ear disorders otitis media , causes , symptoms

Its all about ear diseases

1. EAR DISORDERS

2. Review of anatomy The ear has external, middle, and inner portions. The outer ear is called the pinna and is made of ridged cartilage covered by skin. Sound funnels through the pinna into the external auditory canal, a short tube that ends at the eardrum (tympanic membrane). Sound causes the vibration of eardrum and its tiny attached bones in the middle portion of the ear, and the vibrations are conducted to the nearby cochlea. The spiral-shaped cochlea is part of the inner ear; it transforms sound into nerve impulses that travel to the brain.

3. Infections of the External Ear     Otitis Externa is an infection of the external auditory canal (EAC) that can be divided according to the time course of the infection: acute, subacute , or chronic Acute: less than 6 weeks of duration.

4. Types Chronic OE – This is the same as acute diffuse OE but is of longer duration (>6 weeks) Eczematous ( eczematoid ) OE – This encompasses various dermatologic conditions ( eg , atopic dermatitis , psoriasis,) that may infect the EAC and cause OE Necrotizing (malignant) OE – This is an infection that extends into the deeper tissues adjacent to the EAC; it primarily occurs in adult patients who are immunocompromised ( eg , as a result of diabetes mellitus or AIDS) and is rarely described in children; it may result in cases of cellulitis and osteomyelitis Otomycosis - Infection of the ear canal secondary to fungus species such as Candida or Aspergillus

5. Causes Swimming Constriction of the ear canal from bone growth (Surfer's ear) Saturation diver the use of objects such as cotton swabs or other small objects to clear the ear canal

6. Pathophysiology OE is a superficial infection of the skin in the EAC. The processes involved in the development of OE can be divided into the following 4 categories: Obstruction ( eg , cerumen buildup , surfer’s exostosis , or a narrow or tortuous canal), resulting in water retention Absence of cerumen , which may occur as a result of repeated water exposure or overcleaning the ear canal Trauma Alteration of the pH of the ear canal

7. The two factors that are required for external otitis to develop are (1) the presence of germs that can infect the skin and (2) impairments in the integrity of the skin of the ear canal that allow infection to occur atopic dermatitis , psoriasis otomycosis

8. Symptoms Drainage from the ear - yellow, yellow-green, foul smelling, persistent Ear pain - felt deep inside the ear and may get worse when moving head Hearing loss Itching of the ear or ear canal Fever Trouble swallowing Weakness in the face Voice loss

9. Diagnosis When the ear is inspected, the canal appears red and swollen in well-developed cases. physical examination Otoscope : narrowing of the ear canal from inflammation and the presence of drainage and debris. Culture of the drainage

10. Treatment Aural toilet Aural toilet must be performed and can be done most conveniently by dry mopping. The ear is cleaned with a gentle rotatory action. Once the cotton wool is soiled it is replaced.

11. Dressings If the otitis externa is severe, a length of 1 cm ribbon gauze, impregnated with appropriate medication, should be inserted gently into the meatus , and renewed daily until the meatus has returned to normal

12. The following medications are of value on the dressing: 8% aluminium acetate; 10% ichthammol in glycerine; ointment of gramicidin, neomycin, nystatin and triamcinolone (Tri- Adcortyl );

13. other medication may be used as dictated by the result of culture. If fungal otitis externa is present, dressings of 3% amphotericin , miconazole or nystatin may be used.

14. Otitis media Inflamation of middle ear. Types Acute suppurative non suppurative Chronic suppurative

15. Acute Otitis Media Acute otitis media, i.e. acute inflammation of the middle-ear cavity, is a common condition and is frequently bilateral. It occurs most commonly in children and it is important that it is managed with care to prevent subsequent complications. It most commonly follows an acute upper respiratory tract infection and may be viral or bacterial.

16. Pathology Acute otitis media is an infection of the mucous membrane of the whole of the middle-ear cleft Eustachian tube, tympanic cavity, mastoid antrum and air cells.

17. The bacteria responsible for acute otitis media are: Streptococcus pneumonia 35%, Haemophilus influenzae 25%, Moraxella catarrhalis 15%. Group A streptococci and Staphylococcus aureus may also be responsible.

