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Acute otitis media (AOM) is a common complication of acute upper respiratory infections and ranks as one of the primary reasons doctors prescribe antibiotics to children in the United States. This condition peaks between the ages of three and five, with children from six months to six years most affected, while it's relatively rare after age seven. Historical data shows that two-thirds of infants experience at least one episode of acute otitis media before their first birthday, and nearly half of toddlers have had three or more by age three. Children with congenital craniofacial anomalies, particularly those with midface developmental abnormalities, face a heightened risk due to abnormal bony structures affecting the Eustachian tube's function or structure. Specifically, infants with unrepaired cleft palate have a 100% likelihood of developing acute or chronic otitis media under two years old. Over time, half of these individuals may experience significant hearing impairment, impacting language development and social interactions. This article aims to provide a foundational understanding of diagnosis and treatment for otitis media in patients with craniofacial developmental anomalies.
The Eustachian tube connects the middle ear to the external environment, opening into the nasopharynx and primarily maintaining pressure balance. In children, the Eustachian tube is shorter and positioned at a more horizontal angle compared to adults, with a smaller angle to the horizontal plane (around 45 degrees in adults) and a narrower opening near the nasopharynx. During acute upper respiratory infections, inflammation in the nasopharynx can block the Eustachian tube, creating negative pressure in the middle ear and leading to fluid accumulation that cannot drain properly. Pathogens from the nasopharynx can then migrate into the middle ear, causing acute otitis media. Due to these anatomical differences, children are more susceptible to infections and recurrences.
Between ages two and five, adenoid tissue (also known as lymphoid tissue) in the nasopharynx grows rapidly, often contributing to nasal congestion and mucus buildup that hinders drainage. This can result in otitis media with effusion, where middle ear secretions cannot flow into the nasopharynx due to the blocked Eustachian tube opening. Additionally, aside from incomplete Eustachian tube development, craniofacial anomalies are linked to abnormal development of the Eustachian tube's muscular function and cranial bone structures.
(Note: Otitis media with effusion is defined as persistent middle ear fluid beyond three months, while recurrent acute otitis media involves more than four episodes in a year or three in six months.)
The classic presentation of acute otitis media follows an upper respiratory infection like coughing or runny nose, often waking a child in the middle of the night with pain, accompanied by fever. Younger children may pull at their ears, hit their heads, or cry incessantly. Otoscopic examination reveals red, bulging eardrums with possible thick secretions confirming the diagnosis. Many cases progress to a state of middle ear effusion, known as otitis media with effusion, unrelated to swimming or water entering the ears during bathing.
Otitis media with effusion primarily causes mild conductive hearing loss without other symptoms, making it easy to overlook. In infants and toddlers, this hearing impairment may persist for weeks or months undetected until an infection or routine check-up reveals it. School-aged children might be noticed when they turn up the TV volume at home or are reported by teachers for inattention in class.
Bacterial pathogens like Streptococcus pneumoniae and Haemophilus influenzae account for over 60% of acute otitis media cases, leading most physicians to prescribe antibiotics. After 10-14 days of treatment, symptoms such as ear pain and fever typically improve significantly.
Effusion following acute otitis media often results in mild conductive hearing loss, which can lead to speech and learning delays, especially with bilateral involvement. Fortunately, this hearing loss usually resolves once the effusion clears. However, in some cases, particularly with craniofacial anomalies, effusion may persist beyond three months, progressing to chronic otitis media with effusion and potentially causing long-term hearing impairment. Otolaryngologists may recommend tympanoplasty tubes as an aggressive treatment.
The procedure for inserting tympanoplasty tubes involves general anesthesia under a microscope, making a small incision in the eardrum to drain the effusion and insert the tube, taking about 30 minutes. These small tubes restore middle ear ventilation, improving hearing immediately and reducing recurrence. Tubes typically fall out on their own within six months to a year into the outer ear canal, where they can be removed during an office visit without additional surgery. Before tubes fall out, children can use ear plugs during water activities to prevent water from entering the ear canal and causing infection.
For patients with craniofacial anomalies, especially cleft palate, debate continues on whether tympanoplasty tubes are necessary alongside effusion. Research indicates that cleft palate patients who undergo palate repair and tube insertion before age one have better hearing and middle ear conditions than those treated later. Their outcomes remain poorer compared to non-cleft children, so early intervention with palate repair and tube insertion is recommended, followed by regular hearing monitoring to ensure no ongoing changes that could affect speech and social development.
Due to abnormal Eustachian tube development, children with craniofacial anomalies are more prone to otitis media and its complications, which can impair hearing and language learning, hindering educational progress and interpersonal relationships. Therefore, these children should undergo ongoing ENT evaluations and hearing assessments from birth, coordinated with medical professionals for appropriate management and treatment of otitis media.