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Otitis Media
Dr John Curotta
Head of ENT Surgery
The Children’s Hospital at Westmead
What is Otitis Media?• AOM = Acute OM
• OME = OM with Effusion (= ‘glue ear’)
• CSOM = Chronic Suppurative Otitis
Media ( = a hole in the ear drum
which discharges)
Ear drum without a hole
2 types of fluid in middle ear:
• 1. Pus -> Acute OM = AOM
• 2. Mucous -> Effusion = OME
Ear drum with hole ( >6 weeks)
1. Simple hole: connects outer ear to mucous making lining of middle ear
(“like a nostril”) usually dry, but sometimes runny. = “SAFE’ ear
2. Hole with skin of ear drum growing in
= “UNSAFE” ear
“UNSAFE” ear Also called:
• CHOLESTEATOMA
• Chol est e at oma
• ‘Kol-est-ee-at-oma ‘
• Means skin growing into ear, not out
What is ‘UNSAFE’ about skin growing in ?
• Skin is not normally in the ear and mastoid • Lowest layer of skin makes an enzyme which
eats away the bone• This erodes Bones of hearing Bone covering inner ear Bone between ear and brain
Deaf – Dizzy – Brain Abscess
What makes you suspect an UNSAFE ear ?
• Persistent discharge
• The SMELL……Sneakers taken off after a week in the wet.
• That is ..soggy dirty mouldy skin…
Cholesteatoma• ALWAYS needs surgery
• Surgery: delicate / long / often repeated
(very little pain and discomfort) !
‘Remote’ KidsUsually get early on :
• ‘Safe’ Hole in ear drum ------
• Often Runny ears
Northern Territory OM Survey 2007
1300 children, 6 mo – 30 months old
• 25% AOM
• 5% AOM + perforation
• 15% CSOM
• 10% had completely normal ears.
NT OM Survey 2007
By 6 months age 98% OME
By 12 months age
• 90 % AOM
• 35% AOM + Perforation
• 20% CSOM
‘Town’ and ‘city’ Kids• Usually get what any other town/city
kids get…….Glue ear.
• BUT because it is a hidden condition -
…….may NOT get diagnosed !
Job of Nurses for Ears 1. Runny ears: DRY the runny ears Maximise hearing Optimise learning
2. Glue ears: DIAGNOSE Maximise hearing Optimise learning
RISK factors for Otitis Media
• Boys
• Brother/sister with OM
• Early start to AOM (<6mo)
• Not breast fed
• Poor housing
• Smoker at home
PREVENTION
Vaccination against Strep pneumoniae
(pneumococcus)• PREVENAR works under 2 yrs age
• PNEUMOVAX works after 2 yrs age
• ( Hib – ‘Haemophilus influenzae Type b’ vaccine is NO good for ears as they get ‘H influenzae Non-typeable )’
Pneumococcal Vaccination“PREVENAR”
• 239,000 operations for grommets in Australia in past 10 years
• Since Prevenar introduction in 2005 grommets reduced by: <1 yr…23% 1-2 yrs..16% 2-3 yrs.. 6%
Study effect early Pn Vaccination
‘Remote’ NT Kids - 2009• Minimal benefit in reduction Otitis Media
(unlike town/city kids)
Probably need• Pneumococcal vaccine with wider spread• Vaccine for Haemophilus infections of ears• Vaccinate mothers
Diagnose ‘GLUE Ear’
• SCREEN
vs
• SUSPECT
Aim of NSW Otitis Media Strategy
• is to screen all kids
• Eliminates guesswork
• But: Do they all get screened?
