Understanding Otitis Media and Ear Disorders PDF

Created with Coconote - https://coconote.app Understanding Otitis Media and Ear Disorders Okay. Alright. From last week, the slides say hiss or yeah. H I s. Mhmm. What is that? So the locks of hiss. That's why he's so there well, Hiss is someone's name who discovered how ear was formed during emb...

Created with Coconote - https://coconote.app Understanding Otitis Media and Ear Disorders Okay. Alright. From last week, the slides say hiss or yeah. H I s. Mhmm. What is that? So the locks of hiss. That's why he's so there well, Hiss is someone's name who discovered how ear was formed during embryogenesis. So, oracular hillocks or hillocks of his are primordial embryological tissue that gives rise to your pina. There is 6 of them, and they all sort of migrate and fuse to form your pina. Any other questions? The cauliflower ear, is there any way to treat it once it's turned the cauliflower ear, or does it can it only be targeted once they when it's in the tunnel? Not really. You well, I guess you can shave off the excessive coverage, but no. Not really. It's it's a cosmetic issue. So, I mean, people who engage in activities like, is it, UFC? Is it ultimate fighting champion? Something like that. So people who do stuff like that, they don't really care. I'm assuming what they're doing so much because that's sort of the high risk population. Any other questions? Yes. You guys, like, like, have to do a lot of, like, keloid removal too? Like, I was just kinda a little bit surprised we didn't talk about that last week just because it can't form on the external part of the ear. Yeah. So for those of you who are not familiar what keloids are, keloids are basically hypertrophic or excessive scarring. It's a very general term. So keloids, you can get anywhere. It's very well, not very. It's much more frequent in the African Canadian, African American populations. But keloids can occur in any circumstance whenever there is some type of superficial physical trauma. The reason why I didn't talk about keloids specifically because it's pretty rare. So you probably won't have to well, you probably won't see them or have to deal with them a lot. But that's what they are. Heloids. Novotrophic scotony. Any other questions? Okay. So we are going more inwards. So we're gonna be covering media, which is in the middle ear. K? So last Monday, we discussed external ear problems. So today, we're gonna cover media, which is mainly confined to the middle ear. Next week, we'll cover other middle ear disorders as well. K? I will give you an article on infection control. I'll print that, and then I'll give it to you next week. It's a pretty dated article, but the principles still remain. It's mainly talks of discusses how you should sort of set up your practice in the clinical world, talking about infectious control, measures you need to take. Simple things like, you know, cleaning the headphones in between clients, stuff like that. So it's very practical. So it still applies even though there are articles in a year old. But I'll give that to you next one. Alright. So here's the outline today. So the main focus of today will be otitis media. Right? And, again, the name sort of gives it a way. Right? So o, it means the ear. Anything otitis is some type of an infection or inflammatory condition. Or inflammatory condition. And media for us is the middle ear. And so we're talking about infection or inflammation of the middle ear space. Now it's super common. Very likely, most of us in this room have had an episode of otitis media. And therefore, it's a very common reason for physician visits, health care provider visits, along with antibiotic, prescriptions. That usually occurs in your younger years, and we'll talk about why that's the case. But usually, you get well, Titus Media when you're 2, 3 years, and under? By 3 years of age, about 85% or higher of all children have had at least one episode of Tyroskeremia. K? So that's, again, a lot. Right? And because of that, there's a huge financial, implication with Tyroskeremia. Now what's the lay term for otitis media? Like, what would your mom what would your mom call otitis media? What? Yeah? An ear infection. Yeah. Ear infections. Right? Ear infections. Yeah. Well, I my mom wouldn't say middle ear infections. Yeah. I mean She would probably say ear infections. Well, there's your mom's in this field for some reason. Right? Yeah. Could you. Okay. So you have probably ear infections. Yeah. Ear infections. That's what we say. Right? Most people say ear infections. Now for us, that's not what we call it. We call it acute otitis media. Right? When we hear the term ear infections, it equals acute otitis media. Now there's a different entity called otitis media which is not a ear infection per se. The other term for OME is chronic OME, so you may see the acronym COME. There's another entity related to otitis media called chronic supportive otitis media. So the first one, the ear infection, right, the acute otitis media median, that most people think, is when you have a middle ear effusion. Effusion is another word fluid or liquid. But you must have signs and symptoms or clinical features of acute inflammation. Right? But the key there is the term acute, the word acute. Right? It's an actual acute infectious disease process. So you get things like fever, pain, red and bulging, in the panic membrane that's shown there. Now OME is different. You do have middle ear fusion like the cut of text media. However, you don't have the clinical features of acute, inflammation. K. So you don't have things like fever, pain, redness. Other terms you may hear when people talk about otitis media with effusion is secretoratitis media or chronic serosolatitis media or sometimes gluteal. You can see the years look very different. Right? This does not look like this. The final one is more rare, but it is when you have actually chronic pyruvents or rheas, so chronic pus coming out from the middle ear space through a permanent eardrum perforation, and you see a picture like that. Like, when you look in the ear, you just see pus coming out. That could be due to this thing called cholesteatoma. So another way to define otitis media is along timelines. So acute is, again, immediate. Right? So it has to be, technically speaking, within 3 weeks. Chronic otitis media usually means it's been there for over 3 months. K? And subacute otitis media is in between acute and common. I was just wondering, do you diagnose opetis media just by looking in the ear? Is that enough to be able to We'll we'll talk about that. Yeah. We'll talk about diagnosis. Yeah. So just wanna define them so we have a set a bit of an idea and then how about each more in more detail. K. Now before we talk about how they form or what they are in there, we need to talk about how they form. Right? So what's the pathophysiology of achitis mania? Well, it really has to do with the eustachian tube. Right? So eustachian tube is the key when trying to understand achitis mania. So it's it's a tube that connects the middle ear space to the nasopharynx. K? So it's this tube here. Right? The nasopharynx is at the back of the nose. Right? It's the back most portion of the the nose. It's the nasopharynx. The opening is here. It looks like a little slit. And I can I'll show you some videos of this when we do talk about cleft palate and speech nasopharynx. You'll see the opening. But it connects the middle of your space to the back of the nose, right, or the nasal pharyngeal. It's kind of similar to the ear canal and that it has bony as well as cartilaginous sections. And the cartilaginous section is much longer, and it's where the nasopharynx ends. Right? The bony portion is the connection to the middle ear space. Now the lining of the eustachian tube is important for us to know because it's composed of this of of ciliated respiratory epithelium. Meaning, it's the same lining as the as your nose as your nasal cavity. That's what ciliated respiratory epithelium is. This is the same lining, actually, that starts in your nose, covers your mouth, goes all the way down the trachea, down to the lungs. Is the sliding okay? Where's the is the first I don't know. There must have been something. So you have lining outside your body as well as inside. Right? Your GI tract, your respiratory tract. But anybody have a mark, like a backward marker? There's someone there. Okay. So it's probably passing. Thank you. There you go. So when you have a lining, let's say let's say you have these groups of cells. That's the nucleus. And we'll talk about actually basic cell biology, later