Symposium on Pediatric Allergy
Allergy and Chronic Secretory Otitis Media
Doris J. Rapp, M.D./' and Daniel J. Fahey, M.D. t
In the otologic literature there is a considerable lack of agreement concerning the etiology, pathogenesis, and treatment of chronic secretory otitis media (CSOM), 12· 21 · 28 · 36 defined as impaired hearing due to the prolonged accumulation of fluid behind a tympanic membrane for a period of at least 6 weeks.50 Two recent review articles discuss the CSOM problem in detail, particularly in relation to allergy.36· 40
Etiology There is no doubt that eustachian tube malfunction is the major cause of CSOM. The most common causes of this malfunction are related to infection (upper respiratory, 23, 25, 30. 43, 47. 54 adenoid, 5. 1. 8-12, 16, 20. 23, 25, 3o, 32-34. 44 or sinus42, 49), allergy,7-u. 14, 19, 25, 26, 3o. 31. 46. 47.56 or structural and muscular abnormalities in the nasopharyngeal area. The eustachian tube normally opens every 1 to 5 minutes, mainly during swallowing.'7 This helps to equalize the air pressure on both sides of the tympanic membrane by allowing air to enter the middle ear space. If the tube does not function properly, air in the middle ear is resorbed causing negative pressure in that area. This in turn contributes to the serous fluid transudate found in the middle ear of some patients. Studies by Hopp,21 Lecks,30· 31 and Tonder and Gunderson53 tend to confirm that this transudate is similar to blood serum. Other studies have shown some quantitative differences between some middle ear transudates and blood plasmaP Bernstein et al.2 identified qualitative differences between middle ear fluid and plasma which they attributed to active secretion within the middle ear. In particular, they found secretory immunoglobulin A and secretory component within the middle ear. Ogra et al.38 believe their observations provide evidence for the existence of a distinct system of local immunity functioning in the middle ear of chronic secretory otitis patients. Studies by Miglets36 *Clinical Associate in Pediatrics, School of Medicine, State University of New York at Buffalo t Associate Clinical Professor of Otolaryngology, School of Medicine, State University of New York at Buffalo
Pediatric Clinics of North America- Vol. 22, No. 1, February 1975
259
260
DORIS
J.
RAPP AND DANIEL ]. FAHEY
and Hopp2 1 have definitely shown that a process similar to serous otitis can be produced immunologically in sensitized animals after appropriate antibody challenge.
Diagnosis Although patients at any age can have CSOM, it is most commonly noted between the ages of 5 to 7 years. 1• 7 • 8 • 12 • 14• 23 • 66 SYMPTOMS. Affected children often have a transient or constant hearing loss. Fullness or crackling of the ears, tinnitus, vertigo, or earaches are noted rarely. The condition is insidious and an awareness of the problem is needed. It may be detected by routine audiometry. SIGNS. The tympanic membranes are often tan, yellow, or varying shades from amber to dark blue. At times the drums will appear entirely normal. The surface may be dull, shiny, or waxy. The drums are often retracted, but sometimes are flat or bulging. Bubbles or fluid levels may at times be seen through the drums. Chalky white deposits are occasionally noted in the tympanic membrane or the handle of the malleus may have a chalky appearance. 14 • 16 • 20 • 28 • 29 • 32 • 52 • 55 Pneumatic otoscopic examination often indicates a lack of normal mobility. 7• 8 • 26 • 28 AUDIOMETRY. This usually shows a bilateral 20 to 30 decibel hearing loss for air conduction.3 • 18 • 26 • 32 • 52 Bone conduction is usually normal.5 Prevention Infection, either directly or indirectly, is believed to be the major cause of CSOM. 3 • 7 • 15 • 16 • 20 • 32 • 45 - 47 • 50 If an acute otitis media patient is treated with an inappropriate antibiotic, or for an inadequate period of time, a smoldering subacute inflammation may occur which can result in a hypersecreting mucosal lining within the eustachian tube. 1 • 16 • 50 Suppuration may not occur but the residual fluid (which is usually sterile)'a· 20. 22. 25 • 29 • 31 • 43 • 5 '3• 54 may not be evacuated normally, leading to CSOM. Otologists commonly recommend a broad spectrum antibiotic such as ampicillin for 10 to 14 days to adequately treat H. influenzae and other organisms, such as Pneumococcus, Staphylococcus, and Streptococcus, commonly associated with otitis during childhood. To be certain that fluid is not retained abnormally behind a tympanic membrane, it is essential to do tuning fork tests a few weeks after treatment for acute otitis. Deceptively normal drums may mask fluid, while distinctly abnormal ones may merely reflect a previous problem. The Rinne test compares the loudness of a vibrating tuning fork heard near the ear opening (air conduction) with that heard when the handle of the vibrating fork is placed over the mastoid antrum (bone conduction). Using the 256 and 512 forks, air conduction should be louder than bone conduction. If the vibrating fork is placed in the center of the forehead, the sound should not lateralize to either side (Weber test). If the sound lateralizes to the same side in which you found bone conduction to be better than air conduction, it suggests a conduction loss, possibly due to fluid in the middle ear. CSOM is the commonest cause of conductive losses in childhood.
