Middle Ear Diseases.pptx

Middle ear diseases diagnosis and management

1. Middle Ear Diseases Presenter: Dr. Adhishesh Kaul Post Graduate Student – ENT AIMS & RC Moderator: Dr. Poornima S. Associate Professor – ENT AIMS & RC

2. Middle Ear Diseases Acute Otitis Media Otitis Media with Effusion Eustachian Tube Dysfunction

3. Acute Otitis Media

4. Acute Otitis Media (AOM) Definition Incidence Etiology Route of Spread of Infection Predisposing Factors Disease Course and Stages with Pathology Clinical Outcomes after initiation of antibiotics History Examination Findings Investigations Treatment Complications

5. Definition Acute middle ear inflammation (hours to < 6 weeks) Generally seen in infective conditions – causative organism Bacterial Viral More common in Children than adults

6. Prevalence As per an international study, with 3224 patients it was found that 16% of AOM patients were aged >15years As per a study of 1982, AOM is 200 times more common in first 2 years of life than adult life

7. Etiology Majority of adult patients with AOM have bacterial infections BACTERIA PERCENTAGE Haemophilis influenzae 26% Streptococcus pneumoniae 21% Moraxelaa catarrhalis 3% Streptococcus aureus 3% Others 26% No Growth 26% From Celin et al.

8. Other Infective causes Viral : RSV, Rhinovirus, Corona Virus, Influenza Type A, Adenovirus Fungal : Aspergillus and Candida Other Causes Autoimmune inflammation Neoplastic Traumatic

9. Route of Spread Eustachian tube Via lumen of tube Along subepithelial tubal lymphatics External ear Due to traumatic perforations Blood borne

10. Predisposing Factors Young age Male sex Bottle feeding Daycare environment exposure Crowded living conditions Smoking within home Medical conditions Cleft palate Down’s syndrome Mucus membrane abnormalities – CF, ciliary dyskinesia Immunodeficiency

11. STAGE PATHOLOGY FEATURES Hyperemic (Tubal Occlusion) Upon arrival of Ag into middle ear cavity Ag can come via various routes as described Ag undergoes processing by T Cells, macrophages, B cell bearing Ig- IgM, IgA, IgG Response: Hyperemia and edema of TM and middle ear mucosa Edema and hyperemia of nasopharyngeal end of ET causes negative pressure and TM Retraction Symptom: Deafness and otalgia Sign: TM retracted HoM – horizontal Light reflex: Lost TFT: CHL Exudative ( Presuppuration ) Release of IL-2, PCAM-1, and others result in increased expression of intercellular adhesion molecules, in veins and venules. Inflammatory mediators such as B and T cells, macrophages, PMN rush through vessels rendered leaky by above molecules. IgG arrive first followed by IgM, T Cells appear at 24 hours and peak at 2 – 3 weeks, IgA B Cells come around 3 weeks All these recruited cells participate in complex cascade of CK release, which are implicated in AOM Prolonged occlusion on ET cause organisms to invade TM and cause lining hyperemia Symptoms: throbbing severe ear ache deafness and tinnitus Signs: Pars Tensa – Congestion Leash of blood vessels along HoM and at periphery imparting Cart Wheel appearance TFT: CHL Disease Course and Stages with Pathology

12. STAGE PATHOLOGY FEATURES Suppurative Occurs only in bacterial infection Reflects immunological response destroying offending organism TM can rupture – if suppuration is fulminant Pus in middle ear and mastoid Symptoms: Fever 102F ± vomit and convulsions Signs: TM: bulging and red HoM : Engulfed by swollen and protruding TM Yellow spot: may be seen on TM Mastoid tenderness may be present X Ray: Air cell clouding Resolution Occurs with accumulated fluid in middle ear, with ET blocked by mucosal edema TM ruptures with release of pus and symptoms subside Symptoms: otalgia is relieved with release of pus fever subsides Signs: EAC may have blood tinged discharge with may become mucopurulent AI quadrant may show a small perforation.

