Disease of middle ear,dr.s.s.bakshi,27.03.17

OTITIS MEDIA WITH EFFUSION Also known as (syn. Secretory otitis

media,Mucoid otitis media,glue ear,middle ear effusion)

How Does The Ear Work?

EUSTACHIAN TUBE Connects nasopharynx

with tympanic cavity

FUNCTIONS OF ET Ventilation and regulation of middle ear

pressure Protection against a)nasopharangeal sound pressure b)reflux of nasopharangeal secretions Clearance of middle ear secretions

DISORDER OF EUSTACHIAN TUBE Normally ET is closed

It opens intermittently during swallowing,yawning and sneezing through the active contraction of TVPM.

Air, composed of oxygen,carbon dioxide,nitrogen and water vapour,normally fills the middle ear and mastoid.

When the tube is blocked,first oxy is absorbed,but later other gases,carbon dioxide and nitrogen also diffuse out into the bld---results in neg pressure in middle ear and retraction of TM---”LOCKING” of the tube with collection of transudate and later exudate and even haemorrhage (Acute OME)

What is glue ear? Insidious condition Glue ear is defined as

inflammation of the middle ear, accompanied by the accumulation of fluid in the middle-ear cleft (serous or mucoid,not purulent), without the symptoms and signs of acute inflammation

Effusion is thick and viscid,sometimes may be thin and serous

Commonly seen in school going children

AETIOLOGY MALFUNCTIONING OF THE TUBE Mechanical obstruction-URI,allergy,sinusitis,nasal

polypi,DNS,hypertrophic adenoids,nasopharangeal tm/mass

Functional-Sniffling,abnormal ciliary function of the tube(kartagener’s syndrome,situs inversus,bronchiectasis,cystic fibrosis,chronic sinusitis),palatal defects,Down syndrome,barotrauma

Both

Aetiology contd.. Allergy-seasonal or perennial allergy to foodstuffs Unresolved otitis media Infections Viral-adeno and rhino viruses Bacterial-The same flora found in AOM can be

isolated in OME. With OME, the inflammatory process clearly resolves, and the volume of bacteria decreases.

AETIOLOGY contd… Other risk factors More common in: Bottle feeding Feeding while supine Attending day-care Having a sibbling with OM Allergies to common environmental entities Low socio-economic status Low birth weight Parental history of OME Living in a home in which people smoke Recurrent URI

CLINICAL FEATURES OF MEE SYMPTOMS: PRESENTATION Deafness-h/o aural fullness or an ear being

plugged or diminished hearingo Insidious onseto Rarely exceeds 40dB

Delayed and defective speech-most common morbidity encountered

Earaches are rare or mild

Tugging at ear or repeated inserting of finger

CLINICAL FEATURES cont… SIGNS Otoscopic findings: Opacification of the

drum (other than due to scarring)

Loss of the light reflex, or a more diffused light reflex

Indrawn, retracted, or concave drum

Decreased or absent mobility of the drum

Presence of bubbles or fluid level

Yellow or amber colour change to the drum

Fullness or bulging of the drum, though this is not typical

INVESTIGATIONS contd… HEARING TESTS: 1)TUNING FORK TESTS:

conductive deafnes

2)PURE TONE AUDIOMETRY:

Best way to assess hearing Only suitable for children

who are 4 yrs and older There is C.H.L. of 20-40

dB,sometimes there is ass S.N.H.L. d/t fluid present on R.W. membrane

INVESTIGATIONS contd… 3)IMPEDENCE

AUDIOMETRY/TYMPANOMETRY:

Objective test useful in children and infants

Presence of fluid is indicated by reduced compliance and flat curve with a shift to negative side

Management (medical ) Decongestants Antiallergic measures Antibiotics Middle ear aeration

Surgical Myringotomy Grommet insertion Cortical mastoidectomy Surgical treatment of causative factor

Sequeale of chronic SOM Atrophic TM & atelectasis of ME Ossicular necrosis Tympanosclerosis Retraction pockets Cholesterol granuloma

Acute Otitis Media

Department of E.N.T

Plan1) Etiology2) Risk factors3) Symptoms4) Diagnosis5) Differential diagnosis6) Management7) Complications8) Referrals

