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Middle Ear Diseases.pptx
1.
2. Middle Ear Diseases
Presenter: Dr. Adhishesh Kaul
Post Graduate Student – ENT
AIMS & RC
Moderator: Dr. Poornima S.
Associate Professor – ENT
AIMS & RC
7. Acute Otitis Media (AOM)
1. Definition
2. Incidence
3. Etiology
4. Route of Spread of Infection
5. Predisposing Factors
6. Disease Course and Stages with Pathology
7. Clinical Outcomes after initiation of antibiotics
8. History
9. Examination Findings
10. Investigations
11. Treatment
12. Complications
8. Definition
• Acute middle ear inflammation (hours to < 6 weeks)
• Generally seen in infective conditions – causative organism
Bacterial
Viral
• More common in Children than adults
9. Prevalence
As per an international study, with 3224 patients it was found that 16%
of AOM patients were aged >15years
As per a study of 1982, AOM is 200 times more common in first 2
years of life than adult life
10. Etiology
Majority of adult patients with AOM have bacterial infections
BACTERIA PERCENTAGE
Haemophilis influenzae 26%
Streptococcus pneumoniae 21%
Moraxelaa catarrhalis 3%
Streptococcus aureus 3%
Others 26%
No Growth 26%
From Celin et al.
11. Other Infective causes
• Viral : RSV, Rhinovirus, Corona Virus, Influenza Type A, Adenovirus
• Fungal : Aspergillus and Candida
Other Causes
• Autoimmune inflammation
• Neoplastic
• Traumatic
12.
13. Route of Spread
• Eustachian tube
• Via lumen of tube
• Along subepithelial tubal lymphatics
• External ear
• Due to traumatic perforations
• Blood borne
14. Predisposing Factors
• Young age
• Male sex
• Bottle feeding
• Daycare environment exposure
• Crowded living conditions
• Smoking within home
• Medical conditions
• Cleft palate
• Down’s syndrome
• Mucus membrane abnormalities – CF, ciliary dyskinesia
• Immunodeficiency
15. STAGE PATHOLOGY FEATURES
Hyperemic
(Tubal Occlusion)
1. Upon arrival of Ag into middle ear cavity
2. Ag can come via various routes as described
3. Ag undergoes processing by T Cells, macrophages, B
cell bearing Ig- IgM, IgA, IgG
4. Response: Hyperemia and edema of TM and middle
ear mucosa
1. Edema and hyperemia of nasopharyngeal end
of ET
causes negative pressure and TM Retraction
2. Symptom: Deafness and otalgia
3. Sign: TM retracted
HoM – horizontal
Light reflex: Lost
TFT: CHL
Exudative
(Presuppuration)
1. Release of IL-2, PCAM-1, and others result in
increased expression of intercellular adhesion
molecules, in veins and venules.
2. Inflammatory mediators such as B and T cells,
macrophages, PMN rush through vessels rendered
leaky by above molecules.
3. IgG arrive first followed by IgM, T Cells appear at 24
hours and peak at 2 – 3 weeks, IgA B Cells come
around 3 weeks
4. All these recruited cells participate in complex
cascade of CK release, which are implicated in AOM
1. Prolonged occlusion on ET cause organisms to
invade TM and cause lining hyperemia
2. Symptoms: throbbing severe ear ache
deafness and tinnitus
3. Signs: Pars Tensa – Congestion
Leash of blood vessels along HoM and at
periphery imparting Cart Wheel appearance
TFT: CHL
Disease Course and Stages with Pathology
16. STAGE PATHOLOGY FEATURES
Suppurative 1. Occurs only in bacterial infection
2. Reflects immunological response destroying offending
organism
3. TM can rupture – if suppuration is fulminant
1. Pus in middle ear and mastoid
2. Symptoms: Fever 102F ± vomit and
convulsions
3. Signs: TM: bulging and red
HoM: Engulfed by swollen and
protruding TM
Yellow spot: may be seen on TM
Mastoid tenderness may be present
4. X Ray: Air cell clouding
Resolution Occurs with accumulated fluid in middle ear, with ET blocked
by mucosal edema
1. TM ruptures with release of pus and
symptoms subside
2. Symptoms: otalgia is relieved with release of
pus
fever subsides
3. Signs: EAC may have blood tinged discharge
with may become mucopurulent
AI quadrant may show a small
perforation.
