Otitis Mediaand Eustachian Tube Dysfunction

R. Kent Dyer, Jr., M.D.

Hough Ear Institute

Oklahoma City, Oklahoma USA

Incidence of Otitis Media (OM)

Most common disease of childhood after viral URI

15 million cases of Acute OM/year in U.S.

Cost of treatment: >$5 billion/year

Pathology of Acute Otitis Media

Viral or Bacterial Insult

Edema

Leukocyte Infiltration

Purulent Exudate/Granulation Tissue

ET Obstruction

vs.

Resolution Fibrosis

Pathogenesis of Otitis Media

Infection (viral vs. bacterial)

Abnormal eustachian tube function

Allergy (minor role)

Neoplasm (nasopharyngeal carcinoma)

Sinusitis

Eustachian Tube Function

Protection from nasopharyngeal secretions

Ventilation

Clearance of middle ear secretions

Otitis Media Classification

Classified according to:– Duration of disease

Acute, subacute, chronic

– Quality of effusionSerous, mucoid, purulent

– Tympanic membrane appearance

Acute Otitis Media

Tympanic membrane:

Opaque

Bulging/injected

Reduced mobility

Purulent effusion

Otitis Media with Effusion

Tympanic membrane:

Translucent or opaque

Gray/pink

Reduced mobility

Effusion present +/- air

Chronic Mucoid OM (Glue Ear)

Tympanic membrane:

Opaque/gray

Retracted, reduced mobility

Thick effusion, no air

Hearing loss (>20dB HL)

Tympanosclerosis

White plaques in Lamina Propria

Hyaline deposition

Significant conductive hearing loss possible

Obliterative Tympanosclerosis

Atelectasis

Collapse or retraction of tympanic membrane

Often associated with ossicular pathology

Long-standing eustachian tube dysfunction

Attic Retraction

Isolated collapse of Pars Flaccida

May lead to cholesteatoma

Cholesteatoma

Accumulation of squamous epithelium in middle ear & mastoid

Osteolytic enzymes

Often accompanied by chronic otorrhea

Chronic Suppurative Otitis Media

TM Perforation

+/- cholesteatoma

Otorrhea

Diagnosis of Otitis Media

Ear Examination

Pneumatic OtoscopyEssential for Diagnosis of OM

Keys:

Air tight seal

Adequate visualization of TM

Instrumentation

Tympanometry

Useful for confirming diagnosis (if pneumatic exam inadequate)– Type C (negative peak)

Suggests ET dysfunction

– Type B (flat)

+ effusion

Acute Otitis Media

Microbiology:

S. pneumoniae20-30% PCN resistant

H. influenza30-60% B-Lactamase +

M. catarrhalis90-95% B-Lactamase +

Acute Otitis Media(Day 2)

Acute Otitis Media(1 Week)

Chronic Serous Otitis Media

Microbiology:

50% of effusions culture + for bacteria

S. pneumoniae, H. influenza, M. catarrhalis

Serous Otitis Media

Chronic Suppurative Otitis Media

Microbiology:

P. aeruginosa

S. aureus

Diphtheroids

Klebsiella

Management of Acute Otitis Media

Amoxicillin 90mg/kg/day– Mild PCN allergy (rash)

• Cephalosporin

– Severe PCN allergy (anaphylaxis)• Azithromycin

• Clarithromycin

2nd Line Therapy for Otitis Media

Amoxicillin/Clavulanate

Oral Cephalosporin (2nd or 3rd generation)

Macrolide

Ceftriaxone (IM)

When to Consider 2nd Line Rx

Group day care

Antibiotic Rx within last 30 days

Failure of antibiotic prophylaxis

Refractory AOM

Failure to improve with 72 hours

Management of Persistent OM

Watchful waiting90% of effusions will resolve

within 3 months

Additional 2nd line antibiotics

Intranasal steroids

Eustachian tube inflationValsalva vs. Otovent

Nasal endoscopy

                                      

Factors to Considerwith Long-standing Effusions

Degree of hearing loss (>20dB HL)

Vertigo/imbalance

Tympanic membrane changes (retraction)

Speech & language delay

Behavioral changes

Frequency & severity of AOM

Plan of Therapy

Amoxil

Plan of Therapy

AmoxilIf No Improvement in 72 hrs.

Plan of Therapy

Amoxil

2nd Line Antibiotic

If No Improvement in 72 hrs.

Plan of Therapy

Amoxil

2nd Line Antibiotic

If No Improvement in 72 hrs.

If Persistent Effusion

Plan of Therapy

Amoxil

2nd Line Antibiotic

2nd Line Antibiotic/Monitor (up to 3 months)

If No Improvement in 72 hrs.

If Persistent Effusion

Plan of Therapy

Amoxil

2nd Line Antibiotic

2nd Line Antibiotic/Monitor (up to 3 months)

Modify Risk Factors (when possible)

&Check Hearing Status

If No Improvement in 72 hrs.

If Persistent Effusion

Plan of Therapy

Amoxil

2nd Line Antibiotic

2nd Line Antibiotic/Monitor (up to 3 months)

Modify Risk Factors (when possible)

&Check Hearing Status

Tympanocentesis usually not indicated

If No Improvement in 72 hrs.

If Persistent Effusion

Indications for Tympanostomy Tubes

>5 episodes of AOM in 6-9 months

Persistent ME effusion

x 3 months

Complication of OM

Failure of antibiotic prophylaxis

Acute Mastoiditis

Indications for Tympanostomy Tubes

Craniofacial anomaly

Structural changes to TM

Speech & language delay

Serous Otitis Media w/Retraction

Choice of Tubes

Short-lasting (6-12 mo.)

Intermediate (12-18 mo.)

Long-lasting (>18 mo.)

Straight Vent Tube

Shaft Lumen

Medial flange

Grommet/Bobbin Style

Lumen

Flanges

T TYPE Vent tube

“GOODE T - TUBE” - Xomed

TUBE INDUCED PERFORATIONTUBE INDUCED PERFORATION

Shaft

Medial Flange

Post-tube Otorrhea

Usually secondary to URI or water exposure

Topical antibiotic usually adequate 5-7 days

(Floxin, Ciloxin, Ciprodex)

Water Precautions

Cotton + Vaseline when bathing

Plug

Ear Band-It when swimming

Refractory Otorrhea

Consider fungal etiology

Clotrimazole gtts

Amphotericin B powder

Cresylate

Debridement of ear canal

Water Precautions

No H2O2!!!

Tube Removal

Removal recommended if tube persists >24 months

Risk of TM perforation 12-25% if tube retained >2 years