on. But so we have a lumen here, cells here. K. Let's say that this is a eustachian tube. Now these cells have little hairs on them. So that's the cilia. Cilia means it's like a little hair that's attached to the cell surface. And cilia tends to beat. They sort of move towards one direction. K? And overlying this is a sheet of sort of mucus. Right? Or in our nose, which is continuous with the eustachian tube, there's a layer of snot mucus. Right? That's what our sinuses and nose and the eustachian tube have. Right? So these cilia will beat towards certain way to get rid of things that get trapped in the mucus. K? So that's ciliated respiratory epithelium. Right? So if we inhale toxic smoke, it should get trapped there, for instance, in our airway or lungs. And then when we cough it out, the ciliary is pushing it out. So just remember that picture because it's important for us to Now the eustachian tube, remember I said there's the cartilage portion, and then there's the bony portion. So the bony portion doesn't move. Right? That's a bone bony sort of cylinder that's fixed. However, cartilage moves. Right? So there are these muscles attached to the cartilaginous portion of the eustachian tube, which basically open and close it. K? And that's what this picture is showing here. The 2 major muscles that open and close the cartilage portion of the eustachian tube is the levator villi palatini and the tensor villi palatini, k, which is composed of other smaller submuscles like the dilator tubing. The orientation of the muscles is kinda funny. They sort of loop around this bone in your palate, this little, hook bone. But that's the levator and the tensor veli palatini muscle going towards the eustachian tube and attaching it to the cartilage portion. Right? But think about those names, levator, villi palatini, and tensor, like, veli palatini. So palatini means the palate. Right? So these are muscles that actually contract the soft palate at the back of your mouth. These muscles, not only do they make the soft palate contract, but they also open and close the eustachian tube. So why do we have a eustachian tube? Well, we don't really know. We have some theories. But it's usually a closed structure. K? So usually, eustachian 2 when we're sitting here just listening to me talk, your eustachian tube is typically closed. However, that does open when you're yawning or swallowing your eyes. Right? And, obviously, the opening portion, like I just said, involves the cartilage portion. So you need a cartilage portion and the muscles to function normally. K? So we think the eustachian tube is there because the main function is to equalize pressure. Right? So the middle of your space, right, that's an aerated space, normally. So what happens if you go on an airplane and you're descend you're on the descent? The outside pressure is increasing. Right? When you go up, your outside pressure is decreasing. Right? Just the presence of atmospheric changes with elevation changes. Now how is the middle ear gonna regulate that pressure? Right? It has to have a connection to the outside world. So that's through the eustachian tube through the nasal cavity or the mouth. Right? So that's how it's gonna equalize to the atmospheric pressure in the environment. So that's the main function. The other function is and if you have fluid or secretions in the middle ear, it's way to get rid of it. Right? And that part of that through is the mucociliary lining and the clearance mechanism. Also, we think there's some protective function. So, again, it is usually closed. So if you have lots of snot, it's gonna protect it from not sort of freely traversing to the middle of your space. And also, some of the sound protection is available. Right? So if you're saying really things loud or if you're screaming, that's not gonna go directly up to the use through the eustachian tube and cause auditory hair cells to stimulate. And also the eustachian tube. You know how you when you listen to your own voice on a recording on a recording, do you know how you sound different? You don't sound like the way you think you do. A part of that is because, you know, when I'm speaking, most of the most of the sound energy is coming out and then I'm hearing it this way. Right? But even reality, your voice sounds more you can hear your voice differently if you hear it actually through the u station too, what you're actually generating. Okay. So we know a bit about the eustachian tube. So how is it involved in octagonal? So typically speaking, you start with an upper respiratory infection. Right? So that could mean just a regular cold. It could mean flu. It could mean influenza. It could mean COVID. Anything sort of that can make sure upper airway a bit inflamed. So what happens when you get a cold? You get congestion, inflammation of the nose. You have to blow your nose a lot. Right? So you also get inflammation of the lining of the eustachian tube. Right? Because it's the same lining. So, again, your mucus your nose becomes congested. Same thing with your eustachian tube. And that leads to eustachian tube obstruction or dysfunction. Right? So it's not opening and closing normally. It's usually in a more of a closed manner because of all the inflammation, swelling, congestion. So what happens when you have a more of a fixed closed off space? Well, it starts generating negative pressure, like a vacuum like environment. And that leads to the cells in the middle of your space producing more secretions, and you get basically fluid buildup, middle of your effusion. So that's sort of the the typical pathophysiology of how botidus media happens. Why do kids get it much more? Right? So remember I said kids under 2, 3 years of age tend to get otitis media much more commonly than adults. K? And the reason is here. It comes down to the eustachian tube. Okay? There's a big difference between eustachian tube in younger kids and older children or adults. And the specifics are listed on your next slide, but you can see from this picture, the infant eustachian tube is much more horizontal. Right? While the adult one is more vertical. K? So there's gravity helping the middle ear drainage. Other thing to notice, you see how big the bony portion is while the adult has much more longer cart lat cart latches portion. So that's definitely gonna make the opening function easier. It's also wider. The diameter of the orifice or the tube is wider. And the openings are also wider in that. And the muscles, remember, you need those muscles, tensor and levator be like palatini muscles to open the eustachian tube. So those muscles are more mature. They function better in that. Right? So all of those combined factors leads to younger children having eustachian tube dysfunction or instructions. So main thing or the main disease we're interested is is when the eustachian tube does not open normally. Because that leads to a case. What's that? K. Now there's a, there's a converse condition called patulous eustachian tube. That's actually when your eustachian tube is open it's more open than it's supposed to be. It's very rare, but there is there's a well known audiologist in town who has this, patchless you stage you station too, and I'm sure you'll meet him. Some of you will meet him. But that's a bit of a different, clinical entity. We're more interested in the is when the eustachian tube is not open. Okay. So now we have a bit of a background into why otitis media can form. So we're gonna start talking about ear infections or acute otitis media. So anyone had an ear infection recently over the last you have? Yeah. Okay. So what were your symptoms? Kinda felt like my ear was clogged. Okay. And then I had, like, throbbing pain. Pain? Yeah. And it kinda felt like it went from my throat to my ear, like, along the side. Deeper? No. Did you have any drainage? No. No. Okay. Yeah. So those are some of the common symptoms. Certainly pain, otalgia. If there is ruptured eardrum, you can get otorrhoea. You can get hearing loss. Right? Conductive hearing loss. The eardrum is not gonna vibrate normally with fluid there rather than the oscicles being in a well aerated space. Typically follows upper respiratory tractions or colds. Right? So the most common story we hear is parents say, oh, my kids have this runny nose cold for a few days, and then it led to him having lots of ear pain, fever, stuff like that. And you know why now. That makes sense. Right? Because that causes crustacean tube dysfunction. There are some systemic symptoms and signs as well. Remember, when you're trying to fight off an infection, you can your your immune system can generate