17.
18. Clinical Outcomes after initiation of antibiotics
• Relief of signs and symptoms and resolution of middle ear effusion
(MEE)
• Relief of signs and symptoms but persistence of MEE
• Persistence or recurrence of signs and symptoms during course of
therapy – TREATMENT FAILURE
• Development of suppurative complications
• Spontaneous perforation resulting in purulent otorrhea
• Relief of initial signs and symptoms with relapse within 3-4 weeks
• Symptomatic relief of acute infection but recurrent AOM
19.
20. History
• Pain in the ear (otalgia)
• Mucopurulent discharge
• Hearing loss
• Tinnitus
Differentiate from bullous myringitis – bloody otorrhoea due to bursting
of blood blisters
21. Examination Findings
Otoscopy:
• TM may be red and bulging
• TM may be more lateral than usual
• TM may be perforated –
If perforated : 1. TM reverted will reverted to usual position
2. Perforation may be visible
• Pus may be seen in EAM and on TM –
Micro suction will be required for inspection of perforated drum
Confusion might arise between a normal TM with profusion of blood vessels
from umbo and a case of AOM
Most reliable indicator of AOM on otoscopy: Bulging TM
22. Investigations
Pure Tone Audiometry with Impedance Audiometry:
Required only if AOM has been missed and it shows significant conductive hearing
loss, Flat tympanogram with absent acoustic reflexes
Tympanocentesis:
For definitive diagnosis of Otitis Media, but almost never done
CT Scan:
To differentiate AOM from acute mastoiditis – by identifying subperiosteal abscess
vs coalescence of mastoid air cells
MRI Scan: NOT USEFUL
25. Treatment(Advocated)
• ASOM with complications
• Antibiotics
• Myringotomy ± Ventilating tube placement
Post treatment, Tympanometry and Otoscopy should be done to document resolution
CT Scan /MRI Brain should be advised in case of intracranial compliactions
29. Definition
• Fluid collection (non-purulent) in middle ear, often extending up to
mastoid air cells.
• Characteristic of fluid: Usually thick and viscid
• Usually secondary to URTI, but may precede or proceed an episode
31. Etiology
1. Infections:
Inadequately treated AOM, leads to inactivation of infection but
persistence of low grade infection which causes goblet cells to secrete more
fluid.
2. Allergy: obstructs ET and also causes increased fluid in middle ear
3. Barotrauma
4. Eustachian tube dysfunction – secondary to:
• Adenoid hyperplasia
• Chronic tonsillitis: mechanically obstruct movement of soft palate and interfere with
physiological opening of ET
• Nasopharyngeal tumors (benign and malignant): esp imp in u/l OME
• Palatal defect
5. Miscellaneous
34. History/ Clinical Presentation
• Hearing loss – majority of the patients (97%)
• Aural fullness (77%)
• Tinnitus – pulsatile or crackling (60%)
• Balance disturbance may be reported
• Delayed and defective speech
• Mild ear aches
Unilateral OME with insignificant past history should be managed with
suspicion.
35. Examination Findings
Pneumatic otoscopy: gold standard for diagnosis of OME
• Tympanic Membrane: (Otoscopy/ Microscopy)
1. Retracted
2. Abnormal light reflex
3. Membrane appears dull
4. Fluid may be seen
• Nasopharyngolaryngoscopy
• 0 degree Hopkins rigid endoscope
1. e/o Rhinosinusitis will direct treatment
2. Post nasal space lesion needs imaging and treatment
36.