EPIDEMIOLOGY Peak incidence in the first two years of life

(esp. 6-12 months) Boys more affected girls 50% of children 1 yr of age will have at least 1

episode. 1/3 of children will have 3 or more infections

by age 3 90% of children will have at least one

infection by age 6. Occurs more frequently in the winter months

AOM - Etiology1) Streptococcus pneumoniae (gram + cocci): 40 -

50 %2) Haemophilus influenzae (gram - coccobacilli):

30 - 40 %3) Moraxella catarrhalis (gram - cocci): 10 - 15 %4) Group A streptococcus (gram + cocci): rare5) Staphylococcus aureus (gram + cocci): rare6) Anaerobes: rare7) Viral infection: Less than 10%

Penicillin-resistant Streptococcus pneumoniae is the most common cause of recurrent/persistent

otitis media.

AOM - Risk factors1) Age (6-24 mos)2) Cleft palate / Down syndrome/ Craniofacial

malformations3) Ethnicity (Native American, Alaskan,

Canadian, Inuit)4) Smoking in the home5) Attending daycare6) Male7) Allergic rhinitis8) Viral upper respiratory tract infections?/

Season9) Breastfeeding (at least 3 mos)= protective

AOM - SymptomsOtalgiaFeverIrritabilityVomitingDiarrheaPoor feedingOften associated with cough and rhinitis

AOM – Differential of otalgia1) Referred pain from pharyngitis2) Teething3) Migraine4) Wax in the ear canal5) Foreign body in ear canal6) Otitis externa

AOM - DiagnosisClinical diagnosis which includes….

1) Acute onset of symptoms2) Middle ear effusion; bulging TM,

decreased mobility of TM, air-fluid level 3) Middle ear inflammation; erythema of TM

or otalgia affecting sleep or normal activity

AOM - Differential of an abnormal tympanic membrane1) Myringitis

?: red TM2) Otitis media with effusion (OME)

Serous or Secretory Otitis Media ?: accumulation of fluid in the middle ear without

inflammation

3) Chronic suppurative otitis media ?: persistent fluid in middle ear with persistent or recurrent otorrhea through perforated TM

AOM - Management70-90 % of children will have spontaneous

remission within 7-14 days.

Generally….1) Pain management2) Watchful waiting 3) Antibiotics4) Follow-up

AOM – Pain management

1) Acetaminophen: (15mg/kg q4-6hrs PRN)2) Ibuprofen: (10 mg/kg q 6hrs)3) Antipyrine/benzocaine otic suspension: (2-4

drops tid-qid)

NoteOral decongestants or antihistamines are not useful in decreasing the symptoms

or duration of AOM and may actually prolong AOM.

AOM – Watchful waiting

-Observation for 48-72 hours.-If persistent or worsening symptoms, treat

with antibiotics.-2 approaches:

1) Return to clinic for reassessment. 2) Give prescription to be filled in 48

hrs/call pharmacy.

Watchful waiting vs. antibiotics

ABSOLUTE YES TO ANTIBIOTICS

1) Less than 6 months old.2) 6 mos – 2 years old with certain AOM.3) Older than 2 years old with severe

infection (moderate to severe otalgia or temperature greater than 39 C).

Watchful waiting vs. antibiotics

WATCHFUL WAITING1) 6 mos – 2 years old with mild otitis media

or uncertain diagnosis2) Children older than 2 years old with mild

symptoms or uncertain diagnosis.

NoteParents must be able to evaluate child’s symptoms and return if no improvements

in 48-72 hours.

AOM - AntibioticsFIRST LINE

Amoxicillin (80-90mg/kg divided bid x 10 days)

Note: In children older than 6, treat 5-7 days.Contra-indications1) Concurrent purulent conjunctivitis2) Antibiotic therapy within the past month3) Amoxicillin chemoprophylaxis4) Penicillin allergy

AOM - AntibioticsPENICILLIN ALLERGY?

Urticaria/anaphylaxis: MacrolideNo urticaria/anaphylaxis: Cephalosporin

VOMITING/NON-COMPLIANCE? Ceftriaxone 50mg/kg IV/IM in a single dose

AOM - AntibioticsPERSISTENT AOM

?: No improvement of symptoms within 48-72hrs.

