Otitis MediaOtitis MediaDr. Yasser Dr. Yasser ShewelShewel

Definition Inflammation of the mucoperiosteal lining of the middle ear cleft (Eustachian tube, tympanic cavity, mastoid antrum and mastoid air cell).

• Middle Ear

• Mastoid

Classification Acute otitis media:

• Acute viral (non suppurative) otitis media.• Acute suppurative otitis media.• Acute Necrotizing otitis media.

Chronic otitis media:• Nonspecific:

– Chronic suppurative otitis media:– Chronic non-suppurative otitis media

Otitis media with effusion. Chronic adhesive otitis media Tympanosclerosis Cholesterol granuloma

• Specific e.g. Tuberculous otitis media.

Acute Suppurative Otitis MediaAcute Suppurative Otitis Media

Definition

Acute inflammation of the mucoperiosteal lining of the middle ear cleft with reversible pathology

Incidence• Acute otitis media is

primarily a disease of children. Its peak incidence is during the first 6 years of life.

• Several factors contribute to the prevalence of acute otitis media media in early childhood. These include:– Anatomical features of Eustachian tube :

• The Eustachian tube is – shorter,– wider– and more horizontal than in adults

• The orifices of the tube are surrounded by lymphoid tissues.

– Frequent exposure to upper respiratory infections – Immature immune system

Predisposing factors– poor socioeconomic conditions– Crowding– Bottle feeding– malnutrition, – immunodeficiency– Passive Smoking– Pollution– Mucociliary disorders

BacteriologyThe common organisms include:

– Streptococcus pneumoniae, – Moraxilla catarrhalis – H. influenzae is more frequent during infancy

and early childhood. – Viral infection commonly precedes secondary

bacterial invasion

Routes of infection– Through the Eustachian tubes: This is the

commonest route.– Through a drum perforation.

PathophysiologyPathophysiologyET blockageET blockage

1. ET blockage

2. -ve pressure in ME

Pathology

The inflammatory process passes through continuous stages

• Stage of tubal occlusion…..> negative pressure in the middle ear

• Stage of catarrhal inflammation…> The hyperemia and transudation

• Stage of suppuration• Stage of Resolution: unless complications

occur

Clinical picture

Acute otitis media is frequently preceded by upper respiratory infection.

• Stage of tubal occlusion:– May be mild fever.– Sense of fullness in the ear– Earache.– mild conductive hearing loss– The tympanic membrane appears retracted,

congested, and lusterless.

• Stage of acute catarrhal otitis media:– Fever – Fullness– Increasing ear ache.– Mild conductive hearing loss– The tympanic membrane appears retracted,

congested (especially the pars flaccida) + signs of fluid behind the tympanic membrane

• Stage of acute suppurative otitis media (before rupture of tympanic membrane):– High fever.– Severe throbbing pain.– CHL– The tympanic membrane

• markedly congested, • bulging, first in the posterior half• Later on a yellowish spot appears indicating impending

rupture of tympanic membrane– tenderness over the mastoid process (mastoidism). If it persists,

it indicates bone involvement i.e.mastoiditis.

• Stage of acute suppurative otitis media (after rupture of tympanic membrane):– Rapid relief of pain, fever and CHL.– discharge – Small central perforation. The perforation is

frequently located in the anteroinferior quadrant but may be present anywhere in the pars tensa. If the perforation is small the discharge may appear pulsating,

• Stage of resolution:– Resolution may occur with treatment – or after perforation of the drum membrane.

Differential diagnosis– Other causes of otalgia– Red tympanic membrane

Treatment:• Before the perforation :

• Antibiotic• decongestant• Antipyretic- analgesic preparations.• Myringotomy ( when)

• After the perforation of tympanic membrane • Antibiotics ( Culture and sensitivity of the discharge may be

needed)• Antibiotic ear drops.• Decongestant• Frequent cleaning of the ear.• Myringotomy ( when)

A severe form of otitis media occurring in ill, toxic children suffering from measles and other exanthemata. It is caused by virulent hemolytic streptococci

Acute necrotizing otitis mediaAcute necrotizing otitis media

characterized by necrosis and sloughing of tissues…>– Large tympanic perforation….> predisposes

CSOM– foul smelling discharge– Increase the risk of complications

Treatment:– Frequent aural toilets (cleaning).– Culture and sensitivity of the discharge.– Systemic and local antibiotics.– Treatment of sequels and complications e.g.

tympanoplasty

Chronic non suppurative Chronic non suppurative otitis mediaotitis media

1-Otitis Media with Effusion 1-Otitis Media with Effusion (OME)(OME)

synonyms:

• Secretory otitis media,

• Middle Ear Effusion (MEE).

