Otitis Media Otolaryngology

8/14/2019 Otitis Media Otolaryngology

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Otitis MediaOtitis Media

Dr.SherifDr.SherifBugnahBugnah

ENT Resident | AFHSRENT Resident | AFHSR

Supervised by Dr.MuslihSupervised by Dr.Muslih


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INTRODUCTION & DEFINITIONSINTRODUCTION & DEFINITIONS

Otitis media (OM) is the most commonOtitis media (OM) is the most common

bacterial infection in children and the mostbacterial infection in children and the most

frequent indication for antimicrobial orfrequent indication for antimicrobial or

surgical therapy in this age group. It is alsosurgical therapy in this age group. It is alsothe leading cause of hearing loss in children.the leading cause of hearing loss in children.

OM : any inflammatory process in theOM : any inflammatory process in the

middle-ear cleft behind an intact tympanicmiddle-ear cleft behind an intact tympanic

membrane (TM).membrane (TM).


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CLASSIFICATIONSCLASSIFICATIONS

Two Major Classes of OM areTwo Major Classes of OM areAcute Otitis MediaAcute Otitis Media

Chronic OMChronic OM withwith effusion (OME)effusion (OME)..

A diagnosis ofA diagnosis ofAOMAOM requires the presence of arequires the presence of a (MEE)

(MEE)and the symptoms and signs of acute infectionand the symptoms and signs of acute infection (Fever,

(Fever,

Pain,Red and Bulging TMP

ain,Red and Bulging TM).).

OMEOME indicates anindicates an MEE without signs of inflammationMEE without

signs of inflammation..Equivalent terms are chronic secretory OM, chronicEquivalent terms are chronic secretory OM, chronic

serous OM, and "glue ear." MEE denotes a liquid in theserous OM, and "glue ear." MEE denotes a liquid in the

middle-ear cleft regardless of etiology.middle-ear cleft regardless of etiology.


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CLINICAL AND FUNCTIONAL ANATOMYCLINICAL AND FUNCTIONAL ANATOMY

The middle-ear cleft is a continuous spaceThe middle-ear cleft is a continuous spacethat begins at the nasopharyngeal orifice ofthat begins at the nasopharyngeal orifice of

the Eustachian tube and extends to thethe Eustachian tube and extends to the

farthest mastoid air cells.farthest mastoid air cells.The mucosal lining of the middle-ear cleftThe mucosal lining of the middle-ear cleft

varies from the thick, ciliated, respiratoryvaries from the thick, ciliated, respiratory

epithelium of the Eustachian tube and anteriorepithelium of the Eustachian tube and anteriortympanum to the thin, nonglandular, cuboidaltympanum to the thin, nonglandular, cuboidal

epithelium in the mastoid cells.epithelium in the mastoid cells.


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CLINICAL AND FUNCTIONAL ANATOMYCLINICAL AND FUNCTIONAL ANATOMY

Hyperplasia and an increase in theHyperplasia and an increase in the

number of goblet cells are commonnumber of goblet cells are common

findings in the middle ears of patientsfindings in the middle ears of patientswith OM.with OM.

These metaplastic changes, whichThese metaplastic changes, which

predispose to the formation of effusion,predispose to the formation of effusion,are probably the result of the primaryare probably the result of the primary

process.process.


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EPIDEMIOLOGYEPIDEMIOLOGY

OM afflicts a majority of children atOM afflicts a majority of children at

some point during their early years.some point during their early years.

Study* in the southern United States,Study* in the southern United States,

84%84% of children had one episode of OM,of children had one episode of OM,

50%50% had three or more episodes, andhad three or more episodes, and

25%25% had six or more episodeshad six or more episodes

The highest prevalence occurs in theThe highest prevalence occurs in the

first 2 yearsfirst 2 years of life and decreases there-of life and decreases there-

after.after.*Greater Boston Otitis Media Study*Greater Boston Otitis Media Study


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PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Linked with abnormalities ofLinked with abnormalities ofEEustachian tubeustachian tube

functionfunction,, Three functions ET:Three functions ET:

Aeration, Clearance, and ProtectionAeration, Clearance, and Protection

Early studies suggested that obstruction of theEarly studies suggested that obstruction of thetube (tube (under aerationunder aeration) was the underlying cause of) was the underlying cause of

most AOM.most AOM.