13. Clinical Outcomes after initiation of antibiotics Relief of signs and symptoms and resolution of middle ear effusion (MEE) Relief of signs and symptoms but persistence of MEE Persistence or recurrence of signs and symptoms during course of therapy – TREATMENT FAILURE Development of suppurative complications Spontaneous perforation resulting in purulent otorrhea Relief of initial signs and symptoms with relapse within 3-4 weeks Symptomatic relief of acute infection but recurrent AOM

14. History Pain in the ear (otalgia) Mucopurulent discharge Hearing loss Tinnitus Differentiate from bullous myringitis – bloody otorrhoea due to bursting of blood blisters

15. Examination Findings Otoscopy : TM may be red and bulging TM may be more lateral than usual TM may be perforated – If perforated : 1. TM reverted will reverted to usual position 2. Perforation may be visible Pus may be seen in EAM and on TM – Micro suction will be required for inspection of perforated drum Confusion might arise between a normal TM with profusion of blood vessels from umbo and a case of AOM Most reliable indicator of AOM on otoscopy: Bulging TM

16. Investigations Pure Tone Audiometry with Impedance Audiometry : Required only if AOM has been missed and it shows significant conductive hearing loss, Flat tympanogram with absent acoustic reflexes Tympanocentesis : For definitive diagnosis of Otitis Media, but almost never done CT Scan : To differentiate AOM from acute mastoiditis – by identifying subperiosteal abscess vs coalescence of mastoid air cells MRI Scan : NOT USEFUL

17. Treatment (Practiced) Antibiotics Decongestants – Nasal and Oral Analgesics Ear toilet Myringotomy

18. Treatment(Advocated) ASOM with complications Antibiotics Myringotomy ± Ventilating tube placement Post treatment, Tympanometry and Otoscopy should be done to document resolution CT Scan /MRI Brain should be advised in case of intracranial compliactions

19. Otitis Media with Effusion (OME)

20. Otitis Media with Effusion (OME) Definition Incidence Etiology Predisposing Factors Pathogenesis History/ Clinical Presentation Examination Findings Investigations Treatment Sequalae

21. Definition Fluid collection (non-purulent) in middle ear, often extending up to mastoid air cells. Characteristic of fluid: Usually thick and viscid Usually secondary to URTI, but may precede or proceed an episode

22. Incidence 0.6% patients with OME are aged above 15 years

23. Etiology Infections: Inadequately treated AOM, leads to inactivation of infection but persistence of low grade infection which causes goblet cells to secrete more fluid. Allergy: obstructs ET and also causes increased fluid in middle ear Barotrauma Eustachian tube dysfunction – secondary to: Adenoid hyperplasia Chronic tonsillitis : mechanically obstruct movement of soft palate and interfere with physiological opening of ET Nasopharyngeal tumors (benign and malignant) : esp imp in u/l OME Palatal defect Miscellaneous

24. Predisposing Factors Smoking Childhood ear infections Nasal symptoms URTI AOM usual feature Barotrauma

25. Pathogenesis Malfunction of eustachian tube Increased secretory activity of middle ear mucosa

26. History/ Clinical Presentation Hearing loss – majority of the patients (97%) Aural fullness (77%) Tinnitus – pulsatile or crackling (60%) Balance disturbance may be reported Delayed and defective speech Mild ear aches Unilateral OME with insignificant past history should be managed with suspicion.

