Download Ear III

College of Medicine
King Saud University
ORL Course 431
ORL Department
King Abdulaziz University Hospital
Prof. Mohammed Attallah
Done by: 428-C2
Normal Middle Ear Cavity
Eustachian tube in short
 The normal middle ear cavity has 2 openings.
 Eustachian tube opens into the nasopharynx.
 Functions:
Aeration of ME cavity
Ventilation
Equalizing the pressure in the middle cavity.
 Any malfunction in eustachian tube can lead to
abnormality in the middle ear.
 It can be obstructed by edema.
 Most common is perforation of tympanic membrane.
Chronic otitis media
Chronic non-suppurative otitis media:
 Otitis media with effusion (OME, glue ear, secretory).
 Adhesive otitis media.
Without perforation, meaning no super-added
infection.
2. Chronic suppurative otitis media (more common):
 Tubotympanic (safe).
 Atticontral (unsafe).
 Associated with perforation.
1.
CSOM
 Long standing infection of part or whole of middle ear
cleft, characterized by ear discharge, and permanent
perforation.
 Perforation becomes permanent when its edges are
covered by squamous epithelium and doesn’t heal
spontaneously.
Etiology (from 427 ENT)
 Upper respiratory tract infections.
 Eustachian tube dysfunction.
 Environmental (hot and humid weather).
 Genetic.
 Previous OM (either AOM or OME).
Classifications of CSOM
 According to site of perforation:
1.
Safe (tubotympanic, anteroinferior): central
perforation on TM. On otoscopy: ruminants of
TM around perforation are found.
1.
Unsafe (atticoantaral, posterosuperior): unsafe
because it’s associated with cholesteatoma:
 Marginal is at the margin of TM.
 Attic (pars flaccida).
Pathology (from 427 ENT)
Signs of suppurative infection:
 Discharge (ottorhea) and perforation.
 Chronic inflammatory in the mucosa and bone
(osteitis).
2. Signs of healing attempts (if there is damage to
mucosa):
 Granulation tissue and polyps.
 Fibrosis and typmanosclerosis.
3. Cholesteatoma (in unsafe type).
1.
Symptoms (from 427 ENT)
1. Ottorhea:
 Intermittent, profuse, odorless in safe type
(mucopurulent discharge).
 Persistent, scanty, odorous in unsafe type (odor is due
to involvement of the bone).
2. Deafness: conductive (expect in case of
cholesteaome, where it can cause SNHL).
3. Tinnitus.
 N.B. any other symptom means complication.
Investigations in CSOM
1. Audiology: to assess hearing loss.
 Conductive, sensory, or mixed hearing deafness.
2. Radiology: for all CSOM, to test:
a) Ossicles.
b) Condition of ME cavity.
c) Most importantly, dura level. Tegmen tympani is a very thin
bone, separating ME cavity from middle cranial fossa,
allowing cholesteatoma to extend intra-cranially.
check CT scan pre-operatively to assess the extension,
because neurosurgeons may then be needed.
Low dura: Dural level may be normally low, and you may
unknowingly go into the brain. So you have to check
radiology!
d) Facial nerve. (35% of facial nerve has normal dehiscence)
3. All the others: blood, urine, etc. (mostly for anesthesiologists)
Management of CSOM
1. Surgery in 3 forms depending on the case (of
choice):
a. Tympanoplasty: closure operation.
b. Mastoidectomy: remove the necrotic tissue.
c. Tympanomastoidectomy: cortical
mastoidectomy with tympanoplasty.
2. Medical treatment: as a form of preparation to
the operation; limited use in CSOM.
Healed Tympanic Membrane with tympanosclerosis.
Tympanosclerosis indicates previous perforation that healed,
and is harmless and shouldn’t be treated.
Should be mentioned in the patient’s file, to avoid
pseudoreaction or “shopping patient”: patient rotates around
doctors seeking help.
you can see the head of malleus, the light reflex, right
sclerotic mass presenting perforation.
Safe and Unsafe perforation
in chronic otitis media
TOTAL perforation in CSOM: 75% of TM has been
lost.
It goes with safe and not associated with
cholesteatoma.
Problem with total perforation is failure adaptation
or anterior failure: Graft should be put 2 mm under
the normal skin. In total perforation, uptake of graft
is less anteriorly.
 Malingoplasty: only close the perforation.
 Tympanoplasty type I:
Close the TM perforation with graft from temporalis
fascia.
Examine the ossicles for continuity with each other
and mobility (if ossicles are immobile, patient can’t
benefit from typmanoplasty).
Prevents re-infection.
Cortical mastoidectomy operation
as the possible operation in chronic
suppurative otitis media.
Types of mastoidectomiy
 Cortical:
Opening the mastoid area, and clearing all the
granulation (infected) tissue.
Proper cortical if : visualize the long process of incus,
lateral semicircular canal, sigmoid sinus, seradural
angle, dura plate, tip of mastoid, and area where facial
nerve is most likely there. (posterior meatal wall)
Cortical is done when the infection is limited to the
mastoid, and there is no cholesteatoma.
 Modified radical.
 Radical.
