This document describes a case of a 55-year-old woman who presented with 40 years of bilateral intermittent otorrhea. Cultures from bilateral granulation tissue samples grew nontuberculous mycobacteria (NTM), specifically Mycobacterium abscessus and Mycobacterium fortuitum. She was treated with intravenous and oral antibiotics based on culture sensitivities. Follow up scans and examinations showed resolution of symptoms and infection. The document discusses NTM as a rare cause of chronic otitis media that is often underdiagnosed due to its slow growth, and outlines the challenges in management through surgical debridement and prolonged multidrug antibiotic therapy.
Eustachian tube final PP ANATOMY,EMBRYOLOGY,FUNCTIONS,DYSFUNCTIONS TREATMENT,...social service
The Eustachian tube connects the middle ear cavity to the nasopharynx. It has important functions like regulating middle ear pressure and ventilation, protecting the middle ear, and facilitating mucociliary clearance and drainage. Dysfunction of the Eustachian tube can lead to negative pressure in the middle ear, retraction of the tympanic membrane, fluid accumulation, and acute otitis media. Tests for Eustachian tube function include the Valsalva maneuver, Toynbee's maneuver, and tympanometry. Treatment options for Eustachian tube dysfunction include medical management with nasal decongestants or steroids, as well as surgical procedures like my
Mucosal folds and ventilation of middle ear AlkaKapil
The document discusses the anatomy and embryology of the middle ear spaces and mucosal folds.
1. The middle ear develops from the tubotympanic recess which buds into sacs including the saccus anticus, medius, superior and posterior. Remnants of mesenchyme become ligaments and blood vessels.
2. The middle ear is divided into several compartments by mucosal folds including the protympanum, mesotympanum, epitympanum, hypotympanum, and retrotympanum.
3. The epitympanum or attic is further divided by mucosal folds into the upper unit above
1. Mastoidectomy is a surgical procedure that opens the mastoid cavity to clean infected air cells and improve ventilation. It has evolved from simple trephination for acute infections to modern techniques that preserve normal anatomy.
2. The document outlines the history, surgical anatomy, types (cortical, radical, modified radical), indications, and techniques of mastoidectomy. Types are classified as open (canal wall down) or closed (canal wall up) approaches.
3. Potential complications are discussed briefly. Controversies remain regarding the best surgical techniques and approaches to different pathologies.
1. The document discusses the embryology and anatomy of the frontal sinus and frontal recess. It develops from ethmoidal cells that pneumatize into the frontal bone.
2. It describes different surgical approaches to access and drain the frontal sinus including external approaches and various types of endoscopic frontal sinusotomies.
3. Type 1 and 2 endoscopic procedures involve draining the frontal sinus via the frontal recess and removing obstructions. Type 3 is a more extensive procedure that creates a common chamber between the frontal sinus and nasal cavity via an intranasal modified Lothrop procedure.
The Eustachian tube connects the middle ear cavity to the nasopharynx. It has three parts - a bony portion, a junctional portion, and a cartilaginous portion. The cartilaginous portion is normally closed but opens during swallowing due to the action of the tensor veli palatini and levator veli palatini muscles. The Eustachian tube functions to ventilate and drain the middle ear and protect it from pressure changes and pathogens from the nasopharynx. Dysfunction can lead to conditions like otitis media and patulous Eustachian tube. Evaluation methods include otoscopy, endoscopy, Valsalva maneuver, and ty
Empty Nose Syndrome (ENS) is a condition characterized by paradoxical nasal obstruction despite a widely patent nasal airway. It often results from nasal surgery involving resection of the turbinates. Diagnosis involves identifying a history of turbinate surgery and appropriate symptoms like dryness and improvement with a "cotton test" where cotton is placed in areas of deficit. Treatment planning involves using CT imaging and endoscopy to identify defects and testing placement of cotton or saline to identify locations for grafting. Surgical repair techniques involve implanting tissue like acellular dermis or autogenous tissue into locations identified as beneficial by the cotton test, such as the septum, lateral wall, or expanding the existing inferior turbinate. The
1. Inverted papilloma is a benign epithelial tumor originating from the Schneiderian membrane of the nasal cavity and paranasal sinuses.
2. It most commonly affects males ages 30-50 and presents as a unilateral nasal mass, obstruction, and bleeding.
3. Treatment involves surgical resection, typically an endoscopic medial maxillectomy to remove the entire lateral nasal wall and clear the tumor attachment site.
Sinus Anatomy Lectures: Western Residents Advanced Endsocopic Sinus SurgeryElisabeth Ference
This document provides an overview of advanced endoscopic sinus surgery anatomy. It summarizes key anatomical structures and landmarks involved in sinus surgery, including the ethmoid turbinates, lamellae, infundibulum, frontal recess, sphenoid sinus, and relationships to surrounding structures like the optic nerve and carotid artery. Correct identification of these structures is important for safe surgery. The document references several authoritative sources on endoscopic sinus surgery anatomy.
Eustachian tube final PP ANATOMY,EMBRYOLOGY,FUNCTIONS,DYSFUNCTIONS TREATMENT,...social service
The Eustachian tube connects the middle ear cavity to the nasopharynx. It has important functions like regulating middle ear pressure and ventilation, protecting the middle ear, and facilitating mucociliary clearance and drainage. Dysfunction of the Eustachian tube can lead to negative pressure in the middle ear, retraction of the tympanic membrane, fluid accumulation, and acute otitis media. Tests for Eustachian tube function include the Valsalva maneuver, Toynbee's maneuver, and tympanometry. Treatment options for Eustachian tube dysfunction include medical management with nasal decongestants or steroids, as well as surgical procedures like my
Mucosal folds and ventilation of middle ear AlkaKapil
The document discusses the anatomy and embryology of the middle ear spaces and mucosal folds.
1. The middle ear develops from the tubotympanic recess which buds into sacs including the saccus anticus, medius, superior and posterior. Remnants of mesenchyme become ligaments and blood vessels.
2. The middle ear is divided into several compartments by mucosal folds including the protympanum, mesotympanum, epitympanum, hypotympanum, and retrotympanum.
3. The epitympanum or attic is further divided by mucosal folds into the upper unit above
1. Mastoidectomy is a surgical procedure that opens the mastoid cavity to clean infected air cells and improve ventilation. It has evolved from simple trephination for acute infections to modern techniques that preserve normal anatomy.
2. The document outlines the history, surgical anatomy, types (cortical, radical, modified radical), indications, and techniques of mastoidectomy. Types are classified as open (canal wall down) or closed (canal wall up) approaches.
3. Potential complications are discussed briefly. Controversies remain regarding the best surgical techniques and approaches to different pathologies.
1. The document discusses the embryology and anatomy of the frontal sinus and frontal recess. It develops from ethmoidal cells that pneumatize into the frontal bone.
2. It describes different surgical approaches to access and drain the frontal sinus including external approaches and various types of endoscopic frontal sinusotomies.
3. Type 1 and 2 endoscopic procedures involve draining the frontal sinus via the frontal recess and removing obstructions. Type 3 is a more extensive procedure that creates a common chamber between the frontal sinus and nasal cavity via an intranasal modified Lothrop procedure.
