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Otitis Media

Dr. Yasser Shewel

Definition Inflammation of the mucoperiosteal lining of the middle ear cleft (Eustachian tube, tympanic cavity, mastoid antrum and mastoid air cell).

Mastoid

Middle Ear

Classification
Acute otitis media: Acute viral (non suppurative) otitis media. Acute suppurative otitis media. Acute Necrotizing otitis media. Chronic otitis media:
Nonspecific:

Chronic suppurative otitis media: Chronic non-suppurative otitis media Otitis media with effusion.

Chronic adhesive otitis media Tympanosclerosis Cholesterol granuloma Specific e.g. Tuberculous otitis media.

Acute Suppurative Otitis Media


Definition Acute inflammation of the mucoperiosteal lining of the middle ear cleft with reversible pathology

Incidence
Acute otitis media is primarily a disease of children. Its peak incidence is during the first 6 years of life.

Several factors contribute to the prevalence of acute otitis media media in early childhood. These include: Anatomical features of Eustachian tube : The Eustachian tube is
shorter, wider and more horizontal than in adults

The orifices of the tube are surrounded by lymphoid tissues. Frequent exposure to upper respiratory infections Immature immune system

Predisposing factors
poor socioeconomic conditions Crowding Bottle feeding malnutrition, immunodeficiency Passive Smoking Pollution Mucociliary disorders

Bacteriology
The common organisms include: Streptococcus pneumoniae, Moraxilla catarrhalis H. influenzae is more frequent during infancy and early childhood. Viral infection commonly precedes secondary bacterial invasion

Routes of infection
Through the Eustachian tubes: This is the commonest route. Through a drum perforation.

Pathophysiology ET blockage

2.

-ve pressure in ME

1.

ET blockage

Pathology The inflammatory process passes through continuous stages


Stage of tubal occlusion..> negative pressure in the middle ear Stage of catarrhal inflammation> The hyperemia and transudation Stage of suppuration Stage of Resolution: unless complications occur

Clinical picture Acute otitis media is frequently preceded by upper respiratory infection. Stage of tubal occlusion:
May be mild fever. Sense of fullness in the ear Earache. mild conductive hearing loss The tympanic membrane appears retracted, congested, and lusterless.

Stage of acute catarrhal otitis media:


Fever Fullness Increasing ear ache. Mild conductive hearing loss The tympanic membrane appears retracted, congested (especially the pars flaccida) + signs of fluid behind the tympanic membrane

Stage of acute suppurative otitis media (before rupture of tympanic membrane):


High fever. Severe throbbing pain. CHL The tympanic membrane markedly congested, bulging, first in the posterior half Later on a yellowish spot appears indicating impending rupture of tympanic membrane tenderness over the mastoid process (mastoidism). If it persists, it indicates bone involvement i.e.mastoiditis.

Stage of acute suppurative otitis media (after rupture of tympanic membrane):


Rapid relief of pain, fever and CHL. discharge Small central perforation. The perforation is frequently located in the anteroinferior quadrant but may be present anywhere in the pars tensa. If the perforation is small the discharge may appear pulsating,

Stage of resolution:
Resolution may occur with treatment or after perforation of the drum membrane.

Differential diagnosis
Other causes of otalgia Red tympanic membrane

Treatment: Before the perforation :


Antibiotic decongestant Antipyretic- analgesic preparations. Myringotomy ( when)

After the perforation of tympanic membrane


Antibiotics ( Culture and sensitivity of the discharge may be needed) Antibiotic ear drops. Decongestant Frequent cleaning of the ear. Myringotomy ( when)

Acute necrotizing otitis media


A severe form of otitis media occurring in ill, toxic children suffering from measles and other exanthemata. It is caused by virulent hemolytic streptococci

characterized by necrosis and sloughing of tissues>


Large tympanic perforation.> predisposes CSOM foul smelling discharge Increase the risk of complications

Treatment:
Frequent aural toilets (cleaning). Culture and sensitivity of the discharge. Systemic and local antibiotics. Treatment of sequels and complications e.g. tympanoplasty

Chronic non suppurative otitis media

1-Otitis Media with Effusion (OME)


synonyms: Secretory otitis media, Middle Ear Effusion (MEE).

