Disease of middle ear,dr.s.s.bakshi,27.03.17
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Transcript of Disease of middle ear,dr.s.s.bakshi,27.03.17
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OTITIS MEDIA WITH EFFUSION Also known as (syn. Secretory otitis
media,Mucoid otitis media,glue ear,middle ear effusion)
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How Does The Ear Work?
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EUSTACHIAN TUBE Connects nasopharynx
with tympanic cavity
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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
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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)
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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
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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
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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.
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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
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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
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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
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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
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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
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Management (medical ) Decongestants Antiallergic measures Antibiotics Middle ear aeration
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Surgical Myringotomy Grommet insertion Cortical mastoidectomy Surgical treatment of causative factor
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Sequeale of chronic SOM Atrophic TM & atelectasis of ME Ossicular necrosis Tympanosclerosis Retraction pockets Cholesterol granuloma
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Acute Otitis Media
Department of E.N.T
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Plan1) Etiology2) Risk factors3) Symptoms4) Diagnosis5) Differential diagnosis6) Management7) Complications8) Referrals
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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
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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.
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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
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AOM - SymptomsOtalgiaFeverIrritabilityVomitingDiarrheaPoor feedingOften associated with cough and rhinitis
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AOM – Differential of otalgia1) Referred pain from pharyngitis2) Teething3) Migraine4) Wax in the ear canal5) Foreign body in ear canal6) Otitis externa
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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
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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
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AOM - Management70-90 % of children will have spontaneous
remission within 7-14 days.
Generally….1) Pain management2) Watchful waiting 3) Antibiotics4) Follow-up
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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.
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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.
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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).
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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.
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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
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AOM - AntibioticsPENICILLIN ALLERGY?
Urticaria/anaphylaxis: MacrolideNo urticaria/anaphylaxis: Cephalosporin
VOMITING/NON-COMPLIANCE? Ceftriaxone 50mg/kg IV/IM in a single dose
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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.
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AOM - AntibioticsSECOND LINE ANTIBIOTICS
1) High dose amoxicillin-clavulanate2) Cephalosporin (Cefpodoxime, Ceftriaxone,
Cefuroxime) 3) Macrolide
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AOM - AntibioticsTHIRD LINE ANTIBIOTICS
1) Clindamycin2) Tympanocentesis
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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.
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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)
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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.
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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
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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.
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AOM - Complications1) Meningitis2) Facial weakness/Paralysis3) Mastoiditis 4) Speech and language delay5) Hearing loss
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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
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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
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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)
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Otitic barotrauma
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Otitic barotrauma
Encompasses pathological conditions of ear induced by pressure changes
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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
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causes Greatest chance in shallow dives and low
flying non pressurised aircrafts
Injuries are less pronounced in air travellors than divers
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BAROTRAUMAPathogenesis Closed by tympanic membrane laterally Middle ear is a bony cavity
Blood vessels represent ambient pressureEustachian tube equalises the pressure
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barotrauma
Compression injuries
Decompression injuries
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COMPRESSION INJURIES EXTERNAL EAR BAROTRAUMA
MIDDLE EAR BAROTRAUMA
INNER EAR BAROTRAUMA
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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
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EXTERNAL EAR BAROTRAUMA Pathogenesis Normal eustachian tube function Increasing compression
Increase in middle ear press. Relative negative ex. Ear press
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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
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MIDDLE EAR BAROTRAUMA Barotitis media, middle ear squeeze
Most common form of barotrauma
Transient evidence in 5% of adults and 25 % of children
Pathogenesis
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MIDDLE EAR BAROTRAUMAClinical features Sensation of blocked ear Desire to equalise Otalgia Sudden severe pain ( TM perforation ) Vertigo ( caloric vertigo ) Decreased hearing
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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 )
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MIDDLE EAR BAROTRAUMAOSSICULAR PATHOLOGY
Fracture malleus handle
Incus dislocation
Damage to stapes foot plate
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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
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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
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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
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Inner ear barotraumaPathological entities
Inner ear hemorrhage
Labyrinthine membrane tears
Perilymph fistula
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Inner ear barotraumaInner ear hemorrhage
Minimal and transient vestibular symptoms
Mild sensorineural hearing loss
Good recovery
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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
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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
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Inner ear barotraumaPerilymph fistula 0.5 % of divers suffer
Should be differentiated from inner ear decompression illness
Recognized after surfacing in divers
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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
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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
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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
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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
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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
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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