The Eustachian tube connects the middle ear cavity to the nasopharynx. It has three parts - a bony portion, a junctional portion, and a cartilaginous portion. The cartilaginous portion is normally closed but opens during swallowing due to the action of the tensor veli palatini and levator veli palatini muscles. The Eustachian tube functions to ventilate and drain the middle ear and protect it from pressure changes and pathogens from the nasopharynx. Dysfunction can lead to conditions like otitis media and patulous Eustachian tube. Evaluation methods include otoscopy, endoscopy, Valsalva maneuver, and ty
Empty Nose Syndrome (ENS) is a condition characterized by paradoxical nasal obstruction despite a widely patent nasal airway. It often results from nasal surgery involving resection of the turbinates. Diagnosis involves identifying a history of turbinate surgery and appropriate symptoms like dryness and improvement with a "cotton test" where cotton is placed in areas of deficit. Treatment planning involves using CT imaging and endoscopy to identify defects and testing placement of cotton or saline to identify locations for grafting. Surgical repair techniques involve implanting tissue like acellular dermis or autogenous tissue into locations identified as beneficial by the cotton test, such as the septum, lateral wall, or expanding the existing inferior turbinate. The
1. Inverted papilloma is a benign epithelial tumor originating from the Schneiderian membrane of the nasal cavity and paranasal sinuses.
2. It most commonly affects males ages 30-50 and presents as a unilateral nasal mass, obstruction, and bleeding.
3. Treatment involves surgical resection, typically an endoscopic medial maxillectomy to remove the entire lateral nasal wall and clear the tumor attachment site.
Sinus Anatomy Lectures: Western Residents Advanced Endsocopic Sinus SurgeryElisabeth Ference
This document provides an overview of advanced endoscopic sinus surgery anatomy. It summarizes key anatomical structures and landmarks involved in sinus surgery, including the ethmoid turbinates, lamellae, infundibulum, frontal recess, sphenoid sinus, and relationships to surrounding structures like the optic nerve and carotid artery. Correct identification of these structures is important for safe surgery. The document references several authoritative sources on endoscopic sinus surgery anatomy.
Complications of rhinosinusitis(Dr ravindra daggupati)Ravindra Daggupati
orbital complications of rhino sinusitis,intra cranial complications of rhino sinusitis,classification of complications,diagnosis and treatment of complications
Tympanosclerosis is characterized by hyaline deposits in the tympanic membrane and middle ear space caused by chronic infection or inflammation. It results in the degeneration of connective tissue and deposition of calcium and phosphate. Common symptoms include conductive hearing loss and occasional tinnitus. Diagnosis is made by otoscopy showing white plaques and audiometry showing a conductive hearing loss. Treatment depends on the size and location of plaques, with small plaques sometimes removed before grafting but large plaques usually just addressed with hearing aids.
This document provides information on juvenile nasopharyngeal angiofibroma (JNA), a rare benign tumor that occurs mostly in adolescent males. JNAs originate from sex steroid-stimulated hamartomatous tissue in the nasal cavity. They are highly vascular tumors that can locally invade structures in the nasal cavity, paranasal sinuses, and skull base. Imaging like CT and MRI are used to determine the extent of disease. The Fisch staging system, which classifies JNAs into 4 types based on their extent, is commonly used to guide treatment planning.
This document discusses the anatomy of the nasal cavity and paranasal sinuses. It describes the turbinates, meati, ostia and their locations. It outlines three passes through the nasal cavity and paranasal sinuses, noting the structures encountered in each pass. It also discusses the location, pneumatization, septa, landmarks and variations of the sphenoid sinus.
1. A deviated nasal septum is caused by trauma, developmental issues, masses in the nasal cavity, and racial or hereditary factors.
2. Types of deviations include anterior/caudal dislocation, C-shaped, S-shaped, spurs, and thickening. Clinical features include nasal blockage, recurrent colds, headaches, and epistaxis.
3. Surgical techniques to correct deviations include septoplasty, which involves scoring and removing portions of cartilage, and submucosal resection, which removes larger sections of cartilage. Complications can include hematomas, abscesses, perforations, and synechiae.
The document describes the anatomy of the paranasal sinuses based on endoscopic examination. It discusses the frontal, maxillary, and ethmoid sinuses that make up the anterior group and drain into the middle meatus. The posterior ethmoid cells and sphenoid sinus comprise the posterior group. A key structure is the ostiomeatal complex, which consists of the anterior ethmoid air cells and represents the drainage pathway of the frontal, maxillary, and anterior ethmoid sinuses. Several anatomical structures within the complex are then described in detail, including the uncinate process, bulla ethmoidalis, hiatus semilunaris, ethmoid infundibulum, and maxillary and frontal sinus ostia.
Mastoidectomy is a surgical procedure to access and treat infections or diseases of the mastoid air cells behind the ear. The summary describes:
1. The history of mastoidectomy dates back to ancient times, with modern improvements like the operating microscope in the 20th century.
2. There are different classifications of mastoidectomy based on the extent of air cell removal and whether the ear canal wall is intact or removed.
3. Indications for mastoidectomy include treatment of infections, drainage of abscesses, and approaches for other inner ear surgeries. Complications can include injuries to nearby structures like the dura, facial nerve or blood vessels.
This document discusses different types of fungal sinusitis, including invasive and noninvasive forms. Invasive fungal sinusitis is characterized by fungal hyphae growing within sinus tissues and can be acute, chronic, or chronic granulomatous. Noninvasive types include allergic fungal sinusitis and fungal balls. Imaging findings on CT and MRI are described for each type. Treatment involves surgical removal of fungal material and antifungal medications, with the most aggressive form requiring extensive debridement and high doses of amphotericin B due to its high mortality risk if left untreated. Potential side effects of antifungal drugs are also noted.
This document provides an overview of laryngeal anatomy including:
- The development of the larynx from embryology to differences between pediatric and adult larynx.
- Descriptions of the cartilages, muscles, membranes and nerves of the larynx.
- Details on the sizes and dimensions of structures in the larynx between males and females.
- Identification and descriptions of the supraglottic, glottic, and subglottic regions as well as the spaces within the larynx.
- Explanations of the extrinsic and intrinsic muscles of the larynx and their actions.
Endoscopic anatomy of lateral wall of sphenoid sinusAnkit Choudhary
This document discusses the endoscopic anatomy of the lateral wall of the sphenoid sinus and important relationships. It notes that the sphenoid ostium opens into the sphenoethmoidal recess 1-1.5cm above the roof of the choana. Below the ostium lies the Woodruff's plexus and the septal branch of the sphenopalatine artery runs across the anterior wall. Approaches to the sphenoid sinus include paraseptal, intermediate, and lateral. Precautions are discussed such as dilating the ostium inferiomedially first and taking care with dehiscent structures like the optic nerve or internal carotid artery.
This document provides information about different types of mastoidectomy procedures. It begins with a brief history of mastoidectomy surgery dating back to 1873. It then discusses indications for various procedures like cortical mastoidectomy, canal wall up (CWU) mastoidectomy, modified radical mastoidectomy, and radical mastoidectomy. Key anatomical structures are defined. Surgical techniques for CWU mastoidectomy are outlined, including incision, periosteal elevation, and middle ear dissection steps. Contraindications and debates around CWU versus canal wall down approaches are also summarized.
The document discusses the mucosal folds of the middle ear, which develop as the primitive tympanic cavity expands into the middle ear cleft between 3-7 months of fetal development. This forms four primary sacs that enlarge and replace the mesenchyme, with their walls becoming the mucosal lining of the middle ear. Mucosal folds are the planes of contact between neighboring sacs and carry ligaments and blood vessels to the ossicles. There are 10 important mucosal folds described, including the anterior and posterior malleal folds, lateral malleal ligamental fold, and tensor tympani fold. The folds divide the epitympanum (attic) and orient the progression of
The document discusses electronystagmography (ENG), which tests eye movements using electronic recordings. It lists the main tests done with ENG, including gaze tests, optokinetic nystagmus tests, positional tests, and caloric tests. The caloric test induces nystagmus using temperature changes to evaluate vestibular system function. The document also lists various eye movement findings that can be detected through ENG testing, such as nystagmus, dissociations, dysrythmias, and positional nystagmus.
