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02 Middle Ear Diseases and Their Complications

Dr. Teodoro P. Llamanzares | August 22, 2017

I. MIDDLE EAR
A. Anatomy
1. Tympanic Membrane (TM)
2. Tympanic Cavity
3. Auditory Ossicles
4. Intra-aural Muscles
5. Temporal Bone Air Cells
6. Eustachian Tube
B. Physiology
II. EXAMINATION
A. History
B. Otoscopy
C. Hearing Tests
D. Imaging Studies
E. Diagnostic Tympanotomy
III.OTITIS MEDIA Figure 1. Anatomical Relationships of the Middle Ear
A. Epidemiology
B. Risk Factors
C. Socioeconomic Factors 1. Tympanic Membrane (TM)
D. Etiology • It gathers sound and provides sonic shielding of the round window
E. Pathogenesis membrane
F. Classifications
1. Acute Otitis Media (AOM) • Consists of two portions: pars tensa and pars flaccida
a. Stages of Acute Otitis Media • Pars tensa, a funnel-shaped area stretched between the malleus
b. Pathogens handle and the bony ear canal, is composed of  3 layers:
c. Medical Management
o Outer Squamous Epithelium (cutaneous layer)
d. Control and Prevention
e. Complications ▪ consists of smooth, stratified squamous epithelium
2. Chronic Otitis Media that normally reflects light
3. Chronic Suppurative Otitis Media (CSOM) o Middle Fibrous Layer (lamina propria)
a. Pathogens ▪ has 2 layers: outer layer of radially directed fibers
b. Management
4. Tympanic Membrane Perforation (Radiate layer) and inner layer of circular fibers
5. Otitis Media with Effusion (OME) (Circular layer)
a. Symptoms o Inner Mucosal Lining (mucosal layer)
b. Otoscopic Findings ▪ Consists of a single layer of squamous epithelium
c. Causative Factors
 Tougher than the pars flaccida because it has 3 layers. Thus,
d. Management
e. Clinical Hearing Tests the pars flaccida is affected first (very dull, retracted and dirty
IV. REFERENCES looking) in diseases
V. EXERCISES

No Objectives were given

Legend:
Supplementary Emphasized
Audio Recording
Book Information Notes
  

I. MIDDLE EAR ( and 2019B trans)

A. Anatomy
• The middle ear is a repository of many problems because it gets
infected easily.
• It occupies a central position in the temporal bone
•  The middle ear is about 2.5cm from the external meatus
• The ear is self-cleaning. Moving the mandible (chewing/talking)
brings the wax out.
Figure 2. Otoscopic appearance of a right tympanic membrane. The
• Disturbance in the mechanisms involved in sound transmission by
longitudinal axis of the malleus handle and a line perpendicular to it divide
the ossicles and the ventilation of the temporal air cells via the the tympanic membrane into 4 quadrants. The tympanic membrane is like
Eustachian tube account for much of the middle ear pathologies a pearl: grayish-white and shiny. The cone of light is not always seen.

• Pars Flaccida: also known as Shrapnell membrane

o Located superior to the malleolar folds
o Lacks reinforcing fibrous layers, so it often retracts first in
response to negative pressure in the middle ear, creating an
epithelial pocket

TRANSCRIBERS Bergado, Bernaldez, Bertumen, Besana EDITOR Cortez, Jeo | 09992261137 1 of 11

