Otitis Media

Dr.Sherif Bugnah
ENT Resident | AFHSR
Supervised by Dr.Muslih
INTRODUCTION & DEFINITIONS
Otitis media (OM) is the most common
bacterial infection in children and the most
frequent indication for antimicrobial or
surgical therapy in this age group. It is also
the leading cause of hearing loss in children.
OM : any inflammatory process in the
middle-ear cleft behind an intact tympanic
membrane (TM).
CLASSIFICATIONS
Two Major Classes of OM are
èAcute Otitis Media
èChronic OM with effusion (OME).
A diagnosis of AOM requires the presence of a (MEE)
and the symptoms and signs of acute infection (Fever,
Pain,Red and Bulging TM).
OME indicates an MEE without signs of inflammation.
Equivalent terms are chronic secretory OM, chronic
serous OM, and "glue ear." MEE denotes a liquid in the
middle-ear cleft regardless of etiology.
CLINICAL AND FUNCTIONAL ANATOMY

The middle-ear cleft is a continuous space

that begins at the nasopharyngeal orifice of
the Eustachian tube and extends to the
farthest mastoid air cells.
The mucosal lining of the middle-ear cleft
varies from the thick, ciliated, respiratory
epithelium of the Eustachian tube and anterior
tympanum to the thin, nonglandular, cuboidal
epithelium in the mastoid cells.
CLINICAL AND FUNCTIONAL ANATOMY

Hyperplasia and an increase in the

number of goblet cells are common
findings in the middle ears of patients
with OM.
These metaplastic changes, which
predispose to the formation of effusion,
are probably the result of the primary
process.
EPIDEMIOLOGY
OM afflicts a majority of children at
some point during their early years.
Study* in the southern United States,
84% of children had one episode of OM,
50% had three or more episodes, and
25% had six or more episodes
The highest prevalence occurs in the
first 2 years of life and decreases there-
after.
*Greater Boston Otitis Media Study
PATHOPHYSIOLOGY

Linked with abnormalities of Eustachian tube

function, Three functions ET:
ØAeration, Clearance, and Protection
Early studies suggested that obstruction of the
tube (under aeration) was the underlying cause of
most AOM.
Newer work, has suggested that AOM is the
result of bacterial entry into the middle ear (failure
of protection). This entry is due to an abnormally
patent tube rather than an obstructed
Pathogenesis of acute otitis media

Cohen & Powderly: Infectious Diseases, 2nd ed.

DIAGNOSIS.

The first step in diagnosis is by recognition

of a problem by the family.
Older children will complain of earaches,
but infants become sleep poorly, and often
pull or tug at the affected ear.
OME may be completely asymptomatic.
Often family will notice decrease in hearing
incidentally.
DIAGNOSIS.

OTOSCOPY
AOM Classic signs
èRedness
èBulging of the TM.
DIAGNOSIS.

OTOSCOPY
èEarly stages of AOM, TM
may bulge outward and it
often moves normally.
èIn effusion, drum mobility
is decreased. Severe cases
the usual landmarks may
not be visible.
DIAGNOSIS.

OTOSCOPY
If the process continues, necrosis of the
TM occurs and the effusion passes into the ear
canal through a typically pinpoint perforation.
Massive necrosis of the drumhead is rare,
although necrotizing streptococcal infection is
a known cause of permanent perforation.
DIAGNOSIS.

OTOSCOPY
Clinical variants of AOM
èMyringitis is an inflammation of the TM without MEE.
The etiology and pathogenesis of Myringitisare not well
documented. Treatment is the same for AOM.
èBullous Myringitis is seen in both adults and children.
Pain is an outstanding feature . Most cases bullae on
the TM are associated with the same pathogenic
bacteria as AOM and treated similarly.
DIAGNOSIS.

OTOSCOPY
The classic findings of OME are a retracted,
hypomobile or immobile TM and a dark, fluid-
filled tympanum that obscures visualization of
the long process of the incus.
DIAGNOSIS.
DIAGNOSIS.

