ENT: Otitis Media

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Otitis Media
Definition: "otitis media' means inflammation of the middle ear ,Eustachian tube and mastoid air cell.
Most common among children of low socio economic status following a URTI
Classification:
1 . Acute otitis media

·        Non suppurative (including barotrauma) 
·        Suppurative
2.   Chronic otitis media
·        non suppurative
a.      otitis media with effusion
b.     adhesive otitis media
c.      tympanosclerosis
·        suppurative
3.   Specific type of otitis media (tuberculosis, syphilis, diptheria)
Otitis media with effusion (OME)

 Synonyms: secretory otitis media, serous otitis media, glue ear, seromucinous otitis media
·        insidious onset of accumulation of non purulent effusion in the middle ear without any pyogenic organisms involvement.
·        effusion is thick and viscid or thin or serous
·        fluid is nearly sterile
·        commonly seen among 5-8 years of age
Etiology
      the exact etiology is not known.
      tubal occlusion: in children enlargements of the adenoids and any infection in the nose or throat
      allergy: can cause mucosal edema of the eustachian tube orifice
      hypogammaglobulinemia: predisposes to inflammatory response because of low immune  status.
Pathogenesis
·        increased secretory activity of middle ear mucosa
·        malfunctioning of Eustachian tube
·        if the Eustachian tube does not open and allow equalization of pressure, negative pressure within the middle ear causes fluid to seep from the tissue.
 clinical manifestation:

·        feeling of fullness in ear  
·        hearing loss
·        delayed or defective speech
·        mild ear aches
·        client does not experience pain. Fever, or discharge from ear.
Diagnosis:

·        TM appears as yellow, gray, or bluish in colour
·        fluid level and bubbles may seen when TM is transparent
·        Tuning fork tests:

a.      Rinne test- negative on the affected side
b.     Weber test- lateralization to the affected side
·        Absolute bone conduction- normal
·        plain x-ray — paranasal sinuses, hypertrophied adenoids  
 hypertrophied adenoids  
·        audiometry: conductive hearing loss
Treatment:
Non surgical

·        decongestants
·        anti-allergy treatment antihistamines
·        antibiotics
·        middle ear aeration: by valsalva maneuver and chewing gum to encourage frequent swallowing
Surgical
·        Myringotomy and aspiration of fluids

·        Grommet insertion (tympanostomy or ventilation tubes)
·        surgical management of the causative factors: (adenoidectomy, tonsillectomy etc.)
Otitic barotrauma

Damage that results from failure of the Eustachian tube to equalize air pressure on either side of the tympanic membrane, occurs most commonly during descent from high altitude in an aircraft or descent in under water diving.
Causes:

·        air travel while there is a functional problem with ET tube e.g., URTI   
·        sleep during descent of an aircraft from high altitude
·        in- flight, alcohol leading to sleep thus causing et muscle relaxation
·        patient undergoing hyperbaric O2 therapy in decompression chamber
Signs and symptoms
·        pain
·        swishing sensation in ear on movement
·        hearing loss      
·        tinnitus            
·        erythema of tympanic membrane
·        sensation of wooliness in ear         
·        haemorrhages on tympanic membrane
·        in severe cases- rupture of tympanic membrane 
Treatment
      Prevention is by:    
·        the effusion of barotrauma tends to resolve spontaneously in 6 weeks usually
·        avoiding air travel during URTI     
·        topical nasal decongestants
·        avoidance of alcohol on the journey 
·        topical and systemic decongestants 
·        myringotomy and ventilation tube insertion

Acute suppurative otitis media (ASOM)

·        acute onset of symptoms, evidence of a middle ear effusion, and signs or symptoms of middle ear inflammation by pyogenic organism.
·        it is an acute suppurative inflammation of the periosteal layer of the middle ear clef by suppurative organisms.
·        commonly seen in children
Etiological factors:
·        Streptococcus pneumoniae                     
·        Staph aureus
·        Haemophilus influenza
·        Pseudomonas aeruginosa
·        Streptococcus pyogens
·        Moraxella catarrhalis
risk factors:                       
·        upper respiratory infections                    
·        craniofacial abnormalities (cleft palate)
·        allergies  
·        recurrent common cold
·        infections of tonsils and adenoids           
·        blood borne infections- rare
·        traumatic perforation
Causes (young children)
·        Eustachian tube is narrow, stiff,  shorter and somewhat flat 
·        exposure to cigarette smoke
·        bottle feeding (bottle at night, nap time)
·        direct route for bacteria and viruses
·        easier to get blocked            
·        day care (kid-to-kid)  
·        immune system not fully developed
Pathophysiology & clinical manifestation
Stage I- stage of hyperaemia
The mucosa in the middle ear and the ET will get congested because of invasion by microorganisms
The hyperaemia may extend to the antrum and mastoid region        
CM:
·        otalgia- mild to moderate
·        fever
·        obstruction or fullness of the ear
·        deafness
·        associated symptoms- running nose, nasal obstruction 
·        tympanic membrane- congested
Stage II- stage of exudation
In addition to hyperemia, there will be collection of the exudate in the middle ear cavity
CM
·        pain will increase
·        blocking sensation of the ear will increase
·        Deafness increases
·        Tympanic membrane- thick, congested, bulging
Stage III- stage of suppuration
The collected exudate in the middle ear will increase producing tension on the tympanic membrane
Produces pressure necrosis in the pars tensa of the TM leading to a small central perforation ear starts draining
CM:
·        pain is less, because of discharge
·        discharge — blood stained , serosanguinous, mucopurulent
·        TM- small central perforation
·        Lighthouse sign- pulsatile discharge present through the perforation       
·        x- ray mastóid- cloudy
Stage IV -coalescent mastoiditis/ surgical mastoiditis
There will be reinfection in the middle ear seen usually after a period 2 weeks after the previous stage series of pathological changes in the middle ear cleft leading to colescent of mastoid air cells  mastoid will be a bag of pus