Must return to be reassessed. Confirm diagnosis. Start antibiotic if not started already. If taking amoxicillin, change to a second line.

AOM - AntibioticsSECOND LINE ANTIBIOTICS

1) High dose amoxicillin-clavulanate2) Cephalosporin (Cefpodoxime, Ceftriaxone,

Cefuroxime) 3) Macrolide

AOM - AntibioticsTHIRD LINE ANTIBIOTICS

1) Clindamycin2) Tympanocentesis

INDICATIONS FOR TYMPANOCENTESIS Toxic appearing child Failed treatment regimen with antibiotics Suppurative complications Immunosuppressed pt. Newborn infant in which the usual

pathogens may not be the case.

AOM – Follow-upIf OME and no developmental issues: Follow-up at 3 and 6 months until effusion

resolves.

If OME lasts > 3 months or developmental issues:

Hearing and language testing should be done.

If hearing loss or structural anomalies of middle ear are suspected:

Referral to ENT. May require surgery (tympanostomy & tube

insertion, adenoidectomy)

AOM – Follow-upIf chronic suppurative otitis media: Topical antibiotics: 1) Quinolones 2) Aminoglycosides 3) Polymyxins

Note Aminoglycosides and polymyxins are ototoxic

and may cause vestibular dysfunction in longterm use.

AOM - Prevention1) Influenza vaccination (A)2) Pneumococcal vaccination (A)3) Avoid exposure to cigarette smoke (C)4) Discontinue pacifier use in children with

recurrent AOM and OME (A)5) Avoid feeding in supine position (bottle in

crib)6) Breast feeding for at least 3 months

AOM - AdultsSame antibiotics as in children.

May benefit from nasal/oral steroids if allergies and persistent AOM.

If unilateral middle ear effusion persists for longer than 2 months, need CT scan to rule intracranial neoplasm.

AOM - Complications1) Meningitis2) Facial weakness/Paralysis3) Mastoiditis 4) Speech and language delay5) Hearing loss

AOM – When to refer?Single episode AOM

Complications of AOM Failure of antibiotic treatment with

persistent severe signs (high fever, severe pain)…diagnostic tympanocentesis.

Perforation with persistent otorrhea

AOM – When to refer?Recurrent infections

More than 4 documented infections in 1 year or more than 3 in 6 months.

Child with co-existing illness for which surgical treatment may be more beneficial than repeated Abx therapy (immune deficiency, cystic fibrosis, sickle cell anemia)

Multi-resistant bacteria Antibiotic allergies

AOM – When to refer?1) Suspicion of hearing loss or history of

language delay2) Persistent more than 3-4 months3) Persistent TM retraction or atelectasis4) All children with cleft palate, Down

syndrome or craniofacial malformations (earlier than later)

Otitic barotrauma

Otitic barotrauma

Encompasses pathological conditions of ear induced by pressure changes

causes Barotrauma principally results from air travel

or scuba diving

Maximum changes in gas volume occur during first 10m of descent and 1000m altitude

Scuba divers descending beyond 30 feet must undergo decompression stages during ascent

causes Greatest chance in shallow dives and low

flying non pressurised aircrafts

Injuries are less pronounced in air travellors than divers

BAROTRAUMAPathogenesis Closed by tympanic membrane laterally Middle ear is a bony cavity

Blood vessels represent ambient pressureEustachian tube equalises the pressure

barotrauma

Compression injuries

Decompression injuries

COMPRESSION INJURIES EXTERNAL EAR BAROTRAUMA

MIDDLE EAR BAROTRAUMA

INNER EAR BAROTRAUMA

EXTERNAL EAR BAROTRAUMA Reverse ear , external ear squeeze,

Reverse ear squeeze Causes : cerumen, foreign body,

exostoses, ear plugs Occurs when a pocket of air is trapped in

external meatus

EXTERNAL EAR BAROTRAUMA Pathogenesis Normal eustachian tube function Increasing compression

Increase in middle ear press. Relative negative ex. Ear press

EXTERNAL EAR BAROTRAUMA Pain increasing with depth Injection and petechial hemorrhages in

canal skin or TM Tympanic membrane perforation Treatment : To address causative factor decompression To avoid occclusive ear plugs To modify diving hood

