SUHARYONO

STIKES RS BAPTIS KEDIRI

 DISORDERS OF MIDDLE EAR

I. SEROUS OTITIS MEDIA (GLUE EAR)

II. ACUTE OTITIS MEDIA
III. CHRONIC OTITIS MEDIA
IV. CHOLESTEATOMA
V. MASTOIDITIS
VI. FACIAL PALSY OR PARALYSIS
VII. BEZOLD ABSCESS

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I. SEROUS OTITIS MEDIA (GLUE EAR)

- Syn : otitis media wit efusion secretory otitis media mucoid

otitis media
- Insidious condition characterised by accumulation of non-purulent
effusion in the middle ear cleft
- Effusion is thick and viscid, sometimes thin and serous
- The fluid is nearly sterile
- Commonly seen in school – going children ( 5 – 8 years of age )

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 - Pathogenesis
o Malfunctioning of eustachian tube
o Increased secretory activity of
middle
ear mucosa
- Aetiology
o Malfunctioning of eustachian tube
o Allergy
o Unresolved otitis media
o Viral infection 4
 - Symptoms
o Deafness

o Delayed and defective speech

o Mild earaches
- Otoscopic finding

o Tympanic membrane is often dull

and
opaque with loss of light reflex
It may appear yellow, grey or bluish
in
colour
o Thin leash of blood vessels along

the
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- Treatment
o Medical

- Decongestants
- Antiallergic measures
- Antibiotics
- Middle ear aeration
* Repeatedly perform valsava
manoeuvre
* Politzerisation or eustachian tube
catheterisation

6
o Surgical
- Myringotomi and aspiration of fluid
- Gromet insertion
- Tympanotomy or cortical
mastoidectomy
- Surgical treatment of causative facto
(adenoidectomy, tonsillectomy and /
or
wash – out of maxillary antra)

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II. ACUTE OTITIS MEDIA

- Syn : acute suppurative otitis media

- Acute inflammation of middle ear by
pyogenic organisms. Middle ear
implies
middle ear cleft, i.e. eustachian tube,
middle ear, attic, aditus, antrum and
mastoid air cells
- Typically, the disease follows viral
infection
of upper respiratory tract, but soon
the
pyogenic organisms invade the 10
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- Routes or infection
o Via eustachian tube (the most

common)
o Via external ear (traumatic

perforation)
o Blood-borne (uncommon)

- Bacteriology (in infant and young

children)
o Sreptococcus pneumonia

o Haemophilus influenze

o Moraxella catarrhalis
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- Stages
1. Stage of tubal occlusion
2. Stage of pre-suppuration
3. Stage of suppuration
4. Stage of resolution or
complications
- Stage of tubal occlusion
o Deafness and earache, but not

marked
o Retraction of tympanic membrane

o Some degree of effusion in the middle12

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- Stage of pre-suppuration
o Marked earache
o Deafness and tinnitus (complained
only
by adults)
o Child runs high degree of fever and
restless
o Inflamatory exudate in the middle ear
o Red tympanic membrane
o Conductive hearing loss
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- Stage of suppuration
o Earache becomes excruciating

o Deafness increases

o Child may run fever, may be

accompained
by vomiting and even convulsions
o Red and bulging tympanic membrane

o Tenderness may be elicited over the

mastoid antrum

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- Stage of resolution
o Tympanic membrane rupture with

elease
of pus and subsidence of symptoms
o If proper treatment is started early or if

he
infection was mild, resolution may
tart
even without rupture of tympanic
membrane
o Blood tinged discharge which later

becomes mucopurulent
o Small perforation, antero inferior
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- Stage of complications
o Disease spreads beyond the confines

of
middle ear
o If virulence of organism is high or
resistance of patient poor

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- Treatment
o Antibacterial therapy

o Nasal decongestant nasal drops or

oral
o Analgesics and antipyretics
o Ear toilet
o Dry local heat
o Myringotomy
* Bulging drum and there is acute
pain
* In complete resolution when drum
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Acute otitis media

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III. CHRONIC OTITIS MEDIA

- Syn : chronic suppurative otitis media

- Long standing infection of a part or
whole of
The middle ear cleft
- Characterised by ear discharge and a
permanent perforation
- Types : 1. Tubotimpanic
2. Atticoantral

