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ACUTE OTITIS MEDIA 1.Acute suppurative otitis media Inflammation of the middle ear , the area between the tympanic membrane and the inner ear by pyogenic organism less than 3 weeks. Aetiology : It is more common especially in infants and children of lower socio-economic group. Typically, the disease follows viral infection of upper respiratory tract but soon the pyogenic organisms invade the middle ear. Predisposing factors: anythings that interferes with normal function of Eustachian tube predisposes to middle ear infection - recurrent attacks of common cold , URTI . -infection of tonsils and adenoids . -chronic rhinitis and sinusitis . -nasal allergy . -Associated conditions: cleft palate, Down syndrome. Route of infection: • Eustachian tube: most common route . Eustachian tube in infant and children is shorter , wider and more horizontal , breast or bottle feeding may force fluid into middle ear . Swimming and diving can also force water to middle ear. • External auditory canal : Traumatic perforation of TM. • Blood born: uncommon route . Bacteriology: - Streptococcus pneumonia - Haemophilus influenza - Moraxella catarrhalis . Pathophysiology: The patient has an antecedent event (viral URI or allergy) → the event results in Congestion of the respiratory mucosa → obstruction causes negative pressure followed by Accumulation of secretions → these secretions accumulate in the middle ear space → viruses and bacteria that Colonize the upper respiratory tract can reach the middle ear via aspiration, reflux → microbial growth in the middle ear secretions may result in suppuration. Clinical Features Symptoms: Diminished hearing ear pain may disturb sleep and is of throbbing in nature. Tinnitus child runs high degree of fever and is restless accompanied by vomiting and convulsions Otorrhea Signe: Tympanic membrane is retracted Erythematic tympanic membrane handle of malleus assuming a more horizontal position. prominence of lateral process of malleus and loss of light reflex. conductive deafness. TREATMENT • Antibacterial therapy - Amoxicillin or Augmentin • Decongestant nasal drop - Ephedrine nose drops • Oral nasal decongestants. - Pseudoephedrine • Analgesics and antipyretics. • Dry local heat. • Myringotomy - It is incising the drum to evacuate pus and is indicated when (i) drum is bulging and there is acute pain (ii) there is an incomplete resolution despite antibiotics when drum remains full with persistent conductive deafness (iii)there is persistent effusion beyond 12 weeks 2.OTITIS MEDIA WITH EFFUSION This is an insidious condition characterized by accumulation of non-purulent effusion in the middle ear cleft. often the effusion is thick and viscid but sometimes it may be thin and serous. The fluid is nearly sterile. The condition is commonly seen in school-going children. Pathogenesis Two main mechanisms are thought to be responsible: 1. Malfunctioning of Eustachian tube. Eustachian tube fails to aerate the middle ear and is also unable to drain the fluid. 2. Increased secretory activity of middle ear mucosa. Biopsies of middle ear mucosa in these cases have confirmed increase in number of mucus or seroussecreting cells. Aetiology 1- Malfunctioning of eustachian tube : A- Adenoid hyperplasia b-chronic rhinitis and sinusitis c-chronic tonsilitis d-benign and malignant tumours of nasopharynx e-palatal defect eg: cleft palate 2- allergy 3-unresolved otitis media 4-viral infection Clinical Features Symptoms: The disease affects children of 5- 8 years of age. The symptoms include: (1) Hearing loss. (2 Delayed and defective speech. Because of hearing loss, development of speech is delayed or defective. (3) Mild earaches. • Clinical assessment: • O/E: • Otoscopic findings: Tympanic membrane is often dull and opaque with loss of light reflex. -It may appear yellow, grey or bluish in color. • -Thin leash of blood vessels may be seen along the handle of malleus or at the periphery of tympanic membrane and differs from marked congestion of acute suppurative otitis media. • -Tympanic membrane may show varying degree of retraction. Sometimes, it may appear full or slightly bulging in its posterior part due to effusion. Province of lateral process, Decrease in mobility of T.M has bulging contour “difficult to assessing ossicular land mark • Hearing Tests (1) Tuning fork: • rinne: *air louder than bone “positive” (normal) *Bone louder than air “negative” (conductive hearing loss) • tests show conductive hearing loss • Weber: Sound heard in midline (normal) Sound heard in bad ear (conductive hearing loss) Sound heard in good ear (sensorineural hearing loss) • tests show conductive hearing loss (2) Audiology: •PTA: to masseur hearing sensitivity by threshold levels of individual, the intensity as a function of frequency. Conductive: gap between air and bone by 10 dB Sensorineural: the air and bone within each other 10 dB, and the threshold higher than 25 dB. There is conductive hearing loss •Tympanometry: Type A: look like a teepee and indicate normal middle ear. Type B: flat line, there’s fluid or infection behind eardrum. Type C: teepee but shifted negatively, indicate negative pressure in middle ear space. The test show type B. (4) X-ray mastoids. There is clouding of air cells due to fluid. Treatment The aim of treatment is removal of fluid and prevention of its recurrence. A. Medical 1. Decongestants. 