ORL 39: 68-73 (1977)

S ecreto ry O titis m edia Aspects on Treatment and Control Staffan Edström, Knut Lundin and Pdl-Henry Jeppsson ENT Department, Mölndal

Key Words. Secretory otitis media • Clinical study • Treatment • Prognosis Abstract. In a double-blind study, 228 secretory otitis media patients were evaluated according to mucolytic and decongestive treatment. No definite difference comparing with the placebo group was registered. About 50% of all patients were cured within 4 weeks after the diagnosis was established. Those patients who earlier had been treated with antibiotics because of a preceding acute otitis media had a better cure rate than the untreated group. Suggestions on treatment and control of secretory otitis media are given.

Introduction Secretory otitis media is the most common cause of impaired hearing in children (7, 8). The disease is characterized by fluid in the middle ear. The etiology is not known in every detail. However, infectious agents (17), and tubal dysfunction (2, 13, 14), may initiate an active production of fluid by mucous glands in the middle ear (18). If the effusion persists, retraction of the tympanic membrane with an adhesive otitis may occur. Later, in some cases, perforation with cholesteatoma arises (1, 10, 19, 20). The purpose of the present study was to evaluate the efficiency of deconges­ tive and mucolytic treatment on elimination of middle ear effusion. On the basis of these results, aspects on therapy and control of the secretory otitis media will be presented.

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Received: December 15, 1976; accepted: February 10, 1977.

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Edstrôm/Lundin/Jeppsson

Table I. Cured patients in 7 weeks Group

Number of patients

Cured patients n

1 2 3 4 Total

%

51 38 43 46

31 23 28 27

60 60 65 58

178

109

61

The investigation took place in 1974 at the ENT Department, MolndaFs hospital, and was performed on patients with secretory otitis media. Our criteria of this condition was a dull tympanic membrane with impaired mobility in Siegle’s funnel and, in most cases, impaired hearing. The material comprised two main groups of patients: one group which had earlier been treated with anti­ biotics completed 3 weeks before the study was started, and another group without preceding symptoms of acute otitis media and antibiotic therapy. The first examination included, besides routine ear, nose and throat inspec­ tion, also microscopical examination of the tympanic membrane. Hearing tests were performed on patients older than 3 -4 years of age. The investigation was designed as a double-blind study with the following therapeutic groups: group 1, placebo; group 2, bromhexine (Bisolvon®); group 3, cinnarizin (Rinomar®); group 4, bromhexine® + cinnarizin®. Bromhexine (Bisolvon®; Boehringer-lngelheim) disrupts acid mucopoly­ saccharides into small glucoprotein fragments in sterile bronchial fluid, thus reducing the viscosity of the sputum (4). The preparation was given with the purpose of lowering the viscosity of the effusion in the middle ear and was administered in the following doses: 0—1 year: 2 mgX 3; 2—5 years: 3 mgX 3; 6—12 years: 4 mg X 3; more than 12 years: 8 mg X 3. Cinnarizin (Rinomar®; Mekos) has a decongestive effect on the mucous membrane in the nose. The preparation was given according to the following schedule: 0 -1 year: 2.5 mg X 2; 2 -5 years: 5mgX 2; 6 -1 2 years: l OmgX 2; more than 12 years: 20 mg X 2. The preparations, according to the different groups mentioned above, were given orally daily until healing, but not longer than during 7 weeks. The patients were followed up about every 14 days. The secretory otitis media was consid­ ered to be healed when anatomic and functional restitution occurred.

