What are the Surgical Procedures for Ear Infections?

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Myringotomy and Standard Tympanostomy

General Guidelines. Surgery to drain the ear drum (myringotomy) with or without implanted ventilation tubes to drain the fluid ( tympanostomy) is the basic surgical procedure for otitis media. It is the second most frequently performed procedure for children under two (circumcision is first). In 1996 tubes were placed in the ears of one out of every 110 American children. And, an estimated 280,000 children younger than three years of age underwent the operation. It is usually performed in children with recurrent acute otitis media or otitis media with effusion (OME) under they following circumstances:

They have not responded to aggressive antibiotic treatment or antibiotic treatment is not warranted.
They have evidence of fluid in the ear for more than four months and have experienced hearing difficulties.

Controversies Concerning Surgery. Surgery is as controversial as antibiotic treatment, however.

Arguments supporting tubal procedures are based on the following observations, among others:

Hearing is almost always restored following tympanostomy.
One 2000 study indicated that the operation significantly improves many aspects of a child's quality of life, including emotional distress, impaired hearing and speech, and limitations in activity.

The following are studies suggesting that surgery offers few benefits for many children on whom it is performed:

A 1994 study indicated that a quarter of all tube insertion procedures was not appropriate, and in 30% of procedures the risks were as great as the benefits. The study was done, however, to assess medical procedures for insurance reimbursement and a number of surgeons have questioned it.

Important studies in 2000 and 2001 suggested that the procedures in very young children (one and two years old) who had persistent otitis media offered no advantages for language development by the time the child reached the age of three.

Myringotomy. Myringotomy is used to drain the fluid. It may be used as a single procedure in unresponsive acute otitis media or used in combination with tympanostomy. It involves the following steps.

The surgeon makes a very small incision in the eardrum.
Fluid is sucked out using a vacuum-like device.
The fluid is usually examined for identifying specific bacteria
The eardrum heals in about a week.

Myringotomy and Tympanostomy. If otitis media with effusion persists in spite of drug therapy or if it is caused by structural or inborn problems, a tympanostomy is also performed. It involves the following:

A general anesthetic is required but children typically recover completely within a few hours.
Myringotomy is performed.
After myringotomy, the physician inserts a tube to allow continuous drainage of the fluid from the middle ear.
It is a simple procedure, and the child almost never has to spend the night in the hospital.
Some children report almost no discomfort after surgery and find acetaminophen (Tylenol) sufficient for any pain. About half of children, however, require codeine or more powerful pain relievers. One study found that lidocaine eardrops were effective in relieving pain and stress after the procedure.

Complications. Complications of the operation are very uncommon:

General anesthetic poses risks, although rare, for allergic reactions or other side effects.
Persistent ear drum perforation is the most common serious complication, but it too is rare.
Scarring can also occur, particularly in children who require more than one procedure, but it almost never affects hearing.
Small keratin (skin cell) containing cysts called cholesteatomas develop around the tube site in over 1% of patients. This raises some concern about the long-term safety of the procedure, although other studies have indicated that this complication is rare. More studies are needed.
Sometimes the tubes become blocked from sticky secretions or clotted blood after the operation. If the secretions are purulent (pus-filled) from infection, treatment with antibiotic ear drops, such as ofloxacin or ciprofloxacin, may be very effective.

Success Rates. Hearing is almost always restored following tympanostomy. Failure to achieve normal or near-normal hearing is usually due to complicated conditions, such as preexisting ear problems or persistent OME in children who have had previous multiple tympanostomies. In one ten year study, hearing loss was still present in 12.5% of people who had had surgery, although in half of these individuals, hearing loss was very mild (loss was below 20 decibels). Persistent fluid was the main reason for continued impaired hearing. Only 1.9% of hearing loss cases could be attributed to complications of the operation itself.

Precautions. While the tubes are in place, children may take the following precautions:

Many doctors feel that children should use earplugs when swimming as long as the tubes are in place in order to prevent infection. (Cotton balls coated with petroleum jelly are effective alternatives to ear plugs.)

Children may shower without earplugs.

Some physicians feel that as long as the child does not dive or swim underwater, earplugs may not be necessary, but parents should consult their own child's doctor on this subject.

Follow-Up. After surgery, the children may experience the following course.

Eventually, the tubes fall out as the hole in the eardrum closes. This may happen between several months to over a year. This is painless and the patient and parents may not even be aware that the tubes are out.
The operation may need to be repeated, occasionally several times, if, after the tubes fall out, the effusion and hearing loss still persist.
Antibiotics are often prescribed after surgery to prevent such recurrence.

Laser Tympanostomy

A new tympanostomy technique uses a laser, which creates a tiny hole and allows the fluid to drain immediately. No tubes are inserted and the child does not need general anesthesia. One 1999 study reported that within one week of laser-assisted surgery, 100% of children with acute otitis media were symptom free. After three months, only 8% had repeat infections (compared to an average of 47% when treated with antibiotics). Of those children with OME, 65% were fluid-free after three months.

Adenoidectomy

Adenoids are collections of spongy lymph tissue in the back of the throat. Removal of the adenoids, called adenoidectomy, is sometimes considered if they are overly enlarged and interfere with Eustachian tube function. In such cases, the procedure might follow myringotomy and tympanostomy. Removing tonsils at the same time as adenoids ( adenotonsillectomy) does not appear to add any value to the procedure, and it increases the chance of bleeding (which ranges from 0.5% to 4%). One 2001 study did report that either adenoidectomy or adenotonsillectomy at the time of tympanostomy substantially reduced hospitalizations related to otitis media among children two years of age or older. It is commonly held, however, that, except for special circumstances, adenoidectomy should not be conducted on children under four. More research is needed to confirm any benefits in this group.

Functional Jaw Orthopedics

Functional jaw orthopedics are experimental dental treatments that use appliances to stimulate muscles in the tongue, lips, and cheek. The devices are not supported by the teeth, but directly by the soft tissues in the mouth in order to make changes in bone and teeth. Some experts hope that this experimental approach may benefit a number of conditions now treated medically, including otitis media.

Submitted By:
DR. FAIZUL HUQ

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