Download Tympanic membrane

Jennifer Taylor, ARNP
Otolaryngology
Seattle Children’s Hospital
Learning Objectives
Ear development in utero
 Parts of the ear: Outer ear, middle ear,
inner ear
 Ear Exam: use of otoscope,
tympanometry, positioning of patient
 Other findings: congenital anomalies of
the ear such as tags, pits, microtia
 When to refer

Development of Ear in Utero
Structural ear development starts in the
first 20 weeks’ gestation
 Sensorineural part of the auditory
system develops primarily after 20
weeks' gestational age
 Auditory system functional at 25 weeks
 25 weeks gestation to 5/6 months old
most critical time for hair cells
(sensorineural hearing)

Parts of the Ear
Outer Ear
Auricle (also referred to as pinna), ear
canal, outer part of tympanic membrane
 Protects tympanic membrane
 Produces cerumen
 Directs sound through ear canal
 Can be reshaped if necessary during the
fIrst few months of life d/t circulating
estrogen (must start before 6 weeks of
age)

Middle Ear
Air filled cavity behind tympanic
membrane
 Location of three smallest bones in body

 Malleus (hammer)
 Incus (anvil)
 Stapes (stirrup)

Opening of Eustachian tube
Describing the Tympanic
Membrane
Right Ear
Right Ear
Front of Face
Inner Ear
Semicircular canals
 Vestibule
 Cochlea

Inner Ear cont’d
Associated with hearing and balance.
 Tubes filled with fluid encased within the
temporal bone of the skull.
 Bony tubes (bony labyrinth ) contain a set
of cell membrane lined tubes.
 Filled with perilymph fluid, which the
membranous labyrinth tubes are filed with
endolymph. This is where the cells
responsible for hearing are located (the
hairy cells of Corti).

Ear Exam
Positioning
 Tools
 Cartilaginous development of the ear
lobe, position of ears, shape of auricle
(normal/abnormal), preauricular sinus or
skin tags. External auditory canal
patent.

Ear Exam cont’d




Pull downward and backward. This process will
move the acoustic meatus in line with the canal.
Hold the otoscope like a pen/pencil and use the
little finger area as a fulcrum. This prevents injury
should the patient turn suddenly.
Inspect the external auditory canal.
Inspect tympanic membrane
Inspect posterior ear and mastoid bone
Ear exam

Air inflation otoscopy (pneumaticotoscope) is very useful to evaluate
middle ear disease. Assess the mobility
of tympanic membrane by applying
positive and negative pressures with the
rubber squeeze bulb.
Normal Ear exam



Normal:
Auditory canal: Some hair, often with yellow to
brown cerumen.
Tympanic membrane
 Pinkish gray in color , translucent and in neutral
position.
 Malleus lies in oblique position behind the upper
part of drum.
 Mobile with air inflation.
Causes for Hearing Loss or
Abnormal Ear Development



Genetics
Environmental: born premature, exposed to
ototoxic medications
Infectious: CMV, TORCH, meningitis, family hx,
craniofacial abnormalities, birth weight <1.5kg,
neonatal hyperbilirubinemia, Apgar <4 at 1
minutes, <6 at 5 minutes, prolonged NICU stay or
ECMO or mechanical vent, exposure to ototoxic
meds.
When to refer
Hearing loss
 Suspect hearing loss with behavioral
issues, speech issues, ask about
newborn hearing screen
 Congenital anomaly of ear

Ronna K. Smith, MN, ARNP
Otolaryngology
Seattle Children’s Hospital
Objectives
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Definition of OME and AOM by current standards
and visualization
Current national guidelines for diagnostic criteria
of AOM
Pharmacology for AOM and OME
Referral guidelines to Otolaryngology and
indications for PE tube placement
Hands-on practice with otoscopy and identification
of signs of AOM and OME
Otalgia

Differential diagnosis
 AOM
 OME
 OE
 TMJ dysfunction
 Bruxism
 Dental pain, teething?
 Tonsil or throat pain
Diagnoses


Otitis media: acute, chronic, recurrent
OME: middle ear effusions
Acute Otitis Media

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
Commonly defined as inflammation of
the middle ear
Results in rapid onset of symptoms:
otalgia, fever, irritability, anorexia, or
vomiting
Often associated with upper respiratory
infection
Acute Otitis Media
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One of the most common reasons for
young children to visit the primary care
provider
Morbidity and mortality common before
the introduction of antibiotics/vaccines
80-90% of children have had at least
one episode of AOM by the age of 10
Peak incidence between 6-18 months
Acute Otitis Media

Factors influencing incidence:
 Age under 2 years, male gender, certain ethnic
backgrounds
 Eustachian tube function
 Daycare
 Older siblings
 Exposure to cigarette smoke
 Allergy
 Craniofacial disorders
 Immune function
AOM: Symptoms and Presentation

