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1. Ear Diseases

2. EAR DISEASES:
Diseases of the External Ear
Otitis Media and Middle Ear Effusions
Chronic Otitis Media
Otosclerosis
Meniere’s Disease
Deafness

3. Diseases of the External Ear
The external ear is composed of the
auricle, the external auditory canal
(EAC), and the epithelial surface of the
tympanic membrane
Trauma, infections ,neoplas

4. TRAUMA TO THE EXTERNAL EAR
•Trauma to the external ear is common in all age groups
•The unprotected auricle is at risk for all kinds of trauma:
----cold or hot thermal injury
----blunt or sharp injury
•Results:
----ecchymosis, hematoma, laceration, or fracture

5. TRAUMA TO THE EXTERNAL EAR
AURICULAR HEMATOMA
•Hematoma of the auricle usually develops after blunt trauma
----wrestlers and boxers
•Mechanism :traumatic disruption of a perichondrial blood
vessel.
•Treatment:
----needle aspiration or incision
----application of pressure to prevent reaccumulation of
blood.

6. TRAUMA TO THE EXTERNAL EAR
LACERATIONS
•Auricular lacerations with or without loss of parts of the
auricle
are common from sharp trauma.
•Surgical principles:
----An attempt should be made to repair
----preserving all remaining viable tissue.
This loss of tissue is from a bite

7. INFECTION AND INFLAMMATION OF THE EXTERNAL EAR
AURICLE
Cellulitis of the Auricle:Cellulitis is a bacterial infection that
usually follows abrasion, laceration
Allergic Dermatitis of the Auricle:Allergic dermatitis of the
auricle is haracterized by localized erythema, swelling, and
itching in the area of allergen exposure.
EXTERNAL AUDITORY CANAL
Acute Localized Otitis Externa (Furuncle)
Acute Diffuse Otitis Externa (Swimmer’s Ear)
Chronic Otitis Externa
Necrotizing (Malignant) External Otitis
Fungal Otitis Externa (Otomycosis)

8. INFECTION AND INFLAMMATION OF THE EXTERNAL EAR
Acute Localized Otitis Externa (Furuncle)
•Acute localized otitis externa is an infection of a hair follicle
•Microorganism:Staphylococcus aureus.
•Symptoms: severe pain
•Treatment:
----before suppuration: topical and systemic antibiotics.
----If a localized abscess has formed:
incision and drainage
topical antibiotic ointment
with or without oral antibiotics.

9. Otitis Media and Otitis Media with
DEFINITIONS: Effusions
Otitis media represents an inflammatory condition of the
middle ear space, without reference to cause or
pathogenesis.
Middle ear effusion is the liquid resulting from OM.An
effusion may be either serous (thin, watery), mucoid
(viscid,Synonyms Used in the Past for Otitis
thick), or purulent (pus).
Media
Acute Otitis Media Otitis Media with
Effusion
Suppurative Serous
Purulent Secretory
Bacterial Mucoid
Glue ear
Middle ear
effusion
The process may be acute (0 to 3 weeks in duration), subacute(3 to
12 weeks in duration), or chronic (greater than 12 weeks in
duration).

10. Acute otitis media and
mastoiditis

11. Definition
• AOM:Acute otitis media represents the rapid
onset of an inflammatory process of the
middle ear space associated with one or
more symptoms or local or systemic signs.
Acute suppurative otitis media
Acute non-suppurative otitis media

12. Bacteriology
• Streptococcus pneumoniae
(48%)
• Haemophilus influenzae (31%)
• Moraxella catarrhalis (20%)
• P-hemolytic streptococcus
(decreased following widespread
immunization program)
• Pseudomonas aeruginosa
(uncommon cause of AOM)

13. Routine of infection
• Eustachian tube:ET dysfunction(ETD) is considered the
major etiologic factor &
– upper respiratory infection (acute rhinonitis and nasal
pharyngitis)
– Upper respiratory communicative disease (diaphea, mealse)
–Swimming and dive in unclear
water
–Anatomic contribution
(Eustachian tube in infant is wide
and short and more horizontal )
Why a higher incidence of acute otitis media occurs in children?

