otitis media with effusion

Otitis media with effusionOtitis media with effusion

Chunfu Dai M.D & Ph.DChunfu Dai M.D & Ph.DOtolaryngology Department Otolaryngology Department

Eye Ear Nose & Throat HospitalEye Ear Nose & Throat HospitalFudan UniversityFudan University

BackgroundBackground

Otitis media is a multifactorial disease Otitis media is a multifactorial disease process involving immunology, process involving immunology, infectious disease, anatomic infectious disease, anatomic considerations, social and considerations, social and socioeconomic issues, and genetics, socioeconomic issues, and genetics, among other factors.among other factors.

Approximately 70% of children below Approximately 70% of children below the age of 3 will develop an episode of the age of 3 will develop an episode of otitis media.otitis media.

BackgroundBackground

65-95% 65-95% of children by the age of 7 of children by the age of 7 years will experience one or more years will experience one or more episodes of acute otitis media.episodes of acute otitis media.

It remains the commonest cause for It remains the commonest cause for visit to the doctor in the pediatric visit to the doctor in the pediatric population.population.

Background Background Myringotomy was performed in Myringotomy was performed in

eighteenth and nineteenth centuries to eighteenth and nineteenth centuries to treat otitis media.treat otitis media.

During the preantibiotic era, the primary During the preantibiotic era, the primary concern was the potential for intracranial concern was the potential for intracranial complications of acute otitis media complications of acute otitis media

In 1954, Armstrong’s reintroduction of In 1954, Armstrong’s reintroduction of the tympanostomy tube, after that, few the tympanostomy tube, after that, few true advances in the treatment of otitis true advances in the treatment of otitis media was developed.media was developed.

Definition Definition

OME is an inflammatory condition of OME is an inflammatory condition of the middle ear and mastoid air cell the middle ear and mastoid air cell system characterized by system characterized by accumulation of fluid in the middle accumulation of fluid in the middle ear without signs or symptoms of ear without signs or symptoms of acute infection. acute infection.

Other names: Other names: Secretory otitis media, Secretory otitis media, Serous otitis media, Serous otitis media, Glue ear, Glue ear, Nonpurulent otitis media, Nonpurulent otitis media, Catarrhal otitis media.Catarrhal otitis media.

Pathogenesis Pathogenesis

Dysfunction of Dysfunction of Eustachian tubeEustachian tube Obstruction of Obstruction of

Eustachian tubeEustachian tube Mechanic obstructionMechanic obstruction

enlarged adenoid, tumor, enlarged adenoid, tumor, enlarged inferior enlarged inferior turbinateturbinate

Non mechanic obstructionNon mechanic obstruction Weakness of related Weakness of related

muscle, muscle,

Clearance and defenseClearance and defense Immotile cilia syndromeImmotile cilia syndrome

PathogenesisPathogenesis

Infection Infection PCR detects the middle ear fluid, positive PCR detects the middle ear fluid, positive

findings was 70%findings was 70% S pneumonia, haemophalus influenzae, S pneumonia, haemophalus influenzae,

haemolytic streptocuccus haemolytic streptocuccus ImmunityImmunity

Middle ear is a isolated immune systemMiddle ear is a isolated immune system Inflammatory mediators Inflammatory mediators Specific antibody, immunologic complex Specific antibody, immunologic complex Antigen may from adenoid or nasopharygeal Antigen may from adenoid or nasopharygeal

lymphlymph

Classification of Otitis mediaClassification of Otitis media

Otitis meda with effusion: the Otitis meda with effusion: the presence of middle ear effusion. presence of middle ear effusion.

If the middle ear effusion is present If the middle ear effusion is present for 8 weeks or longer, it is classified for 8 weeks or longer, it is classified chronic otitis media with effusionchronic otitis media with effusion

Microbiology of otitis mediaMicrobiology of otitis media

Bacteria can be isolated from one third of Bacteria can be isolated from one third of patient who have OME. The most common patient who have OME. The most common are S pneumonia, H influenzae, and M are S pneumonia, H influenzae, and M catarrhalis (using traditional culture catarrhalis (using traditional culture method). method).