Definition: It is the accumulation of fluid( non infectious , non suppurative) behind an intact tympanic membrane without symptoms and signs of inflammation

It is the most common cause of hearing loss in children. Age: Any, most frequently under 9 years. Laterality: Usually bilateral

Etiology:
Eustachian tube dysfunction (Most important cause). post otitis : non resolved acute otitis media due inadequate medical treatment

Causes of ET dysfunction. 1) Acute (Serous) middle ear effusion:


Occurs due to acute ET dysfunction which is commonly caused by: a) Otitic barotrauma. b) Acute allergy c) Acute viral upper respiratory tract infections.

2) Chronic (mucoid) middle ear effusion'. Occurs due to chronic ET dysfunction which can be: a) Mechanical obstruction:
i) Adenoids. ii) Nasopharyngeal Tumors

b) Functional obstruction: as in cleft palate.

Clinical Picture: 1-Symptoms


In children:
i) Hearing loss (noticed by the parents) :is usually the only complain. ii) Asymptomatic diagnosed during routine otoscopy.

In the adults
Hearing loss

Sense of fullness in the ear Tinnitus

2- otoscopy:
a) Tympanic membrane:
i) Is retracted as evidenced by:
(1) Handle of the malleus becomes more horizontal. (2) Lateral process of the malleus becomes more prominent. ii) Looks dull and opaque.

b) Behind the tympanic membrane, there may be:


i) Air-fluid level (Hair-line) ii) ii) Air bubbles (indicates that the fluid is serous).

3) Pneumatic of oscopy (Siegelization): Limited


mobility (Hallmark of the disease)

4-Investigations:
A) Tympanometry: Flat tympanogram (Type B) B) Stapedial reflex: Absent C) PTA: CHL

D) Investigations for the cause:


a) X-ray Nasopharynx in children to exclude adenoids b) CT scan Nasopharynx in adults with unilateral middle ear effusion to exclude Nasopharyngeal carcinoma c) Nasal endoscopy: to exclude nasal allergy or Nasopharyngeal carcinoma

Complications:
1. Recurrent ASOM. 2. Atelectasis - retraction pockets (usually posterosuperior) 3-Cholesteatoma. 4. Adhesive OM. 4. Tympanosclerosis 5- SNHL 6- Ossicular erosion

Treatment:
1} Medical treatment:
a) Antibiotics b) Steroids c) Mucolytic drugs d) Systemic decongestants. 2) ET inflation. Medical treatment should be at least for 3 months

2- Surgical treatment
a) Myringotomy with aspiration of fluid and insertion of ventilation tube b) adenoidectomy. c) Both Myringotomy with adenoidectomy( best) d) Cortical mastoidectomy to exenterate mastoid air cells( recurrent)

2) Middle Ear Atelectasis


Definition: Collapse of the lateral wall of the middle ear (tympanic membrane) on to the(medial wall (promontory).

Etiology:
Proteolytic enzymes in middle ear effusion destroy the middle fibrous layer of the tympanic membrane > retraction of the TM by the negative middle ear pressure created by the Eustachian tube obstruction

Pathology:
Four stages are described as follows: 1) Stage I: Mild retraction of the tympanic membrane. 2) Stage //.-Tympanic membrane is more retracted to be in contact with incudostapedial joint.

3) Stage III (Atelectatic stage): Tympanic


membrane is lying on but not adherent to the promontory (tympanic membrane moves if the patient performs Valsalva's manoeuver). 4) Stage IV (Adhesive stage): Tympanic membrane is adherent to the promontory
(it does not move on Valsalva's manoever).

Clinical picture: 1) C/0:Hearing loss.


2) Otoscopy reveals tympanic membrane abnormality according to the pathological stage

Treatment (depending on the stage):


1) Myringotomv and ventilation tube 2) Tympanoplasty: to reinforce the tympanic membrane by cartilage. Ossiculoplasty is performed if needed. 3) Hearing aid

3) Tympanosclerosis
Definition: It is deposition of calcified hyalinized collagen in the tympanic mucosa and / or in the tympanic membrane.

Clinical picture: 1-) C/0;


a) Hearing loss. b) The condition could be asymptomatic and discovered on routine otoscopy.

2) Otoscopy :
Chalky white patches in the TM (myringosclerosis) or in the middle ear (Tympanosclerosis

Treatment:
Myringosclerosis: No treatment if asymptomatic Tympanosclerosis:
Surgical removal or Hearing aid

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