Abstract
Objectives:
To evaluate the effectiveness of mastoidectomy with antibiotic catheter irrigation in patients with chronic tympanostomy tube otorrhea.
Methods:
A chart review of adult and pediatric patients with persistent tympanostomy tube otorrhea who had failed outpatient medical management and underwent mastoidectomy with placement of a temporary indwelling catheter for antibiotic instillation was performed. Patients were retrospectively followed for recurrent drainage after 2 months and outcomes were categorized as resolution (0-1 episodes of otorrhea or otitis media with effusion during follow-up), improvement (2-3 episodes), or continued episodic (>3 episodes).
Results:
There were 22 patients and 23 operated ears. Median age was 46 years (interquartile range, IQR = 29-65). The median duration of otorrhea from referral was 5.5 months (IQR = 2.8-12). Following surgery, 14 ears had resolution of drainage, 6 had improvement, and 3 had episodic. The observed percentage of resolved/improved ears (87%) was significant (P = .0005, 95% CI = 67.9%-95.5%). Median follow-up time was 25 months (IQR = 12-59). Pre and postoperative pure tone averages improved (difference of medians = −3.3 dB, P = .02) with no significant difference in word recognition scores (P = .68). Methicillin-resistant Staphylococcus aureus was the most common isolated microbe while no growth was most frequently noted on intraoperative cultures.
Conclusions:
Mastoidectomy with antibiotic catheter irrigation may be an effective surgical strategy, and single stage alternative to intravenous antibiotics, for select patients with persistent tube otorrhea who have failed topical and oral antibiotics.
Introduction
The treatment of chronic otorrhea, typically defined as persistent drainage through a tympanostomy tube or perforated ear drum beyond 8 weeks, 1 continues to remain a challenge for physicians. Particularly so, when there is absence of cholesteatoma and drainage ensues despite repeated attempts with the current standard of care: topical fluoroquinolones, a trial of culture-directed oral antibiotics, imaging, and consideration of tube removal and exchange. 2,3
It is at this juncture when a provider often considers referral to an otologist. Cultures may be retaken, additional antibiotics are trialed, and serial examinations with additional tube placement are usually performed. When these additional medical treatments fail, surgical management may be considered. In 1969, Sheehy was among the first to propose that a cortical mastoidectomy could be an additional option for achieving resolution of drainage. 4 Initially skeptical himself, he came to believe that in certain cases of a chronically discharging tube, the pathology resided in the mastoid air cell system. Prior reports by Goodhill and Brockman had proposed that chronic inflammatory or infectious changes in the mastoid mucosa itself led to a persistent serous or mucous discharge. 5,6 In Sheehy’s own case series, 4 of 6 patients with persistent tympanostomy tube otorrhea who underwent cortical mastoidectomy for this “chronic serous mastoiditis” were able to achieve long-term resolution.
Today the procedure continues to be indicated for select patients with chronic otorrhea from a tympanostomy tube who have failed medical management, and other etiologies, including cholesteatoma and cerebrospinal fluid leak, have been ruled out. In addition to a standard cortical mastoidectomy, the modern approach includes placement of a rubber catheter into the antrum, through which an antibiotic solution is instilled postoperatively. The direct irrigation of the mastoid and middle ear spaces ensures a larger concentration or dose of antibiotic delivered to the mastoid and middle ear cleft via the antrum, for targeted antibiotic therapy. In our practice, this procedure is performed 1 or 2 times per year as a final step in the treatment algorithm for chronic otorrhea and appears to result in long-term resolution in the majority of cases.
From a recent article at our institution describing the procedure, it appeared that there were few contemporary publications reporting outcomes for patients undergoing mastoidectomy for chronically draining ventilation tubes (the most recent coming from Newburgh in 1984) or studies regarding the use of a catheter through the mastoid. 7,8 The goal of this study was to retrospectively review our patient database and determine the frequency and effectiveness of mastoidectomy with catheter placement for persistent tube otorrhea in chronic serous otitis media.
Patients and Methods
At our institution, patients with chronic serous otitis media who fail medical management and tympanostomy tube placement are offered mastoidectomy with placement of a temporary indwelling catheter for postoperative antibiotic irrigation. The details of medical management and the surgical procedure are described in our previously published clinical review. 8 Briefly, the procedure involves a cortical mastoidectomy and placement of an indwelling red rubber catheter fitted with a Luer-Lock connection into the antrum. The patient is instructed to instill ofloxacin antibiotic drops through the catheter until the first follow-up visit, 1 week after surgery. After removal, the catheter site is closed with a steri strip.