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- Tubotympanic
o Syn : safe or benign type

o Involves anteroinferior middle ear cleft

o Associated with a central perforation

o No risk of serious complications

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o Pathology
* Perforation of pars tensa
* Middle ear mucosa
- Active : oedematous and velvety
- Inactive : normal
* Polyp
* Ossicular chain may so some degree
of
necrosis
* Tympanosclerosis
* Fibrosis and adhesions

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o Bacteriology
* Aerobic organism are Pseudomonas
aeruginosa, Proteus, Escherichia coli,
Staphylococcus aureus
* An aerob are bacteroides fragillis and
anaerobic streptococci

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o Clinical features
* Sar discharge
* Hearing loss
* Perforation
* Middle ear mucosa : looks red,
oedematous and swollen. A polyp
may be seen

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o Treatment
* Aural toilet
* Ear drops
* Systemic antibiotics
* Precautions : keep water out of the ear
avoid hard nose-blowing
* Treatment of contributory causes
* Surgical treatment
* Reconstructive surgery
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- Atticoantral
o Syn : unsafe or dangerous type
o Involves posterosuperior part of the
cleft (attic, antrum and
mastoid)
oAssociated with an attic or a
marginal perforation
o Associated with a bone eroding
process such as cholesteatoma,
granulations or osteitis
o Risk of complications is high 26
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o Clinical features
* Aar discharge
* Hearing loss
* Bleeding
*Perforation, attic or posterosuperior
marginal type
* Retraction pocket
* Cholesteatoma

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o Treatment
* Surgical
~ Primary aim : to remove the disease
and render the ear safe
~ Second in priority : to preserve or
reconstruct the hearing
* Conservative treatment
~ When cholesteatoma is small and
easily accessible
~ In elderly patient above 65 and
those who are unfit for
general anasthesia or those
refusing surgery 28
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- Complications of suppurative otitis

media
- Factors
- High virulence of organisms
- Poor resistance of patient
- Inadequate antibiotic treatment
of acute middle ear and mastoid
infection
- Presence of chronic systemic
diseases
- Resistance of organism to
antibiotics
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- Patways of spread of infections

- Direct bone erosion
- Acute infections : process of
hyperaemic decalcifications
- Chronic infections : osteitis,
erosion by cholesteatoma or
granulation tissue
- Venous thrombophlebitis
- Pre-formed pathways

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- Pre-formed pathways
- Congenital dehiscences
- Patent sutures
- Previous skull fractures
- Surgical defect
- Oval and round windows
- From labyrinth can travel along
m.a.i.,
aqueducts of the vestibule
- From cochlea to meninges

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- Classifications
a. Intratemporal
- Mastoiditis
- Petrositis
- Facial paralysis
- labyrinthitis
b. Intracranial
- Extradural abcess
- Subdural abscess
- Meningitis
- Brain abscess
- Lateral sinus
thrombophlebitis
- otitic hydrocephalus 32
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IV. CHOLESTEATOMA

- Is the presence of keratinising squamous

epitelium in the middle ear or mastoid
- Theory of its genesis
-Presence of congenital cell rest
- Invagination of tympanic membrene
- Basal cell of germinal layer of skin
proliferate under the influence of
infection
- Epithelial invasion from the meatus
- Metaplasia 35
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- Classifications
- Congenital

- Primary acquired (no history of previus

otitis
media or a pre-existing perforation)
- Invagination of pars flaccida
- Basal cell hyperplacia
- Squamous metaplasia
- Secondary acquired (already a pre
existing
perforation in pars tensa)
- Migration of squamous epithelium
- Metaplasia 36
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V. MASTOIDITIS
- Intracranial complication of otitis media
- Acute mastoiditis
- Masked (latent) mastoiditis

Acute mastoiditis
•Infection spreads from the mucosal
lining the mastoid air cell, to involve
bony walls of the mastoid air cell
system
•Usually accompanies or follws acute
suppurative otitis media
•Hildren are affected more
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• Pathology
-Production of pus under
tension
- Hyperaemic decalcification an
osteoclastic resorption of
bony walls
• Lymptoms
- Pain behind the ear
- Fever
- Ear discharge

