Copyright 9 by The Humana Press, Inc. All rights of any nature whatsaever reserved.

Otitis Media C. Warren Bierman* and Gait G. Shapiro Department of Pediatrics, Universityof WashingtonSchool of Medicine, 4540 Sand Point WayNE, Suite200, Seattle, WA 98105

INTRODUCTION Otitis media with effusion (OME), an i n f l a m m a t o r y disease of the mucoperiosteal lining of the eustachian tube, middle ear, a n d mastoid air cells affects large n u m b e r s of children. Approximately 10 million children are treated each year for this condition in the United States alone (1), and it is the most common reason for surgery in children in England and Wales (2) and in the United States. This disease is associated with an accumulation of fluid in the middle ear and is the most common cause of acquired h e a r i n g loss in children today. Although it occurs most often in preschoolaged children, it causes substantial morbidity and m a y be a frequent handicap of children in their early school years. It can occur at any age, however, and even older adults can have middle ear effusions that cause i n t e r m i t t e n t hearing loss and interfere with effective communication. To date, the incidence of such problems in the adult population has not been studied systematically. Some authors believe that this disorder m a y represent the most common precursor of chronic irreversible otitis media in older children and younger adults (3). Even when the disease is self limited, it can result in adverse effects on speech development a n d cognition, especially in the young child (4), although the degree to which this occurs is controversial. It can be especially devastating w h e n *Author to whom all correspondence and reprint requests should be addressed.

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superimposed on an underlying sensorineural hearing loss (5). The term, suppurative otitis media, is considered to be synonymous with acute otitis media (AOM); otitis media with effusion (OME) is generally referred to as nonsuppurative otitis media or "glue ear." Though controversial, "serous, .... mucoid," and "purulent" otitis are believed by some to reflect stages of variations of disease that may coexist (1). These disease states are thought to be secondary to eustachian tube dysfunction (ETD) or to other causes of middle ear dysfunction (MED). Terms otitis media with effusion (OME) and middle ear dysfunction (MED) proposed by several international symposia on otitis media will be employed throughout this chapter.

MIDDLEEARDYSFUNCTION Otitis media with effusion (OME) is the result of m a n y factors acting either on the middle ear, the eustachian tube, or both (6). Animal experiments have demonstrated that with obstruction of the eustachian tube, oxygen in the middle ear and mastoid air cells is absorbed by mucosal capillaries, producing negative middle ear pressure. The middle ear mucosa becomes thickened and edematous and a transudate forms from the subepithelial fluid leaking from blood vessels. This transudate ruptures the basement membrane, distorting nonciliated cells as it traverses these cells to enter the middle ear space (7). With prolonged eustachian tube obstruction, middle ear fluid develops that contains varying amounts of mucus, cellular remnants, and neutrophils. The mucosa becomes hyperplastic with a change to a stratified respiratory epithelium, goblet cells proliferate, the mucosa invaginates to form submucosai cysts, and glands and subepithelial vessels proliferate (8). Inflammatory cells then infiltrate in large numbers. As a result, immunocompetent ceils, especially macrophages, and lymphocytes, enter the middle ear and create a distinct system of local i m m u n i t y (9,10). Negative middle ear pressure impedes sound transmission in the middle ear; middle ear effusion can cause a 20-50 dB hearing loss that affects lower frequencies to a greater extent than higher ones. If normal eustachian tubal function does not return and the above cycle continues, damage from the inflammatory process eventually

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can result in a p e r m a n e n t change in middle ear a n d mastoid mucosa with associated bone resorption.

ETIOLOGYOFMIDDLEEAR DYSFUNCTION Middle ear dysfunction m a y result from abnormal e u s t a c h i a n tube function, infection, allergy, diseases of adenoids and/or sinuses, and such diseases as immotile cilia syndrome. Of these, ETD, acute otitis media and upper respiratory allergy are conditions most frequently associated with middle ear dysfunction a n d OME.

