Otitis Media, Myringotomy, Tympanostomy Tube, and Balloon Dilation

Otitis Media

Acute otitis media (AOM) and chronic otitis media with effusion are conditions well known to all otolaryngologists. Infants are predisposed to otitis media because of their immune-compromised state and altered angulation of the eustachian tube (ET). Later in life, adenoid enlargement with ET obstruction may also play a role. Children with craniofacial and cleft palate disorders are also more likely to develop otitis media because of altered anatomy and physiologic function of the ET.

• AOM refers to rapid onset of middle ear inflammation.

• Recurrent AOM is defined as three episodes of AOM in 6 months or 4 episodes in 12 months with at least 1 episode occurring in the past 6 months.

• Persistent AOM is defined as an infection that fails to resolve with proper antibiotic therapy or when two episodes of otitis media occur in 1 month.

• Chronic otitis media (OM) with effusion refers to an effusion that persists longer than 3 months.

• With severe chronic OM, tympanic membrane retraction and middle ear atelectasis occur.

• Eosinophilic OM implies viscous eosinophilic middle ear fluid (allergic mucin).

Eustachian Tube Dysfunction

Dysfunction of the ET can result from anatomic, physiologic, or inflammatory causes. The middle 8 to 12 mm of the cartilaginous ET serves as a valve that is collapsed at rest and opens with contraction of the tensor veli palatini muscle. Mucosal inflammation from rhinosinusitis, upper respiratory infection, laryngopharyngeal reflux, and exposure to “second-hand” smoke can prevent opening of the valve and results in poor ventilation of the middle ear.

History

• 1.

  History of present illness

  • a.

    Presence of fever, otalgia, otorrhea, headaches, nausea and vomiting, anorexia, sleepless nights, ear tugging, subjective hearing loss, and balance disturbance

  • b.

    Presence of ear popping, fullness, discomfort with barometric challenge, or autophony

  • c.

    Duration of middle ear effusion if previously diagnosed

  • d.

    Number of episodes of AOM

• 2.

  Past medical history

  • a.

    Prior treatment: Previous history of antibiotic, allergy desensitization, nasal steroid, nasal antihistamine, oral antihistamine, oral steroid, or use of a topical or oral decongestant

  • b.

    Medical illness: Concurrent rhinitis, rhinosinusitis, adenoid hypertrophy, laryngopharyngeal reflux, craniofacial disorders, syndromes, ciliary dysfunction, granulomatous disease, tympanic membrane rupture or perforation, cholesteatoma and tympanic membrane retraction, and atelectasis

  • c.

    Surgery: History of previous myringotomy, tympanostomy tube placement, middle ear and mastoid surgery, or ET surgery

  • d.

    Family history: History of parents or siblings with tympanostomy tubes

  • e.

    Social history: Exposure to tobacco smoke directly or through second-hand exposure

  • f.

    Medications:

    • 1)

      Antibiotics

    • 2)

      Nasal or oral steroids

    • 3)

      Nasal or oral antihistamines

    • 4)

      Topical or oral decongestants

    • 5)

      Antireflux medication

Physical Examination

Examination may reveal a normal tympanic membrane, retraction pocket with or without cholesteatoma, severe atelectasis, or adhesive otitis media. Nasopharyngoscopy may reveal peritubal inflammation or adenoid hypertrophy ( Fig. 129.1 ).

An ideal test to measure ET function has yet to be designed. The appearance of a retracted tympanic membrane (TM) on microscopy, presence of negative middle ear pressure on tympanometry, and absence of normal ET opening during nasopharyngoscopy with the patient swallowing may suggest ET dysfunction.

• 1.

  Pneumatic otoscopy and otomicroscopy: This is the gold standard test for otitis media. Patients are evaluated for an opaque, bulging, or perforated TM, active otorrhea, TM atelectasis and retraction with or without cholesteatoma, and TM mobility.

• 2.

  Flexible endoscopy: To assess for ET mucosal hypertrophy and inflammation, adenoidal hypertrophy, sinonasal disease, laryngopharyngeal reflux, or other forms of inflammatory or granulomatous disease

• 3.

  Rigid endoscopy: A 30- or 45-degree rigid endoscope can be used. Evidence of hypertrophic inflamed mucosa and hyperemia along the anterior and posterior cushions, excessive mucus, or adenoidal hypertrophy impacting on the posterior cushion of the ET can be seen in patients with ET dilatory dysfunction (see Fig. 129.1 ). Videoendoscopy is helpful to differentiate obstructive disease from dynamic dysfunction. Having the patient repeat the letter “K” and swallow or yawn causes contraction of the levator veli palatini. Palatal elevation leads to medial rotation of the posterior cushion as contraction of the tensor veli palatini acts on the lateral cartilaginous lamina to open the ET. During the active phase, the resting S -shaped lumen opens to a more rounded patent one.

Testing

Imaging

Indications

Balloon Eustachian Tuboplasty

• Chronic and persistent otitis media with effusion (OME)

• Nonadherent TM atelectasis

• Symptomatic ET dilatory dysfunction including conductive hearing loss, otalgia, and aural fullness with pressure change

• Symptomatic patients with type B or C tympanograms

• Flight and scuba diving baro-challenge

• Past demonstration of symptom improvement with tube placement

In patients with adherent atelectasis, progression of disease can lead to ossicular chain erosion with type II or III tympanoplasty ( Fig. 129.2 ) and in severe cases, cholesteatoma. Tube placement may not be possible and BET may not restore middle ear aeration. Tympanoplasty with tube placement (with consideration for BET) may help restore middle ear ventilation, arrest progression, and improve ET function. Observation alone is also an option in some patients.

Contraindications