Tympanocentesis for Treatment of Acute Otitis Media

This article originally appeared online at DrPullen.com, part of the HCPLive network.

Sounds pretty radical at first, but maybe we should ask ourselves why acute otitis media is the one easily drainable abscess that we don’t routinely drain, but rather try to treat with antibiotics without drainage. Admittedly acute ear infections often get better with or without antibiotic treatment. Still Dr. Mark Grubb makes a lot of sense when he talks about a simple procedure to make a small pinhole in the eardrum to allow the fluid to drain, giving immediate relief of pain and often avoiding the need to use analgesics or antibiotics. I’ve done the procedure myself using Dr. Grubb’s CDT Speculum device (Channel Directed Tympanocentesis) and it really is simple and easy. Any family physician or pediatrician can easily do the procedure. Hear what Dr. Grubb has to say on the pros and cons of various treatments for acute ear infections:

Tympanocentesis for Treatment of Acute Otitis Media

By Dr. Mark Grubb

The ear infection (medical term: acute otitis media, or AOM) is the most common childhood disease in America, and is also the leading cause for antibiotic prescriptions among children.

After antibiotic resistance was recognized as a global problem in the late 1990’s, physicians began to consider alternative therapies for AOM. Current AOM treatment options include oral antibiotic therapy, topical medications, observation (wait & see), and tympanocentesis (a puncture of the ear drum to relieve pressure and aspirate fluid). Most of these therapies are usually accompanied by oral analgesics (acetaminophen or ibuprofen).

This article examines the pros and cons associated with each treatment method.

Immediate antibiotic therapy:

Systemic (oral or intravenous) antibiotic therapy today remains the most common treatment method for AOM. The antibiotics are intended to eradicate the pathogen causing the ear infection, thereby curing the disease. If there were no harmful effects associated with antibiotic usage, antibiotics would be the permanent ideal therapy for ear infections, and for any and all other infections potentially caused by bacterial pathogens. Unfortunately, this is not the case.

Widespread use of antibiotics contributes to the ability of the targeted pathogens to develop resistance to the antibiotic drugs, i.e. antibiotic resistance. The more we use a certain antibiotic drug, the more bacterial pathogens will become resistant to that drug over time. This is an unavoidable outcome associated with use of antibiotics, but it is manageable, because resistance is directly related to usage rates. Medical studies have shown that careful and judicious use of antibiotics within a population reduces the frequency with which resistant pathogens are encountered.

This brings us back to ear infections. We know from a few decades of research that AOM is primarily a self-resolving disease. Evidence shows that approximately 75% of AOM episodes will resolve satisfactorily in one week or less without systemic antibiotic therapy. Other medical studies have demonstrated that about 13 AOM patients must receive an antibiotic drug for 1 to obtain benefit that otherwise would not have occurred.

Pros — blanket antibiotic therapy for AOM patients can provide a slightly increased “cure rate” and may reduce the duration of AOM pain by up to 1 day, as compared to a similar population of AOM patients who do not receive antibiotic therapy.

Cons — our habit of giving many kids antibiotics so that a few can benefit contributes significantly to the development of resistant pathogens. Systemic antibiotics are also associated with other adverse drug-related events such as eradication of beneficial bacteria from the mouth, throat, and digestive tract, contributing to thrush, increased risk of subsequent illness, skin rashes, and diarrhea.

Topical antibiotic drops:

Pros — because they are localized to the ear drum and middle ear space, these non-systemic antibiotic drops have the potential to be effective against AOM pathogens without causing many of the problems associated with systemic antibiotics.

Cons — the antibiotic drug in these drops will not pass effectively across the ear drum to reach the infected fluid on the other side unless there is a perforation in the ear drum. Because only a minority of AOM patients have a perforated eardrum (spontaneous perforation, tubes, or tympanocentesis), the drops are ineffective for most patients.

Other topical medications:

There is very little evidence available on the effect of antipyrine/benzocaine or herbal topical pain relief medications. These solutions may provide a slight benefit in terms of temporary pain relief, but do not contribute to overall resolution of AOM episodes.

Observation Option:

Otherwise known as the wait-and-see approach, this treatment method employs a 2 or 3 day observation period during which AOM symptoms are treated with analgesics and we wait to see if the episode resolves on its own. If the patient is still symptomatic after the observation period, another treatment method is employed. This approach takes advantage of the self-resolving nature of AOM.

Pros — this approach helps reduce the amount of antibiotics that are prescribed for AOM.

Cons — about 25% of AOM patients can be expected to remain symptomatic after an observation period, which means that this percentage of patients will have spent a few “tough” days purely for the purpose of being identified as candidates for another therapy. Furthermore, at the end of the observation period, no more is known about the specific pathogen causing their disease than when observation was begun. This approach relies heavily on the use of analgesics to manage AOM symptoms, which may not be in the best interests of the patient (see the next paragraph below). Lastly, the observation option is not a very pro-active treatment method, and therefore can be difficult for providers and parents to embrace.

Oral analgesics:

AOM is frequently a painful condition, with significant discomfort associated with the infected fluid trapped in the middle ear space.

Pros — oral analgesics (acetaminophen & ibuprofen) can be helpful in reducing AOM pain and contributing to more normal sleep patterns.

Cons —a growing body of evidence suggests that there are potential harms associated with analgesic use. Acetaminophen use has been associated with increased risk of childhood asthma and also liver toxicity. Ibuprofen use has been associated with increased risk of soft tissue infections and gastrointestinal bleeding after only one or two age-appropriate doses.

Tympanocentesis:

This approach involves a needle perforation of the ear drum to relieve the pressure of trapped fluid in the middle ear space, and to obtain a sample of the infected fluid for culture analysis. When used as an adjunct to the observation option, tympanocentesis eliminates the cause of AOM pain and allows identification of the pathogen so that precisely targeted antibiotic therapy can be chosen for the minority of patients who remain symptomatic after the observation period. Tympanocentesis also promotes therapeutic drainage of infected fluid from the middle ear space, which is beneficial to the patient in the same manner as draining any other form of abscess.

Pros — tympanocentesis eliminates pain, which reduces or eliminates the need for analgesic therapy. Therapeutic drainage contributes to clinical resolution. Identification of causative pathogen eliminates the need to empirically select antibiotics, thereby reducing the incidence rate of ineffective antibiotic prescriptions.

Cons — tympanocentesis is infrequently employed in primary care. Some training is necessary for the procedure, but most residency programs do not train for it.

Discussion:

Although the frequency of ear infections in children seems to be somewhat lower after introduction of the pneumococcal vaccine, AOM is still a prevalent disease, and the way we manage it has a profound impact on our children and their families.

To read more about tympanocentesis, including full citations for the evidence summaries above, please visit Dr. Grubb’s blog. Also check out a video of what the device looks like and how it works.

Dr. Mark Grubb works as a full time pediatrician at Woodcreek Healthcare in Puyallup, WA.

Ed Pullen, MD, is a board-certified family physician practicing in Puyallup, WA. He blogs at DrPullen.com — A Medical Bog for the Informed Patient.