11. non suppurative otitis media

OME specially useful for undergraduate medical students

1. Non -suppurative Otitis
Media
Dr. Krishna Koirala, MS
Associate Professor
Dept. of ENT-HNS
2016-04-26

2. Types
1.Otitis Media with effusion (O.M.E.)
2.Adhesive otitis media
3.Tympanosclerosis
4.Barotraumatic otitis media

3. Otitis Media with Effusion
•Presence of serous or mucoid fluid in the middle
ear cleft without frank pus
•Synonyms
–Glue ear
–Serous otitis media
–Seromucinous otitis media
–Secretory otitis media
–Exudative otitis media
–Catarrhal otitis media

4. Etiology
1. Eustachian tube dysfunction
–Vacuum in middle earextravasation of fluid
–Lack of drainage of middle ear secretions
2. Upper respiratory tract allergy / viral infection
–Increase middle ear secretions
3. Low grade middle ear infection
–Inadequate treatment of ASOM

5. Causes of E.T. dysfunction
1. Eustachian Tube obstruction
−Intrinsic : infection, allergy, trauma
−Extrinsic : adenoids, nasopharyngeal tumour
−Functional: floppy eustachian tube
2. Palatal abnormalities : Cleft palate , palatal palsy
3. Mucociliary pathology:
−Infection ,allergy ,smoking
−Kartagener’s syndrome ,Young’s syndrome
−Surfactant deficiency ,Immune deficiency

6. Symptoms
•Mild deafness in a young child that increases during
U.R.T.I.
•Mild otalgia
•Blocking sensation in ear
•Delayed & defective speech due to deafness

7. Signs
1. Otoscopy
−Dull /pinkish/blue eardrum with restricted mobility
−Retraction of T.M. in early stage
−Bulging of T.M. in later stages
−Fluid level and air bubbles seen behind the T.M.
2. Tuning Fork Tests
–Conductive deafness

8. Blue ear drum

9. Air Fluid level

10. Air bubbles

11. Pure Tone Audiometry
Low frequency conductive deafness

12. Impedance Audiometry
C type tympanogram in ear drum retraction
B type tympanogram in middle ear effusion

13. X-ray mastoid & Nasopharynx
Clouding of mastoid air cells + adenoid mass

14. Medicaltreatment
1.Antibiotic (Co -amoxyclav) for 2-4 weeks
2.Nasal decongestants (systemic + topical)
3.H1 anti-histamines
4.Auto-inflation of the Eustachian tube by Valsalva
maneuver
5.Analgesic for acute earache

15. Non-medical, Non-surgical treatment
•Politzerization
•Otovent balloon
•Ear popper device
•Eardoc device

16. Politzerization
•Rubbertubeattachedto
Politzerbagisputintoone
nostril&bothnostrilspinched
•Ptisaskedtoswallow
repeatedly&Politzerbagis
squeezedsimultaneously

17. Otovent balloon device

18. •Balloon is inflated by blowing air out of nose
•When fully inflated, balloon neck is pinched off and
nasal occluder is inserted into one nostril
•Child is instructed to swallow as balloon is deflated
into the nasal cavity
•Portion of air from balloon enters Eustachian tube &
ventilates middle ear

19. Ear Popper Device

20. •Based on Politzer Maneuver, Ear Popper Device
delivers a safe, constant, regulated stream of air into
nasal cavity
•During swallowing, air is diverted to Eustachian tube
clearing and ventilating middle ear

21. EARDOC device

22. EARDOCgeneratesandtransmitsspecialvibration
waveswhichtravelthroughtemporalbonetoreachthe
middleear&Eustachiantube→thewavesease
middleearpressureanddraintrappedfluids→edema
&painarereduced

23. Surgical treatment
1.Myringotomy (Tympanocentesis) + grommet
(Pressure Equalization / Ventilation tube) Insertion
–Radial incision made in antero-inferior quadrant
–For thick fluid, 2 incisions made in antero-inferior
quadrant and antero-superior quadrant (Beer can
principle)

24. 2.Cortical mastoidectomy for refractory cases with
loculated fluid in mastoid
3.Treatment for predisposing factors like adeno-
tonsillectomy ,antral wash ,polypectomy

25. Myringotomy

26. Myringotomy incision

27. Beer can principle

28. Grommet insertion

29. Post-op grommet

30. Grommet extrusion
•Grommetgetsextrudedonits
ownduetoendothelium
growingonitsinnersurface
•Extrudesafter6-9months.

31. Healed tympanic membrane

32. Complications of Grommet
insertion

33. Tympanosclerosis

34. T.M. Perforation

35. Granulations

36. Grommet lost inside the middle ear

37. Sequelae of O.M.E.
1.T.M.atrophy&atelectasis
2.Adhesiveotitismedia
3.Tympanosclerosis
4.Cholesterolgranuloma
5.Ossicularnecrosis
6.Retractionpocket&cholesteatoma

38. Adhesive Otitis Media
•Pathology
–TM atrophy + atelectasis(due to dissolution of
fibrous layer) + adhesions in middle ear cavity,
following chronic O.M.E.
•Clinical Features
–Conductive deafness
–Thin retracted T.M. with no mobility

39. Treatment:
1. Hearing Aid
2. Surgery (long term results are poor)
a. Tympanotomy + release of adhesions + put
silastic sheet b/w promontory & TM
b. Grommet insertion

40. Tympanosclerosis
Depositionofhyaline(acellular
andavascularcollagen)and
calcium deposits in
submucosaltissueofT.M.&
M.E.cavityfollowinglong-
standingotitismediaduring
healingprocess

41. Tympanosclerosis
Treatment:
1. Hearing Aid
2. Surgery
•Remove tymapnosclerotic patch and perform
tympanoplasty

42. Middle Ear Barotrauma

43. Role of Esutachian tube
•E.T. has collapsible cartilaginous and rigid bony portion
•Allows expulsion of air from middle ear into E.T. but
not suction of air into middle ear via ET

44. Etiology
•Failure of Eustachian tube to equalize rapid increase
in pressure difference b/w middle ear & atmosphere,
over a long period
•During ascent
–Middle ear pressure > Atmospheric Pressure no
barotrauma in normal middle ear
•During descent
–Middle ear pressure < Atmospheric Pressure 
barotrauma occurs

45. Pressure
Difference
Pathology in normal
Middle Ear
Symptoms
-60 mm Hg Hyperemia , edema ,
exudation , T.M. retraction
Otalgia,
deafness,
tinnitus
-90 mm HgLocking of ET (collapse of
lumen), microscopic
hemorrhage
Severe otalgia
-100 to 400
mm Hg
T.M. rupture Frank blood
otorrhea

46. Treatment
1.Nasaldecongestants+H1anti-histamines
2.Politzerizationformiddleearaeration
3.Myringotomy+grommetinsertion
–Refractorycases
–Presenceofhemotympanum

47. Prevention
1. Avoid air travel during cold / nasal allergy
2.During descent while flying
–Do repeated swallows (lozenges / chewing gum)
–Do intermittent Valsalva maneuvre
–Avoid sleeping (as swallowing is decreased)
3. Pt with previous episode: take nasal decongestant +
antihistamine at least 30 min before descent