Surgical Treatment

In most instances , both acute otitis media (AOM) and otitis media with effusion (OME), will resolve without antibiotic or invasive treatment. However some circumstances may require surgical treatment. Tympanocentesis, myringotomy and adenoidectomy are the common surgical treatments associated with OM.

Tympanocentesis is the trans-tympanic needle aspiration of ME contents. Aspiration of fluid reduces ME pressure and is very effective in relieving pain. If a culture and sensitivity is to be performed on the aspirate, the external ear canal should be thoroughly cleaned and isopropyl alcohol instilled into the external canal for one minute, then removed. Tympanocentesis can be performed on infants using restraints, local or mild sedation. Older children will be more comfortable if a local or general anesthesia is used.

Insertion of pressure equalizing tubes (PET) is used to treat both AOM and OME. Myringotomy is usually performed under general anesthesia. This is a clean procedure. A surgical prep is not required unless cultures are to be taken. Incision is made in healthy tissue. Fluid is suctioned and cultured if unusual pathogens are suspected. PETs are placed to prolong the time that drainage will occur.

The type of PET used depends on the intended duration. Both short-term and permanent designs are available. Prevention of recurrent disease usually requires the PET to be in place for 12 months or more. A permanent PET design may be used if a duration of 12-18 months is anticipated.

Post-op exam occurs about 2 weeks after insertion. If hearing is normal, re-examination may be scheduled every six months until the tube is spontaneously extruded or removed.

The effectiveness of adenoidectomy as a surgical treatment for OME and recurrent AOM has thus far proved to be modest. The intent is to remove a source of infection and obstruction from the nasopharyngeal opening of the eustachian tube. Tonsillectomy with or without adenoidectomy has not been shown to be effective in preventing AOM or reducing the number of days of OME.

The benefits of surgical intervention must be weighed against the risks. The risks also include those involved in anesthesia required to perform the procedures.

Click here to access video clips of myringotomy surgery and tube placement .

• Complications of otitis media that may require surgical intervention fall into a few broad categories:

•Impending rupture of the TM

Otitis media can result in excessive positive or negative pressure within the middle ear. Positive pressure can result from the accumulation of sterile fluid or pus within the middle ear. Positive pressure causes the TM to bulge into the external canal. If the pressure is not relieved by way of the eustachian tube, the TM will eventually rip. Jagged tears heal poorly and can cause a serious condition known as cholesteotoma. Cholesteotoma is an invasive accumulation of epithelial cells that form from the torn edges of the TM. Cholesteotoma can erode the ossicles and invade the cranium or inner ear and is a complication which must be guarded against.

Negative pressure within the middle ear develops as a normal result of absorption of gas by the middle ear membrane. The middle ear membrane is continuously absorbing gas; the normal middle ear pressure is therefore slightly negative. Ideally the negative pressure is equalized by air moving through the eustachian tube. If the eustachian tube is blocked, the negative pressure may be equalized by the seepage of serous fluid into the middle ear. Initially this can cause a bulging positive pressure. Eventually however, the water portion will be reabsorbed, leaving a thick viscous fluid which can cause the TM to retract. The retraction can cause rupture, cholesteotoma or permanent hearing loss from contracture and fusion of the delicate middle ear contents.

The Ear Surgery Information Center (Mark J. Levenson) has more details and graphics about cholesteatoma. Check out the site, and look for the answer to the following question.

•Infection which has not responded to medical treatment

According to a study published in 2000, about two-thirds of children with uncomplicated ear infections recover in a day. 80% of cases are resolved within a week without antibiotics. (Antibiotics cure up to 95% of infections during the first week.) A small number of cases last longer that a week and an even smaller number go on to develop consequences such as mastoiditis or osteitis of the temporal bone. Very rarely seizures, septicemia or meningitis occur by eroding through the cranium or the membranes of the oval and round windows.

•Infection in an immature or immunocompromised host

When infected, children less than 6 months old are more prone to the serious complications of otitis media. They are less likely to clear infection even with medical treatment for a number of reasons. AOM in infants less than 6 months old may increases the risk of recurrent otitis media (ROM)

•Prolonged serious hearing loss which may compromise speech and IQ development

•Pain or vertigo related to abnormal middle ear pressure

•Recurrent otitis media