TYMPANOMETRY
Acoustic energy reflected from the TM as the pressure
in the external auditory canal is varied from -400 daPa to
100 daPa, the shape of which provides considerable
information about the status of the middle ear.
In air-containing ears, the shape of the tympanogram is
usually peaked at -100 daPa (type A).
In MEA, compliance is low and the tympanogram is
labeled type B by
Negative middle-ear pressure below 150 daPa) with a
sharp peak is labeled type C.
 TYMPANOMETRY

. Type A represents normal middle ear function. Type A curves have normal mobility and pressures |normal hearing
and sensorineural hearing loss with normally functioning middle ear systems. Type B represents restricted tympanic
membrane mobility. Type B curves have little or no point of maximum mobility and reduced compliance, typical of a
stiff middle ear system (Otitis media.) Type C represents significant negative pressure in the middle ear cavity. Type
C curves have normal mobility and negative pressure at the point of maximum mobility,(treatment when more
negative than -200 mm H2O). Type As represents normal middle ear pressure but reduced mobility suggesting
limited mobility of the tympanic membrane and middle ear structure, commonly seen in fixation of the ossicular
chain. Type Ad represents normal middle ear pressure but hypermobility. This pattern is indicative of a flaccid
DIAGNOSIS.

AUDIOMETRY
Guidelines for treatment of OME in young children
recommended that audiometry be used in the decision of
surgical drainage of the middle ear, and that surgery should
not be done if the pure-tone average is less than 20 dB
Limited Giudelines!
ØAudiometry is not always available, no
ØIt is not practical for 2-year-old children.
ØHearing levels may fluctuate frequently so that a normal
pure-tone average on one day does not exclude
abnormal thresholds on another
SEQUELAE AND COMPLICATIONS

The suppurative complications of AOM (pre-antibiotic

era) include Extension of the infection to involve the
bone of the Mastoid, Soft Tissues of The Neck,
Meninges, and Cerebral/Cerebellar Cortex
Today The most likely patients s are those with
postauricular tenderness and fullness in whom the
diagnosis of Mastoiditis is suspected.
SEQUELAE AND COMPLICATIONS

Clouding of air cells on CT is expected and should not

be mistaken for mastoiditis. The key radiographic sign
of Mastoid Osteitis, Demineralization of the air cell
septae, lags behind the clinical findings.
Once Osteitis is diagnosed, Mastoidectomy is
generally warranted to remove the infected necrotic
bone/ subperiosteal postauricular abscess drainage
(if present)
SEQUELAE AND COMPLICATIONS

Intracranial Complications in AOM are rare,

èMeningitis, Extradural Abscess, or Brain Abscess .
Adverse effects of OME on Hearing and on the
Development of Cognitive, Linguistic, Auditive, and
Communicative Skills
Otologic Complications of OM,
èPermanent Perforation Of The TM, Chronic
Suppurative OM, Tympanosclerosis, Adhesive OM,
Ossicular Necrosis, Retraction Pockets In The TM,
Cholesteatoma, And Sensorineural Hearing Loss
TREATMENT

ACUTE OTITIS MEDIA

§ ANTIMICROBIAL THERAPY
èAntimicrobial therapy is the mainstay of treatment for
AOM,
èCurrently in the USA about 25% of pneumococci are
resistant to penicillin, 25% of H. influenzae and 90% of
M. catarrhalis produce beta-lactamase.
èA meta-analysis study of AOM suggests that 80% of
patients with AOM will become asymptomatic within 7
to 14 days without treatment compared with 94%
resolution with antibiotic therapy.
TREATMENT

ACUTE OTITIS MEDIA

§ ANTIMICROBIAL THERAPY
èEuropean study support treating with analgesics and
observation & withholding antibiotics when treating
older children with AOM without significantly increasing
the duration of symptoms.
èStudies support for longer courses of
antibiotics,Showing that resolution of symptoms on
days 12 to 14 improved from 82% to 93% when a 10-
day course of antibiotics is used instead of a shorter 5-
day course
Antibiotics for acute otitis media.
 TREATMENT

ANTIHISTAMINES, DECONGESTANTS!
§ No evidence shows that antihistamines,
decongestants, vasoconstrictors, or any other
form of systemic or topical therapy aimed at
diminishing nasal symptoms result in shortened
duration of pain, fever, effusion, or hearing loss.
§ The combination of an antihistamine &
decongestant was found not affecting the
clearance of MEE
TREATMENT

TYMPANOCENTESIS
Ø Important for selection of therapy by
knowledge of the specific organism in specific
cases of AOM occurring in premature
newborns, immunocompromised patients,
patients with progression of symptoms and
signs while receiving an appropriate
antimicrobial, patients with intracranial
infection, and research subjects.
TREATMENT

