Middle Ear, Eustachian Tube, Inflammation, eustachian tube swelling prednisone.

Middle Ear, Eustachian Tube, Inflammation/Infection Treatment & Management

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In the United States, acute otitis media (AOM) is typically treated with antibiotics. Treatment with amoxicillin for 10 days is the initial antibiotic selection, or Bactrim is substituted if the patient is allergic to penicillin. In Europe, a more conservative approach to treating acute otitis media (AOM) is used. Given the alarming increase in antibiotic resistance, the routine usage of antibiotics in the United States should be reconsidered.

A recent meta-analyses from 30 articles written in English and 3 articles written in a language other than English revealed that acute otitis media (AOM) achieved complete clinical resolution without treatment 81% of the time as compared with resolution 95% of the time with the use of antimicrobials. Criteria for withholding or delaying antibiotic therapy for acute otitis media (AOM) include (1) patient older than 2 years, (2) normal host, (3) intact tympanic membrane, (4) at least 3-6 months since last episode of otitis media (OM), (5) receptive parents, and (6) assurance of medical follow-up care.

A study by Tawfik et al indicated that since the introduction of pneumococcal vaccination, hospital admissions for pediatric acute otitis media (AOM)/complications of acute otitis media (AOM) in the United States have decreased in prevalence, as have admission rates for pneumococcal meningitis with acute otitis media (AOM)/complications of acute otitis media (AOM). Using information from the Kids’ Inpatient Database from between 2000 and 2012, the study found particularly sharp declines in admissions for children under age 1 years, from 22.647 to 8.715 per 100,000 persons, and for children aged 1-2 years, from 13.652 to 5.554 per 100,000 persons. [9]

In the United States, otitis media with effusion (OME) can be treated with observation, antibiotics, or tympanostomy tube placement. Meta-analysis of controlled studies revealed only a 14% increase in resolution rate when antibiotics are given. Antibiotic suppression is not indicated for otitis media with effusion (OME), and multiple courses of antibiotics have no proven benefit. Consider surgical intervention after 3-4 months of effusion with a 20 dB or greater hearing loss. [10]

Eustachian tube dysfunction (ETD) can be treated primarily with a combination of time, autoinsufflation (eg, an Otovent), and oral and nasal steroids (budesonide, mometasone, prednisone, methylprednisolone). The results of one study suggest that intranasal steroid sprays alone do not help eustachian tube dysfunction. [11]

Decongestants (eg, pseudoephedrine, oxymetazoline, phenylephrine) are also helpful, but not as useful for chronic eustachian tube dysfunction (ETD). Consider the cardiovascular effects of oral decongestants and the early development of tachyphylaxis observed with the use of nasal decongestants; limit the use of the decongestant to short-term symptomatic relief (ie, no more than 3-5 d).

Nasal and oral antihistamines can also be beneficial in patients with allergic rhinitis. Leukotriene antagonists (eg, montelukast sodium [Singulair]) are helpful in some patients when oral steroids are not an option. Adequate control of laryngeal pharyngeal reflux helps to resolve eustachian tube dysfunction (ETD) in patients with an associated peritubal inflammation from reflux. Proton pump inhibitors (esomeprazole magnesium [Nexium], rabeprazole [Aciphex], omeprazole [Prilosec]) administered twice a day are often used. Myringotomy with tube insertion is reserved for the refractory patient with debilitating symptoms.

Surgical Care

The primary surgical treatment of all types of otitis media (OM) is myringotomy with tube placement. [12] The typical ventilation tube stays in place for a period of 8-12 months with closure of the perforation occurring after tube extrusion. In a small percentage of patients with poor eustachian tube function or other complicating factors, the perforation may persist.


Consult with an otolaryngologist if the patient has any evidence of complications of otitis media (OM), if the effusion persists for longer than 3 months, if a 20 dB or greater hearing loss exists, or if a patient has more than 3 episodes of otitis media (OM) in 4 months or 6 episodes of otitis media (OM) in 1 year.

Neurosurgery consultation may be required for intracranial complications such as a brain abscess.

Patients with eustachian tube dysfunction (ETD) must be careful when flying or diving because of the risk of barotrauma. Instruct patients with significant eustachian tube dysfunction (ETD) to use oral and topical decongestants 30 minutes before landing. An Otovent may be used to assist with autoinsufflation in the treatment of eustachian tube dysfunction (ETD).


Swarts JD, Alper CM, Luntz M, Bluestone CD, Doyle WJ, Ghadiali SN, et al. Panel 2: Eustachian tube, middle ear, and mastoid–anatomy, physiology, pathophysiology, and pathogenesis. Otolaryngol Head Neck Surg. 2013 Apr. 148(4 Suppl):E26-36. [Medline].

