diseases of the middle ear and eustachian tube yard.doç.dr.müzeyyen doğan
TRANSCRIPT
Diseases of the middle ear Diseases of the middle ear and eustachian tube and eustachian tube
Yard.Doç.Dr.Müzeyyen DoğanYard.Doç.Dr.Müzeyyen Doğan
Otitis MediaOtitis Media
Most common reason for visit to Most common reason for visit to pediatricianpediatrician
Tympanostomy tube placement is Tympanostomy tube placement is 2nd most common surgical 2nd most common surgical procedure in childrenprocedure in children
Development of multidrug-resistant Development of multidrug-resistant bacteria bacteria
Otitis Media - HistoryOtitis Media - History
Egyptian mummies have perforations Egyptian mummies have perforations of TM and mastoid destructionof TM and mastoid destruction
Prehistoric Iranian population has Prehistoric Iranian population has evidence of middle ear diseaseevidence of middle ear disease
Middle Ear StructuresMiddle Ear Structures
1- Malleus1- Malleus
2- Incus --2- Incus --OssiclesOssicles
3- Stapes 3- Stapes
4- Tympanic 4- Tympanic Membrane Membrane (Eardrum)(Eardrum)
5- Round Window5- Round Window
6- Eustachian Tube6- Eustachian Tube
Middle Ear StructuresMiddle Ear Structures
1- Malleus1- Malleus
2- Incus --2- Incus --OssiclesOssicles
3- Stapes 3- Stapes
4- Tympanic 4- Tympanic Membrane Membrane (Eardrum)(Eardrum)
5- Round Window5- Round Window
6- Eustachian Tube6- Eustachian Tube
Eustachian TubeEustachian Tube
Connects middle ear and Connects middle ear and nasopharynxnasopharynx
Lumen shaped like two cones with Lumen shaped like two cones with apex directed toward middleapex directed toward middle
Mucosa has mucous producing cells Mucosa has mucous producing cells and ciliated cellsand ciliated cells
Eustachian tubeEustachian tube
AdultsAdults ant 2/3- ant 2/3-
cartilaginouscartilaginous post 1/3- bonypost 1/3- bony 45 degree angle45 degree angle isthmus 1-2 mmisthmus 1-2 mm nasopharyngeal nasopharyngeal
orifice 8-9 mmorifice 8-9 mm
ChildrenChildren longer bony portionlonger bony portion 10 degree angle10 degree angle isthmus largeristhmus larger nasopharyngeal nasopharyngeal
orifice 4-5 mm in orifice 4-5 mm in infantsinfants
Eustachian tubeEustachian tube
Usually closedUsually closed Opens during swallowing, yawning, Opens during swallowing, yawning,
and sneezing and sneezing Opening involves cartilaginous portionOpening involves cartilaginous portion Tensor veli palatini responsible for Tensor veli palatini responsible for
active tubal openingactive tubal opening No constrictor functionNo constrictor function
Eustachian tubeEustachian tube
Protection from nasopharyngeal Protection from nasopharyngeal sound and secretionssound and secretions
clearance of middle ear secretionsclearance of middle ear secretions ventilation (pressure regulation) of ventilation (pressure regulation) of
middle earmiddle ear
PathologyPathology
Edema, capillary engorgement, and PMN Edema, capillary engorgement, and PMN infiltrationinfiltration
Epithelial ulceration and granulation Epithelial ulceration and granulation tissuetissue
Fibrosis, influx of chronic inflammatory Fibrosis, influx of chronic inflammatory cellscells
Increased columnar and goblet cellsIncreased columnar and goblet cells OsteitisOsteitis Edema and polypoid changesEdema and polypoid changes
Otitis Media - DefinitionOtitis Media - Definition
Inflammation of the middle Inflammation of the middle earear
May also involve inflammation May also involve inflammation of mastoid, petrous apex, and of mastoid, petrous apex, and
perilabyrinthine air cellsperilabyrinthine air cells
Otitis Media - ClassificationOtitis Media - Classification
Acute OM - rapid onset of signs & sx, Acute OM - rapid onset of signs & sx, < 3 wk course< 3 wk course
Subacute OM - 3 wks to 3 mosSubacute OM - 3 wks to 3 mos Chronic OM - 3 mos or longer Chronic OM - 3 mos or longer
OM - EpidemiologyOM - Epidemiology
AgeAge RaceRace Day careDay care SeasonsSeasons
GeneticsGenetics Breast-feedingBreast-feeding Smoke exposureSmoke exposure Medical conditions Medical conditions
OM - EpidemiologyOM - Epidemiology
Increasing incidence?Increasing incidence? Increases after newborn periodIncreases after newborn period 2/3 with AOM by one year of age2/3 with AOM by one year of age 1/2 with >3 episodes by three years1/2 with >3 episodes by three years most common in 6 - 11 mos most common in 6 - 11 mos
