4. FUNCTIONS OF ET
Ventilation and regulation of middle ear
pressure
Protection against a)nasopharangeal
sound pressure
b)reflux of
nasopharangeal
secretions
Clearance of middle ear secretions
5. DISORDER OF EUSTACHIAN
TUBE
Normally ET is closed
It opens intermittently during swallowing,yawning and
sneezing through the active contraction of TVPM.
Air, composed of oxygen,carbon dioxide,nitrogen and water
vapour,normally fills the middle ear and mastoid.
When the tube is blocked,first oxy is absorbed,but later
other gases,carbon dioxide and nitrogen also diffuse out
into the bld---results in neg pressure in middle ear and
retraction of TM---”LOCKING” of the tube with collection of
transudate and later exudate and even haemorrhage
(Acute OME)
6. What is glue ear?
Insidious condition
Glue ear is defined as
inflammation of the middle
ear, accompanied by the
accumulation of fluid in the
middle-ear cleft (serous or
mucoid,not purulent),
without the symptoms and
signs of acute
inflammation
Effusion is thick and
viscid,sometimes may be
thin and serous
Commonly seen in school
going children
7. AETIOLOGY
MALFUNCTIONING OF THE TUBE
Mechanical obstruction-URI,allergy,sinusitis,nasal
polypi,DNS,hypertrophic
adenoids,nasopharangeal tm/mass
Functional-Sniffling,abnormal ciliary function of
the tube(kartagener’s syndrome,situs
inversus,bronchiectasis,cystic fibrosis,chronic
sinusitis),palatal defects,Down
syndrome,barotrauma
Both
8. Aetiology contd..
Allergy-seasonal or perennial allergy to foodstuffs
Unresolved otitis media
Infections
Viral-adeno and rhino viruses
Bacterial-The same flora found in AOM can be
isolated in OME. With OME, the inflammatory process
clearly resolves, and the volume of bacteria
decreases.
9. AETIOLOGY contd…
Other risk factors
More common in:
Bottle feeding
Feeding while supine
Attending day-care
Having a sibbling with OM
Allergies to common environmental entities
Low socio-economic status
Low birth weight
Parental history of OME
Living in a home in which people smoke
Recurrent URI
10. CLINICAL FEATURES OF MEE
SYMPTOMS:
PRESENTATION
Deafness-h/o aural fullness or an ear being
plugged or diminished hearing
o Insidious onset
o Rarely exceeds 40dB
Delayed and defective speech-most common
morbidity encountered
Earaches are rare or mild
Tugging at ear or repeated inserting of finger
11. CLINICAL FEATURES cont…
SIGNS
Otoscopic findings:
Opacification of the
drum (other than due to
scarring)
Loss of the light reflex,
or a more diffused light
reflex
Indrawn, retracted, or
concave drum
Decreased or absent
mobility of the drum
Presence of bubbles or
fluid level
Yellow or amber colour
change to the drum
Fullness or bulging of
the drum, though this is
not typical
12.
13. INVESTIGATIONS contd…
HEARING TESTS:
1)TUNING FORK TESTS:
conductive deafnes
2)PURE TONE
AUDIOMETRY:
Best way to assess hearing
Only suitable for children
who are 4 yrs and older
There is C.H.L. of 20-40
dB,sometimes there is ass
S.N.H.L. d/t fluid present
on R.W. membrane
21. EPIDEMIOLOGY
Peak incidence in the first two years of life
(esp. 6-12 months)
Boys more affected girls
50% of children 1 yr of age will have at
least 1 episode.
1/3 of children will have 3 or more
infections by age 3
90% of children will have at least one
infection by age 6.
Occurs more frequently in the winter
months
22. AOM - Etiology
1) Streptococcus pneumoniae (gram + cocci): 40 -
50 %
2) Haemophilus influenzae (gram - coccobacilli):
30 - 40 %
3) Moraxella catarrhalis (gram - cocci): 10 - 15 %
4) Group A streptococcus (gram + cocci): rare
5) Staphylococcus aureus (gram + cocci): rare
6) Anaerobes: rare
7) Viral infection: Less than 10%
Penicillin-resistant Streptococcus pneumoniae is
the most common cause of recurrent/persistent
otitis media.
23. AOM - Risk factors
1) Age (6-24 mos)
2) Cleft palate / Down syndrome/
Craniofacial malformations
3) Ethnicity (Native American, Alaskan,
Canadian, Inuit)
4) Smoking in the home
5) Attending daycare
6) Male
7) Allergic rhinitis
8) Viral upper respiratory tract infections?/
Season
25. AOM – Differential of otalgia
1) Referred pain from pharyngitis
2) Teething
3) Migraine
4) Wax in the ear canal
5) Foreign body in ear canal
6) Otitis externa
26. AOM - Diagnosis
Clinical diagnosis which includes….
1) Acute onset of symptoms
2) Middle ear effusion; bulging TM,
decreased mobility of TM, air-fluid level
3) Middle ear inflammation; erythema of TM
or otalgia affecting sleep or normal
activity
27. AOM - Differential of an abnormal
tympanic membrane
1) Myringitis
?: red TM
1) Otitis media with effusion (OME)
Serous or Secretory Otitis Media
?: accumulation of fluid in the middle ear
without
inflammation
1) Chronic suppurative otitis media
?:
persistent fluid in middle ear with persistent
28.
