Treatment of OM is as varied as the disease. Since the 1950's, the underlying assumption behind medical therapy for OME is that chronic otitis media is the result of an acute infection that has simply been inadequately treated. Antibiotics are usually prescribed for acute infections, yet are found to be only 22% more effective than placebo.[111] The current algorithm is still to treat children 1-3 years old who present with an acute infection with antibiotics until they resolve. Although by definition OME is fluid with no signs of infection, it is advised that OM with effusion be treated with antibiotics until the fluid resolves.[125] Only "if the effusion is still present at 4-6 months with bilateral hearing loss greater than 20dB then the patient is a candidate for myringotomy and the placement of tympanostomy tubes (M&T)." These guidelines are promulgated despite the fact that meta analysis of 28 studies regarding the use of antibiotics for chronic OM concludes that they are no more effective than placebo in achieving resolution of the fluid.[152] It must be recognized that antibiotics have reduced the morbid complications of mastoiditis associated with acute OM. Unfortunately, the result of 30 years of increasing use of second and third generation antibiotics has only been the development of resistant strains of bacteria with no alteration in the frequency or severity of OME. [101] In fact, Poole notes that "medical treatment failures probably already surpass ET dysfunction as the most common reason for tympanostomy tube insertion."
Management of ears with persistent fluid presents a further dilemma because it may take several months for medical therapy to be effective in eliminating the MEE. Removal of the fluid itself should not be deferred so long as to allow the child to experience delayed speech and language. Once it has been determined that the patient is not responding to medical management surgical intervention, despite its inherent complications, must be pursued.
Failure of 20th Century otologists to eradicate chronic OME with antibiotics has led to the application of multiple surgical procedures in addition to M&T. These include myringotomy alone, tonsillectomy, adenoidectomy and even radical mastoidectomy, all aimed at ameliorating this disease. Each treatment modality has its staunch advocates and detractors. Tympanostomy tubes have indeed revolutionized the treatment of acute otitis media. The Swedish consensus conference advised that tympanostomy tubes could be considered after 3 or more episodes of acute OM within 6 months.[68] Similar guidelines are promulgated in the United States for children under 3 years of age.[125]
In those children with RAOM whose ears clear between infections, ventilation tubes are an ideal treatment[42] but ventilation tubes do not always return the middle ear to normal function, as many children persist in having recurring "infections" or drainage. More controversy is found in the application of ventilation tubes for older children with OME.[14] The most important and accepted feature of the placement of a ventilation tube is the rapid resolution of MEE and the immediate improvement in hearing.[84] The mechanisms by which ventilation tubes serve to eliminate middle ear disease have to do with the pathogenesis of the particular dysfunction. Some studies find that most (60-80%) ears seem to normalize after the ear has been aerated. Smyth pointed out that one out of four ears may require multiple intubations for a variety of reasons.[121] He reported that of 500 children receiving ventilation tubes for OME, 75% cleared with 1 set of tubes, 21% cleared with 2 sets of tubes, and 4% required multiple reintubation.
The reversal of pathological changes in middle ear mucosa upon placement of ventilation tubes are described as those of gradual normalization by aeration of the middle ear cleft.[46] That normalization may often take a long time.[84] The ventilation tubes seem to allow the middle ear disease to resolve by providing a by-pass of the ET and allowing the middle ear cleft to be aerated. Others find that tubal function remains poor in ventilated ears during the entire time the tubes are in place[107] or after they extrude.[139] Mandel studied 109 children with OME unresponsive to 2 months of medical management. Only 20% of ears where the ventilation tubes became nonfunctional remained effusion free during the term of his study.[77] Takahashi and Sando studied the middle ear and ET of 12 temporal bones from children with OME for 3 to 11 months. They found that the severity of submucosal inflammation almost paralleled the amount of effusion and the pathologic findings in the ET are generally more severe than those in the middle ear. The VT was effective in reversing the MEE and the inflammation in the middle ear was reduced, though some inflammation of the ET mucosa persisted even after 11 months.[132]
Patient experience demonstrates two major drawbacks of tympanostomy tubes. First is the "complication" of a draining tube. Otorrhea is most baffling to clinicians who reject the concept of allergy, as many of these patients lack the classic signs of infection, nor will they readily respond to antibiotics. The incidence of otorrhea varies according to the study: Luxford and Sheehy found 19% of 1055 intubations led to a draining ear [119]. Barfoed and Rosborg noted 74% of a group of 90 children had otorrhea.[6] McLelland reported 34% of 307 children.[80] Gates in 1988 reported otorrhea in 26% of 1248 ears intubated because of chronic serous otitis media.[41] The second major problem with re-intubation is the creation of perforations. This is reported in 0 to 9% of ears when small tubes are used,[80] but occurs in as many as 34% of ears when large bore tubes are used.[51]
is frequently advocated for children having nasal airway obstruction with or without recurrent ear or sinus infections. The role of adenoids in OME is also controversial. Gates postulates that effusion may be the result from eustachian tube (ET) obstruction secondary to enlarged adenoids.[41b] Maw, in a randomized, prospective, controlled study of 103 children with OME 2 to 11 years old found that MEE resolved spontaneously in 16% in 6 weeks and in 26% in one year among children with no adenoidectomy. In a second group having their adenoids removed, resolution was 39% and 72% respectively. Thus adenoidectomy improved the resolution of chronic MEE 26% in 6 weeks and 42% in one year, but the effusion was still present despite adenoidectomy in 28% of the children after one year.[79] He found no significant benefit from the addition of tonsillectomy to adenoidectomy. Forsgren evaluated adenoids in 35 children with and without OME and found a similar pattern in both for CD4+ and CD8+ T cells. He concluded that there is no specific alteration in the microenvironment of the adenoid causing development of SOM. Rather, he found that "the adenoid can deliver humoral and cellular factors contributing to inflammation and secondary tissue damage in ET and middle ear mucosa prone to respond to these factors."[38]