Diseases of the middle ear Diseases of the middle ear and eustachian tube and eustachian tube

Yard.Doç.Dr.Müzeyyen DoğanYard.Doç.Dr.Müzeyyen Doğan

Otitis MediaOtitis Media

Most common reason for visit to Most common reason for visit to pediatricianpediatrician

Tympanostomy tube placement is Tympanostomy tube placement is 2nd most common surgical 2nd most common surgical procedure in childrenprocedure in children

Development of multidrug-resistant Development of multidrug-resistant bacteria bacteria

Otitis Media - HistoryOtitis Media - History

Egyptian mummies have perforations Egyptian mummies have perforations of TM and mastoid destructionof TM and mastoid destruction

Prehistoric Iranian population has Prehistoric Iranian population has evidence of middle ear diseaseevidence of middle ear disease

Middle Ear StructuresMiddle Ear Structures

1- Malleus1- Malleus

2- Incus --2- Incus --OssiclesOssicles

3- Stapes 3- Stapes

4- Tympanic 4- Tympanic Membrane Membrane (Eardrum)(Eardrum)

5- Round Window5- Round Window

6- Eustachian Tube6- Eustachian Tube

Middle Ear StructuresMiddle Ear Structures

1- Malleus1- Malleus

2- Incus --2- Incus --OssiclesOssicles

3- Stapes 3- Stapes

4- Tympanic 4- Tympanic Membrane Membrane (Eardrum)(Eardrum)

5- Round Window5- Round Window

6- Eustachian Tube6- Eustachian Tube

Eustachian TubeEustachian Tube

Connects middle ear and Connects middle ear and nasopharynxnasopharynx

Lumen shaped like two cones with Lumen shaped like two cones with apex directed toward middleapex directed toward middle

Mucosa has mucous producing cells Mucosa has mucous producing cells and ciliated cellsand ciliated cells

Eustachian tubeEustachian tube

AdultsAdults ant 2/3- ant 2/3-

cartilaginouscartilaginous post 1/3- bonypost 1/3- bony 45 degree angle45 degree angle isthmus 1-2 mmisthmus 1-2 mm nasopharyngeal nasopharyngeal

orifice 8-9 mmorifice 8-9 mm

ChildrenChildren longer bony portionlonger bony portion 10 degree angle10 degree angle isthmus largeristhmus larger nasopharyngeal nasopharyngeal

orifice 4-5 mm in orifice 4-5 mm in infantsinfants

Eustachian tubeEustachian tube

Usually closedUsually closed Opens during swallowing, yawning, Opens during swallowing, yawning,

and sneezing and sneezing Opening involves cartilaginous portionOpening involves cartilaginous portion Tensor veli palatini responsible for Tensor veli palatini responsible for

active tubal openingactive tubal opening No constrictor functionNo constrictor function

Eustachian tubeEustachian tube

Protection from nasopharyngeal Protection from nasopharyngeal sound and secretionssound and secretions

clearance of middle ear secretionsclearance of middle ear secretions ventilation (pressure regulation) of ventilation (pressure regulation) of

middle earmiddle ear

PathologyPathology

Edema, capillary engorgement, and PMN Edema, capillary engorgement, and PMN infiltrationinfiltration

Epithelial ulceration and granulation Epithelial ulceration and granulation tissuetissue

Fibrosis, influx of chronic inflammatory Fibrosis, influx of chronic inflammatory cellscells

Increased columnar and goblet cellsIncreased columnar and goblet cells OsteitisOsteitis Edema and polypoid changesEdema and polypoid changes

Otitis Media - DefinitionOtitis Media - Definition

Inflammation of the middle Inflammation of the middle earear

May also involve inflammation May also involve inflammation of mastoid, petrous apex, and of mastoid, petrous apex, and

perilabyrinthine air cellsperilabyrinthine air cells

Otitis Media - ClassificationOtitis Media - Classification

Acute OM - rapid onset of signs & sx, Acute OM - rapid onset of signs & sx, < 3 wk course< 3 wk course

Subacute OM - 3 wks to 3 mosSubacute OM - 3 wks to 3 mos Chronic OM - 3 mos or longer Chronic OM - 3 mos or longer

OM - EpidemiologyOM - Epidemiology

AgeAge RaceRace Day careDay care SeasonsSeasons

GeneticsGenetics Breast-feedingBreast-feeding Smoke exposureSmoke exposure Medical conditions Medical conditions

