Very little was known about ear disease until the 17th century. Otitis and draining ears were so common then, especially among the poorest children, that they were considered a normal condition.1 During this century, several publications appeared that described or speculated about the anatomy, function, and diseases of the ear.2
Real progress waited for the mid-19th century. Most important was the discovery of the otoscope by von Troeltsh in Germany in I860,3 19 years after Politzer invented the head mirror. It is interesting that the otoscope and other instruments (the ophthalmoscope in 1851, the laryngoscope in 1854-1855, and the first practical cystoscope in 1879) catalyzed the development of new knowledge, new surgical procedures, and specialization during this era.1'3 Specialists existed before then, but were generally considered charlatans and unethical by the medical profession.
Prior to the existence of antibiotics, ear infections and complications were primarily treated by surgical drainage. Paracentesis, a tympanocentesis by incision of the tympanic membrane to drain the middle ear, was aided greatly by the electrical otoscope. Excerpts from a 1931 presentation by Joseph Brennemann to the American Medical Association demonstrated that some things have changed, some have not.4
If he is a good pediatrician, he has long ago found his otoscope as indispensable as his stethoscope ... he becomes familiar with the normal and with the abnormal through all the stages from the simple redness and congestion, which accompany nearly all nasopharyngeal infections, to the bulging ear that cries for surgical relief.4
Brennemann pointed out that pain and fever were not completely reliable signs of acute otitis and said that the pediatrician should not worry about a ruptured drum because it avoided paracentesis. He referred patients who needed this surgery, but said:
I see, however, no objection to the pediatrician doing his own paracentesis . . . provided the pediatrician is really competent to do the right thing.4
This issue of Pediatrie Annals describes the central nervous system (CNS) complications of otitis and expresses concern that these could rebound as we cut back on antibiotics. Will this happen? Until recently, meningitis was the most common complication, and Haemophilus influenzae was its most frequent culprit, followed by the pneumococcus.5 New vaccines for both should help reduce the risk for meningitis and other otitis complications. But non-typeable H. influenzae can cause meningitis with otitis and is not covered by the vaccine. Also, many CNS complications were secondary to mastoiditis and chronic otitis; we should be able to recognize and treat most of these before complications arise.
What does the future hold? New, more efficient management protocols will help, but will they work? Will we follow them? Will we begin doing tympanocentesis again? Will we see a return of complications? Pediatrics is still interesting, isn't it?
1. Lyons AS, Petrucelle RJ. Mediane: An Illustrated History. New York: Harry N. Abrams; 1978:458, 538.
2. Sebastian A. A Dictionary of the History of Mediane. New York: The Parthenon Publishing Group; 1999:269, 495, 557.
3. Bynum WF, Porter R. Companion Encyclopedia of the History of Mediane, vol. 2. New York: Routledge; 1993: 1011.
4. Brennemann J. Otitis media as a pediatrician sees it JAMA. 1931,-97:449452.
5. Gower D, McGuirt WF. Intracranial complications of acute and chronic infectious ear disease: a problem stiU with us. Laryngoscope. 1983;93:10281033.