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Material and Results

Edström/Lundin/Jeppsson

70

Table II. Curing according to antibiotic and non-antibiotic treatment Group

Treated with antibiotics

Not treated with antibiotics

n

%

n

%

1 2 3 4

21/30 15/19 19/26 18/27

70 78 73 66

10/21 8/19 9/17 9/19

47 42 52 47

Total

73/102

71

36/76

47

Age years

Number of patients

55 38 41 25 6 13

Total

178

Total number of cured patients

1 o

0 -2 3-4 5 -6 7 -8 9-10 > 10

Number of patients cured in different weeks 3-4

5 -6

7

n

%

11 8 11 6 0 3

17 9 8 5 2 3

3 3 5 1 1 3

3 1 2 4 0 0

34 21 26 16 3 9

60 55 63 64 50 69

39 21.9%

44 24.7%

16 8.9%

109

61

10 5.6%

The material initially included 228 patients. 50 patients were excluded be­ cause they did not return, did not follow the prescriptions, got infections in the upper respiratory tract or had aerobic microorganisms in the middle ear by the time of paracentesis (see below). Thus, 178 patients remained of which 109 patients were cured within 7 weeks. The distribution of the patients in the different therapeutic groups is summarized in table I. There was no definite difference found according to cure rate in the different groups. 102 patients had earlier been treated with antibiotics and 76 had not been treated with antibiotics (table II). 73 of the 102 patients earlier treated with antibiotics were cured within 7 weeks, and 36 of the 76 patients not treated with antibiotics were cured. There is, as shown in table II, a difference with respect to healing between

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Table III. Curing correlated to duration of treatment and age

Secretory Otitis media

71

antibiotically and non-antibiotically treated groups; 71%, respectively, 47%. To­ tally 83 patients (47%) were cured during the first 4 weeks, while 109 patients (61%) were cured during 7 weeks (table III). 69 patients were not cured during the observation period and were, there­ fore, myringotomized. In nearly all these cases, there was a viscous fluid in the middle ear. We required that the fluid, at aerobic cultivation, should be sterile, otherwise exclusion was made from the material.

The secretory otitis media occurs mainly in children, and is the most common cause of impaired hearing in earlier ages (8). The effusion is considered to represent a local production of acid mucopolysaccharides from mucoussecreting cells in the mucous membrane of the middle ear(l , 12, 16). The cause of this local production is not, in detail, elucidated. Many authors, however, state that a tubal dysfunction is important for the development of secretion (2, 13, 14). In the present study decongestive and mucolytic therapy did not seem to have any effect on the course of healing of the secretory otitis media (table I). Almost 50% of all patients were cured within 4 weeks after diagnosis, and only another 15% were cured in the following 3 weeks. No clear-cut difference in cure rate between the different age groups could be registered (table III). Two thirds of the cured patients had earlier had antibiotic treatment due to an acute otitis media. This group showed a better cure rate than the group without preceding antibiotic therapy (table II). The better cure rate in the antibiotically treated group might be due to an early established diagnosis caused by a preceding acute otitis media with a later routine check up. The untreated children, however, had often just symptoms of hearing loss which were, in most cases, noticed by their parents and probably the disease might have had a longer duration before the diagnosis was made than the former group. This explanation agrees with McKinnon's (9) statement that the longer the disease is manifest, the more resistant it is to treatment. The aim with the treatment of secretory otitis media is to restore a ventilat­ ed middle ear. When myringotomy was performed Mawson and Brennand (11) had relapses in 40% of the cases within 2 years. In cases with relapses, insertion of transmyringeal tube may lead to a permanent aeration of the middle ear. Gundersen and Tonning (7) showed in a long-term study of children with relaps­ ing secretory otitis media that nearly 80% had normal hearing after treatment with transmyringeal tube. On the other hand, Bonding and Lorenzen (3) found in a long-term study after treatment with transmyringeal tube that only 43% of the patients got a normal tympanic membrane and a normal tympanogram.

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Discussion

Fdström/I.undin/Jeppsson

72

Kilby et al. (10) could not find any difference between one group of patients which was myringotomized and another in which a transmyringeal tube was inserted. After 2 years, all tubes were rejected and both groups had middle ear effusion in 30%. No tympanometric differences were registered. Thus, it seems necessary to follow up the patients for a long time after any kind of treatment of secretory otitis media. As 50% of the patients with secretory otitis media were spontaneously cured in 4 weeks after diagnosis was established, it seems reasonable to wait with any kind of treatment during this time. Of course, the patient is told to see the doctor earlier if any unexpected event occurs, e.g. secretion from the external canal, or aching. Patients which are not cured within a month after the diagnosis is made should be myringotomized, as the chance of spontaneous healing seems to be poor. In cases of relapses, insertion of a transmyringeal tube should be considered. It is doubtful, in these cases, whether adenoidectomy may improve the prognosis (6, 15). After a secretory otitis media, a follow-up during some years is indicated especially since the disease does not necessarily show symp­ toms (5, 7).