By using PCR, these three bacteria were By using PCR, these three bacteria were detected in approximately 70% of Chronic detected in approximately 70% of Chronic middle ear effusion.middle ear effusion.

Diagnosis Diagnosis

It is usually It is usually asymptomatic.asymptomatic.

Hearing lossHearing loss Kid can not concentrate Kid can not concentrate

himselfhimself Turn on TV in loudnessTurn on TV in loudness If one ear is normal, the If one ear is normal, the

above symptoms will be above symptoms will be ignoredignored

FullnessFullness Otalgia Otalgia Tinnitus Tinnitus

DiagnosisDiagnosis

The diagnosis is made at The diagnosis is made at physical exam.physical exam. TM may retracted, dull, and TM may retracted, dull, and

opaque.opaque. The color of TM may range The color of TM may range

from light pink to amber from light pink to amber even dark blue.even dark blue.

The presence of air bubbles The presence of air bubbles or air fluid levels makes the or air fluid levels makes the diagnosis more evident.diagnosis more evident.

DiagnosisDiagnosis

Tympanometry Tympanometry Middle ear pressure more negative than -200 Middle ear pressure more negative than -200

(type C) or a flat tympanometry curve (type B) (type C) or a flat tympanometry curve (type B) is classified as a failure.is classified as a failure.

A child fail test without marked HL (less than A child fail test without marked HL (less than 20 dB) should be retest 2 months later.20 dB) should be retest 2 months later.

10-14% of patients with low compliance 10-14% of patients with low compliance tympanograms have only tympanic membrane tympanograms have only tympanic membrane retraction or thickening without effusion.retraction or thickening without effusion.

While occlusion of the probe by cerumen or the While occlusion of the probe by cerumen or the child’s crying can cause invalid results.child’s crying can cause invalid results.

检查检查

DiagnosisDiagnosis

Hearing testHearing test Rinne test: negativeRinne test: negative Audiogram: conductive hearing loss, no more Audiogram: conductive hearing loss, no more

than 40 dBthan 40 dB Tympanogram: B type or C typeTympanogram: B type or C type

Lateral nasopharyngeal radiograph: Lateral nasopharyngeal radiograph: hypertroph of adenoidhypertroph of adenoid

Nasopharyngeal exam: to exclude space-Nasopharyngeal exam: to exclude space-occupation lesionoccupation lesion

Differentiated diagnosisDifferentiated diagnosis

Nasopharyngeal carcinoma:Nasopharyngeal carcinoma: Unilateral OMEUnilateral OME EBV-VCA-IgAEBV-VCA-IgA NasoendoscopeNasoendoscope CT or MRICT or MRI BiopsyBiopsy

CSF (cerebrospinal fluid) leakageCSF (cerebrospinal fluid) leakage Head trauma Head trauma Meningitis Meningitis CT or MRICT or MRI


Perilymphatic fluid fistulaPerilymphatic fluid fistula Secondary to stapes surgery or barotraumaSecondary to stapes surgery or barotrauma VertigoVertigo Hearing test: sensorineural hearing loss or Hearing test: sensorineural hearing loss or

mixed hearing lossmixed hearing loss Cholestrol granuloma (heamotympanum)Cholestrol granuloma (heamotympanum)

Advanced stage of OMEAdvanced stage of OME Tympanic membrane: blue Tympanic membrane: blue CT: soft tissue in mastoid or middle cavityCT: soft tissue in mastoid or middle cavity


Atelectatic Otitis mediaAtelectatic Otitis media Sequela of OMESequela of OME Conductive hearing lossConductive hearing loss TM contacts with ossicular chain, TM contacts with ossicular chain,

promotorypromotory

Diagnosis of otitis media Diagnosis of otitis media

Differentiate diagnosis of AOM and Differentiate diagnosis of AOM and OME will benefit our treatment, as OME will benefit our treatment, as the latter condition is usually not the latter condition is usually not treated unless it becomes chronic treated unless it becomes chronic

Diagnosis of otitis mediaDiagnosis of otitis media OME is a relatively asymptomatic OME is a relatively asymptomatic

middle ear effusion. middle ear effusion. Pneumatic otoscope frequently Pneumatic otoscope frequently

shows either a retracted or concave shows either a retracted or concave tympanic membrane. tympanic membrane.

