Middle Ear Disease

Question 1

Symptoms and signs of Acute otitis media

Answer 1

-TM red, opacification, bulging (loss of light reflex), decreased mobility on pneumatic otoscopy
-Painful (otalgia): tug/rub ear
-Temperature/ fever (50%)
-Hearing loss (conductive)
-Coryza
-Otorrhea if perforation

-Children most common, URTI/ strep pneumonia, haem influ, catarrhalis
=viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the Eustachian tube

-Lasts about 3 days but can last up to 1 week
-Acute otitis media is extremely common in young children, with around half of children having three or more episodes by the age of 3 years.

Question 2

Treatment of AOM

Answer 2

-Pain relief, antipyretics (paracetamol/ ibuprofen)
-Delayed antibiotics 48-72 hrs
=If child or young person systemically very unwell/ more serious illness or condition like immunocompromised/ lasting more than 4 days and not improving/ high risk of complications, then offer immediate antibiotic and refer to hospital if severe systemic infection or mastoiditis
=Consider antibiotics for otorrhoea (discharge after perforation)/ under 2 years with infection in both ears

-Antibiotics= amoxicillin 5-7 days/ clarithromycin or erythromycin. Co-amoxiclav if worsening on 1st choice for at least 2 to 3 days.

Question 3

Complications of AOM

Answer 3

-Perforation (traumatic= pain at time and visible hole)
=unresolved with acute otitis media with perforation may develop into chronic suppurative otitis media (CSOM)
=CSOM is defined as perforation of the tympanic membrane with otorrhoea for > 6 weeks
-Hearing loss
-Vertigo: labyrinthitis
-Intra-cranial infection
-CN V11 palsy
-Acute mastoiditis, meningitis

Question 4

Treatment of AOM perforation

Answer 4

-Relief of pain and discharge
=Purulent otorrhoea

-Topical drops if ongoing discharge and waterproofing
-Normally heals few weeks 6-8
=it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. NICE support this approach in the 2008 Respiratory tract infection guidelines
=myringoplasty may be performed if the tympanic membrane does not heal by itself

Question 5

Describe Otitis media with effusion

Answer 5

-Children= glue ear
-Unilateral in adult= nasopharyngeal carcinoma/ mass needs excluding (nasoendosocpy)
=It is common with the majority of children having at least one episode during childhood, peak at 2 y/o

-Hearing loss- not pain (mild intermittent ear pain with fullness or popping, conductive)
=secondary problems such as speech and language delay, behavioural or balance problems may also be seen
-Aural discharge
-Recurrent ear infections, URTI, frequent nasal obstruction

-Tympanometry
-Audiometry

-Persistent (>3/12 of active observation) and bilateral with hearing loss= ventilation tubes (grommets simulate eustachian tube) or hearing aids. Autoinflation/ Valsalva manoeuvre
-Adenoidectomy

Question 6

Risk factors for OME

Answer 6

-Male sex
-Siblings with glue ear
-Higher incidence in Winter and Spring
-Bottle feeding
-Day care attendance
-Parental smoking

Question 7

Describe inactive chronic (mucosal) otitis media

Answer 7

-Perforation in TM
-Longstanding
-Not healing
-May be mild hearing loss
-Mucosal as no skin debris (squamous)

-No action mandatory
-Waterproofing

Question 8

Describe active chronic (mucosal) otitis media

Answer 8

-Perforation with discharge
-Persistent or intermittent
-Pain, hearing loss, balance disturbance
-Hearing aids/ water

-Waterproofing
-Topical drops
-Surgery

Question 9

Describe TM retraction

Answer 9

-Negative pressure in middle ear
-Weak TM medialised
-Progression unpredictable
-Erosion of structures

-Keratin debris migration disrupted- accumulates
-Chronic Squamous Otitis media= cholesteatoma

Question 10

Describe chronic squamous OM/ Cholesteatoma

Answer 10

-Squamous debris retained in middle ear cleft/ mastoid= cholesteatoma (non cancerous growth of squamous epithelium trapped in skull base)
-10-20yrs
-Cleft palate

-Foul-smelling, non-resolving discharge and hearing loss
-Vertigo/ facial nerve palsy/ cerebellopontine angle syndrome
-Attic crust in uppermost part of eardrum on otoscopy (rubbish collected in middle ear), pure tone audiogram (conductive hearing loss)
-Surgery, referral ENT

Question 11

Complications/red flag symptoms of chronic squamous OM

Answer 11

-Hearing
-Taste
-Tinnitus
-Vertigo
-Facial nerve palsy/ paralysis
-Intracranial infection
-Labyrinthitis
-Swelling/tenderness behind the ear
-Nystagmus
-Fever
-Headache

Question 12

Symptoms and signs of glomus/ neuroendocrine tumours

Answer 12

-Pulsatile tinnitus
-Conductive hearing loss
-Facial weakness

-Surgery +/- radiotherapy

Question 13

Types of neuroendocrine tumours

Answer 13

-Tympanicum
-Jugulare
-Vagale

Question 14

Criteria for chronic suppurative otitis media

Answer 14

-Ear discharge persisting for more than 2 weeks (no ear pain or fever)
-Hearing loss in affected ear
-History of acute OM, ear trauma, glue ear, allergy, URTI
-Tinnitus and/or sensation of pressure in ear

-Tympanic membrane perforation/ middle ear inflammation

Question 15

Management of chronic otitis media

Answer 15

-ENT assessment
-Antibiotics and topical steroids, intensive cleaning of affected ear
-Ear kept dry

Question 16

Assessing glue ear in children

Answer 16

-Fluctuations in hearing.
-Lack of concentration or attention, or being socially withdrawn.
-Changes in behaviour.
-Listening skills and progress at school or nursery.
-Speech or language development.
-Balance problems and clumsiness

Question 17

Otoscope findings in otitis media with effusion

Answer 17

-Abnormal colour of the drum, such as yellow, amber, or blue.
-Loss of light reflex or a more diffuse light reflex.
-Opacification of the drum (other than that due to scarring).
-Air bubbles or an air/fluid level.
-A retracted, concave, or indrawn drum or, less frequently, fullness or bulging.

Question 18

Describe otosclerosis

Answer 18

-Replacement of normal bone by vascular spongy bone= fixation of stapes at oval window
-Results in progressive conductive hearing loss/ deafness
-Autosomal dominant and typically affects young adults (20-40)

=Tinnitus
=Normal tympanic membrane/ flamingo tinge (hyperaemia) 10%
=Positive family history

-Management= hearing aid/ stapedectomy