References

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1 Bernstein, J.M.; Hayes, Ishikawa, T.; Tomasi, T.B., and Herd, J.K.: Secretory otitis media: a histopathologic and immunochemical report. Trans. Am. Acad. Ophthal. Oto-lar. 76: 1305-1318 (1972). 2 Bluestone, C.D. : Paradise, J.L., and Beery, Q.C.: Physiology of the Eustachian tube in the pathogenesis and management of middle ear effusions. Laryngoscope 82: 1654 — 1670 (1972). 3 Bonding. P. and Lorenzen, F..: Chronic secretory otitis media long-term results after treatment with grommets. ORL 36: 227- 235 (1974). 4 Biirgi, H. and Makin, E.J.B.: Changes in sputum fibre systems and viscosity during treatment with bromhexine (Bisolvon). Clin. Trials J. 3: 37 40 (1971). 5 Cohen, D. and Sudé, J.: Hearing in secretory otitis media. Can. J. Otolar. 1: 27-29 (1972). 6 Dawes, J.D.K.: The aetiology and sequelae of exudative otitis media. J. Lar. Otol. 84: 583-610 (1970). 7 Gundersen, T. and Tönning, F.-M.: Ventilating tubes in the middle ear. Archs Otolar. 102: 198-199 (1976). 8 Harrison, K. and Watson, T.J.: Long-term follow-up of chronic exudative otitis media (glue ears). Proc. R. Soc. Med. 62: 455-459 (1969). 9 MacKinnon, D.M.: The sequel to myringotomy for exudative otitis media. J. Lar. Otol. 85: 773-792 (1971). 10 Kilby, D.: Richards, S.H., and Hart, G.: Grommets and glue ears: two-year results. J. Lar. Otol. 86: 881-888 (1972). 11 Mawson, S.R. and Brennand, J.: Long-term follow-up of 129 glue ears. Proc. R. Soc. Med. 62: 460-463 (1969).

Secretory Otitis media

13 14 15 16 17 18 19 20

Palva, T. and Palva, A.: Mucosal histochemistry in secretory otitis. Ann. Otol. Rhinol. Lar. 84: 112-116(1975). Parisier, S.C.: The clinical estimation of the Eustachian tube function in serous otitis media. Bull. N.Y. Acad. Med. 50: 971-980 (1974). Renvall, U. and Holmquist, J.: Eustachian tube function in secretory otitis media. Scand. Audiol. 3: 87-91 (1974). Rynnel-Dagoo, B. and Schiratzki, H.: Aspekter pa adenoidectomi. Opuscula Med. 2: 40-43(1976). Sade, J.: Pathology and pathogenesis of serous otitis media. Archs Otolar. 84: 297305 (1966). Senturia, B.H.: Classification of middle ear effusions. Ann. Otol. Rhinol. Lar. 79: 358-370 (1970). Tos, M. and Bak-Pedersen, K.: Density of mucous glands in a biopsy material of chronic secretory otitis media. Acta oto-lar. 75: 55-60 (1973). Zalin, H.: On the aetiology of preepidermosis with special reference to the role of exudative otitis media. J. Lar. Otol. 77: 453-461 (1963). Zechner, G.: Mittelohrschleimhaut und Mittelohrfliissigkeit der Otitis media chronica adhesiva. SchrReihe arztl. Fortbiid. 39: 23-32 (1969).

Dr. Staffan Edström, Department of Otolaryngology. Sahlgren's Hospital, University of Gothenburg, Göteborg (Sweden)

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Secretory otitis media. Aspects on treatment and control.

ORL 39: 68-73 (1977) S ecreto ry O titis m edia Aspects on Treatment and Control Staffan Edström, Knut Lundin and Pdl-Henry Jeppsson ENT Department,...
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