ALLERGY AND CHRONIC SECRETORY OTITIS MEDIA
261
ALLERGY CAUSING CHRONIC SECRETORY OTITIS Some CSOM patients respond favorably to the following forms of therapy: the use of decongestants (Actifed, Demazin, Dimetapp, Minagest, Rondec, Triaminic), topical vasoconstricting drugs'~ (NeoSynephrine or Otrivin), antihistamines (Benadryl, Chlortrimeton, Clistin, Co-Pyronil, Tacaryl), and middle ear ventilation techniques such as the Valsalva exercise or politzerization. Other patients need antibiotics,!· 16 tonsilloadenoidectomy/· 16 · 25 · 32 · 43 · 44 · 48 · 50 · 52 myringotomy, spot suction, or Teflon tube insertion. There remains, however, a small core of about 5 to 10 per cent of patients who do not respond in spite of all these measures. In these patients, the problem, which is sometimes referred to as allergic tubotympanitis, may be due to allergies. It is believed that many ear problems in these patients are secondarily due to allergic nasal mucosal swelling which impairs the normal function of the nasal end of the eustachian tube. In others, it is believed that the primary problem is the eustachian tube which itself could be an allergic shock organ reacting in a manner similar to other parts of the respiratory trace· 10. 16, 24. 26, 36. 49. 56 CSOM Patients Most Apt to Have Allergy One should be suspicious of patients who have a strong family history of allergy and those who have any of the classical allergic symptoms, especially rhinitis. 10 • 12 · 14 · 30· 31 · 55 Others may have had repeated adenoidectomies7· 9· 10 · 18· 20· 37· 52 at an early age, especially before age 3 years,44 or may have CSOM which has not responded after repeated tubings of the tympanic membranes. When allergy is significant, the patients will often have a characteristic facies, as shown in Figure 1. These children may have a characteristic Dennie's sign (extra line fold or wrinkle under eye), allergic shiners (black eyes), and possibly an allergic nose wrinkle due to rubbing the tip of the nose upwards towards the forehead. If the child is a mouthbreather, a high arched, V-shaped palate may be noted which is often associated with orofacial dental abnormalities. 35 Laboratory studies sometimes reveal eosinophilia in the blood, nose, 10, 14. 3o. 3L 49. ss or ear :fluid 3. n. 16, 23, 26, 2n. 3L 32. 43, oo. s2 mucus. The patients may or may not have an elevated IgE leveJ.4' Allergy skin tests may be inconclusive or may not correlate with the ear symptoms.9 • 23· 55 Others have found skin tests for inhalants, epidermals, and pollens to be of value."· 14, 3o. 31, 49,56 Methods for Treating CSOM Due to Allergy As with most forms of extrinsic allergy, in addition to symptomatic medication there are basically only three methods of treatment. These include: (1) changes in the patient's home, (2) changes in the patient's diet, and/or (3) immunotherapy (hyposensitization). The latter is indi'''Afrin, Tyzine, and Privine nose drops should not be used in children.
262
DORIS
J.