CM:
·        Fever, high ESR
·        Ear ache increases
·        Mucopurulent discharge
·        Deafness will increase
·        Mastoid tenderness
·        Reservoir sign- copious and continuous discharge which reappears immediately after wiping
·        Cardinal sign- sagging of the posterior superior meatal wall

Stage V- stage of complications
·        If virulence of organism is higher
·        Resolution may not takes place
·        Disease spread beyond middle ear by erosion of bone or by hyperemic decalcification or thromboembolic phenomena

Complication:
Extra cranial
Intracranial
Stage VI- Stage of resolution
·        As resistance of the host overtakes the virulence of the organism or because of proper antibiotic therapy, the acute infection begins to subside
·        The first evidence of resolution will be cessation of ear discharge
Diagnosis:
·        Otoscopic examination: the tympanic membrane looks erythematic, opaque, bulging with loss of anatomic landmarks
·        Pneumatic otoscopy: decreased tympanic membrane mobility

·        impedance tympanometry: measures the resonance of the ear canal for a fixed sound as the air pressure is varied.
·        Diagnostic tympanocentesis: involves puncturing the tympanic membrane and aspirating  middle ear fluid to relieve pressure. 

TREATMENT
Nonsurgical
·        antibacterial therapy- broad spectrum
·        decongestant nasal spray: ephedrine, otrivin
·        nasal drops
·        analgesics and antipyretics
·        dry local heat
·        menthol/ tincture benzoin steam inhalation
·        aural toilet- dry mopping or suction cleaning
Surgical
·        Myringotomy
·        Cortical mastoidectomy and drainage of pus

·        tympanostomy tube: pressure equalization tubes (PE tubes)  
v slit in eardrum
v drain fluid in ear
v place tube in ear (usually bilaterally)
v tube ventilates and equalizes pressure in middle ear, and subsequently will normalize hearing

Complications
·        hearing loss: conductive, sensoneural, mixed
·        acute mastoiditis
·        chronic perforation of the TM
·        tympanosclerosis
·        chronic suppurative OM
·        facial nerve paralysis (bell's palsy)
·        Cholesteatoma

·        intracranial complications- bacterial meningitis, epidural abscess, brain abscess, otitic hydrocephalus, lateral sinus thrombosis
Acute necrotizing otitis media
·        is a special form of ASOM
·        occurs mostly in infants and young children suffering from scarlet fever, measles, pneumonia, influenza, or systemic illness
·        there is an early necrosis and destruction of most of the tympanic membrane
·        TM usually shows a total perforation with foul smelling purulent discharge
·        necrotic ossicles may be seen
Chronic suppurative otitis media(CSOM)
·        it is a long standing infection of a part or whole of the middle ear characterized by ear discharge and a permanent perforation
·        Incidence will be more in developing country
·        low socio economic status  
·        poor nutrition
Pathology:
•     it is the sequela of acute otitis media leaving behind a large perforation
•     the perforation becomes permanent and permits repeated infection from external ear
Types
·        tubotympanic type or safe type
·        attico — antral or dangerous type

tubotympanic type —
etiology:
1 . Predisposing factors:
·        inadequate/ improper treatment of ASOM
·        infection from surrounding areas like nose, nasopharynx & oropharynx  
·        diseases like tuberculosis
·        pneumatization of mastoid- sclerotic mastoid are more prone
2. Exciting factors:
·        gram negative oreamsms like pseudomonas, proteus, E Coli.
·        streptococcus
·        staphylococcus
Symptoms:
Discharge: profuse, intermittent, predominantly mucoid, non foul smelling, whitish/ yellowish and tenacious.
·        It increases with attacks of cold
·        Depending on the discharge it is divided into four stages:
·        Active -actively discharging at the time of clinical examination
·        quiescent- no ear discharge for less than 3 to 6 months period
·        inactive — no ear discharge for more than 6 months
·        healed- central perforation has healed
2.   Deafness- mild conductive
3.   Ear ache- if associated with otitis externa
Diagnosis
*    culture & sensitivity of the discharge
*    examination under microscopy
*    pure tone audiogram
*    x- ray mastoids, paranasal sinuses, soft tissue neck
  *  diagnostic nasal endoscopy
  Patch test-
·        examination under microscopy
·        base line audiogram
·        perforation closed with cigarette foil
·        repeat audiogram
*    improved hearing (intact ossicular chain)  
* decreased hearing (discontinuity)
*    no improvement (technical fault)
Treatment
 Medical management
·        Aural toilet
·        dry mopping/ wet mopping
·        suction and cleaning
·        antibiotics (based on c/s report)
·        topical antibiotics
·        Systemic antibiotics
Surgical treatment
aural polypectomy
meringoplasty- if hearing loss is below 40 db
tympanoplasty- if hearing loss is above 40 db
 mastoidectomy:
precipitating disease: adenoid/ tonsil/ DNS/ nasal polyps/ sinus wash 


Attico- antral or dangerous type
It is usually associated with cholesteatoma formation
Suggested  Further Readings :-


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notes.nursium.com: ENT: Otitis Media
ENT: Otitis Media
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