37.
38. Investigations
• Tympanometry:
Low compliance, with flat tympanogram, because energy does not vary with
pressure change
• Audiology:
level of impaired hearing function
conductive hearing loss
high degree of correlation with MRI
• Myringotomy
presence of fluid on surgery confirms the diagnosis but absence does not
refute it.
MRI may be used for diagnosis and monitoring of OME
39. Treatment
NON MEDICAL
MANAGEMENT
MEDICAL MANAGEMENT HEARING ADIS SURGICAL TREATMENT
WHEN EFFUSION PERSISTS
WITH HEARING LOSS
1. Toynbee maneuver
2. Valsalva technique
Particularly useful in
sniffers
3. Mechanical devices
Otovent™ Balloon /
Ear Popper™
Used when patients are
not cooperative
1. Nasal decongestant
2. Antibiotics
On the basis of culture
techniques and confocal
laser scanning microscopy
3. N-acetyl cysteine:
mucolytic therapy but
no evidence
4. Corticosteroid usage is
equivocal
Effective for conductive
hearing loss
1. Ventilation tubes
2. Laser myringotomy
short term solution
3. Mastoid vents
good long term
efficacy in chronic
OME
4. Laser eustachian
tuboplasty
5. Balloon dilatation of
eustachian tubes
6. Tympanotomy
7. Adenoidectomy
46. Complications of Otitis Media
INTRACRANIAL
1. Meningitis
2. Abscess – Epidural / Subdural
3. Thrombosis – Sigmoid sinus,
Lateral Sinus
4. Brain Abscess
5. Otitis hydrocephalus
INTRATEMPORAL
1. Hearing loss and Balance
2. Speech – Language and child
development
3. Mastoiditis
47. CT scan of a 10-year-old boy showing a
right cerebellar brain abscess (arrows) as a
complication of right acute mastoiditis with
otitis media. The child had a 3-week history
of headache and vertigo 1 day after the
onset of fever and presented with
increasing lethargy, vertigo, slurred speech,
nausea and head-tilting to the left.
Examination revealed ataxia, nystagmus,
mild confusion and right-sided weakness
but no otalgia or otorrhea. Otoscopic
examination revealed left middle ear
effusion, which was confirmed by
tympanocentesis. The brain abscess was
drained, and cortical mastoidectomy and
tympanostomy tube insertion was
performed. Purulent material was found
within the mastoid at the time of mastoid
surgery and culture of the abscess
revealed S. pneumoniae, susceptible to
penicillin. The child made a complete
recovery, without any sequelae, after the
brain and mastoid surgery and intravenous
antimicrobial therapy.
48.
49. Magnetic resonance image of left acute
suppurative labyrinthitis (arrow) as a complication
of the first attack of acute otitis media in a 18-
month-old male child who had a preexisting
congenital perilymphatic/cerebrospinal fluid
fistula of the labyrinthine windows. The child
presented with left otorrhea, fever, vertigo and
dehydration 5 days after the onset of the acute
otitis media; P. aeruginosa was isolated from the
otorrhea. Labyrinthectomy on the left ear and
bilateral tympanostomy tube placement as an
emergency procedure was performed with no
further progression of the infection. The child had
no further hearing loss or suppurative
complication over the ensuing 3-year follow-up
period.
50. CT scan of a 7-week-old male
infant who developed acute otitis
media in the right ear that
progressed into an acute
mastoiditis with osteitis and
subperiosteal abscess (arrow).
Cortical mastoidectomy and
tympanostomy tube placement
was performed, at which time
cultures from the middle ear and
mastoid revealed S. pneumoniae,
susceptible to penicillin. The child
had an uneventful recovery after
the surgery and intravenous
antibiotic therapy.