Fever (~50%), irritability, waking at night
 Anorexia, vomiting, diarrhea, balance
problems, decreased hearing
 Often preceded by URI symptoms
(~50%), increased incidence in winter
months
AOM: Diagnosis

“Diagnostic certainty” requires the
presence of:
 Acute onset of symptoms
 Presence of effusion-bulging TM or poor
mobility
 Evidence of inflammation
(AAP Clinical Practice Guideline, 2004,
updated 2013)
AOM: Microbiology in the postPrevnar era


Strep pneumoniae-can vary in pcn
resistance
non-typeable H. Influenzae
 MOST are beta-lactamase positive
 Associated purulent conjunctivitis makes H.
Flu more likely

M. catarrhalis (nearly 100% betalactamase positive)
AOM: Treatment

60-80% of acute OM will clear
spontaneously (Rosenfeld, 1995)
 60% in 24 hours, 80% in 72 hours


Some studies suggest resolution rate is
higher and complication rate lower if
antimicrobials are used.
S. pneumoniae is often the cause of
persistent otitis and is associated with a
large number of otitis complications
AOM: Treatment

High dose amox has been the main
recommendation for s. pneumoniae (>50%
of cases of AOM historically)
 Daycare, <2 yrs, abx in prev 3 mos=more
likely to have resistant s.pneumoniae
 Post-Prevnar: less s. pneumoniae, more
non-typeable h. influenzae
 High dose amox is STILL the first line
(AAP, 2013) because of safety profile, high
likelihood of effectiveness.
AOM: Treatment

The ‘observation’ option:
 Limit management to symptom relief in
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selected patients
Caregiver must have means of
communication
Must be a system for re-evaluation
Child should be healthy
>6 months of age
Antibiotic Choice
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First line: high dose Amoxicillin (80-90
mg/kg/day)
“Treatment failure” means persistence of
symptoms-pain, fever. Persistence of
effusion does NOT mean treatment failure
2nd line: Augmentin with high amoxicillin
concentration
If allergic to penicillin: Cefdinir,
azithromycin, clarithromycin, erythromycin
For true treatment failure: Rocephin
injections for 1-3 days.
Pain
Management of pain should be addressed
regardless of antibiotic use.
 Analgesics
 Oral analgesics: Tylenol, Ibuprofen
 Benzocaine/antipyrene (Auralgan) drops
 Herbal drops, garlic drops, warm oil

Warm compresses
 Distraction
 Codeine
AOM: Complications

Hearing loss (temporary, conductive)
COMMON
 Perforation of tympanic membrane-less
common, but not unusual
 Uncommon: cholesteatoma, retraction
pocket, ossicular discontinuity and
fixation, mastoiditis, labrynthitis, facial
paralysis, sensory neural hearing loss,
intracranial infection.
AOM: When to Refer

3 episodes in 6 months, or 4 in one year
 Persistent middle ear fluid (3-6 months,
+/- hearing loss)
 Severe bouts of otitis media or
complicating issues, eg febrile seizures,
 Multiple medication allergies making
medical therapy difficult
 Developmental delay, heightened
concern for speech/language
Follow up
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Middle Ear Effusion commonly persists after AOM
 60-70% of cases will have MEE at 2 weeks post
AOM
 40% will have MEE 1 month after AOM
 10% after 3 months (Teele, et al)
2 week follow up: hx of frequent OM, young infant,
hx of prolonged OM, immunocompromised
1 month follow up: most children
If effusions are still present, but no acute
signs….retreat? Refer for hearing test? Consider
allergy management?
Otitis Media with Effusion: Basic Principles
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Middle ear effusion (MEE) without signs
and symptoms of acute infection
May occur spontaneously because of
poor eustachian tube function, or may
follow acute otitis media
May be acute or chronic
More common than AOM: up to 90% of
children have had an episode of OME
by school age
Otitis Media with Effusion: Basic Principles

Potential impacts: hearing, speech,
language, learning, quality of life
 Often accompanies upper
respiratory infections
 TM is typically retracted or neutralnot bulging
 Symptoms: hearing loss,
intermittent discomfort
OME: Diagnosis

Pneumatic otoscopy is primary diagnostic
method. Tympanometry very helpful .
 White or amber colored discoloration to TM
 TM is often opaque
 Decreased or absent mobility
 Absence of acute OM s/s: pain, fever,
inflammation, bulging of TM
 This should NOT be treated as AOM!
Document….