Newer work, has suggested that AOM is theNewer work, has suggested that AOM is the

result of bacterial entry into the middle ear (result of bacterial entry into the middle ear (failurefailure

of protectionof protection). This entry is due to an abnormally). This entry is due to an abnormally

patent tube rather than an obstructedpatent tube rather than an obstructed


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Pathogenesis of acute otitis media

Cohen & Powderly: Infectious Diseases, 2nd ed.


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DIAGNOSISDIAGNOSIS..

The first step in diagnosis is by recognitionThe first step in diagnosis is by recognition

of a problem by the family.of a problem by the family.

Older childrenOlder children will complain ofwill complain ofearachesearaches,,butbut infantsinfants becomebecome sleep poorlysleep poorly, and often, and often

pull or tugpull or tug at the affected ear.at the affected ear.

OMEOME may be completelymay be completely asymptomaticasymptomatic..Often family will notice decrease in hearingOften family will notice decrease in hearing

incidentally.incidentally.


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OTOSCOPYOTOSCOPY

AOM Classic signsAOM Classic signs

RednessRedness

Bulging of the TM.Bulging of the TM.


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OTOSCOPYOTOSCOPY

Early stagesEarly stages of AOM, TMof AOM, TM

maymay bulge outwardbulge outward and itand it

often moves normally.often moves normally.

InIn effusion, drum mobilityeffusion, drum mobility

is decreased.is decreased. Severe casesSevere cases

the usual landmarks maythe usual landmarks may

not be visible.not be visible.


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OTOSCOPYOTOSCOPY

If the process continues,If the process continues, necrosis of thenecrosis of the

TMTM occurs and the effusion passes into the earoccurs and the effusion passes into the earcanal through a typicallycanal through a typically pinpoint perforation.pinpoint perforation.

Massive necrosisMassive necrosis of the drumhead is rare,of the drumhead is rare,

althoughalthough necrotizing streptococcalnecrotizing streptococcal infection isinfection is

a known cause ofa known cause ofpermanent perforation.permanent perforation.


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OTOSCOPYOTOSCOPY

Clinical variants of AOMClinical variants of AOM

MyringitisMyringitis is an inflammation of the TM without MEE.is an inflammation of the TM without MEE.

The etiology and pathogenesis of Myringitisare not wellThe etiology and pathogenesis of Myringitisare not well

documented. Treatment is the same for AOM.documented. Treatment is the same for AOM.

Bullous MyringitisBullous Myringitis is seen in both adults and children.is seen in both adults and children.

Pain is an outstanding feature . Most cases bullae onPain is an outstanding feature . Most cases bullae on

the TM are associated with the same pathogenicthe TM are associated with the same pathogenic

bacteria as AOM and treated similarly.bacteria as AOM and treated similarly.


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OTOSCOPYOTOSCOPY

The classic findings ofThe classic findings ofOMEOME are aare a retracted,retracted,hypomobile or immobilehypomobile or immobile TM and aTM and a dark, fluid-dark, fluid-

filledfilled tympanum that obscures visualization oftympanum that obscures visualization of

the long process of the incus.the long process of the incus.


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TYMPANOMETRYTYMPANOMETRYAcoustic energy reflected from the TM as the pressureAcoustic energy reflected from the TM as the pressure

in the external auditory canal is varied from -400 daPa toin the external auditory canal is varied from -400 daPa to

100 daPa, the shape of which provides considerable100 daPa, the shape of which provides considerable

information about the status of the middle ear.information about the status of the middle ear.

InIn air-containing ears,air-containing ears, the shape of the tympanogram isthe shape of the tympanogram is

usually peaked at -100 daPausually peaked at -100 daPa (type A).(type A).