Uses of cortical mastoidectomy
 As a pathway into the inner ear for cochlear implants.
Therapeutic:
 Adhesive otitis media: when TM adheres to
promontory, and there is no air in ME cavity. Air is put
behind the TM membrane, leading to re-aeration and
reopening of the eustachian tube.
 Compression of facial nerve.
 Labyrinth operations.
 Removal of emboli from the sigmoid sinus.
Post auricular incision approach to middle ear
and mastoid
Elevate the meatal skin, take a graft from
temporalis fascia, then enter the ME cavity.
Complications of mastoidectomy
 Most commonly: facial never paralysis.
 Nowadays, this ugly complication is prevented by
continuous monitoring in the OR.
 Mostly, steroid therapy is given. In severe cases,
decompression of nerve is done.
Facial paralysis as a complication
of middle ear and mastoid surgery
Otitis media with effusion (OME)
 Definition: TM is not perforated, while the ME
cavity is filled with sterile, non-purulent fluid.
 Prolonged obstruction of eustachian tube:
 Air will be absorbed.
 Mucosa of ME cavity will change, and become
secretory in nature.
 Due to eustachian tube blockage, fluid will
accumulate in ME cavity.
Otitis media with effusion (OME)
 Most common complication is conductive deafness.
Treatment of conductive deafness in OME:
 Treat the underlying cause: open the eustachian tube by any
means; e.g. systemic or local antihistamines, remove adenoid,
leading to re-aeration of the middle ear.
 Sometimes we have to surgically re-aerate the ME cavity.
 Aeration is important, because if fluid continues to accumulate,
it will become thick in nature (glue-like), and TM will adhere to
promontory; condition known as adhesive OM.
 End stage of mal-treatment of OME is adhesive otitis media,
and the treatment is very difficult.
Adhesive otitis media (end stage)
adherence of TM to promontory, leading
to inability to elevate TM from
promontory.
Acute Otitis Media – Stage IV
Seen here that TM is congested (bulging).
Presents with severe pain and conductive deafness.
Acute Otitis Media
 Most common in infants, due to the eustachian tube
shape; shorter, wider, and more horizontal.
A. Early stages:
1. Eustachian tube blockage:
 Adenoid in the nasopharynx. Obstruction can lead to
mal-aeration of middle ear, which contains air.
2. Mucosa of the middle ear is cuboidal in nature, not
secretory.
 Permeate: Air absorbed, TM will move medially
(refraction of TM), handle becomes shorter because
it’s pulled upward and backwards, loss of light reflex in
TM.
B. Late stage:
 Prolonged malaeration of ME, mucosa changes its
nature, becoming secretory. Starts to secrete fluid into
ME cavity, leading to conductive deafness.
 Proper otoscopy of canal:
Hair sign: visualizing the air-fluid level in TM (not
seen anymore). At this stage, the patient has
conductive deafness. (OME)
Pathophysiology of Otitis Media
(from 427 ENT)
 Eustachian tube occlusion: discomfort autophony, retracted




drum due to negative pressure.
Exudates inflammation: fever, earache (due to fluid
accumulation), deafness and congested ear drum.
Suppurative inflammation: bulging of drum due to increased
pressure in tympanic cavity, increased severity of fever,
congestion and bulging of the drum, deafness.
TM rupture: due to increased pressure, otorrhea, high
temperature, and ear ache will subside.
Resolution.
 N.B. these stages take place if OM isn’t treated.
 The fever of OM can be raised at any stage of OM.
Stages of AOM
Retrograde infection from nasopharynx:
 Stage I: congestion of blood vessels along the handle of
malleus.
 Stage II: if not treated, congestion radiates to
periphery.
 Stage III: The entire TM becomes red in color with
bulging and severe pain.
 Stage IV: spontaneous rupture of TM, releasing fluid
into EAC, the pain subsides.
Management
Medical (of choice):
 Admission, IV antibiotics, analgesics, antihistamines
to re-open the eustachian tube.
 In some cases if there is bulging like the previous case;
myringotomy is done to evacuate the ME cavity from
its contents.
 If myringotomy was not done, TM may rupture, and
it’s always better to surgically incise than rupture.
Surgical:
 If there is bulging, we do ventilation tube insertion.
Treatment (from ENT 427)
1. Antimicrobial treatment for 7 days:
 Amoxicillin + calvulonic acid = Augmentin.
 Trimethoprim / sulphamethoxazole.
 Cefaclore / cepxime.
 Erythromycin – sulphisomoxazole.
2. Decongestants:
 Nasal drops or spray to iopen the eustachian tube by
vasoconstriction.
3. Myringotomy:
 If the TM is bulging.
 For culture sensitivity if ibfection fails t resolve properly.
4. Ear toilet and local antibiotics.
Ventilation tube insertion (surgical treatment of otitis media)
Inserted in the anterioinferior quadrant of TM, to promote proper
aeration of ME cavity, and to drain the fluid if present.
Types of tubes:
Shahmen: small, and doesn’t cause any irritation.
Golden: not used in KAUH, because it’s thick and heavy.
Done by: Lama Al-Mansour