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ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 6-9

The role of antibiotics in treating secretory otitis media in children aged 2–12 years in an accredited teaching hospital in southeast Asia


1 Department of Otorhinolaryngology, MGIMS, Sevagram, Wardha, Maharashtra, India
2 Department of Biochemistry, Mahaveer Institute of Medical Sciences and Research, Bhopal, Madhya Pradesh, India
3 Department of Medicine, Mahaveer Institute of Medical Sciences and Research, Bhopal, Madhya Pradesh, India
4 Department of Pharmacology, IMS & SUM Hospital, SOA University, Bhubaneswar, Orissa, India
5 Department of Pharmacology, Mahaveer Institute of Medical Sciences and Research, Bhopal, Madhya Pradesh, India

Date of Submission11-Jan-2017
Date of Acceptance16-May-2017
Date of Web Publication31-Aug-2017

Correspondence Address:
Sarmishtha De
Department of Otorhinolaryngology, Mahaveer Institute of Medical Sciences and Research, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aaaj.aaaj_1_17

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  Abstract 

Introduction
Secretory otitis media (SOM) is the most common clinical condition that can cause conductive deafness, especially among school-going children. The outcomes of hearing loss in children include speech problems, behavioral problems, and poor academic performance. Management of SOM therefore remains crucial. We carried out a comparative study of antibiotics versus surgical therapy for the treatment of SOM.
Patients and methods
The present study included 50 patients. Detailed history taking with ENT examinations was performed and documented in a validated pro forma. Routine investigations such as complete blood count, urine examination, audiological investigation such as impedance audiometry, etc, were carried out.
Observation and results
About 70% of the patients presented with symptoms of ear block with mouth breathing. Increased incidence was found in the 2–6 years age group. The present showed that surgery can increase the rate of recovery, shorten the duration of therapy, and prevent the recurrence of SOM compared with treatment with antibiotics.
Conclusion
Both the treatments have complications associated with them. Large, well-controlled studies can help resolve the risk–benefit ratio by measuring SOM recurrence, functional outcome, quality of life, and long-term outcomes.

Keywords: antibiotics, impedance audiometry, secretory otitis media


How to cite this article:
De S, Kachhawa K, Gambhir A, Jain RK, Behera R, Diwan SK, Kumar S. The role of antibiotics in treating secretory otitis media in children aged 2–12 years in an accredited teaching hospital in southeast Asia. Adv Arab Acad Audio-Vestibul J 2017;4:6-9

How to cite this URL:
De S, Kachhawa K, Gambhir A, Jain RK, Behera R, Diwan SK, Kumar S. The role of antibiotics in treating secretory otitis media in children aged 2–12 years in an accredited teaching hospital in southeast Asia. Adv Arab Acad Audio-Vestibul J [serial online] 2017 [cited 2017 Dec 11];4:6-9. Available from: http://www.aaj.eg.net/text.asp?2017/4/1/6/213890


  Introduction Top


Secretory otitis media (SOM) is a clinical condition characterized by the presence of fluid in the middle ear, resulting in conductive deafness [1]. It is the most common cause of deafness in school-going children. Management of SOM therefore remains challenging and controversial [1]. Medical management of otitis media is actively debated in the medical literature primarily because of drug-resistant Streptococcus pneumoniae and β-lactamase-producing Haemoplilus influenza [2]. Therefore, surgical intervention (myringotomy with grommet insertion±adenoidectomy) remains the mainstay of treatment. The present study’s objective was to compare the relative effectiveness of treatment options (antibiotics vs. surgical strategies) in patients with SOM aged 2–12 years.


  Aim Top


Any factor that causes obstruction of the Eustachian tube and causes hypoventilation of middle ear may cause SOM. It is known that loss of hearing may cause impairment in physical and mental development of a child. Therefore, it is of utmost important that this condition be properly diagnosed and treated. The aim of this study was thus to investigate the effect of antibiotics in school children suffering from suppurative otitis media.