febrile responses or fever. Some people, again, just don't feel well, so you feel it's called malaise. Some kids are very irritable, won't sleep well. And again, remember, most commonly, it's 1 year olds, 2 year olds who have ear infections. Right? So some of them may not communicate to you that their ear hurts, especially toddlers. So some of them may be tugging at their ears a lot. Now, however, ear tugging, it's in quotations there because ear tugging is a very, very soft sign. Right? So there are lots of studies to show that ear tugging, for instance, as a primary sign of an ear infection, it's not a good thing because kids pull out their ears for many different reasons. Whether they're exploring or getting attention, they may be teething, they feel it in their ears. Right? So ear tugging alone is not a good indicator that the child has ear infections. Now you're talking about fever, more kids can have ear infections, but still you have to be a bit, skeptical. And unfortunately, when babies tug at their ears a lot and you go to the walk in clinic, you will probably get antibiotics, even though you may not really need it at times. For acute otitis media, there are 3 main bacteria or 3 main microorganisms that causes acute otitis media. These are all pretty common, bacteria that's sort of ubiquitous in our environment, streptococcus pneumoniae. There's actually a vaccine for that. Haemophilus influenz and morgancellular catarrhalis. But remember, before that bacteria infection that occurs in the middle ear, you get usually a viral upper respiratory infection. Right? Before that. That causes the eustachian tube dysfunction. So these are again you get a viral infection, and then you get a bacterial infection after the viral infection. K? So the most common one is the vinyl virus, and that's the just the common cold virus. K? Influenza, paraffluenza, even get your flu vaccines. Those are the ones that vaccines. Those are the ones that typically cover. Adenovirus, RSV, or respiratory syncytial virus is another common one. Now in terms of otitis media, again, you know that it happens when you're younger, and you know why. Right? Because risk factor. Gender as well. More boys tend to get ear infections in females. But there are other sort of very well known risk factors. Right? Attending day care. Some of you will work at day care seeing kids with speech issues or autism. Right? Day cares are disgusting. Right? They're cesspools. Right? Kids like to lick things all the time. So it's not surprising day care is a risk factor because any risk factor for upper respiratory infections is a risk factor for a keto type of skin. So, First Nations communities, certainly, that's been well known to have. Some communities have higher incidence and prevalence of acute otitis media. Winter months, that should make sense. Right? Winter months is when both colds tend to occur. Most upper respiratory infections tend to occur, which will again lead to gestation tube dysfunction. There's good evidence that bottle feeding is a risk factor as well. So breastfeeding has lots of benefits in terms of developing your immunity and passing maternal antibodies. So but again, you know, not everyone can breastfeed. Right? So it, not a big fan when, you know, some centers, really push breastfeeding only and because it can make some moms or, breast or, moms trying to breastfeed. They some moms can't do everything. But it is a risk factor. Smoke exposure, another well known risk factor, though, or socioeconomic status, that's a respect for lots of different infectious diseases and lots of other diseases in our environment, in our in our world. Allergies, that should make sense to you. Right? What happens when you have allergies? You're congested all the time. So that can lead to Eustachian tube dysfunction. Craniofacial disorders, cleft palate, we're gonna cover that in more detail later on. Immune system deficiency, reflux disease. When you have your stomach contents come up, irritate the throat. You can even actually, irritate the back of the nose and the eustachian tube. And there's you can actually, culture some stomach contents in your middle ear. So no reflux disease is a risk factor as well. Finally, nasal obstruction. Right? Remember whether eustachian tube is located at the back of the nose, the nasopharynx. So if you have any sort of pathology there, like enlarged adenoid tissue, which is where they're located in the nasopharynx, you can get eustachian tube dysfunction. So this is what an acute otitis media looks like. Right? So diagnosis to answer the earlier question is you have to have the clinical features. Right? So you should have acute signs and symptoms of inflammation, like pain, fever, irritability in young kids, sometimes hearing loss. Other hearing loss may not always be noticed by the parents. But you also need to look in, and then you should see a picture like this. Right? So it's red. Eardrum is completely or the middle of your space is completely full of pus. Right? So if you look at a normal eardrum, eardrum is actually pushed in a bit. It's a concave structure. But if you look at these two pictures, if you try to think of it in 3 dimensions, it's actually bulging. Right? That's a convex structure, meaning that the middle of yours is so full of pus That's a convex structure, meaning that the middle of yours is so full of pus that it's ready to pop. Right? You can see it's bulging here. Bulging there. So that's what you need to diagnose in the acute of Peyer's movement. Now, again, I did tell you that streptococcus pneumoniae is one of the most common bugs, but it is we do have a vaccine, and it's part of the, norm, the regular vaccine regimen in Nova Scotia and, pretty much all the provinces. So it's the new local conjugate vaccine, which was introduced several years ago in our province. That did lead to about 7% reduction in the, incidence of acute leukemia. So, again, it may not sound like a lot, but actually that's that's a lot when you consider how common a is. Right? So and also it tends to sort of protect against very severe ear infections or those infections that cause complications, which will correct the nerves. So, again, it's a good thing to have. That's why, again, that's part of the regular regimen of, vaccine recommendations in children. K. So the next one is OME, otitis media with fusion. So this is probably something that you'll see much more commonly. Right? So when a child has acute otitis media, again, they have fever, they're in pain, they're crying, they're miserable, they're not gonna come and see you. Right? They're gonna go to their there's practitioner, there's doctor, emergency department, walk in clinics. But patients with OME, you will see in your practice. If you SLPs, if you see kids with speech problems, very likely they'll some of them will have OME as well. So this is when you have middle ear effusion, fluid in the middle ear space, but no clinical features of acute inflammation or infection. So meaning, they don't have fever. They don't have significant pain. And then sometimes, actually, most of the time, it's asymptomatic. Meaning, you see this child, and they look perfectly healthy. They're running around, and they're normal kids. However, you can get hearing loss. Right? When you have fluid in the middle of your space, you can certainly get conductive hearing loss. Right? If the patient is older, they may tell you their ears feel a bit full or they feel like their ears popping a lot. As well, if you have otitis media with effusion so if you have fluid in the middle of your space, sometimes it fat can become infected. So that can be the recurrent acupuncturist media. Now the fluid in the middle of your space, can be of different quality. So the fluid can be very watery, and we call that serous. It's very thin. But very commonly, they can be very thick or molasses or glue like. So we call that mucoid effusion. And then can you can imagine if you have mucoid effusion in the middle ear space, that's gonna prevent the eardrum from it can prevent the eardrum from vibrating more. Or serous effusion, you know, it may not impact the hearing as much. Sometimes you can get purulent or pus like discharge in acute otitis media. And you've seen pictures of those. So acute otitis media, I mean, if you're you've been doing otoscopy for a while, it's actually easy to diagnose, you know, if you know what you're looking for. But this is much more solid. And this is where the diagnostic accuracy becomes very poor. So OME, again, you don't see that redness. You don't see the bulging eardrum. Right? You can actually see the landmarks