Otitis Media With Effusion PDF

OTITIS MEDIA WITH EFFUSION Presenter: Dr.Abdallah B. Outline Introduction Epidemiology Pathophysiology Clinical Presentation Diagnosis Complications Management References INTRODUCTION Otitis media with effusion (OME) is characterized by a non-purul...

OTITIS MEDIA WITH EFFUSION Presenter: Dr.Abdallah B. Outline Introduction Epidemiology Pathophysiology Clinical Presentation Diagnosis Complications Management References INTRODUCTION Otitis media with effusion (OME) is characterized by a non-purulent effusion of the middle ear that may be either mucoid or serous. Symptoms usually involve hearing loss or aural fullness but typically do not involve pain or fever. Epidemiology The epidemiology of AOM and otitis media with effusion (OME) overlaps to such an extent that the risk factors apply to both conditions. Both environmental and host factors play a role in the epidemiology of OM. Epidemiology/Risk Factors Age Race Allergy Day care Seasons Genetics Breast-feeding Smoke exposure Medical conditions Epidemiology ▪ AGE ⚫ Incidence Increases after newborn period ⚫ 2/3 with AOM by one year of age ⚫ 1/2 with >3 episodes by three years ⚫ Most common in 6 - 11 months and it sharply declines in children older than 6 years Epidemiology cont… The reason for OME to be common in young children can be: 1.Poorly/underdeveloped immune mechanisms. 2.Short and more straight Eustachian tube. 3.Adenoids hypertrophy which can interfere ET opening mechanisms. Epidemiology cont… RACE Allergy Multivariate analysis There is controversy to this showed that African, pathogenesis Hispanics and other racial Allergy is a common problem groups were less likely to in children and usually have recurrent OM than occurs with URTI White children, possibly due to less access to care, Its found that OME is resulting in underdiagnosed higher in frequency in episodes of OM. allergic children then non allergic children of the same age Epidemiology cont… Day Care Greater risk of AOM in children < 3 years Home care best, large group day care worst more exposures with wider range of flora increased URI’s Epidemiology cont… Breastfeeding Smoke exposure Decreases incidence of URI Induces changes in and GI disease respiratory tract Inverse relationship Cotinine marker associated between incidence of OM with increased AOM and and duration of persistent effusion breast-feeding Increased pressure Protective factor in equalizing tube(PET), breast-milk? otorrhea, chronic and recurrent AOM in children with hx of parental smoking Medical Conditions Cleft palate ◦ decreases after repair Craniofacial disorders ◦ Treacher-Collins Down’s syndrome Ciliary dysfunction ,Immune dysfunction ◦ AIDS ◦ steroids, chemo ◦ IgG deficiency Obstruction ◦ NG tubes ◦ NT intubation ◦ adenoids ◦ malignancy PATHOPHYSIOLOGY PATHOPHYSIOLOGY OME usually occurs during the resolution of AOM once the acute inflammation has resolved. Two main theories of the cause of OME exist. The classic explanation proposes that Eustachian tube dysfunction is the necessary precursor. The Eustachian tube has been traditionally described to provide 3 main functions: equilibration of pressure between the middle and external ears, clearance of secretions, protection of the middle ear. Pathophysiology cont… Its dysfunction can be caused by any number of circumstances from anatomic blockage to inflammation secondary to allergies, upper respiratory tract infection (URTI), or trauma If present for long enough and with appropriate magnitude, the negative pressure elicits a transudate from the mucosa, leading to the eventual accumulation of a serous, essentially sterile effusion Because the eustachian tube is dysfunctional, the effusion becomes a sessile medium ideal for the proliferation of bacteria and resultant AOM. This classic model is somewhat incorrect, since multiple studies have revealed that the same pathogenic bacteria are present in OME as in AOM Pathophysiology cont.. Regardless of the cause of AOM, eustachian tube dysfunction is nearly universal in OME. Once the acute inflammation and bacterial infection have resolved, a failure of the middle ear clearance mechanism allows MEE to persist. E.g in ciliary dysfunction, mucosal edema, hyperviscosity of the effusion; and, possibly, an unfavorable pressure gradient Micro-organisms The same flora found in AOM can be isolated in OME. With OME, the inflammatory process has clearly resolved, and the volume of bacteria has decreased. However, because of the similarity of AOM and OME, reviewing the pathogenic organisms in AOM is worthwhile. Important Bacteria The most common bacteria in AOM,and OME in order of frequency, are Streptococcus pneumoniae,30-35% Haemophilus influenzae, 20-25% Moraxella catarrhalis.10-15% Group A strep - 2-4% Important Viruses The common viruses isolated by PCR RSV Inflenzavirus