  It cannot always be clearly identified at otoscopy and may blend
with the superior canal wall
 It is also the first to be affected by Otitis Media
• Problems usually located at  posterosuperior part of TM
2. Tympanic Cavity
• Also known as middle ear space or middle ear cleft
• An aerated cavity allowing unrestricted mobility of the tympanic
membrane.
• Most of the air enters the tympanic cavity through the Eustachian
tube, but some gases diffuse directly into the middle ear through
the blood vessels in the mucosa
•  What gives air to middle ear? Mastoid air cells and eustachian
tube. The more air cells you have, the better.
• Anatomical Relations of the Tympanic Cavity
o Lateral wall: tympanic membrane and bony ear canal
o Medial wall: cochlea
o Inferior wall: bulb of the jugular vein
o Superior wall: dura of the middle cranial fossa
o Anterior wall: internal carotid artery
o Posterior wall: mastoid part of the facial nerve
• Levels of the Tympanic Cavity:
o Epitympanum ( aka attic, epitympanic recess)
▪ A compartment above the plane of the tympanic membrane
that contains the principal mass of the auditory ossicles
▪ The tympanic part of the facial nerve is the boundary
between the epi- and mesotympanum on the medial wall of
the middle ear
▪  It communicates with the mastoid antrum via the aditus
ad antrum and also with air cells of the mastoid process
▪ The antrum contains the bony prominence of the lateral
semicircular canal, which is often the first part of the
labyrinth to be attacked by an osteoclastic disease process
in the middle ear
▪ The tegmen tympani, a thin bony layer, forms the roof of
the epitympanum and separates it from the middle cranial
fossa
▪  Epitympanum contains little air and inflammations may
be encapsulated in this area
o Mesotympanum
▪ Located at the level of the tympanic membrane
▪ It contains the round window, oval window with the
stapes, and the promontory (bony prominence overlying
the basal turn of the cochlea)
o Hypotympanum ( aka hypotympanic recess)
▪ Located below the level of the tympanic membrane
▪ It borders on the bulb of the jugular vein and contains cells
(tympanic cells) that communicate with the mastoid air cells
1.02 MIDDLE EAR DISEASES AND THEIR COMPLICATIONS
Figure 3. Tympanic Cavity. Divided into three levels relative to the plane
of the tympanic membrane. Note the connection of the epitympanum
(attic) to the mastoid cells and the connection of the hypotympanum to the
Eustachian tube.
3. Auditory Ossicles
• They are considered the smallest bones in the body and are freely
suspended, being nourished entirely by  periosteal attachments.
• Attached by thin tendons to the smallest muscles of the body, the
intra-aural muscles tensor tympani and stapedius muscles
•  The extra mass of the ossicles probably serves to adjust the
resonance of the middle ear system to reduce sound transmission
by bone conduction
•  Joints in the ossicular chain adjust the position of the ossicles in
response to atmospheric pressure changes
• Malleus (most lateral of the ossicles)
o The handle (manubrium) of the malleus is attached along its
length to the tympanic membrane.
o The handle forms a central spoon-shaped depression, the
 umbo, which is an important landmark
• Incus (between the malleus and stapes)
o Articulates with the malleus
o The head of the malleus and the body of the incus are in the
epitympanum and comprise most of the mass of the ossicles
• Stapes (most medial of the ossicles)
o The long process of the incus articulates with the stapes.
o The footplate of the stapes is attached to the rim of the oval
window by the elastic annular ligament
***Refer to Figure 3 for the image of the ossicles
4. Intra-aural Muscles
• Stapedius: inserts onto the head of the  stapes and occupies a
bony canal parallel to the mastoid part of the facial nerve which also
innervates the muscle
• Tensor tympani: lies parallel to the eustachian tube and is
innervated by the trigeminal nerve; it inserts onto the head of the
 malleus; used in swallowing which opens the eustachian tube
• Reflex contractions of these muscles may serve to moderate the
internal noise level produced by mastication and speech and it may
also be a mechanism to protect the inner ear from high, sustained
external noise levels
 It keeps the ossicular chain joints mobile
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Figure 4. Intra-aural muscles. Tensor tympani muscle (blue circles)
attaches to the malleus, whereas the stapedius muscle (red circles)
attaches to the stapes (green circle)
5. Temporal Bone Air Cells
• The mucosa-lined air cells of the temporal bone communicate with
the tympanic cavity
• These cells are aerated via the Eustachian tube
• Pneumatization of the mastoid develops gradually during childhood
like the development of paranasal sinuses
• The function of the temporal bone air cells is unknown; may be to
help in equalizing pressure differences to  protect the middle ear
 The air volume behind the TM is  unimportant for sound
transmission
6. Eustachian Tube
• Connects the tympanic cavity with the atmosphere and with the
nasopharynx, where the inlet of the tube forms a funnel-shaped
orifice behind the choana
•  Lateral third: bony canal; Medial third: patent cartilaginous tube
• Role of Eustachian Tube
o Protection (serves as a barrier against ascending infection)
o Pressure Regulation and Ventilation
o Drainage of middle ear spaces
o Obstruction of the Eustachian tube is a basic causative factor
for the pathogenesis of Otitis Media
• Adults have long, narrow, and angled Eustachian tubes
• Children have short, wide, and straight Eustachian tubes
o Runs more horizontally in infants and small children than in
adults. It also consists of softer cartilage.
  Higher incidence of otitis media in children
• Function relies on a complex balance between opening forces such
as muscle tone, middle ear pressure, and cartilage resilience
and closing forces generated by tissue pressure, mucosal
surface tension, and a negative pressure in the middle ear
 The act of swallowing, not the movement of the jaw, opens up the
Eustachian tube so that’s what we always advise patients
planning to travel, to not chew gum, but swallow.
 The tube is always closed. During sleep, you swallow involuntarily
wherein the tensor tympani is moved to open the tube
• Causes of Eustachian Tube Obstruction:
o Acute upper respiratory infection (URI)
o Allergy
o Enlarged and infected adenoids
o Failure of physiologic opening of eustachian tube with palatal
maldevelopment (e.g. clefts)
1.02 MIDDLE EAR DISEASES AND THEIR COMPLICATIONS
Figure 5. Eustachian Tube. Consists of a bony part (lateral third) and a
cartilaginous part (medial two-thirds). At their junction is the narrowest part
of the tube, the isthmus.  Tensor tympani muscle controls the opening of
the tube.
B. Physiology
• Sound undergoes 3 transformations during the process of hearing:
o Acoustic ➔ Mechanical
▪ The acoustic energy striking the tympanic membrane (which
vibrates) is converted to mechanical energy and carried
across the middle ear by the transmitting mechanism, mainly