InIn MEAMEA, compliance is low and the tympanogram is, compliance is low and the tympanogram is

labeledlabeled type Btype B byby

Negative middle-ear pressureNegative middle-ear pressure below 150 daPa) with abelow 150 daPa) with a

sharp peak is labeledsharp peak is labeled type Ctype C..


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TYMPANOMETRYTYMPANOMETRY

. Type A represents normal middle ear function. Type A curves have normal mobility and pressures |normal hearingand sensorineural hearing loss with normally functioning middle ear systems. Type B represents restricted tympanicmembrane mobility. Type B curves have little or no point of maximum mobility and reduced compliance, typical of astiff middle ear system (Otitis media.) Type C represents significant negative pressure in the middle ear cavity. TypeC curves have normal mobility and negative pressure at the point of maximum mobility,(treatment when morenegative than -200 mm H2O). Type As represents normal middle ear pressure but reduced mobility suggesting

limited mobility of the tympanic membrane and middle ear structure, commonly seen in fixation of the ossicularchain. Type Ad represents normal middle ear pressure but hypermobility. This pattern is indicative of a flaccid


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AUDIOMETRYAUDIOMETRYGuidelines for treatment of OMEGuidelines for treatment of OME in young childrenin young children

recommended that audiometry be used in therecommended that audiometry be used in the decision ofdecision of

surgical drainagesurgical drainage of the middle ear, and that surgery shouldof the middle ear, and that surgery should

not be done if the pure-tone average is less than 20 dBnot be done if the pure-tone average is less than 20 dB

Limited GiudelinesLimited Giudelines!!

Audiometry is not always available, noAudiometry is not always available, no

It is not practical for 2-year-old children.It is not practical for 2-year-old children.

Hearing levels may fluctuate frequently so that a normalHearing levels may fluctuate frequently so that a normal

pure-tone average on one day does not excludepure-tone average on one day does not exclude

abnormal thresholds on anotherabnormal thresholds on another


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SEQUELAE AND COMPLICATIONSSEQUELAE AND COMPLICATIONS

The suppurative complications of AOM (The suppurative complications of AOM (pre-antibioticpre-antibiotic

eraera) include Extension of the infection to involve the) include Extension of the infection to involve the

bone of thebone of the Mastoid, Soft Tissues of The Neck,Mastoid, Soft Tissues of The Neck,MeningesMeninges, and, and Cerebral/Cerebellar CortexCerebral/Cerebellar Cortex

TodayToday The most likely patients s are those withThe most likely patients s are those with

postauricular tenderness and fullness in whom thepostauricular tenderness and fullness in whom the

diagnosis ofdiagnosis ofMastoiditisMastoiditis is suspected.is suspected.


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Clouding of air cells on CT is expected and should notClouding of air cells on CT is expected and should not

be mistaken for mastoiditis. The keybe mistaken for mastoiditis. The key radiographic signradiographic sign

of Mastoid Osteitisof Mastoid Osteitis,, Demineralization of the air cellDemineralization of the air cellseptae, lags behind the clinical findings.septae, lags behind the clinical findings.

OnceOnce OsteitisOsteitis is diagnosed,is diagnosed, MastoidectomyMastoidectomy isis

generally warranted to remove the infected necroticgenerally warranted to remove the infected necrotic

bone/ subperiosteal postauricular abscess drainagebone/ subperiosteal postauricular abscess drainage

(if present)(if present)


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Intracranial ComplicationsIntracranial Complications in AOM are rare,in AOM are rare,MMeningitis, Extradural Abscess, or Brain Abscess .eningitis, Extradural Abscess, or Brain Abscess .