MIDDLE EAR BAROTRAUMA Barotitis media, middle ear squeeze

Most common form of barotrauma

Transient evidence in 5% of adults and 25 % of children

Pathogenesis

MIDDLE EAR BAROTRAUMAClinical features Sensation of blocked ear Desire to equalise Otalgia Sudden severe pain ( TM perforation ) Vertigo ( caloric vertigo ) Decreased hearing

MIDDLE EAR BAROTRAUMASigns Appearance of tympanic membraneGRADE 0 - SYMPTOMS,NO SIGNS 1 - REDNESS AND RETRACTION 2 - INTRATYMPANIC MEM. HEMORRAGE 3 - GROSS TYMPANIC MEM.HEMORRAGE 4 - HEMOTYMPANUM 5 - PERFORATION (100-400mmHg )

MIDDLE EAR BAROTRAUMAOSSICULAR PATHOLOGY

Fracture malleus handle

Incus dislocation

Damage to stapes foot plate

MIDDLE EAR BAROTRAUMATreatment Serial PTA and tympanometry to monitor

resolutionType I Symptoms,

no signsTo avoid air travel or diving for 24-48 hrs

Type II Signs + Oral or topical decongestantsTo avoid diving till symp. Subside ( 7- 21 days )

Type III perforation Observation +/_ myringoplastyOral or topical decongestants

MIDDLE EAR BAROTRAUMAPrevention Equalisition maneuver every 1-2 feet of

descent Oral decongestants for mild Eustachian

symptoms before flying Not recommended in divers Nasal balloon inflation Myringotomy with grommet insertion

Inner ear barotraumaPathogenesis Relative negative middle ear pressure Inward movement of TM Inward push of stapes foot plate Bulge of round window membrane into middle ear Rupture of round window membrane at a

pressure difference of 120 -300mmHg Facilitate by a forced valsalva

Inner ear barotraumaPathological entities

Inner ear hemorrhage

Labyrinthine membrane tears

Perilymph fistula

Inner ear barotraumaInner ear hemorrhage

Minimal and transient vestibular symptoms

Mild sensorineural hearing loss

Good recovery

Inner ear barotraumaLabyrinthine tears Closely resembles acute menier’s disease attack

Temporal bone studies reveal hemorrhage around reissner’s and round

window membrane rupture of utricle and saccule reissner’s membrane rupture

Inner ear barotraumaLabyrinthine tears Presents with sudden onset vertigo ,

tinnitus and low frequency hearing loss (1-2kHz)

Hearing loss is permanent

May be associated with perilymph fistula

Inner ear barotraumaPerilymph fistula 0.5 % of divers suffer

Should be differentiated from inner ear decompression illness

Recognized after surfacing in divers

Inner ear barotraumaPerilymph fistula Asociated evidence for middle ear barotauma

Nonotological symptoms

Complete neurological examination

Romberg s test, unterberger’s step test and side step test to be done

Inner ear barotraumaPerilymph fistula Fluctuating or rapidly progressive SNHL Positive hennebert sign

Disequilibrium with loud noise or physical exertion

Positional nystagmus

Constant disequilibrium of varying severity between episodes of vertigo

Inner ear barotraumaPerilymph fistula fistula test with siegel speculum- 25 to 40% with tympanometry-90%

Performed along with electronystagmography

CT or MRI – intralabyrinthine air,fluid in middle ear or mastoid, fluid in round windom niche

Inner ear barotrauma Perilymph fistula – treatment Depends on severity of presenting hearing loss failure of vestibular symp. to resolve Conservative : bed rest head end elevation avoidance of straining, coughing steroids monitored with daily audiometry to avoid diving

Inner ear barotraumaPerilymph fistula – treatment Surgical results are good for vestibular symp. And

poor for hearing improvement

Indications : progressive hearing detoriation persistent vestibular symp.after 5 days failure of complete resolution after 1mon

Inner ear barotraumaPerilymph fistula Vein graft is material of choice Identification of fistula site trendelenberg position intrathecal or iv flourescein – not useful endoscopic technique retrospective β- transferrin assay Fistula not identified – graft placed in round

window and over foot plate Ossicular surgery should be staged Tympanic membrane defect can be repaired