Universisty Of Szeged Department of Otorhinolaryngology and Head-Neck Surgery
Nonsuppurative inflammations of the middle ear
János András Jarabin M.D. PhD. INFLAMMATION OF THE MIDDLE EAR
The inflammatory diseases of the middle ear are important because of their frequency and their life-threatening complications due to the close relationship between the middle ear and the cranial cavity. ICD-10 CODES
https://icd.who.int/browse10/2019/en#/H65-H75 ICD-10 CODES
https://icd.who.int/browse10/2019/en#/H65-H75 TYPES OF OTITIS MEDIA
• Nonsuppurative otitis media – Acute nonsuppurative otitis media • Acute tubotympanic catarrh • Acute serous otitis media • Otitic barotrauma – Chronic nonsuppurative otitis media • Chronic tubotympanal catarrh • Chronic serous otitis media • Suppurative otitis media – Acute suppurative otitis media – Chronic suppurative otitis media • Chronic tubotympanic suppurative otitis media (mesotympanal) • Chronic atticoantral suppurative otitis media (cholesteatoma) ACUTE TUBOTYMPANIC CATARRH = Eustachian tube catarrh
Pathophysiology • The acute and temporary disorder of the Eustachian-tube’s function and the consequential decrease in middle-ear pressure.
• The tympanic membrane is pressed towards the medial wall of the tympanic cavity (called „retracted tympanic membrane”) and therefore its vibration is damped.
Background: the epipharyngeal ostium of the Eustachian tube is blocked by the edema of the mucosa, due to rhinitis, rhinosinusitis, adenoiditis. ACUTE TUBOTYMPANIC CATARRH = Eustachian tube catarrh
▪ Symptoms – Pressure/fullness sensation in the ear – Mild tinnitus – Hearing loss (conductive type) ▪ Diagnosis – Otoscopy – Tympanometry ▪ Therapy – Decongestant nasal sprays can ease swollen nasal passages • E.g. xylometazoline (Novorin 0,1%); oxymetazoline (Nasivin 0,5mg/ml); tramazoline (Rhinospray Plus 1,265 mg/ml; etc.) – Valsalvamaneuver – Politzer-insufflation – Eustachian tube catheterization ACUTE SEROUS OTITIS MEDIA
= acute otitis media with effusion
decreased middle-ear pressure (± bacteria or virus with reduced virulence; allergy…etc.)
transsudation
(straw yellow, low viscosity, odourless discharge) ACUTE SEROUS OTITIS MEDIA
= acute otitis media with effusion ▪ Symptoms – Pressure/fullness sensation in the ear – Mild tinnitus – Hearing loss (conductive type) ▪ Diagnosis – Otoscopy – Tympanometry – Audiometry ▪ Therapy – Decongestant nasal sprays can ease swollen nasal passages • E.g. xylometazoline (Novorin 0,1%); oxymetazoline (Nasivin 0,5mg/ml); tramazoline (Rhinospray Plus 1,265 mg/ml; etc.) – Valsalvamaneuver – Politzer-insufflation – Eustachian tube catheterization ACUTE SEROUS OTITIS MEDIA otoscopoy
„retracted” tympanic the short process of the air bubbles are often membrane malleus promine, its present in the fluid behind handle apparently the tympanic membrane shortened ACUTE SEROUS OTITIS MEDIA
= acute otitis media with effusion
* • Audiometry – conductive hearing loss
BC: bone conduction
AC: air conduction
* ABG: air-bone gap ACUTE SEROUS OTITIS MEDIA
= acute otitis media with effusion
Tympanometry
- typical: C, Cround and B type OTITIC BAROTRAUMA AEROOTITIS sudden, expressed pressure drop within the tympanic cavity (usually when the aircraft lands)
▪ Sudden onset:
▪ tympanic membrane tenion ▪ tympanic cavity mucosal edema ▪ transsudation ▪ possibly bleeding OTITIC BAROTRAUMA AEROOTITIS ▪ Symptoms – Severe pain in the ear – Pressure and fullness sensation in the ear – Hearing loss (conductive type) ▪ Diagnosis – Otoscopy – Tympanometry – Audiometry ▪ Therapy – Decongestant nasal sprays can ease swollen nasal passages (before takeoff and LANDING) – Valsalva-maneuver – Politzer-insufflation – Eustachian tube catheterization – Preventive myringotomy (paracentesis) in unconcious patients Chronic nonsuppurative otitis media Chonic tubotympanal catarrh Chronic serous otitis media Chronic mucoid otitis media Glue ear
6 weeks < CHRONIC TUBOTYMPANIC CATARRH
Pathogenesis
• Long-lasting occlusion of the Eustachian tube, and the consequential decrease in middle-ear pressure.