to the ossicles
o Mechanical ➔ Hydraulic
▪ The mechanical energy becomes hydraulic energy when it
reaches the fluid of the vestibular and cochlear structures
through the oval window
o Hydraulic ➔ Neuroelectric
▪ The hydraulic energy is converted by the tiny and complex
sensory cells of the inner ear into neuroelectric energy or
events which are carried to the brain for perceptual analysis
II. EXAMINATION ()
***THIS SECTION IS LIFTED DIRECTLY FROM THE BOOK
A. History
• Do not forget to ask about otalgia, aural discharge (otorrhea), a
feeling of pressure or hearing loss
• Chronic inflammatory ear diseases usually signify otitis media. This
type of inflammation can lead to scarring and decreased ventilation
of the middle ear
• Also inquire about history of tympanic membrane perforation,
previous trauma or surgery of the middle ear
B. Otoscopy
• Before otoscopy, one must inspect the external ear and its
surroundings, particularly the mastoid
• The mobility of the tympanic membrane provides clues to the
condition and ventilation of the tympanic cavity
• Function tests:
o Passive mobility test: the external ear canal is sealed with the
speculum, and a positive pneumatic pressure is produced in
the ear canal, causing movement of the tympanic membrane
(Siegle pneumatic otoscopy)
o Active mobility test: air is forced up the eustachian tube into
the middle ear, inducing an outward movement of the
tympanic membrane. Usually this movement is seen in the
 posterosuperior quadrant. This also tests the patency of
the eustachian tube
• Examples of active mobility tests:
o Valsalva maneuver – patient is told to swallow, then pinch the
nostrils and “bear down” to produce a positive pressure in the
pharynx
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 ▪ Negative Valsalva maneuver may be due to (a)
improper technique, (b) nonpatent eustachian tube, (c)
thickened, scarred tympanic membrane or (d)
perforated tympanic membrane
o Politzer maneuver – air is forced into one side of the nose by
squeezing an air bag while the other nostril is occluded and
the soft palate is closed off
o Toynbee maneuver – a negative pressure is created in the
pharynx by having the patient swallow with the nostrils
pinched shut. This induces an inward movement of the TM.
•  None of these maneuvers should be used in patients with an
acute inflammation of the middle ear or nasopharynx!
C. Hearing Tests
• Typical clinical presentation of middle ear disease includes
 conductive hearing loss
• If the tympanogram is normal, the function of the ossicles can be
assessed by testing the stapedial reflex (REFER TO 1.03 BASIC
AUDIOLOGY FOR THE TYPES OF TYMPANOGRAMS)
• Middle ear disease generally leads to an absence of otoacoustic
emissions (OAEs)
•  Normal middle ear function indications:
o Normal otoscopic appearance of the tympanic membrane
o Positive Rinne test
o Tympanogram type A and positive stapedial reflex
o Detectable OAEs (assuming normal cochlear function)
D. Imaging Studies
• Radiographic studies are the most rewarding due to the
preponderance of bony structures
• Standard projections of the temporal bone will invariably
superimpose numerous structures. This problem can be reduced by
obtaining special views of the temporal bone in which fewer
structures are superimposed. The most important of these are:
o Schuller view: projection along the ear canal to demonstrate
the  mastoid air cells
o Stenvers view: projection angled 45 forward to demonstrate
the  petrous ridge and petrous apex
• High-resolution thin-slice CT scan is the most important modality for
temporal bone imaging
• Conventional radiographs are unnecessary when CT scan is done
• Other imaging modalities include:
o MRI for tumors
o Angiography for tumors, suspected vascular lesions, pulsatile
tinnitus, etc.
1.02 MIDDLE EAR DISEASES AND THEIR COMPLICATIONS
Figure 6. Normal CT of the temporal bone. (A) Axial CT scan through a
normal temporal bone. The epitympanum containing the head of the
malleus and body of the incus, is clearly defined. The ossicles resemble
an ice cream cone. (B) Coronal CT scan across the internal and external
auditory canals. The middle and inner ears are clearly visualized.
E. Diagnostic Tympanotomy
• Tympanotomy – surgical exploration of the middle ear
• Tympanic cavity is opened for inspection through the ear canal
under an operating microscope by incising the canal skin in front of
the TM and reflecting the skin and membrane as a flap
• Bony canal may also have to be taken down, depending on the
pathology involved
• Combined with surgical correction of any abnormalities that were
noted in preoperative studies
III. OTITIS MEDIA ( and 2019B trans)
• Inflammation of the middle ear
• Classified as either: acute, chronic, or serous
• Basic factors
o Lack of middle ear and mastoid air cells
o Pneumatization
o Eustachian tube obstruction
 Chief complaint of pediatric patients?
Irritable, touches ear all the time, and they cannot sleep
A. Epidemiology
• Magnitude of the problem
o < 1 year old – 30%
o < 3 years old – 70%
o Most common cause of consults in US under 5 years old (70%)
• Prevalence
o USA – 24.5 million visits/year
o Vietnam – 7.1 % overall prevalence
o Philippines
▪ OME: 25-30% of ENT consultations
▪ CSOM: 25 to 29.4%
• Age
o Highest incidence of AOM occurs bet. 6 and 24 months of age
o OM is much LESS common after 7 years old
o Asymptomatic middle ear effusion is more common in children
aged 1-4 years and decreases after year 7
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• Research Studies • Diagnosis:
o Studies have shown that 60-70% of children have at least one o Erythematous tympanic membrane, bulging because of
episode of otitis media during the 1 st year of life and about 3 accumulation of purulent exudates within the middle ear
episodes during the first 3 years o Decreased mobility of the tympanic membrane on pneumatic
o UERM Study (Opulencia et al., 1995) otoscopy
▪ Clinical study of 206 patients ages 1 month to 10 years with  AOM is characterized by a rapid onset of signs and symptoms
rhinitis. 120 were males and 86 were females. (e.g. pyrexia, otalgia) leading to inflammation of the middle ear
▪ 110 patients had OM with a prevalence of 53.59%  Recurrent AOM is defined as: three or more episodes in a 6-
month period, or four or more episodes in a 12-month period with
B. Risk Factors  complete resolution of symptoms between episodes
• Passive smoke
• Inhalant allergy Stages of Acute Otitis Media 
o Inflammation of the tubal lining causing obstruction 1.Stage of Hyperemia
o Contributory to adenoiditis, which may spread to involve the  Acute stage
middle ear mucosa o Hyperemia of the eustachian tube and the tympanum
• Food allergy o Presents as earache, sense of fullness, and hearing may be
• Recurrent acute otitis media  normal
• Viral upper respiratory tract infections o Otoscopy Findings: loss of luster and injection of the vessels
• Group daycare of the tympanic membrane ( extreme hyperemia is called
injection)
C. Socioeconomic Factors
• Overcrowding
• Non-breast feeding
• Passive Smoking
• Environmental (e.g. Payatas)

