Infections of the middle ear M.Rogha M.D. Isfahan university of medical sciences 1.
-
Upload
adam-jordan -
Category
Documents
-
view
215 -
download
2
Transcript of Infections of the middle ear M.Rogha M.D. Isfahan university of medical sciences 1.
Infections of the middle ear
M.Rogha M.D.Isfahan university of medical sciences
1
Acute Otitis Media (AOM) “acute onset of symptoms, evidence of a middle
ear effusion, and signs or symptoms of middle ear inflammation.”
Otitis Media with effusion (OME) “Presence of MEE without signs or symptoms of
infection, previously named: secretory, serous, or glue ear. ”
2
3
Difficult to treat AOM (20%)
Recurrent AOM: three or more episodes in the previous six months or four or more in the preceding twelve months.
Treatment failure AOM: a lack of improvement in sign and symptoms within 48-72 hours of AB treatment .
31 million visits to physicians annually in U.S. Most common diagnosis for an AB
prescription in children. Diagnosed > 5 million times a year. 3-5 billion $/year in U.S. 50,000 deaths / year worldwide.
4
● Age <2 years● Bottle propping● Chronic sinusitis● Ciliary dysfunction● Cleft palate and craniofacial anomalies● Child care attendance● Down syndrome and other genetic conditions● First episode of AOM when younger than 6 months of age● Immunocompromising conditions
5
Specific Otalgia Otorrhea Dizziness Hearing loss
Non-specific Fever (50%) Vomiting/diarrhea Anorexia Irritability
6
Otoscopic findings Bulging TM Yellow, white, or bright red color Opacification of eardrum Impaired visibility of ossicular landmarks
7
8
9
Bacterial Streptococcus
pneumoniae Haemophilus
influenzae Moraxella
catarrhalis
Viral RSV Influenzae A & B Parainfluenzae 1,2, &
3 Rhinovirus Adenovirus Enterovirus Coronavirus
10
Mastoid abscess
Facial nerve palsy
Labyrinthitis
Extra/sub dural abscess
Meningitis
Brain abscess
Lateral sinus thrombophlebitis
Petrositis
Heptavalent pneumococcal conjugate vaccine Reduction of otitis office visits Reduction of antibiotic prescriptions
Influenza vaccine Goal: decrease number of URI
Breast feeding Prophylaxis
3 episodes in 6 months or 4 episodes in 1 yr <6 months with >1 episode Cause of resistance in the community
12
80% will resolve within 3 days without treatment, 95% in 5 days
Antibiotics may improve short term symptoms, although evidence for any gain in medium to long term outcome is lacking
Countries with lower rates of antibiotic prescribing for acute otitis media do not have an increase in the number of complications
Culture & sensitivity Simple analgesia
Paracetamol Ibuprofen(some evidence superior)
Antihistamine & decongestant?? Aural toilet Myringotomy
Bulging drum Facial palsy Incomplete resolution
No antibiotic if no fever; analgesic and reassurance Amoxycillin 30-40mg/kg/d 3DDx10d Amoxycillin clavulanate Cefuroxime 30mg/kg/d 2DDx10d Clarithromycin 15mg/kg/d 2DDx10d Azithromycin 10mg/kg OD x 5d,5mg/kg ODx5d Cotrimoxazole 10mg/kg/d 2DDx10d (Trimetho)
Eliminate cause
Long term low dose antibiotics
Amoxycillin/cotrimoxazole
Myringotomy + grommet
Adenoidectomy
Treat allergy
Pneumococcal vaccine
Persistence/reappearance of pain Persistence/reappearance of discharge Persistent fever Symptoms & signs of complications:
Vertigo/Nystagmus/Ataxia Facial palsy/diplopia Headache, vomiting, drowsiness Abscess behind ear/in neck
Infants & young children
Follows measles, influenza, pneumonia
-haemolytic streptococci
Otorrhoea without pain
Foul smelling discharge
Sensorineural deafness
Large perforation
Chronic infection of the middle ear with a non-healing perforation of the tympanic membrane
Otorrhea (ear drainage) for 6-12 weeks Middle ear mucosa becomes edematous,
polypoid, or ulcerated The tympanic cavity usually contains
granulation tissue Most common infecting organisms are
