J Chin Med Assoc. 2012 Jul;75(7):329-34.

New therapeutic strategy for treating otitis media with effusion in postirradiated nasopharyngeal carcinoma patients

 

Chin-Lung Kuo, Mao-Che Wang, Chia-Huei Chu, An-Suey Shiao

Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.

Full text: Elsevier Science

 

Abstract

Background: Postirradiation otitis media with effusion (OME) is the most common radiotherapy-associated otologic complication associated with nasopharyngeal carcinoma (NPC). This study’s aim was to evaluate the efficacy of laser myringotomy followed by intratympanic steroid injection (LMIS) for treating OME in postirradiated NPC patients.

Methods: From August 2002 to January 2006, 27 newly diagnosed NPC patients who developed OME after a full course of radiotherapy were enrolled. Laser myringotomy was performed followed by once-weekly administration of steroids (0.5mL dexamethasone at a concentration of 5.0mg/mL) into the middle ear for 3 consecutive weeks. The success rate of dry eardrum perforation and the prognostic factors associated with OME resolution were analyzed.

Results: The procedure was performed on 44 ears of 27 patients. The mean follow-up period was 37 weeks. Of the 44 ears, 23 (52.3%) developed persistent eardrum perforation, 18 (40.9%) developed recurrent OME, and three (6.8%) were disease-free on follow-up. Of the 23 ears with persistent eardrum perforation, 18 (78.3%) were diagnosed as dry perforation. The absence of pretreatment mastoiditis was an independent factor associated with OME resolution (p<0.001).

Conclusion: LMIS is a quick, minimally invasive, office-based technique that can be repeatedly performed to treat highly recurrent postirradiation OME, and it results in relatively slight pain to NPC patients. Long-lasting dry eardrum perforation allows for adequate middle ear ventilation and drainage and guarantees sustained relief from symptoms. The absence of preoperative mastoiditis is a favorable prognostic factor associated with OME resolution.

PMID: 22824047

 

 

Press Release

To treat, not to cure! A new therapeutic concept for post-irradiation otitis media with effusion

Chin-Lung Kuo, MD; An-Suey Shiao, MD

Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.

Department of Otolaryngology, Hsinchu Armed Force Hospital, Hsinchu, Taiwan, ROC.

 

Compared with Western countries, nasopharyngeal carcinoma (NPC) is endemic in Southeast Asia, and Taiwan is a hyperendemic area.1 The mainstay of treatment is definitive radiotherapy. Recent advances in therapeutic techniques (e.g. intensity-modulated radiation therapy) have reduced the number of complications associated with radiation, however, the exposure of non-target organs during head and neck irradiation is often inevitable. The most common otologic complication of post-irradiated NPC patients is otitis media with effusion (OME), which significantly impairs the quality of life of patients with symptoms including conductive hearing loss, ear discomfort, and muffling.2

 

Although conservative observation or a hearing aid may be an option for patients with post-irradiated OME, most patients prefer aggressive therapy for immediate symptom relief.3 Treatment choices for post-irradiation OME include simple tympanic aspiration, incisional myringotomy and ventilation tube insertion (VTI). The short healing time for simple tympanic aspiration and incisional myringotomy (only 1-2 days) may lead to non-meaningful therapeutic effects for patients due to the high recurrence rate of OME. VTI may cause adverse effects such as secondary acquired cholesteatoma and infectious otorrhea (incidence 29% to 64%). Infectious otorrhea is the most common complication following tube placement and is often refractory to local or medical treatment.2,4 Hence, satisfactory relief of otologic symptoms may not be achieved by such conventional approaches.