14. Routine of infection
• Via external acoustic canal and TM
– Perforation
– Myringotomy or myrigotosis
• Via blood supply

15. Pathology
• Mucosal inflammation
• Serous, hemorrhagic, or purulent in middle
cavity
• Rupture of tympanic membrane

16. Symptoms
• Systemic Symptoms
Fever, vomiting, diarrhea, anorexia
– It may be masked by analgesics or antibiotic
• Topical Symptoms
Otalgia (ear pain)
– 60% patients can spontaneous remission
Aural fullness
Hearing loss
otorrhea

17. Physical examination
• Erythema: It caused by
dilatation and congestion of the
capillaries
Increased vascularization of the
TM, initially located in pars of
flaccida, frequently spreading
beyond the annulus to the skin of
the external canal.
• Bony landmarks are visible.
Physical examination usually reveals a
thickened, erythematous or bulging tympanic
membrane with limited or no mobility to
pneumatic otoscopy.

18. Physical examination
• Thickened or bulging tympanic
membrane
----Rapid middle ear exudation
occurs
----edema and bulging of the pars
flaccida.

19. Physical examination
• otorrhea
• The progression of this
disease may result in rupture
of TM, releasing the middle
ear contents (beating sign)
leads to relief of otalgia and
retraction of the pars flaccida

20. Physical findings
Erythema bulging tympanic membrane
otorrhea perforation

21. Lab tests
• Blood counts usually shows leukocytosis
with polymorphonuclear elevation.
• CT and MRI is necessary only for the rare
patients with a serious complication
(meningitis or brain abscess)

22. Hearing tests
• Conductive hearing loss
– Degree of hearing loss
will depend on the
amount and viscosity of
the middle ear
exudate, TM edema
– It vary from 10-50 dB with
predominant involvement
of the low frequencies
– Hearing loss may mixed
when there is labyrinthine
extension.

23. Diagnosis
• The diagnosis of AOM requires:
– History of acute onset signs and symptoms
– Presence of middle ear effusion (MEE)
– Signs and symptoms of middle ear inflammation
The presence of MEE is indicated by:
- A bulging tympanic membrane
- Limited or absent tympanic membrane mobility
- Air-fluid level behind the TM
- Otorrhea (drainage from the ear)
Signs of middle ear inflammation include:
- Erythema of the tympanic membrane
- Otalgia (ear pain)

24. Managements
• Antibiotic therapy
– Experiences
– Antibiotic sensitivity and bacteriologic culture
– Traditional duration 10-14 d
– Currently duration 5-7 d
Daily Dosage for Common Antibiotic Agents in Acute Otitis Media

25. Managements
• Nasal decongestants or oral decongestants
(antihistamines and sympathomimetic amines)
• Best rest, light diet
• Avoidance of irritants (smoking)
• Analgesics
• Antipyretics

26. Managements
• Pre-perforation
– Surgery: myringotomy
• Progression with a
red, bulging TM, severe
otalgia and fever
• Otitis media with
impending complications
• perforation is not big
enough to drain all pus

27. Managements
• Post-proferation:
– Clear-up pus with 3% hydro-oxygen
– Antibiotic ear drops
– With pus decreased and inflammation
disappeared, alcohol can be used to facilitate
dry ear.

28. Follow-up
• Adequately treated AOM effusion may
persist for 2-6 weeks or even longer.
• Managements may require
– extended antibiotic treatment
– Otoscope and audiometric tests should be
performed 3-4 weeks following apparent
resolution of the acute infection
– Insertion of pressure equalization tubes due
to fluid persists beyond 3 months

29. Acute mastoiditis
• Definition: an infection of the mastoid
characterized by diffuse osteitis followed by
rarefaction and breakdown of the bony septae.
– Acute coalescent mastoiditis
– Haemorrhagic mastoiditis
– Masked mastoiditis
• Predisposition to pneumatic mastoid
• Predilection to kid
• Mastoid is mature at age of 4 year old

30. Acute mastoiditis
• Reduction of immune system
• Strong bacteria (type III
pneumococus, haemolytic streptococcus)
• Obstruction- not effective drainage
• Imcompletely treatment

31. Acute mastoiditis
• Symptoms
– Symptoms may follow AOM, with or without a
symptom-free interval of a few days to several
weeks or more.
• Otalgia
• Aural discharge
• Conductive hearing loss
• fever