Following institutional review board approval, the surgical database was queried to identify patients from 2001 to 2020 who underwent mastoidectomy without tympanoplasty for a chronically draining tympanostomy tube. Thirty patients were initially discovered. Patients were excluded if they had a prior history of cholesteatoma or a draining perforation. Inclusion criteria required placement of a temporary indwelling red rubber catheter into the mastoid antrum (Figure 1), determined through review of the operative report, and had postoperative irrigation of antibiotic drops through the catheter. Applying these inclusion/exclusion criteria resulted in a cohort of 22 patients and 23 operated ears.
(A-B) Placement of a red rubber catheter into the antrum following cortical mastoidectomy to allow for mastoid and middle ear instillation of topical antibiotics (A). The catheter should exit through a drain hole posteriorly and superiorly to the incision to allow for gravity-dependent irrigation (B).
All study participants were referred to otology after failing outpatient medical management with both topical and oral antibiotics. Each had preoperative computed tomography imaging demonstrating mastoid opacification. Patients were retrospectively followed for recurrent drainage after 2 months, and surgical outcomes were categorized as resolution (0 or 1 episodes of otorrhea or resolving otitis media with effusion during follow-up), improvement (2-3 episodes), or continued episodic (>3 episodes). Duration of otorrhea, preoperative use of oral, intravenous (IV), or topical antibiotics, medical comorbidities, pre- and intraoperative bacterial cultures, audiometric data, surgical complications, follow-up time, and basic demographic information were recorded. Descriptive statistics and the percentage of resolved/improved ears were analyzed with a binomial test using Prism 8.0 (GraphPad Software). Audiometric results were reported according to the American Academy of Otolaryngology-Head & Neck Surgery and analyzed with a nonparametric paired t test.
Results
The cohort consisted of 14 men and 8 women with a median age was 46 years (interquartile range, IQR = 29-65). The procedure was performed 23 times over a 19-year period (1.2 cases per year). One patient had a peripherally inserted central catheter (PICC) with antibiotics prior to surgery. The median duration of otorrhea from referral was 5.5 months (IQR = 2.8-12). Following surgery, 14 ears had resolution of drainage, 6 had improvement, and 3 had continued episodic. The observed percentage of resolved/improved ears (87%) was significant (P = .0005, 95% CI = 67.9%-95.5%, Figure 2). Median follow-up time was 25 months (IQR = 12-59). Pre and postoperative pure tone averages (PTA; Figure 3) improved (difference of medians = −3.3 dB, P = .02) with no difference in word recognition scores (P = .68, Figure 4). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common isolated microbe on available preoperative cultures, while no growth was most frequently noted on intraoperative cultures (Table 1). The comorbidities of the 3 patients with continued drainage are listed in Table 2.
Graphical representation of surgical outcomes. The observed proportion of resolved/improved cases (87%) was statistically significant (*).
Scatter gram of preoperative pure tone averages (PTA) and word recognition scores (WRS) for each patient.
Postoperative scatter gram showing change in pure tone average and word recognition score for each patient postoperatively.
Available Preoperative and Intraoperative Culture Results in Decreasing Frequency.
Clinical Demographics of “Episodic” Surgical Subgroup.
Abbreviation: IgG, immunoglobulin G.
Discussion
Several studies have been published over the years examining the value of mastoidectomy for chronic otitis media without cholesteatoma. Recently, Trinidade et al performed a systematic review of 9 studies involving tympanoplasty with and without mastoidectomy for both active and inactive mucosal chronic otitis media and found that overall mastoidectomy adds no additional therapeutic benefit. 9 These studies, however, were notably heterogeneous, including patients with dry perforations and atelectasis, and the authors themselves also concluded that a selective mastoidectomy may be therapeutic under the conditions of failed tympanoplasty, antibiotic resistance, or an unsuitable middle ear environment. This retrospective analysis, in contrast, differentiates itself in focusing solely on the use of a mastoidectomy with postoperative delivery of antibiotics via antral catheter, and only for patients with chronic tympanostomy tube otorrhea.
The practice of cortical mastoidectomy for persistent otorrhea has been in place since at least the late 1950s. 4 -6 Although the need for surgical intervention in these circumstances has decreased over the years due to the development of other ototopical antibiotics, rare cases refractory to medical treatment can be considered for mastoidectomy with the addition of antral catheter placement to allow for targeted antibiotic delivery. Our results from a tertiary care otologic clinic spanning almost 2 decades identified an incidence rate of 1.2 cases per year. The large majority of patients (87%) experienced either resolution of drainage or had a significant improvement with a median follow-up time of over 2 years. There was a slight improvement in PTA scores and no documented perioperative complications in this cohort, indicating that an antral mastoidectomy and catheter placement can be both a safe and efficacious procedure.
