jennifer taylor, arnp otolaryngology seattle children’s hospital
TRANSCRIPT
THE DEVELOPING EAR
Jennifer Taylor, ARNP
Otolaryngology
Seattle Children’s Hospital
Learning Objectives
Ear development in utero Parts of the ear: Outer ear, middle ear,
inner ear Ear Exam: use of otoscope,
tympanometry, positioning of patient Other findings: congenital anomalies of
the ear such as tags, pits, microtia When to refer
Development of Ear in Utero
Structural ear development starts in the first 20 weeks’ gestation
Sensorineural part of the auditory system develops primarily after 20 weeks' gestational age
Auditory system functional at 25 weeks 25 weeks gestation to 5/6 months old
most critical time for hair cells (sensorineural hearing)
Parts of the Ear
Outer Ear
Auricle (also referred to as pinna), ear canal, outer part of tympanic membrane
Protects tympanic membrane Produces cerumen Directs sound through ear canal Can be reshaped if necessary during the
fIrst few months of life d/t circulating estrogen (must start before 6 weeks of age)
Middle Ear
Air filled cavity behind tympanic membrane
Location of three smallest bones in bodyMalleus (hammer)Incus (anvil)Stapes (stirrup)
Opening of Eustachian tube
Describing the Tympanic Membrane
Front of F
aceRight Ear Right Ear
Inner Ear
Semicircular canals Vestibule Cochlea
Inner Ear cont’d Associated with hearing and balance. Tubes filled with fluid encased within the
temporal bone of the skull. Bony tubes (bony labyrinth ) contain a set
of cell membrane lined tubes. Filled with perilymph fluid, which the
membranous labyrinth tubes are filed with endolymph. This is where the cells responsible for hearing are located (the hairy cells of Corti).
Ear Exam
Positioning Tools Cartilaginous development of the ear
lobe, position of ears, shape of auricle (normal/abnormal), preauricular sinus or skin tags. External auditory canal patent.
Ear Exam cont’d
Pull downward and backward. This process will move the acoustic meatus in line with the canal. Hold the otoscope like a pen/pencil and use the little finger area as a fulcrum. This prevents injury should the patient turn suddenly.
Inspect the external auditory canal. Inspect tympanic membrane Inspect posterior ear and mastoid bone
Ear exam
Air inflation otoscopy (pneumatic-otoscope) is very useful to evaluate middle ear disease. Assess the mobility of tympanic membrane by applying positive and negative pressures with the rubber squeeze bulb.
Normal Ear exam Normal: Auditory canal: Some hair, often with yellow to
brown cerumen. Tympanic membrane
Pinkish gray in color , translucent and in neutral position.
Malleus lies in oblique position behind the upper part of drum.
Mobile with air inflation.
Causes for Hearing Loss or Abnormal Ear Development
Genetics Environmental: born premature, exposed to
ototoxic medications Infectious: CMV, TORCH, meningitis, family hx,
craniofacial abnormalities, birth weight <1.5kg, neonatal hyperbilirubinemia, Apgar <4 at 1 minutes, <6 at 5 minutes, prolonged NICU stay or ECMO or mechanical vent, exposure to ototoxic meds.
When to refer
Hearing loss Suspect hearing loss with behavioral
issues, speech issues, ask about newborn hearing screen
Congenital anomaly of ear
EARACHE: OTITIS MEDIA AND BEYOND
Ronna K. Smith, MN, ARNPOtolaryngology
Seattle Children’s Hospital
Objectives Definition of OME and AOM by current standards
and visualization Current national guidelines for diagnostic criteria of
AOM Pharmacology for AOM and OME Referral guidelines to Otolaryngology and
indications for PE tube placement Hands-on practice with otoscopy and identification
of signs of AOM and OME
Otalgia
Differential diagnosisAOMOMEOETMJ dysfunctionBruxismDental pain, teething?Tonsil or throat pain
Diagnoses
Otitis media: acute, chronic, recurrent OME: middle ear effusions
Acute Otitis Media
Commonly defined as inflammation of the middle ear
Results in rapid onset of symptoms: otalgia, fever, irritability, anorexia, or vomiting
Often associated with upper respiratory infection
Acute Otitis Media
One of the most common reasons for young children to visit the primary care provider
Morbidity and mortality common before the introduction of antibiotics/vaccines
80-90% of children have had at least one episode of AOM by the age of 10
Peak incidence between 6-18 months
Acute Otitis Media Factors influencing incidence:
Age under 2 years, male gender, certain ethnic backgrounds
Eustachian tube functionDaycareOlder siblingsExposure to cigarette smokeAllergyCraniofacial disordersImmune function
AOM: Symptoms and Presentation
Fever (~50%), irritability, waking at night Anorexia, vomiting, diarrhea, balance
problems, decreased hearing Often preceded by URI symptoms
(~50%), increased incidence in winter months
AOM: Diagnosis “Diagnostic certainty” requires the
presence of:Acute onset of symptomsPresence of effusion-bulging TM or poor
mobilityEvidence of inflammation
(AAP Clinical Practice Guideline, 2004, updated 2013)
AOM: Microbiology in the post-Prevnar era
Strep pneumoniae-can vary in pcn resistance
non-typeable H. InfluenzaeMOST are beta-lactamase positiveAssociated purulent conjunctivitis makes H.