very clearly. Right? You can see the light reflects again, which some textbooks say, oh, if you see light reflects, it's normal. But this is not these are not normal looking mirrors. Right? So here, the only thing I can say is that there's a bit of yellowish hue. It's probably better on your monitors or your screen. But it looks yellowish. Right? That's all I can say. So that tells me there's actually fluid in the middle of your space. Here, you can see air fluid. You can see bubbles. Right? You can see air bubble there, air bubble there. Don't worry about the the air on there. And there's fluid here. Right? So that's partial serice effusion. Right? Here, the entire middle of your space is filled with fluid. Here, there's some pockets of air. Would you expect that you're gonna also be bulging a bit with, this No. No. So when the eardrum is bulging, what does that mean? That means there's so much fluid inside, pus or fluid inside. It's making the ear come bulge out. Right? So that's what causes the pressure pain and fever. Right? And what did I say about OME? Do you have those things? No. Right? You don't have fever. You don't have pain. It's usually asymptomatic. You're not gonna see bulging. Now this year, again, some people may think, oh, this looks red. Lots of blood vessels. But you can get that just from kid being upset. But this eardrum, it's really not bulging a lot. But what do you notice here? I mean, here you can say you can see the landmarks. Actually, that's the chord of tympanular. But, you can see that the eardrum looks very white. Right? Here you can see you can see through much better. Right? Here it's a bit more opaque, and it's actually a bit retracted this eardrum. It's pulled in a little bit, which is opposite topology because of the negative pressure. Filled up. That's why, again, the eardrum is actually draped along the ossicles as well as the incus coming down the stapes. But there's fluid there. This is more of a thick mucoid fluid, and that's why you can't see through the eardrum as well. It looks thickened, and, again, you can't really, see through it because the eardrum looks very sort of opaque. Same thing here. Right? The eardrum looks a little bit more red, but also not transparent. So that's OME. But you can see how, again, years look like this. Some people may get a glimpse a little bit, or especially here, if you get a glimpse, then you may think, well, this looks pretty normal. Especially when they're asymptomatic. Now there are other couple other pictures here. You can see again more air bubbles. Right? So there's partial serosifusion, I would say. This eardrum looks a bit a bit yellowish. And, again, you can see through, but a bit of yellowish hue, and not, like, super clear. So you can see how subtle some of these are. And these are pictures taken with digital endoscopes. And then imagine trying to look in a little child who's moving around a lot with someone else. Right? So it is a bit of a challenging skill. So, well, tightest media with the future, the important thing to note is you don't have to do anything initially. So most of the time, no treatment is necessary because it is often self limiting. And this is an important chart graph for you to, understand and know. So if you have 100 kids, let's say, 100 kids with middle ear effusion, that's what MMEs MEE stands for, or otitis media with effusion. Right? What happens if you just observe them without doing anything? And so this is the horizontal axis is months, time, and months. So 1, 2, 3 months. So about 90% of them will clear their middle year of fusion, just over time. Right? So about 90% will clear their middle ear effusion in about 90 days or 3 months. Right? So this is the reason why when you see OME, we're not gonna jump to trading it. K? Because all you need most of the time, 90% of the time, is to give it some time. Now if you have significant OME or persistent OME or prolonged OME, let's say that you're in the 10% where you persist to have fluid, that's when you may run into some problems. So what are those problems? Well, obviously, there's the chronic hearing loss. Obviously, if you don't hear well in that early formative age, that can be too much. Speech speech and language problems. Right? Some kids may be hearing okay, but they may not hear things clearly as well. Right? So you may produce some articulation errors or other developmental consequences from not hearing normally for a while. I'm still a bit controversial in terms of the degree of hearing loss that can cause long term effects. Obviously, the more severe it is, the worse the outcomes may be. But for those children with very mild hearing loss, it's hard to say how much it will impact them later on. So most of the time, for people with OME or patients with OME, children with OME, you don't have to do anything. However, those with some of these other risk factors or other factors to consider. So do they have other medical problems, like cleft palate or other, contributing factors? Do they have speech and language issues? So if you child if you see a child with fluid hearing loss and their speech they have speech and speech delay, then again, you may be more in a position to recommend intervention. If you have prolonged or persistent bilateral hearing loss, as well as parental concerns. Now the treatments for OME, they're the medical treatments. So things like antihistamines, possibly reduce inflammation, decongestants, or sort of nose sprays to decongest the nose. Right? That makes sense? Because that should make your eustachian tube function better. Steroid sprays. So steroids are better. Steroid sprays. So steroids are anti inflammatory medications. You can use some nasal steroid sprays or antimicrobials or antibiotics. Right? Now antibiotics should not be used for Alzheimer's media with infusion. Right? Because it's not an acute infection that's caused by a bacteria. But unfortunately, very commonly, they're given antibiotics if you go to walk in clinics or other health centers. But, again, all of these treatments don't really help a lot. They're more of a Band Aid solution. It's not like you're gonna get kids to use nose sprays very commonly, regularly. Right? It's just not well tolerated. So the best treatment for otitis media with effusion, for those who need treatment, because those won't, is tympanostomy tubes or ear tubes. And we'll talk we'll show you some pictures of ear tubes. I'll show you a video as well. Follow-up audio brands are very important as well. Right? Because if you're gonna see if you see a child with OME, you don't really need to refer. Right? All you have to do is you can bring them back in 2 or 3 months and retest their hearing. Right? Because, again, 9 out of 10 9 out of 10 kids will have normal hearing them subsequent visit. It will clear their renal ear effusion. Now those that persist to have fluid, those are the ones we're gonna need to confirm. Again, this is the key when you talk about otitis media with effusion, those not at risk. Right? Parents are not super concerned about their speech development. They seem to be functioning okay. You're just gonna watch them. Right? And then, again, retest their hearing about 3 months. Or earlier if they have other concerns, like significant hearing loss or speech and language problems. And then you may need to repeat, the audio Alright. So let's take a 10 minute break. It's 3:27 right now. Notice that I didn't really talk about treatment for acute otitis media because, again, we're not gonna really see them. So I'd say most of the time when you see a young child with otitis b acute otitis b, they may end up getting antibiotics, right, because it's a bacterial infection. And, again, that's sort of not really relevant for us. But OME certainly is. The so some parts of the world, parts of Western Europe, United Kingdom, Lot of physicians won't treat uncomplicated otitis media, acute otitis media with antibodies. Because most of the time in healthy kids, their bodies can deal with it. So just be aware of that because just because you have an acute otitis mediate, media doesn't always mean you need antibiotics. Now when we top up diagnosis of otitis mediate, the most important thing is the history. Right? Again, if you have a parent who says, oh, my kid's been getting a lot of colds, start a day after starting day care, starting having episodes of fever. I sometimes see pus coming out of the ears, really irritable, not sleeping well, not saying a word, although my child is now 2 years of age. Right? Those are all very important and very suspicious history for leukitus median. Now you do have to obviously