D. Etiology
• Bacterial Infections (70%)
o Streptococcus pneumoniae, Haemophilus influenzae,
Streptococcus Group A, Branhamella catarrhalis, Gram
negative enteric bacilli
o Therefore, there is a need for bacteriologic examination of the
exudate to determine the specific antibiotic to be used Figure 7. Stage of Hyperemia.
• Viral Infections (30%)
o Can cause OM by themselves or increase susceptibility to 2.Stage of Exudation
bacteria (changes in mucosal defense or immunologic status) o Outpouring of serum containing fibrin and RBC, PMN
• Others leukocytes
o Presents as increased pain and fever
o Allergy – inflammation of the tubal lining causing obstruction
o Otoscopy Result: Red, thickened, and bulging tympanic
o Genetic – presence of markers correlate with good antibody
membrane
response
o Enlarged adenoids creates a reservoir for pathogenic
microorganisms, inducing adenoid hyperplasia
o Failure of physiologic opening of Eustachian tube with palatal
maldevelopment (clefts)
o Functional problem with tensor veli palatini which may cause ear
discharge.

E. Pathogenesis
• Pathogenesis of Otitis Media:
o Viral upper respiratory tract infection -> mucosal edema of
nasopharynx and eustachian tube -> decreased ventilation of
the middle ear -> impaired local immune process ->
otitis media Figure 8. Stage of Exudation. Tympanic membrane becomes stretched
and thinner, producing more pain. The pointed structure are exudates
F. Classifications within the TM.
1. Acute Otitis Media (AOM)
3.Stage of Suppuration
• Middle ear infection lasting up to 4 weeks.
 Definite infection
o Specific symptoms include: otalgia, ear tugging
o Non-specific symptoms: restlessness, rhinitis, feeding o Spontaneous perforation draining ear  at first hemorrhagic
difficulty, cough, fever, sudden crying becoming mucopurulent

