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OTITIS MEDIA
Cuneyt M. Alper, MD
Associate Professor, Department of Otolaryngology
University of Pittsburgh School of Medicine
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennyslvania
Charles D. Bluestone, MD
Eberly Professor of Pediatric Otolaryngology
University of Pittsburgh School of Medicine
Director, Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Joseph E. Dohar, MD
Associate Professor, Department of Otolaryngology
University of Pittsburgh School of Medicine
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Ellen M. Mandel, MD
Research Associate Professor
Department of Otolaryngology and Pediatrics
University of Pittsburgh School of Medicine
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania
2004
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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages,
is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards,
the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves
inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform
and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.
DEDICATION
We dedicate this book to our families, teachers, colleagues, house staff, and studentsbut
especially to clinicians. They will benefit from the most up-to-date, advanced information
on the management of otitis media and its complications and sequelae. In turn, we hope this
knowledge will improve the health care of their patients who suffer from this common disease. The contents of this text have already helped us in the management of our patients
because we have had the pleasure of editing chapters from many distinguished, worldrenowned experts and have learned a great deal by contributing our own chapters.
CONTENTS
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Ackowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Section I: Introduction
1.
2.
Diagnostic Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Olli Ruuskanen, MD, Aino Ruohola, MD
3.
4.
Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Kathleen A. Daly, PhD
5.
7.
8.
9.
Myringitis Bullosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
L. Nicole Murray, MD
vi / Contents
29. Prevention of Acute Otitis Media during the Common Cold. . . . . . . . . . . . . 152
Craig A. Buchman, MD, Subinoy Das, MD
Contents / vii
35. Steroids for Chronic Otitis Media with Effusion in Children . . . . . . . . . . . . . 180
Ellen M. Mandel, MD
37. Autoinflation for the Treatment of Otitis Media with Effusion . . . . . . . . . . . 189
Cuneyt M. Alper, MD
viii / Contents
61. External Ear Canal Polyp versus Mass in the External Ear Canal . . . . . . . . . . 306
Tauno Palva, MD, Hans Ramsay, MD
Contents / ix
70. Cholesterol Granuloma of the Middle Ear and Mastoid (Blue Ear) . . . . . . 355
A. Necmettin Akyldz, MD, Yusuf K. Kemalo
glu, MD
x / Contents
93. Acute Otitis Media and Otitis Media with Effusion in the
Immunocompromised Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
Britta Rynnel-Dag MD, PhD
Contents / xi
96. Otitis Media and Its Complications in Congenital Aural Atresia . . . . . . . . . . 474
Robert F. Yellon, MD
107. Treatment of Otitis Media in Regions with Limited Health Care. . . . . . . . . . 526
Amanda Leach, PhD, Peter Morris, FRACP, PhD
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
PREFACE
It is common knowledge that otitis media is the most frequent diagnosis made by physicians
who provide health care to infants and children. However, clinicians often confront older
patients who develop this disease, which occurs in all age groups. It is estimated that over
20,000 adults have tympanostomy tubes inserted in their ears annually. Otitis media is a
worldwide disease that not only has a substantial impact on patients and their families, but
also is a burden on health care systems in both industrialized nations and developing countries. Thus, we now have Advanced Therapy in Otitis Media, which provides answers to clinical care questions from the most common problems to the relatively rare complications and
sequelae of otitis media. This content is targeted at clinicians who face this disease daily, in
their practice, in a variety of presentations. They include primary care physicians in the community and in tertiary care medical centers, including pediatricians, internists, family care
practitioners, specialists in otolaryngology, immunology and allergy, and infectious diseases,
and medical students and residents in training. Because the disease is universal, the information provided is directed toward clinicians around the world.
We are fortunate to have recruited a group of distinguished authorities in the field from
many countries who are making important advances in our knowledge base related to the
management of otitis media. We are unaware of any other similar text that has focused on
therapy in otitis media in which there are over 100 chapters by experts on this disease entity.