Flu more likely
M. catarrhalis (nearly 100% beta-lactamase positive)
AOM: Treatment
60-80% of acute OM will clear spontaneously (Rosenfeld, 1995)60% in 24 hours, 80% in 72 hours
Some studies suggest resolution rate is higher and complication rate lower if antimicrobials are used.
S. pneumoniae is often the cause of persistent otitis and is associated with a large number of otitis complications
AOM: Treatment High dose amox has been the main
recommendation for s. pneumoniae (>50% of cases of AOM historically)
Daycare, <2 yrs, abx in prev 3 mos=more likely to have resistant s.pneumoniae
Post-Prevnar: less s. pneumoniae, more non-typeable h. influenzae
High dose amox is STILL the first line (AAP, 2013) because of safety profile, high likelihood of effectiveness.
AOM: Treatment The ‘observation’ option:
Limit management to symptom relief in selected patients
Caregiver must have means of communication
Must be a system for re-evaluationChild should be healthy >6 months of age
Antibiotic Choice First line: high dose Amoxicillin (80-90
mg/kg/day) “Treatment failure” means persistence of
symptoms-pain, fever. Persistence of effusion does NOT mean treatment failure
2nd line: Augmentin with high amoxicillin concentration
If allergic to penicillin: Cefdinir, azithromycin, clarithromycin, erythromycin
For true treatment failure: Rocephin injections for 1-3 days.
Pain
Management of pain should be addressed regardless of antibiotic use.
AnalgesicsOral analgesics: Tylenol, IbuprofenBenzocaine/antipyrene (Auralgan) dropsHerbal drops, garlic drops, warm oil
Warm compresses Distraction Codeine
AOM: Complications Hearing loss (temporary, conductive)
COMMON Perforation of tympanic membrane-less
common, but not unusual Uncommon: cholesteatoma, retraction
pocket, ossicular discontinuity and fixation, mastoiditis, labrynthitis, facial paralysis, sensory neural hearing loss, intracranial infection.
AOM: When to Refer
3 episodes in 6 months, or 4 in one year Persistent middle ear fluid (3-6 months,
+/- hearing loss) Severe bouts of otitis media or
complicating issues, eg febrile seizures, Multiple medication allergies making
medical therapy difficult Developmental delay, heightened
concern for speech/language
Follow up Middle Ear Effusion commonly persists after AOM
60-70% of cases will have MEE at 2 weeks post AOM
40% will have MEE 1 month after AOM10% after 3 months (Teele, et al)
2 week follow up: hx of frequent OM, young infant, hx of prolonged OM, immunocompromised
1 month follow up: most children If effusions are still present, but no acute
signs….retreat? Refer for hearing test? Consider allergy management?
Otitis Media with Effusion: Basic Principles
Middle ear effusion (MEE) without signs and symptoms of acute infection
May occur spontaneously because of poor eustachian tube function, or may follow acute otitis media
May be acute or chronic More common than AOM: up to 90% of
children have had an episode of OME by school age
Otitis Media with Effusion: Basic Principles
Potential impacts: hearing, speech, language, learning, quality of life
Often accompanies upper respiratory infections
TM is typically retracted or neutral-not bulging
Symptoms: hearing loss, intermittent discomfort
OME: Diagnosis Pneumatic otoscopy is primary diagnostic
method. Tympanometry very helpful . White or amber colored discoloration to TM TM is often opaque Decreased or absent mobility Absence of acute OM s/s: pain, fever,
inflammation, bulging of TM This should NOT be treated as AOM!
Document….
Laterality: which side is it on? Mobility with pneumatic otoscopy Retraction pockets? Appearance of ossicles Be sure to document the duration of the
effusion if possible
OME: Treatment Observation: Document laterality, when
effusion was first observed and symptoms. Follow up periodically.
