Otitis Media

A Power Point presentation on Otitis Media

1. Afolabi, Boluwatife 170043 BDS GROUP A, 2015 7 th February, 2017 OTITIS MEDIA

2. Introduction Case Presentation Epidemiology Anatomy of the ear Classification Aetiology Risk factors Pathology Clinical Features Differential diagnoses Management Complications Prognosis Conclusion References Outline

3. Otitis media can be defined as inflammation of the cleft mucosal lining of the middle ear . May also involve inflammation of mastoid, petrous apex, and peri -labyrinthine air cells. In most cases, it develops from an infection in the upper respiratory tract (the nasopharynx ) that then extends into the middle ear via the Eustachian tube . Introduction

4. A.T is a 4 year old male brought in by his mother. He has had a low grade fever of 38.3 C for 3 days. He complained that his ears hurt with difficulty sleeping. He also had a non productive cough that started the day before. Examination of both ears reveal significant redness and fluid in both middle ears with no apparent involvement of the eardrum or tympanic membrane. Further examination of the patient’s breathing and other manifestations indicate an upper respiratory infection. The patient’s parents are chronic heavy smokers and the child is exposed to second hand smoke in the home environment. Case Presentation

5. Acute otitis media is very common in childhood. It is one of the most common condition for which medical care is provided for children in Nigeria. The prevalence is found to be 14.7%. The peak incidence is in children aged 1-4 years. The incidence is slightly higher in boys than girls. Some infants may experience their first attack shortly after birth and are considered otitis-prone (i.e. at risk for recurrent otitis media). Epidemiology

6. Anatomy of the ear

7. The human ear contains sense organs that serve two quite different functions: that of hearing and that of postural equilibrium and coordination of head and eye movements. Anatomically the ear has three distinguishable parts: the outer, middle, and inner ear. The outer ear consists of the visible portion called the auricle or pinna, which projects from the side of the head, and the short external auditory canal, the inner end of which is closed by the tympanic membrane, commonly called the eardrum. The thin, semitransparent tympanic membrane, or eardrum, which forms the boundary between the outer and middle ear, is stretched obliquely across the end of the external canal. The uppermost small area of the membrane where the ring is open is slack and is called the pars flaccida , but the far greater portion is tightly stretched and is called the pars tensa . Anatomy of the ear

8. The middle ear is a narrow, air-filled cavity in the temporal bone. It is spanned by a chain of three tiny bones—the malleus (hammer), incus (anvil), and stapes (stirrup), collectively called the auditory ossicles . The inner ear consists of two functional units: the vestibular apparatus, consisting of the vestibule and semicircular canals, which contains the sensory organs of postural equilibrium; and the snail-shell-like cochlea, which contains the sensory organ of hearing. These sensory organs are highly specialized endings of the eighth cranial nerve; the vestibulocochlear nerve. The middle-ear space roughly resembles a rectangular room with four walls, a floor, and a ceiling. The outer (lateral) wall of the middle-ear space is formed by the tympanic membrane. Its ceiling (superior wall) is a thin plate of bone that separates it from the cranial cavity and brain above. …anatomy of the ear contd.

9. The floor (inferior wall) is also a thin bony plate separating the cavity from the jugular vein and carotid artery below. The back (posterior) wall partly separates it from another cavity, the mastoid antrum . In the front (anterior) wall is the opening of the eustachian or auditory tube, which connects the middle ear with the nasopharynx . The inner (medial) wall, which separates the middle ear from the inner ear, or labyrinth, is a part of the bony otic capsule of the inner ear. It has two small openings, or fenestrae, one above the other. The upper one is the oval window (fenestrae vestibuli ), which is closed by the footplate of the stapes. The lower one is the round window (fenestrae rotundum ), which is covered by a thin membrane. …anatomy of the ear contd.

10. There are several subtypes of Otitis Media, as follows: 1 . Acute otitis media (AOM) 2. Otitis media with effusion (OME) 3. Chronic suppurative otitis media (CSOM) 4. Adhesive otitis media Classification

11. Acute Otitis Media (AOM) AOM results from infection of fluid that has become trapped in the middle ear. It can occur in suppurative , non- suppurative , and recurrent forms. In non- suppurative AOM, inflammation of the middle ear cleft mucosa occurs either without formation of an effusion or with a sterile effusion. This type of AOM is often seen prior to, or in the resolution stage of, the acute suppurative otitis media; however, resolution may occur before frank suppuration. Recurrent AOM is defined as 3 episodes of acute suppurative otitis media in a 6-month period, or 4 episodes in a 12-month period, with complete resolution of symptoms and signs between the episodes. Here, patients usually present with concurrent or recent symptoms of upper respiratory infection (URI), such as cough, rhinorrhea or sinus congestion. … contd