1.02 MIDDLE EAR DISEASES AND THEIR COMPLICATIONS 5 of 11

 o There is relief of pain as the ear begins to drain
o Increase in hearing impairment
o Otoscopy Result: perforation with pus from the pars tensa
Figure 9. Stage of Suppuration. Arrow points to the perforation. The
larger the perforation, the greater the hearing loss.
4.Stage of Coalescence and Surgical Mastoiditis
o The virulence of the infecting organism will cause
progressive hyperemia of the mucoperiosteum obstructing
the free drainage of the mucopurulent secretions
o Profused purulent discharge, mastoid tenderness, abscess
formation
o  Infection spreads to the mastoid air cells via aditus ad
antrum
Medical Management
• Antibiotics –  Amoxicillin 40 mg/kg for 7 days
o If no response, and there is persistence of infection, shift to
2nd generation cephalosporin, co-amoxiclav, macrolides
• Adjunctive therapy: nasal decongestants, antihistamines,
analgesics
 Tympanocentesis/Surgical
• Indications for Myringotomy
o Extreme toxicity/febrile convulsions
o Immunologically compromised Child
o Failure of antibiotic therapy
o Severe pain in a cooperative Patient
o Complications of otitis media
• Ventilation Tubes (from 2019B)
o This is sometimes what we do in the stage of exudation to
relieve intense pain. We bring it to the next stage of
suppuration. It is better to drain the ear for it heals faster
o It is a small hole in the center that allows to pass from the
canal into the middle ear
o Acts as an artificial Eustachian tube
o Stays for several months until Eustachian tube function
returns to normal
o Complication: real infections of the middle ear as water may
enter from the canal; tympanosclerosis; scarring
o Incision site:  Posteroinferior quadrant
Control and Prevention
• Education
o Breast feeding is advocated
o Increase index of suspicion if with recurrent URI
o If with recurrent acute otitis media, environmental control
• Prevention
o Pneumococcal vaccine

Complications
• Middle ear complications
•  Facial Paralysis
• Labyrinthine Fistula and Labyrinthitis
 Patients with labyrinthitis present with sudden
sensorineural hearing loss, severe vertigo, and
nystagmus accompanied by nausea and vomiting.
• Extradural complications:
o Petrositis
Figure 10. Stage of Coalescent Mastoiditis. o Lateral sinus thrombosis
o Extradural abscess
5.Stage of Complication o Subdural abscess
• CNS Complications
o Extension of the infection beyond the middle ear into
o Meningitis
adjacent structures o Brain abscess
o Spread of infection may be by  thrombophlebitis or o Otitic hydrocephalus
by  bone
2. Chronic Otitis Media
6.Stage of Resolution • Middle ear infection lasting  more than 4 weeks
o End result of acute suppurative otitis media • Specific symptoms
o There is eventual resolution and healing of the ear o Hearing loss
o Fetid (foul-smelling) discharge
Pathogens • Nonspecific symptoms
• Streptoccocus pneumoniae o Irritability
• Haemophilus influenzae o Restlessness
• Streptococcus Group A
o Vertigo
• Branhamella catarrhalis
o Tinnitus
• Gram negative enteric bacilli
 The most common bacterial pathogens found in AOM are o Sense of fullness of the ear
Streptococcus pneumoniae, Haemophilus influenzae, and
Branhamella catarrhalis. 1/3 of cases are from respiratory viruses.