RAPP AND DANIEL j. FAHEY
Figure 1. Facies characteristic of the presence of significant allergy.
cated only if the problem is seasonal (due to pollens or mold spores) or if it is perennial and nonresponsive to home and diet changes. If the above methods have not been successful, some researchers have recommended a trial of stock or autogenous dusr or respiratory bacterial vaccine7· s. 2
Allergy and Chronic Secretory Otitis Media
Doris J. Rapp, M.D./' and Daniel J. Fahey, M.D. t
In the otologic literature there is a considerable lack of agreement concerning the etiology, pathogenesis, and treatment of chronic secretory otitis media (CSOM), 12· 21 · 28 · 36 defined as impaired hearing due to the prolonged accumulation of fluid behind a tympanic membrane for a period of at least 6 weeks.50 Two recent review articles discuss the CSOM problem in detail, particularly in relation to allergy.36· 40
Etiology There is no doubt that eustachian tube malfunction is the major cause of CSOM. The most common causes of this malfunction are related to infection (upper respiratory, 23, 25, 30. 43, 47. 54 adenoid, 5. 1. 8-12, 16, 20. 23, 25, 3o, 32-34. 44 or sinus42, 49), allergy,7-u. 14, 19, 25, 26, 3o. 31. 46. 47.56 or structural and muscular abnormalities in the nasopharyngeal area. The eustachian tube normally opens every 1 to 5 minutes, mainly during swallowing.'7 This helps to equalize the air pressure on both sides of the tympanic membrane by allowing air to enter the middle ear space. If the tube does not function properly, air in the middle ear is resorbed causing negative pressure in that area. This in turn contributes to the serous fluid transudate found in the middle ear of some patients. Studies by Hopp,21 Lecks,30· 31 and Tonder and Gunderson53 tend to confirm that this transudate is similar to blood serum. Other studies have shown some quantitative differences between some middle ear transudates and blood plasmaP Bernstein et al.2 identified qualitative differences between middle ear fluid and plasma which they attributed to active secretion within the middle ear. In particular, they found secretory immunoglobulin A and secretory component within the middle ear. Ogra et al.38 believe their observations provide evidence for the existence of a distinct system of local immunity functioning in the middle ear of chronic secretory otitis patients. Studies by Miglets36 *Clinical Associate in Pediatrics, School of Medicine, State University of New York at Buffalo t Associate Clinical Professor of Otolaryngology, School of Medicine, State University of New York at Buffalo
Pediatric Clinics of North America- Vol. 22, No. 1, February 1975
259
260
DORIS
J.
RAPP AND DANIEL ]. FAHEY
and Hopp2 1 have definitely shown that a process similar to serous otitis can be produced immunologically in sensitized animals after appropriate antibody challenge.
Diagnosis Although patients at any age can have CSOM, it is most commonly noted between the ages of 5 to 7 years. 1• 7 • 8 • 12 • 14• 23 • 66 SYMPTOMS. Affected children often have a transient or constant hearing loss. Fullness or crackling of the ears, tinnitus, vertigo, or earaches are noted rarely. The condition is insidious and an awareness of the problem is needed. It may be detected by routine audiometry. SIGNS. The tympanic membranes are often tan, yellow, or varying shades from amber to dark blue. At times the drums will appear entirely normal. The surface may be dull, shiny, or waxy. The drums are often retracted, but sometimes are flat or bulging. Bubbles or fluid levels may at times be seen through the drums. Chalky white deposits are occasionally noted in the tympanic membrane or the handle of the malleus may have a chalky appearance. 14 • 16 • 20 • 28 • 29 • 32 • 52 • 55 Pneumatic otoscopic examination often indicates a lack of normal mobility. 7• 8 • 26 • 28 AUDIOMETRY. This usually shows a bilateral 20 to 30 decibel hearing loss for air conduction.3 • 18 • 26 • 32 • 52 Bone conduction is usually normal.5 Prevention Infection, either directly or indirectly, is believed to be the major cause of CSOM. 3 • 7 • 15 • 16 • 20 • 32 • 45 - 47 • 50 If an acute otitis media patient is treated with an inappropriate antibiotic, or for an inadequate period of time, a smoldering subacute inflammation may occur which can result in a hypersecreting mucosal lining within the eustachian tube. 1 • 16 • 50 Suppuration may not occur but the residual fluid (which is usually sterile)'a· 20. 22. 25 • 29 • 31 • 43 • 5 '3• 54 may not be evacuated normally, leading to CSOM. Otologists commonly recommend a broad spectrum antibiotic such as ampicillin for 10 to 14 days to adequately treat H. influenzae and other organisms, such as Pneumococcus, Staphylococcus, and Streptococcus, commonly associated with otitis during childhood. To be certain that fluid is not retained abnormally behind a tympanic membrane, it is essential to do tuning fork tests a few weeks after treatment for acute otitis. Deceptively normal drums may mask fluid, while distinctly abnormal ones may merely reflect a previous problem. The Rinne test compares the loudness of a vibrating tuning fork heard near the ear opening (air conduction) with that heard when the handle of the vibrating fork is placed over the mastoid antrum (bone conduction). Using the 256 and 512 forks, air conduction should be louder than bone conduction. If the vibrating fork is placed in the center of the forehead, the sound should not lateralize to either side (Weber test). If the sound lateralizes to the same side in which you found bone conduction to be better than air conduction, it suggests a conduction loss, possibly due to fluid in the middle ear. CSOM is the commonest cause of conductive losses in childhood.
