Download The Pediatric Ear - Dr. Kristelle Chueng, MD FRCSC

The Paediatric Ear
Dr. Kristelle Chueng, MD FRCSC
Otolaryngology—Head & Neck Surgery
Stratford, ON
Disclosures
• None
Objectives
1. To outline the relevant anatomy and
physiology of the paediatric ear.
2. To provide a differential diagnosis for
external and middle ear pathology.
3. To review the surgical management of otitis
media according to the current guidelines.
Objectives
1. To outline the relevant anatomy and
physiology of the paediatric ear.
2. To provide a differential diagnosis for
external and middle ear pathology.
3. To review the surgical management of otitis
media according to the current guidelines.
Anatomy of the Ear
Anatomy of the Tympanic Membrane
Anatomy of Eustachian Tube
Anatomy of Eustachian Tube
Anatomy of Eustachian Tube
Physiology of Normal Eustachian Tube
Open Eustachian Tube
• Ventilates middle ear
• Equalizes middle ear
pressure
• Drains middle ear secretions
into nasopharynx
Closed Eustachian Tube
• Prevents reflux of
nasopharyngeal contents
into middle ear
• Protects the middle ear
from loud sounds
Eustachian Tube Dysfunction
Development of Eustachian Tube
Stages of Otitis Media
1
Eustachian tube dysfunction
Viral upper respiratory tract infection (nasopharyngitis)
2
Hyperemia
Vasodilatation and mucoperiosteal edema
3
Exudation
Extravasation of serous fluid from dilated blood vessels causes tympanic
membrane to bulge
4
Suppuration
Bacterial infection of middle ear fluid
5
Resolution or Complication
a) Resolution
Tympanic membrane perforation and drainage of secretions
b) Complication
Retained infected middle ear fluid leads to venous stasis, acidosis,
bone calcium dissolution and coalescent mastoiditis
Anatomy of the Mastoid
Mastoiditis
Mastoid effusion vs. true (coalescent) mastoiditis
Treated Acute Otitis Media
Treated Acute Otitis Media
Objectives
1. To outline the relevant anatomy and
physiology of the paediatric ear.
2. To provide a differential diagnosis for
external and middle ear pathology.
3. To review the surgical management of otitis
media according to the current guidelines.
Objectives
1. To outline the relevant anatomy and
physiology of the paediatric ear.
2. To provide a differential diagnosis for
external and middle ear pathology.
3. To review the surgical management of otitis
media according to the current guidelines.
External Ear Pathology
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Aural atresia
Otitis externa
Cerumen impaction
Foreign body
Osteoma
Exostoses
External Ear Pathology
Osteoma
• Benign bony neoplasm
Bony Exostoses
• Cold-induced periosteitis
Tympanic Membrane Pathology
• Tympanic membrane
perforation
• Myringosclerosis
Middle Ear Pathology
• Otitis media
• Tympanosclerosis
• Inflammatory
granuloma
• Cholesteatoma
• Neoplasm
Types of Hearing Loss
Conductive Hearing Loss
• External or middle ear
pathology
• Hearing loss from abnormal
transmission of sound from
the external environment to
the inner ear
• Usually acquired in pediatric
population.
Sensorineural Hearing Loss
• Inner ear pathology
• Hearing loss from abnormal
transmission of sound from
the inner ear to the brain
• Usually congenital in
pediatric population.
Types of Hearing Loss
Objectives
1. To outline the relevant anatomy and
physiology of the paediatric ear.
2. To provide a differential diagnosis for
external and middle ear pathology.
3. To review the surgical management of otitis
media according to the current guidelines.
Objectives
1. To outline the relevant anatomy and
physiology of the paediatric ear.
2. To provide a differential diagnosis for
external and middle ear pathology.
3. To review the surgical management of otitis
media according to the current guidelines.
Tympanostomy Tubes
Tympanostomy Tube
Tympanostomy Tube
Tympanostomy Guidelines (2013)
• Source
– American Academy of Otolaryngology—Head &
Neck Surgery
• Population
– 6 months to 12 years old
• Purpose
– To avoid unnecessary tympanostomy tube
insertion in otitis media that is likely to resolve
spontaneously.
