Ear Diseases

EAR DISEASES:

Diseases of the External Ear

Otitis Media and Middle Ear Effusions

Chronic Otitis Media

Otosclerosis

Meniere’s Disease

Deafness

Diseases of the External EarThe external ear is composed of the auricle, the external auditory canal (EAC), and the epithelial surface of the tympanic membrane

Trauma, infections ,neoplasms

TRAUMA TO THE EXTERNAL EAR

• Trauma to the external ear is common in all age groups

• The unprotected auricle is at risk for all kinds of trauma:

----cold or hot thermal injury

----blunt or sharp injury

• Results:

----ecchymosis, hematoma, laceration, or fracture

TRAUMA TO THE EXTERNAL EAR

AURICULAR HEMATOMA

• Hematoma of the auricle usually develops after blunt trauma

----wrestlers and boxers

• Mechanism :traumatic disruption of a perichondrial blood vessel.

• Treatment:

----needle aspiration or incision

----application of pressure to prevent reaccumulation of blood.

TRAUMA TO THE EXTERNAL EAR

This loss of tissue is from a bite

LACERATIONS• Auricular lacerations with or without loss of

parts of the auricle are common from sharp trauma.• Surgical principles: ----An attempt should be made to repair ----preserving all remaining viable tissue.

INFECTION AND INFLAMMATION OF THE EXTERNAL EARAURICLE

Cellulitis of the Auricle:Cellulitis is a bacterial infection that usually follows abrasion, laceration

Allergic Dermatitis of the Auricle:Allergic dermatitis of the auricle is haracterized by localized erythema, swelling, and itching in the area of allergen exposure.

EXTERNAL AUDITORY CANAL

Acute Localized Otitis Externa (Furuncle)

Acute Diffuse Otitis Externa (Swimmer’s Ear)

Chronic Otitis Externa

Necrotizing (Malignant) External Otitis

Fungal Otitis Externa (Otomycosis)

INFECTION AND INFLAMMATION OF THE EXTERNAL EAR

Acute Localized Otitis Externa (Furuncle)

• Acute localized otitis externa is an infection of a hair follicle

• Microorganism:Staphylococcus aureus.

• Symptoms: severe pain

• Treatment:

----before suppuration: topical and systemic antibiotics.

----If a localized abscess has formed:

incision and drainage

topical antibiotic ointment

with or without oral antibiotics.

Otitis Media and Otitis Media with Effusions

Synonyms Used in the Past for Otitis MediaAcute Otitis Media Otitis

Media with EffusionSuppurative SerousPurulent SecretoryBacterial Mucoid Glue ear Middle ear effusion

DEFINITIONS:Otitis media represents an inflammatory condition of the middle ear space, without reference to cause or pathogenesis.Middle ear effusion is the liquid resulting from OM.An effusion may be either serous (thin, watery), mucoid (viscid, thick), or purulent (pus).

The process may be acute (0 to 3 weeks in duration), subacute(3 to 12 weeks in duration), or chronic (greater than 12 weeks in duration).

Acute otitis media and mastoiditis

Definition

• AOM:Acute otitis media represents the rapid onset of an inflammatory process of the middle ear space associated with one or more symptoms or local or systemic signs.

Acute suppurative otitis media

Acute non-suppurative otitis media

Bacteriology

• Streptococcus pneumoniae (48%)

• Haemophilus influenzae (31%)• Moraxella catarrhalis (20%)• P-hemolytic streptococcus

(decreased following widespread immunization program)

• Pseudomonas aeruginosa (uncommon cause of AOM)

Routine of infection

• Eustachian tube:ET dysfunction(ETD) is considered the

major etiologic factor &– upper respiratory infection (acute rhinonitis and nasal

pharyngitis)– Upper respiratory communicative disease (diaphea, mealse)

–Swimming and dive in unclear water

–Anatomic contribution (Eustachian tube in infant is wide and short and more horizontal )

Why a higher incidence of acute otitis media occurs in children?

