Download OTOLOGY SEMINAR

OTOLOGY SEMINAR
Bullous myringitis
R3 羅武嘉
Introduction
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In 1891: Lowenberg first recognize
Synonym: myringitis bullosa, myringitis bullosa hemorrhagica
Some authors divided acute myringitis into two clinical entities based on
physical examination
„ Bullous myringitis(BM)
„ Hemorrhagic myringitis: hemorrhagic redness on TM
Unknown etiology, incidence, predilection and pathology
Clinical presentation
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Sudden onset of very severe, usually unilateral and “throbbing” otalgia
Bulla may be single or multiple
Blood-filled, serous or serosanquinous blisters involving the tympanic
membrane and/or the deep meatal walls
TM may be partially or totally covered by bullous lesions
Scanty blood-stained watery otorrhea
Occur between the richly innervated outer epithelium and middle fibrous
layer of the TM
Middle ear effusion are frequently found
HL and/or vertigo
Kotikoski(2003): bullous myringitis in children< 2 years
„ Middle ear fluid: 97%
„ Otalgia: 58%
„ Fever(> 38oC): 62%
„ Symptoms of UTI(rhinitis in 93% and cough in 73% of events) were
present in a majority of cases
„ One blister in 71% ears, two in 24% ears and three in 2% ears;
ruptured vesicle in 3% ears; blister spread to EEC in 10% ears
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No cases of BM in ears with
patent tympanostomy tube
Relieved 1~2 days in a
majority of cases
Hearing loss
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Conductive HL, SNHL or mixed HL
SNHL occur in 30~67% of patients
Hoffman(1983): 15 patients with 21 ears had HL
„ 7 had SNHL, 7 had mixed HL; complete recovery in 8 of 14 ears
Lashin(1988): 4 of 24 patients had SNHL(all unilateral)
Hariri(1990): 18 patients with 20 affected ears, 17 had hearing impairment
„ 6 had SNHL, 7 had mixed HL and 4 had conductive HL
„ Average SNHL was 28 dB(in comparison with the good ear) with
greater loss in the higher frequencies(range15~60dB)
„ Recovery was complete in 12 of the 17 ears and the time range of
recovery was between 3 and 11 weeks
„ Stapedial reflexes all showed recruitmentÆ suggest that the site of the
lesion is in the cochlea
Actual mechanism of SNHL is a matter of conjecture, since no post-mortem
pathological specimens have yet been reported
„ The cochlear appears to be the site of HL
„ Milligan(1926): hemorrhagic intra-cochlear effusion
„ Dawes(1952): a neurotrophic virus
„ Goycoolea and Paperella(1980): use animal models with AOM,
suspected increased permeability of the OW to bacterial toxins as a
result of middle ear inflammation with resultant cochlear damage
Vestibular involvement
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Jenkins(1926) was the first to observe vertigo associated with nystagmus to
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the same side of the lesion in a few patients
Dawes(1953) described cases with persistent vertigo and vomiting lasting
from 2~7 days
R. Eliashar reported (A prospective study)
13 patients with 17 affected ears all had HL; 11 patients recovered their
auditory function
7 patients(54%) reported a sensation of vertigo at presentation
Duration of vertigo ranged from a few hours to 4 days and all patients fully
recovered clinically after treatment
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Vestibular involvement in 85% of patients(demonstrated by an abnormal
ENG)
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Vestibular involvement may occur through blood-borne, viral-induced
endolabyrinthitis
Vertigo can be related to serous labyrinthitis in which toxic or metabolic
products of bacteria or of the host inflammatory response enter through the
round window membrane
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Etiology
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Unknown
Yoshie: influenzal etiology
Clyde and Denny: the only case in the English literature with Mycoplasma
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pneumoniae isolated from bullous fluid
Some case reports have suggested Psittacosis, adenovirus, Epstein-Barr
virus and a multitude of viruses
Other investigators failed to show any connection between BM and either
mycoplasma, influenza virus or any other virus
Roberts(1979): simply a variant of AOM and should be treated as such
Some studies showed positive bacterial cultures for Streptococcus
pneumoniae, Haemophilus influenza and B-hemolytic streptococci
Kotikoski et al.(2004): MEF in 37 cases of myringitis and blister fluid in 12
cases sent for PCR analysisÆ all were negative for M. pneumoniae
Palmu et al.(2001): a prospective longitudinal cohort study(randomized
double blinded) of 2028 children age 7 to 24 months at primary care level in
the Finnish Otitis Media Vaccine trial
„ Middle ear disease was associated with BM in 97% of ears
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Bacterial pathogen distribution was similar to that of AOM, although a
