otitis media with effusion ome
DESCRIPTION
Acute Otitis Media with EffusionTRANSCRIPT
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 wintersMore than a third of consultations to pediatricians each yearEach episode of ASOM increases odd ratio of developing OME
by 12Chinese children have lower prevalenceM > F
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Aetiology
2012
ET DysfunctionObstruction
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 SecretionsAllergy
Milk Cigarette smoke (specially mother smoking) GERD
Infections Unresolved AOM Viral Infections
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Pathogenesis
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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 yearsGender ( Males > Females)Race (Caucasian)Genetic predisposition Sibling with history of OMEDown’s syndrome, cleft palate, tumors,
immunodeficiency statesPoor mastoid pneumatizationMaxillectomyProlonged intubationCystic fibrosis
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2012
AllergiesSecond hand smoke + wood burning stovesNot breastfeedingSeasonal - wintersAttending day care centre with > 4 childrenLow socioeconomic groupUse of pacifiers
Risk Factors: Environment 9
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Clinical Features: Symptoms
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Hearing lossMild otalgiaEar fullnessTinnitus
Children Delayed Speech Poor Academics
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Clinical Features: Signs
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Hearing Loss - TFTOtoscopy (sensitivity 85 – 93%)
Signs of retraction Loss of light reflex Colour – Yellow/Grey/ Blue Stage of retraction
Signs of Effusion Air Bubbles Fluid 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’s Increasing 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
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Newer methods
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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
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Post rhinoscopyNasopharyngoscopyEBV titres (in adults)
EBV IgA anti VCA EBV IgA anti EA
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Treatment
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Medical Treatment Decongestants
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) Grommet T 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
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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 atelectasisTM atrophy Retraction Pockests
Cholesteatoma
Ossicular NecrosisTympanosclerosis
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Thank You
2012
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