27. Examination Findings Pneumatic otoscopy: gold standard for diagnosis of OME Tympanic Membrane: (Otoscopy/ Microscopy) Retracted Abnormal light reflex Membrane appears dull Fluid may be seen Nasopharyngolaryngoscopy 0 degree Hopkins rigid endoscope e/o Rhinosinusitis will direct treatment Post nasal space lesion needs imaging and treatment

28. Investigations Tympanometry: Low compliance, with flat tympanogram, because energy does not vary with pressure change Audiology: level of impaired hearing function conductive hearing loss high degree of correlation with MRI Myringotomy presence of fluid on surgery confirms the diagnosis but absence does not refute it . MRI may be used for diagnosis and monitoring of OME

29. Treatment NON MEDICAL MANAGEMENT MEDICAL MANAGEMENT HEARING ADIS SURGICAL TREATMENT WHEN EFFUSION PERSISTS WITH HEARING LOSS Toynbee maneuver Valsalva technique Particularly useful in sniffers Mechanical devices Otovent ™ Balloon / Ear Popper™ Used when patients are not cooperative Nasal decongestant Antibiotics On the basis of culture techniques and confocal laser scanning microscopy N-acetyl cysteine: mucolytic therapy but no evidence Corticosteroid usage is equivocal Effective for conductive hearing loss Ventilation tubes Laser myringotomy short term solution Mastoid vents good long term efficacy in chronic OME Laser eustachian tuboplasty Balloon dilatation of eustachian tubes Tympanotomy Adenoidectomy

30. Sequalae Tympanic membrane atrophy and atelectasis Ossicular necrosis Tympanosclerosis Retraction pocket and cholesteatoma Cholesterol granuloma

31. Complications of Otitis Media

32. Complications of Otitis Media INTRACRANIAL Meningitis Abscess – Epidural / Subdural Thrombosis – Sigmoid sinus, Lateral Sinus Brain Abscess Otitis hydrocephalus INTRATEMPORAL Hearing loss and Balance Speech – Language and child development Mastoiditis

33. CT scan of a 10-year-old boy showing a right cerebellar brain abscess ( arrows ) as a complication of right acute mastoiditis with otitis media . The child had a 3-week history of headache and vertigo 1 day after the onset of fever and presented with increasing lethargy, vertigo, slurred speech, nausea and head-tilting to the left. Examination revealed ataxia, nystagmus, mild confusion and right-sided weakness but no otalgia or otorrhea. Otoscopic examination revealed left middle ear effusion, which was confirmed by tympanocentesis . The brain abscess was drained, and cortical mastoidectomy and tympanostomy tube insertion was performed . Purulent material was found within the mastoid at the time of mastoid surgery and culture of the abscess revealed  S. pneumoniae , susceptible to penicillin. The child made a complete recovery, without any sequelae, after the brain and mastoid surgery and intravenous antimicrobial therapy.

34. Magnetic resonance image of left acute suppurative labyrinthitis ( arrow ) as a complication of the first attack of acute otitis media in a 18-month-old male child who had a preexisting congenital perilymphatic /cerebrospinal fluid fistula of the labyrinthine windows . The child presented with left otorrhea, fever, vertigo and dehydration 5 days after the onset of the acute otitis media; P. aeruginosa  was isolated from the otorrhea. Labyrinthectomy on the left ear and bilateral tympanostomy tube placement as an emergency procedure was performed with no further progression of the infection. The child had no further hearing loss or suppurative complication over the ensuing 3-year follow-up period.

35. CT scan of a 7-week-old male infant who developed acute otitis media in the right ear that progressed into an acute mastoiditis with osteitis and subperiosteal abscess ( arrow ). Cortical mastoidectomy and tympanostomy tube placement was performed , at which time cultures from the middle ear and mastoid revealed  S. pneumoniae , susceptible to penicillin . The child had an uneventful recovery after the surgery and intravenous antibiotic therapy.