52. Tympanic Membrane Perforation
• Incidence: up to 10%
• Symptoms: Otorrhea (purulent or bloody)
Pain relief
• Site: Posterior half of pars tensa with loss of fiberous middle layer
53. Acute Mastoiditis
Class Signs and Symptoms
Acute Mastoiditis During the course of AOM, infection may spread to mastoid cavity and not
associated with typical signs of mastoiditis
Acute Mastoiditis with Periosteitis 1. No abscess
2. Post auricular crease is full
3. Pinna pushed forward
4. Post auricular: mild swelling, erythema, fullness
Acute Mastoid Osteitis 1. Subperiosteal abscess develops
2. Zygomatic abscess may develop above and in front of pinna
3. Bezold’s abscess: result from perforation of medial mastoid cortex
Subacute (masked) mastoiditis 1. In case of incompletely treated AOM
2. Signs: absent
3. Otalgia and Fever: Persistent
54.
55. Petrositis
• Seen if infection spreads to petrous apex
• Gradenigo’s traid:
6th nerve palsy
5th nerve distribution pain
Middle ear infection
57. Labyrinthitis
• Pathogenesis: change in round window permeability in acute infection
Type Feature
Perilabyrinthitis Not Associated with AOM
Serous Labyrinthitis Inflammation of labyrinth without pus formation
Full recovery of auditory and vestibular system
Suppurative Labyrinthitis Due to spread of infection from mastoid/ middle ear
Symptoms:
Severe Vertigo
Nausea
Vomiting
Nystagmus
Permanent hearing loss
Treatment: Ventilation tube
Tympanomastoidectomy
Cochleotomy
60. Indications
• Ventilation of retraction pocket
• Middle ear effusion
• Aeration of barotrauma
• Conductive hearing loss
• Diagnostic myringotomy if TM is opaque and does not move
63. Procedure for Myringotomy ± Ventilation Tube
Clean the EAC of cerumen, keratin debris. (concomitant OE will require further cleaning)
Adult/ Cooperative child: local anesthesia with phenol over TM
Postero-inferior or Anterior quadrants are easily available
Myringotomy tube in Anterior or Antero-Superior Quadrant
(tube are retained for longer, because of migration pattern of epithelium of tympanic membrane)
Fluid is aspirated with 5F or 7F suction tube, if difficult, another incision is
made Postero-inferior quadrant
Grommet tube should be avoided at
1. Annulus : leads to marginal perforation
2. Adjacent to malleus : may cause pulsatile tinnitus
64. Ventilation tube in Adults
EAC is cleaned under microscope
Tube is placed in anterior aspect in adults, may be placed in postero-inferior
quadrant, if access to anterior TM is restricted because of convexity
If tube is required for indefinite period,
1. T – Tube is the choice
2. Per-Lee tube provides indefinite ventilation
3. Jahn – Hydroxyapetite tube placement needs lengthier procedure
65.
66.
67.
68.
69. Complications
• Post-Tympanostomy Tube Otorrhea
• Tympanosclerosis, Retraction Pockets and Atrophy
• Persistent TM perforation after extrusion of tube
• Retained tube
• Confusion of congenital or aberrant blood vessels with fluid, especially
dehiscent high rising jugular bulb.