  Patients and methods Top


The present study was carried out on 50 cases of SOM (more than three episodes/year), both indoor and outdoor patients, at the Department of ENT at MGIMS, Sevagram, Wardha, India, from January 2013 to January 2016.

Detailed history taking with ENT examinations was carried out and documented in a validated pro forma. Routine investigations such as complete blood count, urine examination, and audiological investigation such as impedance audiometry, etc., were performed for all cases. We divided our patients into two groups:
  1. Group I was treated with antibiotics and decongestive nasal drops along with anti-inflammatory drugs.
  2. Group II was scheduled for surgery (myringotomy with grommet insertion with or without adenoidectomy along with decongestive nasal drops). Patients who underwent surgery were followed-up at regular intervals of 6 weeks and thereafter 3 months.


Inclusion criteria

  1. Children aged 2–12 years.
  2. Confirmation of persistent SOM.


Exclusion criteria

  1. Children aged more than 12 years.
  2. Children with conductive hearing loss of more than 40 dB.
  3. Children with sensory neural hearing loss or mixed hearing loss.
  4. Children with active otitis externa.



  Observation and results Top


All children were discharged on the next day of surgery and were asked to visit for regular follow-up. During follow-up, improvement of symptoms and signs and hearing were assessed using an otoscope and by tympanometry.

Of the 50 patients included, 29 were from rural areas and 21 were from urban areas ([Figure 1]). The study included 33 males and 17 females ([Figure 2]). The youngest patient in this sample was 2 years old, and the oldest patient was 12 years old. About 70% of the patients presented with symptoms of ear block with mouth breathing. Increased incidence was found in the 2–6 years age group. Seventy-five percent of patients presented with more than three episodes/year, 95% of patients showed ‘B’-type flat curve for impedance audiometry, and 70% of patients showed adenoid hypertrophy on lateral-view radiography of the nasopharynx with compromised airway (Graph 1).
Figure 1: Ratio of rural and urban population of study

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Figure 2: Distribution of male and female children in this study

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As per the pro forma, through history was taken. All patients were subjected to general and systemic physical examinations mainly to determine fitness for surgery. Local ENT examination was performed to rule out neighboring infective foci or associated conditions. A clinical diagnosis was made after impedance audiometry. Statistics were collected for observation and inferences were drawn:
  1. Distribution among the study group.
  2. Preoperative impedance curve.
  3. Postoperative impedance curve (at 6 weeks and 3 months of follow-up).
  4. Impedance curve after administering antibiotics to patients (at 6 weeks and 3 months).


In the present study, 50% patients were treated with antibiotics, and 50% of patients underwent surgery, that is myringotomy with grommet insertion and adenoidectomy (if required).

In the antibiotics group (treated with amoxicillin according to body weight for 4 weeks), only 12% of patients showed type-‘A’ curves at 6 weeks, and 22% of patients showed type-‘A’ curve at 3 months (Graph 2).



On the other hand, in the second group, 80% patients showed type-‘A’ curves at the 6-week follow-up after surgery, and 11% of patients showed type-‘A’ curves at the 3-month follow-up after surgery (Graph 2).


  Discussion Top


SOM is an insidious condition characterized by accumulation of nonpurulent effusion in the middle ear cleft [1]. The fluid is nearly sterile and commonly seen in school-going children. Two main mechanisms are considered to be responsible:
  1. Malfunction of the Eustachian tube.
  2. Increased secretory activity of the middle ear mucosa.


Impedance audiometry is an objective test useful to diagnose SOM, especially in infants and children. Presence of fluid in the middle ear is indicated by reduced compliance, and a normal ‘A’-type curve will be replaced by a ‘B’-type of curve in impedance audiometry. The main aim of treatment is removal of fluid and prevention of its recurrence [3]. Antibiotics are useful in cases of upper respiratory tract infection or unresolved acute suppurative otitis media [4]. Amoxicillin is the antibiotic of choice, unless the child does not receive treatment within 30 days. The dose used for empiric treatment is 40–45 mg/kg/day for 10 days. The following crucial issues in SOM treatment were not clearly addressed by the Centers for Disease Control and Prevention recommendation [5]:
  1. Patient compliance, associated factors of dosing frequency, duration of therapy, palatability, and cost [5].
  2. Guidance for special situations (e.g. allergic to penicillin, β-lactam drug) is not clear.


