held regarding the value of different types of medical and surgical treatment regimes, evaluation being rendered difficult by the tendency to lower incidence with increasing age [ 27,291. Treatment of SOM in children has two primary objectives: to maintain socially adequate hearing at an age when sensory input is important for learning and intellectual

162

growth, and to prevent the development of permanent damage to the middle ear transmission system. There is at present an urgent need for the establishment of clear guide lines for the management of SOM in childhood. This applies not only to the choice of treatment modality, but also to the more fundamental question of selection of those cases which require treatment. The otoscopic demonstration of SOM is not necessarily an indication for active intervention since middle ear effusion may be only an innocuous and transitory phenomenon. Hearing thresholds show a wide variation in SOM [4], and pure-tone audiometry is notoriously inefficient as a screening method for the detection of this condition [ 1,5,20] ; many children with SOM will, therefore, have normal hearing according to the criteria employed in most screening studies. Although the development of cholesteatoma and permanent middle ear damage has been observed in most series of SOM reported in the literature, the incidence has been comparatively low, and the majority of patients has had a satisfactory functional result [ 3,9,16,27,40]. The objectives of the present investigation were to evaluate the results of treatment of SOM in a pediatric population, with particular reference to clinical aspects which might indicate a poor prognosis and/or the necessity for long-term follow-up. A short interim report has appeared elsewhere [ 111. MATERIAL

AND METHODS

A study of SOM was instituted in 1972. The diagnosis was first established at out-patient consultation, and the majority of patients treated with nosedrops and oral decongestants. Persistence of SOM at control examination 6-8 weeks later resulted in admission to hospital for evaluation and surgical treatment. In addition to a complete clinical examination, X-ray studies of the paranasal sinuses and nasopharynx, and pure-tone audiometry were performed in those age groups in which these were feasible. A total of 242 patients were evaluated, the oldest being 19, with a median of 7 years. There were 142 boys and 100 girls. Seventy-six of the series had received their first treatment for SOM prior to 1972, the earliest case dating from 1963. All ears were examined with the otomicroscope under general anesthesia, and myringotomy performed. A randomized treatment trial was made in the early months of 1972, the otological procedure being restricted to myringotomy and aspiration of middle ear fluid in one group, while transmyringeal insertion of ventilation tubes was also performed in the second. This investigation was terminated when the 3-month recurrence rates were found to be respectively 34.8% and 7.6%, and tympanostomy tubes were inserted routinely thereafter, both in atelectatic ears and in ears with effusion. Adenoidectomy has been performed at the time of the first otological treatment on the basis of nasal symptoms alone, supplemented by the radiological demonstration of nasopharyngeal obstruction. Subsequent

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recurrence of middle ear effusion has, however, been regarded as a relative indication for adenoidectomy, and this procedure has been repeated in a few cases with frequent recurrence and prolonged course. Diagnostic sinus washouts have been performed in cases with X-ray evidence of antral involvement, and antibiotic treatment instituted on the basis of sensitivity tests. Patients with persistent middle ear pathology have been followed at regular intervals, and treatment repeated when necessary. All patients were contacted after the lapse of 5 years, and 212 or 87.6% presented for control examination. The ear, nose and throat status was evaluated, and pure-tone audiometry and typanometry were performed. A small desk computer was used for data registration and analysis. RESULTS

A total of 1150 myringotomies were performed, 810 of which have been supplemented by insertion of tympanostomy tubes. The number of surgical treatments per ear varied from 1 to 12, with 98 patients requiring no more than one procedure. Glue ear was found in approximately 60% of cases, and serous fluid in 30%, this distribution remaining more or less constant irrespective of the number of previous myringotomies (Fig. 1). In those ears

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3 Number

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d+

myringotomies

Fig. 1. Percentage distribution later myringotomies.

of mucous and serous fluid and dry taps at the first and

164

Number

of

Fig. 2. Changes in myringotomy was performed most frequently.

myringotomies

findings in the 4 ears of the series in which myringotomy

which had most persistent middle ear pathology the myringotomy findings showed no consistent pattern, and varied apparently haphazardly (Fig. 2). Insertion of aeration tubes was complicated by purulent secretion in 10% of cases. Adenoidectomy was performed in 168 patients, in 107 of whom the procedure was carried out at the time of the first myringotomy. The necessity for subsequent myringotomies and insertion of tympanostomy tubes is significantly lower in the latter group of patients (Table I). The clinical and audiometric findings in 1972 and 1977 are compared in Tables II and III, respectively. The percentage of otoscopically normal ears increased from 6.4 to 40.6 in the course of the 5-year period, whilst 11.1% of ears had persistent secretory otitis, and chronic suppurative otitis media TABLE I Need for repeated tubuiation in patients in whom adenoidectomy was performed at the time of the first treatment compared with those without nasopharyngeal surgery (significance assessed by Fisher-Irwin method) Number of patients Number of tubulations 1