Laterality: which side is it on?
 Mobility with pneumatic otoscopy
 Retraction pockets?
 Appearance of ossicles
 Be sure to document the duration of the
effusion if possible
OME: Treatment
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Observation: Document laterality, when
effusion was first observed and
symptoms. Follow up periodically.
Medications: antibiotics and oral
steroids may help in the short term, but
effusion often recurs after course is
complete.
Allergy treatment
Tympanostomy tube placement for
persistent effusions, hearing loss
‘glue ear’ prolonged OME
Decision to Treat/Refer:

Evaluate risk of developmental delays
 Speech delay
 OME causing hearing loss
 Already has DD

Evaluate likelihood of spontaneous
resolution
 Family hx of needing tubes
 Family hx of allergy, kid w/allergy
 Time of year
Otitis Media with Effusion

For children not at risk for developmental
delays
 Observation for 3 months
 Hearing testing if OME lasts beyond 3 months
 Language testing if hearing loss occurs
 Follow up every 1-3 months until OME is gone
 Decrease environmental risk factors (tobacco
smoke)
 Optimize listening and learning until effusion
resolves
Otitis Media with Effusion

In the setting of other developmental
delays
 Early referral to OTO
 Needs hearing exam
 May have earlier recommendation for tubes
 Consider social setting—foster care, etc.
OME Treatment
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No evidence to support use of
decongestants, antihistamines, or
steroids
No evidence to support long term effects
of antibiotics - there has been some
evidence of occasional short term
benefit
Consider 10 day course of antibiotic
and/or 5 day course of oral steroid as an
option when tube placement is only
other option
Ear Tubes (Pressure equalization-PE- or
Tympanostomy tubes
The decision to place tubes is based on many factors…
-quality of life
-season, age
-presence of hearing loss/speech delay
-other co-morbid factors
-parents have reached ‘otitic exhaustion’
Bobbin or grommet style: last 6-12 months
‘t-tube’ lasts 2 years
Care of PE tubes


Ok for swimming/bathing
Treat drainage topically
 No ototoxic drugs
 Clear drainage and pump the tragus

Older kids and diving?
 F/U with audiology after extrusion
 F/U with surgeon ?
Ashley Sapin, ARNP
Otolaryngology
Seattle Children’s Hospital
Why does my child have fluid behind their ear?
Persistent Effusions in “Non-complainers”
 Why
are these not okay?
 May be causing hearing loss
 Potential for retraction of the TM and
sequelae from chronic retraction
 The longer fluid is present, the less
likely it is to resolve spontaneously
and more likely it is to have a
negative impact
 May be indicator of nasopharyngeal
mass
Things to Note About Middle Ear Effusions

Anything obvious to treat?
 Allergic rhinitis
 Sinusitis/Rhinosinusitis
 Child drinking liquids while laying down

What do the effusions look like?
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Air bubbles?
Air-fluid level?
Color/texture of middle ear fluid?
Position of eardrum?
When to Refer for Persistent Effusion
•
In the presence of cognitive or sensory deficit
– Speech and language acquisition and pronunciation
– Reading
– Behavioral- Poor focus or attention, abnormal family/peer interactions
– Vestibular disturbance
•
When the effusion has been present for 3 or more months
– If hearing loss accompanies effusion, may be indication for ear tubes
•
Underlying medical diagnosis
– Abnormal ciliary function
• Primary ciliary dyskinesia
• Cystic fibrosis
– Craniofacial abnormality or syndrome
• Cleft palate
• Submucous cleft palate
• Trisomy 21
• Craniofacial microsomia
Perforations & Retraction Pockets
Tympanic Membrane Perforation

Common Causes
 Abnormal middle ear pressure
○ Middle ear effusions
○ Barotrauma
 Foreign body
○ Tympanostomy tubes
○ Traumatic injury
Tympanic Membrane Perforation

Treatment
 If acute perforation with infection/otorrhea
○ Dry ear precautions
○ Treat with antibiotic ear drops
 Sulfacetamide-prednisolone
 Ciprodex
 Ofloxacin (+/- dexamethasone)
 Do NOT use gentamycin, tobramycin, or
cortisporin drops (ototoxic!)
○ If in 1 month, no improvement and/or recurrent
otorrhea- ENT referral
 If vertigo or facial nerve involvement
○ Urgent ENT referral
 If chronic perforation
○ Non-urgent ENT referral
Retraction Pockets

Cause
 Eustachian tube dysfunction

Potential Problems
 Hearing loss
○ Reduction of TM mobility
○ Ossicular erosion
 Granulation tissue formation
 Cholesteatoma formation

Orders
 Audiogram (ENT will order)
 Referral to ENT
Retraction Pockets

Treatment Possibilities
 Watchful waiting
 Treat infection (if present) with
antibiotic ear drops
 Trial of steroid nasal spray if
allergic component
 Surgical intervention
○ Ear tube placement
○ Excision of squamous debris
Cholesteatoma
Cholesteatoma