12. Otitis Media with E ffusion (OME) -Serous OM/ Glue ear This is characterized by non purulent effusion of the middle ear that may be serous or mucoid . OME can occur within the resolution phase of AOM Leading theory suggests that eustachian tube dysfunction is the main factor in OME, either by anatomical blocks, allergic reaction (smoke) or upper respiratory tract infection. This leads to a negative pressure within the middle ear that then causes transudate from the mucosa. OME often follows an episode of AOM. Symptoms that may be indicative of OME include the following: -Hearing loss: parents often describe the child as inattentive -Tinnitus: occurs, though rarely -Vertigo: may not be profound, but some unsteadiness or clumsiness may be reported It should, however, be noted that although fluid is present in the middle ear in both conditions, the fluid is not infected in OME as is seen in AOM patients. … contd

13. Chronic Suppurative Otitis Media (CSOM) Chronic suppurative otitis media is a persistent ear infection that results in tearing or perforation of the eardrum. Can occur with or without cholesteatoma (destructive tumor consisting of keratinizing epithelial cells in the middle ear and/or mastoid process) Surgery is the model modality of treatment with medical intervention used as an adjunct. It should be noted that CSOM is different from chronic otitis media in that the latter is defined as middle ear effusion without perforation and persists for 1-3 months. … contd

14. Adhesive Otitis Media Adhesive otitis media occurs when a thin retracted ear drum becomes sucked into the middle ear space and stuck. It is an abacterial inflammation of the middle ear and the adjoining pneumatic spaces. Here, there is occlusion of the eustachian tube and adhesion of the tympanum. … contd

15. The Aetiology of otitis media can be classified as follows; VIRAL PATHOGENS Of the viral pathogens, the RSV (Respiratory Syncytial Virus) is the most common cause of pneumonia and bronchiolitis in young persons and this can lead to upper respiratory tract infection, not just in children, but in all age groups. RSV was identified early as a pathogen that appeared to create long-term pulmonary complications, primarily asthma, in as many as half of infants with bronchiolitis. Other viruses include: Rhino & Adeno Virus. Aetiology

16. BACTERIAL PATHOGENS Four bacteria—namely,  Streptococcus pneumoniae , Heamophilus influenzae , Moraxella catarrhalis ,  and  Streptococcus pyogenes  —are responsible for the majority of episodes of otitis media in persons older than 6 weeks. Other bacteria recovered and implicated include  Staphylococcus aureus , Viridans streptococci, and  Pseudomonas aeruginosa . It should be noted that pneumococcal infections are probably responsible for at least 50% of otitis media episodes … a etiology contd.

17. Age - Children between 6 to 36 months are most likely to get ear infections. Attending daycare. Recent illness, such as a cold or sinus infection. History of allergies, like hay fever, also called allergic rhinitis, or sinusitis. Exposure to secondhand smoke. Having family members who are prone to ear infections; studies show a clear genetic component for both acute and recurrent otitis media. Using a pacifier. Having a history of gastroesophageal reflux disease (GERD ) Obesity. Risk Factors

18. Catarrhal stage: Is characterized by occlusion of Eustachian tube and congestion of middle ear. Stage of exudation: Exudate collects in the middle ear and ear drum is pushed laterally. Initially the exudate is mucoid , later it becomes purulent. Stage of suppuration: Pus in the middle ear collects under tension, stretches the drum & perforates it by pressure necrosis & the exudate starts escaping into external auditory canal Stage of healing: The infection starts resolving from any of the stages mentioned & usually clears up completely without leaving any sequelae . Stage of complications: Infection may spread to the mastoid antrum . Initially it causes Catarrhal mastoiditis [congestion of the mastoid mucosa], stage of coalescent mastoiditis & later empyema of the mastoid. Pathology

19. Patients usually present with following: Otalgia : Young children may exhibit signs of otalgia (ear pain) by pulling on the affected ear or pulling on the hair. It apparently occurs more often when the child is lying down (e.g., during the night, during nap time) Otorrhoea : Discharge may come from the middle ear through a recently perforated tympanic membrane Headache Fever Loss of appetite Diarrhea Vomiting Clinical Features

20. Myringitis Mastoiditis Cholesteatoma Differential Diagnoses

21. History History of previous Upper Respiratory Tract Infection Otalgia , Otorrhoea Fever, vomiting and diarrhea Cough and nasal discharge In older patients, hearing loss and stuffiness of the ear History of exposure to risk factors e.g smoke, use of pacifiers in babies etc . Management

22. Examination Pneumatic otoscopy remains the gold standard for OM diagnosis Otoscopy shows signs of inflammation, beginning with reddening of the mucosa and progressing to the formation of purulent middle ear effusion In the posterior quadrants, the tympanic membrane may bulge, and the superficial epithelial layer may exhibit a scalded appearance Examination of the entire head and neck is also important because several congenital anomalies are associated with OM e.g. Treacher Collins syndrome, cleft palate, Down’s syndrome etc. … contd