Total

2+

Adenoidectomy No adenoidectomy

60 38

47 97

107 135

Total

98

144

242

P = 0.000003

165 TABLE II Otoscopic

findings in 1972 and in 1977 (OMCS = chronic suppurative otitis media). % Ears

OtoscopY

Normal SOM Scarred/myringosclerosis Atelectasis OMCS

1972 (n = 484)

1977 (n = 424)

6.4 90.1 2.3 0.6 0.6

40.6 11.1 42.9 2.8 2.6

TABLE III Aii condution thresholds in 1972 and 1977; mean of 0.5. 1 and 2 kHz. Thresholds

% Ears

<21 dB 21-36 dB >35 dB

1972 (n = 356)

1977 (n = 424)

39.9 49.7 10.4

87.7 9.9 2.4

TABLE IV Percentage of pathological air-conduction thresholds (>20 dB) and tympanograms (>-lo0 mm HzO) correlated with the otoscopic findings in 1977. otoscopy

Pathological findings %

Normal SOM Scarring/myringofxlerosis Atelectasis OMCS

Air-conduction

Tympanogram

2.3 43.5 10.4 33.3 45.5

20.1 100 44.1 90.0 100

TABLE V Percentage distribution first myringotomy. First myringotomy

Mucous Serous Dry

of otoscopic

Otoscopy

findings in 1977 compared with the results of the

in 1977 (%)

Normal

Sequelae

SOM

OMCS

37.6 37.8 59.5

49.8 44.7 31

11 14.6 9.5

1.6 2.9 0

166 TABLE VI Air-conduction thresholds (mean of thresholds at 0.5, 1 and 2 kHz) in 1977 compared with results of first myringotomy. First myringotomy

Mucous Serous Dry

Mean air-conduction

thresholds (%)

<21 dB

21-35

87.3 88.3 90.5

10.7 8.8 9.5

dB

>35 dB 2 2.9 0

occurred in 2.6%. Although scarring of the drumhead and myringosclerosis were found in 42.9% of the ears in 1977, the pure-tone audiogram was 20 dB or better in 87.7%. The otoscopy findings in 1977 are compared with the results of both pure-tone audiometry and tympanometry in Table IV. Of ears with normal otoscopy, 2.3% had a sensory-neural, high-frequency hearing loss which had developed in the course of the observation period. In the groups with pathological otoscopy, at least half of the ears had air-conduction thresholds of 20 dB or better in the speech frequencies. On the other hand, all ears with secretory or chronic suppurative otitis media had pathological tympanograms. The latter also occurred in 20.1% of the otoscopically normal ears. The otoscopic appearance and air-conduction thresholds in 1977 are compared with the finding at the first myringotomy in Tables V and VI respectively, and show that the characteristics of the middle ear fluid (MEF) do not influence the long-term results. DISCUSSION

Longitudinal studies based on tympanometric and otoscopic evaluation of young children have recently shown a marked tendency to spontaneous improvement in SOM and tubal function [6,41]. Treatment of all cases of SOM irrespective of duration will therefore produce a favourable bias in the results. An observation period of at least several weeks [35] or months [41], is therefore recommended prior to the institution of surgical treatment. In the present series, patients were admitted to hospital with persistent SOM after a 6-8 week trial period of medical treatment. Since waiting lists for out-patient appointments vary from 1 to 3 months, the duration of SOM in the majority of cases has been from 3 to 5 months, and should therefore satisfy criteria for chronicity. Unfortunately, many reports in the literature fail to mention, or do not take cognizance of this factor [ 28,291, whilst others have restricted surgical treatment to chronic cases [9,16,18,39]. The results reported in the literature on the management of SOM have varied considerably, and in some cases [3,8,29] have been so unexception-

