Advanced Therapy of

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

Margaretha L. Casselbrant, MD, PhD

Professor, Department of Otolaryngology
University of Pittsburgh School of Medicine
Director of Research and Education
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
BC Decker Inc
Hamilton London

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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.

Definitions of Otitis Media and Related Diseases . . . . . . . . . . . . . . . . . . . . . . . . 1

Charles D. Bluestone, MD

2.

Diagnostic Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Olli Ruuskanen, MD, Aino Ruohola, MD

3.

Examination of the Tympanic Membrane for Otitis Media . . . . . . . . . . . . . . . 14

Glenn C. Isaacson, MD, FACS, FAAP

4.

Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Kathleen A. Daly, PhD

5.

Risk Factors for Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Margaretha L. Casselbrant, MD, PhD, Ellen M. Mandel, MD

Section II: Acute Otitis Media

6.

First-Line Treatment of Acute Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Michael E. Pichichero, MD

7.

Short-Course Antibiotics for Acute Otitis Media. . . . . . . . . . . . . . . . . . . . . . . . 39

Robert Cohen, MD, Philippe Ovetchkine, MD, Pierre Gehanno, MD

8.

Management of Acute Otitis Media without Antibiotics. . . . . . . . . . . . . . . . . . 44

Anne G. M. Schilder, MD, PhD

9.

Myringitis Bullosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
L. Nicole Murray, MD

10. Acute Otitis Media with Perforation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

David L. Mandell, MD

11. The Red Eardrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Richard H. Schwartz, MD

12. Myringotomy and Tympanocentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Michael J. Belmont, MD

vi / Contents

13. Viral Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Tasnee Chonmaitree, MD

14. Acute Otitis Media and HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Paola Marchisio, MD, Nicola Principi, MD

15. Acute Otitis Media in Children with Penicillin/Antibiotic Allergy. . . . . . . . . . 76

Thanai Pongdee, MD, James T.-C. Li, MD, PhD

16. Antibiotic Management of Refractory Acute Otitis Media . . . . . . . . . . . . . . . . 83

Stan L. Block, MD, FAAP

17. Management of Acute Otitis Media in an Antibiotic-Resistant

Era Worldwide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Faryal Ghaffar, MD, George H. McCracken Jr, MD

18. Intramuscular Antimicrobial Therapy for Acute Otitis Media . . . . . . . . . . . . 101

Angela Ellison, MD, Howard Bauchner, MD

Section III: Recurrent Acute Otitis Media

19. When Is Acute Otitis Media Too Often? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Kari Jorunn Kvaerner, MD, PhD

20. The Otitis-Prone Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

David J. Kay, MD

21. Ventilation Tubes for Recurrent Acute Otitis Media . . . . . . . . . . . . . . . . . . . . 113

Margaretha L. Casselbrant, MD, PhD

22. Antibiotic Prophylaxis for Recurrent Acute Otitis Media . . . . . . . . . . . . . . . . 117

Richard M. Rosenfeld, MD, MPH

23. Adenoidectomy with and without Tonsillectomy for

Recurrent Acute Otitis Media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Jacob Friedberg, BA, MD, FRCSC

24. Role of Nasopharyngeal Colonization in Recurrent Otitis Media . . . . . . . . . 125

Howard Faden, MD

25. Viral Vaccines for Recurrent Acute Otitis Media . . . . . . . . . . . . . . . . . . . . . . . 130

Terho Heikkinen, MD, PhD

26. Bacterial Vaccines for Prevention of Acute Otitis Media . . . . . . . . . . . . . . . . . 134

Jerome O. Klein, MD

27. Mucosal Immunity and Nasal Immunization in the Treatment

of Infectious Diseases of the Upper Respiratory Tract. . . . . . . . . . . . . . . . . . . 138
Joel Bernstein, MD, PhD, Noboru Yamanaka, MD

28. Allergy Testing/Treatment for Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Deborah A. Gentile, MD, David P. Skoner, MD

29. Prevention of Acute Otitis Media during the Common Cold. . . . . . . . . . . . . 152
Craig A. Buchman, MD, Subinoy Das, MD

Contents / vii

30. Rhinosinusitis in Recurrent Acute Otitis Media. . . . . . . . . . . . . . . . . . . . . . . . 158

Anil Gungor, MD

31. Immune Workup/Management for Recurrent Otitis Media. . . . . . . . . . . . . . 164

Stephen I. Pelton, MD

32. Immunoglobulins for Recurrent Acute Otitis Media. . . . . . . . . . . . . . . . . . . . 169

Michiya Matsumura, MD, PhD

Section IV: Otitis Media with Effusion

33. Watchful Waiting for Otitis Media with Effusion. . . . . . . . . . . . . . . . . . . . . . . 171
Michael J. Belmont, MD