Adverse effects of OMEAdverse effects of OME on Hearing and on theon Hearing and on the

Development of Cognitive, Linguistic, Auditive, andDevelopment of Cognitive, Linguistic, Auditive, and

Communicative SkillsCommunicative Skills

Otologic Complications of OM,Otologic Complications of OM,

Permanent Perforation Of The TM, ChronicPermanent Perforation Of The TM, Chronic

Suppurative OM, Tympanosclerosis, Adhesive OM,Suppurative OM, Tympanosclerosis, Adhesive OM,

Ossicular Necrosis, Retraction Pockets In The TM,Ossicular Necrosis, Retraction Pockets In The TM,

Cholesteatoma, And Sensorineural Hearing LossCholesteatoma, And Sensorineural Hearing Loss


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TREATMENTTREATMENT

ACUTE OTITIS MEDIAACUTE OTITIS MEDIA ANTIMICROBIAL THERAPYANTIMICROBIAL THERAPY

Antimicrobial therapy is the mainstayAntimicrobial therapy is the mainstay of treatment forof treatment for

AOM,AOM,

Currently in the USA about 25% of pneumococci areCurrently in the USA about 25% of pneumococci are

resistant to penicillin, 25% of H. influenzae and 90% ofresistant to penicillin, 25% of H. influenzae and 90% of

M. catarrhalis produce beta-lactamase.M. catarrhalis produce beta-lactamase.

A meta-analysis study of AOM suggests that 80% ofA meta-analysis study of AOM suggests that 80% of

patients with AOM will become asymptomatic within 7patients with AOM will become asymptomatic within 7

to 14 days without treatment compared with 94%to 14 days without treatment compared with 94%

resolution with antibiotic therapy.resolution with antibiotic therapy.


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TREATMENTTREATMENT

ACUTE OTITIS MEDIAACUTE OTITIS MEDIA ANTIMICROBIAL THERAPYANTIMICROBIAL THERAPY

European study supportEuropean study support treating with analgesics andtreating with analgesics and

observation & withholding antibioticsobservation & withholding antibiotics when treatingwhen treating

older children with AOM without significantly increasingolder children with AOM without significantly increasing

the duration of symptoms.the duration of symptoms.

Studies support forStudies support for longer courses oflonger courses of

antibiotics,antibiotics,Showing that resolution of symptoms onShowing that resolution of symptoms on

days 12 to 14days 12 to 14 improved from 82% to 93% when a 10-improved from 82% to 93% when a 10-

day course of antibiotics is used instead of a shorter 5-day course of antibiotics is used instead of a shorter 5-

day courseday course


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Antibiotics for acute otitis media.Antibiotics for acute otitis media.


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TREATMENTTREATMENT

ANTIHISTAMINES, DECONGESTANTS!ANTIHISTAMINES, DECONGESTANTS!

No evidenceNo evidence shows that antihistamines,shows that antihistamines,

decongestants, vasoconstrictors, or any otherdecongestants, vasoconstrictors, or any other

form of systemic or topical therapy aimed atform of systemic or topical therapy aimed at

diminishing nasal symptoms result in shorteneddiminishing nasal symptoms result in shortened

duration of pain, fever, effusion, or hearing loss.duration of pain, fever, effusion, or hearing loss.

The combination of an antihistamine &The combination of an antihistamine &

decongestant was founddecongestant was found not affecting thenot affecting the

clearance of MEEclearance of MEE


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TREATMENTTREATMENT

TYMPANOCENTESISTYMPANOCENTESIS

Important forImportant for selection of therapyselection of therapy byby

knowledge of the specific organism inknowledge of the specific organism in specificspecificcasescases of AOM occurring in prematureof AOM occurring in premature

newborns, immunocompromised patients,newborns, immunocompromised patients,

patients with progression of symptoms andpatients with progression of symptoms and

signs while receiving an appropriatesigns while receiving an appropriate

antimicrobial, patients with intracranialantimicrobial, patients with intracranialinfection, and research subjects.infection, and research subjects.


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TREATMENTTREATMENT

MYRINGOTOMYMYRINGOTOMY

Although severe AOM has many of the clinicalAlthough severe AOM has many of the clinical

features of a closed-space abscess, incision andfeatures of a closed-space abscess, incision anddrainage (myringotomy) hasdrainage (myringotomy) has proven to be of limitedproven to be of limited

value.value. Myringotomy promptlyMyringotomy promptly relieves severe painrelieves severe pain ofof

AOM in patients with severe pain but adds little toAOM in patients with severe pain but adds little to

either remission of infection or clearance of MEE ineither remission of infection or clearance of MEE incases of AOM treated with amoxicillin-clavulanatecases of AOM treated with amoxicillin-clavulanate


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TREATMENTTREATMENT

FOLLOW-UPFOLLOW-UP

Infants,Infants, at greater risk of AOM and meningitis.at greater risk of AOM and meningitis.