Routine of infection

• Via external acoustic canal and TM– Perforation – Myringotomy or myrigotosis

• Via blood supply

Pathology

• Mucosal inflammation• Serous, hemorrhagic, or purulent in middle

cavity• Rupture of tympanic membrane

Symptoms • Systemic Symptoms

Fever, vomiting, diarrhea, anorexia– It may be masked by analgesics or antibiotic

• Topical Symptoms

Otalgia (ear pain)– 60% patients can spontaneous remission

Aural fullness

Hearing loss

otorrhea

Physical examination

• Erythema: It caused by dilatation and congestion of the capillaries

Increased vascularization of the TM, initially located in pars of flaccida, frequently spreading beyond the annulus to the skin of the external canal.

• Bony landmarks are visible.Physical examination usually reveals a thickened, erythematous or bulging tympanic membrane with limited or no mobility to pneumatic otoscopy.

Physical examination

• Thickened or bulging tympanic membrane

----Rapid middle ear exudation

occurs

----edema and bulging of the pars

flaccida.

Physical examination

• otorrhea• The progression of this

disease may result in rupture of TM, releasing the middle ear contents (beating sign) leads to relief of otalgia and retraction of the pars flaccida

Physical findings

Erythema bulging tympanic membrane

otorrhea perforation

Lab tests

• Blood counts usually shows leukocytosis with polymorphonuclear elevation.

• CT and MRI is necessary only for the rare patients with a serious complication (meningitis or brain abscess)

Hearing tests

• Conductive hearing loss– Degree of hearing loss

will depend on the amount and viscosity of the middle ear exudate, TM edema

– It vary from 10-50 dB with predominant involvement of the low frequencies

– Hearing loss may mixed when there is labyrinthine extension.

Diagnosis• The diagnosis of AOM requires:

– History of acute onset signs and symptoms– Presence of middle ear effusion (MEE)– Signs and symptoms of middle ear inflammation

The presence of MEE is indicated by:- A bulging tympanic membrane- Limited or absent tympanic membrane mobility- Air-fluid level behind the TM- Otorrhea (drainage from the ear)

Signs of middle ear inflammation include:- Erythema of the tympanic membrane- Otalgia (ear pain)

Managements • Antibiotic therapy

– Experiences– Antibiotic sensitivity and bacteriologic culture– Traditional duration 10-14 d– Currently duration 5-7 d

Daily Dosage for Common Antibiotic Agents in Acute Otitis Media

Managements

• Nasal decongestants or oral decongestants (antihistamines and sympathomimetic amines)

• Best rest, light diet • Avoidance of irritants (smoking)• Analgesics• Antipyretics

Managements

• Pre-perforation – Surgery: myringotomy

• Progression with a red, bulging TM, severe otalgia and fever

• Otitis media with impending complications

• perforation is not big enough to drain all pus

Managements

• Post-proferation:– Clear-up pus with 3% hydro-oxygen– Antibiotic ear drops– With pus decreased and inflammation

disappeared, alcohol can be used to facilitate dry ear.

Follow-up

• Adequately treated AOM effusion may persist for 2-6 weeks or even longer.

• Managements may require – extended antibiotic treatment– Otoscope and audiometric tests should be

performed 3-4 weeks following apparent resolution of the acute infection

– Insertion of pressure equalization tubes due to fluid persists beyond 3 months

Acute mastoiditis

• Definition: an infection of the mastoid characterized by diffuse osteitis followed by rarefaction and breakdown of the bony septae. – Acute coalescent mastoiditis– Haemorrhagic mastoiditis– Masked mastoiditis

• Predisposition to pneumatic mastoid• Predilection to kid• Mastoid is mature at age of 4 year old

Acute mastoiditis

• Reduction of immune system• Strong bacteria (type III pneumococus,

haemolytic streptococcus)• Obstruction- not effective drainage• Imcompletely treatment

Acute mastoiditis

• Symptoms– Symptoms may follow AOM, with or without a

symptom-free interval of a few days to several weeks or more.• Otalgia• Aural discharge• Conductive hearing loss• fever