34. Antibiotics for Otitis Media with Effusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

Richard M. Rosenfeld, MD, MPH

35. Steroids for Chronic Otitis Media with Effusion in Children . . . . . . . . . . . . . 180
Ellen M. Mandel, MD

36. Adjuvant Therapy for Otitis Media with Effusion . . . . . . . . . . . . . . . . . . . . . . 185

David L. Mandell, MD

37. Autoinflation for the Treatment of Otitis Media with Effusion . . . . . . . . . . . 189
Cuneyt M. Alper, MD

38. Myringotomy and Tympanostomy Tubes for Otitis Media

with Effusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Charles D. Bluestone, MD

39. Ventilation Tube Placement in Ears with Thin Eardrum

or Myringosclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Gregory C. Allen, MD

40. Management of Otitis Media and Otitis Media with Effusion in

the Speech-Delayed Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Robert J. Ruben, MD, FACS, FAAP

41. Laser-Assisted Myringotomy in Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . 207

James S. Reilly, MD, Gordon J. Siegel, MD

42. Adenoidectomy with and without Tonsillectomy for Otitis Media

with Effusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
A. Richard Maw, MS, FRCS

43. Long-Lasting Tubes for Otitis Media with Effusion. . . . . . . . . . . . . . . . . . . . . 214

Richard L. Goode, MD

44. Mastoidectomy in Chronic Otitis Media with Effusion. . . . . . . . . . . . . . . . . . 218

O. Nuri zgirgin, MD

45. Incidental Middle Ear/Mastoid Fluid in Computed

Tomography/Magnetic Resonance Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Cuneyt M. Alper, MD

viii / Contents

46. Type of Tube To Insert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

David J. Kay, MD

Section V: Complications of Ventilation Tubes

47. Post-Tympanostomy Tube Otorrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Terho Heikkinen, MD, PhD

48. Water Precautions with Tympanostomy Tubes . . . . . . . . . . . . . . . . . . . . . . . . 242

Nira A. Goldstein, MD

49. Eardrops for Otorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Joseph E. Dohar, MD, MS, FACS, FAAP

50. Ototoxicity owing to Eardrops. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

Marcos V. Goycoolea MD, PhD

51. Oral Antibiotic Treatment for Purulent Ear Discharge . . . . . . . . . . . . . . . . . . 258

Pierre Gehanno, MD, Robert Cohen, MD

52. Intravenous Antibiotics for Otorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261

Margaret A. Kenna, MD, FAAP, FACS

53. Evaluation and Treatment of Recurrent Post-Tympanostomy Otorrhea . . . . . 266

Patrick J. Antonelli, MD

54. Workup and Management of Chronic Otorrhea . . . . . . . . . . . . . . . . . . . . . . . 271

Charles D. Bluestone, MD

55. Methicillin-Resistant Staphylococcus aureus Otorrhea. . . . . . . . . . . . . . . . . . . 278

Charles M. Myer III, MD

56. Other Complications of Tympanostomy Tubes . . . . . . . . . . . . . . . . . . . . . . . . 281

Adele Yarrington Evans, MD, Michael J. Cunningham, MD

57. Persistent Tympanic Membrane Perforation following Surgical

Insertion of Ventilation Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Emmanuel Helidonis, MD, FACS

58. Retained Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Karin Stenfeldt, MD, PhD

Section VI: Chronic Suppurative Otitis Media

59. Chronic Suppurative Otitis Media with Cholesteatoma . . . . . . . . . . . . . . . . . 295
William M. Luxford, MD, Mark J. Syms, MD

60. Chronic Suppurative Otitis Media without Cholesteatoma . . . . . . . . . . . . . . 299

Harvey Coates, MS, FRACS

61. External Ear Canal Polyp versus Mass in the External Ear Canal . . . . . . . . . . 306
Tauno Palva, MD, Hans Ramsay, MD