Definition:

It is the accumulation of fluid( non infectious , non suppurative) behind an intact tympanic membrane without symptoms and signs of inflammation

• It is the most common cause of hearing loss in children.

• Age: Any, most frequently under 9 years.

• Laterality: Usually bilateral

Etiology:

• Eustachian tube dysfunction (Most important cause).

• post otitis : non resolved acute otitis media due inadequate medical treatment

Causes of ET dysfunction.

1) Acute (Serous) middle ear effusion:Occurs due to acute ET dysfunction which is

commonly caused by:

a) Otitic barotrauma.

b) Acute allergy

c) Acute viral upper respiratory tract infections.

2) Chronic (mucoid) middle ear effusion'.

Occurs due to chronic ET dysfunction which can be:

a) Mechanical obstruction:i) Adenoids.

ii) Nasopharyngeal Tumors

b) Functional obstruction: as in cleft palate.

Clinical Picture:

1-SymptomsIn children:

i) Hearing loss (noticed by the parents) :is usually the only complain.

ii) Asymptomatic diagnosed during routine otoscopy.

In the adults– Hearing loss – Sense of fullness in the ear– ±Tinnitus

2- otoscopy:a) Tympanic membrane:

i) Is retracted as evidenced by:(1) Handle of the malleus

becomes more horizontal.

(2) Lateral process of the malleus becomes more prominent.

ii) Looks dull and opaque.

b) Behind the tympanic membrane, there may be:i) Air-fluid level (Hair-line)

ii) ii) Air bubbles (indicates that the fluid is serous).

3) Pneumatic of oscopy (Siegelization): Limited mobility (Hallmark of the disease)

4-Investigations:A) Tympanometry:

B) Stapedial reflex:

C) PTA:

Flat tympanogram (Type B)

AbsentCHL

D) Investigations for the cause:a) X-ray Nasopharynx in children to exclude

adenoids

b) CT scan Nasopharynx in adults with unilateral middle ear effusion to exclude Nasopharyngeal carcinoma

c) Nasal endoscopy: to exclude nasal allergy or Nasopharyngeal carcinoma

Complications:1. Recurrent ASOM.

2. Atelectasis - retraction pockets (usually posterosuperior)

3-Cholesteatoma.

4. Adhesive OM.

4. Tympanosclerosis

5- SNHL

6- Ossicular erosion

Treatment:1} Medical treatment:

a) Antibiotics

b) Steroids

c) Mucolytic drugs

d) Systemic decongestants.

2) ET inflation.

Medical treatment should be at least for 3 months

2- Surgical treatment a) Myringotomy with aspiration of fluid and

insertion of ventilation tube

b) adenoidectomy.

c) Both Myringotomy with adenoidectomy( best)

d) Cortical mastoidectomy to exenterate mastoid air cells( recurrent)

2) Middle Ear Atelectasis2) Middle Ear Atelectasis

Definition:

Collapse of the lateral wall of the middle ear (tympanic membrane) on to the(medial wall (promontory).

Etiology: Proteolytic enzymes in middle ear effusion

destroy the middle fibrous layer of the tympanic membrane …> retraction of the TM by the negative middle ear pressure created by the Eustachian tube obstruction

Pathology:Four stages are described as follows:

1) Stage I: Mild retraction of the tympanic membrane.

2) Stage //.-Tympanic membrane is more retracted to be in contact with incudostapedial joint.

3) Stage III (Atelectatic stage): Tympanic membrane is lying on but not adherent to

the promontory (tympanic membrane moves if the patient performs Valsalva's manoeuver).

4) Stage IV (Adhesive stage): Tympanic membrane is adherent to the promontory

(it does not move on Valsalva's manoever).

Clinical picture:

1) C/0:Hearing loss.

2) Otoscopy reveals tympanic membrane abnormality according to the pathological stage

Treatment (depending on the stage):1) Myringotomv and ventilation tube

2) Tympanoplasty: to reinforce the tympanic membrane by cartilage.

Ossiculoplasty is performed if needed.

3) Hearing aid

3) Tympanosclerosis3) Tympanosclerosis

Definition:

It is deposition of calcified hyalinized collagen in the tympanic mucosa and / or in the tympanic membrane.

Clinical picture:

1-) C/0;a) Hearing loss.

b) The condition could be asymptomatic and discovered on routine otoscopy.

2) Otoscopy : Chalky white patches in the TM (myringosclerosis)

or in the middle ear (Tympanosclerosis

Treatment: – Myringosclerosis: No treatment if

asymptomatic – Tympanosclerosis:

• Surgical removal• or Hearing aid