OM - persistent middle ear OM - persistent middle ear effusion (MEE)effusion (MEE)
High incidence of MEE, avg of 40 High incidence of MEE, avg of 40 daysdays
Children less that 2 years much more Children less that 2 years much more likely to have persistent MEElikely to have persistent MEE
White children with higher incidence White children with higher incidence of MEEof MEE
Otitis Media - RaceOtitis Media - Race
Higher incidence in:Higher incidence in: EskimosEskimos Native AmericansNative Americans Australian and African aboriginesAustralian and African aborigines
OM - Day Care OM - Day Care
Greater risk of AOM in children < 3 Greater risk of AOM in children < 3 yearsyears
Home care best, large group day care Home care best, large group day care worstworst more exposures with wider range of floramore exposures with wider range of flora increased URI’sincreased URI’s more frequent visits to MD to decrease more frequent visits to MD to decrease
parental leave time from workparental leave time from work
OM - Breast-feedingOM - Breast-feeding
Decreases incidence of URI and GI Decreases incidence of URI and GI diseasedisease
Inverse relationship between Inverse relationship between incidence of OM and duration of incidence of OM and duration of breast-feedingbreast-feeding
Protective factor in breast-milk?Protective factor in breast-milk?
OM - smoke exposureOM - smoke exposure
Induces changes in respiratory tractInduces changes in respiratory tract Increased otorrhea, chronic and Increased otorrhea, chronic and
recurrent AOM in children with hx of recurrent AOM in children with hx of parental smokingparental smoking
OM - Medical ConditionsOM - Medical Conditions
Cleft palateCleft palate decreases after decreases after
repairrepair Craniofacial Craniofacial
disordersdisorders Treacher-CollinsTreacher-Collins
Down’s syndromeDown’s syndrome Ciliary dysfunctionCiliary dysfunction
Immune dysfunctionImmune dysfunction AIDSAIDS steroids, chemosteroids, chemo IgG deficiencyIgG deficiency
ObstructionObstruction NG tubesNG tubes NT intubationNT intubation adenoidsadenoids malignancymalignancy
PathologyPathology
Eustachian tube abnormalitiesEustachian tube abnormalities Impaired openingImpaired opening shorter tubeshorter tube
Impaired immunityImpaired immunity children have poorer immune responsechildren have poorer immune response less cytokines in nasopharynx in children with OMless cytokines in nasopharynx in children with OM
Inflammatory mediatorsInflammatory mediators Bacterial products induce inflam response with IL-1, Bacterial products induce inflam response with IL-1,
IL-6, and TNFIL-6, and TNF AllergyAllergy
MicrobiologyMicrobiology
S. pneumoniaeS. pneumoniae - 30-35% - 30-35% H. influenzaeH. influenzae - 20-25% - 20-25% M. catarrhalisM. catarrhalis - 10-15% - 10-15% Group A strep - 2-4%Group A strep - 2-4% Infants with higher incidence of gram Infants with higher incidence of gram
negative bacillinegative bacilli
VirologyVirology
RSV - 74% of middle ear isolatesRSV - 74% of middle ear isolates RhinovirusRhinovirus Parainfluenza virusParainfluenza virus Influenza virusInfluenza virus
Chronic MEE Chronic MEE
Previously thought sterilePreviously thought sterile 30-50% grow in culture30-50% grow in culture over 75% PCR +over 75% PCR + Usual organismsUsual organisms
DiagnosisDiagnosis
Acute OMAcute OM preceding URIpreceding URI fever, otalgia, fever, otalgia,
hearing loss, hearing loss, otorrheaotorrhea
may have assoc may have assoc constitutional sxconstitutional sx
Chronic MEEChronic MEE poss asymptomaticposs asymptomatic hearing losshearing loss ““plugged”plugged” ““popping”popping”
DiagnosisDiagnosis Pneumatic otoscopy is Pneumatic otoscopy is
gold standardgold standard Color - opaque, yellow, Color - opaque, yellow,
blue, red, pinkblue, red, pink Position - bulging, Position - bulging,
retractedretracted Mobility - normal, Mobility - normal,
hypomobile, neg pressurehypomobile, neg pressure Assoc pathology - perfs, Assoc pathology - perfs,
cholesteatoma, cholesteatoma, retraction pocketsretraction pockets
Head & neck examHead & neck exam
DiagnosisDiagnosis
AudiogramAudiogram document CHL, SNHL, baseline, preopdocument CHL, SNHL, baseline, preop sooner if high risksooner if high risk
ImpedanceImpedance Acoustic reflexesAcoustic reflexes
Treatment - AOMTreatment - AOM
Adults and older children - Adults and older children - observation?observation?
