MANAGEMENT OPTIONS IN OTOLOGY
| MANAGEMENT OF THE DRAINING EAR —Soham Roy, MD, Assistant Professor of Pediatric Otolaryngology, Miller
School of Medicine at the University of Miami
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| Drainage caused by: acute otitis media (AOM)—signs and symptoms of middle ear infection include fever, ear pain,
irritability, erythema of tympanic membrane (TM), purulent effusion, and TM bulging under pressure; systemic antibiotics
preferred when TM intact; recurrent AOM defined as 3 infections in 6 mo or 4 infections in 12 mo (tympanostomy
tube usually placed); systemic antibiotics preferred when TM intact; AOM with spontaneous TM rupture—symptoms
improve with onset of otorrhea (perforation of TM usually small); oral or topical antibiotics achieve ≈96% resolution
rate; otitis media with effusion (OME)—middle ear space contains fluid; lacks signs and symptoms of AOM; chronic
OME defined as bilateral effusion lasting 3 mo or unilateral effusion lasting 6 mo; serous effusion and air bubbles visible
in middle ear cleft; otorrhea—fluid from inflamed middle ear cleft drains through damaged TM; caused by AOM or
OME; generally viewed as AOM that drains through patent tympanostomy tube or ruptured TM; chronic suppurative
otitis media (CSOM)—persistent purulent drainage caused by middle ear infection draining through damaged TM; may
involve cholesteatoma
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| Tympanostomy tube otorrhea: most common complication of intubation, ie, ≈50% of children with patent tubes experience
≥1 episode; caused by AOM related to upper respiratory infection, nasopharyngeal reflux, adenoiditis, or contamination
of external ear canal; suction and culture drainage; originates from—nasopharyngeal reflux entering
middle ear; water exiting ear canal and producing middle ear inflammation; signs and symptoms — controlled rupture
from intubation drains fluid from middle ear and reduces pain level and canal edema; fluid occlusion can impair hearing;
goal— suction drainage to allow entry of topical medication; pathogens—same as in AOM (Streptococcus
pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) but different from that of CSOM (Pseudomonas
aeruginosa)
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 | Topical antibiotics: first-line therapy; ofloxacin (Floxin Otic) and ciprofloxacin plus dexamethasone (Ciprodex Otic) approved
by Food and Drug Administration (FDA) for use in open middle ear; aminoglycosides—not approved by
FDA; associated with risk for ototoxicity; include gentamicin, dexamethasone plus tobramycin (TobraDex), and hydrocortisone
plus neomycin sulfate and polymyxin B (Cortisporin); when administering ear drops at home—wash
hands; warm bottle in hands; place child on side; perform aural toilette; pull ear canal straight; insert drops; pump tragus
to ensure drops enter middle ear; aural toilette in office—helpful when home therapy fails; daily ear cleaning and
application of drops achieves high resolution rate among nonresponders
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| Observations: if no improvement occurs by ≤7 days, culture and retreat; surgery rarely indicated unless disease recurs or
tube-induced otorrhea present; at 1 wk—antibiotic drops achieve 90% to 96% cure rate; if treatment fails, repeat culture
(60% of patients have P aeruginosa and require fluoroquinolones); if problem—does not resolve in 2 to 3 wk, consider
intravenous (IV) antibiotics or extubation; continues >4 wk, consider tube removal and replacement, adenoidectomy,
looking for cholesteatoma, or immunodeficiency; granulation around tympanostomy tube—frequently presents as
bloody or recurrent otorrhea; often covers tube; responds to topical Ciprodex; systemic antibiotics rarely needed; if medical
therapy fails, tube and granuloma may be removed
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| OTITIS MEDIA: UPDATE OF ETIOLOGIES AND CLINICAL PRACTICE GUIDELINES —Ramzi Younis, MD, Associate
Professor and Chief of Pediatric Otolaryngology, Miller School of Medicine at the University of Miami
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| Otitis media with effusion: can resolve spontaneously; multifactorial in origin; main cause of pediatric hearing loss;
signs and symptoms—absent in 50% of patients; include aural fullness, ear rubbing, failure to respond to voice, and recurrent
otitis media (OM); eustachian tube dysfunction with poor drainage of middle ear space—main cause of
OME; may involve obstruction, poor opening, large adenoids, poor compliance, and/or inflammation; risk factors—
bottle feeding; smoking; allergy; recurrent infection; enlarged adenoids; culture—aids treatment selection; H influenzae
or S pneumoniae found in ≈30% of cultures
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| Diagnostic guidelines: pneumatic otoscopy—primary diagnostic tool; sensitive and specific means of evaluating TM