Causes
 Congenital- occur during fetal
formation
 Acquired
○
Tympanic membrane perforationentryway for skin into middle ear
○ Eustachian tube dysfunction
○ Basal cell hyperplasia resulting from
infection
○ Metaplasia resulting from chronic
irritation from middle ear infection
Cholesteatoma
Symptoms
Sensation of fullness in ear
Hearing loss in affected ear- may be reported
by patient or found on audiogram
Dizziness
Intermittent or continuous otorrhea despite
treatment
Facial muscle weakness on affected side
Painful or painless
There may be no symptoms at all…
Signs
White mass behind intact tympanic membrane
Tympanic membrane perforation or retraction
pocket
Focal granulation tissue on tympanic
membrane
Cholesteatoma

Treatment
 Imaging
○
○
CT
MRI
 Antibiotics if needed
 Surgical Intervention
○ 1st-Tympanomastoidectomy
○ 2nd- May need additional surgery
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Re-examination of middle ear space to
confirm no regrowth of skin cells
Ossicular repair or prosthesis
Possible Complications
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Brain abscess
Meningitis
Labrynthitis
Facial paralysis
Deafness
Tympanosclerosis/Myringosclerosis
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Calcification affecting connective tissue of
tympanic membrane
Causes
 Previous otitis media
 Previous ear tubes
 Trauma to eardrum
May look like cholesteatoma- it isn’t
Children with asymptomatic myringosclerosis
do not need ENT referral
If symptomatic- then refer to ENT

Conductive hearing loss
○ Surgical removal
 Remove plaques (frequently refix
to ossicles)
 Middle ear reconstruction
○ Hearing aids
Persistent Ear Drainage

Potential Causes
 Acute tympanic membrane rupture with acute otitis
media
 Chronic tympanic membrane perforation
 AOM with patent ear tubes
 Otitis externa
○ Bacterial
○ Fungal
 Retained tympanostomy tube
 Cholesteatoma
(Remember, color of drainage may vary- serous, yellow, white, green, bloody…it can
all be “normal” for otorrhea)
Persistent Ear Drainage

Questions to ask
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Any recent illness/co-morbid conditions?
Frequency/recurrence of drainage?
Do otic antibiotics help?
Is there pain? (1-10, progressive, improve with drainage)
Is there pruritis?
Has child been swimming frequently/recently?
Pain with external ear palpation?
How is the patient’s hearing?
Does the patient have ear tubes?
○ How long have these tubes been in place?
○ When were they last seen by their ENT?
Retained Tympanostomy Tubes
Retained Tympanostomy Tubes

Duration of Pressure Equilization (PE) tubes?
 Armstrong/Reuter-Bobbin/Baxter
○ Generally last 6-12 months
○ Should be in no longer than 2 years*
 Soft T-Tubes
○ Generally last 1-2 years
○ Should be in no longer than 3 years*
 Why remove retained PE tubes?
○ Chronic TM perforation
○ Infection of the PE tubes
○ Persistent drainage
○ Granulation tissue
○ Most people outgrow the need for them
*There are always exceptions to this
Jennifer Hart, ARNP, CPNP
Otolaryngology
Seattle Children’s Hospital
What the Wax?!?
Cerumen is the substance that is
secreted by your ear canal
 It protects the external auditory canal
and the tympanic membrane
 It contains antibacterial properties

Types of Cerumen

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Cerumen can be
sticky, hard or flakey
Multi colored: white,
caramel, brown,
black
When To Remove Cerumen

Only when it is a problem
 If you suspect otitis media and can’t see TM
 If there is hearing loss associated with
impaction
 If there is pain due to impaction
 *If none of these exist, LEAVE IT ALONE
Home Methods
Q-Tips NO!!!!
 Debrox- yes
 Mineral/Olive Oil-yes
 ½ strength hydrogen peroxide- OK
 Ear Candling NO!!!!
 Wipe the bowl of the pinnae with warm
wet wash cloth

Safe removal

In clinic irrigation with warm water
 *caution do not shoot water directly down
the ear canal
 Loop curette, only if able to safely stabilize
child
 If unable to clear refer to OTO but start on
home routine(Debrox, oil, ½ strength
peroxide)
Fun With Foreign Bodies
When to Remove and when to Refer

Remove if:
 The object is easy to grasp with minimal
chance of trauma or anxiety for the child.
 You are able to safely restrain the child.
 If it is causing acute pain.
Why to Refer?

OTO has better equipment
 Binocular microscope
 Suction
 Multiple curettes and probes
 Experience to do this safely, with minimal
trauma and drama
 Able to make the call for sedation
Remember

Don’t put anything smaller than your
elbow in your ear. If you can put your
elbow in your ear go ahead and use it to
clean your ear.