Middle Ear Conditions Flashcards
Acute otitis media
- Frequently precipitated by impaired function of Eustachian tube, hence leading to retention and suppuration of retained fluids
- Ascending infection from nasopharynx up Eustachian tube to middle ear
- Acute suppurative infectious process with infected middle ear fluid and inflammation of the mucosal lining of the middle ear
Causative organisms for acute otitis media
- Strep Pneumonia
- Moraxella Catarrhalis
- H. Influenza
- Staph aureus
- Strep pyogenes
Clinical features of acute otitis media
- Preceding Hx of URTI
- Otalgia (Relieved by TM perforation)
- Otorrhea (If TM perforated)
- Conductive hearing loss
- Fever
- Toxic-looking
- Erythematous and bulging TM, pus with air-fluid level behind TM
Complications of acute otitis media
Ear
- TM perforation (Causes ear pain relief and otorrhea)
- Chronic suppurative otitis media
- Mastoiditis (If spreads posteriorly)
- Labyrinthitis (If spreads medially into inner ear)
- Tympanosclerosis
- Conductive hearing loss
CNS
- Meningitis
- Brain abscess
- Facial palsy
- Vertigo
- SNHL (From labyrinthitis)
*Won’t cause labyrinthine fistula as pus doesn’t have enough mass effect to cause erosion into bone, usually cholesteatoma or tumour (Rare)
Management of acute otitis media
- Self-limiting so conservative (analgesia, anti-pyretics) unless cx
- PO Augmentin / Amoxicillin (1st in Paeds) / Clarithromycin (Klacid)
- If symptoms worsen or still present after 1 week / >2 episodes in 6 months, myringotomy and tympanostomy tube insertion/ Ventilation tube/Grommet (M&T)
- Warn patient to come back if develop new symptoms and shld f/u in few days to prevent Cx
Otitis media with effusion
- Presence of (sterile) fluid in middle ear without signs and symptoms of ear infection
- Yellowish fluid +/- bubbles, intact ear drum, air-fluid level
- Intact TM
- Unilateral otitis media with effusion is NPC until proven otherwise* (do nasoendoscope)
Clinical features of otitis media with effusion
- Aural fullness/sensation of blocked ear
- Conductive hearing loss
- Otoscopy: yellowish fluid, intact ear drum, air-fluid level, air bubbles behind TM
Investigations for OME
- Pure tone audiogram: CHL
- Tympanogram: Type B pattern impedance tympanometry - poor TM motility
- Nasoendoscopy
- GOLD: Pneumatic otoscopy
Management for OME
- Abx not indicated
- Wait 3 months for spontaneous resolution
- Conservative: Valsalva manoeuvre to reduce obstruction (‘Pop ear’)
- If persists >3 months, refer to ENT for myringotomy (Gromet) and tympanostomy tube insertion (M&T)
Long term tube
- does not have outer flange
- unable to self-extrude
Short term tube
- able to self extrude
- as skin cells grow underneath flange of gromet and pushes gromet out
Chronic suppurative otitis media (CSOM)
- Repeated or prolonged bouts of AOM damaging the TM causing non-healing perforation
- Chronic central perforation of TM with recurrent ear discharge
- Causative organisms come from external ear
- Chronic infx of middle ear spread to mastoid system –> Infected mucosa produces copious amounts of mucopus –> Leaks through TM perforation
–> Otorrhea
Clinical features of chronic suppurative otitis media
- Otorrhea: Purulent middle ear discharge
- Chronic >6 weeks (6-12 weeks)
- Conductive hearing loss
- Painless
± Facial nerve palsy - On PE: Large TM perforation
Management of CSOM
- Aural toilet
- Topical abx (ciprofloxacin)
- Definitive: Surgical closure of perforation via myringoplasty
Pathophysio of cholesteatoma (epidermoid inclusion cyst)
- Pars flaccida (Superior 10% of TM)/attic/epitympanum region (where roof of canal meets TM) problem
- Chronic negative pressure in middle ear due to Eustachian tube dysfunction (Or patient’s habit to sniff in)
–> Inward retraction of pas flaccida (Lacks middle fibrous layer)
–> Retraction pocket behind TM in middle ear initially shallow and self- cleaning, later deepens and traps squamous keratinising epithelium, debris and cerumen
–> Pressure + skin cells are active and secrete pro-inflammatory cytokines
–> Erosion and destruction of surrounding bony structures
TLDR trapping of skin (keratin) in middle ear
Clinical features of cholesteatoma
- Foul-smelling ear discharge due to infecting organisms (Pseudomonas) and dead skin trapped in ear
- Conductive hearing loss, sensorineural hearing loss in late stage
- Recurrent/non-resolving infection
- Granulation seen at pars flaccida (suspicious for cholesteatoma)
Complications of cholesteatoma
Inside ear:
- Erosion of ossicles (Esp joint b/w incus and stapes) –> CHL
- Erosion of facial nerve canal –> Facial palsy
- Labyrinthine fistula and labyrinthitis –> Vertigo
- SNHL
- Erosion of tegmen (Roof of middle ear) –> Intracranial sepsis
Outside ear:
- Mastoiditis
- Meningitis