Natural History of OME
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70% prevalence at 2 weeks
40% prevalence at 1 month
20% prevalence at 2 months
10% prevalence at 3 months
• 20% resolution after 3 months
• 25% resolution after 6 months
• 30% resolution after 1 year
Natural History of OME
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70% prevalence at 2 weeks
40% prevalence at 1 month
20% prevalence at 2 months
10% prevalence at 3 months
• 20% resolution after 3 months
• 25% resolution after 6 months
• 30% resolution after 1 year
Sequelae of Tympanostomy Tubes
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Myringosclerosis
Tympanosclerosis
Tympanic membrane retraction pocket
Tympanic membrane focal atrophy
Retained tympanostomy tube
Complications of Tympanostomy Tubes
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26%
7%
6%
4%
4%
2%
0.5%
Rare
Tube otorrhea
Tube obstruction
Persistent tympanic membrane perforation
Tube granulation tissue
Premature tube extrusion
TM perforation requiring repair
Tube displacement into middle ear
Cholesteatoma
Tympanostomy Indications
1. Persistent middle ear fluid
2. Frequent ear infections
3. Persistent ear infection following antibiotic
therapy
Tympanostomy Indications
1. Persistent middle ear fluid
- Chronic otitis media with effusion (OME) > 3 mths
2. Frequent ear infections
3. Persistent ear infection following antibiotic
therapy
Recommended Surgery
Bilateral OME > 3 months
AND
Documented hearing loss > 20 dB
Optional Surgery
• Unilateral or bilateral OME > 3
months AND
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Language/developmental delay
Poor school performance OR
Behavioural problems OR
Vestibular/balance problems OR
Ear discomfort OR
Poor quality of life
Hearing loss > 20 dB
Structurally abnormal tympanic
membrane
• Posterosuperior retraction pockets
• Ossicular erosion
• Adhesive atelectasis
At-Risk Children
Optional Surgery for At-Risk Children
Chronic OME > 3 months
OR
Unilateral or bilateral OME
of any duration AND flat
(type B) tympanogram
Tympanostomy Indications
1. Persistent middle ear fluid
- Chronic otitis media with effusion (OME) > 3 mths
2. Frequent ear infections
3. Persistent ear infection following antibiotic
therapy
Tympanostomy Indications
1. Persistent middle ear fluid
2. Frequent ear infections
- Recurrent acute otitis media or AOM
3. Persistent ear infection following antibiotic
therapy
Recurrent AOM
• 3+ well-documented and separate AOM
episodes in the past 6 months
OR
• 4+ well-documented and separate AOM
episodes in the past 12 months AND at least 1
episode of AOM in the past 6 months
Optional Surgery for Recurrent AOM
• Recurrent acute otitis media AND
– Unilateral or bilateral middle ear
effusion at the time of assessment for
tube candidacy OR
– Intolerance to multiple antibiotics OR
– Developmental delay OR
– Immunosuppression OR
– Severe complications of otitis media
Tympanostomy Indications
1. Persistent middle ear fluid
2. Frequent ear infections
- Recurrent acute otitis media or AOM
3. Persistent ear infection following antibiotic
therapy
Tympanostomy Indications
1. Persistent middle ear fluid
2. Frequent ear infections
3. Persistent ear infection following antibiotic
therapy
- Persistent AOM
Persistent AOM
• Persistence of symptoms or signs of AOM
during antibiotic therapy (i.e. treatment
failure)
OR
• Relapse of AOM within 1 month of completing
antibiotic therapy.
Optional Surgery for Persistent AOM
“Increasing problems with bacterial resistance have
created a role for tympanostomy tube placement to
allow drainage of infected secretions, obtain middle
ear fluid for culture, and provide a direct route for
delivering antibiotic eardrops to the middle ear.”
Water Precautions
• Clinicians should NOT encourage routine
prophylactic water precautions for children
with tympanostomy tubes
• Exceptions (The 5 D’s)
– Drainage (recurrent/persistent otorrhea)
– Discomfort during swimming
– Dirty water
– Deep diving
– Decreased immunity
Objectives
1. To outline the relevant anatomy and
physiology of the paediatric ear.
2. To provide a differential diagnosis for
external and middle ear pathology.
3. To review the surgical management of otitis
media according to the current guidelines.
•
There is only one indication for recommended
surgery