18. The sequence of events in acute otitis media is as follows: organisms invade the mucous membrane causing inflammation, oedema, exudate and later, pus; oedema closes the Eustachian tube, preventing aeration and drainage ;

19. pressure from the pus rises, causing the drum to bulge; necrosis of the tympanic membrane results in perforation; the ear continues to drain until the infection resolves

20. Causes Common cold Acute tonsillitis Influenza whooping cough

21. Symptoms, signs Earache Deafness It is conductive in nature and may be accompanied by tinnitus Pyrexia Tenderness There is usually some tenderness to pressure on the mastoid antrum.

22. contd ……. The tympanic membrane varies in appearance Redness and fullness of the drum;. Bulging, with loss of landmarks. Purple colour.. Perforation with otorrhoea .

23. Treatment Antibiotics: , amoxycillin will be more effective. Co- amoxiclav is useful in Moraxella infections.

24. Analgesics Nasal vasoconstrictors Ear drops ( steroides or antibiotics) Myringotomy is necessary when bulging of the tympanic membrane persists, despite adequate antibiotic therapy

25. Chronic suppurative otitis media(CSOM) CSOM is a chronic inflammatory process involving the middle ear cleft producing irreversible pathological changes .

26. causes Late treatment of acute otitis media. Inadequate or inappropriate antibiotic therapy. Upper airway infection. Lowered resistance, e.g. malnutrition, anaemia,immunological impairment. Particularly virulent infection, e.g. measles.

27. Classification It is of two types . Tubotympanic(safe) Attico antral(dangerous)

28. Types of CSOM Mucosal disease with tympanic membrane perforation ( tubo -tympanic disease, relatively safe). Bony : cholesteatoma—dangerous ( attico -antral disease).

29. Tubo tympanic : this is a benign type of CSOM confined only to the middle ear cleft. Attico antral : this involves the attic, antrum and the posterior tympanum. It is characterized by bone eroding cholesteatoma.

30. Mucosal infection Symptoms Discharge- non foul smelling Deafness Earache

31. Signs : discharge, tympanic membrane perforation, Tuning fork test: rinne -negative Weber-lateralised to one side

32. Investigations Culture and sensitivity Examination under microscope Pure tone audiogram:mild conductive loss between 20 to 30dB X-ray of mastoid, Nasal endoscopy

33. Treatment of mucosal-type csom Myringoplasty if hearing loss below 40dB Tympanoplasty :if above 40dB

34. Attico antral type – clinical features Ear discharge : foul smelling scanty,, blood stained, Deafness : progressive conductive deafness Itching and pain in the ear Tinnitus and giddiness

35. Sign In Otoscopic examination: foul smelling discharge in the ext. Auditory canal Granulation tissue in the meatus Attic or marginal perforation of tymanic membrane Cholesteatoma Mastoid tenderness Tuning fork test- Rinne negative, weber localised to lateral side,

36. Investigations Examination under microscope Culture and sensitivity Audiogram Imaging- X-ray mastoid,CT scan,MRI scan

37. Management Goal – to make the ear safe and dry To restore and improve hearing Surgical management Main line treatment. 1. canal wall down mastoidectomy: consists of radical and modified radical mastoidectomy. These procedures ensures safety and dry ear but functional improvement may not be achieved.

38. 2. Canal wall up mastoidectomy: or combined approach tympanoplasty , where functional improvement can be achieved but not the safety.

39. Medical management It is used only for patient who are unfit for surgery. Topical antibiotic and steroid are used. In some cases 5- flurouracil used.

40. Complications-CSOM Brain abscess Otitic hydrocephalus Meningitis Mastoiditis Labyrynthitis Petrositis

41. Difference between TTD&AAD TTD AAD Parts involved Antero inferior Postero superior Discharge Mucoid, profuse, non foul smelling Purulent, scanty, foul smelling Perforation Central Marginal, Involving attic Polyp Usually pale Pink, fleshy Granulation tissue Rare Common Cholesteatoma Absent Common Complications Rare Common audiogram Mild- moderate conductive hearing loss. Conductive/mixed