higher proportion of Streptococcus pneumoniae
Support the idea of a middle ear disease with inflammatory reaction on
the TM
Kotikoski et al.(2002): Nasopharyngeal aspirate(NPA) and middle ear
fluid(MEF) samples taken at the time of diagnosis to detect antigen of
adenoviruses; influenza viruses A and B; parainfluenza viruses 1,2 and 3;
and respiratory syncytial virus by a time-resolved fluoroimmunoassay
(TR-FIA) and human rhinovirus and human enterovirus by RT-PCR
„ Respiratory virus was detected in 70% of NPA samples and in 27% of
MEF samples
„ The viral distribution was similar to that of AOM(virus positive 64%
of NPA and 37% of MEF)
„ The etiology of acute myringitis is similar to that in AOM: a complex
interaction of viral and bacterial pathogens
Epidemiology
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A slightly majority(50-60%) of patients consisted of boys
Following or during the course of an upper respiratory tract infection
More common during the cold season(winter)
In patients of any age(children, adolescents and young adults are frequently
affected)
The majority of cases are diagnosed at the age of 2-8 years
Present 1~16% of clinically diagnosed episodes of AOM
Occur more often in older children than AOM does
Kotikoski et al.(2003): in children less than 2 years of age
„ BM was diagnosed in 5.7% of children in a 1-year follow-up
„ It was present in almost 1 of every 20 AOM events
„ BM increases the subsequent risk of recurrent AOM(2.9 per person
year vs. 1.8 per person year) for about 2 months
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„ 1.8 times higher in boys compared with girls
McCormick(2003): 518 cases of AOM in children age 6 months to 12 years,
use tele-otoscopy to assist the diagnosis
„ BM accounts for 7.9% of AOM cases
„ Children who had AOM with BM were older than AOM patients
without BM(4.3 years vs 18 months)
„ 97% bulging of the TM in patients had AOM with BM vs 42% in
AOM patients
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children with AOM and BM were older, had higher symptom scores,
and had more severe otoscopic findings in the portions of the TM not
occupied by the bulla
Treatment
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Controversial
Treat as AOM
Marais(1997): oral antibiotic for a minimum of 10 days if middle ear fluid
exist
R. Eliashar
„ 10 days amoxicillin-clavulanate,
„ patients with HL were treated with steroid and with inhalations of
carbogen(95% oxygen, 5% CO2)
Adequate analgesia
Warm compression
Conclusion
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Seem to be a variant of AOM but more painful
present in 1~16% AOM events
Occur more often in older children
May have HL and/or vertigo
References
1. Kotikoski MJ, Kleemola M, Palmu AA. No evidence of Mycoplasma pneumoniae
in acute myringitis. Pediatr Infect Dis J. 2004 May;23(5):465-6.
2. Wild DC, Spraggs PD. Myringitis bullosa haemorrhagica associated with
meningo-encephalitis. Eur Arch Otorhinolaryngol. 2003 Jul;260(6):320-1. Epub
2003 Feb 6.
3. Eliashar R, Gross M, Saah D, Elidan J. Vestibular involvement in myringitis bullosa.
Acta Otolaryngol. 2004 Apr;124(3):249-52.
4. Kotikoski MJ, Palmu AA, Huhtala H, Savolainen H, Puhakka HJ. The epidemiology
of acute bullous myringitis and its relationship to recurrent acute otitis media in
children less than 2 years of age. Int J Pediatr Otorhinolaryngol. 2003
Nov;67(11):1207-12.
5. McCormick DP, Saeed KA, Pittman C, Baldwin CD, Friedman N, Teichgraeber DC,
Chonmaitree T. Bullous myringitis: a case-control study.
Pediatrics. 2003 Oct;112(4):982-6.
6. Kotikoski MJ, Palmu AA, Puhakka HJ. The symptoms and clinical course of acute
bullous myringitis in children less than two years of age. Int J Pediatr
Otorhinolaryngol. 2003 Feb;67(2):165-72.
7. Kotikoski MJ, Palmu AA, Nokso-Koivisto J, Kleemola M. Evaluation of the role of
respiratory viruses in acute myringitis in children less than two years of age. Pediatr
Infect Dis J. 2002 Jul;21(7):636-41.
8. Palmu AA, Kotikoski MJ, Kaijalainen TH, Puhakka HJ. Bacterial etiology of acute
myringitis in children less than two years of age. Pediatr Infect Dis J. 2001
Jun;20(6):607-11.
9. Marais J, Dale BA. Bullous myringitis: a review. Clin Otolaryngol Allied Sci. 1997
Dec;22(6):497-9
10. Hariri MA. Sensorineural hearing loss in bullous myringitis. A prospective study of
eighteen patients. Clin Otolaryngol Allied Sci. 1990 Aug;15(4):351-3.
11. Lashin N, Zaher S, Ragab A, ElGabri TH. Hearing loss in bullous myringitis.
Ear Nose Throat J. 1988 Apr;67(4):206, 208, 210.
12. Hoffman RA, Shepsman DA. Bullous myringitis and sensorineural hearing loss.
Laryngoscope. 1983 Dec;93(12):1544-5.
13. Feinmesser R, Weissel MJ, Levi H, Weiss S. Bullous myringitis: its relation to
sensorineural hearing loss. J Laryngol Otol. 1980 Jun;94(6):643-7.
14. Roberts DB. The etiology of bullous myringitis and the role of mycoplasmas in ear
disease: a review. Pediatrics. 1980 Apr;65(4):761-6.