This document discusses various surgical approaches for treating sinusitis. It covers procedures for the maxillary, frontal, ethmoid, and sphenoid sinuses. For the maxillary sinus, approaches include antral washout/lavage, intranasal antrostomy, and Caldwell-Luc procedures. For the frontal sinus, approaches include trephination, intranasal ethmoidectomy, and external frontoethmoidectomy. Complications of each procedure are also outlined.
1) The document discusses the surgical approach and procedure for cortical mastoidectomy. Key steps include raising skin and periosteal flaps, drilling along anatomical landmarks like the sigmoid sinus and facial nerve to identify structures, and widening the aditus and performing a posterior tympanotomy to access the mesotympanum.
2) Post-operative care involves drain removal within 48 hours and dry dressing of the ear. Potential complications discussed are persistent deafness, facial nerve injury, CSF leak, hemorrhage and infection.
3) The patient is advised restricted activity for 3 weeks followed by a gradual return to normal activity over 4 weeks, and to keep the operation site dry.
Basic principle of rhinoplasty. by venukumar.tvenukumar55
This document provides an overview of the basic principles of rhinoplasty surgery. It discusses nasal anatomy including landmarks like the radix, rhinion, septal angle, and lower lateral cartilages. It covers surgical techniques for both endonasal and external rhinoplasty approaches. Key steps for various nasal deformity corrections are outlined such as hump removal, dorsal augmentation, and tip work. The document also lists common instruments used in rhinoplasty surgery.
This document provides an overview of endoscopic nasal anatomy. It begins with a brief introduction to endoscopy and its historical evolution. It then describes the external nose, nasal septum, lateral nasal wall including the inferior, middle, and superior turbinates. Various anatomical variations are also discussed. The paranasal sinuses, anterior skull base, and endoscopic approaches to different nasal and sinus structures like the frontal sinus and sphenoid sinus are summarized. Key landmarks and variations are highlighted to provide a concise yet comprehensive summary of the essential endoscopic nasal anatomy concepts covered in the document.
This document provides a history of surgery for otosclerosis and stapes surgery from the late 1800s to modern times. It summarizes key developments such as the first stapedectomy performed by John Shea in 1956 using an oval window vein graft and nylon prosthesis. The goals, indications, contraindications, surgical techniques including stapedectomy and stapedotomy are described in detail. Potential problems during surgery like floating footplates, perilymph gushers, and overhanging facial nerves are also outlined along with post-operative care and complications. Long term results tend to show initial hearing improvements are often not maintained over decades with re-operation or hearing aid use often needed.
This document provides an overview of the steps involved in primary sinus surgery via an endoscopic approach. It begins with a brief history of sinus surgery and then discusses preoperative assessment, including CT scans to evaluate sinus anatomy and disease patterns. The basic techniques of Messerklinger and Wigand are described. The key steps of the surgery are then outlined in detail, including uncinectomy, antrostomy of the maxillary sinus, anterior and posterior ethmoidectomy, sphenoid sinusotomy, and frontal sinusotomy when necessary. Throughout, anatomical landmarks and variations are discussed to guide safe dissection and avoid complications.
Mastoidectomy is a surgical procedure to access and treat infections of the mastoid air cells behind the ear. Over time, the procedure has evolved from simple cortical mastoidectomies described in the 17th century to more advanced techniques using an operating microscope and drill. Modern mastoidectomies are typically classified as canal wall up or canal wall down depending on whether the bony ear canal wall is preserved. Indications include treatment of cholesteatoma, refractory ear infections, and approaches for other inner ear procedures. The surgery involves an incision behind the ear to access and clean out the infected mastoid air cells.
Complications of rhinosinusitis(Dr ravindra daggupati)Ravindra Daggupati
orbital complications of rhino sinusitis,intra cranial complications of rhino sinusitis,classification of complications,diagnosis and treatment of complications
Tympanosclerosis is characterized by hyaline deposits in the tympanic membrane and middle ear space caused by chronic infection or inflammation. It results in the degeneration of connective tissue and deposition of calcium and phosphate. Common symptoms include conductive hearing loss and occasional tinnitus. Diagnosis is made by otoscopy showing white plaques and audiometry showing a conductive hearing loss. Treatment depends on the size and location of plaques, with small plaques sometimes removed before grafting but large plaques usually just addressed with hearing aids.
This document provides information on juvenile nasopharyngeal angiofibroma (JNA), a rare benign tumor that occurs mostly in adolescent males. JNAs originate from sex steroid-stimulated hamartomatous tissue in the nasal cavity. They are highly vascular tumors that can locally invade structures in the nasal cavity, paranasal sinuses, and skull base. Imaging like CT and MRI are used to determine the extent of disease. The Fisch staging system, which classifies JNAs into 4 types based on their extent, is commonly used to guide treatment planning.
This document discusses the anatomy of the nasal cavity and paranasal sinuses. It describes the turbinates, meati, ostia and their locations. It outlines three passes through the nasal cavity and paranasal sinuses, noting the structures encountered in each pass. It also discusses the location, pneumatization, septa, landmarks and variations of the sphenoid sinus.
1. A deviated nasal septum is caused by trauma, developmental issues, masses in the nasal cavity, and racial or hereditary factors.
2. Types of deviations include anterior/caudal dislocation, C-shaped, S-shaped, spurs, and thickening. Clinical features include nasal blockage, recurrent colds, headaches, and epistaxis.
3. Surgical techniques to correct deviations include septoplasty, which involves scoring and removing portions of cartilage, and submucosal resection, which removes larger sections of cartilage. Complications can include hematomas, abscesses, perforations, and synechiae.
The document describes the anatomy of the paranasal sinuses based on endoscopic examination. It discusses the frontal, maxillary, and ethmoid sinuses that make up the anterior group and drain into the middle meatus. The posterior ethmoid cells and sphenoid sinus comprise the posterior group. A key structure is the ostiomeatal complex, which consists of the anterior ethmoid air cells and represents the drainage pathway of the frontal, maxillary, and anterior ethmoid sinuses. Several anatomical structures within the complex are then described in detail, including the uncinate process, bulla ethmoidalis, hiatus semilunaris, ethmoid infundibulum, and maxillary and frontal sinus ostia.
Mastoidectomy is a surgical procedure to access and treat infections or diseases of the mastoid air cells behind the ear. The summary describes:
1. The history of mastoidectomy dates back to ancient times, with modern improvements like the operating microscope in the 20th century.
2. There are different classifications of mastoidectomy based on the extent of air cell removal and whether the ear canal wall is intact or removed.
3. Indications for mastoidectomy include treatment of infections, drainage of abscesses, and approaches for other inner ear surgeries. Complications can include injuries to nearby structures like the dura, facial nerve or blood vessels.
This document discusses different types of fungal sinusitis, including invasive and noninvasive forms. Invasive fungal sinusitis is characterized by fungal hyphae growing within sinus tissues and can be acute, chronic, or chronic granulomatous. Noninvasive types include allergic fungal sinusitis and fungal balls. Imaging findings on CT and MRI are described for each type. Treatment involves surgical removal of fungal material and antifungal medications, with the most aggressive form requiring extensive debridement and high doses of amphotericin B due to its high mortality risk if left untreated. Potential side effects of antifungal drugs are also noted.
This document provides an overview of laryngeal anatomy including:
- The development of the larynx from embryology to differences between pediatric and adult larynx.
- Descriptions of the cartilages, muscles, membranes and nerves of the larynx.