ALLERGY AND CHRONIC SECRETORY OTITIS MEDIA
261
ALLERGY CAUSING CHRONIC SECRETORY OTITIS Some CSOM patients respond favorably to the following forms of therapy: the use of decongestants (Actifed, Demazin, Dimetapp, Minagest, Rondec, Triaminic), topical vasoconstricting drugs'~ (NeoSynephrine or Otrivin), antihistamines (Benadryl, Chlortrimeton, Clistin, Co-Pyronil, Tacaryl), and middle ear ventilation techniques such as the Valsalva exercise or politzerization. Other patients need antibiotics,!· 16 tonsilloadenoidectomy/· 16 · 25 · 32 · 43 · 44 · 48 · 50 · 52 myringotomy, spot suction, or Teflon tube insertion. There remains, however, a small core of about 5 to 10 per cent of patients who do not respond in spite of all these measures. In these patients, the problem, which is sometimes referred to as allergic tubotympanitis, may be due to allergies. It is believed that many ear problems in these patients are secondarily due to allergic nasal mucosal swelling which impairs the normal function of the nasal end of the eustachian tube. In others, it is believed that the primary problem is the eustachian tube which itself could be an allergic shock organ reacting in a manner similar to other parts of the respiratory trace· 10. 16, 24. 26, 36. 49. 56 CSOM Patients Most Apt to Have Allergy One should be suspicious of patients who have a strong family history of allergy and those who have any of the classical allergic symptoms, especially rhinitis. 10 • 12 · 14 · 30· 31 · 55 Others may have had repeated adenoidectomies7· 9· 10 · 18· 20· 37· 52 at an early age, especially before age 3 years,44 or may have CSOM which has not responded after repeated tubings of the tympanic membranes. When allergy is significant, the patients will often have a characteristic facies, as shown in Figure 1. These children may have a characteristic Dennie's sign (extra line fold or wrinkle under eye), allergic shiners (black eyes), and possibly an allergic nose wrinkle due to rubbing the tip of the nose upwards towards the forehead. If the child is a mouthbreather, a high arched, V-shaped palate may be noted which is often associated with orofacial dental abnormalities. 35 Laboratory studies sometimes reveal eosinophilia in the blood, nose, 10, 14. 3o. 3L 49. ss or ear :fluid 3. n. 16, 23, 26, 2n. 3L 32. 43, oo. s2 mucus. The patients may or may not have an elevated IgE leveJ.4' Allergy skin tests may be inconclusive or may not correlate with the ear symptoms.9 • 23· 55 Others have found skin tests for inhalants, epidermals, and pollens to be of value."· 14, 3o. 31, 49,56 Methods for Treating CSOM Due to Allergy As with most forms of extrinsic allergy, in addition to symptomatic medication there are basically only three methods of treatment. These include: (1) changes in the patient's home, (2) changes in the patient's diet, and/or (3) immunotherapy (hyposensitization). The latter is indi'''Afrin, Tyzine, and Privine nose drops should not be used in children.
262
DORIS
J.
RAPP AND DANIEL j. FAHEY
Figure 1. Facies characteristic of the presence of significant allergy.
cated only if the problem is seasonal (due to pollens or mold spores) or if it is perennial and nonresponsive to home and diet changes. If the above methods have not been successful, some researchers have recommended a trial of stock or autogenous dusr or respiratory bacterial vaccine7· s. 2