Current understanding in the pathophysiology of acute recurrent and chronic otorrhea has now focused on the role of bacterial biofilm development in both the middle ear and on tympanostomy tubes. 10 -12 It is thought that the presence of biofilms allows microorganisms to survive at a low metabolic rate, at times avoiding detection, and still contributing to pathologic responses from the middle ear. 13,14 Although this study did not perform a biofilm analysis, 40% of the intraoperative culture results showed no growth and a third were positive for MRSA; findings that appear to be in concordance with the literature for refractory otorrhea and chronic otitis media with effusion. MRSA, the most isolated pathogen, is a well-known culprit of chronic otorrhea and biofilm formation. 15,16 Culture-negative results are also common. For example, in 2006, Hall-Stoodley and others performed a multicenter study investigating the presence of biofilms by sampling middle ear mucosa in 26 children undergoing tube placement for chronic otitis media with effusion or recurrent acute otitis media. Although mucosal biofilms were visualized in 92% of the 50 middle ear mucosa specimens, only 6 of 27 ears with an effusion were culture positive for any pathogen. 10
If biofilms are a significant factor in the chronically discharging ear, several issues become apparent in the clinical management. Although topical fluoroquinolones can reach concentrations in the middle ear that are significantly greater than that of systemic oral antibiotics, 17 delivery and dose may be limited by the size of the tube, especially since biofilms are also thought to be relatively resistant to topical and even IV antibiotics. 14 The location of the pathophysiology, however, may not just reside in the middle ear or on the tympanostomy tube. The mastoid air cell system could also be involved, and, while it has been implicated, no studies to date have documented the presence of biofilms in the mastoid specifically for otorrhea. We therefore believe that the improvement in otorrhea occurs through mastoidectomy and catheter placement by decreasing the burden of diseased mucosa and providing a conduit for a large concentration or dose of antibiotic to enter the middle ear cleft and inhibit biofilm formation.
For the minority of patients with chronic otorrhea who fail standard medical therapy and tympanostomy tube exchange, we favor this relatively low-risk surgical strategy over administering IV antibiotics through a PICC. Upon literature review, success rates with IV treatment for active chronic otitis media appear comparable with our reported surgical outcomes, but with a shorter follow-up period. Fliss et al found dry ear rates of 75% at 6 months for 48 children receiving either IV mezlocillin or ceftazidime; 4 underwent tympanomastoidectomy. 18 Later work performed in 2010 by Choi et al showed that IV teicoplanin or vancomycin was 78.9% and 80% effective in achieving dry ears in 19 and 10 adult patients, respectively, with MRSA chronic otitis media. 19 However, follow-up time in that study was reported at only 16 days. Although IV antibiotics do present a viable alternative, a surgical strategy avoids the risk of PICC line complications, including thrombus formation and infection, along with the logistical and economic burden associated with receiving IV therapy. 20 In this study, one patient did initially receive a PICC line, which had to be replaced after falling out, and eventually underwent mastoidectomy after antibiotic treatment failed to resolve their otorrhea.
The findings herein also help to identify patients who may be less suitable surgical candidates (Table 2) as 2 of 3 had a comorbidity predisposing to recurrent infections. It is worth noting that while the outcomes were suboptimal within the cohort, their otorrhea became episodic in comparison to their preoperative state of continuous drainage.
To our knowledge, there are no other studies reporting on the effectives of mastoidectomy with catheter placement, which is likely because it is rarely indicated. Gaining adequate power therefore is challenging. Charts were reviewed to identify as many patients as possible over almost 2 decades and that time frame poses limitations. Given the incidence of biofilm development on the tube, our current algorithm involves consideration of tube removal and replacement in the office at least once and to also give topical drops targeting MRSA (such as tobramycin or sulfacetamide) before proceeding with any surgical intervention. Although preoperative clinical management was not uniform for all cases, every patient did have a computed tomography scan demonstrating mastoid opacification and involvement. Additionally, as no standardization in reporting exits, our outcome criteria for otorrhea were defined arbitrarily based upon the frequency of recurrent episodes.
Mastoidectomy with antibiotic catheter irrigation may be an effective surgical intervention, and alternative to IV antibiotics, in carefully selected patients with persistent tympanostomy tube otorrhea. Future work investigating biofilm involvement of the mastoid, multicenter collaboration to review larger outcomes, and a pooled analysis comparing long-term IV antibiotics against mastoidectomy for otorrhea would provide additional insights regarding the timing and indications for management.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