- Details on the sizes and dimensions of structures in the larynx between males and females.
- Identification and descriptions of the supraglottic, glottic, and subglottic regions as well as the spaces within the larynx.
- Explanations of the extrinsic and intrinsic muscles of the larynx and their actions.
Endoscopic anatomy of lateral wall of sphenoid sinusAnkit Choudhary
This document discusses the endoscopic anatomy of the lateral wall of the sphenoid sinus and important relationships. It notes that the sphenoid ostium opens into the sphenoethmoidal recess 1-1.5cm above the roof of the choana. Below the ostium lies the Woodruff's plexus and the septal branch of the sphenopalatine artery runs across the anterior wall. Approaches to the sphenoid sinus include paraseptal, intermediate, and lateral. Precautions are discussed such as dilating the ostium inferiomedially first and taking care with dehiscent structures like the optic nerve or internal carotid artery.
This document provides information about different types of mastoidectomy procedures. It begins with a brief history of mastoidectomy surgery dating back to 1873. It then discusses indications for various procedures like cortical mastoidectomy, canal wall up (CWU) mastoidectomy, modified radical mastoidectomy, and radical mastoidectomy. Key anatomical structures are defined. Surgical techniques for CWU mastoidectomy are outlined, including incision, periosteal elevation, and middle ear dissection steps. Contraindications and debates around CWU versus canal wall down approaches are also summarized.
The document discusses the mucosal folds of the middle ear, which develop as the primitive tympanic cavity expands into the middle ear cleft between 3-7 months of fetal development. This forms four primary sacs that enlarge and replace the mesenchyme, with their walls becoming the mucosal lining of the middle ear. Mucosal folds are the planes of contact between neighboring sacs and carry ligaments and blood vessels to the ossicles. There are 10 important mucosal folds described, including the anterior and posterior malleal folds, lateral malleal ligamental fold, and tensor tympani fold. The folds divide the epitympanum (attic) and orient the progression of
The document discusses electronystagmography (ENG), which tests eye movements using electronic recordings. It lists the main tests done with ENG, including gaze tests, optokinetic nystagmus tests, positional tests, and caloric tests. The caloric test induces nystagmus using temperature changes to evaluate vestibular system function. The document also lists various eye movement findings that can be detected through ENG testing, such as nystagmus, dissociations, dysrythmias, and positional nystagmus.
This document discusses various surgical approaches for treating sinusitis. It covers procedures for the maxillary, frontal, ethmoid, and sphenoid sinuses. For the maxillary sinus, approaches include antral washout/lavage, intranasal antrostomy, and Caldwell-Luc procedures. For the frontal sinus, approaches include trephination, intranasal ethmoidectomy, and external frontoethmoidectomy. Complications of each procedure are also outlined.
1) The document discusses the surgical approach and procedure for cortical mastoidectomy. Key steps include raising skin and periosteal flaps, drilling along anatomical landmarks like the sigmoid sinus and facial nerve to identify structures, and widening the aditus and performing a posterior tympanotomy to access the mesotympanum.
2) Post-operative care involves drain removal within 48 hours and dry dressing of the ear. Potential complications discussed are persistent deafness, facial nerve injury, CSF leak, hemorrhage and infection.
3) The patient is advised restricted activity for 3 weeks followed by a gradual return to normal activity over 4 weeks, and to keep the operation site dry.
Basic principle of rhinoplasty. by venukumar.tvenukumar55
This document provides an overview of the basic principles of rhinoplasty surgery. It discusses nasal anatomy including landmarks like the radix, rhinion, septal angle, and lower lateral cartilages. It covers surgical techniques for both endonasal and external rhinoplasty approaches. Key steps for various nasal deformity corrections are outlined such as hump removal, dorsal augmentation, and tip work. The document also lists common instruments used in rhinoplasty surgery.
This document provides an overview of endoscopic nasal anatomy. It begins with a brief introduction to endoscopy and its historical evolution. It then describes the external nose, nasal septum, lateral nasal wall including the inferior, middle, and superior turbinates. Various anatomical variations are also discussed. The paranasal sinuses, anterior skull base, and endoscopic approaches to different nasal and sinus structures like the frontal sinus and sphenoid sinus are summarized. Key landmarks and variations are highlighted to provide a concise yet comprehensive summary of the essential endoscopic nasal anatomy concepts covered in the document.
This document provides a history of surgery for otosclerosis and stapes surgery from the late 1800s to modern times. It summarizes key developments such as the first stapedectomy performed by John Shea in 1956 using an oval window vein graft and nylon prosthesis. The goals, indications, contraindications, surgical techniques including stapedectomy and stapedotomy are described in detail. Potential problems during surgery like floating footplates, perilymph gushers, and overhanging facial nerves are also outlined along with post-operative care and complications. Long term results tend to show initial hearing improvements are often not maintained over decades with re-operation or hearing aid use often needed.
This document provides an overview of the steps involved in primary sinus surgery via an endoscopic approach. It begins with a brief history of sinus surgery and then discusses preoperative assessment, including CT scans to evaluate sinus anatomy and disease patterns. The basic techniques of Messerklinger and Wigand are described. The key steps of the surgery are then outlined in detail, including uncinectomy, antrostomy of the maxillary sinus, anterior and posterior ethmoidectomy, sphenoid sinusotomy, and frontal sinusotomy when necessary. Throughout, anatomical landmarks and variations are discussed to guide safe dissection and avoid complications.
Mastoidectomy is a surgical procedure to access and treat infections of the mastoid air cells behind the ear. Over time, the procedure has evolved from simple cortical mastoidectomies described in the 17th century to more advanced techniques using an operating microscope and drill. Modern mastoidectomies are typically classified as canal wall up or canal wall down depending on whether the bony ear canal wall is preserved. Indications include treatment of cholesteatoma, refractory ear infections, and approaches for other inner ear procedures. The surgery involves an incision behind the ear to access and clean out the infected mastoid air cells.
In this file, you can ref final interview tips with interview questions & answers, other final interview tips materials such as: interview thank you letters, types of interview questions
Acute suppurative otitis media is an inflammation of the middle ear caused by bacterial infection, usually following a viral upper respiratory infection. It involves several stages: tubal occlusion from Eustachian tube swelling, presuppuration with bacterial invasion and symptoms like earache, suppuration with pus formation and high fever, resolution upon rupture of the eardrum and drainage of pus, and potential complications like mastoiditis. Treatment involves antibiotics and analgesics; myringotomy may be needed for persistent fluid or complications. Prevention includes childhood vaccines and reducing risk factors like passive smoking.
The document discusses wound healing and fibrosis. It describes that wound healing occurs in three phases: inflammation, proliferation, and maturation. It also discusses primary and secondary wound healing. Primary healing involves wounds with opposed edges that heal with a thin scar, while secondary healing involves wounds with tissue loss that heal with more scarring and contracture. The document also discusses factors that influence wound healing and complications that can arise. It provides details on cutaneous wound healing and fracture healing processes. Finally, it discusses fibrosis, describing that it is excessive collagen deposition in tissue during repair. It notes the role of macrophages and TGF-beta in promoting fibrosis.
inflammation of the ear, usually distinguished as otitis externa (of the passage of the outer ear), otitis media (of the middle ear), and otitis interna (of the inner ear; labyrinthitis).
This document discusses tumours of the ear, including both benign and malignant types. It provides details on the epidemiology, risk factors, pathology, diagnosis and treatment of various tumours such as basal cell carcinoma, squamous cell carcinoma, melanoma, and others. Treatment options discussed include surgical excision with various techniques depending on tumour size and location, Mohs surgery, radiation therapy, and reconstruction after tumour removal. Staging criteria and classifications of temporal bone tumours are also presented.