In addition, an air-fluid level or In addition, an air-fluid level or bubbles, or both may be observed bubbles, or both may be observed through a translucent tympanic through a translucent tympanic membrane.membrane.

Managements Managements

Principles:Principles: discharge middle fluiddischarge middle fluid Drainage, ventilation Drainage, ventilation Eliminate pathogenesisEliminate pathogenesis

ManagementsManagements

Non surgical treatmentNon surgical treatment AntibioticsAntibiotics SteroidSteroid Improvement of nose congestion Improvement of nose congestion

ManagementsManagements

Surgical treatmentSurgical treatment TympanocentesisTympanocentesis MyrigotomyMyrigotomy Tympanotomy with PTTympanotomy with PT mastoidectomymastoidectomy

Management of AOMManagement of AOMalternative medical treatmentalternative medical treatment

Corticosteroid (orally or intranasally), Corticosteroid (orally or intranasally), Antihistamine, decongestantsAntihistamine, decongestants Orally corticosteroid and intranasally Orally corticosteroid and intranasally

corticosteroid help clear chronic middle corticosteroid help clear chronic middle ear effusion. However, there is no ear effusion. However, there is no evidence of efficacy in treatment of evidence of efficacy in treatment of AOM.AOM.

Antihistamine and decongestants are Antihistamine and decongestants are used in the treatment of OME, it does used in the treatment of OME, it does not benefit AOM.not benefit AOM.

Children who have nasal congestion Children who have nasal congestion and allergic rhinitis there may be a role and allergic rhinitis there may be a role for these preparation.for these preparation.


The nature history of this disease is for The nature history of this disease is for spontaneous resolution in the majority of spontaneous resolution in the majority of casecase More the 80% resolution by 2 month. It is the More the 80% resolution by 2 month. It is the

small number of children who continue to small number of children who continue to have effusion after 2-3 months that are have effusion after 2-3 months that are concern.concern.

A trial of antibiotics would be appear to be A trial of antibiotics would be appear to be appropriate in those children who have not appropriate in those children who have not received antibiotics recently.received antibiotics recently.

OME is probably underdiagnosis.OME is probably underdiagnosis.


Chronic OME is defined as an effusion Chronic OME is defined as an effusion persisting for more than 3 months persisting for more than 3 months duration.duration.

A dense effusion typically may confer up A dense effusion typically may confer up to a 30 dB hearing loss.to a 30 dB hearing loss.

Chronic OME may have a role in Chronic OME may have a role in development of retraction pockets, development of retraction pockets, ossicular chain erosion, and ossicular chain erosion, and cholesteatoma formation.cholesteatoma formation.


Meta-analyses have come to conclusion that Meta-analyses have come to conclusion that antibiotics have a small but distinct advantage antibiotics have a small but distinct advantage over placebo in the treatment of persistent over placebo in the treatment of persistent OME.OME.

When the effusion is chronic, surgical When the effusion is chronic, surgical intervention should be considered, especially intervention should be considered, especially when antibiotic therapy fail.when antibiotic therapy fail.

The primary surgical therapy remains The primary surgical therapy remains placement of tympanostomy tubes for pressure placement of tympanostomy tubes for pressure equalization and drainage of middle ear.equalization and drainage of middle ear.

Surgical treatment for otitis Surgical treatment for otitis mediamedia

Placement of tympanostomy tubes.Placement of tympanostomy tubes. Middle ear effusion for more than 3 months Middle ear effusion for more than 3 months

or more.or more. OME associated with hearing loss of >30dBOME associated with hearing loss of >30dB Chronic severe TM retraction.Chronic severe TM retraction. Impending intracranial complicationImpending intracranial complication Recurrent otitis media with more than 3 Recurrent otitis media with more than 3

episode within a 6 months period, or more episode within a 6 months period, or more than 4 episode within a 12 month period.than 4 episode within a 12 month period.