Contents / ix

Section VII: Complications of Otitis Media

62. When to Suspect Complicated Suppurative Otitis Media . . . . . . . . . . . . . . . . 312
Vedantam Rupa, MS, DLO

63. Periauricular/Postauricular/External Ear Canal Swelling . . . . . . . . . . . . . . . . 318

Nira A. Goldstein, MD

64. Acute Mastoiditis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

Michal Luntz, MD, Alexander Brodsky, MD

65. Chronic Mastoiditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

Stephanie Moody Antonio, MD, Derald E. Brackmann, MD, FACS

66. Facial Paralysis in Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

Barry Schaitkin, MD, FACS

67. Balance and Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

Margaretha L. Casselbrant, MD, PhD

68. Sensorineural Hearing Impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343

Ellis M. Arjmand, MD, PhD

69. Labyrinthitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348

Charles D. Bluestone, MD

70. Cholesterol Granuloma of the Middle Ear and Mastoid (Blue Ear) . . . . . . 355
A. Necmettin Akyldz, MD, Yusuf K. Kemalo
glu, MD

71. Subperiosteal Abscess/Bezolds Abscess. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359

Joseph Haddad Jr, MD

72. Petrositis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362

Charles D. Bluestone, MD

73. Epidural Abscess and Subdural Empyema . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365

David H. Chi, MD

74. Lateral Sinus Thrombosis and Otitic Hydrocephalus . . . . . . . . . . . . . . . . . . . 369

Kenny H. Chan, MD

75. Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374

Ellen R. Wald, MD

76. Cerebritis and Brain Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379

Kitirat Ungkanont, MD

Section VIII: Sequelae of Otitis Media

77. Tympanic Membrane Perforation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Sten Hellstrm, MD, PhD

78. Tympanosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387

Stephanie Moody Antonio, MD, Antonio De La Cruz, MD, Karen Borne Teufert, MD

x / Contents

79. Dimeric Tympanic Membrane. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392

Sten Hellstrm, MD, PhD

80. Middle Ear Atelectasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394

Sven-Eric Stangerup, MD

81. Adhesive Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398

Gregory C. Allen, MD

82. Retraction Pockets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400

Pedro Clars, MD, PhD

83. Cholesteatoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406

Chris A. J. Prescott, CAJ, FRCS

84. Ossicular Discontinuity/Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414

James S. Batti, MD

85. Conductive Hearing Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419

Yael Raz, MD

86. Effects of Otitis Media on Childrens Speech and Language . . . . . . . . . . . . . . 425

Joanne E. Roberts, PhD

87. Tympanoplasty in the Young Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431

Mirko Tos, MD, DMSc

88. State of Eustachian Tube Function in Tympanoplasty . . . . . . . . . . . . . . . . . . 436

Haruo Takahashi, MD, Seishi Hasebe, MD, Masaharu Sudo, MD

89. Persistent Perforation after Tympanoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . 440

Ryo Yuasa, MD, Tomonori Takasaka, MD, PhD

90. Ventilation Tubes in Association with Tympanoplasty . . . . . . . . . . . . . . . . . . 447

Michael M. Paparella, MD

Section IX: Miscellaneous Topics on Otitis Media

91. Imaging in Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Jane L. Weissman, MD, James C. Anderson, MD

92. Otitis Media in Newborn Infants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458

Elizabeth D. Barnett, MD

93. Acute Otitis Media and Otitis Media with Effusion in the
Immunocompromised Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
Britta Rynnel-Dag MD, PhD

94. Acute Otitis Media/Otitis Media with Effusion in Children

with Cleft Palate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Rudolf Leuwer, MD

Contents / xi

95. Acute Otitis Media/Otitis Media with Effusion in . . . . . . . . . . . . . . . . . . . . . . 468

Craniofacial Syndromes
Udayan K. Shah, MD

96. Otitis Media and Its Complications in Congenital Aural Atresia . . . . . . . . . . 474
Robert F. Yellon, MD

97. Exclusively Unilateral Recurrent Acute Otitis Media or

Otitis Media with Effusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
David H. Chi, MD, Cuneyt M. Alper, MD

98. Otitis Media in Teenagers and Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483

Barry E. Hirsch, MD, FACS

99. Effect of Season in the Treatment of Acute Otitis Media and

Otitis Media with Effusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Carlton J. Zdanski, MD

100. Nosocomial Otitis Media: Hospital and Pediatric Intensive Care

UnitAcquired Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Craig S. Derkay, MD, Nariman Dash, MD

101. Persistent/Recurrent Otalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496

Mark E. Whitaker, MD, Barry E. Hirsch, MD, FACS

102. Persistent or Recurrent Negative Middle Ear Pressure . . . . . . . . . . . . . . . . . . 501

Otavio B. Piltcher, MD, PhD, Cuneyt M. Alper, MD

103. Management of Acute Otitis Media or Mastoiditis in Children

with Cochlear Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
Hans-Georg Kempf, MD, PhD