Hearing Testing
Tiny Tots
• SWISH for all newborns• NSW 99% cover ….Who is most likely to miss out ?Usual Tymps: unreliable under 6 months
Hearing Testing
Baby – to - 4 yrs old
VROA / Behavioural…test overall /
better ear hearing
Usual Tymps: ‘Reliable’
Hearing Testing
• Over 4 yrs
• PTA + Tymps generally reliable
AOM = pus in middle ear
• Body’s immune +/- antibiotics kill bacteria BUT the mucous can take weeks to clear out
POM = Fluid in ear since infection
• POM : “Persisting” Otitis Media
i.e. after AOM, up to 12 weeks
Once fluid is there > 12 weeks,
Then call it : OME or ‘Glue ear’
Fluid in middle ear
AOM POM OME
0 weeks >12 weeks
Benefit of Hearing Testing
• Learning to talk
vs
• Learning in classroom
Hearing under 4-5 years
• One ear is enough to learn to talk and to get along at home
• So ‘general’ tests of hearing are OK
Hearing, over 4-5 yrs
• Unilateral OR Bilateral HL : very important to diagnose
• Poor hearing even in ONE ear is a major problem in classroom
Hearing over 5 yrs• This means at school
• Absolutely need both ears hearing
Unilateral hearing Loss• Very serious problem in class room
• Placement
• Background noise
• Direction
• Anything other than one-to-one talking
Grommets - time working
• Small: Shepard………………6 mo
• Medium: Reuter Bobbin………12 mo
• Large: Sheehy Collar Button.18 mo
• Larger: T – Tubes……………24 mo +
The bigger the grommet
• The longer it stays
• The bigger the risk of a larger perforation
• So, NO T-tubes in children
Grommets• The GOOD
• The BAD
• The UGLY
Grommets- The GOOD• Instant relief
• Consistent relief
• Helps balance too
• Reduces AOMs as well
Grommets-The BAD• Need admission to hospital
• Waiting list
• General anaesthetic
• How long effective
• Repeat grommets
Grommets-The UGLY• Limit water exposure - e.g. swimming
• Discharging grommet a problem
Social / hearing / extrude grommet
• Residual perforations, esp if large large > 20% area TM (large is bad)
in between…….(nuisance)
small < 10% area TM (small is good ! )
If not grommets – What ?
• Seating position……….counting chooks
• FM System
• Hearing Aid/s
• Room amplification
Looking after grommets
• Its not the water
• It’s the GERMS in the water
Looking after grommets
• Clean water…OK shower, beach, well-maintained pool (Chlorine : High end +
pH : Low end of range)Some Remote WA - No School…No Pool
Looking after grommets
AVOID• Bath water• Spa’s• Indoor heated pools• Creeks OR USE• Ear plugs and cap / head band
Infected grommets• Foreign material in the body - if infected
gets covered in “slime”
• Called “BIOFILM”
• Like the inside of water pipes etc
• Also plaque on teeth / infected catheters/ IV cannulas etc
BIOFILM• Bacteria exude a jelly to cover
themselves
• So, antibiotics cannot reach them
• To clean biofilm – must mechanically break it up – brush it / scrub it
If not possible – remove the device.
Discharge through Grommets ..How?
• Head cold Virus: Increase secretion in nose / sinuses / ears
• Secondary bacterial infection (like AOM)
• Overflow through grommet
Discharge through Grommets ..How?
• If virus…dries up when nose dries up
• If bacterial.. May / may not dry up with nose….
Antibiotic medicine or capsules (eg Amoxil) helps
Discharge through Grommets ..How?
• Bacteria which live on skin in outer ear can get into middle ear through the mucous discharge…..(pseudomonas) ..these are resistant to most oral antibiotics … Need DROPS
Ear Drops for Grommets
• Ciprofloxacin (= Ciloxan / Ciproxin HC) is always safe in ears
• Sofradex usually safe in infected ears
• Sofradex is unsafe in clean ears
Ear Drops for wax• 1. Sodium Bicarbonate Ear drops
( chemist makes them up) • 2. Waxsol drops• 3. Ear Clear Drops for Wax Removal
Then syringe. Never Cerumol - too harsh
Discharge through grommets
• If so much discharge ear drops cannot get in
• Use 3% Hydrogen Peroxide as drops first, to clean the ear, dab dry and then put in drops. (only for a day or so at a time)
(probably is breaking up Biofilm)
Wax or discharge in Ears
Gently syringe with dilute baby shampoo 1/2 teaspoonful in 1 cup warm water (= 1%) (or 1 tsp in 500ml)
• Finish by syringing Betadine (1 tsp in 100ml)
10 ml syringe with a cut-off scalp vein needle
Safe in perforations or grommets
References• Aboriginal Ear Health Manual – Harvey
Coates et al from WA
• Aboriginal Otitis Media ENT Program Evaluation Report 2002“
• Surgical Management of Otitis Media with Effusion in children” – Clinical Guideline, February 2008 - UK