MYRINGOTOMY
Ø Although severe AOM has many of the clinical
features of a closed-space abscess, incision and
drainage (myringotomy) has proven to be of limited
value. Myringotomy promptly relieves severe pain of
AOM in patients with severe pain but adds little to
either remission of infection or clearance of MEE in
cases of AOM treated with amoxicillin-clavulanate
TREATMENT

FOLLOW-UP
Infants, at greater risk of AOM and meningitis.
Therefore, a 3-day check is recommended.
Ø 2-week check is often performed in children of all
ages to determine whether the MEE has cleared.
Ø Initial follow-up at 4 weeks in routine cases of
AOM in older children.
Ø If TM has ruptured, indicating a severe episode, it
is better to continue the antimicrobial agent until
drainage stopped/TM sealed
TREATMENT

RECURRENT ACUTE OTITIS MEDIA

Antimicrobial Prophylaxis
Antimicrobial agents have some
efficacy in preventing AOM, but they do
so at the risk of promoting
antimicrobial resistance in common
pathogens.
TREATMENT

RECURRENT ACUTE OTITIS MEDIA

Surgical Prophylaxis
Surgical prophylaxis with Tympanostomy Tubes is
recommended for children with repeated episodes
of AOM. Recurrent AOM is a common indication for
tympanostomy tube placement.
The American Academy of Otolaryngology
currently recommends that children be considered
for tympanostomy tube placement if the child has
had four bouts of AOM in 6 months or six bouts in
1 year
TREATMENT

OTITIS MEDIA WITH EFFUSION

Antimicrobial Therapy
Ø OME, like AOM, is a bacterial disease, and the MEE is
known to contain viable, pathogenic bacteria. Efficacy
of Antimicrobial therapy has been determined in
several reports.

SURGICAL TREATMENT
Ø Surgical treatment is an option for children with
hearing loss and is recommended when the effusion
and hearing loss persist for 4 to 6 months.
Ø Type of procedure to be used. Myringotomy,
Adenoidectomy, Tympanostomy Tubes.
 TREATMENT

SURGICAL THERAPY FOR OME

MYRINGOTOMY
Ø Benefit ratio for myringotomy and aspiration is too
low to justify myringotomy as an independent
procedure requiring anesthsia .
Ø Reccomendations tympanostomy tubes to be inserted
or an adenoidectomy performed (or both)
ADENOIDECTOMY
Ø Adenoidectomy is being increasingly used for the
treatment of OME because recent studies have
Confirmed its effectiveness.
Ø Adenoidectomy is used far less with widespread use
of tympanostomy tubes
TREATMENT

SURGICAL THERAPY FOR OME

TYMPANOSTOMY TUBES
 TREATMENT

SURGICAL THERAPY FOR OME

TYMPANOSTOMY TUBES
Ø Modern Tympanostomy Tubes have become the
therapeutic gold standard and the most widely used
treatment option for OME. Improved hearing and a
decreased rate of recurrent AOM are predictable
benefits.
Ø The goal of using tympanostomy tubes is prolonged
ventilation of the tympanum. Removal of the MEE
and restoration of an aerated tympanum
Ø Risks vs effectiveness should be considered in light
of the needs of the child and family.
 TREATMENT

SURGICAL THERAPY FOR OME

Tympanostomy Tube Selection.
Ø The ideal tympanostomy tube would be easy to insert,
remain in situ as long as desired, be easily removed in
the office without anesthesia, and be associated with few
complications
Ø Tubes are variations of the Grommet or the T-tube, and,
generally speaking, the larger and stiffer the flange, the
longer the tube remains in situ. Small-flanged grommet
tubes generally remain in place for 6 months to a year
and are associated with a low rate of tympanic
membrane perforation, usually less than 5%.
.COMPLICATIONS OF TYMPANOSTOMY TUBES
 Suppurative complications of otitis media.

Ø Severe tympanic membrane Retraction with

Hearing Loss, impending Cholesteatoma
formation, or Ossicular Chain Erosion.
Ø Untreated tympanic membrane Atelectasis is
frequently complicated by cholesteatoma
formation and erosion of the long process of the
incus
Ø The retraction-atelectasis of the tympanic
membrane may be reversed by early
tympanostomy tube placement.
Suppurative Complications of Otitis Media

A schema for managing otorrhea

Suppurative Complications of Otitis Media
 Suppurative Complications of Otitis Media

Cholesteatoma Formation
Suppurative Complications of Otitis Media

Stages Of Middle Ear Atelectasis.

Otitis Media

THE END