Eustachian Tube Dysfunction This can result from abnormal patency or obstruction of the eustachian tube. An abnormally p a t e n t tube permits reflux of nasop h a r y n g e a l secretions into the middle ear, which induces infectious or noninfectious inflammation. E u s t c a h i a n tube obstruction prevents ventilation of the middle ear and leads to creation of negative middle ear pressure and the process t h a t results in OME. It can result from intrinsic factors such as mucosal edema from inflammation owing to viral or bacterial infections, chronic exposure to i r r i t a n t s such as cigaret smoke, nasal allergy, or congenital or acquJred abnormalities in structure or function of involved tissues (e.g., cystic fibrosis, Down's syndrome, cleft palate, immotite celia syndrome, immunodeficiency). Viral or bacterial infections can be p r i m a r y or secondary to poor drainage of middle ear secretions with stasis a n d bacterial growth.

Infection The role of infection in the pathophysiology of OME is not clear at present. Acute otitis media, an extraordinarily common infection in children, h a s its highest incidence between 6-24 mo of age (Teele et al., 1980). Subsequently the incidence falls until age 5 to 6 y, w h e n a second peak coincides with school entrance, possibly owing to an increased incidence of viral respiratory t r a c t infections. Boys develop acute and recurrent otitis media more common!y t h a n do girls. AOM also occurs more frequently in some racial groups, especially in Eskimos and Ammbcan Indians, and in whites more commonly t h a n in blacks.

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The relationship between viral infections of the nasopharynx and bacterial infection of the middle ear has been suggested clinically andin animal models (11). Bernstein (9) has proposed a mechanism by which RSV virus, known to induce an IgE response in some children, may induce edema of the eustachian tube, impaired ciliary function, and OME and/or AOM. Upper respiratory allergy is recognized increasingly as a factor that may contribute substantially to OME and/or MED. Circumstantial evidence suggests that it may act directly on the middle ear to induce mucociliary dysfunction and effusion in a small proportion of patients, and/or more commonly on the eustachian tube by inducing proliferation of lymphoid tissue or by inducing peritubal edema, which impairs lymphatic drainage and obstructs the tube at its pharyngeal outlet. Allergy, also, could act indirectly by causing nasal obstruction and nasopharyngeal pressure differences which could induce reflux of pharyngeal secretions into the middle ear by the Toynbee phenomena (8,12). Direct evidence of eustachian tube involvement in OME comes from nasal challege studies in both human and subhuman primates. Walker et al. (13) challenged atopic and non-atopic subjects with nasal histamine insufflation. Nine of the 12 atopic subjects developed eustachian tube obstruction as well as increased nasal resistance. By contrast, none of the 10 non-atopic subjects studied showed eustachian tube involvement, even though all subjects showed increased nasal resistance after challenge, suggesting that the eustachian tube of atopic patients are more likely to react to histamine than those of normal subjects. Friedman et al. (14,15) employing double-blind intranasal pollen challenges in subjects with allergic rhinitis, induced both allergic rhinitis and eustachian tubal obstruction with pollen but not with placebo preparation. In some subjects, ETD persisted for several days.

HISTORY A comprehensive clinical history is essential to the proper diagnosis and management of middle ear disease. The importance of a thorough history cannot be overemphasized. The origin, course, progression, and treatment of disease should be documentedo A thorough environmental history is necessary to identify Clinical Reviews in Allergy

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allergic or irritant factors in the home, school, or work environment that may predispose that patient to nasal congestion. A history of exposure to irritants such as cigaret smoke or allergens such as housedust, molds, or pets in the home, school, or work environment will aid in selection of allergy tests as well as provide information necessary to modify the patient's environment. Symptoms suggesting adenoidal hypertrophy such as snoring and nasal obstruction should be sought.

PHYSICAL EXAMINATION Examination of the Ear A proper otoscopic examination requires optimal light, airtight otoscope head, and a large enough speculum to seal the ear canal. The position, color, transluecency, and mobility of the tympanic membrane is noted. A normal tympanic membrane should be translucent and permit a view of the middle ear landmarks. A reddish tympanic membrane alone may not indicate pathology, since the blood vessels to the drum may be engorged by crying, sneezing, or blowing the nose. Mild retraction of the tympanic membrane usually indicates negative middle ear pressure, effusion, or both. Severe retraction of the tympanic membrane is characterized by a prominent lateral process of the malleus and abnormally acute angulation of the malleus handle (16). Only fifteen percent of middle ear effusions present with an air fluid level or bubbles of air mixed with liquid and a bluish or yellowish hue to the drum; however, an effusion affects the mobility of the tympanic me mbr a ne when negative pressure is applied to the external auditory canal. The use of the pneumatic otoscope is described in the next section. The nose should be examined carefully for signs of chronic rhinitis, obstruction, and allergic disease. Mouth breathing and hyponasal speech can indicate nasal obstruction. A submucous cleft palate or bifid uvula often is associated with ETD. Nasal examination m a y reveal edema of the turbinates, nasal septa! deviation, or n a sal polyps. Nasal polyps in children are associated frequently with cystic fibrosis and, in adolescents or adults, are associated with chronic sinus disease (17) more consistently t h a n with "allergy."

