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