DR. SUPREET SINGH NAYYAR, AFMC

2012

OTITIS MEDIA WITH EFFUSION

(OME)1

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Synonyms

2012

Serous Otitis Media

Secretory Otitis Media

“Glue Ear”

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Definition

2012

Chronic accumulation of mucus within middle ear and sometimes mastoid air cell system

Time that fluid has to be present for the condition to be chronic is usually taken as 12 weeks (Scott Brown)

Affects children Insidious onset Sterile effusion in middle ear Behind an intact but retracted TM With hearing loss

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Epidemiology

2012

First Episode 50% of all children- before the first birthday 80% of all children - before the third birthday

Scott Brown – Prevalence bimodal at 2 & 5 yrs when child first attends playgroup school & when goes to primary school

Above 15 yrs prevalence 0.6% More during winters More than a third of consultations to pediatricians each year Each episode of ASOM increases odd ratio of developing OME

by 12 Chinese children have lower prevalence M > F

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Aetiology

2012

ET Dysfunction Obstruction

Adenoid hyperplasia Tumours (nasopharyngeal carcinoma) Palatal defects Barotrauma Hyperbaric oxygen therapy Oedema during radiation therapy

Spread of Infection Chronic adenoiditis Chronic rhino-sinusitis Chronic tonsillitis High prevalence in HIV patients

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Aetiology contd.

2012

Increased Secretions Allergy

Milk Cigarette smoke (specially mother smoking) GERD

Infections Unresolved AOM Viral Infections

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Pathogenesis

2012

Eustachian tube dysfunction Failure of aeration Failure of drainage

Increased secretion in ME Increase in secretory glands

Spontaneous resolution if Drainage via ET restablished Perforation of the tympanic membrane

If both continue OME

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Risk Factors: Host

2012

Age < 2 years Gender ( Males > Females) Race (Caucasian) Genetic predisposition Sibling with history of OME Down’s syndrome, cleft palate, tumors,

immunodeficiency states Poor mastoid pneumatization Maxillectomy Prolonged intubation Cystic fibrosis

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2012

Allergies Second hand smoke + wood burning stoves Not breastfeeding Seasonal - winters Attending day care centre with > 4 children Low socioeconomic group Use of pacifiers

Risk Factors: Environment 9

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Clinical Features: Symptoms

2012

Hearing loss Mild otalgia Ear fullness Tinnitus

Children Delayed Speech Poor Academics

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Clinical Features: Signs

2012

Hearing Loss - TFT Otoscopy (sensitivity 85 – 93%)

Signs of retractionLoss of light reflexColour – Yellow/Grey/ BlueStage of retraction

Signs of EffusionAir BubblesFluid Levels

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Clinical Features: Signs

2012

Pneumatic Otoscopy Used to assess the mobility and position of TM Observe TM movement by

Increasing Pressure in EAM – Siegel’sIncreasing pressure in ME - Valsalva

Mobile/ Partially Mobile/ Immobile

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Evaluation

2012

Audiometry (sensitivity 92 %) Pure Tone Audiometry Bilateral Conductive Hearng Loss

Air-Bone Gap 20 – 40 dB

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Evaluation

2012

Tympanometry (sensitivity 96 %) Assess compliance of TM Mobility of TM on increase/ decrease of pressure in EAM Graphic representation 4 patterns

A/As/Ad/B/C In OME – B & C

William’s test for ET patency

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Tympanogram

2012

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Newer methods

2012

Sonotubometry

Acoustic reflectometry

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Evaluation

2012

Radiology Xray Skull Lateral View

Adenoid Hyperplasia Xray Mastoid Schuller’s View

Clouding MRI

Absence of fluid does not imply an absence of OME, as one-third of patients in MRI study had fluid in mastoid, but not in the mesotympanum (Kew et al)

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Nasopharynx evaluation

2012

Post rhinoscopy Nasopharyngoscopy EBV titres (in adults)

EBV IgA anti VCA EBV IgA anti EA

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Treatment

2012

Medical TreatmentDecongestants

Systemic Triaminic Syr 5-10 ml 8 hrly

• Phenylpropanolamine 12.5 mg/5ml• Chlorpheniramine 2 mg/5ml

Actifed Tab ½ tab BD/ TDS Pseudoephedrine 25 mg Triprolidine 2.5 mg

Local Nasivion – Oxymetazoline 0.05% drops Otrivin – Xylometazoline 0.1% drops

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Treatment

2012

Medical Treatment Anti-allergy measures

Antihistamines – Azelastine 2mg daily x 8 wks proven to be beneficial

Topical Nasal Steroids Surface tension lowering agent

N acetyl cyteine 30 mg tds X 15 days beneficial Antibiotics (no long term benefit, can be used for initial 2

wks) Amoxycillin Augmentin

Middle Ear Aeration Valsalva Manouevre Politzerisation

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Treatment

2012

Surgical Treatment Myringotomy Myringotomy with ventillation tubes (improves hearing by 12

dB)GrommetT Tubes

Adenoidectomy (improves hearing by 8 dB) Tonsillectomy Cortical Matoidectomy (in failure of ventilation tube cases) Research methods

Percutaneous mastoid vent following CM CO2 assisted 2 mm circular perforation in AI quadrant for adult OME

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Ventilation tubes

2012

Longer a tube stays in situ longer it can be potentially of benefit

On other hand, longer a tube is in situ the greater the chance of complications Infection Granulation tissue Permanent perforation Thinning of TM with possible retraction

However, in adults T-tubes are justified routinely, as in them OME is likely to be persistent over years rather than months

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Types

2012

Grommet Stay upto 6 mths T tubes stay upto 1-2 yrs Materials for tubes

Silicone Teflon Stainless steel Titanium Gold

Few names (see photographs on next slide) Shepard Armstrong Reuter Bobbin Goodle

Can be inserted AI or PI quad Stay longer in AI quadrant Guttenplan et al. (scott brown) no difference in radial vs

circumferential incision

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Complications of ventilation tubes

2012

Intra op Displacement into middle ear Damage to ossicles

Early post op Blockage of tube by blood Granulation around tube Ear infection Otorrhoea

Late post op Permanent perforation Tympanosclerosis TM atrophy & retraction

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Sequelae of OME

2012

Adhesive Otitis Media / TM atelectasis TM atrophy Retraction Pockests

Cholesteatoma Ossicular Necrosis Tympanosclerosis

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Thank You

2012

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