This document discusses the phases and cellular processes involved in wound healing. It describes three phases - inflammatory, proliferative, and maturation. The inflammatory phase involves hemostasis, recruitment of inflammatory cells, and production of growth factors. The proliferative phase involves angiogenesis, fibroplasia, and re-epithelialization to form granulation tissue. The maturation phase involves remodeling of scar tissue and collagen. Local and systemic factors that can impact wound healing are also discussed.
1. Otitis media is inflammation of the middle ear that can involve surrounding areas. It is commonly seen in children and caused by infections that spread from nearby areas like the throat.
2. The condition progresses through stages from initial congestion to collection of fluid/pus in the middle ear. Without treatment, the ear drum may rupture, allowing drainage of pus from the ear.
3. Treatment involves antibiotics and drainage procedures. Chronic or recurring cases may require surgery to repair damaged tissues and prevent complications like infection of the mastoid bone behind the ear.
Wound healing [including healing after periodontal therapy]Jignesh Patel
The document discusses wound healing and periodontal wound healing in particular. It describes the processes of regeneration and repair. Regeneration involves renewal of tissues through growth of same tissue type, while repair involves replacement of tissues through scar formation. The molecular biology of wound healing is explained, including roles of fibrin clot, growth factors, matrix degradation and connective tissue formation. Healing by primary and secondary intention is also defined. Healing processes following various periodontal procedures like scaling, root planing, flap surgery and implant placement are outlined. Factors influencing wound healing and potential complications are briefly mentioned.
This document discusses wound healing and the healing process after tooth extraction. It defines a wound and classifies wounds based on origin, contamination, and depth. The two main processes of healing are regeneration and repair. Repair involves granulation tissue formation and wound contraction. There are two types of wound healing: primary intention and secondary intention. Healing after tooth extraction involves blood clot formation, fibroblast proliferation, angiogenesis, and bone remodeling over 4 weeks. Complications can include dry socket and fibrous union.
Otitis externa refers to infections of the external ear canal. It can be acute or chronic. Acute otitis externa is commonly known as swimmer's ear and is caused by bacterial or fungal infections due to water exposure. Chronic otitis externa is defined as lasting over 4 weeks and is often due to bacterial, fungal, or dermatological causes. Necrotizing external otitis is a potentially lethal infection seen in immunocompromised patients like diabetics. Treatment involves topical or oral antibiotics, cleaning of the ear canal, and surgery in severe cases. Proper diagnosis depends on history, exam, and sometimes imaging or labs.
This document provides an overview of chronic otitis media, including its definition, classification, clinical features, treatment, and epidemiology. It is divided into chronic nonspecific otitis media and chronic specific otitis media. Chronic suppurative otitis media is further classified as tubotympanic disease or atticoantral disease, with the latter including cholesteatoma, granulation tissue, or cholesterol granuloma involvement. Treatment involves antibiotics, surgery for refractory cases, and tympanoplasty to repair perforations and reconstruct hearing.
This document summarizes chronic suppurative otitis media (CSOM), a long-standing middle ear infection characterized by ear discharge and perforation. It describes two main types - tubotympanic (safe) and atticoantral (unsafe). Tubotympanic CSOM has a central perforation and mild deafness, while atticoantral has a foul discharge, cholesteatoma, and more complications. Treatment involves cleaning, antibiotics, and sometimes surgery to reconstruct damaged areas or remove cholesteatoma. Surgical options are canal wall up or down procedures.
this contain detailed information about introduction, definition, causes, risk factor,treatment, medical and surgical management, nursing care given to the patient ,patient teaching.
This document discusses chronic otitis media, including the histology and pathogenesis. It notes that chronic inflammation is characterized by both tissue destruction and attempts at healing. Repeated infections from the nasopharynx or external ear canal can prevent resolution of otitis media. Persistent bacterial biofilms and chronic perforations of the tympanic membrane also contribute. Chronic retraction of the pars tensa portion of the eardrum can lead to atrophy and complications like cholesteatoma formation over time if not addressed. Early intervention may be warranted for more advanced retractions to prevent future problems.
Otitis Media can be acute or chronic. Acute Suppurative Otitis Media is caused by bacterial infection spreading from the nose or throat to the middle ear through the Eustachian tube. It progresses from catarrhal to exudative to suppurative stages, sometimes causing mastoiditis. Chronic Otitis Media can be suppurative or non-suppurative. Chronic Suppurative Otitis Media may be benign or dangerous, with the dangerous type at risk of complications like cholesteatoma. Chronic Non-Suppurative Otitis Media involves non-purulent effusion, causing conditions like serous otitis media and atelectasis. Tuberculous
Furunculosis is a localized infection of a single hair follicle in the external ear canal caused mainly by Staphylococcus aureus bacteria. It presents as a painful, blocked ear with tender swelling and scanty discharge. Treatment involves oral or intravenous antibiotics depending on severity, with topical treatments like antibiotics also used. Granular myringitis is a form of external otitis characterized by granulation tissue on the tympanic membrane and possibly in the ear canal. It typically causes foul-smelling discharge but little pain. Diagnosis is based on appearance during otoscopy. Topical steroid/antibiotic drops are the main treatment approach.
Furunculosis is a localized infection of a single hair follicle in the external ear canal caused mainly by Staphylococcus aureus bacteria. It presents as a painful, blocked ear with discharge and tender swelling around the pinna. Treatment involves antibiotics, incision and drainage of abscesses, and topical antiseptic ear drops. Without treatment, it can cause scarring and narrowing of the ear canal.
This document discusses respiratory tract infections, specifically focusing on infections of the upper respiratory tract. It defines otitis media as an inflammation of the middle ear and describes its three subtypes. Otitis media is common, especially in young children, and can be caused by bacteria like Streptococcus pneumoniae that enter the middle ear following a viral upper respiratory infection. Symptoms include ear pain, fever, and hearing loss. The document also discusses acute bacterial rhinosinusitis, noting that it is commonly caused by the same bacteria as otitis media and that differentiating between viral and bacterial infections is important to avoid overprescribing antibiotics.
Chronic Suppurative Otitis Media (CSOM)DeviNadilah1
Chronic suppurative otitis media (CSOM) is inflammation of the middle ear with permanent perforation of the eardrum and discharge for more than 12 weeks. It affects 65-330 million people worldwide, with over 5% prevalence in Indonesia. CSOM often occurs in children and is caused by bacteria like Pseudomonas aeruginosa and Staphylococcus aureus. Treatment involves antibiotics and surgery to repair damage and prevent complications like hearing loss and intracranial infections that can lead to death. Prognosis is generally good with adequate treatment and avoiding complications.
This document discusses diseases of the middle ear, including acute suppurative otitis media and chronic suppurative otitis media. It describes the pathology, clinical presentation, investigations and treatment options for these conditions. Acute suppurative otitis media typically presents with otalgia, otorrhea and deafness, and is usually treated with antibiotics. Chronic suppurative otitis media can be the safe/tubotympanic type or dangerous/atticoantral type, with the former confined to the middle ear cleft and carrying less risk.
This document discusses space infections that can arise from dental infections. It defines fascial spaces and outlines the pathways of odontogenic (dental) infections. It describes different classifications of infections including by location (e.g. maxillary vs mandibular spaces), etiology, and causative organisms. Specific spaces that can become infected are discussed such as the canine, buccal, and infratemporal fossa. Clinical features, treatment including incision and drainage, and potential spread are covered for each space.