 

Unfortunately, there are currently no ideal solutions to solve the otologic problems associated with radiotherapy. This reflects the fact that therapeutic strategies to treat OME in post-irradiated NPC patients need to be based on the etiology. The pathogenesis of post-irradiation OME is quite different from that of non-radiation related OME, which is commonly caused by Eustachian tube dysfunction.2,4 Furthermore, OME related to tubal dysfunction can probably be “cured” with conventional treatments. In contrast, in post-irradiation OME, the generally acknowledged etiologies are associated with direct and irreversible radiation damage to the Eustachian tube, including scarring of the tubal opening, poor mucociliary function and fibrosis of the tube-associated muscles. Importantly, a critical but frequently ignored cause is radiation-compromised inflammation of the middle ear.2

 

In response to the complex and delicate process of OME formation in post-irradiated NPC patients, this study proposes a new therapeutic strategy for post-irradiation OME: to treat, not to cure! Although some authors have attempted to cure post-irradiation OME in patients with NPC, our research shows that the issue is more complex, and that such patients should be treated as if they have a chronic disease such as hypertension or diabetes mellitus. This is because radiation injuries are irreversible in NPC patients, and a high recurrence rate can therefore be expected. Under these circumstances, we believe that curing the disease may be the advice given with the best intentions but based on unrealistic expectations.

 

The new therapeutic strategy proposed in this study is to “treat the chronic disease”, i.e. laser myringotomy followed by intratympanic steroid injection (LMIS) with the aim of both middle ear ventilation and to treat the radiation-compromised inflammation of the middle ear. Immune restoration and epithelial repair of the middle ear mucosa may be achieved by topical steroid administration, which is a safe and simple intervention. Additionally, topical steroid administration may delay healing of the eardrum perforation, providing longer-lasting and significant relief of symptoms. In the current study, the mean perforation healing time was 6.5 weeks (range 1-24 weeks).

 

“To treat, not to cure!” is a new therapeutic concept for post-irradiation OME in NPC patients. We suggest that LMIS is an effective strategy, creating a longer-lasting dry perforation of the eardrum for sustained symptom relief rather than curing the disease.2 Although the 40.9% recurrence rate observed in our research is not inconsequential, it is lower than that in previously published studies (77.8%-88.9%). Importantly, this is balanced by the advantages of using LMIS, i.e. it is a quick, minimally-invasive, office-based technique, allowing for repeated procedures with minimal patient discomfort.2

 

References

  1. Chin-Lung Kuo, Donald Ming-Tak Ho, Ching-Yin Ho. Dural metastasis of nasopharyngeal carcinoma: rare, but worth considering. Singapore Medical Journal In press.
  2. Chin-Lung Kuo, Mao-Che Wang, Chia-Huei Chu, An-Suey Shiao. New therapeutic strategy for treating otitis media with effusion in postirradiated nasopharyngeal carcinoma patients. J Chin Med Assoc 2012; 75:329-334.
  3. Kai-Li Liang, Mao-Chang Su, Chih-Wen Twu, Rong-San Jiang, Jin-Ching Lin, Shiao J-Y. Long-term result of management of otitis media with effusion in patients with post-irradiated nasopharyngeal carcinoma. Eur Arch Otorhinolaryngol 2011; 268:213-217.
  4. Chin-Lung Kuo, Chiang-Feng Lien, Chia-Huei Chu, An-Suey Shiao. Otitis media with effusion in children with cleft lip and palate: a narrative review. International Journal of Pediatric Otorhinolaryngology In press.

 

Author Information

guo fig11. Chin-Lung Kuo is the first author in this study. Dr. Kuo is the Director of the Department of Otolaryngology, Hsinchu Armed Force Hospital, Hsinchu, Taiwan, ROC. Dr. Kuo is also a Lecturer of the Department of Otolaryngology, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC. He completed his residency and fellowship training in Otolaryngology at Taipei Veterans General Hospital, Taipei, Taiwan, ROC. Dr. Kuo enrolled on a PhD programme at the Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan, ROC. Dr. Kuo’s research mainly focuses on neuroplasticity of the auditory cortex in patients with hearing loss. Clinically, he is also interested in middle ear surgery. His Dr. Kuo can be contacted via e-mail at drkuochinlung@gmail.com or ResearchGate. His Curriculum Vitae can be found on his personal webpage.

 

 

 

 

 

2. An-Suey Shiao is Chief of the Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC. He can be contacted via e-mail at asshiao@gmail.com.

 

 

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