Non-Suppurative Otitis Media

Dr. Vishal Sharma

Types

1. Otitis Media with effusion (O.M.E.)

2. Adhesive otitis media

3. Tympanosclerosis

4. Baro-traumatic otitis media

Otitis Media with effusion

Presence of serous or mucoid effusion in middle

ear cleft with no frank pus.

Synonyms:

1. Secretory / Serous otitis media

2. Seromucinous / exudative otitis media

3. Catarrhal otitis media

4. Glue ear

Etiology

1. Eustachian tube dysfunction

Vacuum in M.E. extravasation of fluid

Lack of drainage of M.E. secretions

2. Upper respiratory tract allergy / viral infection

Increase M.E. secretions

3. Low grade middle ear infection

Inadequate treatment of A.S.O.M.

Causes for E.T. dysfunction

1. Eustachian Tube obstruction

• Intrinsic edema = infection / allergy / trauma

• Extrinsic = adenoid / nasopharyngeal tumour /

post – Radiotherapy scarring

• Functional = floppy Eustachian tube

2. Patulous Eustachian tube: reflux of secretions

Causes for E.T. dysfunction

3. Palatal abnormality:

cleft palate / palatal palsy

4. Muco-ciliary pathology:

Infection / allergy / smoking

Kartagener’s syndrome / Young’s syndrome

Surfactant deficiency / Immune deficiency

Causes of E.T. dysfunction

Predisposing conditions

• Child going to a nursery

• Early weaning with formula milk

• Parents who smoke

• Recurrent respiratory infections

• Crowded living condition

• Poor nutrition

• Cleft palate

Clinical Symptoms

• Mild deafness in a young child

• Deafness increases during U.R.T.I.

• Mild otalgia

• Blocking sensation in ear

• Delayed & defective speech due to deafness

Clinical signs

1. Otoscopy:

• Blue eardrum with restricted mobility

• Retraction of T.M. in early stage

• Bulging of T.M. in later stages

• Fluid level + air bubbles seen behind T.M.

2. Tuning Fork Tests: conductive deafness

Otoscopy

Blue ear drum

Left retracted ear drum

Right air-fluid level

Left air-fluid level

Right air bubbles

Left air bubbles

Investigations

Pure Tone Audiometry

P.T.A.: low frequency conductive deafness

Impedance Audiometry

C curve in ear drum retraction

Impedance Audiometry

B curve 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 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

Technique of inflation

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 nasal cavity. Portion of air from

balloon enters Eustachian tube & ventilates middle

ear.

Ear Popper Device

Ear Popper Device

Based on Politzer Maneuver, EarPopper ™

Device delivers a safe, constant, regulated

stream of air into nasal cavity. During

swallowing, air is diverted to Eustachian tube

clearing & ventilating middle ear.

EARDOC device

EARDOC device

EARDOC ™ generates & transmits special

vibration waves which travel through temporal

bone to reach middle ear & Eustachian tube. The

waves ease middle ear pressure & drain trapped

fluids. As a result edema & pain are reduced.

Surgical treatment

1. Myringotomy (Tympanocentesis) + grommet

(Pressure Equalization tube) insertion:

Radial incision made in antero-inferior

quadrant. For thick fluid, 2 incisions made in

antero-inferior quadrant & antero-superior

quadrant (Beer can principle).

Surgical treatment

2. Laser or radio-frequency assisted myringotomy:

grommet insertion not required

3. Cortical mastoidectomy: for refractory cases

with loculated fluid in mastoid

4. Treatment for predisposing factors: adeno-

tonsillectomy / antral wash / polypectomy

Myringotomy & grommet insertion

Myringotome

Right Myringotomy incision

Left Myringotomy incision

Myringotomy performed

Beer can principle

Glue like fluid

Shepard’s Grommet

Armstrong’s grommet

Donaldson grommet

Shah’s grommet

T-tube grommet

Grommet insertion

Right grommet in position

Left grommet in position

Grommet in ant-sup quadrant

T-tube grommet in situ

Grommet extrusion

Grommet gets extruded

on its own due to

endothelium growing

on its inner surface.

Extrudes after 6 - 9

months.

Grommet extrusion

Healed tympanic membrane

Complications of Grommet insertion

Tympanosclerosis

T.M. Perforation

T.M. Perforation

Granulation over grommet

Grommet lost inside

Radiofrequency assisted myringotomy

Cortical Mastoidectomy

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

Prevention of O.M.E.

• Avoid irritants like cigarette smoke

• Identify & avoid any allergens

• Consider a smaller day care centre (< 6 children)

• Wash hands & toys frequently

• Use air filters & provide fresh air at home

• Encourage breastfeeding

• Use of pneumococcal vaccine

Adhesive Otitis Media

Pathology: TM atrophy + atelectasis (due to

dissolution of fibrous layer) +

adhesions in M.E. cavity, following chronic

O.M.E.

Clinical Features:

1. Conductive deafness

2. Thin retracted T.M. with no mobility

Adhesive Otitis Media

Adhesive Otitis Media

Treatment:

1. Hearing Aid

2. Surgery (long term results are poor)

a. Tympanotomy + release adhesions + put

silastic sheet b/w promontory & TM.

b. Grommet insertion

Left grommet in position

Tympanosclerosis

Deposition of hyaline

(acellular + avascular

collagen) + calcium

deposits in submucosal

tissue of T.M. & M.E.

cavity following long-

standing otitis media

Tympanosclerosis

Treatment:

1. Hearing Aid

2. Surgery (long term results are poor)

Remove tymapnosclerotic plaque & perform

tympanoplasty

Barotrauma of middle ear

Pathogenesis

E.T. has collapsible

cartilaginous part &

rigid bony part

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 is more than

Atmospheric Pressure no barotrauma in

normal middle ear

During descent: middle ear pressure is less than

Atmospheric Pressure barotrauma occurs

Pressure Difference

Pathology in normal Middle Ear

Symptoms

- 60 mm Hg Hyperaemia + edema + exudation + T.M.

retraction

Otalgia, deafness, tinnitus

- 90 mm Hg (less in pt with cold)

Locking of E.T. (collapse of lumen),

microscopic hemorrhage

Severe otalgia

- 100 to 400 mm Hg

T.M. rupture Frank blood otorrhoea

Treatment

1. Nasal decongestants + H1 anti-histamines

2. Politzerization for middle ear aeration

3. Myringotomy + grommet insertion done for:

– refractory cases

– presence of haemotympanum

Prevention

1. Avoid air travel during cold / nasal allergy

2. During descent while flying:

Do repeated swallows (lozenges / gum)

Do intermittent Valsalva maneuvre

Avoid sleeping (as swallowing is decreased)

3. Pt with previous episode: take nasal decon-

gestant + antihistamine 30 min before descent.

Thank You