have a look to make the diagnosis of otoscopy, and we'll talk about pneumatic otoscopy in more detail. But hearing test is extremely extremely important. Right? Especially for those kids with OME. Right? If you have otitis media with diffusion, but you do a urine test and it's normal, then who cares? Right? It's really not causing a lot of problems. But if it's causing moderate to severe conductive hearing loss, and there are other concerns like speech delay, then, you know, that's much more concerning. Now tympanometry is important, and we'll review that as well. But pneumatical telescopy is when you have this bulb like attachment. I don't think you guys have it in your clinic. Sarah Sarah Mason's clinic or right? I don't think you have this. But not most ENT, clinics or offices, you'll see pneumatic melatonin. But it's literally a bulb that just has air in it. And you squeeze that bulb and it pushes air. Now the important thing is to form a forming a seal with the ear canal with your ear speculum on your otoscope. Because if there is no seal, that puff of air that you generate will just come right out. So you have to have a seal. So normally, what's supposed to happen in pneumatical coscopy, when you have a normal eardrum. Right? You see how nice looking that eardrum is. You can clearly see through. There's no discoloration. Is when you puff air in, the eardrum moves in a little bit. Right? That's the black part. And then it comes back out. Right? So it sort of moves in, and then it comes back out. So that's normal tympanic membrane mobility. K? And you can see that with the medical tostrophiform osteo because you're puffing you're, putting in the air pressure. However, when you have AOM, right, AOM is when you have middle ear that's completely full of fluid. Right? It's bulging. It's ready to rupture. Urdrum is actually, again, more of a convex structure rather than a concave structure. So that happens when you pop air in. It doesn't move because the eardrum is under so much tension and pressure. Doesn't move at all. Now when you have OME, that's a bit different. Right? And it really depends on the type of fluid that's there as whether as well as whether whether the middle ear space is completely full. So in OME, when you push the air in, it probably won't move much because there's already sort of fluid there preventing it from moving. But when you actually release the bulb, it may move out a little bit. Basically, there should be no or reduced mobility of the ear drum in the organ. Now tympanometry, can you cover this at the end of lecture 1? Remember, this is part of your audio brand. Right? And, again, it's very easy to do. You put put in this probe, which is the stimulus as well as the detect detecting probe. And you push a button, and that, again, generates the sound pressure energy, which gets directed to the eardrum, and it makes the eardrum sort of move in and then back out. So you're measuring that compliance or mobility compliance of the eardrum. So again, type a is when you when the eardrum sort of moves in and then out. Right? So that you can think of the sound pressure energy going in, then it pushes the eardrum in and then back down. And it's centered around 0 pressure, that capacitor pressure. Now there's type a s and a d. Right? A s is think of it as stiff. So the eardrum moves. There is a bit of a peak there, but a tiny one. K? Because the eardrum is stiff. So when would you get this? Can anybody guess where you could have eardrum movement but it's shallow like that? Yeah. I would say o e because of the fluid. Sorry? O e because of the fluid. O m e? O e. Otitis externa? Yeah. If you have true otitis externa, you probably won't be able to do true tympanometry because there will be so much discharge and swelling in the ear canal. So I don't know if that's the finding in OE. Could be. I don't know, to be honest. Anyone else? Yes. Would it be OME just because you get that slight movement from the air? Yeah. Possibly. But OME is usually type b. It's usually flat on the phenomenons. But, yeah, I mean, there can be some partial movement. And it's a bit of a difficult question. The I well, type a s and type a d are pretty rare. But you can get type Yeah? It looks like a perforated or something? No. You would get a type b. So type s, you can get if you have a circular, fixation. K. So if your ossicles are not moving well, but they're still moving, it may make the eardrum a bit stiff. Head AD is, again, you can think of it as the peak is there. It's really deep. K. Peak is really, really high. That means the eardrum is super compliant at the right pressure level. Okay. So that's the converse. Right? That's when you can have a circular discontinuity. So the the ossicles are not connected to each other, for instance. So nothing is holding it. The eardrum is freely mobile. But again, AS and ADR, not super common. Type b is very common. Right? This is what we expect to see when you have a cutotidus media or otitis medial diffusion. Type c is when you have just chronic eustachian tube dysfunction. Right? Again, that should make sense to you. There's a negative pressure environment in the middle of your space, which makes the eardrum colder. So how does that happen? Well, you get that through eustachian tube dysfunction. Right? So you can see how helpful tympanometry is in telling whether there's, mid or ear effusion or not. Right? So I've been try I've been trying to teach pharmacists throughout our province to look in mirrors. And you ever see those signs at some pharmacies, they say, you can get your ear and sinus infections type every year. Have you ever seen those signs? Right? So they do strep throat and UTIs, and some of them more routine infections, so they can take a burden on health care. Routine infections. So they can take a burden off healthcare emergency department. So what I recommended to the pharmacy clinics is they have actually a portable tympanometer. Because, again, it's very hard looking in ears, but you can get objective tympanometry results. And if there's type b, at least they can say there's fluid. Now it doesn't tell you whether it's acute infection versus OME, but it at least tells you there's fluid, which is actually better than sometimes what you may get in a walk in front of it. Yeah? Out of curiosity, because you said sometimes in, like, the UK, it's much less common to give antibiotics for, like, acute otitis media. Yes. I was wondering if there's any risk of, like, an eardrum rupturing from too much fully filled up. If it's Yes. There is a rupture. There is a risk, I mean. Yeah. Yeah. But the risk is pretty small. And if you rupture, most of the time it just heals. Yeah. But we'll talk about that. So, let's talk about ear tubes because that's the best treatment if needed for OME. So again, what's the best thing to do for OME? Nothing. Nothing. Right? But if you do need to do something, let's say that the fluid's been there for over 3 months. Speech delay. Then ear tubes is the best option rather than using decongestants or other stuff. Right? So the technical name is tympanostomy tube. Some people call it ventilation tube or PET or pressure utilization tubes. In the UK, again, it's called bromet, very commonly. It's more of a colloquial term, but, they all mean the same thing. And it is other than clubfoot, it's the most or the second most common surgical procedure in children in North America. Because again, ear infections and OME are recurring acute otitis media. Very common. So ear tubes are again recommended for these reasons, for kids who get lots of acute otitis media. So if you get 1 or 2 throughout your life, that's probably normal. Right? Everyone gets that. But if you get 4 or 5 year infections during the winter season, and you're on antibiotics, the kid's miserable, parents can't go to work because they have to stay at home with them. You can't send them to day care. Then your tubes, is a good option, because it would prevent those ear infections from happening. Right? It would just drain right out. Chronic OMEs, certainly, to restore hearing and other functions like speech development. There are other sort of related risk factors, coexisting medical conditions, like cleft palate, trisomy 21. All of those stuff we'll cover in more detail. There are some tympanic membrane abnormalities. For instance, atelectasis or tympanic membrane retraction. So there's actually believe it or not, there's a thin sheet of eardrum that's very thin and completely collapsed onto the middle ear space. Right? So there's no aeration of the middle ear at all. So he would try to put in a tube to put some air in the