• Edema of the mucosa, passive transsudation (straw yellow effusion)
• Mucosal metaplasia – accumulation of goblet cells
• Mixing of mucus with the transsudate - seromucosus exsudatum
• Formation of cholesterol granulomas CHRONIC TUBOTYMPANIC CATARRH
Pathogenesis: long-lasting Eustachian tube occlusion
• Nasal airway obstruction
– Adenoid vegetation
– Nasal septum deviation • Maxillary sinusitis, ethmoiditis, pansinusitis)
• Chronic rhinitis, allergic rhinitis
• Developmental disorders: cleft palate, choanal atresia
• Paralysis of the palatal muscles
• Nasopharyngeal tumors (endoscopy, fiberoscopy!!!)
CHRONIC TUBOTYMPANIC CATARRH
Symptoms
• Fullness and pressure sensation in the ear • Hearing loss (pure/dominantly conductive type) • Tinnitus CHRONIC TUBOTYMPANIC CATARRH
Diagnosis
• „Adenoid facies” • In the case of adenoid vegetation, the middle ear process must always be considered! CHRONIC TUBOTYMPANIC CATARRH
Otoscopy
„retracted” tympanic membrane the short process of the air bubbles are often malleus promine, its present in the fluid behind handle apparently the tympanic membrane shortened
exsudatum accumulates within the tympanic cavity – the tympanic membrane is amber colour, sometimes dark discoloration is seen CHRONIC TUBOTYMPANIC CATARRH
Diagnosis
• Audiometry – conductive hearing loss CHRONIC TUBOTYMPANIC CATARRH
Diagnosis
• Impedance audiometry: – typical tympanogram
(flat line: Cround and B) CHRONIC TUBOTYMPANIC CATARRH
Therapy
• Ethiological and predisposing factors must be eliminated: – adenotomy – sanation of sinusitis – etc.
• Myringotomy/paracentesis – drainage of the middle ear CHRONIC TUBOTYMPANIC CATARRH
Therapy CHRONIC TUBOTYMPANIC CATARRH
Therapy CHRONIC TUBOTYMPANIC CATARRH
Therapy
• Myringotomy and drainage – anaesthesia, operating microscope
– incision in the anterior-inferior quadrant
– drainage
– ventillation tube or grommet insertion CHRONIC TUBOTYMPANIC CATARRH
Therapy
• Myringotomy and drainage – anaesthesia, operating microscope
– incision in the anterior-inferior quadrant
– drainage
– ventillation tube or grommet insertion CHRONIC TUBOTYMPANIC CATARRH
Therapy CHRONIC TUBOTYMPANIC CATARRH
Therapy
• Myringotomy and drainage – anaesthesia, operating microscope
– incision in the anterior-inferior quadrant
– drainage
– ventillation tube or grommet insertion CHRONIC TUBOTYMPANIC CATARRH
Prognosis
• Inadequate therapy – the exudate is organized; connective tissue remodeling occurs in the middle ear
– adhesions are formed = adhesive otitis media
– permanent hearing loss (conductive type) CHRONIC TUBOTYMPANIC CATARRH
Prognosis
• Inadequate therapy – atrophy of the tympanic membrane
– retraction pocket formation
– cholesteatoma (aquired) THANK YOU FOR YOUR ATTENTION!