As editors of and contributors to this unique text, we are overwhelmed by the number of
international experts in the management of otitis media who agreed to contribute chapters
on relatively narrowly focused aspects of the medical and surgical treatment and prevention
of otitis media and its complications and sequelae. We specifically requested that the authors
provide the latest advances in one or two aspects of the management of the disease. We recognized that probably every current textbook in pediatrics, primary care, otolaryngology, and
infectious diseases has one or more chapters devoted to otitis media written by one or two
authors, and there are other authors who have written monographs on the other aspects of this
disease (eg, epidemiology, pathogenesis, microbiology, immunology, and diagnosis), in addition to management. (Indeed, one of us is a coauthor of such a blook [Bluestone CD, Klein JO.
Otitis media in infants and children. 3rd ed. Philadelphia (PA): WB Saunders; 2001]), but no
other text, to our knowledge, is quite like this one. We have provided chapters on the management of not only the most common initial stages of the disease (ie, acute otitis media and
otitis media with effusion) but also have included the complications and sequelae of otitis
media that can be life threatening, such as meningitis and brain abscess.
We have organized the chapters in such a way that clinicians can select the specific question being asked and gain comprehensive but succinct answers from the expert. The text is
directed at all health care professionals who are faced with patients with otitis media.
xiv / Preface
We are not only colleagues who provide health care on a daily basis for infants and children who have otitis media at the Childrens Hospital of Pittsburgh some of us have been
together for over 20 yearswe have also had a long-standing commitment to the research
aspects of the management of this disease. Our Department of Pediatric Otolaryngology has
had continuous funding for clinical trials and other basic and laboratory studies related to
otitis media from the National Institutes of Health for the past 25 years. It is hoped that we
will have more answers to important management questions in the future with our current
investigations, as well as with the investigations of others who conduct research and who
have contributed to this book. We hope this will prompt frequent future editions similar to
other texts in this series on various common diseases published by BC Decker Inc.
Cuneyt M. Alper, MD
Charles D. Bluestone, MD
Margaretha L. Casselbrant, MD, PhD
Joseph E. Dohar, MD
Ellen M. Mandell, MD
October 2003
ACKNOWLEDGMENTS
We thank all of our invited clinicians from around the world who are authorities in the management of otitis media and who contributed chapters for this textbook. Without their commitment, hard work, and prompt submission of their manuscripts, this book could never
have been published. We also want to recognize the dedicated leadership provided by Cuneyt
M. Alper, MD, without whose commitment this text would not have reached the publisher.
The first edition of any book that has over 100 chapters is a difficult and somewhat painstaking task, but he kept the rest of us motivated. Equally important in completing this book was
Maria B. Bluestone, whom we wish to acknowledge for her outstanding editorial assistance in
bringing this text into a highly readable form with her expertise in English grammar and syntax. Also, we thank Debi Hepple for her secretarial help and organization skills in contacting
the contributors. Finally, we thank the editors at BC Decker Inc, our publisher, and especially
Brian Decker and Rochelle Decker, who invited and inspired us to write this unique book.
