Chronic Otitis Media

Question 1

Following on from acute otitis media, 50% of patients will have persistent middle ear fluid known as otitis media w/ effusion (OME).

How does OME present clinically?

Answer 1

• “glue ear”
• same risk factors as acute otitis media
• chronic inflammation of middle ear mucosa w/ accumulation of fluid in middle ear (behind TM) with no sign of infection
• Sx →
  
  • conductive hearing loss
  • sense of fullness
  • can be asymptomatic
  • impaired speech + language development (in kids)
• O/E → dull, intact TM, bubbles behind TM + air fluid level behind TM

Question 2

How is otitis media with effusion investigated?

Answer 2

• adult AOM uncommon therefore OME uncommon
• but 20% of children have OME by 2 years
• unilateral OME needs to be investigated → ?nasopharyngeal cancer
  
  • endoscopy of nasopharynx
• other causes in adults → eustachain tube dysfunction, trauma, recurrent infection, post-radiation
• initial tests → pneumatic otoscopy, impedance tympanometry
• audiometry if persistent OME > 3months or speech impairment

Question 3

What is the management of otitis media w/ effusion?

Answer 3

• most resolve within 3 months so watch + wait
• if lasts >3months → myringotomy +/- grommet insertion +/- adenoidectomy (if ≥4yrs)
• pts w/ cleft palate or Down’s can be offered hearing aids

Question 4

Chronic otitis media (OM) refers to a group of chronic inflammatory diseases of the middle ear, which often affects children. Chronic suppurative otitis media (CSOM) is characterized by a persistent drainage from the middle ear through a perforated tympanic membrane (TM).

What are the causes of chronic otitis media?

Answer 4

Bacterial infection following perforation of the tympanic membrane due to:

• late or inadequate treatment of AOM
• upper airway sepsis
• host susceptibility → anaemia, malnutrition, immune deficiency
• virulent infections eg. measles
• trauma
• recurrent acute otitis media
• placement of ventilation tube

Question 5

What is the pathophysiology of chronic otitis media?

Answer 5

• infection secondary to translocation of bacteria of the external ear canal into the middle ear through the perforated tympanic membrane
• 2 main types:
  
  • mucosa (‘safe’) → perforation of TM following AOM fails to heal, allowing pathogens from ear canal into middle ear
  • attico-antral (‘unsafe’) → cholesteatomas form in attic, much more serious

Question 6

What ar ethe clinical features of chronic otitis media?

Answer 6

• painless recurrent otorrhoea (usually odourless)
• conductive hearing loss → Weber test lateralises to affected ear
• possibly development of concurrent choleosteatoma
• fever not typical + indicative of complications if occurs
• O/E → peforated TM, granulation tissue

Question 7

What investigations are done for chronic otitis media?

Answer 7

• clinical diagnosis
• otoscopy → visible defect of TM
• cranial CT or MRI → if complications suspected

Question 8

The treatment goal for chronic otitis media is to restore integrity of tympanic membrane and prevent permanent hearing loss.

What is the treatment for chronic otitis media?

Answer 8

• conservative → rinsing of ear (aural toilet); topical antibiotic (eg. ciprofloxacin) and steroid drops (eg. dexamethasone)
• surgical → tympanoplasty w/ insertion of graft

Question 9

The prognosis for chronic otitis media is usually good with adequate treatment; conductive hearing loss can often be improved, but may not be fully recovered.

What are the complications of chronic otitis media?

Answer 9

• possibly life-threatening infection spread (eg. meningitis, intracranial abscess, facial paralysis) ; rarely occurs w/ adequate treatment
• tympanosclerosis
  
  • scarring of tympanic membrane due to recurrent ear infections or otitis media w/ effusion
  • may be asymptomatic or lead to conductive hearing loss
  • white calcified plaques in tympanic membrane seen on otoscopy

Question 10

Grommets usually last for a year, before they fall out as the TM heals. They may need to be reinserted if symptoms redevelop.

What are indications for grommet insertion?

Answer 10

The child has OME following a period of watchful waiting, for 3 months from diagnosis in primary care AND the child suffers from at least one of the following:

• at least 5 recurrences of acute OME in one year
• evidence of delay in speech development
• educational or behavioural problems attributable to persistent hearing impairment
• a second relevant health problem, eg. Down’s syndrome or cleft palate

Question 11

What is cholesteatoma?

Answer 11

• misnomer - neither composed of cholesterol nor malignant
• destructive + expanding growth consisting of keratinising squamous epithelium in the middle ear and/or mastoid process
• can be congenital or acquired
• acquired → retraction of TM (most common), ear trauma, recurrent OM infection

Question 12

How does cholesteatoma present clinically?

Answer 12

• otorrhoea → scanty, foul smelling discharge
• conductive hearing loss
• untreated → facial nerve palsy, labyrinthitis, meningitis, extra/subdural abscess

Surgical treatment is required or lesion will continue to grow and erode into temporal bone → tympanoplasty