29. AOM - Management
70-90 % of children will have spontaneous
remission within 7-14 days.
Generally….
1) Pain management
2) Watchful waiting
3) Antibiotics
4) Follow-up
30. AOM – Pain management
1) Acetaminophen: (15mg/kg q4-6hrs PRN)
2) Ibuprofen: (10 mg/kg q 6hrs)
3) Antipyrine/benzocaine otic suspension: (2-
4 drops tid-qid)
Note
Oral decongestants or antihistamines are
not useful in decreasing the symptoms
or duration of AOM and may actually prolong
AOM.
31. AOM – Watchful waiting
-Observation for 48-72 hours.
-If persistent or worsening symptoms, treat
with antibiotics.
-2 approaches:
1) Return to clinic for reassessment.
2) Give prescription to be filled in 48
hrs/call pharmacy.
32. Watchful waiting vs. antibiotics
ABSOLUTE YES TO ANTIBIOTICS
1) Less than 6 months old.
2) 6 mos – 2 years old with certain AOM.
3) Older than 2 years old with severe
infection (moderate to severe otalgia or
temperature greater than 39 C).
33. Watchful waiting vs. antibiotics
WATCHFUL WAITING
1) 6 mos – 2 years old with mild otitis
media or uncertain diagnosis
2) Children older than 2 years old with mild
symptoms or uncertain diagnosis.
Note
Parents must be able to evaluate child’s
symptoms and return if no
improvements in 48-72 hours.
34. AOM - Antibiotics
FIRST LINE
Amoxicillin (80-90mg/kg divided bid x
10 days)
Note: In children older than 6, treat 5-7
days.
Contra-indications
1) Concurrent purulent conjunctivitis
2) Antibiotic therapy within the past month
3) Amoxicillin chemoprophylaxis
4) Penicillin allergy
35. AOM - Antibiotics
PENICILLIN ALLERGY?
Urticaria/anaphylaxis: Macrolide
No urticaria/anaphylaxis: Cephalosporin
VOMITING/NON-COMPLIANCE?
Ceftriaxone 50mg/kg IV/IM in a single dose
36. AOM - Antibiotics
PERSISTENT AOM
?: No improvement of symptoms within 48-
72hrs.
Must return to be reassessed. Confirm
diagnosis. Start antibiotic if not started
already. If taking amoxicillin, change to a
second line.
37. AOM - Antibiotics
SECOND LINE ANTIBIOTICS
1) High dose amoxicillin-clavulanate
2) Cephalosporin (Cefpodoxime, Ceftriaxone,
Cefuroxime)
3) Macrolide
39. INDICATIONS FOR TYMPANOCENTESIS
Toxic appearing child
Failed treatment regimen with antibiotics
Suppurative complications
Immunosuppressed pt.
Newborn infant in which the usual
pathogens may not be the case.
40. AOM – Follow-up
If OME and no developmental issues:
Follow-up at 3 and 6 months until effusion
resolves.
If OME lasts > 3 months or developmental
issues:
Hearing and language testing should be done.
If hearing loss or structural anomalies of
middle ear are suspected:
Referral to ENT.
May require surgery (tympanostomy & tube
insertion, adenoidectomy)
41. AOM – Follow-up
If chronic suppurative otitis media:
Topical antibiotics:
1) Quinolones
2) Aminoglycosides
3) Polymyxins
Note
Aminoglycosides and polymyxins are ototoxic
and may cause vestibular dysfunction in
longterm use.
42. AOM - Prevention
1) Influenza vaccination (A)
2) Pneumococcal vaccination (A)
3) Avoid exposure to cigarette smoke (C)
4) Discontinue pacifier use in children with
recurrent AOM and OME (A)
5) Avoid feeding in supine position (bottle in
crib)
6) Breast feeding for at least 3 months
43. AOM - Adults
Same antibiotics as in children.
May benefit from nasal/oral steroids if
allergies and persistent AOM.
If unilateral middle ear effusion persists for
longer than 2 months, need CT scan to
rule intracranial neoplasm.
44. AOM - Complications
1) Meningitis
2) Facial weakness/Paralysis
3) Mastoiditis
4) Speech and language delay
5) Hearing loss
45. AOM – When to refer?
Single episode AOM
Complications of AOM
Failure of antibiotic treatment with
persistent severe signs (high fever,
severe pain)…diagnostic
tympanocentesis.
Perforation with persistent otorrhea
46. AOM – When to refer?
Recurrent infections
More than 4 documented infections in 1
year or more than 3 in 6 months.
