Treatment Strategies

My strategy for managing PTO is based on a condition driven escalation of therapeutic invasion. I try to reserve complicated solutions for complicated problems. In most cases, PTO can be successfully managed by topical or systemic antibiotics, or both. In children younger than age 3 years, bacteriology is similar to that of acute otitis media (AOM). For minor cases, the application of steroid-containing antibiotic drops (SCAD), 3 drops in the affected ear on a t.i.d. schedule is effective. As a general rule, my endpoint is 7 days or at any time the child reacts to drop application as if it were painful. Even with the milder ophthalmic preparations, the pH can elicit pain when it comes in contact with normal mucosa. MeyerhofPs 1983 study16 in chinchillas clearly demonstrated drop ototoxicity when applied through tubes in ears with normal eustachian tubal function and middle ear mucosa. Infected mucosa offers a barrier to this ototoxicity, the absence of which is heralded by the pain elicited in ears with "healed" mucosa. If the PTO is the only site of infection, drop therapy should suffice. However, in this toddler population, upper respiratory infection is often concomitant. In such cases I add an appropriate oral antibiotic or enlist the help of the child's pediatrician to do so.

For the older child, extensive sources of contamination are more common and the bacteriology more complicated. Pseudomonas species are more common. In such cases, oral preparations are not realistic, except for ciprofloxacin, which is contraindicated in this population. For these cases, I rely on SCAD therapy.

This protocol is effective in most cases. When PTO is persistent, antennae should go up and treatment be advanced. First, what is "persistent"? If PTO continues beyond 2 to 3 weeks or recurs within a week or so after cessation of treatment, rarer disorders or immunologic compromise should be considered. This is one of the few times I will culture a draining ear and consider the results in specific therapy. Rare disorders, such as diabetes, cystic fibrosis, tuberculosis, the histiocytoses, or immunodeficiency syndromes, should be addressed. I do so by means of pediatric consultation.

Based on the cultures and the pediatric evaluation, I then begin to treat these children with intravenous antibiotics supervised by a pediatric infectious disease colleague. Hospital admission for at least 24 h to 72 h for culture specific intravenous therapy is usually necessary, the course completed by administration of home health care. The PTO usually resolves promptly within 5 days. The duration of treatment is generally 10 days to 2 weeks. If the PTO is not clinically under control in 5 days or so, I consider the tube a foreign body corrupting control of infection and remove it. Replacement is determined by the subsequent clinical course.

Failing this strategy or, again, if PTO recurs in the absence of external contamination after seemingly successful conservative therapy, the situation is adjudicated to be medically refractory. The implication is that infected tissue is retained, mastoiditis has been established, or purulent material has been sequestered, not eliminated; that is, a surgical disease exists. A tympanoplasty with mastoidectomy is executed. Granulation tissue is extensively derided, diseased mucosa evacuated, and a very complete mas-toidectomy performed, employing a canal wall-up strategy.

I generally do not drain the mastoid bowl postoperatively unless acute mastoiditis is the problem. This is rare. Because of the infrequency with which this protocol is prescribed and the condition encountered, a final search for the unexpected should prompt preoperative imaging. High-resolution temporal bone computed tomography (CT) both with and without contrast is warranted. The chaos of the prolonged infection precludes even competent otomicroscopic assessment of ears in customers small enough to defy compliance. Even examinations under anesthesia are confounded by the overwhelming picture of infection. Congenital cholesteatoma, masked intratemporal or intracramal com plication, temporal bone abnormality, aberrant carotid artery, or even infratemporal fossa disease affecting eustachian tube should declare themselves on imaging. Don't forget the nasopharynx!

With this strategy of treatment outlined, perhaps a word on prevention as a management structure is in order. What instructions do I give my patients with tubes, as well as their parents, to prevent post-tympanostomy complications? I am convinced that medicine has created a society of cripples by restriction. I practice a medicine of involvement, with only notable cautions:

Office visits every 6 months while tubes are in place Swimming and bathing with water exclusion

For bathing, Vaseline and cotton or custom plugs/molds For swimming, custom molds, again Vaseline under a snug-fitting swim cap or other commercial device Taking care with soapy water and, in my region, lakes, rivers, creeks, or ponds. Swimming in moderation Aggressive treatment of allergy and upper respiratory episodes

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