AOM & OME PDF

re i i ii v.v u Acute otitis media Dr. Abdullah Alkhalil MRCS-ENT(UK), DOHNS(London) Higher specialty(JUST), Jordanian Board.  Inflanalmed Otitis Media Otitis media is an inflammation of part or a...

re i i ii v.v u Acute otitis media Dr. Abdullah Alkhalil MRCS-ENT(UK), DOHNS(London) Higher specialty(JUST), Jordanian Board.  Inflanalmed Otitis Media Otitis media is an inflammation of part or all of the mucosa of the middle-ear cleft, the collective term for the eustachian tube, tympanic cavity, and mastoid air cells. eustachian tube Mastoid air as  Otitis Media Classification of otitis media. Acute Otitis Media Suppurative Nonsuppurative Recurrent Chronic Otitis Media I Suppurative Tubotympanic Cholesteatoma Nonsuppurative Otitis media with effusion  Otitis Media Acute OM - rapid onset of signs & symptoms, < 3 wk course up 3rem Subacute OM - 3 wks to 3 mos 3Wh Chronic OM - 3 mos or longer Recurrent otitis media – 3 attacks in 6 months or 4 attacks in one year 3 oct Guns 4m17s  Otitis Media The eustachian tube appears to be central to the pathogenesis of all forms of OM. The normal physiologic functions of the eustachian tube are to (1) maintain the gaseous pressure within the middle ear cleft at a level that approximates I atmospheric pressure; (2) prevent reflux of the I contents of the nasopharynx into the middle ear; and (3) clear secretions from the middle ear by both mucociliary transport and a “pump action” of the eustachian tube. Middle ear is air filled, mucosa lined and sterile cavity Nasopharynx has normal flora which should not reflux normally Opening of eustachian tube (pump action) is mediated by tensor velli palatini & levator velli palatini which contracts during chewing  Otitis Media no Shorter, more horizontal and wider in children viralInte congestionedema a I.IEEiio Eustachiantube occlusion 1August in ear Negprove Middle Aumoffiddies Yawning diffuse satistidin one  Acute suppurative otitis media I EPIDEMIOLOGY Peak incidence in the first two years of life (esp. 6-12 months) Boys more affected girls 50% of children 1 yr of age will have at least 1 episode. 1/3 of children will have 3 or more infections by age 3 90% of children will have at least one infection by age 6. Occurs more frequently in the winter months  Acute suppurative otitis media Factors relevant to the epidemiology of otitis media. Environmental Factors Day-care attendance More transmission Not being breast-fed mounted Exposure to tobacco smoke Damages cilia Seasonal variation in respiratory infections Winter → URTI Host Factors Genetics Immunodeficiency Birth defects Cleft palate Bcz of weak insertion of tensor velli palatini on median raphe Down syndrome e of soft palate with subsequent dysfunction of eustachian tube Adeniods (nasal obstruction, eustachian obstruction, bacterial reservoir) u u  Acute suppurative otitis media Pathogenesis In most cases of AOM, an antecedent viral upper respiratory tract infection leads to disruption of eustachian tube function. Inflammation of the middle ear mucosa results in an effusion, which cannot be cleared via the obstructed eustachian tube. This effusion provides a favorable medium for proliferation of bacterial pathogens, which reach the middle ear via the eustachian tube, resulting in suppuration.  Acute suppurative otitis media Pathogenesis Although viral infection is important in the pathogenesis ofEAOM, the majority of patients develop subsequent bacterial colonization, and therefore AOM should be considered a predominantly bacterial infection. Many studies, using tympanocentesis, have identified Streptococcus pneumoniae (up to 40%), Haemophilus influenzae (25–30%), and Moraxella catarrhalis (10–20%) as the organisms most commonly responsible for AOM. Less frequently identified pathogens include group A streptococci, Staphylococcus aureus, and gram-negative organisms such as Pseudomonas aeruginosa.  