Download Tumors of the Lateral Skull Base and

ACUTE AND CHRONIC OTITIS
MEDIA
Prof. İlhan TOPALOĞLU M.D
Otolaryngology Department
Yeditepe University, School of Medicine
Objectives
• To define acute otitis media (AOM) and chronic otitis media (COM)
• To understand the clinical presentation and diagnostic evaluation of
AOM and COM
• To define the various types of cholesteatoma and how they develop.
• To provide an overview of the management of AOM and COM.
Acute Otitis Media (AOM)
• The diagnosis of AOM requires:
– History of acute onset signs and symptoms
– Presence of middle ear effusion (MEE)
– Signs and symptoms of middle ear inflammation
The presence of MEE is indicated by:
-
A bulging tympanic membrane
Limited or absent tympanic membrane mobility
Air-fluid level behind the TM
Otorrhea (drainage from the ear)
Signs of middle ear inflammation include:
- Erythema of the tympanic membrane
- Otalgia (ear pain)
Acute Otitis Media (AOM)
Etiology of Acute Otitis Media
• S. pneumoniae
• H. influenzae
• M. catarrhalis
• S. pyogenes (gr. A)
• S. aureus
• No growth
25%
20-25%
10-20%
2%
1%
up to 35%
Recurrent Acute Otitis Media
• Multiple bouts of acute otitis media with
complete resolution between episodes
• 4 episodes in 6 months or 6 episodes in 1 year
is an indication for tympanostomy tube
placement
Otitis Media with Effusion
(Chronic non-suppurative Otitis Media)
• Middle ear filled with serous or mucoid fluid
• No purulence
• Often present after acute otitis media is treated
appropriately with antibiotics
• Most will clear within 3 months
Etiology of OME
• 50% sterile to culture
– Molecular techniques find bacterial
products
• When culture +, similar to AOM
Medical Treatment of OME
• Observation – many European countries wait 6-9
months prior to placement of ear tubes
• Antibiotics
– Meta-analysis shows beneficial short-term resolution of
OME
– Unclear long-term impact
• Audiogram at 3 months with persistent effusion to
determine impact on hearing
Tympanostomy Tubes
• In the US, chronic OME >3mos with hearing loss and/or
speech delay is an indication for tympanostomy tube placement
• Not just there to “drain fluid”
• Bypass Eustachian tube to ventilate middle ear
Middle Ear Atelectasis
• Lack of middle ear ventilation results in negative pressure
within the tympanic cavity
• The ear drum retracts onto structures within the middle
ear
• The result of long standing Eustachian tube dysfunction
• The drum loses structural integrity and becomes flaccid
• Contact between the drum and the incus or stapes can
cause bone erosion at the IS joint
• Can sometimes be treated with tympanostomy tubes
Middle Ear Atelectasis
Middle Ear Atelectasis
• Patient is at risk for cholesteatoma due to skin
accumulation within retraction pockets
• Drum contact with the incus and/or stapes cause
erosion of the incudostapedial (IS) joint
• TM is flaccid and non-vibratory – affects hearing
• Early atelectasis may be treatable with tympanostomy
tubes
• Severe atelectasis requires removal of the flaccid ear
drum and replacement using cartilage (cartilage
tympanoplasty)
– This adds rigidity to the drum at the expense of vibratory
capacity
Chronic otitis media (COM) with and
without cholesteatoma
Definition
• COM: unresolved inflammatory process of
the middle ear and mastoid associated
with TM perforation, otorrhea and hearing
loss.
Etiology
•
Unresolved middle ear infection
•
Dysfunction of Eustachian tube
•
Chronic inflammation in nose and pharynx
•
Dysfunction of immune system
Chronic otitis media
• Chronic infection of the middle ear
• Perforation of the tympanic membrane
• Patients present with hearing loss
• Otorrhea (ear drainage)
• Middle ear mucosa becomes edematous, polypoid, or
ulcerated
• The tympanic cavity usually contains granulation tissue
Near Total TM Perforation
Clinical presentations
• Hearing loss
– Air conduction threshold is within 30 dB
means TM proferation with intact ossicular
chain
– İf air conduction threshold is more than 30 dB
is associated with discontinuity of ossicular
chain
• Ossicular erosion is frequent
in COM
– It most commonly affect the
lenticular process of the incus
and head of the stapes
– Necrosis following vascular
thrombosis
Clinical presentations
• Otorrhea
– Frequently, malodorous associated with
cholesteatoma
Pathology
• Middle ear mucosa is lined by secretory
epithelium forming glandlike structure.