This document discusses different types of otitis media including acute otitis media, chronic otitis media, and serous otitis media. It covers the etiology, risk factors, clinical manifestations, diagnostic evaluations, and management for each type. The main types are acute bacterial infection of the middle ear (acute otitis media), chronic infection with tissue damage (chronic otitis media), and non-infectious fluid accumulation (serous otitis media). Diagnosis involves examination, tests to check for fluid/infection, and treatment involves antibiotics, drainage procedures, and addressing underlying causes.
Otitis media is an infection of the middle ear that is usually caused by bacteria or viruses. It is common in young children due to the short, horizontal shape of the eustachian tubes. Risk factors include exposure to cigarette smoke, overcrowding, bottle feeding, and allergies. Acute otitis media presents with severe ear pain over days to weeks and visible inflammation of the eardrum. Chronic otitis media is characterized by persistent fluid buildup behind an intact eardrum, while chronic suppurative otitis media involves long-term drainage through a perforated eardrum. Treatment involves antibiotics, antihistamines, tubes, or surgery depending on the type and severity of
This presentation defines otitis media with effusion (OME), also known as "glue ear", and summarizes its epidemiology, risk factors, clinical presentation, pathophysiology, diagnosis, and management. OME is a common condition in young children that results in fluid buildup in the middle ear without signs of infection. It peaks between ages 2-5 years and often resolves spontaneously within 3 months. Risk factors include upper respiratory infections and Eustachian tube dysfunction. Symptoms include conductive hearing loss and possible speech or behavioral issues. Diagnosis involves examination, audiometry, and tympanometry. Initial management focuses on watchful waiting but may include hearing aids, ventilation tubes, or adeno
This document discusses different types of ear infections, including otitis externa (infection of the external ear canal), otitis media (infection of the middle ear), and mastoiditis (infection of the mastoid bone behind the ear). It describes the anatomy of the ear canal and risk factors for ear infections like age and environment. Common bacteria that cause ear infections are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Symptoms, treatment, and diagnostic testing for each type of ear infection are provided.
The prevalence of chronic otitis media (COM) is approximately 4.1%, with higher rates in older adults and those from lower socioeconomic backgrounds. Childhood ear infections and ear tube placements can cause changes to the eardrum that make it more susceptible to COM over time. COM is also associated with genetic factors, environmental exposures, Eustachian tube dysfunction, craniofacial abnormalities, and autoimmune conditions. Mucosal COM arises from acute ear infections that fail to heal fully, while cholesteatoma develops from retraction pockets in the eardrum that allow skin cells to accumulate behind the eardrum. Precise examination with microscopy is required to diagnose COM and assess its characteristics and severity.
Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis, characterized by vague constitutional symptoms and a protracted course of illness. India accounts for one third of the global tuberculosis burden, with an estimated 15 million people infected and 3-4 million children infected. Tuberculosis is most commonly transmitted via inhalation of airborne droplets expelled through coughing or sneezing, with the bacilli then multiplying in the lungs to cause a primary infection which can spread systemically through the blood or lymphatics.
Granulomatous diseases affecting the nose can be classified as infective, inflammatory, or neoplastic. Infective causes include bacteria like rhinoscleroma, tuberculosis, and syphilis, as well as various fungi. Rhinoscleroma is caused by Klebsiella Rhinoscleromatis and presents in four stages from catarrhal to cicatricial, with granulomatous nodules appearing in the nasal mucosa. Syphilis presents differently based on whether it is acquired or congenital, but can cause gummatous lesions, septal perforation, and saddle nose deformity in the tertiary stage. Leprosy also involves the nose more in the lepromat
This document provides information about acute otitis media and otitis media with effusion in adults. It discusses the etiology, diagnosis, examination findings, investigations, and management of both conditions. For acute otitis media, common symptoms include pain and hearing loss. Examination may reveal a bulging eardrum. Complications can include mastoiditis. For otitis media with effusion, causes include prior infections and Eustachian tube dysfunction. Examination shows a retracted eardrum. Management involves hearing aids, ventilation tubes, or surgery in persistent cases.
This document provides an overview of trachoma, the leading infectious cause of preventable blindness worldwide. It is caused by repeated infections with Chlamydia trachomatis bacteria, which leads to conjunctival scarring and trichiasis (turned in eyelashes). The highest prevalence is in parts of Africa, the Middle East, South Asia, and South America. Trachoma is diagnosed clinically and managed using the SAFE strategy of surgery, antibiotics, facial cleanliness and environmental improvement.
This document provides an overview of otitis media with effusion (OME), also known as glue ear. It defines OME as the accumulation of mucus within the middle ear, often due to malfunction of the eustachian tube or increased middle ear secretions. Risk factors include young age, winter season, and history of acute otitis media. Symptoms include hearing loss, ear fullness, and delayed speech. Treatment involves initial medical management with decongestants and antibiotics, with surgical placement of ventilation tubes as needed for persistent cases or hearing impairment. Complications of ventilation tubes can include infection, granulation tissue, or permanent perforation of the ear drum.
Infections of the gingivae and oral mucosaSana Rasheed
This document discusses various infections that can affect the oral mucosa and gingivae. It describes acute necrotizing ulcerative gingivitis (ANUG), an infection of the gingiva caused by a complex of bacteria including fusobacteria and spirochetes. It presents syphilis and gonorrhea as examples of sexually transmitted infections that can manifest orally. It also discusses tuberculosis, non-specific urethritis, and various fungal infections including oral candidiasis. Treatment involves identifying the causative organism and using antibiotics or antifungals as appropriate.
Similar to The formation and management of middle ear granulation (20)
Viral laryngitis is the most common cause of laryngeal infection and presents with symptoms like dysphonia, odynophagia, and laryngeal trauma from phonation and coughing. Bacterial laryngitis can also occur from pathogens like Streptococcus and Staphylococcus and may result in supraglottitis or epiglottitis. Fungal, mycobacterial, and other infections like leprosy and syphilis can also infect the larynx, especially in immunocompromised patients. Autoimmune conditions such as Wegener's granulomatosis, rheumatoid arthritis, relapsing polychondritis, and pemphigus/pemphigoid can cause
Endoscopic single handed septoplasty with batten graft for caudalDaria Otgonbayar
This study evaluated the effectiveness of an endoscopic single-handed septoplasty technique using a batten graft to correct deviations of the caudal septum. 17 patients underwent the procedure, which uses a modified Killian incision and preserves the L-strut to prevent deformities. Post-operation, CT scans showed significantly improved nasal cavity ratios and patient surveys found improvements in nasal obstruction and other symptoms. The technique provides an easy, minimally invasive option to correct caudal septum deviations in select cases.
Brainstem auditory evoked responses (baer or abrDaria Otgonbayar
This document summarizes information about brainstem auditory evoked responses (BAER or ABR) testing. It provides normative data for BAER wave latencies and intervals. It then discusses using BAER threshold differences as a new diagnostic index for detecting small vestibular schwannomas. The document describes a study of 7 patients with untreated vestibular schwannomas that found all patients had abnormal ABR threshold differences between normal and diseased ears, and 5 patients also had traditional abnormal BAER indices. The mean threshold difference was 41.4 dB for diseased ears and 15.8 dB for normal ears. This suggests threshold differences may help increase BAER sensitivity for detecting small tumors.
Brainstem auditory evoked responses (baer or abrDaria Otgonbayar
1) Brainstem auditory evoked responses (BAER or ABR) testing involves measuring electrical activity in the auditory pathway in response to clicks or tones. It is used to identify sensorineural hearing loss and retrocochlear pathologies like acoustic neuromas.
