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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
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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
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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