Acute mastoiditis

• Physical findings– Fever, from a slight elevation to 39– Otorrhea may be absent– Pulsatile may be observed– Tympanic perforation is present, but it may be obscured by

intense edema – Swelling of the superior TM and posterosuperior wall of EAC– Postauricular area

• erythema and tenderness• Pitting edema• Obliteration of the postauricular crease

Acute mastoiditis

• Radiographic evaluation– Diffuse

rarefaction of bone and breakdown of cellular septae

Acute mastoiditis

• interventions– Medical management

• Antibiotic – Intravenous antibiotic therapy should be maintained for at

least 24-48 h after the resolution of symptoms– Then followed with oral antibiotic for 2 weeks

– Surgical management• Emergency surgery: simple mastoidectomy• Mastoidectomy + ventilation tube placement

Otitis media with effusion

Background

• Otitis media is a multifactorial disease process involving immunology, infectious disease, anatomic considerations, social and socioeconomic issues, and genetics factors.

• Approximately 70% of children below the age of 3 will develop an episode of otitis media.

Definition of OME

• OME is an inflammatory condition of the middle ear and mastoid air cell system characterized by accumulation of fluid in the middle ear without signs or symptoms of acute infection.

• Other names: – Secretory otitis media, – Serous otitis media, – Glue ear, – Nonpurulent otitis media, – Catarrhal otitis media.

Epidemiology

– 90% of children suffer from OME before school age (usually 6 months to 4 years)

– 30-40% of children with recurrent OME– 5-10% last greater than 1 year

Pathogenesis(Etiology)

• Dysfunction of Eustachian tube– Obstruction of Eustachian tube

• Mechanic obstruction– enlarged adenoid, tumor, enlarged inferior turbinate

• Non mechanic obstruction– Weakness of related muscle,

– Reduction of clearance and defense• Immotile cilia syndrome

Pathogenesis (Etiology)• Infection

– PCR detects the middle ear fluid, positive findings was 70%

– S pneumonia, haemophalus influenzae, haemolytic streptocuccus

• Immunity– Middle ear is a isolated immune system– Inflammatory mediators – Specific antibody, immunologic complex – Antigen may from adenoid or nasopharygeal lymph

• Gastroesophageal reflux － resulting in mucosa inflammatory of ET

Classification of Otitis media

• Otitis meda with effusion: the presence of middle ear effusion.

• If the middle ear effusion is present for 12 weeks or longer, it is classified chronic otitis media with effusion

Symptoms of OME

• Hearing loss may be the only symptom.– Kid can not concentrate himself– Turn on TV in loudness– If one ear is normal, the above symptoms

will be ignored• Otalgia(ear pain ,occasionally)• Fullness • Tinnitus

Physical examinationThe tympanic membrane may present

numerous physical findings:• thickening, opacification• impaired mobility• air-fluid level• bubbles

Physical examination

• Conductive hearing loss --Tuning fork test Rinne test(-); Weber test →ill side --Pure tone test

Physical examination

• Tympanometry – Middle ear pressure more negative than -

200 (type C) or a flat tympanometry curve (type B) is classified as a failure.

Diagnosis

• According to Symptoms and examination,it is easy to make the clinical diagnosis.

-- The presence of air bubbles or air fluid levels makes the

diagnosis more evident

--Lateral nasopharyngeal radiograph: hypertroph of adenoid--Nasopharyngeal exam: to exclude space-occupation lesion

Differentiated diagnosis

• Nasopharyngeal carcinoma:– Unilateral OME– EBV-VCA-IgA– Nasoendoscope– CT or MRI– Biopsy

• CSF (cerebrospinal fluid) leakage– Head trauma – Meningitis – CT or MRI

Differentiated diagnosis

• Perilymphatic fluid fistula– Secondary to stapes surgery or trauma– Vertigo– Hearing test: sensorineural hearing loss or

mixed hearing loss• Cholestrol granuloma (heamotympanum)

– Advanced stage of OME– Tympanic membrane: blue – CT: soft tissue in mastoid or middle cavity