Therefore, aTherefore, a 3-day check3-day check is recommended.is recommended.

2-week check2-week check is often performed in children ofis often performed in children ofallall

agesages to determine whether theto determine whether the MEE has cleared.MEE has cleared.

Initial follow-upInitial follow-up at 4 weeks in routine cases ofat 4 weeks in routine cases of

AOM in older children.AOM in older children.

If TM has ruptured, indicating a severe episode, itIf TM has ruptured, indicating a severe episode, it

is better to continue the antimicrobial agent untilis better to continue the antimicrobial agent until

drainage stopped/TM sealeddrainage stopped/TM sealed


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TREATMENTTREATMENT

RECURRENT ACUTE OTITIS MEDIARECURRENT ACUTE OTITIS MEDIAAntimicrobial ProphylaxisAntimicrobial Prophylaxis

Antimicrobial agents have someAntimicrobial agents have some

efficacy in preventing AOM, but they doefficacy in preventing AOM, but they do

so at the risk of promotingso at the risk of promoting

antimicrobial resistance in commonantimicrobial resistance in common

pathogenspathogens..


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TREATMENTTREATMENT

RECURRENT ACUTE OTITIS MEDIARECURRENT ACUTE OTITIS MEDIA

Surgical ProphylaxisSurgical Prophylaxis

Surgical prophylaxis withSurgical prophylaxis with Tympanostomy TubesTympanostomy Tubes isis

recommended for children with repeated episodesrecommended for children with repeated episodes

of AOM. Recurrent AOM is a common indication forof AOM. Recurrent AOM is a common indication fortympanostomy tube placement.tympanostomy tube placement.

The American Academy of OtolaryngologyThe American Academy of Otolaryngology

currently recommends that children be consideredcurrently recommends that children be considered

for tympanostomy tube placement if the child hasfor tympanostomy tube placement if the child hashad four bouts of AOM in 6 months or six bouts inhad four bouts of AOM in 6 months or six bouts in

1 year1 year


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TREATMENTTREATMENT

OTITIS MEDIA WITH EFFUSIONOTITIS MEDIA WITH EFFUSION

Antimicrobial TherapyAntimicrobial Therapy

OME, like AOM, is a bacterial disease, and the MEE isOME, like AOM, is a bacterial disease, and the MEE is

known to contain viable, pathogenic bacteria. Efficacyknown to contain viable, pathogenic bacteria. Efficacy

of Antimicrobial therapy hasof Antimicrobial therapy has been determined inbeen determined in

several reports.several reports.

SURGICAL TREATMENTSURGICAL TREATMENT

Surgical treatment is an option forSurgical treatment is an option for children withchildren with

hearing losshearing loss and is recommended when theand is recommended when the effusioneffusionand hearing loss persist for 4 to 6 months.and hearing loss persist for 4 to 6 months.

Type of procedure to be used. Myringotomy,Type of procedure to be used. Myringotomy,

Adenoidectomy, Tympanostomy Tubes.Adenoidectomy, Tympanostomy Tubes.


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TREATMENTTREATMENT

SURGICAL THERAPY FOR OMESURGICAL THERAPY FOR OME

MYRINGOTOMYMYRINGOTOMY

Benefit ratio for myringotomy and aspirationBenefit ratio for myringotomy and aspiration is toois too

low to justifylow to justify myringotomy as an independentmyringotomy as an independent

procedure requiring anesthsia .procedure requiring anesthsia .

Reccomendations tympanostomy tubesReccomendations tympanostomy tubes to be insertedto be inserted

oror an adenoidectomy performed (or both)an adenoidectomy performed (or both)

ADENOIDECTOMYADENOIDECTOMY

Adenoidectomy is being increasingly used for theAdenoidectomy is being increasingly used for the

treatment of OME because recent studies havetreatment of OME because recent studies haveConfirmed its effectiveness.Confirmed its effectiveness.