Child with co-existing illness for which
surgical treatment may be more
beneficial than repeated Abx therapy
(immune deficiency, cystic fibrosis, sickle
cell anemia)
Multi-resistant bacteria
Antibiotic allergies
47. AOM – When to refer?
1) Suspicion of hearing loss or history of
language delay
2) Persistent more than 3-4 months
3) Persistent TM retraction or atelectasis
4) All children with cleft palate, Down
syndrome or craniofacial malformations
(earlier than later)
50. causes
Barotrauma principally results from air travel
or scuba diving
Maximum changes in gas volume occur during
first 10m of descent and 1000m altitude
Scuba divers descending beyond 30 feet must
undergo decompression stages during ascent
51. causes
Greatest chance in shallow dives and low
flying non pressurised aircrafts
Injuries are less pronounced in air
travellors than divers
52. BAROTRAUMA
Pathogenesis
Closed by tympanic membrane laterally
Middle ear is a bony cavity
Blood vessels represent ambient pressure
Eustachian tube equalises the pressure
55. EXTERNAL EAR BAROTRAUMA
Reverse ear , external ear squeeze,
Reverse ear squeeze
Causes : cerumen, foreign body,
exostoses, ear plugs
Occurs when a pocket of air is trapped in
external meatus
56. EXTERNAL EAR BAROTRAUMA
Pathogenesis
Normal eustachian tube function
Increasing compression
Increase in middle ear press.
Relative negative ex. Ear press
57. EXTERNAL EAR BAROTRAUMA
Pain increasing with depth
Injection and petechial hemorrhages in
canal skin or TM
Tympanic membrane perforation
Treatment : To address causative factor
decompression
To avoid occclusive ear plugs
To modify diving hood
58. MIDDLE EAR BAROTRAUMA
Barotitis media, middle ear squeeze
Most common form of barotrauma
Transient evidence in 5% of adults and
25 % of children
Pathogenesis
59. MIDDLE EAR BAROTRAUMA
Clinical features
Sensation of blocked ear
Desire to equalise
Otalgia
Sudden severe pain ( TM perforation )
Vertigo ( caloric vertigo )
Decreased hearing
62. MIDDLE EAR BAROTRAUMA
Treatment
Serial PTA and tympanometry to monitor
resolution
Type I Symptoms,
no signs
To avoid air travel or
diving for 24-48 hrs
Type II Signs + Oral or topical
decongestants
To avoid diving till symp.
Subside ( 7- 21 days )
Type III perforation Observation +/_
myringoplasty
Oral or topical
decongestants
63. MIDDLE EAR BAROTRAUMA
Prevention
Equalisition maneuver every 1-2 feet of
descent
Oral decongestants for mild Eustachian
symptoms before flying
Not recommended in divers
Nasal balloon inflation
Myringotomy with grommet insertion
64. Inner ear barotrauma
Pathogenesis
Relative negative middle ear pressure
Inward movement of TM
Inward push of stapes foot plate
Bulge of round window membrane into middle ear
Rupture of round window membrane at a
pressure difference of 120 -300mmHg
Facilitate by a forced valsalva
66. Inner ear barotrauma
Inner ear hemorrhage
Minimal and transient vestibular symptoms
Mild sensorineural hearing loss
Good recovery
67. Inner ear barotrauma
Labyrinthine tears
Closely resembles acute menier’s disease attack
Temporal bone studies reveal
hemorrhage around reissner’s and round
window membrane
rupture of utricle and saccule
reissner’s membrane rupture
68. Inner ear barotrauma
Labyrinthine tears
Presents with sudden onset vertigo ,
tinnitus and low frequency hearing loss
(1-2kHz)
Hearing loss is permanent
May be associated with perilymph fistula
69. Inner ear barotrauma
Perilymph fistula
0.5 % of divers suffer
Should be differentiated from inner ear
decompression illness
Recognized after surfacing in divers
70. Inner ear barotrauma
Perilymph fistula
Asociated evidence for middle ear barotauma
Nonotological symptoms
Complete neurological examination
Romberg s test, unterberger’s step test and side
step test to be done
71. Inner ear barotrauma
Perilymph fistula
Fluctuating or rapidly progressive SNHL
Positive hennebert sign
Disequilibrium with loud noise or physical
exertion
Positional nystagmus
Constant disequilibrium of varying severity
between episodes of vertigo
72. Inner ear barotrauma
Perilymph fistula
fistula test
with siegel speculum- 25 to 40%
with tympanometry-90%
Performed along with electronystagmography
CT or MRI – intralabyrinthine air,fluid in middle ear or
mastoid, fluid in round windom niche
73. Inner ear barotrauma
Perilymph fistula – treatment
Depends on severity of presenting hearing loss
failure of vestibular symp. to resolve
Conservative : bed rest
head end elevation
avoidance of straining, coughing
steroids
monitored with daily audiometry
to avoid diving
74. Inner ear barotrauma
Perilymph fistula – treatment
Surgical results are good for vestibular symp. And
poor for hearing improvement
Indications : progressive hearing detoriation
persistent vestibular symp.after 5 days
failure of complete resolution after 1mon
75. Inner ear barotrauma
Perilymph fistula
Vein graft is material of choice
Identification of fistula site
trendelenberg position
intrathecal or iv flourescein – not useful
endoscopic technique
retrospective β- transferrin assay
Fistula not identified – graft placed in round
window and over foot plate
Ossicular surgery should be staged
Tympanic membrane defect can be repaired
Hinweis der Redaktion
A= randomized control trial
C: Observational trials