middle ear space. And then there are complications of autherus media, which is the final thing we'll cover today. Now I did I did run over during the break to my office and brought you some year too, so you can have a look at it. Okay? So, actually, these are look at there's 2 different kinds. There's a white white one, and then there's the, other one. No. You you open it. You actually open it like this, and then you put it on your hand. That's super tiny. K? So try not to lose it. I'm not gonna use it in patience, but I wanna use it next year too. K. So when you're done looking at it, just put it back in the thing and then give it to so you can see how small they are. You can see some of them are different shape, Some of them have different coatings, but So those are real, tympanostomy tubes that you insert in the arteries. They insert there. So the first thing we do is we make a maryngotomy. Right? And you can automate means incision. Is the eardrum, and then we put the r two in. And then we that should equalize the pressure. Okay? Now let's try this. Sometimes when we do videos, Connection here. Okay. So this is a video of one of my residents putting it in the air tube there. So so just bear with the video for a second. We'll be centered. So what my resident is doing is she's cleaning some wax from the ear canal first. It should be centered in a bit. So first thing is we clean out the wax in the ear canal. K? To get a view of the ear canal. It's not a sterile procedure because you can't make ear canal really sterile. So we just do it wearing disposable gloves. Okay. So that's the eardrum there. Now she's gonna introduce a blade. That's so that's a little knife, and she's gonna make an incision in the eardrum. So that's the meringue on the knife. You can see again, she's a bit shaky, but So you make an incision in the eardrum. Right? And that's just a few millimeters. You saw how small the ear tubes are. It just needs to fit through. So a little bit of blood, which is normal. Now, we will suction out the fluid, and you'll see how thick this fluid is. So this would be a mucoid, that glue like, a middle ear fluid. Right? It's literally snot in the middle ear space. Okay. So it's not even really coming out. Oh, you see that? It's Are they awake for this? What's that? Are they awake for this? Pardon me? Is the patient awake? No. No. There are some. There are some. Right. So imagine having that in your middle ear space. Right? That's gonna prevent the eardrum from vibrating. Right? Because it's such a thick fluid. It's not even coming up through the suction. Right? Or it's having a very difficult time. So I've got most of it out. So that's the it's called an Armstrong grommet tympanosamine tube. Well, there's still a little bit left, but that will drain out over time. So the distal flange is not complete. Okay. Now it's in so now there's an there's an artificial connection to the middle ear space. Right? That's what the ear tube is doing. And then put some of your nose in. So you see how quick I mean, even for my trainees, see how quick that was? So, you know, when we do it as, it literally takes less than 5 minutes. It's a very quick minor procedure. Yes? What happens to the cases where the tubes might fall into the middle ear space? So that's very, very rare. It just doesn't happen because the ear tubes have a so if you saw the ear tubes Yeah. You saw the you saw the flanges on the outside. So the flanges will actually keep it in, keep it from migrating into the finger space. Okay. So the ear tubes kinda look like so if you Let's say that's the eardrum here. It's ear tube. That's the ear. They're held in the eardrum by the flanges. Now the one of the one one of the ones had a funny shape. They kinda look like this. Right? So that's a longer lasting tympanostomy tube. And the reason is because, again, this is all lined by skin, squamous epithelium. Right? What is skin doing? It's shedding all the time. Right? So you'll see what happens is there's keratin debris or skin debris that gets collected there over time, and that's what pushes the ear tube out. Okay? So ear tube stays in the eardrum for about 24, 36 months or so. Right? And then when they fall out, there's a hole in the eardrum which usually heals by itself. Okay? Now you see there's no outer flange in this one. Right? So again, these ones, there's no sort of skin debris to push up against the outer flange. So that's why those ones can last longer. 5, 6, 7 years. Right? So people with, like, a lot of risk factors or multiple sets of ear tubes may get the get the other stuff in there. Oh, okay. Yep. Why would you opt for the the more temporary one over? Is it just more invasive of a procedure? Or So when so what age do most kids have ear infections or otitis media? Looks like 3. Yeah. 3 and under. Right? So after that, their eustachian tube has matured. K? So after that, they don't need ear tubes. Right? So you want the ear tubes to fall out after a year or 2. Right? You don't want it to be in there permanently. So are those ones permanent than the other ones? They can be, but some they'll eventually fall out as well most of the time. Yeah. Yeah. When the tube falls out, you mentioned that it'll take a while for the eardrum to repair the the No. It won't take a while. Okay. It won't take a while. So there's not that big of a conductive hearing loss? No. Probably No. We'll talk yeah. We'll talk about the natural progression of the ear tubes. But the ear tubes, again, the most common one we we have at the IW case, the white one that you guys saw. But sometimes they're green. Sometimes they're blue. But, again, you can see the different shapes. Right? The different shapes confer how long they will last. Is it common for them to follow-up before you would typically want them to, like, before the 20 months? Rarely. Yes. Sometimes you can have premature falling up in the ear tubes. Do you guys do another surgery? Yes. Is that your the most common procedure you do, or would it be not me personally. But, like, general ENT surgeons. But I do them pretty commonly, but it's not the most common one I do, because I do more complex cases at the IWK. So this would be done by, like, a ENT surgeon with Dartmouth and stuff. Well, we do them commonly, but, it's not the most common one that I would do. But it's very common. You don't know me speaking. So whenever see how again, very quick, I would say very minor procedure. Right? But so you go home on the same day. You can go back to school or daycare the next day. Parents are super happy. Because, again, kids don't feel the urge to act. But there are some complications that can happen. So the first one is called tympanosclerosis or moringosclerosis. So sclerosis, when you hear that term, that means scarring. But we'll we're gonna cover this next week. Perforation, again, like we just discussed, ear tubes fall out. Right? You can see the crusting there. Right? That means it's about to fall out. Right? So when that falls out, it can leave it will leave a little hole there. But 98, 99% of the time, that hole will heal very quickly. Okay? So there's no gap. There's no conductive hearing loss. Usually, again, it's sitting in the ear canal or falls out while the kid's playing outside, and this is what we may see. Right? Just the thin area of the eardrum where it has healed. But permanent perforation is the most common, albeit very rare, risk of ear tubes. The good news about that is we can fix it. Right? And we'll talk about how we fix it next week. Now tube otorrhea, which may look like this, is another complication. Right? So the again, your tube is in there. If there's lots still a lot of middle ear secretions that's being generated, well, it's gonna come right out. K? So, actually, this is not a bad thing. You want the fluid to come out. Right? That's the whole point of getting your tubes. It's when it stays in, that's when it causes pressure, discomfort, fever, eating antibiotics, and all of that stuff. So and you see this is not a bad thing. You just have to use some topical ear drops, and it settles it down. However, some kids with, like, immune system problems or things like cystic fibrosis, which means that your mucociliary clearance is abnormal. Some of these kids may have chronic orophobia. So their ears draining all the time. That's something you may have to take out that ear tube earlier than expected. Okay? Blockage. Now those ear tubes, you saw how small they are. So if you get bit of wax or bit of, discharge that gets stuck in there and it hardens, it can block the ear tube. The good news is that if you just use some ear drops, it tends to