2) The study evaluated 7 patients with untreated, MRI-confirmed unilateral vestibular schwannomas to determine if using auditory brainstem response threshold differences could increase the sensitivity of ABR testing in detecting small tumors compared to traditional ABR indices.
3) The results found that all 7 patients had an abnormal ABR threshold difference of over 30dB between ears, and 5 patients also showed abnormal traditional ABR indices, indicating threshold
- Three days after traumatic perforation of the rat tympanic membrane, the epithelial layer was thicker with more cell rows. The lamina propria showed disorganized fibroblasts and edema, while inflammation was predominant.
- Between 5-7 days, the healing process was proliferative with closure of the perforation beginning around 7-10 days. By 14 days, healing was complete.
- The study histologically examined the rat tympanic membrane at set time points after traumatic perforation to analyze the inflammatory, proliferative, and remodeling phases of the spontaneous healing process.
The formation and management of middle ear granulation
1. The formation and management of
middle ear granulation tissue in
chronic ear disease
2. First
stage
The formation of
granulation tissue
in the middle ear
space begins with
a break in the
basement
membrane of
surface epithelial
cells.
Inflammatory cells in
the underlying
lamina propria
traverse through the
broken basement
membrane and enter
the lumen of the
middle ear space.
The rupture of the
basement membrane
and epithelial cell lining
is caused by bacterial
toxins, inflammatory
mediators produced by
ruptured lysozymes, and
the accumulation of
subepithelial fluid and
vacuoles, all of which
exert pressure on the
surface epithelium.
3. Second
stage
The second step in the
formation of
granulation tissue
occurs when a small
piece of the herniated
lamina propria
extrudes through the
ruptured area of the
epithelial cell surface
The result of this
extrusion is that the
affected tissue is no
longer epithelialized.
In some cases,
angiogenic growth -
incite capillary budding,
vascular
hyperpermeability, and
fibroblast recruitment. If
the growth of
granulation tissue is
vigorous and aggressive,
polyps can form (figure
3).
5. • Following the rupture of the lamina propria into the middle
ear space, re-epithelialization begins.
• Re-epithelialization is a continuous process, although it
occurs at different rates and is often incomplete.
• When the epithelium surrounds a polyp, it can become
metaplastic. Microsectioning of these polyps generally
reveals the presence of a variety of different types of
epithelial surfaces in different portions of the polyp.
• The presence or absence of a significant amount of
keratinizing epithelium on a polyp surface during biopsy
analysis can provide clues to the polyp's etiology.
• The presence of significant keratinizing epithelium
indicates that the cause of the polyp is a cholesteatoma, as
opposed to a purely infectious process. On the other hand,
the absence of squamous keratinizing epithelium is a fairly
reliable sign that no cholesteatoma is present.
6. Tympanostomy-tube-related
granulation tissue
• Kay et al performed a meta-analysis of more than 7,000
ears and found that the mean incidence of granulation
tissue in patients with tympanostomy tubes was slightly
less than 5%.
• Of these, 8.1% required surgical debridement.
• El-Bitar et al found that the incidence of granulation tissue
was 13.8% in tympanostomy tubes
• had been in place for 2 to 3 years and more than 40%
tubes that had been in place for more than 5 years.-60%
• They also noted that children who were older than 7 years
were much more likely to have granulation tissue than
were younger children, regardless /of how long the tubes
had been in place.
7. Etiology.
• The etiology of tympanostomy-tube-related granulation
tissue is still disputed.
• In some cases, of course, its development is almost
certainly the result of the actual middle ear infection itself.
• Granulation tissue might also arise as a direct response to
the presence of the foreign body in the tympanic
membrane, or it might represent a direct response to
trapped squamous epithelium that has become lodged
between the flange of the tube and the tympanic
membrane.
• Post suggested that tympanostomy-tube-related
granulation tissue might be related to the development of
bacterial biofilms that adhere to the surface of the tube.3
8.
9. Consequences.
• There are several potential consequences of
tympanostomytube-related granulation tissue.
• One is that it might impede the delivery of topical antibiotic
solution to the site of infection so that the eardrop cannot
penetrate into the middle ear space, which, of course,
would result in a treatment failure.
• Another complication is that the granulation tissue can
cause bloody otorrhea. This in itself is not serious, but it
can alarm the child's parents and lead them to seek
emergency treatment, which significantly drives up the cost
of care.
• Finally, over long periods of time, granulation tissue can
fibrose and lead to permanent/тогтмол байнгийн/
scarring.
10. Granulation tissue in other types of
chronic ear disease
• Meyerhoff et al reported that granulation tissue
develops in 94% of all cases of chronic suppurative
otitis media (CSOM),
• usually in the epitympanum, and in 100% of cases of
CSOM that are characterized by intracranial
complications.4
• Granulation tissue also develops in many cases of
chronic otitis externa.
• Finally, chronic granular myringitis is, in effect, a
granulation tissue disease-that is, granulation tissue is
essentially its only manifestation.
11.
12. Control and management
The control and management of granulation
tissue involves the use of four modalities:
1. aural toilet
2. antiinfectives
3. steroids
4. cautery -silver nitrate wrong site - paralysis FN
or debridement.
13. Aural toilet.
• The easiest method of aural toilet is irrigation, which,
of course, can be performed by virtually anyone in any
setting. The best results are achieved with one or two
syringefuls or bulbfuls of either full-strength (3%) or
half-strength hydrogen peroxide, which is safe and
generally painless. Flushing of the ear should take
place 15 to 20 minutes prior to the administration of
therapeutic eardrops so that the irrigation solution has
had sufficient time to dissipate. Once the ear is dry, the
therapeutic eardrops will be able to penetrate to the
source of the granulation tissue.
14. Chart shows that ciprofloxacin/dexamethasone was significantly more
effective than ofloxacin alone in eradicating granulation tissue in 90 children
with acute otitis media with otorrhea at 11 and 18 days from the initiation of
treatment
16. Abstract
• Nontuberculous Mycobacterium (NTM) middle ear
infection is a rare cause of chronic bilateral intermittent
otorrhea. We report a rare case of bilateral NTM
middle ear infection in which a 55-year-old woman
presented with intermittent otorrhea of 40 years'
duration. The patient was treated medically with
success. We conclude that NTM is a rare but probably
under-recognized cause of chronic otitis media. A high
index of suspicion is needed for the diagnosis to avoid
prolonged morbidity. Treatment includes surgical
clearance of infected tissue with appropriate
antimycobacterial drugs, which are selected based on
culture and sensitivity.
17. Introduction
• Nontuberculous mycobacteria (NTM) are related to but are
different species from Mycobacterium
tuberculosis and Mycobacterium leprae.1,2 They are
important low-virulence, environmental pathogens that
have been associated with human diseases, particularly in
immunocompromised patients. They are found in soil,
biofilms, drinking water, and
aerosols.3 Otorhinolaryngologic (ORL) infections due to
NTM are rare. The most common ORL nontuberculous
mycobacterial infections are head and neck lymphadenitis
and middle ear infections; these infections always target
healthy young children. We report a case of NTM middle
ear infection in a 55-year-old woman who had experienced
bilateral otorrhea intermittently for 40 years.
•
18. • A 55-year-old woman was referred to our ORL clinic for
chronic intermittent bilateral otorrhea lasting 40 years; it
was associated with decreased hearing bilaterally. She had
only sought medical advice from general practitioners
when her ear discharge increased or bothered her. She
claimed multiple oral antibiotics and local otic drops had
been prescribed for her, but none of these medications had
completely dried her ears.