104. Tuberculous Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512

Soham Roy, MD

105. Treatment of Otitis Media in the Managed Care Environment . . . . . . . . . . . 516

Charles M. Myer III, MD

106. Cost-Effectiveness in the Treatment of Otitis Media . . . . . . . . . . . . . . . . . . . . 520

Glenn S. Takata, MD, MS, Linda S. Chan, PhD

107. Treatment of Otitis Media in Regions with Limited Health Care. . . . . . . . . . 526
Amanda Leach, PhD, Peter Morris, FRACP, PhD

108. Parental Counseling in Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531

Jaimie De Rosa, MD, Kenneth M. Grundfast, MD, FACS, FAAP

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

STEPHANIE MOODY ANTONIO, MD

Department of Otolaryngology
University of Maryland
Baltimore, Maryland

ELLIS M. ARJMAND, MD, PHD

Department of Pediatric Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

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

JOEL BERNSTEIN, MD, PHD

Departments of Otolaryngology and Pediatrics
School of Medicine and Biomedical Sciences
Department of Communicative Disorders and Sciences
State University of New York at Buffalo
Buffalo, New York

STAN L. BLOCK, MD, FAAP

Kentucky Pediatric Research, Inc.
Bardstown, Kentucky

CHARLES D. BLUESTONE, MD
Department of Otolaryngology
University of Pittsburgh School of Medicine
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania

DERALD E. BRACKMANN, MD, FACS

House Ear Clinic
Los Angeles, California

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

MARGARETHA L. CASSELBRANT, MD, PHD

Department of Otolaryngology
University of Pittsburgh School of Medicine
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania

KENNY H. CHAN, MD
Department of Otolaryngology
University of Colorado School of Medicine
Denver, Colorado

xviii / Contributors

LINDA S. CHAN, PHD

Departments of Pediatrics, Emergency Medicine, and Surgery
Keck School of Medicine
University of Southern California
Los Angeles, California

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

PEDRO CLARS, MD, PHD

Department of Otolaryngology
Barcelona University
Barcelona, Spain

HARVEY COATES, MS, FRACS

Department of Otolaryngology, Head and Neck Surgery
University of Western Australia
Crawley, Western Australia

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

KATHLEEN A. DALY, PHD

Department of Otolaryngology
University of Minnesota
Minneapolis, Minnesota

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

JOSEPH E. DOHAR, MD, MS, FAAP, FACS

Department of Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

ANGELA ELLISON, MD
Department of Pediatrics
Boston University School of Medicine
Boston, Massachusetts

ADELE YARRINGTON EVANS, MD

Department of Otology and Laryngology
Harvard Medical School
Boston, Massachusetts

HOWARD FADEN, MD
Department of Pediatrics
State University of New York
Buffalo, New York

JACOB FRIEDBERG, BA, MD, FRCSC

Hospital for Sick Children
Toronto, Ontario

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

MARCOS V. GOYCOOLEA, MD, PHD

Department of Otolaryngology
University of Minnesota
Minneapolis, Minnesota

Contributors / xix

KENNETH M. GRUNDFAST, MD, FACS, FAAP

Department of OtolaryngologyHead and Neck Surgery
Boston University School of Medicine
Boston, Massachusetts

ANIL GUNGOR, MD
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania

JOSEPH HADDAD JR, MD

Department of Otolaryngology, Head and Neck Surgery
Columbia University of Physians and Surgeons
New York, New York

SEISHI HASEBE, MD
Department of Hearing and Speech Sciences
Kyoto University Graduate School of Medicine
Kyoto, Japan

TERHO HEIKKINEN, MD, PHD

Department of Pediatrics
University of Turku
Turku, Finland

EMMANUEL HELIDONIS, MD, FACS

Department of Otorhinolaryngology
University of Crete Greece
Heraklion, Greece

STEN HELLSTRM, MD, PHD

Department of Clinical Sciences
University Hospital of Ume
Ume, Sweden

BARRY E. HIRSCH, MD, FACS

Departments of Otolaryngology, Neurological Surgery,
and Communication Science and Disorders
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania

GLENN C. ISAACSON, MD, FACS, FAAP

Department of Otolaryngology, Head and Neck Surgery
Temple University School of Medicine
Philadelphia, Pennsylvania