unblock it pretty quickly. But that's another complication. Granulation tissue is sort of this sort of reddish fleshy looking tissue. Right? Granulation tissue is anytime you have, like, some type of a wound in your healing, that's what it is. So the the reason why you get granulation tissue with ear tubes sometimes is your body, thinks it's some type of a foreign body, so it's generating an immune response. Right? So when you have, like, a knee replacement, the joint replacement, if you get you know, your body may reject that sometimes, for instance. Right? Because it's a foreign substance. Same thing with the ear tube. If an ear tube is in there for really, really long time, let's say that somehow it gets stuck in there, it's not coming out, it gets bacteria biofilm on it, the response may be this granulation tissue. Problem is, again, it may bleed. It may cause discharge. It can cause some urine problems as well. So if we see this, again, we have to move remove the ear tube. Yes? So in the image on the right, is the skin actually, like, covering where the tube tube would be? Yeah. That's there's an old tube behind this. There's no tube behind this? There's the there's an old ear tube. Yeah. Behind this. Yeah. That that's the granulation tissue. K. And finally, cholesteatoma, which, we'll talk about, next week. That's another very rare complication of hair tubes. Now what happens when you do pneumatical toscopy with, someone with a patent tympanostomy tube? Right. The same thing as as having a perforation will be a very small one. Right? So the air pressure air energy pressure energy is just gonna go right through the tympanostomy tube. So there's no movement of the earthen, which pneumatically. So there's absent mobility. Alright. So the final bit has to do with complications of otitis media itself. K? So we talked about complications of ear tubes. Again, any procedure we do, there are potential complications, even though quick microphones. But if you don't treat botitis media, and we're mainly talking about acute otitis media for those individuals who don't get appropriate treatment. And it's just if it's a severe disease, and you can get some of these complications here. K? Obviously, you're not gonna see them during the acute phase of the complications, but, you know, you may see a client who's had mastoiditis before. Right? Or you may have someone who's had meningitis, and that caused their hearing loss. Right? So you have to have an understanding of what some of these are. So when we I like to think about about complications of otitis media into intracranial and then extracranial categories. Right? And this is where having the basic knowledge of anatomy and physiology is so important. Because if you know that, you can actually guess or you can understand how these complications occur. Or if you're stuck in an exam setting, you can sort of try to remember by thinking, well, what's around that structure. Right? So, again, we're talking about acute otitis media, when there's lots of pus in the middle of your space. Now the middle of your space, this is a cadaveric temporal bone specimen that's been drilled out. So this is the right ear canal right here. So that's the bottom, inferior, superior, anterior, posterior. This is just to show you that if you go deep in the ear canal, the top part of the middle ear space is connected to the mastoid. Right? Remember the mastoid bone is the bone behind the ear? So your middle ear space is actually connected to your mastoid bone. Okay? So they're once sort of continuous space. So what happens if you get lots of pus or bad infection in the middle ear? Well, that would travel to your mastoid bone. Right? Because it there's a connection there. Right? So that can lead to what we call mastoiditis. Diodes. And, again, this picture is to show you that middle ear space is there. That's the eustachian tube. But if if you go all of the top part of the middle ear, that goes to the mastoid bone. Okay. And when you do a CT scan, you can see mastoid bone, middle ear space. That's all supposed to be really black, like here. Right? Because that's supposed to be filled with air. When it's gray like that, you know there's some fluid or some infection going on there. That's just going into the mastoid. Now clinically speaking, the ears will or the back of the ear will look really red and swollen. K? Because there's lots of really bad infection fluid in the middle of mastoid space. Right? So it can make the ears really pop out. Okay? There's lots of pus actually coming out through the thin cortical bone, pushing the ear out. So, again, when this happens, again, it's a pretty serious acupunctemia. Right? This is where you need very strong antibiotics. Right? This isn't where you can just say, well, your body will deal with it. And the mastoiditis, can actually spread to other areas as well. But it starts out with the cutotidus media and then into mastoiditis, and then it may go other places. We'll talk more about those. But the treatment is again, all of these will require hospital admission, intravenous or IV antibiotics, and then possibly some other surgery. We may have to put urgent ear tubes in to drain out that pus or even drill out the mastoid. Boom. To clean out that pus. That's called mastoidectomy. And that's showing you an abscess or collection of pus behind the right ear. So, again, that makes sense, right, if you know your anatomy. The middle ear space is connected to the mastoid bone. Now what happens if that mastoid that is starts tracking lower? Right? The mastoid bone is the tip of the mastoid bone is attached to your sternocleidomastoid muscle. Right? So that's the muscle that spans the mastoid tip to your medial part of your sternum. Right? So if it contracts, does this. Right? That's the sternocleidomastoid muscle, the big muscle along your neck. So that infection can spread along that muscle, which is called bezels or bezels abscess, as you can see here. You can see the skin has mastoiditis, and then now it's the redness and the swelling is spreading inferiorly along the neck, along the sternocleidomastoid muscle. So again, treatment is the same, but just more further progressing interaction. Now this is a pretty rare one, but so the temporal bone temporal bone is part of your skull bone that really includes or contains all the important ear structures, including the middle ear, inner ear, and, external auditory canal. K. So the temporal on this here, it's like a you can think of it like a pyramid. It's a pyramidal structure. K. So, again, base of the pyramid is here laterally, and the apex is here for the top. So again, it's a it's a pyramid triangular structure right here. K. So that's the apex. So what happens if you get a bad infection that spreads along the temporal bone sort of anteromedially? So that's following the temporal bone to the apex. So that's called petrous apocidus. So the temporal bone has different parts. It has the mastoid portion behind the ear. The petrous part is the the top of the pyramid. So that's why it's called petrous apicetus. You can see, again, pretty subtle, but you can see there's black here, which is air filled, which is normal. But here, it's just gray. So interestingly, with this complication, you get what we what's called grab the needle's triad. Again, someone who described it. It has anual nerve number 6 palsy. So again, they can't move their eyes normally. They have otorrhea because of the severe ear infection. It ruptures the eardrum and then retro orbital pain. So the orbit is here. So somehow you feel that pain or discomfort behind your orbit. Again, the treatment is similar to what we already discussed. It's just the infection is spread in different ways. Now remember, the facial nerve runs inside the middle ear. Right? So again, if you remove some part of the, middle ear temporal bone, you see the stapes there. Right on top of the stapes is the main trunk of the facial nerve. Right? The nerve that moves your face along, provides lacrimation, tearing. So imagine if you have really bad infection there. Right? And let's say that the facial nerve is exposed, or we call that dehiscent. So usually there's a thin layer of bone covering the facial nerve above the staphys' foot plate. And sometimes the bone may be missing or dehiscent. So in that case, that pus is gonna make that nerve inflamed. Right? So you can get facial nerve paralysis or pheresis. So, again, it's not like you're cutting the nerve physically. So when the infection settles down with the treatments we already discussed, the facial nerve function should come back. But, obviously, it's very