and middle ear effusion; hearing tests—indicated when OME lasts >3 mo or when problems with language development
or learning accompany hearing loss; screening of healthy schoolchildren of no value; speech and language
development—language testing essential in all children with hearing loss; risk factors for delayed speech and language development
include persistent OME with hearing loss, low maternal education level, unfavorable child-care environment,
and low socioeconomic level; comprehensive audiometric evaluation—recommended; visual or conditioned response-
oriented audiometry indicated for infants 6 to 24 mo of age; play audiometry indicated for children 24 to 48 mo of age; auditory
brainstem response (ABR) testing and measurement of otoacoustic emissions (OAE)—not recommended; assess
auditory pathways, not hearing
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| Treatment guidelines: ineffective options—antibiotics; systemic steroids; antihistamines; decongestants
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| Watchful waiting: recommended for patients not at risk for speech, language, or learning impairment; not recommended for
patients at risk for complications; risk factors mandating evaluation and prompt treatment—recurrent or persistent
OM during summer; hearing loss; history of intubation; suspected diagnosis of speech problem; autism syndromes, blindness,
or cleft palate; points—be careful when selecting treatment; repeat assessment of hearing, speech, and language capabilities
may be necessary; children with hearing loss of—≥30 decibels (dB) require treatment; 20 dB to 39 dB require
individualized management approach; <20 dB can be monitored
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| Tympanostomy tubes: necessary when patient has complications of OM; indicated in—symptomatic OM lasting >4
mo; persistent OM and high risk; OM with structural changes of TM
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| Additional options: adenoidectomy—useful in children >4 yr of age; associated with high risk for complications and no
additional benefit in asymptomatic children <4 yr of age; second surgery reduces risk for additional surgery by ≈50%;
no role for—tonsillectomy; myringotomy; complementary or alternative medicine; allergy therapy
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| VESTIBULAR DISORDERS —Fred F. Telischi, MD, Director, University of Miami Ear Institute, Miami
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| Benign paroxysmal positional vertigo (BPPV): involves free floating particles in endolymph of semicircular canals;
characterized by vertiginous episode—lasting ≤1 min; occurring with head movement in association with rolling to
one side while in bed; not associated with nausea or vomiting; can resolve spontaneously and recur; Dix-Hallpike
maneuver—key; positive for nystagmus with affected ear down; particle repositioning maneuver—performed once
nystagmus detected; eliminates vertigo by repositioning particles in endolymph; requires patient to avoid vigorous activity
and not lie flat for 48 hr to allow particles to settle; surgery to occlude posterior canal—can treat intractable cases
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| Vestibular neuritis: probably viral; involves vestibular portion of eighth cranial nerve; acute and severe for ≤24 hr; tends to
recur over months to years; associated with—nausea and vomiting; minimal to no hearing loss; imaging—usually normal;
brightness occasionally detected on eighth cranial nerve; treatment—symptomatic during acute phase; options include steroids
and/or antivirals and vestibular suppressants; decreased vestibular response can be treated initially with vestibular rehabilitation;
intratympanic gentamicin—creates stable relative vestibular reduction (RVR) lesion in those individuals who
fail rehabilitation, have RVR, and are suspected of having unstable lesion
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| Labyrinthitis: more severe than vestibular neuritis; episodes last from 1 to several days; patients with severe episode—
hospitalized; require continuous administration of vestibular suppressants as well as steroids and antiviral agents; antibiotics
indicated if otologic infection or meningitis suspected; patients often experience—complete loss of vestibular
function; severe hearing loss; points—patients require time to compensate after acute phase (vestibular rehabilitation
and exercise facilitate recovery); if patient fails to respond to rehabilitation, use surgery or intratympanic chemical labyrinthectomy
to create stable lesion, then follow with additional rehabilitation
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| Superior semicircular canal dehiscence: can occur in combination with—pressure or sound-induced vertigo, ie,