36. Extracranial Complications Tympanic Membrane Perforation Acute mastoiditis Petrositis Facial Nerve Palsy Labyrinthitis

37. Tympanic Membrane Perforation Incidence: up to 10% Symptoms: Otorrhea (purulent or bloody) Pain relief Site: Posterior half of pars tensa with loss of fiberous middle layer

38. Acute Mastoiditis Class Signs and Symptoms Acute Mastoiditis During the course of AOM, infection may spread to mastoid cavity and not associated with typical signs of mastoiditis Acute Mastoiditis with Periosteitis No abscess Post auricular crease is full Pinna pushed forward Post auricular: mild swelling, erythema, fullness Acute Mastoid Osteitis Subperiosteal abscess develops Zygomatic abscess may develop above and in front of pinna Bezold’s abscess: result from perforation of medial mastoid cortex Subacute (masked) mastoiditis In case of incompletely treated AOM Signs: absent Otalgia and Fever: Persistent

39. Petrositis Seen if infection spreads to petrous apex Gradenigo’s traid : 6 th nerve palsy 5 th nerve distribution pain Middle ear infection

40. Facial Nerve Palsy Incidence: 0.005% patients of AOM (bacterial > viral AOM) Management: Ventilation tube insertion and Antibiotics

41. Labyrinthitis Pathogenesis : change in round window permeability in acute infection Type Feature Perilabyrinthitis Not Associated with AOM Serous Labyrinthitis Inflammation of labyrinth without pus formation Full recovery of auditory and vestibular system Suppurative Labyrinthitis Due to spread of infection from mastoid/ middle ear Symptoms: Severe Vertigo Nausea Vomiting Nystagmus Permanent hearing loss Treatment: Ventilation tube Tympanomastoidectomy Cochleotomy

42. Myringotomy

43. Myringotomy Indications Instruments for Myringotomy ± Ventilation Tube Procedure for Myringotomy ± Ventilation Tube Complications

44. Indications Ventilation of retraction pocket Middle ear effusion Aeration of barotrauma Conductive hearing loss Diagnostic myringotomy if TM is opaque and does not move

45. Instruments for Myringotomy ± Ventilation Tube

46. Procedure for Myringotomy ± Ventilation Tube Clean the EAC of cerumen, keratin debris. (concomitant OE will require further cleaning) Adult/ Cooperative child: local anesthesia with phenol over TM Postero -inferior or Anterior quadrants are easily available Myringotomy tube in Anterior or Antero-Superior Quadrant ( tube are retained for longer, because of migration pattern of epithelium of tympanic membrane ) Fluid is aspirated with 5F or 7F suction tube, if difficult, another incision is made Postero -inferior quadrant Grommet tube should be avoided at Annulus : leads to marginal perforation Adjacent to malleus : may cause pulsatile tinnitus

47. Ventilation tube in Adults EAC is cleaned under microscope Tube is placed in anterior aspect in adults, may be placed in postero -inferior quadrant, if access to anterior TM is restricted because of convexity If tube is required for indefinite period, T – Tube is the choice Per-Lee tube provides indefinite ventilation Jahn – Hydroxyapetite tube placement needs lengthier procedure

48. Complications Post-Tympanostomy Tube Otorrhea Tympanosclerosis, Retraction Pockets and Atrophy Persistent TM perforation after extrusion of tube Retained tube Confusion of congenital or aberrant blood vessels with fluid, especially dehiscent high rising jugular bulb. Glomus tumor may be confused with AOM Tube may fall into middle ear if opening made is too large Ossicular chain discontinuity if tube is placed in Posterosuperior quadrant

49. Eustachian Tube Dysfunction

50. Eustachian Tube Dysfunction History Basic Points to Be Considered Functions of Eustachian Tube Definition of Eustachian Tube Dysfunction Pathogenesis Clinical Presentation Examination findings Investigations of ET Dysfunction Eustachian tube endoscopy Management of ET Dysfunction Sequalae

51. History Scientist Year Contribution Alcnaeon 400BC 1 st Mentioned ET Bartolomeus Eustachius 1562 Discovery, anatomy and function Valsalva Described ET having osseous and cartlagenous part Described importance of Tensor Veli Palatini Described Valsalva maneuver Toynbee Extensive investigations of peritubal muscles Politzer The role of eustachian tube in middle ear pathology