Hasegawa K, Tsugawa Y, Cohen A, et al. Infectious Disease-related Emergency Department Visits Among Children in the United States. Pediatr Infect Dis J. 2015 Apr 8. [Medline].

Handzic J, Radic B, Bagatin T, Savic A, Stambolija V, Nevajda B. Hearing in children with otitis media with effusion–clinical retrospective study. Coll Antropol. 2012 Dec. 36(4):1273-7. [Medline].

Doyle WJ, Alper CM, Buchman CA, Moody SA, Skoner DP, Cohen S. Illness and otological changes during upper respiratory virus infection. Laryngoscope. 1999 Feb. 109(2 Pt 1):324-8. [Medline].

Paltura C, Can TS, Yilmaz BK, Dinc ME, Develioglu ON, Kulekci M. Eustachian tube diameter: Is it associated with chronic otitis media development?. Am J Otolaryngol. 2017 Mar 31. [Medline].

Niemelä M, Pihakari O, Pokka T, Uhari M. Pacifier as a risk factor for acute otitis media: A randomized, controlled trial of parental counseling. Pediatrics. 2000 Sep. 106(3):483-8. [Medline].

Contencin P, Maurage C, Ployet MJ, Seid AB, Sinaasappel M. Gastroesophageal reflux and ENT disorders in childhood. Int J Pediatr Otorhinolaryngol. 1995 Jun. 32 Suppl:S135-44. [Medline].

Tarabichi M, Najmi M. Visualization of the eustachian tube lumen with Valsalva computed tomography. Laryngoscope. 2015 Mar. 125(3):724-9. [Medline].

Tawfik KO, Ishman SL, Altaye M, Meinzen-Derr J, Choo DI. Pediatric Acute Otitis Media in the Era of Pneumococcal Vaccination. Otolaryngol Head Neck Surg. 2017 May. 156 (5):938-45. [Medline].

Sudhoff H, Schröder S, Reineke U, Lehmann M, Korbmacher D, Ebmeyer J. [Therapy of chronic obstructive eustachian tube dysfunction : Evolution of applied therapies]. HNO. 2013 Jun. 61(6):477-82. [Medline].

Gluth MB, McDonald DR, Weaver AL, Bauch CD, Beatty CW, Orvidas LJ. Management of eustachian tube dysfunction with nasal steroid spray: a prospective, randomized, placebo-controlled trial. Arch Otolaryngol Head Neck Surg. 2011 May. 137(5):449-55. [Medline].

Haddad J Jr, Saiman L, San Gabriel P, et al. Nonsusceptible Streptococcus pneumoniae in children with chronic otitis media with effusion and recurrent otitis media undergoing ventilating tube placement. Pediatr Infect Dis J. 2000 May. 19(5):432-7. [Medline].

Black S, Shinefield H, Fireman B, et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group. Pediatr Infect Dis J. 2000 Mar. 19(3):187-95. [Medline].

Asbjornsen A, Holmefjord A, Reisaeter S, et al. Lasting auditory attention impairment after persistent middle ear infections: a dichotic listening study. Dev Med Child Neurol. 2000 Jul. 42(7):481-6. [Medline].

Bernstein JM. Immunologic reactivity in the middle ear in otitis media with effusion. Otolaryngol Clin North Am. 1991 Aug. 24(4):845-58. [Medline].

Block SL, Hedrick J, Harrison CJ, et al. Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiology of acute otitis media. Pediatr Infect Dis J. 2004 Sep. 23(9):829-33. [Medline].

Bluestone CD. Epidemiology and pathogenesis of chronic suppurative otitis media: implications for prevention and treatment. Int J Pediatr Otorhinolaryngol. 1998 Jan. 42(3):207-23. [Medline].

Casey JR, Pichichero ME. Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J. 2004 Sep. 23(9):824-8. [Medline].

Conrad DA. Should acute otitis media ever be treated with antibiotics?. Pediatr Ann. 1998 Feb. 27(2):66-7, 70-4. [Medline].

Contencin P, Narcy P. Nasopharyngeal pH monitoring in infants and children with chronic rhinopharyngitis. Int J Pediatr Otorhinolaryngol. 1991 Oct. 22(3):249-56. [Medline].

Daly KA, Giebink GS. Clinical epidemiology of otitis media. Pediatr Infect Dis J. 2000 May. 19(5 Suppl):S31-6. [Medline].

Ghaffar F, Barton T, Lozano J, et al. Effect of the 7-valent pneumococcal conjugate vaccine on nasopharyngeal colonization by Streptococcus pneumoniae in the first 2 years of life. Clin Infect Dis. 2004 Oct 1. 39(7):930-8. [Medline].