Differentiated diagnosis

• Atelectatic Otitis media– Sequela of OME– Conductive hearing loss– TM contacts with ossicular chain

Other name:Middle Ear Atelectasis

Middle Ear Atelectasis

• Lack of middle ear ventilation results in negative pressure within the tympanic cavity

• The ear drum retracts onto structures within the middle ear

• The result of long standing Eustachian tube dysfunction

• The drum loses structural integrity and becomes flaccid

• Contact between the drum and the incus or stapes can cause bone erosion at the IS joint

• Can sometimes be treated with tympanostomy tubes

Middle Ear Atelectasis

Patient is at risk for cholesteatoma due to skin accumulation within retraction pockets

Diagnosis of otitis media

• Differentiate diagnosis of AOM and OME will benefit our treatment, as the latter condition is usually not treated unless it becomes chronic

Managements

• Principles:– discharge middle ear fluid– Drainage, ventilation – Eliminate pathogenesis

Managements

• Non surgical treatment– Antibiotics– Steroid– Improvement of nose congestion

Managements

• Surgical treatment– Tympanocentesis– Myrigotomy– Tympanotomy with PT– mastoidectomy

Management of AOMalternative medical treatment

• Corticosteroid (orally or intranasally), Antihistamine, decongestants– Orally corticosteroid and intranasally

corticosteroid help clear chronic middle ear effusion. However, there is no evidence of efficacy in treatment of AOM.

– Antihistamine and decongestants are used in the treatment of OME, it does not benefit AOM.

– Children who have nasal congestion and allergic rhinitis there may be a role for these preparation.

Medical Treatment of OME

• Observation – many European countries wait 6-9 months prior to placement of ear tubes

• Antibiotics– Meta-analysis shows beneficial short-term

resolution of OME– Unclear long-term impact

• Audiogram at 3 months with persistent effusion to determine impact on hearing

Surgical treatment for otitis media

• Indications– Middle ear effusion for more than 3 months .– Hearing loss >30dB and/or speech delay. – Chronic severe TM retraction.– Recurrent otitis media with more than 3

episode within a 6 months period, or more than 4 episode within a 12 months period.

----Tympanostomy tubes placement.

Tympanostomy Tubes(aim)

• Chronic OME >3mos with hearing loss and/or speech delay is an indication for tympanostomy tube placement(improve hearing)

• Not just there to “drain fluid”• Bypass Eustachian tube to ventilate middle ear

Surgical treatment for otitis media ----Adenoidectomy

– Indications• Children with chronic otitis media who are

candidates for tympanostomy tube placement• Children have symptoms for chronic adenoid

hypertrophy, • Children require multiple sets of tympanostomy

tube.• Adenoidectomy be a consideration in the child

older than 3 years.– It has been demonstrated that adenoidectomy may

accelerate the resolution of chronic otitis media regardless of the size of the adenoid pad.

• Background and benefit– It has been advocated for the management of acute

otitis media (unresponsive to medical management) and chronic otitis media with effusion, barotrauma, transtympanic inner ear perfusion.

– A history of allergies, the presence of a thick tympanic membrane and or high viscocity fluid are all contraindications for laser assisted tympanostomy

Surgical treatment for otitis media ---- Laser-assisted myringotomy

– It can provide symptom relief and avoid placement of tympanostomy tube by alleviating infection and inflammation or improving middle ear ventilation.

– Fenestration creates a round opening in the TM within a a fraction of a second and is usually bloodless. It generally last 2-4 weeks

Surgical treatment for otitis media ---- Laser-assisted myringotomy

The ET has three functions

(1) ventilation of the middle ear associated with equalization of air pressure in the middle ear with atmospheric pressure.

(2) protection of the middle ear from sound and secretions.

(3) drainage of middle ear secretions into the nasopharynx with the assistance of the mucociliary system of the ET and middle ear mucous membrane.

ETD is central to the development of otitis mediaAcute otitis mediaRecurrent acute otitis media (ROM)Otitis media with effusion (chronic non-suppurative otitis

media) Middle ear atelectasisChronic suppurative otitis media &