52. Basic Points To Be Considered Mucociliary action from middle ear to nasopharynx Proximal: in middle ear: Bony/ funnel shaped, lined by cuboidal epithelium Distal: towards nasopharyngeal opening: cartilaginous skeleton Cross-section has : Superior and Inferior Halves Anterolateral and Posteromedial Halves Peritubal muscles levator veli palatini TVP Tensor Tympanii Salphingopharyngeus

53. Pharyngeal ET: Cartilaginous skeleton Tubal Muscles Submucosa Epithelium

54. Functions of Eustachian Tube

55. Definition of Eustachian Tube Dysfunction Inadequate ability to open the tubal valve OR Inadequate dilatory function causing secondary ear pathology Due to Anatomical obstruction due to neoplasms or mass lesions Physiological failure due to Hereditary factors Mucosal inflammation with functional obstruction or failure of dilation Muscular problems causing dilatory dynamic dysfunction

56. Eustachian Tube Dysfunction Obstructive Dysfunction Dynamic Dysfunction There is increasing evidence that ET Dysfunction is because of cartilaginous portion of ET In a study of 58 ears, all had significant pathology and compromise of tubal dilation within cartilaginous portion. PATHOLOGIES Mucosal Edema : 83% Reduced lateral wall motion : 74% Obstructive Mucosal Disease : 26%

57. Pathogenesis Mucosa Submucosa Dynamic dysfunction Hypofunction Hyperfunction Lack of coordination Decreased luminal diameter Decreased ability to dilate tube Of TVP or LVP

58. Clinical Presentation Ear Pain: mild to severe Aural fullness Decreased hearing Tinnitus/ popping sound Imbalance/ vertigo

59. Examination Findings Otoscopy : Retracted TM, Congestion along Handle of malleus and Pars Tensa Transudate behind tympanic membrane Post Nasal Examination : for adenoids / any other nasopharyngeal mass Tuning Fork Test : Normal or conductive hearing loss

60. Functional test for Eustachian Tube Valsalva Maneuver Poltizer Test: Hissing sound on auscultation Toynbee Maneuver: Inward movement of tympanic membrane Sonotubometry

61. Investigations Pure Tone Audiometry Tympanometry Endoscopic Examination

62. Eustachian Tube Endoscopy Endoscopes Used Microfiber-optic endoscope (<1mm): Image resolution compromised Contact with secretions obscures inspection in lumen Only describe gross observations like patency and lesions Fiber-Optic nasopharyngeal endoscope (3-4mm) Rigid Hopkins endoscopes

63. Management Medical Management Surgical Management Mucosal Inflammation Identify underlying cause LPR: Diet, PPI and H2 blocker Sleep on inclined bed Fundoplication Allergic disease: LT inhibitor, antihistamine, mast cell stabilizer, immunotherapy Oral and nasal steroids Anatomical Obstruction do CECT to r/o malignancy CHRONIC FULLNESS IN EAR WITH NORMAL TM, to R/O other causes Eustachian Tuboplasty Persistent dysfunction with OME or atelectasis

64. Sequalae

65. Patulous Eustachian Tube Definition: Abnormally patent eustachian tube Etiology: Idiopathic Rapid weight loss Pregnancy: 3 rd trimester Multiple Sclerosis Signs and Symptoms Autophony TM movement seen on otoscopy Management Usually self limiting Weight gain Potassium Iodide Cauterization Grommet insertion Submucosal Graft implantation

66. References /Bibliography Bluestone CD. Clinical course, complications and sequelae of acute otitis media. Pediatr Infect Dis J. 2000; 19(5 Suppl):S37-46 Cummings Otolaryngology Head and Neck Surgery: ed 6 Diseases of Ear, Nose and Throat & Head and Neck Surgery: ed 7 Diseases of Ear, nose and Throat Glasscock- Shambaugh Surgery of the Ear: ed 6 Scott-Brown’s Otorhinolaryngology Head & Neck Surgery: ed 8 www.kenhub.com