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ably good that one may legitimately question whether identical, or even comparable, pathological processes have been involved. Factors which may help to account for these differences are the above-mentioned selection of cases for treatment, differing criteria for evaluation, variations in the duration of post-treatment follow up and, possibly, differences in treatment regimes. There are, therefore, comparatively few series in the literature with which valid comparisons can be made. Air conduction thresholds of 15-25 dB or better have been reported in 76-95s of ears with chronic SOM treated by adenoidectomy and ventilation tubes after variable observation periods of 3-8 years [9,16,40]. Two-thirds of ears have been reported as cured on the basis of otoscopy [16,40], which corresponds well with the 28% incidence of irreversible tympanic membrane changes from an earlier investigation [39]. On the other hand, Gundersen and Tonning [9], in an investigation of 196 ears, have reported scarring of all drumheads. The incidence of chronic suppurative otitis media has varied from 2.7 to 5.6% [ 9,16,40]. Both the otoscopic and pure-tone audiometric results from the present investigation are in agreement with the above-cited figures. The occurrence of sensory-neural hearing loss in 2.3% of the otoscopically normal ears is not necessarily a complication of the SOM, although other investigators have reported similar findings [ 7,251, and Paparella et al. [ 301 have documented permanent, high-frequency threshold shifts following uncomplicated otitis media. A conspicuous absence of severe middle ear pathology, such as chronic suppurative otitis media and atelectasis, characterizes many reports in which treatment has been instituted irrespective of the chronicity of the MEF [3,21,29]. A low, 2.7%, incidence of persistent MEF and sequelae changes restricted to scarring and myringosclerosis have been reported after a 5 year follow-up of 100 ears with SOM, the treatment being adenoidectomy and randomized myringotomy or insertion of tympanostomy tubes [3]. Adenoidectomy and myringotomy alone have produced a 96.9% success rate [8], but reappearance of MEF later than one month post-treatment was regarded as a new disease and not a recurrence. Our finding of considerable and unpredictable variation in type of MEF in the most chronic cases of SOM, including intermittent dry taps at myringotomy, would tend to refute this view. The well-known morphological changes in the middle ear mucosa of SOM ears [22,35] would also indicate chronicity of middle ear involvement, while the dynamics of fluid formation and resorption could account for the fluctuating clinical and operative findings. Mawson and Fagan [27] have stated that it was uncertain whether the mucous and serous types of MEF could interchange, although MacKinnon [25] had earlier reported gradual transformation from thick mucous to thin serous fluid following repeated myringotomies over a number of years. The mucous type of MEF is commonly regarded as a more serious therapeutic problem [ 10,14,18], and therefore an indication for more liberal use of tympanostomy tubes [ 25,371. The present investigation has, however, demon-

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&rated that MEF does vary over time in individual ears, and that both the otoscopic appearance and the audiometric results 5-14 years later are independent of the findings at the first myringotomy. The characteristics of the MEF have, therefore, no prognostic value, nor can a decision as to which patients require long-term observation be based on these findings, although follow-up of “glue” ears alone has been recommended [ 261. The contentious question of whether adenoidectomy should be included in the management of SOM has received considerable attention in the literature. It has frequently been stated that adenoidectomy has no influence on the subsequent incidence of SOM, either in patients with [36] or without cleft palate [ 12,27,34,35]. Other reports have been less dogmatic, and have concluded that definite evidence for or against adenoidectomy has not yet been produced [ 17,311, whilst Kjellman et al. [ 151 reported that the operation did not prevent recurrence of SOM in children with a previous history of many episodes. Adenoidectomy has, however, been performed in a very high percentage of patients in most studies of SOM in the literature [16,18, 25,401, and has, therefore, been considered to have had no beneficial effect

PIA highly significant relationship has been found between SOM and enlargement of the adenoids [ 28 3, and improvement in the otological condition has been demonstrated when adenoidectomy has been performed on the basis of large size and symptoms of nasal obstruction 11,321. A 3% incidence of SOM recurrence has been reported following this operation, while a control group without nasopharyngeal surgery showed a 40% recurrence rate [ 191. Over 60 years ago it was maintained that adenoidectomy produced an improvement in the public intellect [42], a result which may have been due to lower hearing thresholds! The size of the adenoids removed at surgery shows a significant correlation with the appearances in the lateral X-ray projection of the nasopharynx [ 131. Radiological examination was performed in the majority of our patients, this investigation being omitted only in those cases where cooperation was impossible. Adenoidectomy performed at an early stage, in cases with large adenoids and concurrent symptoms of nasal obstruction and infection, resulted in a highly significant reduction in the need for subsequent otological procedures. However, no beneficial effect could be demonstrated when the same operation was performed late in the course of SOM, and in the absence of nasal symptoms and radiological confirmation. The latter situation should, therefore, no longer be regarded even as a relative indication for this operation. A possible confirmation of, and explanation for, these results may be found in the investigation of Ruokonen et al. [33], who reported that both H. infhenzae and several different viruses could be more frequently cultured from the adenoids of children with SOM than from those without middle ear involvement. These authors have, therefore, proposed that adenoidectomy could be of therapeutic value when performed early in the course of SOW a

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conclusion which is in agreement with our clinical results, recent evidence for an infectious aetiology of SOM [ 23,24,35].

and also with

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