Incidence based on sex in the present series showed a slightly higher male predominance. Patients (between 2 and 12 years of age) who had a history of SOM (more than three episodes/year) were randomly divided into two groups. One group was scheduled for surgery (myringotomy with grommet insertion with or without adenoidectomy), and amoxicillin was prescribed for the other group. We observed that antibiotic treatment has a potential serious side effect − that is, increased antibiotic resistance [6]. The cost of antibiotics has also risen recently [7]. Antibiotic treatment did not improve the rate of recovery of patients with SOM.

On the other hand, surgery can accelerate the rate of recovery, shorten the duration of therapy, and prevent the recurrence of SOM [8]. However, patients often required repeated surgery or long-action grommet insertion, which may cause permanent damage to the tympanic membrane, otorrhea, and other complications [9]. Children with Down syndrome often exhibit Eustachian tube dysfunction, external auditory canal stenosis, and sensory neural hearing loss. The subtle immunological deficiency disease conditions create a high risk for surgery for SOM [10]. Adenoidectomy can also increase the risk of postsurgical hemorrhage [11]. However, the outcome of surgery is far better than treatment with antibiotics in children with SOM.


  Conclusion Top


This study presents the clinical profile of the incidence of SOM and its probable audiological presentations with the role of surgery in its management. There was increased incidence in the rural population, which account for low socioeconomic status, poor hygiene, and poor nutritional status. This study shows that children suffering from frequent SOM (more than three episodes/year) will benefit from surgery (myringotomy) with grommet insertion with or without adenoidectomy compared with antibiotic therapy. It also shows that only antibiotics are not very effective in treating SOM in school-going children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Kashyap RC. Management of common otological diseases at a peripheral medical set up. Med J Armed Forces India 2003; 59:332–336.  Back to cited text no. 1
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Dai C, Wood MW, Gan RZ. Combined effect of fluid and pressure on middle ear function. Hear Res 2008; 236:22–32.  Back to cited text no. 3
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4.
Little P, Moore M, Kelly J, Williamson I, Leydon G, McDermott L et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ. 2014; 348:g1606.  Back to cited text no. 4
    
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Ibia E, Sheridan M, Schwartz R. Knowledge of the principles of judicious antibiotic use for upper respiratory infections: a survey of senior medical students. South Med J. 2005; 98:889–896.  Back to cited text no. 5
    
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Fair RJ, Tor Y. Antibiotics and bacterial resistance in the 21st century. Perspect Medicin Chem 2014; 6:25.  Back to cited text no. 6
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Andersson DI, Levin BR. The biological cost of antibiotic resistance. Curr Opin Microbiol 1999; 2:489–493.  Back to cited text no. 7
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Sedlmaier B, Jivanjee A, Gutzler R, Huscher D, Jovanovic S. Ventilation time of the middle ear in otitis media with effusion (OME) after CO2 laser myringotomy. Laryngoscope 2002; 112:661–668.  Back to cited text no. 8
    
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Chole RA, Sudhoff HH. Chronic otitis media, mastoiditis, and petrositis. In: Cumming’s otolaryngology head and neck surgery. Vol. 4. 1998. pp. 2997–3002.  Back to cited text no. 9
    
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Kong K, Coates HL. Natural history, definitions, risk factors and burden of otitis media. Med J Aust 2009; 191:S39.  Back to cited text no. 10
    
11.
Windfuhr JP, Chen YS, Remmert S. Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients. Otolaryngol Head Neck Surg. 2005; 132:281–286.  Back to cited text no. 11
    


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   Abstract
  Introduction
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  Patients and methods
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