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3. Chronic Suppurative Otitis Media (CSOM)
• A tympanic membrane perforation will usually heal spontaneously
in a few weeks
• A non-healing perforation is almost most certainly the result of
chronic inflammation.
• Chronic Otitis Media should be diagnosed in the presence of a
chronic tympanic membrane perforation, even if there are no active
signs of mucosal inflammation.
• If a specific infection or cholesteatoma can be excluded, the disease
should be classified as Chronic Suppurative Otitis Media
• 2 types: Figure 13. Cholesteatoma. Pars flaccida cholesteatoma in a right ear
o Dry: without active inflammatory signs such as pain, with infection and discharge.
discharge, and swelling of the mucosa
o Wet: or draining form; here, discharge is present Management
 Usually presents initially with chronic otorrhea – generally a • Oral Antibiotics
mucopurulent discharge o For acute exacerbation
 Diagnosis is made from patient history and otoscopic findings o When complications arise, you may have to hospitalize the
patient and give IV antibiotics. Bacterial causative agent
needs to be determined for proper prescription of antibiotics
o If there are exudates, do culture and sensitivity
• Aural toilette
• Topical antibiotic eardrops
o Ciprofloxacin, ofloxacin, polymyxin, neomycin
• Surgical intervention – Mastoidectomy

Figure 11. Chronic Suppurative Otitis Media. Chronic perforation of

the tympanic membrane with purulent discharge.

Pathogens
• Staphylococci
• Proteus vulgaris
• Pseudomonas aeruginosa
• Klebsiella pneumoniae
• Anaerobic bacteria (Bacteroides spp.)
Figure 14. Managements of CSOM
• Mixed Infection

4. Tympanic Membrane Perforation

• A tympanic membrane perforation without acute inflammatory
changes is usually very easy to detect through otoscopy
• A chronic tympanic membrane perforation can contribute to the
resolution of chronic otitis media, but it can also pose a hazard such
as:
o Recurrent infections of the middle ear
o Conductive hearing loss
o Cholesteatoma
•  “Safe” Perforations: Central, Tubal
•  “Unsafe” Perforations: Marginal, Attic

Figure 12. CSOM Otoscopic Findings. (a) The Pars flaccida is retracted
inward (arrow) by negative pressure in the epitympanum. (b) Epithelial
debris creates a nidus for infection and inflammation, which leads to the
actual cholesteatoma

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 Figure 15. Perforations. Left: “Safe” Perforation. Right: “Unsafe” Figure 17. Acute Inflammation of the Tympanic Membrane. Otoscopic
Perforation findings in acute otitis media. The left tympanic membrane is bulging and
erythematous. Incipient perforation with discharge is evident in the
posteroinferior quadrant
5. Otitis Media with Effusion (OME)
• Presence of fluid inside the middle ear with intact tympanic
membrane  without clinical signs of infection
• Refers to an inflammatory effusion behind an intact tympanic
membrane that is  not associated with acute otologic
symptoms, or systemic signs
• Maybe classified as:
o Acute – 3 weeks
o Subacute – 3 months
o Chronic – more than 3 months
• Most common ear disease in preschool age children and generally
both ears are affected Figure 18. Partial Middle Ear Effusion. Serous effusion behind an
uninflamed tympanic membrane, which is slightly retractable. Air bubbles
Symptoms are clearly visible.
 Hearing loss (major symptom)
• Clogged or pressure sensation in affected ear Causative Factors
• Learning difficulties • Eustachian Tube disfunction
• Inattention in school • Hypertrophy of adenoids
• Decreased language perception and cognitive ability • Cleft palate
• Barotrauma
Otoscopic Findings • Rhinitis / Sinusitis
• Air fluid levels • Allergy
• Air bubbles o Among preschool – age children, it is generally caused by viral
or bacterial URI by ascending infection from Eustachian tube
to the middle ear
o May also be non-infectious, allergic or toxic inflammations of
the upper respiratory tract by nasal airway obstruction or reflux
of gastric juice among infants fed lying flat
o Among adults, is it the same disease as it is in children but it
is necessary to consider eustachian tube disfunction, such as
 Sleep apnea syndrome and/ or  Tumors of the
nasopharynx

Figure 16. Otitis Media with Effusion. Pointed structure: air fluid level.
Fluid is present but is not hyperemic. It seems to be glued to the lateral
wall of the middle ear cavity.
• In the absence of otoscopic findings, Siegel’s Pneumatic
otoscopy must be performed to diagnose OME and demonstrate
the absence of tympanic membrane movement
Management
• Medical Treatment – antibiotics, antihistamines, decongestants,
eustachian tube ventilation exercises, allergic hyposensitization
• Surgical Treatment (if disease persists for more than 3 months and
the tympanic membrane becomes markedly thickened)
o myringotomy and ventilation tube; adenoidectomy
• Conservative treatment for acute/subacute forms to improve nasal
breathing and eustachian tube function
• Short term use of nasal decongestants
• Occasional topical steroids
• Regular Valsalva maneuvers
• Antibiotic therapy is controversial
• Chronic OME is treated surgically if significant hearing loss is
present
• Paracentesis may be done to aspirate the effusion, immediately
restoring normal hearing
• Emphasis is placed on relieving nasal airway obstruction and
treating possible infections of the nose and paranasal sinuses