Medications: antibiotics and oral steroids may help in the short term, but effusion often recurs after course is complete.
Allergy treatment Tympanostomy tube placement for
persistent effusions, hearing loss ‘glue ear’ prolonged OME
Decision to Treat/Refer: Evaluate risk of developmental delays
Speech delayOME causing hearing lossAlready has DD
Evaluate likelihood of spontaneous resolutionFamily hx of needing tubesFamily hx of allergy, kid w/allergyTime of year
Otitis Media with Effusion
For children not at risk for developmental delaysObservation for 3 monthsHearing testing if OME lasts beyond 3 monthsLanguage testing if hearing loss occursFollow up every 1-3 months until OME is goneDecrease environmental risk factors (tobacco
smoke)Optimize listening and learning until effusion
resolves
Otitis Media with Effusion
In the setting of other developmental delaysEarly referral to OTONeeds hearing examMay have earlier recommendation for tubesConsider social setting—foster care, etc.
OME Treatment No evidence to support use of
decongestants, antihistamines, or steroids
No evidence to support long term effects of antibiotics - there has been some evidence of occasional short term benefit
Consider 10 day course of antibiotic and/or 5 day course of oral steroid as an option when tube placement is only other option
Ear Tubes (Pressure equalization-PE- or Tympanostomy tubes
The decision to place tubes is based on many factors…
-quality of life
-season, age
-presence of hearing loss/speech delay
-other co-morbid factors
-parents have reached ‘otitic exhaustion’
Bobbin or grommet style: last 6-12 months‘t-tube’ lasts 2 years
Care of PE tubes
Ok for swimming/bathing Treat drainage topically
No ototoxic drugsClear drainage and pump the tragus
Older kids and diving? F/U with audiology after extrusion F/U with surgeon ?
WHAT NOT TO MISS…
Ashley Sapin, ARNPOtolaryngology
Seattle Children’s Hospital
Why does my child have fluid behind their ear?
Persistent Effusions in “Non-complainers”
Why are these not okay?May be causing hearing lossPotential for retraction of the TM
and sequelae from chronic retraction
The longer fluid is present, the less likely it is to resolve spontaneously and more likely it is to have a negative impact
May be indicator of nasopharyngeal mass
Things to Note About Middle Ear Effusions
Anything obvious to treat?Allergic rhinitisSinusitis/RhinosinusitisChild drinking liquids while laying down
What do the effusions look like?Air bubbles?Air-fluid level?Color/texture of middle ear fluid?Position of eardrum?
When to Refer for Persistent Effusion
• In the presence of cognitive or sensory deficit– Speech and language acquisition and pronunciation– Reading– Behavioral- Poor focus or attention, abnormal family/peer interactions– Vestibular disturbance
• When the effusion has been present for 3 or more months– If hearing loss accompanies effusion, may be indication for ear tubes
• Underlying medical diagnosis– Abnormal ciliary function
• Primary ciliary dyskinesia• Cystic fibrosis
– Craniofacial abnormality or syndrome• Cleft palate• Submucous cleft palate• Trisomy 21• Craniofacial microsomia
Perforations & Retraction Pockets
Tympanic Membrane Perforation
Common Causes Abnormal middle ear pressure
○ Middle ear effusions○ Barotrauma
Foreign body○ Tympanostomy tubes○ Traumatic injury
Tympanic Membrane Perforation
Treatment If acute perforation with infection/otorrhea
○ Dry ear precautions○ Treat with antibiotic ear drops
Sulfacetamide-prednisolone Ciprodex Ofloxacin (+/- dexamethasone) Do NOT use gentamycin, tobramycin, or
cortisporin drops (ototoxic!)○ If in 1 month, no improvement and/or recurrent
otorrhea- ENT referral If vertigo or facial nerve involvement
○ Urgent ENT referral If chronic perforation
○ Non-urgent ENT referral
Retraction Pockets Cause
Eustachian tube dysfunction Potential Problems
Hearing loss○ Reduction of TM mobility○ Ossicular erosion
Granulation tissue formation Cholesteatoma formation
OrdersAudiogram (ENT will order)Referral to ENT
Retraction Pockets
Treatment Possibilities Watchful waiting Treat infection (if present) with
antibiotic ear drops Trial of steroid nasal spray if
allergic component Surgical intervention
○ Ear tube placement○ Excision of squamous debris
Cholesteatoma
Cholesteatoma Causes