scary, right, to lose your facial nerve function. Now what happens if if the infection goes medially? Right? So, again, what's sort of beyond the safety split plate, round window niche? What's this area inside? Well, that's the labyrinth. Right? That's the inner ear. Right? External ear, middle ear, inner ear. Right? So if the infection somehow spreads medially into the labyrinth, you get labyrinthitis. K? So you're getting all this sort of really bad dangerous pus going into your inner ear. Right? And that's bad. Right? Because what happens when you get labyrinthitis? Well, you lose your hearing. You get sensory neural neurons, and you also lose your balance. Right? Your inner ear, those semicircular canals and the utricosaccharal vestibular organ is also affected. Right? So this really, really sucks. You can get things like nystagmus, which is eye flickering, which we'll cover later on. That comes with, vertigo or, balance disorders at times, tinnitus, centrieneural hearing loss, vertigo, and they come on very quickly. So it's a very, very scary and miserable thing to have. And even with good treatment, sometimes your function may not fully recover. Now what happens if it if the infection now starts so so those are the main extra cranial ones. But now it starts spreading superiorly. Right? So again, here's the middle ear and the inner ear. And what's on top here? Well, that's the temporal lobe of your brain. Your brain is very close, actually, to the roof of the middle ear here. That's very it's a thin sheet of bone there. So let's say that this is a bad infection that's eroding and it's eroding into bone. Right? You can start getting what we call meningitis. Right? The meninges are the lining of your central nervous system. Right? There are people's jura matter, or acrimembran, pia matter. So these layers can be infected or inflamed because for the proximity of the middle ear. Can this result in either type of meningitis, or is it typically, like, viral meningitis versus bacterial? Well, it would usually be bacterial. Right? Because acute otitis media is usually bacterial. So it's usually not the viral aseptic meningitis. Now, again, this is where, the pneumococcal conjugate vaccine is very helpful because it prevents severe complications like meningitis. Meningitis, anything intracranial, obviously, you can get headaches. Meningitis, you get really neck, rigidity. So you when you task them, turn their neck, they turn their whole body. And you'll see these patients in the emergency department with, like, sunglasses on in the waiting room because they can't stand, fluorescent lights, for instance. So we call it aporopobia. Sometimes they lose their consciousness. Right? So they usually need imaging, CT scan, or lumbar puncture, and then, you know, IV antibiotics or other treatments like earaches. Now the thing to note about meningitis, which we'll cover in more detail later in the call, is meningitis can lead to delayed sensory neural urine loss. So this is an important infection for us to know. Now what happens if the infection spreads more? Right? Well, you can actually get into your brain tissue. Right? So you can get brain abscess or cerebral abscess, not just the lining of your brain. Right? It gets into the brain tissue. So, again, you do imaging, MRIs, and you can see it in abscess or collection of postulates forming inside the brain tissue. Right? Obviously, not a good thing to have. These patients will have focal neurological, signs or symptoms. You know, they may have numbness, tingling, some motor deficits, depending on where the that access is in your brain. Obviously, sometimes they need neurosurgor or neurosurgeons to drain up that access, if it's really big or bad. So the second last one complication is called sigmoid sinus thrombosis. So that's when the infection spreads from the mastoid bone posteriorly into the cranium, into the cranial vault. Okay. So RAIN, just like anywhere in our body, has a circulatory system attached to it. Right? So blood gets delivered, and then it has to drain along with the cerebral spinal fluid. Right? So the drain is through is through some of these big veins shown in blue here, or sometimes they're called sinuses in the brain. So the sigmoid sinus is like an s shape. That's the sigmoid part. It's like an s shaped big vein that drains up blood and cerebral spinal fluid from your brain, which is situated right behind the mastoid bone. So again, the mastoid bone is here, and the sigmoid sinus is right there. So let's say that you get a again, this is the mastoiditis. There's infection for lightning up, and that's the sigmoid sinus there. So let's say that this infection spreads into the sigmoid sinus. Right? That can lead to what we call a thrombosis, where you form a blood clot. So you know how you can get blood clots in your, like, coronary arteries that leads to heart attacks or myocardial infarction or strokes in your brain. Well, this can happen in the sigmoid sinus, which is, again, you know, directly, behind the mastoid. So what happens if you get sigmoid sinus thrombosis? So this is now blocked. So blood and cerebral spinal fluid cannot drain through that sinusoidal vein. K? So this is an angiogram. So you inject dye into the person's circulatory system, and then you can follow her along. So you can see again, this is draining veins. You can see this is the sylmoid sinus there that's draining well on this side. But the other side, there's no drainage. So obviously, these patients will need the treatments to be discussed as well as anti anticoagulants, right, to train to dissolve that blood clot. Would that ever lead to stroke or would it depend on, like, if it goes elsewhere within the brain? Yeah. Usually, it depends on where it goes from. It would bear it wouldn't make the strokes. Strokes are usually due to we'll actually talk a bit about stroke later on. Strokes are usually due to bleeds. So you bleed into the brain. Or you could have an emboli or a blood clot in sort of not the major draining vessels, though. Yeah. So the blood clot is yeah. The locations are very different than sigmoid sinus. And again, it's usually the arteries that get blocked because that's the blood supply to the brain. Right? We're talking about drainage, so it's a bit of a different beast. So the final one to note is called otitic hydrocephalus. K. This is actually when you have too much cerebral spinal fluid. And that would lead to increased intracranial pressure. So you can see this is a normal looking brain on this side. The brain has ventricles, which are sort of little slits here, which produces cerebral spinal fluid, and that's how they drain through. But if it's not draining, what happens is they start collecting in the ventricles. It starts really getting big, and it starts pushing on the adjacent brain tissue. So that's ulterior hydrocephalus. Obviously not good. Right? So how do you get that from an ear infection? Well, you get it through basically thrombosis. Right? So if you have if you start thrombosing big drainage veins or sinuses on both sides of the brain, then you can get build up because of poor drainage, build up of CSF. So, obviously, this needs to be dealt with right away. Again, these are rare, thankfully. However, mastoiditis is pretty common. Brain abscesses and stuff, thankfully, are not. But usually, we do hear about a case or 2 every year. And a few years ago, there's a teenager who died from any area, who had sigmoid sinus thrombosis and brain damage. Right? So it still can happen, but the main thing for you main thing for you is to be aware of some of these. So if you read about it, that your client had it, then you understand what it was. Right? Okay. So so otitis media, very, very common. For us, it's not good enough to say otitis media or ear infection. Right? We have to distinguish between acupatitis media, otitis media with infusion, and very rarely chronic superior to otitis media. We know how it happens. We know about the eustachian tube and how it can, how it can, lead to dysfunction and that lead to otitis media. Again, usually, it happens in the younger population, but it's one of those self limited processes most of the time. Meaning that as kids get older, they're gonna stop having a lot of problems. Some kids with, you know, chronic middle ear effusion, hearing loss, associated speech delay, they may need treatments like ear tubes. And, again, just so that you are aware, even though otitisplenia is very common and readily treatable now, sometimes severe complications can happen. Alright. Okay. So we'll see you, yeah, next week. We'll talk about more middle ear disorders.