Antibiotics - consider drug resistance Antibiotics - consider drug resistance patternspatterns Amoxil - not for Amoxil - not for BB lactamase + lactamase + TMP-SMT - not for group A strepTMP-SMT - not for group A strep Need high middle ear concentrationsNeed high middle ear concentrations
AntibioticsAntibiotics
First lineFirst line Amoxil - 60-90 mg/kg divided tidAmoxil - 60-90 mg/kg divided tid Ceftin - B lactam stableCeftin - B lactam stable Augmentin - B lactam stableAugmentin - B lactam stable Bactrim, PediazoleBactrim, Pediazole
Second lineSecond line AugmentinAugmentin CeftinCeftin RocephinRocephin Macrolides - Zithromax, BiaxinMacrolides - Zithromax, Biaxin
Treatment - Recurrent AOMTreatment - Recurrent AOM
ChemoprophylaxisChemoprophylaxis Sulfisoxazole, amoxicillin, ampicillin, pcnSulfisoxazole, amoxicillin, ampicillin, pcn less efficacy for intermittent propylaxisless efficacy for intermittent propylaxis
Myringotomy and tube insertionMyringotomy and tube insertion decreased # and severity of AOMdecreased # and severity of AOM otorrhea and other complicationsotorrhea and other complications may require prophylaxis if severemay require prophylaxis if severe
AdenoidectomyAdenoidectomy 28% and 35% fewer episodes of AOM at first and 28% and 35% fewer episodes of AOM at first and
second yearssecond years
Treatment - OMETreatment - OME
MEE > 3 mos or assoc hearing loss, MEE > 3 mos or assoc hearing loss, vertigo, frequency, ME pathology, vertigo, frequency, ME pathology, discomfortdiscomfort
AntibioticsAntibiotics shown to be of benefit, 75% PCR + bacterial DNAshown to be of benefit, 75% PCR + bacterial DNA
Antibiotics + steroidAntibiotics + steroid 21% improvement compared to abx alone21% improvement compared to abx alone
Myringotomy & tympanostomy +/- Myringotomy & tympanostomy +/- adenoidectomyadenoidectomy
Tympanostomy tube Tympanostomy tube insertioninsertion
Recurrent MEE with excessive Recurrent MEE with excessive cumulative durationcumulative duration
Recurrent AOM - >3/6 mos or >4/12 Recurrent AOM - >3/6 mos or >4/12 mosmos
Eustachian tube dysfunctionEustachian tube dysfunction Suppurative complicationSuppurative complication
ComplicationsComplications IntratemporalIntratemporal
hearing losshearing loss TM perforationTM perforation CSOMCSOM retraction pocketsretraction pockets cholesteatomacholesteatoma mastoiditismastoiditis petrositispetrositis labyrinthitislabyrinthitis adhesive OMadhesive OM tympanosclerosistympanosclerosis ossicular dyscontinuity and ossicular dyscontinuity and
fixation fixation facial paralysisfacial paralysis cholesterol granulomacholesterol granuloma necrotizing OEnecrotizing OE
IntracranialIntracranial meningitismeningitis extradural abscessextradural abscess subdural empyemasubdural empyema focal encephalitisfocal encephalitis brain abscessbrain abscess lateral sinus thrombosislateral sinus thrombosis otitic hydrocephalusotitic hydrocephalus
adhesive OMadhesive OM
TM perforationTM perforation
CSOMCSOM (dry) (dry)
CSOMCSOM
cholesteatomacholesteatoma
tympanosclerosistympanosclerosis