MiddleMiddle EarEar DiseasesDiseases

MarizeMarize ViljoenViljoen ENTENT TygerbergTygerberg

AcuteAcute OtitisOtitis MediaMedia

„ InflammationInflammation +/+/ infectioninfection ofof middlemiddle earear

„ ShortShort ++ severesevere episodeepisode

„ MostMost commoncommon childrenchildren

„ AssociatedAssociated withwith respiratoryrespiratory infxinfx// blockedblocked sinusessinuses oror ET(allergiesET(allergies// enlargeenlarge adenoids)adenoids)

„ BacteriaBacteria--S.S. PneumoniaePneumoniae,, H.InfluenzaeH.Influenzae,, M.CatarrhalisM.Catarrhalis

„ VirusesViruses--RSV,RSV, InfluenzaeInfluenzae A+B,A+B, RhinovirusRhinovirus RiskRisk FactorsFactors

„ RecurrentRecurrent URTIURTI

„ GroupGroup dayday carecare

„ SecondhandSecondhand smokesmoke exposureexposure

„ ImmuneImmune statusstatus

„ VaccineVaccine statusstatus

„ NasalNasal allergiesallergies

„ HighHigh altitude/coldaltitude/cold climateclimate SymptomsSymptoms

„ SevereSevere otalgiaotalgia (50(50--75%)75%)

„ ConductiveConductive HearingHearing lossloss

„ Fever/Chills/anorexiaFever/Chills/anorexia

„ <2yrs<2yrs--Irritability/Irritability/ AcutelyAcutely ill/ill/ unconsolableunconsolable cryingcrying SignsSigns

„ EarEar inspectioninspection-- dullness,dullness, rednessredness ,, airair bubblesbubbles oror fluidfluid behindbehind eardrumeardrum

„ BulgingBulging eardrum/eardrum/ retractedretracted

„ PerforationsPerforations withwith otorrheaotorrhea/bleeding/bleeding

„ DecreasedDecreased mobilitymobility ofof eardrumeardrum

„ TypeType BB tympanogramtympanogram

TreatmentTreatment

„ AntipyreticAntipyretic ++ analgesicsanalgesics

„ AntibioticsAntibiotics-- 1)Amoxil1)Amoxil // 2)Augmentin/2)Augmentin/ 3)Cefuroxime3)Cefuroxime forfor 1010 daysdays

„ NasalNasal spray/spray/ drops/drops/ antihistaminesantihistamines (ET)(ET)

„ FollowFollow upup afterafter 2/522/52 toto ensureensure resolutionresolution

„ KeepKeep earear drydry ++ cleanclean OtitisOtitis MediaMedia withwith effusion:effusion:

*Inflammation*Inflammation-- resultingresulting collectioncollection ofof fluidfluid behindbehind eardrumeardrum *6*6--7yrs7yrs eustachianeustachian tubetube functionfunction normalizesnormalizes *ET*ET--tubetube obstruction/obstruction/ ongoingongoing middlemiddle earear inflammationinflammation *Resolve*Resolve spontaneouslyspontaneously Signs:Signs:

*Children*Children-- asasyymptomaticmptomatic --pullpull ear/ear/ cloggedclogged earear *Parents*Parents ofof childrenchildren––poorpoor hearinghearing --speechspeech ++ languagelanguage developmentaldevelopmental delaydelay *Adults*Adults ––auralaural pressurepressure --hearinghearing lossloss --clicking/clicking/ poppingpopping soundssounds Symptoms:Symptoms:

„ DullDull ,immobile,,immobile, bulging,bulging, retractedretracted TMTM

„ AirAir bubbles/bubbles/ airair--liquidliquid interfaceinterface

DxDx workup:workup:

„ PneumaticPneumatic otoscopyotoscopy

„ TypeType BB tympanogramtympanogram

„ AudiogramAudiogram-- 1010--30dB30dB conductiveconductive hearinghearing lossloss

„ FlexibleFlexible fiberopticfiberoptic nasopharyngoscopynasopharyngoscopy (adults)(adults) Rx:Rx:

„ ObserveObserve ++ followedfollowed closelyclosely

„ MyringotomyMyringotomy ++ grommetsgrommets insertioninsertion forfor persistentpersistent OME(NoOME(No resolutionresolution afterafter 3/12)3/12) IndicationsIndications forfor referralreferral

„ IfIf symptomssymptoms worsen/newworsen/new appearappear „ NoNo improvementimprovement afterafter 48H48H onon A/BA/B „ PersistentPersistent feverfever „ SevereSevere headacheheadache „ PersistentPersistent otalgiaotalgia „ MastoiditisMastoiditis „ FacialFacial ticstics „ VertigoVertigo ChronicChronic SupperativeSupperative OtitisOtitis MediaMedia

„ Recurrent/Recurrent/ persistentpersistent inflammationinflammation +/+/infxinfx ofof middlemiddle earear oror mastoidmastoid cavitycavity

„ ClassificationClassification -- withoutwithout cholesteatomacholesteatoma -- withwith cholesteatomacholesteatoma

„ MoreMore bacterialbacterial

„ HigherHigher incidenceincidence resistantresistant organismsorganisms

„ SeriousSerious ++ fatalfatal complicationscomplications CausesCauses

„ ETET blockedblocked ––allergies,allergies, multiplemultiple infxinfx,, earear trauma,trauma, swellingswelling ofof adenoidsadenoids