2. Antiallergic measures. 3. Antibiotics. B. Surgical When fluid is thick and medical treatment alone does not help, fluid must be surgically removed. 1. Myringotomy and aspiration of fluid. 2. Tympanotomy or cortical mastoidectomy. 3. Surgical treatment of causative factor. CHRONIC OTITIS MEDIA Chronic suppurative otitis media with and without cholesteatoma csom • CHRONIC SUPPURATIVE OTITIS MEDIA IS A LONG STANDING INFECTION OF A PART OR WHOLE OF THE MIDDLE EAR CLEFT CHARACTERIZED BY: • EAR DISCHARGE (OTORRHEA) • PERMANENT PERFORATION OF TYMPANIC MEMBRANE. EPIDEMIOLOGY: Incidence is higher in developing countries Affects both sexes and all age groups Most important cause of hearing impairment in rural population Diagnosis: Duration > 3 months despite treatment Discharge mucopurulent otorrhea Deafness Perforation /Ossicular chains Etiology: Pseudomonas aeruginosa Staphylococcus aureus Proteus species Pathogenesis: ET dysfunction Poor aeration Mucosal edema and ulceration Capillary proliferative Osteitis TYPES Clinically it is divided into two types : 1. Tubotympanic 2. Atticoantral Tubotympanic type (Safe) SIMPLE PERFORATION INTERMITTENT NON OFFENSIVE NON BLOODY EAR DISCHARGE ON EXAMINATION (CENTRAL PERFORATION ) ATTICO-ANTRAL (UNSAFE) Chronic ,Scanty, offensive and bloody ear discharge On examination marginal perforation You may see cholesteatoma Risk of complications is high property Tubotympanic Atticoantral Discharge Profuse,mucoid, odourless Scanty,purulent, smelling Perforation Central Marginal Granulations Uncommon Common Polyp Pale Red and fleshy Cholesteatoma Absent Present Complications Rare Common Audiogram Mild to moderate conductive deafness Conductive or mixed deafness foul ADHESIVE OTITIS MEDIA • FORMATION OF ADHESION IN THE MIDDLE EAR AFTER RE-INFECTION AND HEALING OF CSOM OR OME. • -VE PRESSURE IN THE TYMPANIC CAVITY. • EARDRUM RETRACTS ONTO STRUCTURE WITHIN THE MIDDLE EAR. MAY CAUSE MIDDLE EAR ATELECTASIS: • RESULT OF DYSFUNCTION OF EUSTACHIAN TUBE. • THE EAR DRUM BECOMES FLACCID. • WILL CAUSE BONE EROSION AT IS JOINT. • CAN BE TREATED WITH TYMPANOSTOMY. CHOLESTEATOMA • Normally, middle ear cleft is lined by different types of epithelium in different regions: ciliated columnar in the anterior and inferior part, cuboidal in the middle part and pavement-like in the attic. The middle ear is nowhere lined by keratinizing squamous epithelium. It is the presence of latter type of epithelium in the middle ear or mastoid that constitutes a cholesteatoma. • In other words, cholesteatoma is a “skin in the wrong place. • The term cho- lesteatoma is a misnomer because it neither contains cholesterol crystals. Essentially, cholesteatoma consists of two parts: • (i) the matrix, which is made up of keratinizing squamous epithe- lium resting on a thin stroma of fibrous tissues. •(ii) a central white mass, consisting of keratin debris produced by the matrix (Figure 11.1). For this reason, it has also been named epidermosis or keratoma. ORIGIN OF CHOLESTEATOMA • Presence of congenital cell rests. • Invagination of tympanic membrane from the attic or posterosuperior part of pars tensa in the form of retrac- tion pockets (Wittmaack’s theory). The outer surface of tympanic membrane is lined by stratified squa- mous epithelium which after invagination forms the matrix of cholesteatoma and lays down keratin in the pocket. • Basal cell hyperplasia (Ruedi’s theory). The basal cells of germinal layer of skin proliferate under the influ- ence of infection and lay down keratinizing squamous epithelium. • Epithelial invasion (Habermann’s theory). The epithelium from the meatus or outer drum surface grows into the middle ear through a pre-existing perforation especially of the marginal type where part of annulus tympanicus has already been destroyed. • Metaplasia (Sade’s theory). Middle ear mucosa, like respi- ratory mucosa elsewhere, undergoes metaplasia due to repeated infections and transforms into squamous epithelium. CLASSIFICATION OF CHOLESTEATOMA • 1. Congenital cholesteatoma. It arises from the embryonic epidermal cell rests in the middle ear cleft or temporal bone. Congenital cholesteatoma occurs at three important sites: middle ear, petrous apex and the cerebellopontine angle, and produces symptomatology depending on its location. • A middle ear congenital cholesteatoma presents as a white mass behind an