Adenovirus Parainfluenza Rhinoviruses MORTALITY AND MORBILITY OME is the leading cause of hearing loss in children. It is associated with delayed language development in children younger than 10 years. The loss is usually conductive,  CLINICAL PRESENTATION Children OME present with. Adults with OME present with ❖ hearing loss ❖ hearing loss ❖ delayed speech and language development ❖ Aural fullness ❖ poor social behavior ❖ Pulsatile or crackling tinnitus. ❖ Difficulties with balance. ❖ Autophony. ❖ Learning difficulties. Diagnosis Pneumatic otoscopy is gold standard Proper pneumatic otoscopy is important to distinguish between AOM and OME since the mngt is different. Diagnosis Every otoscopic examination should include description of the following 4 tympanic membrane(TM) characteristics: 1.Color: which is opaque yellow or blue in MEE. NB:color alone is not sufficient diagnostically.Its position and mobility is more important.Eg crying, nose blowing, fever or irritation to EAC can cause red TM. 2.Position: In AOM TM is bulging while in OME it is typically retracted or in neutral position. 3.Mobility: movement during negative pressure only suggest ETD. If it move slight in both positive and neg pressure it indicates MEE. Diagnosis Findings that suggest the presence of OME include observable air-fluid levels (which may be vertically oriented), serous middle ear fluid, and a translucent membrane with diminished mobility. Extensiveinflammation and purulent MEE should not be evident. OME can also be associated with negative pressure in the middle ear. Negative pressure is suggested by the prominence of the lateral process, a more horizontal orientation of the malleus, and movement only with negative pneumatoscopy  Diagnosis Tympanometry and audiometry are important adjuvant techniques used to evaluate pts with MEE. Tympanometry Diagnosis. Air fluid levels retracted right tympanic membrane ABNORMAL TM Bulging TM: COMPLICATIONS OF OME Intratemporal Intracranial TM perforation Meningitis CSOM Extradural abscess Cholesteatoma Subdural empyema Mastoiditis Focal encephalitis Petrositis Brain abscess Labyrinthitis Lateral sinus Adhesive OM thrombosis Tympanosclerosis Otitic hydrocephalus Ossicular dyscontinuity and fixation Facial paralysis Cholesterol granuloma LAB investigations. Traditionally, laboratory tests have rarely been used in the workup and diagnosis of OME unless another process is suspected. History taking and physical examination are sensitive and specific enough to facilitate accurate diagnosis and treatment of the disease. CULTURE- in some selected cases INVST ctd Plain radiography MRI CT scan MANAGEMENT Watchful waiting Modification of risk factors Medical treatment Surgery  Watchful waiting ⚫ 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. Modification of risk factors: Avoiding secondhand smoke Vaccination Breastfeeding whenever possible Avoidingfeeding, either by breast or bottle, while completely supine Avoiding exposure to a large number of children, particularly in daycare centers Avoiding exposure to children who are known to be affected Avoiding known allergens MEDICAL Management The strategies advocated in medical treatment includes:- Antimicrobials Antihistamine Intranasal steroids NSAIDs Mucolytics. Non surgical management of OME. Autoinflation Autoinflation with a nasal balloon three times a day for 1-3 months has increased the rate of normal tympanograms in children with OME.  SURGERY As with all surgery, the Indications for surgery benefits of intervention must outweigh the risks. i) OME with hearing loss of 40dB or more Previously, surgical intervention was advocated ii) tympanic if fluid persisted beyond 3 membrane changes e,g months. postero superior Therefore, in the presence retraction, and retraction of hearing thresholds better pockets. than 20 dB, observation is an option. MYRINGOTOMY AND ASPIRATION OF EFFUSION When performed alone without the placement of Pressure equalization tubes, this procedure has proved disappointing in long-term follow-up in children. It should be done with gromet tube insertion. Myringotomy and aspiration may be more reasonable treatment in adults. GROMET INSERTION PE tube in place MYRINGOTOMY… PE TUBE in right tympanic membrane Surgical management Adenoidectomy Tonsilectomy PROGNOSIS In general, the prognosis for OME is good. Most episodes spontaneously resolve without intervention, and many resolve undiagnosed. Still, 5% of children who are not treated surgically have persistent OME at 1 year. Surgical intervention significantly improves the prognosis in this population. References Head and neck surgery-Otorhinolaryngology 4th ed.by B.J.Bailey. Ballenger’s Otorhinolaryngology Head and neck surgery 16th ed.by James.B.Snow. Current Diagnosis&Treatment Otorhinolaryngology 2nd ed. By Anil k.Lalwani Cummings Otolaryngology – 6th Edition