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LABORATORYEXAMINATION The laboratory examination of the patient with otitis m e d i a can be divided into three sections. First, the examination of the ears employs three techniques: p n e u m a t i c otoscopy, pure tone audiomerry, a n d impedence audiometry or tympanornetry. Second, laboratory examination of the nose provides information on processes t h a t m a y affect the middle ear directly. Techniques available are examination of nasal cytology, which will provide information on nasal inflammation, posterior rhinometry, which provides inform a t i o n on functional obstruction of the nose, and radiographic examination of the nose, which provides information on anatomic obstruction of the nose as well as pathology within the adjoining p a r a n a s a l sinuses. Third, immunologic tests provide information on i m m u n e deficiencies or specific allergic factors t h a t m a y be responsible for IgE-mediated n a s a l or middle ear i n f l a m m a t i o n .

Pneumatic

Otoscopy

During the physical examination, a fiberoptic otoscope should be used to observe the tympanic membranes. The head of the scope m u s t have a n airtight seal and an a t t a c h m e n t for r u b b e r tubing through which air m a y be blown into the ear canal to exert pressure on the tympanic membrane. In the absence of middle ear fluid, a normal m e m b r a n e will move in response to positive and negative pressure. The presence of effusion will d i m i n i s h this response~ P n e u m a t i c otoscopy allows visual assessment of the t y m p a n i c m e m b r a n e and some information concerning middle ear status~

Pure Tone Audiometry This can be used in the office or clinic as a screening test. It is performed by testing hearing at four sound frequencies (500, I000, 2000, and 4000 Hz) at three sound intensities (20 or 25, 40, and 60 dB). More accurate thresholds are abtained when tests are performed in a soundproofroomo Hearingis tested by octaves from 125 to 8000 Hz with the threshold of hearing being determined for each tone. This is performed for both air and bone conduction. Bone conduction bypasses the middle ear and the sound is carried directly to the i n n e r ear~

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This procedure permits determination of how much h e a r i n g loss is caused by disease in the middle ear, in the organ of Corti, or in the auditory nerve. OME is associated with a low-frequency hearing loss and often is associated with a conductive h e a r i n g toss in the speech frequencies. By contrast, sensorineural disease is associated frequently with a high frequency hearing loss.

Impedance Audiometry Impedance audiometry or t y m p a n o m e t r y has been developed to test middle ear function and can be performed easily in a n office (18)o It is i m p o r t a n t to u n d e r s t a n d that this is not a h e a r i n g test, but merely tests some aspects of middle ear physiology. It is a usefut screening test, but has limited applications for an experienced clinician with respect to the medical m a n a g e m e n t of OME; it is not a substitute for a test of hearing. It can be used to evaluate middle ear function in children too young to perform pure tone audiometry. Because it is noninvasive and does not require the child to respond, it can be performed readily on children as young as 12 mo of age (19). It is also particularly useful in uncooperative children whose ear canals are incompletely occluded by cerumen. Very useful information can be obtained with m i n i m a l manipulation. T y m p a n o m e t r y can determine the pressure of air in the middle ear, the mobility of the tympanic m e m b r a n e and of the ossicles, and relate information that indicates the presence of middle ear fluid (Fig. 1). T y m p a n o m e t r y is performed by inserting a probe containing three microchannels in a rubber earplug that seals the ear canal. One microchannel transmits a sound at 220 Hz; a n o t h e r contains a sensitive microphone that picks up the reflection of the signal; the third regulates pressure in the ear canal. Most instruments can alter ear canal pressure from +200 to -400 mL H20. As tympanic membrane compliance is greatest when air pressure on both sides of the drum is equal, peak sound conductance normally occurs between 0 and -I00 mL. This is referred to as an A curve. As middle ear pressure decreases, the peak shifts to the negative pressure zone. As middle ear pressure becomes increasingly negative, the tympanogram peak becomes flatter and wider and a C curve is seen. A more recent classification divides the C curve into C I (-100-199 mm water) and C2 (>199 mm with a deft-