DAVID J. KAY, MD
Department of Pediatric Otolaryngology
Childrens Hospital of Pittsburgh
Pittsburgh, Pennsylvania

YUSUF K. KEMALO G LU, MD

Department of Otolaryngology
Gazi University Faculty of Medicine
Ankara, Turkey

HANS-GEORG KEMPF, MD, PHD

Department of Otolaryngology
Medical University of Hannover
Hannover, Germany

MARGARET A. KENNA, MD, FAAP, FACS

Department of Otolaryngology and Laryngology
Harvard Medical School
Boston, Massachusetts

JEROME O. KLEIN, MD
Maxwell Finland Laboratory for Infectious Diseases
Boston Medical Center
Boston, Massachusetts

KARI JORUNN KVAERNER, MD, PHD

Center for Health Administration
University of Oslo
Oslo, Norway

AMANDA J. LEACH, PHD

Department of Infectious Diseases
Menzies School of Health Research
Darwin, Australia

RUDOLF LEUWER, MD
ENT Department
Hamburg University Medical School
Hamburg, Germany

JAMES T.-C. LI, MD, PHD

Department of Internal Medicine
Division of Allergic Diseases
Mayo Clinic
Rochester, Minnesota

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

MICHIYA MATSUMURA, MD, PHD

Department of Otolaryngology
Hokkaido University School of Medicine
Sapporo, Japan

xx / Contributors

A. RICHARD MAW, MS, FRCS

Department of Otolaryngology
University of Bristol
Bristol, England

GEORGE H. MCCRACKEN JR, MD

Department of Pediatrics
University of Texas Southwestern Medical Center
Dallas, Texas

PETER MORRIS, FRACP, PHD

Department of Infectious Diseases
Menzies School of Health Research
Darwin, Australia

L. NICOLE MURRAY, MD
Department of Pediatric Otolaryngology
Louisiana State University Health Sciences Center
New Orleans, Louisiana

CHARLES M. MYER III, MD

Department of OtolaryngologyHead and Neck Surgery
University of Cincinnati
Cincinnati, Ohio

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

OTAVIO B. PILTCHER, MD, PHD

ENT Department
Hospital de Clinicas de Porto Alegre
Porto Alegre, Brazil

THANAI PONGDEE, MD
Department of Internal Medicine
Division of Allergic Diseases
Mayo Clinic
Rochester, Minnesota

CHRIS PRESCOTT, CAJ, FRCS

Department of Otorhinolaryngology
University of Cape Town
Cape Town, South Africa

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

JOANNE E. ROBERTS, PHD

Frank Porter Graham Child Development Center
University of North Carolina
Chapel Hill, North Carolina

RICHARD M. ROSENFELD, MD, MPH

Department of Otolaryngology
SUNY Downstate Medical Center
Brooklyn, New York

SOHAM ROY, MD
Department of OtolaryngologyHead and Neck Surgery
University of Miami
Miami, Florida

ROBERT J. RUBEN, MD, FACS, FAAP

Departments of Otolaryngology and Pediatrics
Albert Einstein College of Medicine
Bronx, New York

AINO RUOHOLA, MD
Department of Pediatrics
Turku University Hospital
University of Turky
Turku, Finland

VEDANTAM RUPA, MS, DLO

Department of ENT, Speech and Hearing
Christian Medical College and Hospital
Vellore, India

Contributors / xxi

OLLI RUUSKANEN, MD
Department of Infectious Diseases
Turku University
Turku, Finland

BRITTA RYNNEL-DAG, MD, PHD

Department of Otolaryngology
Karolinska Institute
Huddinge University Hospital
Stockholm, Sweden

BARRY SCHAITKIN, MD, FACS

Department of Otolaryngology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

ANNE G. M. SCHILDER, MD, PHD

Wilhelmina Childrens Hospital
University Medical Center
Utrecht, The Netherlands

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

KARIN STENFELDT, MD, PHD

Department of Clinical Sciences
Ume University
Ume, Sweden

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

TOMONORI TAKASAKA, MD, PHD

Tohoku University
Sendai, Japan

GLENN S. TAKATA, MD, MS

Department of Pediatrics
Keck School of Medicine
University of Southern California
Los Angeles, California

KAREN BORNE TEUFERT, MD

House Ear Clinic
Los Angeles, California

MIRKO TOS, MD, DMSC

Department of Otorhinolaryngology,
Head and Neck Surgery
Gentofte University Hospital of Copenhagen
Copenhagen, Denmark

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