23. During examination of the tympanic membrane, the following parameters are to be noted; Color: A normal membrane is pale grey. An opaque yellow or blue membrane indicates Medial Ear Effusion, MEE. Dark red indicates recent trauma or blood behind the membrane. Dark pink or light red is consistent with AOM. Position: The position of the tympanic membrane is key in differentiating AOM from OME. Typically, in AOM, the membrane is bulging while in OME, the membrane is retracted. Mobility: Abnormal movements can suggest various conditions or disorders. Studies though, have shown that the most consistent physical finding in patients with OME is reduced tympanic membrane motility during pneumatic otoscopy . Perforation: Single perforations are most common but the patient may have multiple perforations also. … contd

24. Investigations In most cases of OM, no further investigations are necessary since the diagnosis is clinical. If symptoms are severe; FBC: often reveals leukocytosis Blood cultures may detect bacteremia during episodes of high fever. A culture and sensitivity test of the ear discharge by tympanocentesis ( Tympanocentesis  involves aspiration of the contents of the middle ear cleft by piercing the tympanic membrane with a needle and collecting that material for diagnostic examination) or ear swab is helpful in guiding antibiotic therapy in patients in whom the first-line treatment is unsuccessful. If recurrent AOM occurs along with recurrent infections in other systems, then an underlying immune should be considered and appropriate investigations requested. … contd

25. Petromastoid Computed tomography (CT) scan: may be necessary to determine if a complication has occurred. Magnetic resonance imaging (MRI): might be more appropriate for diagnosing suspected intracranial complications Tympanometry may also be done to confirm Otitis media. … contd

26. Treatment Control infection Local therapy … contd

27. Control Infection Arrest & reverse inflammation Prevent suppuration and perforation Relieve symptoms Hasten resolution Reduce risk of complications AMPICILLIN ( 50 mg/kg/day in 4 divided doses) AMOXICILLIN ( 40 mg/kg/day in 3 divided doses) … contd

28. Local Therapy Before Perforation: Relieve earache Control inflammation Prevent perforation(spontaneous ) After Perforation: Clear external acoustic canal toilet Control infection Repair TM Decongestant nasal drops(ephedrine, oxymetazoline , xylometazoline ) Oral nasal decongestant (pseudoephedrine) Analgesic & antipyretic( paracetamol ) … contd

29. Myringotomy   Tiny incision eardrum  Relieve pressure Drain pus from the middle ear. A tympanostomy tube  Keep the middle ear aerated Prevent re-accumulation of fluid. Indications for myringotomy Symptoms are not relieved by antibiotics TM bulges significantly TM perforation is too small Incomplete resolution Persistent effusion beyond 12 weeks … contd

30. Complications that may occur following the development of OM are as follows: Acute infection of the mastoid air cells: resulting in a dangerous mastoid abscess Meningitis Brain abscess Epidural abscess: usually occurs through the temporal bone Septicemia Infection of the labyrinth Facial nerve paralysis Complications

31. At some point, surgery often is required to reconstruct the perforated eardrum ( tympanoplasty ), clear the mastoid air cells of infection ( mastoidectomy ), and remove the growth of excess tissue in the ear canal (removal of cholesteatoma ). Conductive hearing loss from acute otitis media typically resolves with time. Prognosis

32. Otitis media is a common pediatric disease that can lead to various symptoms in the neonate and infant. It is could be caused by both host factors and pathological factors and, in the absence of complications, usually resolves spontaneously. Pneumatic otoscopy is the gold standard diagnostic test and a broad spectrum antibiotic, usually Amoxicillin, is mostly employed. Conclusion

33. Encyclopedia Britannica. Encyclopædia Britannica Chicago:  Encyclopædia Britannica, 2013.  Chicago: Encyclopedia Britannica, 2013. Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy, 6th edn . Williams & Wilkins. 2010.Basic Otorhinolaryngology by Rudolf Probst , Gerhard Grevers and Heinrich Iro American Academy of Pediatrics. Respiratory syncytial virus.  Red Book: Report of the Committee on Infectious Diseases . 27th ed. Elk Grove Village, Ill: 2006. 560-566. Medscape –Otitis media Lalwani AK. Current Diagnosis and Treatment in otolaryngology, 2 nd edn . McGraw Hill. 2007. Probst R, Grevers G, Heinrich I. Basic otorhinolaryngology, 2 nd edn . Georg Thieme Verlag , Stuttgart. 2006. Wood DN, Nakas N, Gregory CW. International Journal of Pediatric Otorhinolaryngology. Volume 76, Issue 9, September 2012 https://www.ncbi.nlm.nih.gov/pubmed/16276700 References

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