32. Acute mastoiditis
• Physical findings
– Fever, from a slight elevation to 39
– Otorrhea may be absent
– Pulsatile may be observed
– Tympanic perforation is present, but it may be obscured by
intense edema
– Swelling of the superior TM and posterosuperior wall of EAC
– Postauricular area
• erythema and tenderness
• Pitting edema
• Obliteration of the postauricular crease

33. Acute mastoiditis
• Radiographic
evaluation
– Diffuse
rarefaction of
bone and
breakdown of
cellular septae

34. Acute mastoiditis
• interventions
– Medical management
• Antibiotic
– Intravenous antibiotic therapy should be maintained for at
least 24-48 h after the resolution of symptoms
– Then followed with oral antibiotic for 2 weeks
– Surgical management
• Emergency surgery: simple mastoidectomy
• Mastoidectomy + ventilation tube placement

35. Otitis media with effusion

36. Background
• Otitis media is a multifactorial disease process
involving immunology, infectious
disease, anatomic considerations, social and
socioeconomic issues, and genetics factors.
• Approximately 70% of children below the age
of 3 will develop an episode of otitis media.

37. Definition of OME
• OME is an inflammatory condition of the
middle ear and mastoid air cell system
characterized by accumulation of fluid in
the middle ear without signs or symptoms
of acute infection.

38. • Other names:
– Secretory otitis media,
– Serous otitis media,
– Glue ear,
– Nonpurulent otitis media,
– Catarrhal otitis media.

39. Epidemiology
– 90% of children suffer from OME before
school age (usually 6 months to 4 years)
– 30-40% of children with recurrent OME
– 5-10% last greater than 1 year

40. Pathogenesis(Etiology)
• Dysfunction of Eustachian tube
– Obstruction of Eustachian tube
• Mechanic obstruction
– enlarged adenoid, tumor, enlarged inferior turbinate
• Non mechanic obstruction
– Weakness of related muscle,
– Reduction of clearance and defense
• Immotile cilia syndrome

41. Pathogenesis (Etiology)
• Infection
– PCR detects the middle ear fluid, positive findings was
70%
– S pneumonia, haemophalus influenzae, haemolytic
streptocuccus
• Immunity
– Middle ear is a isolated immune system
– Inflammatory mediators
– Specific antibody, immunologic complex
– Antigen may from adenoid or nasopharygeal lymph
• Gastroesophageal reflux
－ resulting in mucosa inflammatory of ET

42. Classification of Otitis media
• Otitis meda with effusion: the presence of
middle ear effusion.
• If the middle ear effusion is present for
12 weeks or longer, it is classified
chronic otitis media with effusion

43. Symptoms of OME
• Hearing loss may be the only symptom.
– Kid can not concentrate himself
– Turn on TV in loudness
– If one ear is normal, the above symptoms
will be ignored
• Otalgia(ear pain ,occasionally)
• Fullness
• Tinnitus

44. Physical examination
The tympanic membrane may present numerous
physical findings:
• thickening, opacification
• impaired mobility
• air-fluid level
• bubbles

45. Physical examination
• Conductive hearing loss
--Tuning fork test
Rinne test(-); Weber test →ill side
--Pure tone test

46. Physical examination
• Tympanometry
– Middle ear pressure more negative than -
200 (type C) or a flat tympanometry curve
(type B) is classified as a failure.

47. Diagnosis
• According to Symptoms and examination,it is easy to
make the clinical diagnosis.
-- The presence of air bubbles or air fluid levels makes the
diagnosis more evident
--Lateral nasopharyngeal radiograph:
hypertroph of adenoid
--Nasopharyngeal exam: to exclude
space-occupation lesion

50. Differentiated diagnosis
• Nasopharyngeal carcinoma:
– Unilateral OME
– EBV-VCA-IgA
– Nasoendoscope
– CT or MRI
– Biopsy
• CSF (cerebrospinal fluid) leakage
– Head trauma
– Meningitis
– CT or MRI

51. Differentiated diagnosis
• Perilymphatic fluid fistula
– Secondary to stapes surgery or trauma
– Vertigo
– Hearing test: sensorineural hearing loss or
mixed hearing loss
• Cholestrol granuloma (heamotympanum)
– Advanced stage of OME
– Tympanic membrane: blue
– CT: soft tissue in mastoid or middle cavity