• Hyalinization or tympanosclerosis
–
–
–
–
A healing response
It occurs during quiescent periods
It is formed by fused collagenous fibers
It is hardened by the deposition of calcium and
phosphate crystals
– Conductive hearing loss is associated with masses
restricting ossicular mobility
Chronic otitis media
Most common infecting organisms are
• Pseudomonas aeruginosa,
• Staphylococcus aureus,
• Proteus species,
• Klebsiella pneumoniae,
• Diphteroids
Cholesteatoma
Cholesteatoma
• Cholesteatomas are epidermal inclusion cysts of the
middle ear and/or mastoid with a squamous epithelial
lining
• Contain keratin and desquamated epithelium
• Natural history is progressive growth with erosion of
surrounding bone due to pressure effects and
osteoclast activation
Classification
– Congenital cholesteatoma
– Acquired cholesteatoma
Congenital cholesteatoma
• Diagnosis criteria:
– Patients without
previous history of ear
disease, with normal
and intact TM
– The temporal bone
pneumatization should
be normal
Congenital cholesteatoma
– Epidermal inclusion cysts usually present in the anterior
superior quadrant of the middle ear near the Eustachian
tube orifice
– Diagnosed as a pearly white mass behind an intact tympanic
membrane in a child who does not have a history of chronic
ear disease
Acquired
Cholesteatoma
Pathogenesis
• Invagination
• Basal cell hyperplasia
• Migration (through a
perforation)
• Squamous metaplasia
Invagination Theory
– Retraction pocket cholesteatoma usually within the
pars flaccida or posterior superior tympanic
membrane
– Secondary to ETD
– Keratin debris collects within a retraction pocket
Epytympanic cholesteatoma
Mesotympanic
cholesteatoma
Migration Theory
• Most accepted
• Originates from a tympanic membrane perforation
• As the edges of the TM try to heal, the squamous
epithelium migrates into the middle ear
Acquired cholesteatoma
Diagnosis
• History, physical examination, CT scan of the
temporal bone
Axial Section
Coronal Section
Cholesteatoma Imaging
Cholesteatoma Imaging
Ototopical Medications
• Antibiotic only otic drops
Siprogut (ciprofloxin )
• Ophthalmic antibiotic preparations
Exocin (ofloxacin)
• Steroid only otic drops
Cebedex (dexamethasone)
Norsol (prednisolon)
The concentration of antibiotic in ototopical drops is 100-1000x
greater than what can be achieved systemically.
Tympanoplasty
• Paper patch myringoplasty
• Fat myringoplasty
• Underlay tympanoplasty (medial graft technique)
Underlay Tympanoplasty
Ossicular Chain Reconstruction
Mastoidectomy
• Intact (bony ear) canal wall mastoidectomy
• Canal wall down mastoidectomy
– Radical Mastoidectomy
– Modified Radical Mastoidectomy
Mastoidectomy
Tympanoplasty with mastoidectomy and
hydroxyapatite bone cement ossicular
reconstruction
Complications of Otitis Media
EKSTRA CRANIAL
• Facial paralysis
• Acute or coalescent
mastoiditis
• Petrositis
• Sub-periosteal abscess
• Post-auricular fistula
• Bezold abscess
• Labyrinthitis
Complications of Otitis Media
INTRA CRANIAL
• Meningitis
• Epidural abscess
• Subdural abscess
• Brain abscess
• Sigmoid sinus
thrombosis
• Cavernous sinus
thrombosis
• Otitic Hydrocephalus
• Encephalitis
• Cerebellitis
Complications of Otitis Media
• Due to antibiotics, the incidence of
complications has greatly declined.
• Complications are usually associated with some
degree of bone destruction, granulation tissue
formation, or the presence of a cholesteatoma.
• Complications arise most commonly by
infection spreading by direct extension from
the middle ear or mastoid cavity to adjacent
structures.
Acute mastoiditis with sub-periosteal abscess
Brain
Abscess