OM - EpidemiologyOM - Epidemiology

Increasing incidence?Increasing incidence? Increases after newborn periodIncreases after newborn period 2/3 with AOM by one year of age2/3 with AOM by one year of age 1/2 with >3 episodes by three years1/2 with >3 episodes by three years most common in 6 - 11 mos most common in 6 - 11 mos

OM - persistent middle ear OM - persistent middle ear effusion (MEE)effusion (MEE)

High incidence of MEE, avg of 40 High incidence of MEE, avg of 40 daysdays

Children less that 2 years much more Children less that 2 years much more likely to have persistent MEElikely to have persistent MEE

White children with higher incidence White children with higher incidence of MEEof MEE

Otitis Media - RaceOtitis Media - Race

Higher incidence in:Higher incidence in: EskimosEskimos Native AmericansNative Americans Australian and African aboriginesAustralian and African aborigines

OM - Day Care OM - Day Care

Greater risk of AOM in children < 3 Greater risk of AOM in children < 3 yearsyears

Home care best, large group day care Home care best, large group day care worstworst more exposures with wider range of floramore exposures with wider range of flora increased URI’sincreased URI’s more frequent visits to MD to decrease more frequent visits to MD to decrease

parental leave time from workparental leave time from work

OM - Breast-feedingOM - Breast-feeding

Decreases incidence of URI and GI Decreases incidence of URI and GI diseasedisease

Inverse relationship between Inverse relationship between incidence of OM and duration of incidence of OM and duration of breast-feedingbreast-feeding

Protective factor in breast-milk?Protective factor in breast-milk?

OM - smoke exposureOM - smoke exposure

Induces changes in respiratory tractInduces changes in respiratory tract Increased otorrhea, chronic and Increased otorrhea, chronic and

recurrent AOM in children with hx of recurrent AOM in children with hx of parental smokingparental smoking

OM - Medical ConditionsOM - Medical Conditions

Cleft palateCleft palate decreases after decreases after

repairrepair Craniofacial Craniofacial

disordersdisorders Treacher-CollinsTreacher-Collins

Down’s syndromeDown’s syndrome Ciliary dysfunctionCiliary dysfunction

Immune dysfunctionImmune dysfunction AIDSAIDS steroids, chemosteroids, chemo IgG deficiencyIgG deficiency

ObstructionObstruction NG tubesNG tubes NT intubationNT intubation adenoidsadenoids malignancymalignancy

PathologyPathology

Eustachian tube abnormalitiesEustachian tube abnormalities Impaired openingImpaired opening shorter tubeshorter tube

Impaired immunityImpaired immunity children have poorer immune responsechildren have poorer immune response less cytokines in nasopharynx in children with OMless cytokines in nasopharynx in children with OM

Inflammatory mediatorsInflammatory mediators Bacterial products induce inflam response with IL-1, Bacterial products induce inflam response with IL-1,

IL-6, and TNFIL-6, and TNF AllergyAllergy

MicrobiologyMicrobiology

S. pneumoniaeS. pneumoniae - 30-35% - 30-35% H. influenzaeH. influenzae - 20-25% - 20-25% M. catarrhalisM. catarrhalis - 10-15% - 10-15% Group A strep - 2-4%Group A strep - 2-4% Infants with higher incidence of gram Infants with higher incidence of gram

negative bacillinegative bacilli

VirologyVirology

RSV - 74% of middle ear isolatesRSV - 74% of middle ear isolates RhinovirusRhinovirus Parainfluenza virusParainfluenza virus Influenza virusInfluenza virus

Chronic MEE Chronic MEE

Previously thought sterilePreviously thought sterile 30-50% grow in culture30-50% grow in culture over 75% PCR +over 75% PCR + Usual organismsUsual organisms

DiagnosisDiagnosis

Acute OMAcute OM preceding URIpreceding URI fever, otalgia, fever, otalgia,

hearing loss, hearing loss, otorrheaotorrhea

may have assoc may have assoc constitutional sxconstitutional sx

Chronic MEEChronic MEE poss asymptomaticposs asymptomatic hearing losshearing loss ““plugged”plugged” ““popping”popping”