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,

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Fig. 1. A normal tympanogram (A) shows peak compliance at normal atmospheric pressure (+ 100 mm H20). Poorlymobile tympanic membranes have low compliance and no peak may be visible(B). This occurswhen there is middleeffusion. Negative middle ear pressure, as one sees in the case of a retractedtympanic membrane, gives a tympanogram with a point of maximum compliance more negative than-150 mm H20.

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nite peak) curves, which represent the phases that children pass through when they are developing a B curve or when the process producing a B curve is resolving. The A and C1 curves appear most stable, whereas the C2 curve is the least stable (20). A fiat curve with no recognizable peak (B curve usually is indicative of fluid. Fluid also may be present with other curve configurations.

Nine Step Tympanometry Nine step tympanometry (involving five actual tympanograms) is a method for evaluating eustachian tube function by determining the tube's ability to equalize positive and negative pressures (21). After a baseline tympanogram (#1) is obtained, a positive pressure of 200 m m H~0 is applied to the middle ear. The patient swallows three times to equilibriate pressure and another tympanogram is obtained (#2). Middle ear pressure normally will be slightlynegative at this time. The patient then takes several swallows of water and a tympanogram is obtained again to see if the negative pressure is equilibriated to the original baseline (#3) by the eustachian tube. Next, a negative pressure of 200 m m H20 is applied. The patient swallows three times and again a tympanogram is obtained (#4), this time it should be slightly positive. The patient again swallows several times and the tracing is repeated to see i f positive pressure is equilibriated (#5). This functional test is often abnormal in individuals with normal baseline tympanometry who complain of the sensation of plugged or popping ears~ It has provided the sensitivity needed to study the affects of inhaled allergens and irritants on eustachian tube physiology (Fig. 2).

Nasal Cytology The cellular composition of nasal secretions is an easily assessible clue to what pathophysiologic phenomena are occurring in the nose, middle ear, and paranasal sinuses. Normal nasal secretions typically contain epithelial cells, some mononuclear cells, some polymorphonuclear cells, and very few eosinophils. The presence of greater than 5-10% eosinophils suggests allergic disease. Less commonly, however, eosinophiles can occur in the absence of allergy, presumably owing to non-allergic release of mast cell eosinophil chemotactic factors.

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ACTIVITY

STEP

MODEL

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Fig. 2. The nine step tyrnpanornetry technique is more sensitive than ordinary tyrnnpanornetry for detecting eustachian tube dysfunction.

Patients with acute viral upper respiratory infections will sometimes show karyolysis, a fragmenting of the cfliated epithelial cells with round bases being sheared from the elongated stem of the cell. Often some polymorphonuclear cells will be present. Patients with bacterial sinusitis are likely to have nasal secretions that appear purulent. Microscopically, they contain sheets of polymorphonuclear cells and bacteria, often present intracellularly. A single specimen reflects the pathophysiotogic process occurring in the nose at one point in time and must be viewed in t h a t context: diagnostically, it can be helpful or misleading, for examClinical Reviews in Allergy

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ple, when the subject who has allergic rhinitis has an upper respiratory infection at that moment in time, since eosinophils may appear only after recovery.

Nasal Cytological Technique The patient should blow his or her nose into plastic wrap. In the case of young children who cannot perform this maneuver voluntarily and in situations where the patient cannot provide nasal secretions, a cotton swab applicator can be placed in the nasal vault for a brief interval. Secretions can be rubbed from the plastic wrap or applicator onto a glass slide. After briefly heat-fixing the material, Hansel's stain (an eosin-methylene blue stain) is used, according to the protocol in Table 1. An alternative technique involves the use of a plastic curet that is gently scraped in the mid-anterior portion of the middle turbinate. The epithelial scraping that is obtained can be stained with Hansel's stain and may show mast cells in addition to other cell types mentioned above.