52. Differentiated diagnosis
• Atelectatic Otitis media
– Sequela of OME
– Conductive hearing loss
– TM contacts with ossicular chain
Other name:Middle Ear Atelectasis

53. Middle Ear Atelectasis
• Lack of middle ear ventilation results in negative
pressure within the tympanic cavity
• The ear drum retracts onto structures within the middle
ear
• The result of long standing Eustachian tube dysfunction
• The drum loses structural integrity and becomes flaccid
• Contact between the drum and the incus or stapes can
cause bone erosion at the IS joint
• Can sometimes be treated with tympanostomy tubes

54. Middle Ear Atelectasis
Patient is at risk for
cholesteatoma due to
skin accumulation
within retraction
pockets

55. Diagnosis of otitis media
• Differentiate diagnosis of AOM and OME
will benefit our treatment, as the latter
condition is usually not treated unless it
becomes chronic

56. Managements
• Principles:
– discharge middle ear fluid
– Drainage, ventilation
– Eliminate pathogenesis

57. Managements
• Non surgical treatment
– Antibiotics
– Steroid
– Improvement of nose congestion

58. Managements
• Surgical treatment
– Tympanocentesis
– Myrigotomy
– Tympanotomy with PT
– mastoidectomy

59. Management of AOM
alternative medical treatment
• Corticosteroid (orally or
intranasally), Antihistamine, decongestants
– Orally corticosteroid and intranasally
corticosteroid help clear chronic middle ear
effusion. However, there is no evidence of
efficacy in treatment of AOM.
– Antihistamine and decongestants are used in the
treatment of OME, it does not benefit AOM.
– Children who have nasal congestion and allergic
rhinitis there may be a role for these preparation.

60. Medical Treatment of OME
• Observation – many European countries wait 6-9
months prior to placement of ear tubes
• Antibiotics
– Meta-analysis shows beneficial short-term resolution of
OME
– Unclear long-term impact
• Audiogram at 3 months with persistent effusion to
determine impact on hearing

61. Surgical treatment for otitis media
----Tympanostomy tubes placement.
• Indications
– Middle ear effusion for more than 3 months .
– Hearing loss >30dB and/or speech delay.
– Chronic severe TM retraction.
– Recurrent otitis media with more than 3
episode within a 6 months period, or more
than 4 episode within a 12 months period.

62. Tympanostomy Tubes(aim)
• Chronic OME >3mos with hearing loss and/or speech delay is
an indication for tympanostomy tube placement(improve
hearing)
• Not just there to “drain fluid”
• Bypass Eustachian tube to ventilate middle ear

63. Surgical treatment for otitis media
----Adenoidectomy
– Indications
• Children with chronic otitis media who are
candidates for tympanostomy tube placement
• Children have symptoms for chronic adenoid
hypertrophy,
• Children require multiple sets of tympanostomy
tube.
• Adenoidectomy be a consideration in the child
older than 3 years.
– It has been demonstrated that adenoidectomy may
accelerate the resolution of chronic otitis media
regardless of the size of the adenoid pad.

64. Surgical treatment for otitis media
---- Laser-assisted myringotomy
• Background and benefit
– It has been advocated for the management of acute
otitis media (unresponsive to medical management)
and chronic otitis media with
effusion, barotrauma, transtympanic inner ear
perfusion.
– A history of allergies, the presence of a thick tympanic
membrane and or high viscocity fluid are all
contraindications for laser assisted tympanostomy

65. Surgical treatment for otitis media
---- Laser-assisted myringotomy
– It can provide symptom relief and avoid
placement of tympanostomy tube by
alleviating infection and inflammation or
improving middle ear ventilation.
– Fenestration creates a round opening in the
TM within a a fraction of a second and is
usually bloodless. It generally last 2-4 weeks

67. The ET has three functions
(1) ventilation of the middle ear associated with equalization of air
pressure in the middle ear with atmospheric pressure.
(2) protection of the middle ear from sound and secretions.
(3) drainage of middle ear secretions into the nasopharynx with the
assistance of the mucociliary system of the ET and middle ear mucous
membrane.
ETD is central to the development of otitis media
Acute otitis media
Recurrent acute otitis media (ROM)
Otitis media with effusion (chronic non-suppurative otitis
media)
Middle ear atelectasis
Chronic suppurative otitis media &