Adenoidectomy isAdenoidectomy is used far lessused far less with widespread usewith widespread use

of tympanostomy tubesof tympanostomy tubes


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TREATMENTTREATMENT

SURGICAL THERAPY FOR OMESURGICAL THERAPY FOR OMETYMPANOSTOMY TUBESTYMPANOSTOMY TUBES


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TREATMENTTREATMENT

SURGICAL THERAPY FOR OMESURGICAL THERAPY FOR OMETYMPANOSTOMY TUBESTYMPANOSTOMY TUBES

Modern Tympanostomy TubesModern Tympanostomy Tubes have become thehave become the

therapeutic gold standard and the most widely usedtherapeutic gold standard and the most widely used

treatment option for OMEtreatment option for OME. Improved hearing and a. Improved hearing and adecreased rate of recurrent AOM are predictabledecreased rate of recurrent AOM are predictable

benefits.benefits.

The goal of using tympanostomy tubes isThe goal of using tympanostomy tubes is prolongedprolonged

ventilation of the tympanumventilation of the tympanum

.

.Removal of the MEERemoval of the MEE

and restoration of an aerated tympanumand restoration of an aerated tympanum

Risks vs effectiveness should be considered in lightRisks vs effectiveness should be considered in light

of the needs of the child and family.of the needs of the child and family.


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TREATMENTTREATMENT

SURGICAL THERAPY FOR OMESURGICAL THERAPY FOR OME

Tympanostomy Tube Selection.Tympanostomy Tube Selection.

The ideal tympanostomy tube would beThe ideal tympanostomy tube would be easy to insert,easy to insert,

remain in situremain in situ as long as desired, beas long as desired, be easily removed ineasily removed in

the office without anesthesiathe office without anesthesia, and be, and be associated with fewassociated with fewcomplicationscomplications

Tubes are variatioTubes are variationsns of theof the Grommet or the T-tubeGrommet or the T-tube, and,, and,

generally speaking, the larger and stiffer the flange, thegenerally speaking, the larger and stiffer the flange, the

longer the tube remains in situ. Small-flanged grommetlonger the tube remains in situ. Small-flanged grommet

tubes generally remain in place for 6 months to a yeartubes generally remain in place for 6 months to a year

and are associated with a low rate of tympanicand are associated with a low rate of tympanic

membrane perforation, usually less than 5%.membrane perforation, usually less than 5%.


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..COMPLICATIONS OF TYMPANOSTOMY TUBESCOMPLICATIONS OF TYMPANOSTOMY TUBES


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Suppurative complications of otitis media.Suppurative complications of otitis media.

Severe tympanic membraneSevere tympanic membrane RetractionRetraction withwithHearing LossHearing Loss, impending, impending CholesteatomaCholesteatomaformation, orformation, or Ossicular Chain ErosionOssicular Chain Erosion..

Untreated tympanic membraneUntreated tympanic membrane AtelectasisAtelectasis isis

frequently complicated by cholesteatomafrequently complicated by cholesteatomaformation and erosion of the long process of theformation and erosion of the long process of the

incusincus

The retraction-atelectasis of the tympanicThe retraction-atelectasis of the tympanic

membranemembrane may be reversedmay be reversed by earlyby earlytympanostomy tube placement.tympanostomy tube placement.

Su urative Com lications of Otitis MediaSu

ppurative Complications of Otitis Media


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A schema for managing otorrheaA schema for managing otorrhea

Su urative Com lications of Otitis MediaSuppurative Complications of Otitis Media


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Suppurative Complications of Otitis MediaSuppurative Complications of Otitis Media


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Cholesteatoma FormationCholesteatoma Formation

Suppurative Complications of Otitis Media


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Suppurative Complications of Otitis MediaSuppurative Complications of Otitis Media

Stages Of Middle Ear AtelectasisStages Of Middle Ear Atelectasis.


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Otitis MediaOtitis Media

THE ENDTHE END

Otitis Media Otolaryngology

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