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Non - suppurative Otitis Media
Dr. Krishna Koirala, MS
Associate Professor
Dept. of ENT- HNS
2016-04-26
Types
1. Otitis Media with effusion (O.M.E.)
2. Adhesive otitis media
3. Tympanosclerosis
4. Barotraumatic otitis media
Otitis Media with Effusion
• Presence of serous or mucoid fluid in the middle ear cleft without frank pus• Synonyms
– Glue ear– Serous otitis media– Seromucinous otitis media– Secretory otitis media– Exudative otitis media– Catarrhal otitis media
Etiology1. Eustachian tube dysfunction
– Vacuum in middle ear extravasation of fluid– Lack of drainage of middle ear secretions
2. Upper respiratory tract allergy / viral infection– Increase middle ear secretions
3. Low grade middle ear infection– Inadequate treatment of ASOM
Causes of E.T. dysfunction1. Eustachian Tube obstruction
−Intrinsic : infection, allergy, trauma
−Extrinsic : adenoids, nasopharyngeal tumour
−Functional : floppy eustachian tube
2. Palatal abnormalities : Cleft palate , palatal palsy
3. Mucociliary pathology:
−Infection ,allergy ,smoking
−Kartagener’s syndrome ,Young’s syndrome
−Surfactant deficiency ,Immune deficiency
Symptoms
• Mild deafness in a young child that
increases during U.R.T.I.
• Mild otalgia
• Blocking sensation in ear
• Delayed & defective speech due to deafness
Signs1. Otoscopy
−Dull /pinkish/blue eardrum with restricted mobility
−Retraction of T.M. in early stage
−Bulging of T.M. in later stages
−Fluid level and air bubbles seen behind the T.M.
2. Tuning Fork Tests
– Conductive deafness
Blue ear drum
Air Fluid level
Air bubbles
Pure Tone Audiometry
Low frequency conductive deafness
Impedance Audiometry
C type tympanogram in ear drum retraction B type tympanogram in middle ear effusion
X-ray mastoid & Nasopharynx
Clouding of mastoid air cells + adenoid mass
Medical treatment
1. Antibiotic (Co - amoxyclav) for 2-4 weeks
2. Nasal decongestants (systemic + topical)
3. H1 anti-histamines
4. Auto-inflation of the Eustachian tube by Valsalva maneuver
5. Analgesic for acute earache
Non-medical, Non-surgical treatment
• Politzerization
• Otovent balloon
• Ear popper device
• Eardoc device
Politzerization• Rubber tube attached to
Politzer bag is put into one nostril & both nostrils pinched
• Pt is asked to swallow repeatedly & Politzer bag is squeezed simultaneously
Otovent balloon device
• Balloon is inflated by blowing air out of nose
• When fully inflated, balloon neck is pinched
off and nasal occluder is inserted into one
nostril
• Child is instructed to swallow as balloon is deflated into the nasal cavity
• Portion of air from balloon enters Eustachian tube & ventilates middle ear
Ear Popper Device
• Based on Politzer Maneuver, Ear Popper
Device delivers a safe, constant, regulated
stream of air into nasal cavity
• During swallowing, air is diverted to
Eustachian tube clearing and ventilating
middle ear
EARDOC device
EARDOC generates and transmits special
vibration waves which travel through temporal
bone to reach the middle ear & Eustachian tube
→ the waves ease middle ear pressure and drain
trapped fluids → edema & pain are reduced
Surgical treatment1. Myringotomy (Tympanocentesis) + grommet
(Pressure Equalization / Ventilation tube)
Insertion
– Radial incision made in antero-inferior quadrant
– For thick fluid, 2 incisions made in antero-
inferior quadrant and antero-superior quadrant
(Beer can principle)
2. Cortical mastoidectomy for refractory
cases with loculated fluid in mastoid
3. Treatment for predisposing factors
like adeno-tonsillectomy ,antral
wash ,polypectomy
Myringotomy
Myringotomy incision
Beer can principle
Grommet insertion
Post-op grommet
Grommet extrusion
• Grommet gets extruded on
its own due to endothelium
growing on its inner
surface
• Extrudes after 6 - 9
months.
Healed tympanic membrane
Complications of Grommet insertion
Tympanosclerosis
T.M. Perforation
Granulations
Grommet lost inside the middle ear
Sequelae of O.M.E.1. T.M. atrophy & atelectasis
2. Adhesive otitis media
3. Tympanosclerosis
4. Cholesterol granuloma
5. Ossicular necrosis
6. Retraction pocket & cholesteatoma
Adhesive Otitis Media• Pathology
– TM atrophy + atelectasis (due to
dissolution of fibrous layer) + adhesions in
middle ear cavity, following chronic O.M.E.
• Clinical Features
– Conductive deafness
– Thin retracted T.M. with no mobility
Treatment:
1. Hearing Aid
2. Surgery (long term results are poor)
a. Tympanotomy + release of adhesions
+ put silastic sheet b/w promontory & TM
b. Grommet insertion
TympanosclerosisDeposition of hyaline (acellular and avascular collagen) and calcium deposits in submucosal tissue of T.M. & M.E. cavity following long- standing otitis media during healing process
Tympanosclerosis
Treatment:
1. Hearing Aid
2. Surgery
•Remove tymapnosclerotic patch and perform tympanoplasty
Middle Ear Barotrauma
Role of Esutachian tube • E.T. has collapsible cartilaginous and rigid bony
portion
• Allows expulsion of air from middle ear into E.T. but not suction of air into middle ear via ET
Etiology• Failure of Eustachian tube to equalize rapid
increase in pressure difference b/w middle ear & atmosphere, over a long period
• During ascent– Middle ear pressure > Atmospheric Pressure
no barotrauma in normal middle ear• During descent
– Middle ear pressure < Atmospheric Pressure barotrauma occurs
Pressure Difference
Pathology in normal Middle
Ear
Symptoms
- 60 mm Hg
Hyperemia , edema , exudation , T.M.
retraction
Otalgia, deafness, tinnitus
- 90 mm Hg
Locking of ET (collapse of
lumen), microscopic hemorrhage
Severe otalgia
- 100 to 400 mm
Hg
T.M. rupture Frank blood
otorrhea
Treatment
1. Nasal decongestants + H1 anti-
histamines
2. Politzerization for middle ear aeration
3. Myringotomy + grommet insertion
– Refractory cases
– Presence of hemotympanum
Prevention1. Avoid air travel during cold / nasal allergy
2. During descent while flying– Do repeated swallows (lozenges / chewing gum)– Do intermittent Valsalva maneuvre– Avoid sleeping (as swallowing is decreased)
3. Pt with previous episode: take nasal
decongestant + antihistamine at least 30 min
before descent