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Otitis Media with Effusion in Children:
Chiropractic Implications of Clinical Practice Guidelines
Christopher J. Colloca, D.C.
Oswego, NY

Otitis media constitutes a popular clinical presentation in chiropractic practice. With the several controversial issues surrounding its management, the literature has produced very interesting facts, and recently, clinical practice guidelines. Following a brief discussion of this subject, the clinical guideline recommendations as set forth by the Agency for Health Care Policy and Research J (AHCPR) are reviewed providing a factual basis for "treat ment" recommendations. As cited by Hendricks et al,l by the age of two 33% of all children have had three or more episodes of otitis media, approximately 66% have had at least one attack.l.2 Conventional medical treatment has relied upon antibiotic therapy, as well as surgery for modes of treatment, despite their ineffectiveness in many cases. In the 1950's and early 1960's the practice of lancing the tympanic membrane (myringotomy) was the procedure of choice. Although children two and younger whom have had two or more episodes of acute otitis media in the same ear are considered to be appropriate candidates for such lancingl, 98% of children who have had myringotomies will experience a recurrence of effusion buildup after 53 days.5,6. Following the myringotomy, fluid is only released for a short time and the opening created closes quickly, allowing fluid buildup. The short period of ventilation with the procedure has been found not to have any effect on the negative pressure vacuum in the middle ear created by the eustachian tube dysfunction.7 In the mid 1960's tympanostomy tubes were introduced. In this surgical procedure, the tympanic membrane is again lanced and a drainage tube is inserted and kept present for six months until removed. As cited by Hendricks et al,l literature shows that 75% of children with ventilation tubes will experience a recurrence after 223 days.6.8 Due to the poor results of surgery for this condition, the medical approach to treatment of otitis media has of course been antibiotic therapy, although 40% of otitis media cases are the result of sterile effusion (fluid buildup Nithout the presence of microbes) which are therefore unresponsive to antibiotics.9 Some sources believe that the increased frequency of otitis media noted in the 1980's and 1990's is due to antibiotic resistance.t.to McCaig et altO report that a study of the drug-prescribing patterns ofinternal medicine residents for outpatients found that 50% of antibiotic prescriptions were inappropriate. This accounts for at least 150 million courses of antibiotics each year in the U.S. Unnecessary costs of resistance have been estimated to range from a staggering $75 million to $7.5 billion annually. In a recent double-bind, placebo-controlled, randomized trial involving 518 infants and children with otitis media with effusion, amoxicillin, a commonly prescribed antibiotic for otitis media with effusion was found ineffective. "Six weeks after the termination of amoxicillin therapy, the recurrence of effusion was two to six times higher in the amoxicillin-treated children than in those treated with placebo, and the resolution of effusion was not significantly different among antibiotic and placebo group! Understanding the pathophysiology of otitis media.may assist in the realization of why the aforementioned therapies have failed to produce desired results, while providing insight to a different approach. "The middle ear consists of the tympanic membrane and three additional openings or windows. The round window and the oval window communicate with the inner ear and the final opening permits the eustachian tube to provide a drainage mechanism into the paranasal sinuses."l The eustachian tube under normal conditions clears fluid and equalizes pressure gradients within the middle ear, which receives an influx of transmucosal exudates. The tensor veli palatini muscle is responsiblefor contractions which allows the tube to clear fluid buildup. If the normally patent ostium of the eustachian tube is obstructed even partially, as occurs in sinusitis, colds, and sore throats, accumulation of fluid with inflammation and/or infection will result.l With this knowledge, getting to the source of the problem lies in the eustachian tube itself, Vertebral subluxation in the upper cervical spine is thought to be responsible for .inappropriate function of the tensor veli palatini muscle, which is responsible for the opening and closing of the eustachian tube, resulting in otitis media. Removal of vertebral subluxation in such patients normalizes loads on tissues, thereby reducing reflexogenic muscular and other soft tissue alterations and associated edema promotingdrainage of the middle ear. Phillips12 reported tremendous success in resolution of otitis media with effu. sion in a 23 month old female who had undergone tradi. tional medical treatment including broad spectrum anti. biotic therapy, and bilateral myringotomies with tympanostomy tube placement. Restoration of normal mechanical function to the upper cervical spine following chiropractic acijustments resulted in noticeably reduced ear drainage and pain within 3 days after the initial ad. justment. Under continuing care, the patient's symptoms cleared and the tubes were expelled two years following the first visit. Controlled clinical trials are currently underway at chiropractic colleges investigating the chiropractic management of otitis media with effusion. AHCPR GUIDELINES FOR OTITIS MEDIA WITH EFFUSION IN YOUNG CIllLDREN Stool SE, Berg AO, Berman S, et al. Managing Otitis Media with EflUsion in YoungChildren. QuickIle{erenaGuide for Clinicians. AHCPR Publication 94-0628. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services July 1994 In: Pediatrics 1994; 94:766-73. . After comprehensively analyzing the research literature and current scientific knowledge of the development. diagnosis, and treatment of otitis media with effusion in young children, The Otitis Media Guideline Panel developed clinical practice guidelines pertaining to this subject. After reviewing the document, although medical approaches are favored, I found that the implications for conservative care were excellent. Addressed in the document is the option of the clinician to use observation (as in letting the body heal itself as a mode of treatment, since most cases will resolve spontaneously. This is a well received option of care to many whom have refuted the use of antibiotics, especially in early and mild cases. Now having these guidelines published promotes such practice as the standard of care. Read on for the facts. Acute otitis media is defined as, "fluid in the middle ear accompanied by signs or symptoms of ear infection (bulging eardrum usually accompanied by pain, or perforated eardrum, often with drainage of purulent material)." Otitis media with effusion is dermed as, "fluid in the middle ear without signs or symptoms of ear infection." ']'he clinical practice guideline discusses only otitis media with effusion targeted at children 1-3 years, with no craniofacial or neurologic abnormalities or sensory deficits, and who is healthy except for otitis media with effusion. "Longitudinal studies of otitis media with effusion show spontaneous resolution of the condition in more than half of children with 3 months from development ofthe effusion. Mter 3 months the rate of spontaneous resolution remains constant, so that only a small percentage of children experience otitis media with effusion lasting a year or longer." Scientific evidence showed that environmental factors such as bottle-feeding rather than breast-feeding infants, and passive smoking may increase potential risks of getting acute otitis media or otitis media with effusion. Facts from the guideline: -Observation alone OR antibiotic therapy are treatment options for children with effusion that has been present less than 4-6 months and at any time in children without a 20-decibel hearing threshold level or worse in the better-hearing ear. -Most cases of otitis media with effusion resolve spontaneously. -The most common adverse effects of antibiotic therapy are gastrointestinal. Dermatologic reactions may occur in 3% to 5% of cases; severe anaphylactic reactions are much rarer; severe hematologic, cardiovascular, central nervous system, endocrine, renal, hepatic, and respiratory adverse effects are rarer still. The potential for the development of microbial resistance is alw present with antibiotics. -For the child who has had bilateral effusions for a total of 3 months and who has a bilateral hearing deficiency (defined as a 20-decibel hearing threshold level or worse in the better-hearing ear), bilateral myringotomy with tube. insertion becomes an addition treatment OPTION. Placement oftympanostomy tubes is only recommended AFTER a total of 4-6 months of bilateral effusion with a bilateral hearing deficit. There is insufficient evidence to prove that there are long-term deleterious effects of otitis media with effusion, although the panel recommends surgery in this situation based on "their expert opinion." Tympanosclerosis might occur after surgery in 51% and postoperative otorrhea in 13% of children. -Steroid medications m,-e not recommended to treat otitis media with effusion in a child of any age because of limited scientific evidence that this treatment is effective. -Antihistamine/decongestant therapy is not recommended for treatment of otitis media with effusion in a child of any age. -Adenoidectomy is not an appropriate treatment for uncomplicated middle ear effusion in the child younger than age 4 years when adenoid pathology is not present. -Tonsillectomy, either alone or with adenoidectomy, has not been found effective for the treatment of otitis media with effusion. . -The association between allergy and otitis media with effusion was not clear from available evidence. -No recommendation was made for chiropractic, holistic, homeopathic, or other treatments were made because no randomized controlled studies were obtained for thier intervention and management. References 1. Hendricks CL, Larkin- Thier SM. Otitis Media in Young Chil. dren. Chiropractic 1989; 2(1):9-13. 2. Stangerup SE, Tos M. Etiologic role of suppurative otitis me dia in chronic secretory otitis. Am J Otol1985; 10:27-35. 3. Tox M, Poulsen G, Borch J. Tympanometry in 2-year-old children. ORL 1978; 40:77-85. 4. Archard JC. The place of myringotomy in the management of secretory otitis media in children. J Laryngol Otol1967 8J:309-15. 5. MacKinnon DM. The sequel to myringotomy for exudative otitis media. J Laryngol Otol1971;85(8):773-94. 6. Gates GA, WachtendorfC, Hearne EM, Holt GR. Treatment of otitis medi.a with effusion. Am J Otolargyngol 1985; 6:249-53. . 7. BennettRJ, Chakraborty AN. Primarymyringotomyforsecretory otitis media in children. J Laryngol Otol1969; 83: 589-600. 8. Van Cauwenberg P. The long term results of the treatment with transtympanic'ventilation tubes in children with chronic secretory otitis media. Int J. Pediatr Otorhinolaryngol 1979; 1:109-16. 9. Sipila P, Jokipii AM, Jokipii 1., Karma P. Bacteria in the middle ear and ear canal of patients with secretory otitis media and the non-inflamed ear. Acia Otolaryngoll981; 92:123-30. 10. McCaig LF, Hughes JM. Trends in Antimicrobial Drug Prescribing Among Office-Based Physicians in the United States. JAMA.1995; 273:214-9. 11. Cantekin EI, McGuire TW, Griffith IL. Antimicrobial Therapy for Otitis Media With Effusion ('Secretory' Otitis Media). JAMA 1991 December 18; 266:3309-3317. 12. Phillips NJ. Vertebral Subluxation and Otitis Media: A Case Study. Chiropractic 1 92; 8:38-9.

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