Congenital- occur during fetal formation
Acquired○ Tympanic membrane perforation-
entryway for skin into middle ear○ Eustachian tube dysfunction○ Basal cell hyperplasia resulting from
infection○ Metaplasia resulting from chronic
irritation from middle ear infection
Cholesteatoma
SymptomsSensation of fullness in earHearing loss in affected ear- may be reported
by patient or found on audiogramDizzinessIntermittent or continuous otorrhea despite
treatmentFacial muscle weakness on affected sidePainful or painlessThere may be no symptoms at all…
SignsWhite mass behind intact tympanic membraneTympanic membrane perforation or retraction
pocketFocal granulation tissue on tympanic
membrane
Cholesteatoma
Treatment Imaging
○ CT○ MRI
Antibiotics if needed Surgical Intervention
○ 1st-Tympanomastoidectomy○ 2nd- May need additional surgery
Re-examination of middle ear space to confirm no regrowth of skin cells
Ossicular repair or prosthesis
Possible Complications Brain abscess Meningitis Labrynthitis Facial paralysis Deafness
Tympanosclerosis/Myringosclerosis
Calcification affecting connective tissue of tympanic membrane
Causes Previous otitis media Previous ear tubes Trauma to eardrum
May look like cholesteatoma- it isn’t Children with asymptomatic myringosclerosis
do not need ENT referral If symptomatic- then refer to ENT
Conductive hearing loss○ Surgical removal
Remove plaques (frequently refix to ossicles)
Middle ear reconstruction○ Hearing aids
Persistent Ear Drainage
Potential CausesAcute tympanic membrane rupture with acute otitis
mediaChronic tympanic membrane perforationAOM with patent ear tubesOtitis externa
○ Bacterial○ Fungal
Retained tympanostomy tubeCholesteatoma
(Remember, color of drainage may vary- serous, yellow, white, green, bloody…it can all be “normal” for otorrhea)
Persistent Ear Drainage Questions to ask
Any recent illness/co-morbid conditions?Frequency/recurrence of drainage?Do otic antibiotics help? Is there pain? (1-10, progressive, improve with drainage) Is there pruritis?Has child been swimming frequently/recently?Pain with external ear palpation?How is the patient’s hearing?Does the patient have ear tubes?
○ How long have these tubes been in place?○ When were they last seen by their ENT?
Retained Tympanostomy Tubes
Retained Tympanostomy Tubes Duration of Pressure Equilization (PE) tubes?
Armstrong/Reuter-Bobbin/Baxter○ Generally last 6-12 months ○ Should be in no longer than 2 years*
Soft T-Tubes○ Generally last 1-2 years○ Should be in no longer than 3 years*
Why remove retained PE tubes?○ Chronic TM perforation○ Infection of the PE tubes○ Persistent drainage○ Granulation tissue○ Most people outgrow the need for them
*There are always exceptions to this
CERUMEN AND FOREIGN BODIES: TAKE IT OR LEAVE
IT
Jennifer Hart, ARNP, CPNP
OtolaryngologySeattle Children’s Hospital
What the Wax?!?
Cerumen is the substance that is secreted by your ear canal
It protects the external auditory canal and the tympanic membrane
It contains antibacterial properties
Types of Cerumen Cerumen can be
sticky, hard or flakey
Multi colored: white, caramel, brown, black
When To Remove Cerumen
Only when it is a problemIf you suspect otitis media and can’t see TMIf there is hearing loss associated with
impactionIf there is pain due to impaction*If none of these exist, LEAVE IT ALONE
Home Methods
Q-Tips NO!!!! Debrox- yes Mineral/Olive Oil-yes ½ strength hydrogen peroxide- OK Ear Candling NO!!!! Wipe the bowl of the pinnae with warm
wet wash cloth
Safe removal
In clinic irrigation with warm water*caution do not shoot water directly down
the ear canalLoop curette, only if able to safely stabilize
childIf unable to clear refer to OTO but start on
home routine(Debrox, oil, ½ strength peroxide)
Fun With Foreign Bodies
When to Remove and when to Refer Remove if:
The object is easy to grasp with minimal chance of trauma or anxiety for the child.
You are able to safely restrain the child.If it is causing acute pain.
Why to Refer?
OTO has better equipmentBinocular microscope SuctionMultiple curettes and probesExperience to do this safely, with minimal
trauma and dramaAble to make the call for sedation
Remember
Don’t put anything smaller than your elbow in your ear. If you can put your elbow in your ear go ahead and use it to clean your ear.