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• Signs
- Mastoid tenderness
- Ear discharge
- Sagging of posterosuperior
meatal
wall
- Perforation of tympanic
membrane
- Swelling over the mastoid
- Deafness
- Patient appears ill and toxic with
fever
• Differential diagnosis
- Suppuration of mastoid lymph
nodes 40
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• Treatment
- Hospitalisation
- Antibiotics
o Atart with amoxicillin or

ampicillin
o Specific antimicrobial is started

on the receipt of sensitivity

report
o Chloramphenicol or

metronidazole,
since anaerobic organism are
often
present
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- Indication of cortical
mastoidectomy :
o Subperiosteal abscess

o Sagging of posterosuperior

meatal
wall
o Positive reservoir sign

o No change or worsens inspite of

adequate medical treatment for

48 hours
o Mastoiditis, leading to

complications 42
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• Subperiosteal abscess in relation

mastoiditis
- Post - auricular abscess
- Zygomatic abscess
- Bezold abscess
- Meatal abscess
- Behind the mastoid
- Parapharingeal or retropharyng
abscess

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Masked (latent) mastoiditis

• Slow destruction of mastoid air cell but
without the acute signs and symptoms
• Often results from inadequate antibiotic
therapy

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• Clinical features
- Patient is often a child
- Tympanic membrane appears thick
with loss of translucency
- Slight tenderness over the mastoid
- Conductive hearing loss
- X-ray : clouding of air cells with loss of
cell outline

• Treatment
- Cortical mastoidectomy
- Full dosis of antibiotics

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IV. FACIAL PALSY OR PARALYSIS

- It can occur as a complication of both

acute and chronic otitis media
- Acute otitis media
o The bony canal is dehiscent, and the

nerve lies just under the middle ear

mucosa
o Facial nerve function fully recovers if

acute
otitis media is controlled with
systemic
antibiotics
o Myringotomy or cortical
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- Chronic otitis media

o Results from cholesteatoma or from

penetrating granulation tissue

o Treatment is urgent exploration of

the
middle ear and mastoid
o If a segment of the nerve has been

destroyed by the granulation tissue :

resection of nerve and grafting
(better
when infection has been controlled
and
fibrosis has matured)
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VII. BEZOLD ABSCESS

- It can occur following acute

coalescent mastoiditis
- Pain, fever, swelling in the neck and
torticollis
- Treatment
o Cortical mastoidectomy with careful

exploration of the tip

o Drainage of neck abcess

o Intravenous antibiotics

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INNER EAR

 SENSORINEURAL HEARING LOSS (Modul THT)

 DISORDERS OF VESTIBULAR SYSTEM
I. MENIERE’S DISEASES
II. BENIGN POSTURAL VERTIGO
III. MOTION SICKNES
IV. LABYRINTHITIS
V. ACOUSTIC NEUROMA
VI. VESTIBULAR NEURITIS

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DISORDER OF VESTIBULAR SYSTEM

A. Peripheral
- Involve vestibular end organs and
their first order neurons
- The cause lies in the internal ear or
the VIIIth nerve.
- Responsible for 85% of all cases of
vertigo
B. Central
- Involve central nervous system after
the
entrance of vestibular nerve in the
brainstem
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VERTIGO AND DIZZINESS

- Disorientation in space causes vertigo or

dizziness
-Can arise from disorders of any of the
three systems, vestibular, visual or
somatosensory.
-Normally, the impulses reaching the brain
from the three systems are
-If any component on one side is equal and
opposite.
inhibited or Stimulated, the information
reaching the cortex is mismatched,
resulting in disorientation and vertigo.
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THE COMMON CAUSES OF VERTIGO OF PERIPHERAL ORIGIN

 Meniere’s disease
 Benign paroxysmal positional vertigo
 Vestibular neuronitis
 Labyrinthitis
 Vestibulotoxic drugs
 Head trauma
 Perilymp fistula
 Syphilis
 Acoustic neuroma

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I. MENIERE DISEASE KBK 10

- Syn : endolymphatic hydrops.