Tullio’s phenomenon; pressure-induced nystagmus, ie, Hennebert’s sign; conductive hearing loss—similar to hearing
loss of otosclerosis, but acoustic reflexes intact (no stiffening of ossicular chain); caused by “third window” phenomenon,
ie, one-third dehiscence of inner ear labyrinth; closing off dehiscence—can manage severely debilitated patients; may
improve conductive hearing loss in some cases; diagnosis—requires high index of suspicion and good radiologist; diagnostic
hallmark absence of arcuate eminence over superior semicircular canal on oblique coronal computed tomography
(CT)
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| Perilymph fistula: characteristics—episodic vertigo related to Valsalva-type maneuvers; fluctuating or progressive
sensorineural hearing loss (SNHL); history of trauma, eg, barotrauma, head trauma, often to ear canal and TM;
diagnosis—no reliable preoperative diagnostic tests; positive pneumatic otoscopy or fistula test helpful; middle ear
exploration—provides best diagnostic information; can be carried out in office, eg, when unsure of situation, form
small myringotomy and evaluate oval window niche and round window niche and membrane (look for tear or fluid collection)
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| Meniere’s disease: symptoms—vertigo; fluctuating SNHL; tinnitus; pressure; physical examination—generally normal;
head-shaking test detects nystagmus; abnormalities on static and dynamic vestibular testing; electrocochleography
may be positive with elevated summating-to-action potential ratio; rule out retrocochlear pathology; electronystagmography
(ENG) variable; treatment—low sodium diet; avoidance of sugar and alcohol; allergy management; diuretics; vasodilators;
steroids (oral and intratympanic); endolymphatic sac surgery; ablative treatment (intratympanic gentamicin;
surgical labyrinthectomy gold standard)
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| MEDICALLY TREATABLE ACUTE HEARING LOSS —Thomas Balkany, MD, Hotchkiss Professor and Chairman,
Department of Otolaryngology; Professor, Departments of Neurological Surgery and Pediatrics, Miller School of Medicine
at the University of Miami
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| Noise-induced hearing loss (NIHL): L-N-acetylcysteine (L-NAC)—aural precursor of methionine; available without
prescription; effective; better prophylactic than therapeutic agent, but used therapeutically in early stages of NIHL; transtympanic
methionine—strong antioxidant in cochlea; under investigation for treating late-stage NIHL
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| Platinum ototoxicity, eg, cisplatin: therapeutic doses of aspirin (acetylsalicylic acid) block platinum-induced ototoxicity;
if aspirin ineffective and substantial decline in hearing occurs—fractionate platinum dose and increase hydration;
0.5 mL of transtympanic dexamethasone (Decadron) administered binaurally to middle ear produced rescue and
prophylactic benefit; point—salicylates and Decadron do not block antineoplastic effects of cisplatin
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| Aminoglycoside-induced deafness: better control has reduced incidence; iron-chelating drugs prevent ototoxic and
nephrotoxic effects without blocking antibiotic efficacy
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| Sudden sensorineural hearing loss (SSNHL): bed rest helpful; oral prednisone—definitive; methylprednisolone
(Medrol Dosepak) inadequate; administer 1 mg/kg per day for 2 wk, then taper dose; if patient cannot tolerate dose, taper after
1 wk; acyclovir or ganciclovir—indicated when patient presents ≤24 hr after onset; used in combination with oral steroids;
transtympanic Decadron—candidates include brittle diabetics, patients with history of steroid complications or
failed oral therapy, prepubescent children, and patients willing to try every option to restore hearing; administers more steroid
to cochlea than oral prednisone; can be combined with oral steroid
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| Autoimmune inner ear disease: nonfluctuating, bilateral, progressive SNHL key clinical characteristic; oral
prednisone—effective; cyclosporin used to “hold” steroid effect (methotrexate ineffective); transtympanic Decadron administered
when—patients cannot take oral steroids; prednisone effect lost and additional prednisone does not restore
steroid effect and reverse hearing loss
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| Imaging: mandatory, eg, acute unilateral SNHL can be caused by acoustic neuroma in ≤10% of patients; CT imaging detects
mild dysplasia that may present later in life
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| PROPHYLACTIC ANTIBIOTICS IN REDUCING POSTOPERATIVE INFECTION RATES IN MASTOID AND MIDDLE
EAR SURGERY —Natasha Pollak, MD, University of Missouri Health Care, Columbia