DiagnosisDiagnosis Pneumatic otoscopy is Pneumatic otoscopy is

gold standardgold standard Color - opaque, yellow, Color - opaque, yellow,

blue, red, pinkblue, red, pink Position - bulging, Position - bulging,

retractedretracted Mobility - normal, Mobility - normal,

hypomobile, neg pressurehypomobile, neg pressure Assoc pathology - perfs, Assoc pathology - perfs,

cholesteatoma, cholesteatoma, retraction pocketsretraction pockets

Head & neck examHead & neck exam

DiagnosisDiagnosis

AudiogramAudiogram document CHL, SNHL, baseline, preopdocument CHL, SNHL, baseline, preop sooner if high risksooner if high risk

ImpedanceImpedance Acoustic reflexesAcoustic reflexes

Treatment - AOMTreatment - AOM

Adults and older children - Adults and older children - observation?observation?

Antibiotics - consider drug resistance Antibiotics - consider drug resistance patternspatterns Amoxil - not for Amoxil - not for BB lactamase + lactamase + TMP-SMT - not for group A strepTMP-SMT - not for group A strep Need high middle ear concentrationsNeed high middle ear concentrations

AntibioticsAntibiotics

First lineFirst line Amoxil - 60-90 mg/kg divided tidAmoxil - 60-90 mg/kg divided tid Ceftin - B lactam stableCeftin - B lactam stable Augmentin - B lactam stableAugmentin - B lactam stable Bactrim, PediazoleBactrim, Pediazole

Second lineSecond line AugmentinAugmentin CeftinCeftin RocephinRocephin Macrolides - Zithromax, BiaxinMacrolides - Zithromax, Biaxin

Treatment - Recurrent AOMTreatment - Recurrent AOM

ChemoprophylaxisChemoprophylaxis Sulfisoxazole, amoxicillin, ampicillin, pcnSulfisoxazole, amoxicillin, ampicillin, pcn less efficacy for intermittent propylaxisless efficacy for intermittent propylaxis

Myringotomy and tube insertionMyringotomy and tube insertion decreased # and severity of AOMdecreased # and severity of AOM otorrhea and other complicationsotorrhea and other complications may require prophylaxis if severemay require prophylaxis if severe

AdenoidectomyAdenoidectomy 28% and 35% fewer episodes of AOM at first and 28% and 35% fewer episodes of AOM at first and

second yearssecond years

Treatment - OMETreatment - OME

MEE > 3 mos or assoc hearing loss, MEE > 3 mos or assoc hearing loss, vertigo, frequency, ME pathology, vertigo, frequency, ME pathology, discomfortdiscomfort

AntibioticsAntibiotics shown to be of benefit, 75% PCR + bacterial DNAshown to be of benefit, 75% PCR + bacterial DNA

Antibiotics + steroidAntibiotics + steroid 21% improvement compared to abx alone21% improvement compared to abx alone

Myringotomy & tympanostomy +/- Myringotomy & tympanostomy +/- adenoidectomyadenoidectomy

Tympanostomy tube Tympanostomy tube insertioninsertion

Recurrent MEE with excessive Recurrent MEE with excessive cumulative durationcumulative duration

Recurrent AOM - >3/6 mos or >4/12 Recurrent AOM - >3/6 mos or >4/12 mosmos

Eustachian tube dysfunctionEustachian tube dysfunction Suppurative complicationSuppurative complication

ComplicationsComplications IntratemporalIntratemporal

hearing losshearing loss TM perforationTM perforation CSOMCSOM retraction pocketsretraction pockets cholesteatomacholesteatoma mastoiditismastoiditis petrositispetrositis labyrinthitislabyrinthitis adhesive OMadhesive OM tympanosclerosistympanosclerosis ossicular dyscontinuity and ossicular dyscontinuity and

fixation fixation facial paralysisfacial paralysis cholesterol granulomacholesterol granuloma necrotizing OEnecrotizing OE

IntracranialIntracranial meningitismeningitis extradural abscessextradural abscess subdural empyemasubdural empyema focal encephalitisfocal encephalitis brain abscessbrain abscess lateral sinus thrombosislateral sinus thrombosis otitic hydrocephalusotitic hydrocephalus

adhesive OMadhesive OM

TM perforationTM perforation

CSOMCSOM (dry) (dry)

CSOMCSOM

cholesteatomacholesteatoma

tympanosclerosistympanosclerosis