„ UnresolvedUnresolved acuteacute earear infxinfx

„ RecurrentRecurrent earear infxinfx-- perforationperforation

„ PathogensPathogens-- P.P. aeruginosaaeruginosa,, S.aureusS.aureus,, Anaerobe,Anaerobe, FungalFungal infectionsinfections SymptomsSymptoms

„ PainlessPainless // discomfortdiscomfort

„ OtorrheaOtorrhea

„ HearingHearing lossloss

„ MayMay bebe continuouscontinuous oror intermittentintermittent SignsSigns

„ PurulentPurulent foulfoul smelligsmellig dischargedischarge

„ PerforationPerforation--

„ AuralAural polyppolyp

„ HearingHearing lossloss

„ CholesteatomaCholesteatoma--WhiteWhite debris/debris/ retractionretraction pocket/pocket/ granulationgranulation tissue/tissue/ atticattic perforationperforation

ComplicationsComplications ofof OM:OM:

„ Extracranial:CSOMExtracranial:CSOM withwith cholesteatomacholesteatoma

„ AcuteAcute MastoiditisMastoiditis

„ LabyrinthitisLabyrinthitis

„ FacialFacial paralysisparalysis

„ TympanosclerosisTympanosclerosis

„ Partial/Partial/ completecomplete deafnessdeafness

„ PetrousPetrous apicitisapicitis Intracranial:Intracranial:

„ MeningitisMeningitis

„ SigmoidSigmoid sinussinus thrombosisthrombosis

„ SubduralSubdural empyemaempyema

„ IntracranialIntracranial abscessesabscesses

„ EpiduralEpidural abscessabscess Treatment(MedicallyTreatment(Medically):):

„ AntibioticsAntibiotics-- ForFor 1414 daysdays

„ EarEar toilettoilet-- syringing/syringing/ drydry mopping/mopping/ suctioningsuctioning

„ EarEar dropsdrops-- A/BA/B ++ steroid/steroid/ steroid/steroid/ acidacid dropsdrops

„ AudiogramAudiogram ifif drydry

„ ENTENT referralreferral

CholesteatomasCholesteatomas

„ StratifiedStratified squamoussquamous epitheliumepithelium inin middlemiddle earear

„ TheoriesTheories ofof origin:origin: MigrateMigrate fromfrom EAC/EAC/ HyperplasiaHyperplasia basalbasal layerlayer ofof parspars flaccidaflaccida –– healinghealing oror retraction/retraction/ squamoussquamous metaplasiametaplasia duedue toto longstandinglongstanding infxinfx

„ BeginsBegins desquamatedesquamate ++ accumulatesaccumulates

„ CollagenasesCollagenases ++ destroydestroy adjacentadjacent bonebone

Treatment(SurgeryTreatment(Surgery):):

„ ReferRefer forfor mastoidmastoid surgerysurgery

„ KeepKeep earear dry+dry+ cleanclean-- locallocal RxRx

„ AudiogramAudiogram AcuteAcute MastoiditisMastoiditis::

„ ContiguousContiguous spreadspread AOMAOM toto mastoidmastoid

„ SequelaSequela ofof partially/untreatedpartially/untreated AOMAOM

„ MucosalMucosal edemaedema ++ infxinfx withwith cloudingclouding ofof mastoidmastoid airair cellscells

„ MeanMean ageage 33 yearsyears

„ DiagnosisDiagnosis basedbased onon clinicalclinical featuresfeatures Symptoms:Symptoms:

„ Fever/Fever/ RigorsRigors

„ OtalgiaOtalgia

„ SignificantSignificant retroauricularretroauricular painpain

„ OtorrheaOtorrhea atat timestimes Signs:Signs:

„ PostauricularPostauricular tendernesstenderness toto palpation+palpation+ edemaedema

„ EarEar protrusionprotrusion

„ SaggingSagging ofof posterosuperiorposterosuperior EACEAC

„ TMTM-- AOM/AOM/ CSOMCSOM

„ ConductiveConductive hearinghearing lossloss

„ LeukocytosisLeukocytosis

DxDx ++ Rx:Rx:

„ CTCT--scanscan delineatedelineate extentextent ofof infxinfx

„ OrganismsOrganisms--S.S. Pyogenes,SPyogenes,S.. PneumoniaePneumoniae,, H.H. Influenza,Influenza, P.P. AeruginosaAeruginosa,, AnaerobesAnaerobes

nd „ IVIV A/BA/B (2(2 gen.cephalosporingen.cephalosporin))

„ MyringotomyMyringotomy ++ grommetsgrommets

„ MastoidMastoid surgerysurgery-- coalescencecoalescence ofof mastoid/mastoid/ nono improvementimprovement onon A/B/A/B/ complicationcomplication Complications:Complications:

„ ExtracranialExtracranial ––subperiostealsubperiosteal abscessabscess --middlemiddle earear pathologypathology --lucluc’’ss abscessabscess --bezoldbezold’’ss abscessabscess --citellicitelli’’ss abscessabscess --petrositispetrositis „ IntracranialIntracranial --meningitis/epiduralmeningitis/epidural abscess/abscess/ sigmoidsigmoid sinussinus thrombosis/brainthrombosis/brain abscessabscess TheThe EndEnd