Nasal Resistance Measurements One can elucidate pathophysiologic mechanisms with nasal provocation challenge or study the effects of pharmacologic intervention by performing resistance studies before and after therapy by measuring nasal resistance to airflow. Nasal resistance is defined as the ratio of the pressure change between the nose and nasopharynx (P) and the airflow through the nose (R =AP/v). Two methods of measurement are anterior and posterior rhinometry. With anterior rhinometry, flow is measured with a pneumotachograph placed in one nostril. Pressure differential is determined from pressure tr~msducers located at the occluded and patent nares. Thus, all measurements are performed from the anterior airway. There may be some artifact introduced by altering the nares, but this technique is easier to perform in children tha n posterior rhinometry. For performing posterior rhinometry, the patient wears a diving mask that contains a flowmeter and pressure transducer. Another pressure transducer is attached to a mouthpiece. The patient must breathe without obstructing the mouthpiece and must be cooperative with the cumbersome diving mask in place. While the patient breathes, pressure change and flow are measured. Detailed explanations of these techniques can be found elsewhere (22,23).

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Table 1 Techniques of Staining Nasal Secretion Transfer the specimen to a glass slide, dry, and fix with heat Stain for 30 s with Hansel's stain (1:500 eosin and 1:200 methylene blue in alcohol) Add distilled water to take up the stain for 30 s Wash with water Decolorize with methanol or 95% ethyl alcohol (do not over decolorize) Dry and examine under oil immersion

Radiographic Examination Sinus disease is a common finding among children with chronic otitis. Although there are no controlled evaluations tha t document the incidence of sinusitis in a non-allergic person compared to an allergic person, up to 70% of youngsters presenting to an allergist's office for chronic rhinitis may have abnormal sinus radiographs (24). The majority respond specifically to antimicrobial therapy, possibly indicating bacterial disease. Even in infancy, ethmoid and maxillary sinuses are pneumatized. In asymptomatic children under I y of age, maxillary antra may be cloudy on radiograph, minimizing the value of films. In children over age 1 y, however, abnormal findings are likely to correlate with disease. Crying will not cause clouding of the sinuses

(25). A sinus radiograph should be considered when an older subject complains of chronic purulent rhinorrhea or localized facial pain and tenderness or a child has symptoms of chronic rhinorrhea and cough, particularly if nasal cytology shows a predominance ofpolymorphonuclear cells and bacteria. For optimal visualization of the sinuses, three views should be performed: the antero-posterior (Caldwell), occipito-mental (Waters), and lateral. The ethmoid and frontal sinuses are best visualized with the Caldwell, the maxillary antra with the Waters, and the sphenoid sinuses with the lateral, which also is useful for visuMizing the frontal sinuses. Actually one can often obtain adequate info.,znation tu one or two views. For example, young children do not yet have sphenoid and frontal sinuses: a Waters

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view offcenadequately visualizes ethmoid sinuses and provides the best view of the maxillary antra. The clinician should give careful consideration to the history and physical examination in order to determine the views that will be most helpful. Lateral head films are useful for a gross estimate of adenoid size (Figs. 3 and 4). Several of methods for measuring the adenoid shadow have been used, e.g., distance from the anterior adenoid shadow to the posterior turbinate and distance from the anterior adenoid to the maxillary antrum. Commonly, adenoid size is interpreted from the degree that theyimpinge upon the nasopharyngeal airway. Although the lateral head film provides only a two dimensional estimate of adenoid size, it may provide important information when the nasal airway is patent but the voice is markedly hyponasal.

Immunologic Tests Total Serum Immunoglobulin E In certain situations it is valuable to measure the patient's total serum Immunoglobulin E concentration. Approximately 45% of the patients with allergic rhinitis will have a total serum IgE level that is greater than one standard deviations from the nonatopic population's mean.

In Vivo Tests for IgE (Allergy Skin Testing) The history provides the information on possible environmental or dietary factors that may be inciting or aggravating the patient's difficulties. In order to identify the factors that may be causative, one may need to determine the patient's specific immunoglobulin E antibodies. Allergy skin testing is an extraordinarily sensitive bioassay for specific allergic homocytotropic antibody. This so-called skin sensitizing or reagenic antibody usually belongs to the IgE class. There usually is a good correlation between antibody found in the skin and in the respiratory tract and blood. The interaction of antigen introduced into the skin with antibody fixed to dermal mast cells results in local release of mediators such as histamine that induce local vasodilation with wheal and flare formation peaking after 10-15 n~n. Although this "immediate" reaction fades after 20 rain, patients occasionally will experience "late" cutaneous reactivity