Acute suppurative otitis media Pathogenesis There are two mechanisms by which the adenoids may influence OM: (1) physical obstruction of the eustachian tube when the adenoids are enlarged and (2) a reservoir of pathogenic bacteria harbored in the adenoid tissue, which predisposes the patient to repeated episodes of AOM. Physiological hypertrophy between 3-9 years  Acute suppurative otitis media SIGNS & SYMPTOMS Neonates/Infants: change in behavior, irritability, tugging at ears, decreased appetite, vomiting. Children(2-4): otalgia, fever, noises in ears, cannot hear properly, changes in personality Children (>4): complain of ear pain, changes in personality  Acute suppurative otitis media SIGNS & SYMPTOMS Preceding URTI 00 Pain, which may increase rapidly in intensity to become deep and throbbing. Blocked ear sensation. Fever. Deafness progresses as suppuration occurs and both symptoms may rapidly improve if rupture of the tympanic membrane produces a mucopurulent otorrhoea.  Acute suppurative otitis media SIGNS & SYMPTOMS Dull tympanic membrane on examination. Hyperaemia rapidly follows and leashes of vessels may be seen running along or parallel to the malleus handle. Soon radial vessels are visible on the drumhead and a middle ear effusion occurs. The drumhead takes on a full, red, angry appearance. Pressure necrosis cause drumhead to rupture allowing mucopus to drain into the external ear canal.  Acute suppurative otitis media Left side bcz cone of light on left Right side bcz cone of light on right Angry tympanic membrane, Perforation, 90-95% resolves completely with antibiotic treatment. Acute suppurative otitis media I Dx is clinical by Hx, Otoscope & Pneumatoscope: push air and see no mobility of membrane  Acute suppurative otitis media Treatment Goals: Decreasing the duration of fever and pain Expediting the resumption of normal activity Limiting the small potential for suppurative complications  Acute suppurative otitis media Treatment NONSURGICAL MEASURES 1. Watchful waiting— without antibiotic therapy for healthy 2-year-olds or older children with nonsevere illness (mild otalgia and fever < 39 °C) because AOM symptoms improve in most within 1–3 days. Watchful waiting is not recommended for children < 2 years old if AOM is certain.  i Acute suppurative otitis media Treatment NONSURGICAL MEASURES 2. Antibiotic therapy T to sus troll Augmentin (amoxicillin/clavulanate) 90 mg/kg/day divided bid for 10-14 days. Ceftin (cefuroxime axetil [a second generation cephalosporin]) 30 mg/kg/day divided bid Rocephin (ceftriaxone) 50 mg/kg/dose IM/IV q day for 3 days  Acute suppurative otitis media Treatment NONSURGICAL MEASURES 2. Antibiotic therapy For penicillin allergic children, trimethoprim/sulfamethoxazole or erythromycin/sulfisoxazole sulfafurazole are the initial choices  Acute suppurative otitis media Treatment NONSURGICAL MEASURES 3. Adjunctive therapy—The adjunctive therapy for AOM should include analgesics and antipyretics. 4. Conditions predisposing to ASOM should be treated on their own merit after resolution.  Acute suppurative otitis media Treatment Myringomyd SURGICAL MEASURES A minority of patients with AOM fail to respond to medical therapy or develop a complication. Myringotomy is then indicated to allow the drainage of pus from the middle ear space. Surgical cut (myringotomy) has clear edges so healing is much more (within 2 days) than spontaneous rupture with necrotic edges. Acute suppurative otitis media I  Acute suppurative otitis media INDICATIONS FOR TYMPANOCENTESIS Toxic appearing child Failed treatment regimen with antibiotics Suppurative complications Immunosuppressed pt. Newborn infant in which the usual pathogens may not be the case.  Acute suppurative otitis media Sequel of ASOM Non-suppurative middle-ear effusion. These persist for over 30 days fg in 40% of children and for over 3 months in 10%. High-tone sensorineural to hearing loss, perhaps secondary to bacterial toxins migrating across the round window. Tympanic membrane perforation.  