بسم الله الرحمن الرحيم
DESCRIPTION
بسم الله الرحمن الرحيم. CHRONIC OTITIS MEDIA. Classification of Chronic Otitis Media. Chronic Non Suppurative Otitis Media Otitis media with effusion “OME” Adhesive otitis media Chronic Suppurative Otitis Media “CSOM” Tubotympanic (Safe) Atticoantral (Unsafe). - PowerPoint PPT PresentationTRANSCRIPT
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الرحيم الرحمن الله بسم
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CHRONIC OTITIS MEDIA
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Classification of Chronic Otitis Media
• Chronic Non Suppurative Otitis Media
– Otitis media with effusion “OME”
– Adhesive otitis media
• Chronic Suppurative Otitis Media “CSOM”
– Tubotympanic (Safe)
– Atticoantral (Unsafe)
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OTITIS MEDIA WITH EFFUSION
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DEFINITION
Presence of non-purulent fluid within the
middle ear cleft
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SYNONYMS
• Secretory otitis media
• Middle ear effusion
• Sero-mucinous otitis media
• Catarrhal otitis media
• Glue ear
• Serous otitis media
• Non-suppurative otitis media
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PREVALENCE
• Between 20% and 50% of children do have
OME at some time between 3 and 10 years
of age
• Two peaks at 2 and 5 years of age
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RISK FACTORS
• Race• Age• Gender• Season• Nasopharyngeal anatomical abnormalities• Cleft palate• Smoking• ? Allergy
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HISTOPATHOLOGY
• Changes in the mucosa– Vasodilatation & mononuclear cell infiltration– Metaplasia of the epithelium to ciliated columnar– Mucus secreting gland formation
• Formation of fluid in the middle ear– Transudate– Exudate– Secretion
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ETIOPATHOLOGY
• Eustachian tube dysfunction
• Chronic inflammation
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ETIOLOGY
• Eustachian tube dysfunction– Poor muscular function– Adenoids– Barotrauma– Others
• Infections– Unresolved AOM– Adenoiditis and other URTIs
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SYMPTOMS
• Hearing impairment
• ± Otalgia
• Fluid sensation
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Diagnosis
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DIAGNOSIS
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DIAGNOSIS
• Otoscopy
• Tuning fork tests
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DIAGNOSIS
• Otoscopy
• Tuning fork tests
• PTA
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DIAGNOSIS
• Otoscopy
• Tuning fork tests
• PTA
• Tympanometry
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DIAGNOSIS
• Otoscopy
• Tuning fork tests
• PTA
• Tympanometry
• Myringotomy
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TREATMENT
• Treatment of the cause if feasible
• Observation
• Medical treatment– Antibiotics– Decongestants, ?Auto-inflation– ?Steroids
• Surgical– Myringotomy– Ventilation tubes (grommets)
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COMPLICATIONS OF VENTILATION TUBES INSERTION
• Infection
• Blockage
• Extrusion
• Tympanosclerosis
• Perforation
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Iatrogenic Cholesteatoma
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FACTORS AFFECTING TREATMENT
• Age• Duration• Unilateral or bilateral• Degree of hearing impairment• Previous treatment• Associated conditions• Tympanic membrane changes• Others
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SEQUELAE
• Spontaneous resolution– 50% resolve within 3 months.
