otitis media and eustachian tube dysfunction
DESCRIPTION
Otitis Media and 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. - PowerPoint PPT PresentationTRANSCRIPT
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