intact tympanic membrane and causes con- ductive hearing loss. It may sometimes be discovered on rou- tine examination of children or at the time of myringotomy. • It may also spontaneously rupture through the tympanic membrane and present with a discharging ear indistinguish- able from a case of chronic suppurative otitis media. • 2. Primary acquired cholesteatoma . It is called primary as there is no history of previous otitis media or a pre-existing perforation. Theories on its genesis are: • (a) Invagination of pars flaccida. Persistent negative pressure in the attic causes a retraction pocket which accumu- lates keratin debris. When infected, the keratin mass expands towards the middle ear. Thus, attic perfora- tion is in fact the proximal end of an expanding invagi- nated sac. • (b) Basal cell hyperplasia. There is proliferation of the basal layer of pars flaccida induced by subclinical childhood infections. Expanding cholesteatoma then breaks through pars flaccida forming an attic perforation. • (c) Squamous metaplasia. Normal pavement epithelium of attic undergoes metaplasia, keratinizing squamous epi- thelium due to subclinical infections. Such a change has also been demonstrated in cases of otitis media with effusion. • 3. Secondary acquired cholesteatoma. In these cases, there is already a preexisting perforation in pars tensa. This is often associated with posterosuperior marginal perforation or sometimes large central perforation. Theories on its gen- esis include: • (a) Migration of squamous epithelium. Keratinizing squa- mous epithelium of external auditory canal or outer surface of tympanic membrane migrates through the perforation into the middle ear. Perforations, involv- ing tympanic annulus as in acute necrotizing otitis media, are more likely to allow in-growth of squamous epithelium. • (b) Metaplasia. Middle ear mucosa undergoes metaplasia due to repeated infections of middle ear through the pre-existing perforation. EXPANSION OF CHOLESTEATOMA AND DESTRUCTION OF BONE • Once cholesteatoma enters the middle ear cleft, it invades the surrounding structures, first by following the path of least resistance, and then by enzymatic bone destruction . • An attic cholesteatoma may extend backwards into the aditus, antrum and mastoid; downwards into the mesotympanum; medially, it may surround the incus and/or head of malleus. • Cholesteatoma has the property to destroy bone. It may cause destruction of ear ossicles, erosion of bony labyrinth, canal of facial nerve, sinus plate or tegmen tympani and thus cause several complications. Bone destruction by cho- lesteatoma has been attributed to various enzymes such as collagenase, acid phosphatase and proteolytic enzymes, liberated by osteoclasts and mononuclear inflammatory cells, seen in association with cholesteatoma. The earlier theory that cholesteatoma causes destruction of bone by pressure necrosis is not accepted these days. FORMATION OF ACQUIRED CHOLESTEATOMA SYMPTOMS OF CHOLESTEATOMA • Hearing loss. • Discharge from the ear with or without an odor. • Tinnitus. • Dizziness • Fullness or pressure in ear. • Facial weakness or paralysis HOW IS CHOLESTEATOMA DIAGNOSED? • Physical examination of the ear with an otoscope. The dead skin tissue can sometimes be seen through the eardrum. • A CT scan and audiology evaluation may also be necessary to determine the size and extent of damage of the cholesteatoma. TREATMENT: • Initial treatment involve cleaning of the ear , antibiotics and ear drops to treat any infection. • A. Ototopical medications: • Antibiotic only otic drops: • Floxin. • Antibiotic with steroid otic drops: • Ciprodex • Cipro HC SURGICAL PROCEDURES FOR CHOLESTEATOMA Cholesteatoma Surgery Mastoidectomy: Canal wall up Canal wall down •Tympanoplasty. •Tympanomastoidectomy. Ossiculoplasty. CAN CHOLESTEATOMA CAUSE LASTING PROBLEMS? • If left untreated, cholesteatomas can become large and infected. It can spread to the inner ear and brain. • This can lead to permanent hearing loss , dizziness , facial paralysis , brain abscess , or meningitis. COMPLICATIONS OF OTITIS MEDIA 1.Impaired hearing. 2. Speech or developmental delays. 3.Spread of infection. 4.Tearing of the eardrum. 5.Cholesteatoma COMPLICATIONS OF OTITIS MEDIA 1.Impaired hearing. 2. Speech or developmental delays. 3.Spread of infection. 4.Tearing of the eardrum. 5.Cholesteatoma COMPLICATIONS 3.Spread of infection: • Intratemporal (Within the Confines of Temporal Bone) 1. Mastoiditis 2. Petrositis 3. Facial nerve paralysis 4. Labyrinthitis • Intracranial 1.extradural abscess 2.subdural abscess 3.mningitis 4.Brain abscess 5.Otitic hydrocephalus 6.Lateral sinus thrombosis REFERENCES : • Diseases of Ear, Nose and throat ( PL Dhingra) 6th edition. • http://emedicine.medscape.com/article/994656treatment?src=refgatesrc1 • http://www.mayoclinic.org/diseases-conditions/earinfections/symptoms-causes/dxc-20199484