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Indications for Myringotomy Clinical Hearing Tests
• Persistent effusion for more than 12 weeks
• Failure to respond to treatment
• Severe otitis media
• Severe conductive deafness
• Impending cholesteatoma
• Otitis media prone child
• Cleft palate

Figure 22. Tuning Fork Tests. Classification of sensorineural and

conductive hearing loss with the tuning fork tests. A normal result
(symmetrical Weber and positive Rinne) is not substantially different with
bilateral sensorineural hearing loss)
Figure 19. Myringotomy Tube. Placed in the anteroinferior quadrant of
the tympanic membrane, the myringotomy tube provides ventilation of • The goal of tuning fork tests is to differentiate between
the tympanic cavity through the ear canal. conductive hearing loss and sensorineural hearing loss
• Conductive hearing loss – caused by disease of the external
auditory canal or middle ear
• Sensorineural hearing loss – cause is in the cochlea or the neural
structures of the auditory system

Weber Test

Figure 20. Myringotomy Site. Site is at the posteroinferior quadrant

(pointed structures)

Figure 23. The Weber Test. (a) When hearing is symmetrical, the sound
is perceived with equal loudness in or between both ears. (b) With
unilateral sensorineural hearing loss, the sound is lateralized to the better
ear. (c) With unilateral conductive hearing loss, the sound is lateralized to
the affected side.

Rinne Test

Figure 21. Traumatic Rupture of the Tympanic Membrane. Fresh

tympanic rupture in the right ear. Otoscopy reveals a triangular
perforation with hemorrhagic margins.

Figure 24. The Rinne Test. Air and bone conduction are compared in the
same ear to determine the auditory threshold for the tuning fork and/or its
loudness. (a) In the absence of conductive hearing loss, air conduction
is perceived as being louder and/or of longer duration than bone
conduction. (b) When conductive hearing loss is present, bone
conduction is perceived as being louder and/or more prolonged than air
conduction.

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 V. EXERCISES
REVIEW QUESTIONS (2019 B)
1. Which perforation of the tympanic membrane is considered a
“dangerous perforation” for dead skin to migrate into the middle
ear and results in a cholesteatoma?
a. Attic
b. Central
c. Marginal
d. Peripheral
2. A man who was accidentally slapped on one of his ears suffered
a perforation in his eardrum. Which one of the following
perforations may result in a greater amount of hearing loss?
a. A 40% perforation of the pars flaccida
b. A 40% marginal perforation of the pars tensa
c. A 40% central perforation of the pars tensa
d. A 40% peripheral perforation of the pars tensa
3. Using the ESSC, what is the best drug to give for relief of Otalgia?
a. Paracetamol
b. Celecoxib
c. Ibuprofen
d. Morphine
4. Which one of the following conditions may result in Otalgia in a
child who had a recent upper respiratory tract infection with a
Figure 25. Normal and Abnormal Tympanogram patterns. (a) The history of blowing of the nose?
normal tympanogram has a prominent, sharp peak between +100 and - a. Acute otitis externa
100 daPa. (b) The type B tympanogram is flat or has a very low, rounded b. Acute otitis media
peak. This indicates immobility of the tympanic membrane, which may be c. Otitis media with effusion
due to fluid in the middle ear or tympanic atelectasis. (c) The type C
d. Acute mastoiditis
tympanogram has a peak in the negative pressure region below -100
daPa, consistent with impaired middle ear ventilation. 5. What stage of an acute otitis media manifests as sudden relief of
Otalgia?
a. Stage of Hyperemia
b. Stage of Exudation
c. Stage of Suppuration
d. Stage of Resolution
6. What is the most common pathogen in acute purulent otitis media
in children under five years of age?
a. Haemophilus influenza
b. Moraxella catarrhalis
c. Pseudomonas aeruginosa
d. Streptococcus pneumoniae
7. Myringotomy can be an outpatient procedure either to relieve
pain, provide ventilation to the middle ear, and permit drainage
of the middle ear fluid. Which one of the following is an indication
of Myringotomy in Acute Otitis Media (AOM)?
a. Failure of antibiotic therapy given for 2 days
b. Acute otitis media in a stage of suppuration
Figure 26. Classification System for Tympanograms. Type AD – A c. Adult patient with acute exudative otitis media
deep; Type AS – A shallow d. Patient with beginning otalgia
8. Which quadrant in the tympanic membrane is a myringotomy
incision best performed?
IV. REFERENCES a. Anterior superior quadrant
1. Lecture Notes b. Anterior inferior quadrant
2. Recordings c. Posterior superior quadrant
3. Lecturer’s Powerpoint Presentation d. Posterior inferior quadrant
4. 2019B Transcription 9. What is the most common intracranial complication of acute
5. Probst, R., Grevers, G., & Iro, H. (2006). Basic suppurative otitis media with mastoiditis?
otorhinolaryngology: a step-by-step learning guide. a. Brain abscess
6. Ballenger, J.J., Snow, J.B. (2003). Otorhinolaryngology b. Cavernous sinus thrombosis
Head and Neck Surgery. 16th edition. c. Lateral thrombophlebitis
7. Lalwani, A.K. (2012). Current Diagnostic & Treatment in d. Meningitis
Otorhinolaryngology – Head & Neck Surgery. 3rd edition. 10. Which one of the following conditions would present with a type
C tympanogram?
a. Acute otitis media
b. Eustachian tube dysfunction
c. Large tympanic membrane perforation
d. Otorrhea