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Fig. 3: The airway is markedly narrowed by the large adenoid mass, which almost abuts on the palate. Nasal breathing is compromised by this degree of adenoidal enla[gement. Clinical Reviews h~Allerqy

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Fig. 4. There is an ample nasal airway in this case. where the adenoid shadow is quite small.

hours after initial antigen application, which may be owing to a second, later phase of mediator released from infiltrating cells after antigen challenge. This late reactivity may be similar to the clinicat late phase reaction that can occur with allergic a s t h m a and rhinitis. A positive skin test reaction usually indicates that the subject has IgE directed toward the antigen that has been tested. This does not prove, however, that this sensitization causes clinically significant disease. The likelihood that !gE antibody present has clinical importance correlates with the amount of antibody present, and therefore roughly with the intensity of the skin test reaction. In other words, the weaker the antigen necessary to provoke a positive sMn test reaction, the greater the likelihood that it is clinically relevant. Clinical Reviews in Allergy

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Bierman and Shapiro In Vitro Testing for IgE Antibody

Specific serum IgE antibody can be measured by means of the radioallergosorbent test or RAST. Antigen is coupled covalently to an inert carrier such as latex particles, a cellulose disk, or polystyrene microtiter tubes. These are incubated with the patient's serum. If there is serum IgE directed against the antigen, antigen antibody complexes will be formed that can be isolated. A radiolabeled or monoclonal antibody to IgE is then added to interact with the antigen-antibody complexes. The resulting combination of antigen-IgE-anti-IgE can now be assessed. Modifications of the RAST are numerous (e.g., MAST, FAST), these are variations on the same procedure that utilize different carriers for antigen, and radiolabeled or enzyme labeled anti-IgE instead (enzyme-linked assays or ELISAs), which are detected with a fluorometer (26). There are few clinical situations in which serologic tests are preferable to skin tests, since skin tests generally are more sensifive, less expensive, and potentially offer more comprehensive information. The disadvantages of serologic tests include 1.

2. 3. 4. 5. 6.

Not all laboratories performing RAST or other serologic tests are reliable and quality control standards are not required; Expense is significantly greater than for skin testing; Sensitivity is significantly less than for skin testing; Attempts to modify RAST by increasing the scale to enhance sensitivity have resulted in a significant loss of specificity; Results are not immediately available to the patient; and Not all antigens are readily coupled to insoluble materials.

MEDICALMANAGEMENT An in-depth discussion of management is beyond the scope of this chapter, but there are a few common principles involved in the care of patients with otitis media. Strategy for the medical m a n a g e m e n t of the patient with OME includes three distinct procedures. First, it is important to identify and avoid allergic and irritant factors in the patient's environment that predispose him or her to OME. Second, various medications such as antibiotics, antihistamines,

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oral decongestants, and corticosteroids may be indicated to clear infection, alleviate inflammation, and reduce secondary obstruction. Third, immunotherapy (desensitization, hyposensitization) may be indicated in atopic children who cannot avoid specific airborne allergens. Fourth, inflation with a Mathes inflator may open a tube that is functioning poorly, ventilate the middle ear, and rid the middle ear of fluid. Finally, if these fail, the use of middle ear ventilating tubes will restore hearing while medical management is carried out. Irritants and allergens to which the child may be allergic shouldbe avoidedifpossible. Parents should be instructed about the specific procedures for avoidance of such household allergens as house dust mites, household molds, and animal danders. Particularly important for the OME patient is the avoidance of tobacco smoke. Parents and babysitters must not smoke in the home, automobile, or any place where the patient might be in a confined space. If the child is exposed to cigaret smoke in a day care center, an alternative day care facility should be sought.

ANTIHISTAMINE/DECONGESTANT THERAPY The use of antihistamine/decongestant preparations has become controversial in pediatrics. A double-blind study of these agents vs placebo in children with upper respiratory infections showed that they did not protect children from developing acute otitis media

(27,28). Antihistamine-decongestant drugs may be useful in allergic patients who have middle ear dysfunction. Whether they are of any value in patients with OME has not been established.