- Characterized by episodic vertigo,
fluctuating sensorineural hearing loss,
tinnitus and sense of pressure in the
involved ear.
- Hearing improves after the attack and
may be normal during the
periods of remission
- The exact cause of Meniere’s disease is
not yet known
- Commonly in 35 -60 years old, males
more than females, usually unilateral
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- General measures
1. Reassurance
2. Cessation of smoking
3. Low salt diet
4. Avoid excessive intake of water
5. Avoid over – indulgence in coffee,
tea and alcohol
6. Avoid activities requiring good body
balance

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- Management of acute attack

1. Reassurance and psychological
support to allay worry and
anxiety
2. Bed rest with head supported on
pillows to prevent
excessive movement
3. Vestibular sedatives to relieve vertigo,
dimenhydrinate (dramamine),
promethazine theoclate
(avomine), prochlorperazine
(stemetil) 56
- Surgical treatment
KBK 10

1. Conservative procedures (in cases

where vertigo is disabling but
hearing is still useful)
- Decompression of endolympatic sac
- Endolypatic shunt operation
- Sacculotomy
- Section of vestibular nerve
- Ultrasonic destruction
2. Destructive procedures (used only
when cochlear function is not
serviceable)
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II. BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV).

- Characterized by vertigo when the

head is placed in a certain critical
position.
- No hearing loss or other neurologic
symptoms.
- Positional testing establishes the
diagnosis and helps to differentiate it
from positional vertigo of central
- Typical history and Hallpike
origin
manoeuvre establishes the diagnosis.
- The condition can be treated by
performing Epley’s manoeuvre 58
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III. MOTION SICKNESS

-Characteristic by nausea, vomiting,

pallor and sweating during sea, air,
bus or car travel, in certain
susceptible individuals.
-Can be induced by both real and
apparent motion
- Thought to arise from the mismatch
of information reaching the vestibular
nuclei and cerebellum from the visual,
labyrinthine and somatosensory system.
-Can be controlled by the usual 59
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IV. LABYRINTHITIS

There are three types of labyrinthitis :

1. Circumscribed labyrinthitis
2 .Diffuse serous labyrinthitis
3. Diffuse suppurative labyrinthitis

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Circumscribed labyrinthitis (fistula of labyrinth)

- There is thinning or erosion of bony

capsule of labyrinth, usually of the
horizontal semicircular canal
- Chronic suppurative otitis media with
chlolesteatoma is the most common
cause
- A part of membranous labyrinth is
exposed and become sensitive to
pressure changes.
- It is diagnosed by “fistula test”
- Mastoid exploration is often required to
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Diffuse Serous Labyrinthitis

- Diffuse intralabyrinthine inflammation

without pus formation
- A reversible condition if treated early.
- Most often it arises from preexisting
circumscribed labyrinthitis associated
with chronic middle ear suppuration or
cholesteatoma

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- Treatment :
o Patient is put to bed, his head

immobilized with affected ear above

o Antibacterial therapy

o Labyrinthine sedatives

o Myringotomy, in acute otitis media and

the drum is bulging.

o Cortical mastoidectomy (in acute

mastoiditis)
o Modified radical mastoidectomy (in

chronic middle ear infection or

cholesteatoma) will often be
required to treat the source of 63
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Diffuse suppurative labyrinthitis

- Diffuse pyogenic infection of the

labyrinth
- Permanent loss of vestibular and
cochlear functions.
- Usually follows serous labyrinthitis,
pyogenic organism entering through
a pathological or surgical fistula.

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- Clinical features.
o Severe vertigo with nausea and

vomiting
o Spontaneous nystagmus

o Patient is markedly toxic.

o There is total loss of hearing.

- Treatment is same as for serous

labyrinthitis.

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V. ACOUSTIC NEUROMA.

- It has been classified in peripheral

vestibular disorders as it arises from
CN VIII within internal acoustic meatus.
- It causes only unsteadiness or vague
sensation of motion.

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VI. VESTIBULAR NEURONITIS

- Characterised by severe vertigo

of sudden onset with no cochlear
symptoms.
- Attacks may last from a few days
to 2 or 3 weeks.
- Thought to occur due to a virus
that attacks vestibular ganglion.
- Management of acute attack is
similar to that in Meniere’s disease.
- Usually self limiting.
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SUGESTED READING

Dhingra PL : Diseases of Ear Nose and Throat, 3rd ed , New Delhi , Elsevier,
2004

JBS 300910

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