1.02 MIDDLE EAR DISEASES AND THEIR COMPLICATIONS 10 of 11

11. Patients presenting with multiple perforations of tympanic QUIZ (External Diseases of the Ear and Middle Ear
membrane would probably have a history of: Complications)
a. Frequent ear cleaning 1. The distance of the middle ear from the external meatus is
b. Frequent scuba diving approximately how long?
c. Multiple ear infection during childhood 2-3. One of the surgical managements of Otitis Media with effusion
d. Tuberculosis is myringotomy. Give two indications for a myringotomy.
12. Which of the following is the primary function of the Eustachian 4. Herpes zoster Oticus also known as Ramsay Hunt syndrome
tube? caused by reactivation of the dormant Varicella Zoster virus
a. Creates a barrier to descending infection in ganglion cells may result to deafness due to the invasion
b. Dampens sound of what cranial nerves?
c. Drains the middle ear spaces 5. What are the 6 stages of Acute Otitis Media (in correct order)
d. Impedance matching
13. What is the position of the Eustachian tube that results in the
increased incidence of Otitis media with effusion among toddlers
and early school children?
a. Anteriorly placed
b. Diagonally placed
c. Horizontally placed
d. Vertically placed
14. What is the primary goal for mastoidectomy for referred cases of
Chronic Otitis Media with cholesteatoma?
a. Eradicate infection
b. Improve hearing
c. Improve quality of life
d. Relieve mastoid pressure
15. A patient complains of severe ear pain and moderate grade
fever. Otoscopy reveals a hyperemic bulging tympanic
membrane with no light reflex.
a. AOM, exudative stage
b. AOM, hyperemic stage
c. AOM, suppurative stage
d. AOM, complicated stage
16. In an audiogram, what type of hearing loss can one conclude if
the results show an air conduction (AC) threshold level 40dB and
the bone conduction (BC) threshold at the level of 20dB?
a. Conductive hearing loss
b. Sensorineural hearing loss
c. Mixed hearing loss
d. Normal hearing
17. What type of tympanogram would a patient with presbycusis (age
related hearing loss) have?
a. Type AD
b. Type A
c. Type B
d. Type C
18. Nose- induced hearing loss (NIHL) would show permanent Answer key:
damage to the cochlea in the vicinity of ____________.
a. 8 kHz REVIEW QUESTIONS:
b. 4 kHz ACABC DCDDB DCCAA ABBAC
c. 2 kHz
d. 1 kHz QUIZ
19. What is the ratio between the tympanic membrane and stapes 1. 2.5 cm
footplate that provides a considerable amount of gain in Decibels
2-3.
to counter the impudence mismatch as sound travels in air
through fluid in the cochlea? • Persistent effusion for more than 12 weeks
a. 17:1 • Failure to respond to treatment
b. 17:3 • Severe otitis media
c. 20:1 • Severe conductive deafness
d. 20:3 • Impending cholesteatoma
20. What is the tympanogram result in a patient with a perforation of • Otitis media prone child
the pars tensa? • Cleft palate
a. Type A 4. VZV invades CN 7 and/or 8 (and occasionally CN 9,10)
b. Type AD
5.
c. Type B
d. Type C • Stage of hyperemia
• Stage of exudation
• Stage of suppuration
• Stage of coalescence and surgical mastoiditis
• Stage of complication
• Stage of resolution

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