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17 Otitis Media withEusion
Fig. 17.7 Postoperative images of a 4-year-old child at 3months follow-up of VT insertion surgery. The Shepard-style grommet tube stays in place in the right ear (a), whereas the tube is
expelled into the external ear canal in the left ear (b). Note the healthy appearance of both tympanic membranes
357
Fig. 17.8 Postoperative follow-up view of a 10-year-old 3months after Shepard-style grommet
tube insertion to the anteroinferior quadrant of the right (a) and the left (b) tympanic membrane
Otorrhea is the most common complication of VT placement operation [82]. Early
otorrhea is the drainage of the existing effusion and begins immediately after the surgical procedure, is self-limiting, and disappears over time. Late otorrhea which is seen
more commonly begins a few months after the procedure, secondary to upper respiratory tract infections and is usually treated with topical drops. Myringosclerosis is also
a very common condition and is characterized by accumulation of calcic deposits
during the proliferation of broblasts of the brous layer of the tympanic membrane.
Although it is usually not of clinical importance, myringosclerosis can trigger the
development of tympanosclerosis and cause conductive hearing loss with ossicular
358
Fig. 17.9 Postoperative
image of a retracted
tympanic membrane of an
adult 6months after T-tube
insertion procedure. The
T-tube is expected to stay
in place and function for
much longer time than
grommets
A. Y. Gunduz et al.
chain xation [83]. Other less common complications include tube obstruction and,
rarely, tube migration into the middle ear cavity. Although not very often again, the
tube may sometimes be expelled earlier than expected. The perforation in the tympanic
membrane may persist after the tube falls off in 1%–10% of cases [83]. A wider inner
ange of the tube, a longer stay time of the tube on the membrane, and a history of
previous VT application are the conditions that increase the risk of a permanent perforation. Occurrence of iatrogenic cholesteatoma is extremely rare, and it is thought to
develop from a part of epidermis that is migrated into the middle ear by the VT [83].
It is important to note that VT placement does not prevent the progression of tympanic membrane atrophy or retraction. And with that said, young children who are
surgically treated with VT promptly after the diagnosis of chronic OME show signicantly more tympanic membrane abnormalities such as local atrophy or tympanosclerosis than their peers who are operated 6–9 months after the diagnosis [84].
Moreover, the development of chronic otitis media with cholesteatoma, which is a
serious complication of OME in the long term, is seen more in children with refractory OME that requires multiple VT insertions. Interestingly, despite increased tympanic membrane abnormalities that VT insertion leads, prompt treatment after the
diagnosis at an early age and shorter time between the VT insertions reduce the risk
of developing cholesteatoma [19]. This is thought to be due to a reduction in the time
of exposure to negative middle ear pressure. In addition, in patients with a history of
VT placement, recurrence of OME is also less frequent within 2years after the VT
has completed its functional role on the tympanic membrane and is expelled [85].
Another surgical procedure that can be combined with the insertion of VT for the
treatment of OME is adenoidectomy. Especially over the age of 4, when adenoidectomy is performed in the same session with VT insertion, OME recurrences with the
17 Otitis Media withEusion
359
need for re-insertion of VT decrease as well as occurring later compared to VT
insertion alone in the 2-year follow-up period [86, 87]. While the American clinical
practice guideline for OME routinely recommends performing adenoidectomy in
children over 4years of age, it recommends adenoidectomy to be performed only
when the child has accompanying symptoms of nasal obstruction or in the presence
of recurrent OME under the age of 4 [73]. One of the reasons to perform adenoidectomy is to remove mechanical obstruction at the orice of Eustachian tube, so that
the secretion from the Eustachian tube is drained and air can again pass retrogradely,
as a result, the middle ear pressure is equalized with the ambient pressure. Therefore,
adenoidectomy as a treatment protocol for OME is conventionally effective in large
adenoid vegetations that block the Eustachian orices [88]. However, studies also
showed that adenoidectomy was benecial in children with OME even if the adenoids are small and non-obstructive [89]. In this sense, the reason for removing the
adenoid pad is actually to remove a source of infection rather than to relieve blockage of the Eustachian tube. After all, one should always consider adenoidecotmy as
a treatment method that has been proven to improve the clinical course of OME [90].
Last but not least, considering that OME is substantially prevalent among the
children with Down syndrome and the intrinsic learning challenges these children
already have, early intervention, especially early VT insertion, is crucial to avoid
any potential deteriorative effect of a mild hearing loss in these children; so that they
could be reintegrated into the society [91].
17.7 Conclusion
OME is a very common disease that can be regarded as a public health problem
especially in the pediatric era. Unless timely and correct diagnosis and relevant
treatment are made, OME can lead to signicant problems both medically and
sociologically. Diagnosis can be made quite easily with examinations performed in
the outpatient settings. Hearing evaluation should not be missed and must be done
both before and after the treatment. There is no denitive medical treatment for
OME, and medications usually just provide symptomatic relief. In OMEs that do
not improve after 3months of wait-and-see approach, that is, in chronic OMEs, VT
insertion is the only treatment recommended in global guidelines as their effectiveness, and benets have been proven. Including adenoidectomy to the treatment protocol should strongly be considered especially in children over 4 years of age.
Regular follow-up of the disease is crucial in order not to miss the complications.
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Chronic Suppurative Otitis Media
18
MehmetİlhanŞahin, BurcuBakıcı, andDusanMilisavljevic
18.1 Introduction
Chronic suppurative otitis media (CSOM) is a widespread and persistent infectious
disease of the middle ear and mastoid cavity, which leads to signicant morbidity.
CSOM typically develops as a sequela of protracted acute otitis media (AOM), a
common condition affecting roughly 80% of children by the age of 3 [1]. Although
the majority of AOM cases resolve spontaneously, a fraction of cases advance to a
persistent state, which is characterized by chronic purulent ear discharge through a
perforated eardrum as well as varying degrees of hearing loss [2].
18.2 Epidemiology
The worldwide prevalence of chronic suppurative otitis media is 65–330 million
people and evenly distributed across genders. Each year, complications from CSOM
are responsible for approximately 28,000 deaths worldwide [3]. CSOM has a broad
impact, aficting individuals of all ages across diverse geographical and ethnic
M. İ. Şahin
Faculty of Medicine, Department of Otorhinolaryngology, Erciyes University,
Kayseri, Turkey
B. Bakıcı (*)
Faculty of Medicine, Department of Otorhinolaryngology, Istanbul Medeniyet University,
Istanbul, Turkey
Goztepe Prof. Dr. Suleyman Yalcin City Hospital, ENT Clinic, Istanbul, Turkey
D. Milisavljevic
Niš University, Faculty of Medicine, Department of Otolaryngology, University Clinical
Center Niš, Niš, Republic of Serbia
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
M. T. Kalcioglu et al. (eds.), Otology Updates, Comprehensive ENT,
https://doi.org/10.1007/978-3-031-76173-7_18
367