ANTiBiOTiCS The effectiveness of prolonged antibiotic therapy for otitis media with effusion is not clear. Most published studies have consisted of open trials (29,30). Some show benefit for prolonged antimicrobial therapy (trumethoprim sulfamethorazole, cefaclor, or erythromycin/sulfisoxazole) and some do not. A double-blind controlled trial of prolonged antibiotic therapy in atopic children has yet to be carried out. Clinical Reviews in Allergy

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TOPICALNASALSTEROIDS Shapiro and coworkers (31) have studied the effectiveness of topical dexamethasone and fltmisotide nasal sprays in children with OME. When they were compared to placebo there was a significant improvement in tubal function at the end of the first week in patients treated with active drug. However, by the third week of therapy both active and placebo groups showed similar resolutions of ETD. Fasting 8:00 A.~{~cortisol levels were similar for the two groups, suggesting that three weeks of topical aerosolized did not interfere with adrenal function.

SYSTEMICCORTICOSTEROIDS Systemic corticosteroids have been recommended for OME, but most studies showing efficacy have been poorly controlled and all have been short term. The only controlled study did not examine hypothalamic-pituitary-adrenal axis effects (32). Until a welt-designed study examines both safety and efficacy, one should use systemic steroids for OME cautiously.

TOPICALCROMOLYN Topical intranasal cromolyn sodium solution appears to help reduce nasal symptoms in children with hay fever, however, there are no data concerning its effects on middle ear function.

SURGICALMANAGEMENTOFCHRONICOME Strategy for surgical management of the patient with OME has included tonsillectomy, adenoidectomy, myringotomy, and ventilating tube insertion.

SUMMARY Otitis media with effusion is a common disorder in children and occurs more frequently in adults than has been generally appredated. Laboratory tools have permitted a more specific characterization of this disorder by objective means. These laboratory tests Clinical Reviews in Allergy

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include specific e a r t e s t s ( p n e u m a t i c otoscopy, p u r e tone, a n d imped a n c e a u d i o m e t r y ) , n a s a l t e s t s ( i n f l a m m a t o r y cytology), f u n c t i o n a l t e s t s for o b s t r u c t i o n ( a i r w a y r e s i s t a n c e m e a s u r e m e n t s ) , a n d a n a t o mic t e s t s of o b s t r u c t i o n a n d i n f l a m m a t i o n ( r a d i o g r a p h i c of nose a n d p a r a n a s a l sinuses). I m m u n o l o g i c t e s t s define t h e p r e s e n c e of h y p e r s e n s i t i v i t y ( s ~ n t e s t i n g , RAST) a n d i m m u n o d e f i c i e n c y ~n t h i s disorder.

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90~ 552-562. Georgitis, J. W. (t985), J. Allergy Clin. Immunol. 75~ 614--620. Morgan, M., Marshall, S., Shapiro, G., Pierson, W. E., Bierman, C. W., and Furukawa, C. T. (1988), in press. 24. Rachelefsky, G., Goldberg, M., Katz, R. M., Borris, G., Gyepes, M. T., Shapiro, M. J., Mickey, M. R., Finegold, S. M., and Siegel, S. C. (1978), J. Allergy Clin. Immunol. 81,310-314. 25. Kovatch, A. L. (1984), Pediatrics 73, 306-308. 26. Tsay, Y. G. andHalpren, G. (1984),ImmunologyandAllergy Practice6, 27-32. 27. Haugeto, O. K, Schroder, K E., and Malt, I. W. S. (1981), J. Otolaryngol. 10~ 359-362. 28. Cantekin, E. I., Mandel, E~M., and Bluestone, C. D., et al. (1983), 27. Eng. J. Med. 308, 297. 29. Healy, G. B. (1984), in Lira, D. G. (ed.), Recent Advances in Otitis Media with Effusion, B. C. Decker, Inc., Philadelphia, pp. 285-287. 30. Giebink, G. S., Le C. T., and Batalden, P. B., et al. (1986), Pediatric Research 20~ 310A. 31. Shapiro, G. G., Bierman, C. W., Furukawa, C. T., Pierson, W. E., Betman, R., Donaldson, J., and Rees, T. (1982), Ann. Allergy 49, 81. 32. Schwartz, R. H., Puglese, J., and Schwartz, D. M. (1980), Ann. Otol. Rhinol. Laryngol. 89, 296-300. 22. 23.

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