Pseudomonas aeruginosa, Staphylococcus aureus, Proteus species, Klebsiella pneumoniae, and diphteroids
Annual incidence approximately 40 cases/100,000 population
Patients present with hearing loss and otorrhea
Pain, vertigo, fevers, facial nerve palsy, mental status changes or fetid drainage signify impending intra-temporal or intra-cranial complications
Cholesteatomas are epidermal inclusion cysts of the middle ear and/or mastoid with a squamous epithelial lining
Contain keratin and desquamated epithelium Term “cholesteatoma” coined by Johannes
Muller in 1838 Misnomer because the cysts don’t contain
cholesterol Can be congenital or acquired Natural history is progressive growth with
erosion of surrounding bone due to pressure effects and osteoclast activation
Epidermal inclusion cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice
Michaels found epidermoid formation in 37 of 68 temporal bones of fetuses at 10 to 33 weeks' gestation. (Michaels L: An epidermoid formation in the developing middle ear; possible source of cholesteatoma, Otolaryngol 15:169, 1986)
Diagnosed as a pearly white mass behind an intact tympanic membrane in a child who does not have a history of chronic ear disease
Pathogenesis
Invagination Basal cell
hyperplasia Migration (through a
perforation) Squamous
metaplasia
Retraction pocket cholesteatoma usually within the pars flaccida or posterior superior tympanic membrane (invagination Theory)
Secondary to ETD Keratin debris collects within a retraction
Normal TM Mucoid effusion and primaryacquired cholesteatoma
Mesotympanic cholesteatoma
Migration Theory – most accepted Originates from a tympanic membrane perforation As the edges of the TM try to heal, the squamous
epithelium migrates into the middle ear
History, physical examination, high resolution CT scan of the temporal bone
Axial Section Coronal Section
Ototopical antibiotics Surgical repair of the TM perforation Repair of the ossicular chain if
necessary
Antibiotic only otic drops
Floxin (ofloxacin) Antibiotic with steroid otic drops
Ciprodex (ciprofloxin and dexamethasone) Cipro HC (ciprofloxin and hydrocortisone)
Cortisporin (neomycin, polymyxin, and hydrocortisone)
Ophthalmic antibiotic preparations Tobradex (tobramycin and dexamethasone)
The concentration of antibiotic in ototopical drops is 100-1000x greater than what can be achieved systemically.
Paper patch myringoplasty Fat myringoplasty Underlay tympanoplasty (medial graft technique)
Ototopical antibiotics Surgical repair of the TM perforation Repair of the ossicular chain if
necessary Often requires mastoidectomy
Intact (bony ear) canal wall mastoidectomy
Canal wall down mastoidectomy Radical Mastoidectomy Modified Radical Mastoidectomy
Tympanoplasty with mastoidectomy and hydroxyapatite
bone cement ossicular reconstruction
Acute mastoiditis Sub-periosteal
abscess Cholesteatoma Labyrinthitis Facial paralysis Meningitis Epidural/subdural
abscess Brain abscess Sigmoid sinus
thrombosis Otitic
Hydrocephalus
Due to antibiotics, the incidence of complications has greatly declined.
Complications are usually associated with some degree of bone destruction, granulation tissue formation, or the presence of a cholesteatoma.
Complications arise most commonly by infection spreading by direct extension from the middle ear or mastoid cavity to adjacent structures.
Patients appear more ill than expected fever, new onset vertigo, sensorineural hearing
loss, fetid drainage, facial nerve weakness, proptotic ear
lethargy and mental status changes CT and MRI are indicated
CT is superior for evaluating the bony details of the middle ear and mastoid space
MRI is more sensitive for diagnosing suspected intracranial complications.
Broad spectrum antibiotics and surgery are required