CONTRIBUTORS
A. NECMETTIN AKY LDZ, MD
Department of Otolaryngology
Gazi University Faculty of Medicine
Ankara, Turkey
GREGORY C. ALLEN, MD
Department of OtolaryngologyHead and Neck Surgery
University of Colorado Health Sciences Center
Denver, Colorado
CUNEYT M. ALPER, MD
Department of Otolaryngology
University of Pittsburgh School of Medicine
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania
JAMES C. ANDERSON, MD
Department of Radiology
Oregon Health and Science University
Portland, Oregon
PATRICK J. ANTONELLI, MD
Department of Otolaryngology
University of Florida
Gainesville, Florida
ELIZABETH D. BARNETT, MD
Department of Pediatrics
Boston University School of Medicine
Boston, Massachusetts
JAMES S. BATTI, MD
Division of Pediatric Otolaryngology
University of Connecticut School of Medicine
Hartford, Connecticut
HOWARD BAUCHNER, MD
Department of Pediatrics
Boston University School of Medicine
Boston, Massachusetts
MICHAEL J. BELMONT, MD
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania
CHARLES D. BLUESTONE, MD
Department of Otolaryngology
University of Pittsburgh School of Medicine
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania
ALEXANDER BRODSKY, MD
Department of OtolaryngologyHead and Neck Surgery
Bnai-Zion Medical Center
Haifa, Israel
CRAIG A. BUCHMAN, MD
Department of OtolaryngologyHead and Neck Surgery
University of North Carolina
Chapel Hill, North Carolina
KENNY H. CHAN, MD
Department of Otolaryngology
University of Colorado School of Medicine
Denver, Colorado
xviii / Contributors
DAVID H. CHI, MD
Department of Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
TASNEE CHONMAITREE, MD
Department of Pediatrics
University of Texas Medical Branch
Galveston, Texas
ROBERT COHEN, MD
Pediatrie
Centre Hpital Intercommunal de Creteil
Creteil, France
MICHAEL J. CUNNINGHAM, MD
Department of Otology and Laryngology
Harvard Medical School
Boston, Massachusetts
SUBINOY DAS, MD
Department of OtolaryngologyHead and Neck Surgery
University of North Carolina
Chapel Hill, North Carolina
NARIMAN DASH, MD
Department of OtolaryngologyHead and Neck Surgery
Eastern Virginia Medical School
Norfolk, Virginia
ANTONIO DE LA CRUZ, MD
Department of Otology
University of Southern California
Los Angeles, California
JAIMIE DE ROSA, MD
Department of OtolaryngologyHead and Neck Surgery
Boston University School of Medicine
Boston, Massachusetts
CRAIG S. DERKAY, MD
Departments of Otolaryngology and Pediatrics
Eastern Virginia Medical School
Norfolk, Virginia
ANGELA ELLISON, MD
Department of Pediatrics
Boston University School of Medicine
Boston, Massachusetts
HOWARD FADEN, MD
Department of Pediatrics
State University of New York
Buffalo, New York
PIERRE GEHANNO, MD
Department of Otorhinolaryngology and
Cervico-Facial Surgery
Bichat-Claude Bernard Teaching Hospital
Paris, France
DEBORAH A. GENTILE, MD
Department of Pediatric Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
FARYAL GHAFFAR, MD
Department of Pediatric Infectious Diseases
University of Texas Southwestern Medical Center
Dallas, Texas
NIRA A. GOLDSTEIN, MD
Department of Otolaryngology
State University of New York Downstate Medical Center
Brooklyn, New York
RICHARD L. GOODE, MD
Department of Otolaryngology
Stanford University School of Medicine
Stanford, California
Contributors / xix
ANIL GUNGOR, MD
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania
SEISHI HASEBE, MD
Department of Hearing and Speech Sciences
Kyoto University Graduate School of Medicine
Kyoto, Japan
DAVID J. KAY, MD
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania
JEROME O. KLEIN, MD
Maxwell Finland Laboratory for Infectious Diseases
Boston Medical Center
Boston, Massachusetts
RUDOLF LEUWER, MD
ENT Department
Hamburg University Medical School