Only 5% persists for more than 12 months
• Tympanosclerosis
• Scarring, retraction and atelectasis
• Cholesteatoma
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Conclusion
• OME is very common in children• Etiology is associated with ET dysfunction and
or chronic infection• In adults: Nasopharyngeal pathology should be
considered• Most cases resolve spontaneously• Conservative treatment is of doubtful value• VT insertion restore hearing in the selected
cases
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Classification of Chronic Otitis Media
• Chronic Non Suppurative Otitis Media
– Otitis media with effusion “OME”
– Adhesive otitis media
• Chronic Suppurative Otitis Media “CSOM”
– Tubo-tympanic (Safe)
– Attico-antral (Unsafe)
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Chronic Adhesive Otitis Media
• Formation of adhesion in the middle ear
after reactivation and subsequent healing of
either CSOM or OME
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Clinical Features
• History of CSOM or
OME
• Deafness is usually the
only symptoms
• TM shows various
structural changes
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Treatment
• Observation
• Surgical treatment
• Hearing aid
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Classification of Chronic Otitis Media
• Chronic Non Suppurative Otitis Media
– Otitis media with effusion “OME”
– Adhesive otitis media
• Chronic Suppurative Otitis Media “CSOM”
– Tubo-tympanic (Safe)
– Attico-antral (Unsafe)
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CHRONIC SUPPURATIVE OTITIS MEDIA
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ETIOLOGY
• Environmental
• Genetic
• Previous OM
• Upper respiratory tract infections
• Eustachian tube dysfunction
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Tubo-tympanic
CLINICO-PATHOLOGICAL TYPES
Attico-antral
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PATHOLOGY
• Signs of suppurative infection
– Discharge & perforation
– Chronic inflammatory reaction in the mucosa and the
bone (ostietis)
• Signs of healing attempts
– Granulation tissue & polyps
– Fibrosis & tympanosclerosis
• Cholesteatoma (attico-antral type)
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CHOLESTEATOMA
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DEFINITION
• The presence of a desquamating stratified
squamous epithelium in the middle ear
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PATHOGENESIS OF CHOLESTEATOMA
• Implantation (congenital or
acquired)
• Metaplasia
• Epithelial migration
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CLASSIFICATION OF CHOLESTEATOMA
• Congenital
• Acquired– Primary
– Secondary
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Effect of Cholesteatoma
• Keratin encourages
persistence of the infection
• Matrix causes bone erosion
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Clinical Features of CSOM
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Tubo-tympanic
CLINICO-PATHOLOGICAL TYPES
Attico-antral (cholesteatoma)
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SYMPTOMS OF CSOM
• Otorrhea
– Intermittent, profuse & odorless in TT type
– Persistent, scanty & malodorous in AA type
• Deafness
• Tinnitus
N.B. Any other symptom means complication
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OTOSCOPIC EXAMINATION
• Discharge– Present in TT type if active but may be absent– Usually is present in AA type
• Perforation– Central: in TT type– Marginal or attic in AA type with
cholesteatoma
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PERFORATION IN TT CSOM
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PERFORATION IN AA CSOM
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OTOSCOPIC EXAMINATION
• Discharge– Present in TT type if active but may be absent– Usually is present in AA type
• Perforation– Central: in TT type– Marginal or attic in AA type with
cholesteatoma
• Polyps, granulation tissue, tympanosclerosis
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Bacteriology
P seu d om on as aeru g in osaS tap h ylococcu s au reu sP ro teu sK leb s ie lla an d E sch erich ia co li
A erob es
B ac te ro id esP ep tococcu sP ep tos trep tococcu s
A n aerob es
B ac te rio log y
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INVESTIGATIONS
• Audiometry
• Bacteriology
• Imaging
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Congenital Cholesteatoma
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Cloudy middle ear in CSOM
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Cholesteatoma with attic erosion
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TREATMENT OF CHRONIC SUPPURATIVE OTITIS
MEDIA
• Depends on the type and presentation
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Active TT type Inactive TT type
Attico-antral type
(usually active)
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Active TT type Inactive TT type
Conservative treatment
Conservative Treatment•Treat any predisposing factor•Keep the ear dry•Ear toilet•Antibiotics•Removal of polyps and granulations
TYMPANOPLASTY
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TYMPANOPLASTY
An operation performed to eradicate disease
in the middle ear cavity and to reconstruct the
hearing mechanism
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MYRINGOPLASTY
An operation performed to repair the tympanic membrane
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AIMS OF TYMPANOPLASTY
• To close the perforation
• To prevent re-infection
• To improve hearing
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TREATMENT OF ATTICO-ANTRAL CSOM
Removal of cholesteatoma by mastoid operation
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RADICAL MASTOIDECTOMY
An operation in which the mastoid antrum
and air cells, attic and middle ear are
converted into common cavity, exteriorized to
the external canal. The tympanic membrane,
malleus and incus are removed leaving only
the stapes in situ.
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MODIFIED RADICAL MASTOIDECTOMY
An operation in which the mastoid antrum
and air cells, attic and middle ear are
converted into common cavity, exteriorized to
the external canal. The tympanic membrane
and ossicles remnants are retained
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AIMS OF RADICAL & MODIFIED RADICAL MASTOIDECTOMY
• Safety
• Dry ear
• Preserve hearing
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Conclusion
• In TT type the discharge is usually copious, intermittent and odorless. The perforation is central. Treatment is conservative (if there is active infection) followed by tympanoplasty to prevent re-infection and improve hearing.
• In the AA type the discharge is usually scanty, persistent and of bad odor. The perforation is attic or marginal with cholesteatoma. Treatment is by mastoidectomy to provide safety and dry ear
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