Middle ear Flashcards
What are infective/inflammatory conditions seen in the middle ear?
- Glue ear
- Acute suppurative otitis media
- CSOM
- Cholesteatoma
- Otosclerosis
- Granulomatous disorders
What are the most common symptoms seen in middle ear disease?
- Hearing loss
- Tinnitus
- Otalgia
- Otorrhoea
What type of hearing loss is normally associated with middle ear disease?
Conductive hearing loss
What might pulsatile tinnitus indicate?
Vascular tumour close to the ear
What is otalgia?
Ear pain
What is the most common cause of otalgia?
Rapidly accumulating effusion in the middle ear - ear drum becomes stretched causing intense pain
What proportion of otalgia is non-otological?
50%
What are the main causes of a otorrhoea?
- Otitis media/externa
- Cholesteatoma
What red flag symptoms would you ask about (excluding pain, otorrhoea, hearing loss and tinnitus) when someone had a middle ear infection?
- Vertigo
- Headache
- Facial weakness
What can cause CSF otorrhoea?
Following trauma
What does offensive discharge suggest?
Cholesteatoma
What is acute otitis media?
Inflammation of the middle ear, most commonly due to infection
What is acute otitis media most commonly associated with?
Upper respiratory tract infection
What are symptoms of acute otitis media?
- Hearing loss
- Pain
- Otorrhoea
- Pyrexia
- Systemic upset
What are signs of acute otitis media?
- Purulent Otorrhoea
- Pyrexia
- Bulging, inflammed red drum
- Perforation
What age group does acute otitis media occur in?
Children
How would you manage acute otitis media?
- Amoxicillin - 7 days
- NSAIDs
What can be complications of acute otitis media?
- Mastoiditis
- Petrositis
- Meningitis
- Labrynthitis
- Facial nerve palsy
- Intracranial abscess
- Tympanosclerosis
What is otitis media with effusions?
Glue ear
Poor ventilation of the middle ear leads to accumulation of non-purulent/sterile effusion which is often stick and thick
What can cause the development of glue ear?
- Acute otitis media
- Eustachian tube dysfunction
- Poor/delayed developement
- Large adenoid - obstruction
- Cleft palate
What are the effects of glue ear on hearing?
Can lead to mild hearing loss
How long would you wait for a glue ear to resolve before intervening with treatment?
3 months
How would you treat a glue ear that had not resolved after 3 months?
Grommet insertion
How long do grommets normally remain in situ to treat glue ear?
1-2 years before being slowly extruded
What are risk factors for the development of otitis media?
- URTI
- Bottle-feeding
- Passive smoking
- Dummy/pacifier
- Presence of adenoids
- Asthma
- Malformations
- GORD
- Increased BMI in adults
What is the most common presentation of glue ear?
Hearing impairment noticed by parents - 80% of cases
What sex is glue ear more common in?
Males
What are signs of glue ear?
- Retracting or bulging drum - dull/grey/yellow in appearence
- Bubbles/fluid level
What tests would you perform in someone suspected of having a glue ear?
- Formal hearing assessment
- Tympanometry
- Audiogram
How would you approach managing someone with glue ear?
- Active observation for 3 months
- Autoinflation
- Surgery - grommets
- Consider hearing aids
Can you swim with grommets in?
Yes
What should you exclude in adults with apparent middle ear fluid?
Postnasal space tumour
What is chronic otitis media?
Defined as an ear with a tympanic membrane perforation in the setting of recurrent or chronic infections
What are the main types of perforation in chronic otitis media?
- Central pars tensa perforation
- Marginal pars tensa perforation
- Attic/pars flaccida perforation
- Subtotal/central perforation
What type of perforation is the following, and how safe is it?
Central pars tensa perforation - This is safe
What type of perforation is the following, and how safe is it?
Marginal pars tensa perforation - This is unsafe
What type of perforation is the following, and how safe is it?
Attic/pars flaccida perforation - This is unsafe
What is chornic suppurative otitis media?
Chronic otitis media with persitent drainage (purulent) through a perforated tympanic membrane
What type of perforation is the following, and how safe is it?
Subtotal perforation (central) - This is safe
How would you manage someone with chronic otitis media?
- Swab the ear - Topical/systemic Abx based on results
- Aural cleaning
- Water precautions
- Surgery
What is mastoiditis?
Middle ear inflammation leading to destruction of air cells in the mastoid bone +/- abscess formation
What are signs of mastoiditis?
- Fever
- Mastoid tenderness
- Swelling and redness behind pinna
- Protruding auricle
What are surgical options for chronic suppurative otitis media?
- Myringoplasty - repair of tympanic membrane
- Mastoidectomy - mastoiditis/advanced cholesteatoma
What can be a complications of chronic otitis media?
Cholesteatoma
What is cholesteatoma?
A cyst/sac of keratinising squamous epithelium, which most commonly occurs in the attic or epitympanic part of the middle ear
What are symptoms of cholesteatoma?
- Foul-smelling discharge
- Hearing loss
- Headache
- Pain
What are signs of cholesteatoma?
- Foul-smelling discharge
- Conductive hearing loss
- Attic retraction filled with squamous debrus
- Discharging attic perforation
- Attic aural polyp
- Facial palsy
How does cholesteatoma form?
Postulated that negative pressure within the middle ear sucks pars flaccida in, forming a pocket where migratory cells of the outer layer of the tympanic membrane collect and can’t escape. This ball of debris enlarges and becomes infected with pseudomonas, leading to foul otorrhoea
What direction does cholesteatoma tend to grow?
- Into the attic
- Into the mastoid
What are complications of cholesteatoma?
- Conductive deafness
- Facial nerve palsy
- Vertigo
- Cerebral abscess
- Mastoiditis
- Meningitis
What is the treatment of cholesteatoma?
Surgical removal - atticotomy/radical mastoidectomy
What are extracranial complications of otitis media?
- Mastoiditis
- Facial nerve palsy
- Labrynthitis
- Perositis
What is petrositis?
Spread of infection into the petrous bone and can involve V and VI cranial nerves
What are intracranial complications of otitis media?
- Temporal lobe abscess
- Cerebellar abscess
- Sigmoid sinus thrombosis
- Meningitis
- Jugular vein thrombosis
- Otitis hydrocephalus
What is otosclerosis?
Disease of the otic capsule/bony labyrinth, which leads to hearing loss - hard compact bone is replaced by soft spongy bone which produces toxins that can affect the cochlea, causing sensorineural hearing loss. More commonly though, the bony overgrowth affects the foot of the stapes, causing conductive hearing loss
What is the most common type of hearing loss in otosclerosis?
Conductive hearing loss
What are symptoms of otosclerosis?
- Deafness
- Tinnitus
- Mild, transient vertigo
What age does otosclerosis most commonly occur in?
Around 30 years old
What can worsen otosclerosis symptoms?
Pregnancy
If someone presented with progressive hearing loss and a normal ear drum, what would you be thinking of as a cause?
Otosclerosis
How would you manage someone with otosclerosis?
- Watch and wait
- Hearing aids
- Surgery - stapedectomy/otomy
- Microdrill and CO2 laser stapedotomy
- Cochlear implant - if severe
How might children with glue ear present with regards to their development?
Speech/language delay
What is the mode of inheritance of otosclerosis?
Autosomal dominant with incomplete penetrance