Acute suppurative otitis media Sequelae of ASOM Adhesions between the tympanic membrane, ossicles and the medial wall of the middle ear. Tympanosclerosis which may spread from the tympanic membrane to the ossicular chain, fixing the latter. Erosion of the ossicular chain, in particular the long process of the incus, especially following recurrent episodes of ASOM. Acute suppurative otitis media Typmanosclerosis, can lead to conductive hearing loss if it goes to middle ear and ossicles involved I Complete adhesion  OTITIS MEDIA WITH EFFUSION Otitis media with effusion is defined as the persistence of a serous or mucoid middle ear E effusion for 3 months or more. Various terms, such as chronic secretory otitis media, chronic serous otitis media, and “glue ear,” have been used to describe the same condition. Nonsterile non suppurative fluid (there is bacteria but no pus, no fever no pain) → decreased hearing a  OTITIS MEDIA WITH EFFUSION It is the most common cause of hearing loss in children in the developed world and has peaks in incidence at 2 and 5 years of age. The risk factors for OME are closely interrelated with those associated with AOM. In fact, the formation of a middle ear effusion frequently occurs after an episode of AOM, I and children with OME are far more likely to suffer from recurrent AOM.  OTITIS MEDIA WITH EFFUSION Pathogenesis Under normal conditions, the middle ear mucosa constantly secretes mucus, which is removed by mucociliary transport into the nasopharynx via the eustachianE tube. As a consequence, factors resulting in an overproduction of mucus, an impaired clearance of mucus, or both can result in the formation of a middle ear effusion.  OTITIS MEDIA WITH EFFUSION Pathogenesis Both viral and bacterial infection can lead to the increased production and viscosity of secretions from the middle ear mucosa. Eustachian tube dysfunction Barotrauma(scuba diving) Exposure to smoking  Asymptoed Usually OTITIS MEDIA WITH EFFUSION c SYMPTOMS AND SIGNS Asymptomatic Decreased hearing. School !! Decreased performance Delayed speech in younger children Blocked ear Rarely earache, tinnitus, or balance disorder may be present.  OTITIS MEDIA WITH EFFUSION SYMPTOMS AND SIGNS 0 Otoscopy classically reveals a dull gray- or yellow colored tympanic membrane that has reduced mobility on pneumatic otoscopy. If the tympanic membrane is translucent, an air- fluid level or small air bubbles within the middle ear effusion may be seen. OTITIS MEDIA WITH EFFUSION LOSING  OTITIS MEDIA WITH EFFUSION SPECIAL TESTS Type A, normal pressure & mobility → normal tympanometery Type B: flat graph → OME Type C: there is mobility but to the ⊖ side → ⊖ middle ear pressure → beginning of middle ear problems  OTITIS MEDIA WITH EFFUSION SPECIAL TESTS Audiometery Conductive hearing loss https://youtu.be/acYMy9b0F2A  OTITIS MEDIA WITH EFFUSION Treatment OBSERVATION I A large number of patients with OME require no treatment, particularly if the hearing impairment is mild. Spontaneous resolution occurs in a significant proportion of patients. A period of watchful waiting of 3 months from the onset (if known) or from the diagnosis (if onset unknown) before considering intervention is therefore advisable.  OTITIS MEDIA WITH EFFUSION Treatment NONSURGICAL MEASURES Medical treatments include antibiotics, steroids, decongestants, and antihistamines. o ↓ Antibiotics inflammation around eustachian tube to Steroids enhance drainage  OTITIS MEDIA WITH EFFUSION Treatment Erred The surgical options for OME are tympanostomy tubes and adenoidectomy. Myringotomy and aspiration of middle ear effusion without ventilation tube insertion has a short-lived benefit and is not recommended.  OTITIS MEDIA WITH EFFUSION Treatment Replace function of eustachian tube 1. Insertion of tympanostomy tubes—The aim of tympanostomy tube insertion is to allow ventilation of the middle ear space—hence to improve hearing thresholds. The prolonged ventilation of the middle ear may also allow resolution of chronic inflammation of the middle ear mucosa. Complications include myringosclerosis, purulent otorrhea, and residual perforation after extrusion.  Ventilation tubes Short term tubes are extruded within 6-12 months with 3% risk of persistent perforation. Long duration ventilation tube (T tube), used after extrusion of the first one but get OME again. They are more effective, stays 2-4 years but much more risk of persistence of perforation  OTITIS MEDIA WITH EFFUSION Treatment 2. Adenoidectomy— The rationale for adenoidectomy is that it relieves nasal obstruction, improves eustachian tube function, and eliminates a potential reservoir of bacteria.