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SECRETORY OTITIS MEDIA Definition Subacute or chronic inflammation of the middle ear accompanied by endotympanic effusion without the signs and symptoms of acute infection. Incidence SOM is a paediatric pathology since most patients are under the age of 8-10 years. In children it is bilateral in 80% of cases, while in adults it more frequently affects only one ear. The incidence peak of the disease is around the age of 2-5 years, then it progressively decreases. As a rule, healing is spontaneous (at 3 months in over 50% of cases). Epidemiology There are congenital and environmental risk factors. The former include the age at which the first episode occurs (SOM is most likely to occur in children who have suffered from otitis media at least once within the first two months of life), congenital malformations with facial dysmorphism as in Down’s syndrome and cleft palate, allergic factors, immunologic deficits and ciliary defects, GERD. Environmental factors comprise weather and season (most frequent in autumn and winter), socio-economical conditions, lifestyle (crowded environments as nursery schools or kindergartens, passive smoking, breast feeding, premature childbirth). Etiopathogenesis It is a multi-factor event with a non well-defined etiology. At the basis there is a chronic Eustachian tube dysfunction (due to inflammatory, mechanical, dysmorphic causes) that modifies the endotympanic gas and pressure balance with consequent alteration of the mucoregulatory system and gas exchanges. As a whole the tympanic mucosa inflammation is self-maintained. Development The disease usually develops towards the resolution of the inflammatory process. There may be possible recurrences with acute otitis media alternating with silent otitis media; more rarely it may develop into a chronic otitis media with possible functional (delay in speech and behavioural disorders) and anatomical consequences (atrophic tympanic membrane, retraction pockets and tympanic atelectasis, tympanosclerosis and cholesteatomas. Clinics A conductive hearing loss of variable degree is always present (SOM is the most frequent cause of deafness in children). It is related to endotympanic effusion. The parents’ attention is fundamental for an early diagnosis (behavioural changes in the child who tends to increase the TV or radio volume, does not reply to calls, is distracted at school and in younger children a delay in language acquisition). If the hearing deficit is > 30 dB there are serious effects on speech learning and school performances. In children the hearing impairment is typically bilateral. Children often complain ear pain without fever with recurrent acute otitis media. In adults and older children there might be ear fullness, autophony, vertigo and tinnitus. Diagnosis Diagnosis is simple and based on anamnesis, clinical examination with otoscopy (the tympanic membrane appears thick and edematous, loses its semi-transparency, is retracted, hypomobile, effusion can be seen with hydro-air levels up to blue eardrum due via Massarenti, 162 - Bologna Tel. 05139.84.04 dal lunedì al venerdì dalle 14.00 alle 19.30 [email protected] - www.massimobalbi.it to hemosiderin deposits), audiometry and impedancemetry (showing conductive hearing loss with Type-B or C flat tympanogram). Treatment The purpose of treatment is the restoration of ventilation in the middle ear up to the resolution of the chronic inflammatory process and evacuation of the endotympanic effusion for hearing function recovery. Medical Treatment Uncertain and debated is the benefit of antibiotics and (either steroidal or non-steroidal) anti-inflammatory drugs because the role played by infection in the development of the pathology is still unclear, and above-all the risk of antibiotic-resistance is very high. Controversial is also the use of anti-histaminics, mucolitics, nasal decongestants that on the one side are supported by a theoretical rationale and on the other side present side effects and alter the mucociliary clearence. In spite of existing doubts, the first-choice medical treatment is nasal aerosol therapy with topical cortisonics and mucolitics associated with nasal decongestants. Crenotherapy (inhalations, Politzer, vaporization, tube-tympanic insufflations) is also included as a first-choice treatment of rhinogenic deafness and therefore of SOM, improving Eustachian tube permeability and mucosa trophism. Finally, Eustachian tube rehabilitation is important by means of self-insufflations (Valsala, Otovent), avoiding sniffing, blowing one’s nose very well, through deglutition and palatine velum contraction exercises. Surgical treatment Surgical treatment is taken into consideration in the event of failure of the medical treatment with long-lasting endotympanic effusion (3-6 months) associated with socially relevant hearing impairment (>30 dB especially if bilateral), in case of permanent ongoing alterations of the TM and coexisting risk factors (cleft palate, syndromes). The possible surgical options are: - Adenoidectomy: it consists in the removal of lymphatic vegetations of the rhinopharynx and is indicated in the case of adenoid hypertrophy or recurrent rhinopharyngitis. The purpose is the mechanical disobstruction of tubal ostium and eradication of infectious focus. It enhances the therapeutic benefit of myringotomy and transtympanic drainage. It is contraindicated in velar deficiency (cleft palate), in coagulopathies, in the very young age. Complications are haemorrhage, post-op pain, velar-pharyngeal insufficency. - Myringocentesis with aspiration of endotympanic secretions: it provides quick evacuation of effusion with consequent hearing function restoration. The effect is transitional if performed isolated (without adenoidectomy or TTD). - Myringotomy with transtympanic drainage: through transtympanic drainage it is possible to re-ventilate the tympanic cavity eliminating the physiopathological cause of SOM, that is chronic endotympanic depression. In this way, by restoring the pressure balance on both sides of the tympanic membrane, the phlogistic process is resolved, the drainage of secretions in the rhinopharynx and OEC enhanced and mucous trophism normalised. The TT drainage remains in place for a variable period from few months up to over one year, typically for a period of around 6-7 months. In the event it tends to remain in optimal position without being spontaneously extruded for over 18 months, its surgical removal is indicated. Complications related to the positioning of a transtympanic ventilation tube may arise early and late in time. Early complications include the possible falling down of the drainage as soon as it is placed in the tympanic cavity (usually it is a surgical mistake associated to an excessively wide myringocentesis), otorrhea especially during rhinitis, early expulsion of the drainage again due to an excessively wide myringotomy, drainage obstruction following otorrhea with crusts or cerumen secretions, labyrinthization (due to a hypothetical mechanism related to aspiration of endotympanic secretion, accidental trauma to the ossicular chain during the positioning of the ventilation tube, use of ototoxic drops). Late complications include persistent tympanic perforation in the via Massarenti, 162 - Bologna Tel. 05139.84.04 dal lunedì al venerdì dalle 14.00 alle 19.30 [email protected] - www.massimobalbi.it drainage site, structural alteration of the tympanic membrane with atrophic areas and retractions, calcified plates and granulations, iatrogenic cholesteatoma. via Massarenti, 162 - Bologna Tel. 05139.84.04 dal lunedì al venerdì dalle 14.00 alle 19.30 [email protected] - www.massimobalbi.it