• Glomus tumor may be confused with AOM
• Tube may fall into middle ear if opening made is too large
• Ossicular chain discontinuity if tube is placed in Posterosuperior quadrant
72. Eustachian Tube Dysfunction
1. History
2. Basic Points to Be Considered
3. Functions of Eustachian Tube
4. Definition of Eustachian Tube Dysfunction
5. Pathogenesis
6. Clinical Presentation
7. Examination findings
8. Investigations of ET Dysfunction
9. Eustachian tube endoscopy
10. Management of ET Dysfunction
11. Sequalae
73. History
Scientist Year Contribution
Alcnaeon 400BC 1st Mentioned ET
Bartolomeus Eustachius 1562 Discovery, anatomy and function
Valsalva 1. Described ET having osseous and cartlagenous part
2. Described importance of Tensor Veli Palatini
3. Described Valsalva maneuver
Toynbee Extensive investigations of peritubal muscles
Politzer The role of eustachian tube in middle ear pathology
74. Basic Points To Be Considered
1. Mucociliary action from middle ear to nasopharynx
2. Proximal: in middle ear: Bony/ funnel shaped, lined by cuboidal
epithelium
3. Distal: towards nasopharyngeal opening: cartilaginous skeleton
4. Cross-section has:
1. Superior and Inferior Halves
2. Anterolateral and Posteromedial Halves
5. Peritubal muscles
levator veli palatini
TVP
Tensor Tympanii
Salphingopharyngeus
77. Definition of Eustachian Tube Dysfunction
Inadequate ability to open the tubal valve
OR
Inadequate dilatory function causing secondary ear pathology
Due to
1. Anatomical obstruction due to neoplasms or mass lesions
2. Physiological failure due to
1. Hereditary factors
2. Mucosal inflammation with functional obstruction or failure of dilation
3. Muscular problems causing dilatory dynamic dysfunction
78. Eustachian Tube Dysfunction
Obstructive Dysfunction Dynamic Dysfunction
There is increasing evidence that ET Dysfunction is because of cartilaginous portion of ET
In a study of 58 ears, all had significant pathology and compromise of tubal dilation within cartilaginous portion.
PATHOLOGIES
1. Mucosal Edema : 83%
2. Reduced lateral wall motion : 74%
3. Obstructive Mucosal Disease : 26%
81. Examination Findings
• Otoscopy: Retracted TM,
Congestion along Handle of malleus and Pars Tensa
Transudate behind tympanic membrane
• Post Nasal Examination: for adenoids / any other nasopharyngeal
mass
• Tuning Fork Test: Normal or conductive hearing loss
82. Functional test for Eustachian Tube
1. Valsalva Maneuver
2. Poltizer Test: Hissing sound on auscultation
3. Toynbee Maneuver: Inward movement of tympanic membrane
4. Sonotubometry
84. Eustachian Tube Endoscopy
Endoscopes Used
1. Microfiber-optic endoscope (<1mm):
Image resolution compromised
Contact with secretions obscures inspection in lumen
Only describe gross observations like patency and lesions
2. Fiber-Optic nasopharyngeal endoscope (3-4mm)
3. Rigid Hopkins endoscopes
85. Management
Medical Management Surgical Management
Mucosal Inflammation
Identify underlying cause
LPR: Diet, PPI and H2 blocker
Sleep on inclined bed
Fundoplication
Allergic disease:
LT inhibitor, antihistamine,
mast cell stabilizer, immunotherapy
Oral and nasal steroids
Anatomical Obstruction
do CECT to r/o malignancy
CHRONIC FULLNESS IN EAR WITH NORMAL TM, to R/O other causes
Eustachian Tuboplasty
Persistent dysfunction with OME or atelectasis
87. Patulous Eustachian Tube
• Definition: Abnormally patent eustachian tube
• Etiology:
Idiopathic
Rapid weight loss
Pregnancy: 3rd trimester
Multiple Sclerosis
• Signs and Symptoms
Autophony
TM movement seen on otoscopy
• Management
Usually self limiting
Weight gain
Potassium Iodide
Cauterization
Grommet insertion
Submucosal Graft implantation
88. References /Bibliography
1. Bluestone CD. Clinical course, complications and sequelae of
acute otitis media. Pediatr Infect Dis J. 2000; 19(5
Suppl):S37-46
2. Cummings Otolaryngology Head and Neck Surgery: ed 6
3. Diseases of Ear, Nose and Throat & Head and Neck Surgery: ed 7
4. Diseases of Ear, nose and Throat
5. Glasscock-Shambaugh Surgery of the Ear: ed 6
6. Scott-Brown’s Otorhinolaryngology Head & Neck Surgery: ed 8
7. www.kenhub.com