• The patient underwent left myringoplasty in 1982 in a
private hospital, but the graft failed. Since then, she had
been followed inconsistently in a private clinic. In 2001, she
underwent a left modified radical mastoidectomy, but it did
not solve her problem. She was then referred to our ORL
clinic in 2003.
• At the patient's presentation to our clinic, her symptoms
were still persistent despite the multiple treatments she
had been given. Her medical history was otherwise
unremarkable, and she had no evidence of
immunodeficiency.
19. • Clinical examination revealed bilateral intact
facial nerves. Her ear examination revealed
bilateral mucopus discharge with bilateral
subtotal tympanic membrane perforation. There
was minimal granulation tissue noted in the
middle ears bilaterally.
• Multiple biopsies of granulation tissue, as well as
culture and sensitivity swabs, were taken from
both ears. The biopsy revealed acute-on-chronic
inflammation of nonspecific origin and no growth
culture from the granulation tissue. The culture
and sensitivity swabs grew Staphylococcus
aureus.
20. • The patient was treated with oral antibiotics and local
otic drops based on culture results, but the otorrhea
persisted.
• She was then scheduled for an otoscopic examination
under anesthesia and underwent mastoidectomy
revision surgery to clear the remaining granulation
tissue.
• Granulation tissue obtained from both ears yielded
rapidly growing Mycobacterium
abscessus andMycobacterium fortuitum that were
resistant to trimethoprim-sulfamethoxazole but
sensitive to imipenem, clarithromycin, and
azithromycin.
21. • High-resolution computed tomography (HRCT) and
gallium scans revealed bilateral temporoparietal
osteitis.
• The patient was given intravenous imipenem 500 mg
three times daily and oral clarithromycin 500 mg twice
daily. Amikacin was added to the treatment regimen
for a synergistic effect, but the patient was unable to
tolerate it. Therefore, the dual treatment was
continued for a total of 40 days without any
complications. The patient was then continued on oral
doxycycline 100 mg twice daily, clarithromycin 500 mg
twice daily, and moxifloxacin 400 mg once daily. The
medications were continued for 1 year after her illness
had resolved, during follow-up.
•
22. . Axial HRCT of the temporal bone shows soft-tissue thickening in the left external auditory canal
posteriorly (arrow). Osteitis changes are noted in the left temporal bone. The presence of left
mastoid air cells indicates previous surgery
23. Repeat axial HRCT of the temporal bone
obtained 1 year after treatment reveals no
evidence of recurrence of the otitis media and
osteitis.
Six months after the
treatment with the three
oral antibiotics, both of the
patient's ears were dry and
her hearing had improved. A
repeat gallium scan revealed
a significant response to
treatment. HRCT of the
temporal bones was
performed 1 year after
completion of the three oral
antibiotics; it revealed no
evidence of recurrence of
otitis media and osteitis
24. Discussion
• Runyon identified NTM species as human pathogens in 1959. He classified
NTM into four groups depending on the speed of growth, morphology, and
carotenoid pigmentation of colonies of solid media, as well as biochemical
reactions. The Runyon group IV was identified based on rapid growth
characteristics and nonpigmented colonies. Three species from Runyon
group IV-M fortuitum, Mycobacterium chelonae, and M abscessus-can
cause human disease in any part of the body.
• NTM species are low-virulence, opportunistic pathogens that can cause
disseminated disease in immunocompromised individuals and localized
disease in otherwise normal hosts. Localized NTM infection is usually
precipitated by penetrating trauma or surgery. Most NTM infections
present as chronic cervical lymphadenitis in healthy children with ORL
infection. Tympanomastoid infection due to NTM is rare. Nearly all the
cases of NTM middle ear infection are caused by the M fortuitumcomplex
(which includes M fortuitum, M chelonae, and M abscessus; 67%) or by
theMycobacterium avium complex (27%). In our case, the middle ear
infection was caused by M abscessus.
• Entry of NTM into the middle ear is most probably by direct inoculation via
the external ear canal. Other possible entry routes include the eustachian
tube and hematogenous or direct spread. Most of the studies show
tympanostomy tubes as the most preferential route of entry of NTM.
25. • In our case, there was no history of ventilation tube
insertion, but our patient had undergone two left ear
operations. These operations might have been the route of
direct inoculation of NTM into the middle ear when it was
exposed to the ambient environment.
• Clinical suspicion of NTM middle ear infection should be
raised in any chronically draining ear unresponsive to
standard antibiotic therapy regardless of a patient's age or
immune system status. Clinical examination of an ear that
shows persistent otorrhea with granulation tissue will add
more suspicion for an NTM infection.
• Redaelli de Zinis et al reported that NTM infections
appeared to develop over a preexistent chronic or
recurrent middle ear inflammatory disease. However, there
is no direct evidence that these conditions were not
actually NTM infections that had been misdiagnosed. The
incubation time varies from 1 week to 2 years, but most of
the infections manifest themselves within 1 month. There is
no evidence of human cross-infection.
26. • Flint et al and Franklin et al reported bone erosion
caused by the progression of NTM infection. The
eroded bones, identified by CT, were the cortical
mastoid, tegmen, posterior ear canal, and middle ear
ossicles. Although CT of the temporal bone cannot
confirm the diagnosis, it can detect the extent of the
lesion, bone erosion, and intracranial extension. In our
case, both HRCT of the temporal bone and a gallium
bone scan revealed bilateral temporoparietal osteitis
without any intracranial complications.
• Histopathologic examination of NTM infection shows
noncaseous granulomatous changes of the tissue
specimens, but acid-fast bacilli staining will be
negative. However, the diagnosis can only be
confirmed by a positive culture from the infected tissue
or ear discharge
27. • . Because of the small numbers of this microorganism
and its slow growth rate, the organism cannot always
be detected. It often takes 2 to 6 weeks before the
species can be identified biochemically. This issue has
been emphasized in almost all the literature reviews
regarding NTM infection.With the aid of polymerase
chain reaction testing, it is possible to make a more
rapid identification of the type of NTM.
• Management of NTM middle ear infection is
challenging. The ideal treatment is complete surgical
excision of the infected tissue and long-term antibiotic
therapy. However, because of the complicated
anatomy of the middle ear, complete surgical excision
is rarely possible. (In our case, some granulation tissue
was left to avoid injury to the facial nerve and cochlea.)
28. • Moreover, the rate of resistance to antibiotics is high,
and they should be continued for a long period until
repeated cultures are negative or there is dramatic
improvement in the clinical signs and symptoms.
• Antibiotic therapy that should be given intravenously is
high-dose cefoxitin or imipenem for 3 to 6 weeks,
together with clarithromycin and intravenous amikacin.
It should later be followed by at least 4 to 6 months of
clarithromycin. However, this therapy should be based
on individual organism susceptibilities and clinical
response. In our case, the patient was also given
doxycycline and moxifloxacin for 1 year of long-term
therapy because one of the tissue specimens grew M
fortuitum.
29. • A common suggestion for medical therapy from the
literature is to provide multidrug treatment based on
cultural examinations to avoid antibiotic resistance for a
period varying from 1 to 3 months after the patient is
disease-free.
• In conclusion, NTM is a rare and probably under-recognized
cause of chronic otitis media. A high index of suspicion is
needed for the diagnosis to avoid prolonged morbidity. A
thorough history and physical examination, along with
appropriate investigations, are needed to diagnose NTM
infection in the middle ear. Tissue specimens from
granulation tissue for histology and culture should be
obtained in cases of chronic otitis media unresponsive to
conventional antibiotic therapy. The diagnosis of NTM only
can be confirmed by growth of the NTM species. Treatment
includes surgical clearance of infected tissue with
appropriate antimycobacterial drugs based on culture and
sensitivity.