Non suppurative otitis media

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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. Medical treatment
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
•Rubber tube attached
to Politzer bag is put
into one nostril & both
nostrils pinched
•Pt is asked to swallow
repeatedly & Politzer
bag is squeezed
simultaneously

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. EARDOC generates and transmits special
vibration waves which travel through
temporal bone to reach the middle ear &
Eustachian tube → the waves ease middle
ear pressure and drain trapped fluids →
edema & pain are reduced

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
•Grommet gets extruded
on its own due to
endothelium growing
on its inner surface
•Extrudes after 6 - 9
months.

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.Adhesive otitis media
3.Tympanosclerosis
4.Cholesterol granuloma
5.Ossicular necrosis
6.Retraction pocket & 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
Deposition of hyaline
(acellular and avascular
collagen) and calcium
deposits in submucosal
tissue of T.M. & M.E.
cavity following long-
standing otitis media
during healing process

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
Differen
ce
Pathology in
normal Middle
Ear
Symptom
s
- 60 mm
Hg
Hyperemia , edema ,
exudation , T.M.
retraction
Otalgia,
deafness,
tinnitus
- 90 mm
Hg
Locking of ET
(collapse of lumen),
microscopic
hemorrhage
Severe
otalgia
- 100 to
400 mm
Hg
T.M. rupture Frank
blood
otorrhea

46. Treatment
1.Nasal decongestants + H1 anti-
histamines
2.Politzerization for middle ear
aeration
3.Myringotomy + grommet insertion
–Refractory cases
–Presence of hemotympanum

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