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| Postoperative infections: data suggest antibiotic prophylaxis does not reduce postoperative infection rates; independent
risk factors for surgical wound infection identified by Centers for Disease Control and Prevention (CDC)—
high preoperative wound contamination level; long duration of surgery; high American Society of Anesthesiologists
(ASA) score; points—combining CDC risk factors into single index enhances predictive ability; Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) requirements for reporting postoperative infection rates of individual
surgeons will potentially increase use of perioperative antibiotics
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| Retrospective chart review of patients who underwent tympanoplasty with or without mastoidectomy:
even though prophylactic antibiotics not administered, overall postoperative infection rate remained low (1.8%); combining
CDC risk factors into single index showed—high level of preoperative wound contamination (ie, draining ears) and high
ASA ratings predictive of increased risk for postoperative wound infection; increased duration of surgery not associated
with increased risk; conclusion—neither medicolegal concerns nor JCAHO requirements to publish surgeon-specific infection
rates acceptable reasons for administering expensive and potentially harmful antibiotics on prophylactic basis
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Educational Objectives
| The goal of this program is to educate the listener about current techniques for managing common otologic diseases. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Diagnose and treat disorders causing middle ear otorrhea
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| 2. Implement current guidelines for managing otitis media with effusion
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| 3. Assess current options for treating vestibular disorders
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| 4. Review nonsurgical options for managing common forms of acute hearing loss
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| 5. Determine the efficacy of prophylactic antibiotic therapy in preventing infection after mastoid and middle ear surgery.
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Discussed on This Program
Acyclovir (acycloguanosine) [Zovirax]
Cefazolin sodium [Ancef, Zolicef]
Ciprofloxacin and dexamethasone [Ciprodex Otic]
Cisplatin (CDDP) [Platinol-AQ]
Cyclosporine (cyclosporin A) [Gengraf, Neoral, Sandimmune]
Dexamethasone [Decadron, others]
Dexamethasone and tobramycin [TobraDex]
Ganciclovir sodium (DHPG) [Cytovene]
Gentamicin sulfate (several trade names and preparation)
Heparin sodium injection
Hydrochlorothiazide (several trade names and preparations)
Hydrochlorothiazide and triamterene [Dyazide, Maxzide, Maxzide-25MG]
Hydrocortisone, neomycin sulfate, and polymyxin B [Cortisporin Otic, others]
Hydrocortisone, neomycin sulfate, and polymyxin B (several trade names)
Methionine [M-Caps, Pedameth, Uracid]
Methylprednisolone [Medrol]
Ofloxacin [Floxin Otic, others]
Prednisone (several trade names and preparations)
Aspirin (acetylsalicylic acid; ASA) [several trade names and preparations]
Suggested Reading
Brandt T: Management of vestibular disorders. J Neurol 247:491, 2000; Brantberg K et al: Gentamycin treatment in
peripheral vestibular disorders other than Meniere’s disease. ORL J Otorhinolaryngol Relat Spec 58:277, 1996; Brantberg
K et al: Symptoms, findings, and treatment in patients with dehiscence of the superior semicircular canal. Acta Otolaryngol
121:68, 2001; Daniel SJ et al: guidelines for the treatment of tympanostomy tube otorrhea. J Otolaryngol
34:S60, 2005; Harris JP et al: Treatment of corticosteroid-responsive autoimmune inner ear disease with methotrexate: a
randomized clinical control. JAMA 290:1875, 2003; Kopke R et al: Prevention of impulse noise-induced hearing loss
with antioxidants. Acta Otolaryngol 125:235, 2005; Rosenfeld RM et al: Clinical practice guidelines: otitis media with
effusion. Otolaryngol Head Heck Surg 130:S95, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Balkany is affiliated with MED-EL: Medical Electronics and Cochlear Corporation.
Drs. Balkany, Roy, Telischi, and Younis gave their scientific presentations at the 32nd Annual Chandler Clinical Concepts
of Otolaryngology presented June 2 to 5, 2005, in Duck Key, Florida by the Miller School of Medicine of the University of
Miami; Dr. Pollak gave her presentation at the 138th Annual Meeting of the American Otological Society, Inc. presented
May 14 to 15, 2005, in Boca Raton, Florida as part of the annual Combined Otolaryngological Spring Meetings (COSM).
The Audio-Digest Foundation thanks the speakers and the sponsors for cooperation in the production of this program.
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