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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 • • • • • • 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 • • • • 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 • • • • 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 • • • • • Myringosclerosis Tympanosclerosis Tympanic membrane retraction pocket Tympanic membrane focal atrophy Retained tympanostomy tube Complications of Tympanostomy Tubes • • • • • • • • 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 – – – – – – – – 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