Heikkinen T. Role of viruses in the pathogenesis of acute otitis media. Pediatr Infect Dis J. 2000 May. 19(5 Suppl):S17-22; discussion S22-3. [Medline].

Ilicali OC, Keles N, Deger K, Savas I. Relationship of passive cigarette smoking to otitis media. Arch Otolaryngol Head Neck Surg. 1999 Jul. 125(7):758-62. [Medline].

Meek RB 3rd, McGrew BM, Cuff CF, Berrebi AS, Spirou GA, Wetmore SJ. Immunologic and histologic observations in reovirus-induced otitis media in the mouse. Ann Otol Rhinol Laryngol. 1999 Jan. 108(1):31-8. [Medline].

Niemelä M, Uhari M, Möttönen M, Pokka T. Costs arising from otitis media. Acta Paediatr. 1999 May. 88(5):553-6. [Medline].

Pelton SI. Otitis media: re-evaluation of diagnosis and treatment in the era of antimicrobial resistance, pneumococcal conjugate vaccine, and evolving morbidity. Pediatr Clin North Am. 2005 Jun. 52(3):711-28, v-vi. [Medline].

Pelton SI, Loughlin AM, Marchant CD. Seven valent pneumococcal conjugate vaccine immunization in two Boston communities: changes in serotypes and antimicrobial susceptibility among Streptococcus pneumoniae isolates. Pediatr Infect Dis J. 2004 Nov. 23(11):1015-22. [Medline].

Pichichero ME. A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients. Pediatrics. 2005 Apr. 115(4):1048-57. [Medline].

Pichichero ME, Reiner SA, Brook I, et al. Controversies in the medical management of persistent and recurrent acute otitis media. Recommendations of a clinical advisory committee. Ann Otol Rhinol Laryngol Suppl. 2000 Aug. 183:1-12. [Medline].

Rinaldo A, Ferlito A. The pathology and clinical features of “glue ear”: a review. Eur Arch Otorhinolaryngol. 2000. 257(6):300-3. [Medline].

Rovers MM, Straatman H, Ingels K, van der Wilt GJ, van den Broek P, Zielhuis GA. The effect of ventilation tubes on language development in infants with otitis media with effusion: A randomized trial. Pediatrics. 2000 Sep. 106(3):E42. [Medline].

Rovers MM, Zielhuis GA, Straatman H, Ingels K, van der Wilt GJ, van den Broek P. Prognostic factors for persistent otitis media with effusion in infants. Arch Otolaryngol Head Neck Surg. 1999 Nov. 125(11):1203-7. [Medline].

Ruuskanen O, Arola M, Putto-Laurila A, et al. Acute otitis media and respiratory virus infections. Pediatr Infect Dis J. 1989 Feb. 8(2):94-9. [Medline].

Shaw CB, Obermyer N, Wetmore SJ, Spirou GA, Farr RW. Incidence of adenovirus and respiratory syncytial virus in chronic otitis media with effusion using the polymerase chain reaction. Otolaryngol Head Neck Surg. 1995 Sep. 113(3):234-41. [Medline].

Skull SA, Morris PS, Yonovitz A, et al. Middle ear effusion: rate and risk factors in Australian children attending day care. Epidemiol Infect. 1999 Aug. 123(1):57-64. [Medline].

Takahashi M, Peppard J, Harris JP. Immunohistochemical study of murine middle ear and Eustachian tube. Acta Otolaryngol. 1989 Jan-Feb. 107(1-2):97-103. [Medline].

Uhari M, Hietala J, Tuokko H. Risk of acute otitis media in relation to the viral etiology of infections in children. Clin Infect Dis. 1995 Mar. 20(3):521-4. [Medline].

US Otitis Media Guideline Panel, Stool SE, US Agency for Health Care Policy and Research. Otitis media with effusion in young children/Otitis Media Guideline Panel. Rockville, Md: US Dept. of Health and Human Services, Public Health Service; 1994. Clinic practice gudeline, No. 12.

Wright CG, Meyerhoff WL. Pathology of otitis media. Ann Otol Rhinol Laryngol Suppl. 1994 May. 163:24-6. [Medline].

Zhou F, Shefer A, Kong Y, Nuorti JP. Trends in acute otitis media-related health care utilization by privately insured young children in the United States, 1997-2004. Pediatrics. 2008 Feb. 121(2):253-60. [Medline].

Zielhuis GA, Gerritsen AA, Gorissen WH, et al. Hearing deficits at school age; the predictive value of otitis media in infants. Int J Pediatr Otorhinolaryngol. 1998 Aug 1. 44(3):227-34. [Medline].

Contributor Information and Disclosures

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Ari J Goldsmith, MD Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center

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