Hamburg, Germany
MICHAL LUNTZ, MD
Department of Otolaryngology, Head and
Neck Surgery
Bnai Zion Medical Center
Haifa, Israel
WILLIAM M. LUXFORD, MD
House Ear Clinic
Los Angeles, California
ELLEN M. MANDEL, MD
Department of Otolaryngology and Pediatrics
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
DAVID L. MANDELL, MD
Department of Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
PAOLA MARCHISIO, MD
Department of Pediatrics
University of Milan Medical School
Milan, Italy
xx / Contributors
L. NICOLE MURRAY, MD
Department of Pediatric Otolaryngology
Louisiana State University Health Sciences Center
New Orleans, Louisiana
PHILIPPE OVETCHKINE, MD
Department of Pediatrics
Hopital Sainte-Justin
Montreal, Quebec
O. NURI ZGIRGIN, MD
Department of Otolaryngology
Baskent University
Ankara, Turkey
TAUNO PALVA, MD
Department of Otolaryngology
University of Helsinki
Helsinki, Finland
MICHAEL M. PAPARELLA, MD
Department of Otolaryngology
University of Minnesota
Minneapolis, Minnesota
STEPHEN I. PELTON, MD
Department of Pediatrics
Boston University School of Medicine
Boston, Massachusetts
MICHAEL E. PICHICHERO, MD
Elmwood Pediatric Group
University of Rochester Medical Center
Rochester, New York
THANAI PONGDEE, MD
Department of Internal Medicine
Division of Allergic Diseases
Mayo Clinic
Rochester, Minnesota
NICOLA PRINCIPI, MD
Department of Pediatrics
University of Milan Medical School
Milan, Italy
HANS RAMSAY, MD
Department of Otolaryngology
University of Helsinki
Helsinki, Finland
YAEL RAZ, MD
Department of Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
JAMES S. REILLY, MD
Department of Otolaryngology and Pediatrics
Thomas Jefferson Medical University
Philadelphia, Pennsylvania
SOHAM ROY, MD
Department of OtolaryngologyHead and Neck Surgery
University of Miami
Miami, Florida
AINO RUOHOLA, MD
Department of Pediatrics
Turku University Hospital
University of Turky
Turku, Finland
Contributors / xxi
OLLI RUUSKANEN, MD
Department of Infectious Diseases
Turku University
Turku, Finland
RICHARD H. SCHWARTZ, MD
Department of Pediatric Allergy and Immunology
Inova Fairfax Hospital for Children
Falls Church, Virgina
UDAYAN K. SHAH, MD
Department of Otolaryngology, Head and Neck Surgery
University of Pennsylvania
Philadelphia, Pennsylvania
GORDON J. SIEGEL, MD
Department of Otolaryngology, Head and Neck Surgery
Feinberg School of Medicine
Chicago, Illinois
DAVID P. SKONER, MD
Department of Pediatrics and Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
SVEN-ERIC STANGERUP, MD
Department of ENT
Gentofte University Hospital
Hellerup, Denmark
MASAHARU SUDO, MD
Department of Otolaryngology
Fukui Red Cross Hospital
Fukui, Japan
MARK J. SYMS, MD
Department of Neurosurgery
Barrow Neurological Institute
Phoenix, Arizona
HARUO TAKAHASHI, MD
Department of Translational Medical Sciences
Nagasaki University Graduate School of Biomedical Sciences
Nagasaki, Japan
KITIRAT UNGKANONT, MD
Department of Otolaryngology
Mahidol University Siriraj Hospital
Bangkok, Thailand
ELLEN R. WALD, MD
Department of Pediatrics
University of Pittsburg School of Medicine
Pittsburgh, Pennsylvania
JANE L. WEISSMAN, MD
Department of Diagnostic Radiology
Oregon Health and Science University
Portland, Oregon
MARK E. WHITAKER, MD
Department of Otolaryngology
Geisinger Medical Center
Danville, Pennsylvania
NOBORU YAMANAKA, MD
Department of Otorhinolaryngology
Wakayama Medical College
Wakayama, Japan
ROBERT F. YELLON, MD
Department of Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
RYO YUASA, MD
Department of Otolaryngology
Tohoku University School of Medicine
Sendai, Japan
CARLTON J. ZDANSKI, MD
Department of Otolaryngology, Head and Neck Surgery
University of North Carolina School of Medicine
Chapel Hill, North Carolina