AdenoidectomyAdenoidectomy indications for adenoidectomy indications for adenoidectomy

Children with chronic otitis media who are Children with chronic otitis media who are candidates for tympanostomy tube candidates for tympanostomy tube placementplacement

Children have symptoms for chronic Children have symptoms for chronic adenoid hypertrophy, adenoid hypertrophy,

Children require multiple sets of Children require multiple sets of tympanostomy tube.tympanostomy tube.

It has been demonstrated that adenoidectomy It has been demonstrated that adenoidectomy may accelerate the resolution of chronic otitis may accelerate the resolution of chronic otitis media regardless of the size of the adenoid media regardless of the size of the adenoid pad.pad.


AdenoidectomyAdenoidectomy With significant risks in children With significant risks in children

younger than 3 years of age that usually younger than 3 years of age that usually outweight its benefit.outweight its benefit.

Adenoidectomy be a consideration in Adenoidectomy be a consideration in the child older than 3 years of age at the the child older than 3 years of age at the time of insertion of a second set of tube.time of insertion of a second set of tube.


Laser-assisted myringotomy (background)Laser-assisted myringotomy (background) It has been advocated for the management of It has been advocated for the management of

acute otitis media (unresponsive to medical acute otitis media (unresponsive to medical management) and chronic otitis media with management) and chronic otitis media with effusion, barotrauma, transtympanic inner ear effusion, barotrauma, transtympanic inner ear perfusion.perfusion.

A history of allergies, the presence of a thick A history of allergies, the presence of a thick tympanic membrane and or high viscocity fluid tympanic membrane and or high viscocity fluid are all contraindications for laser assisted are all contraindications for laser assisted tympanostomytympanostomy


It can provide symptom relief and avoid It can provide symptom relief and avoid placement of tympanostomy tube by placement of tympanostomy tube by alleviating infection and inflammation or alleviating infection and inflammation or improving middle ear ventilation.improving middle ear ventilation.

Fenestration creates a round opening in Fenestration creates a round opening in the TM within a a fraction of a second the TM within a a fraction of a second and is usually bloodless. It generally last and is usually bloodless. It generally last 2-4 weeks2-4 weeks


Laser-assisted myringotomy Laser-assisted myringotomy (technique requirement)(technique requirement) Spot size ranged from 1.8-2.8mm and Spot size ranged from 1.8-2.8mm and

power from 7-22w, in general, thicker power from 7-22w, in general, thicker tympanic membranes required higher tympanic membranes required higher power or more than 1 laser discharge.power or more than 1 laser discharge.

Topic anesthesia in an office setting and Topic anesthesia in an office setting and general anesthesia in operating room or general anesthesia in operating room or office-based procedure.office-based procedure.


Laser-assisted myringotomy (related Laser-assisted myringotomy (related results)results) 2.4 and 2.6 mm spot size resulted in a greater 2.4 and 2.6 mm spot size resulted in a greater

percentage of patent fenestrations, long percentage of patent fenestrations, long duration of fenestration was associated with duration of fenestration was associated with higher cure ratehigher cure rate

Age of patient, type of fluid, wattage, Age of patient, type of fluid, wattage, preoperative tympanogram, or quadrant of TM preoperative tympanogram, or quadrant of TM undergoing fenestration are not predictors for undergoing fenestration are not predictors for duration of fenestration patency.duration of fenestration patency.

..


The incidence of cure at 90 days for is The incidence of cure at 90 days for is greater than 60%, and the incidence of greater than 60%, and the incidence of cure for OM treated in conjunction with cure for OM treated in conjunction with adenoidectomy is greater than 80%.adenoidectomy is greater than 80%.

Reduced risk and cost, and more Reduced risk and cost, and more effective and satifaction from parentseffective and satifaction from parents

Prognosis Prognosis

otitis media with effusion

Documents

chronic otitis media

nonpurulent otitis media

serous otitis media

catarrhal otitis media

secretory otitis media

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episode of otitis media

episodes of acute otitis