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Paeds Respiratory / ENT > Middle ear infection / glue ear > Flashcards

Middle ear infection / glue ear Flashcards

1
Q

What is acute otitis media?

Which common organisms cause acute otitis media?

A

Acute otitis media = middle ear inflammation

Extremely common in young children - 50% of children have >3 episodes by age of 3.

Common organisms:
=> Pneumococcus
=> Haemophillus 
=> Moraxella
=> Other staph and streps
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2
Q

What is the pathophysiology of acute otitis media?

A
  1. Viral upper respiratory tract infections (URTI) usually precedes otitis media but most ear infections are secondary to bacteria esp. Strep. pneumo, Haemophilus influenzas and Moraxella catarrhalis

=> viral URTI disturb normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the eustachian tube

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3
Q

Description of middle ear discharge:

  1. Mucous discharge always due to middle ear disease
  2. Serosanguinous discharge suggests granular mucosa of chronic otitis media.
  3. Offensive discharge suggests cholesteatoma
A

INFO CARD

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4
Q

How does acute otitis media present?

A

Acute otitis media = middle ear inflammation

Presents with acute onset of symptoms:

  1. Rapid onset of pain (otalgia) / ear tugging in young children
  2. Fever (50%) ± irritability
  3. Hearing loss
  4. Coryza post recent viral URTI
  5. Vomiting (often post viral URTI)
  6. Ear discharge if tympanic membrane perforated => eases pain
    * bulging of tympanic membrane causes pain; perforation of membrane relieves pain
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5
Q

What are the otoscope findings for acute otitis media?

A
  1. Bulging tympanic membrane => loss of light reflex + causes pain
  2. Opacification / erythema of tympanic membrane
  3. Perforation with purulent otorrhoea
  4. Decreased mobility if using a pneumatic otoscope
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6
Q

How is acute otitis media diagnosed?

A
  1. Acute onset of symptoms = otalgia / ear tugging
  2. Presence of middle ear effusion
    => bulging of tympanic membrane
    => otorrhoea
    => decreased mobility on pneumatic otoscopy
  3. Inflammation of tympanic membrane i.e. erythema
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7
Q

How is acute otitis media managed?

A

Acute otitis media usually self-limiting therefore doesn’t require antibiotic prescription (except in exceptions).

=> Analgesia to relieve otalgia

=> Parents advised to seek medicine help if symptoms worsen / do not improve after 3 days.

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8
Q

What are the exceptions under which antibiotics are prescribed in acute otitis media?

A
  1. Symptoms lasting >4d or not improving
  2. Systematically unwell but not requiring admission
  3. Immunocompromised or high risk of complications secondary to significant heart, lung, kidney, liver or neuromuscular disease
  4. Younger than 2 years with bilateral otitis media
  5. Otitis media with perforation and/or discharge in the canal

*5-7 days course of amoxicillin 40mg/kg/day TDS = first line.
=> if penicillin allergy, give erythromycin or clarithromycin

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9
Q

What are the sequelae of acute otitis media?

A
  1. Perforation of tympanic membrane => otorrhoea

=> unresolved with acute otitis media with perforation may develop into chronic suppurative otitis media (CSOM)

  • Chronic suppurative otitis media is defined as perforation of the tympanic membrane with otorrhoea for >6weeks
    2. Hearing loss
    3. Labyrinthitis
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10
Q

What are the complications of acute otitis media?

A
  1. Mastoiditis
  2. Meningitis
  3. Brain abscess
  4. Facial nerve paralysis
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11
Q

What is otitis media with effusion (glue ear)?

A

Effusion is present even after symptoms of acute otitis media have resolved.

50% of 3 year olds have >1 ear effusion/year.

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12
Q

How does otitis media with effusion (glue ear) present?

A
  1. 80% of the time parents notice hearing impairment in child
  2. Primary cause of hearing loss in young children
  3. No pain so difficult to pick up sometimes
  4. Poor listening, speech and hearing
  5. Language delay
  6. Inattention / poor behaviour / poor progress at school
  7. Ear infections / URTIs
  8. Balance problems
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13
Q

Who does otitis media with effusion (glue ear) most commonly affect?

A

Boys > girls

Down’s syndrome

Cleft palate

Winter season

Atopy

Children of smokers

Primary ciliary diskinesia

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14
Q

What is the pathophysiology otitis media with effusion (glue ear)?

A

Dysfunction of eustation tubes

Association with URTI, oversized adenoids, narrow nasopharyngeal dimensions, presence of bacterial biofilms on the adenoids

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15
Q

On examination:

  1. Retracted or bulging tympanic membrane
  2. Tympanic membrane dull, grey or yellow
  3. Bubbles or fluid level
  4. Superficial radial vessels
  5. Reduced drum mobility when tested with pneumatic attachment
A

Tests / investigations:

  1. Formal hearing assessment appropriate for child’s developmental stage
  2. Audiograms - look for conductive defects
  3. Tympanometry - look for flat tympanogram => helps distinguish otitis media withe effusion from other causes i.e. otosclerosis
  4. Consider co-existing causes of hearing loss
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16
Q

How is otitis media with effusion (glue ear) treated?

A

Usually mild, transient and resolves spontaneously (50% of children with bilateral hearing loss of 20dB resolves within 3 months)

=> Active observation for 3 months if bilateral otitis media with effusion (OME) confirmed. Give strategies to minimise hearing loss i.e. reduce background noise. Reassess with repeat hearing test at 3 months

=> Autoinflation of eustachian tube may help

=> Surgery if persistent bilateral OME + hearing level in better ear of 25-30 dB or worse confirmed over 3 months => consider insertion of grommet or other tympanostomy tube.

*grommet complications = infections => treat with aural clearing, topical antibiotics / steroid ear drops may be needed.

17
Q

Grommets:

  1. It’s okay to swim with grommets but avoid diving / high pressure water into middle ear. Consider ear plug
  2. Grommets extrude after 3-12 months; recheck hearing. 25% need reinsertion of grommets.
    * Grommets help to ventilate middle ear.
A

INFO CARD

18
Q

What is chronic otitis media?

A

Chronic otitis media defined as tympanic membrane perforation due to recurrent or chronic infections.

19
Q

What are the symptoms of chronic otitis media?

A

Hearing loss

Otorrheoa

Fullness

Otalgia

20
Q
  1. Benign (or inactive) chronic : dry tympanic membrane perforation without active infection
  2. Chronic serous otitis media : continuous serous drainage (typically straw coloured)
  3. Chronic suppurative otitis media : persistent purulent drainage through a perforated tympanic membrane
A

INFO CARD

21
Q

What is the treatment for chronic otitis media?

A
  1. Topical/systemic antibiotics (based on swab results)
  2. Aural cleaning
  3. Water precautions
  4. Careful follow up
  5. Surgery i.e. myringoplasty / mastoidectomy
22
Q

What is the complication of chronic otitis media?

A

Cholesteatoma:

Prolonged low middle ear pressure => development of retraction pocket of the pars tense or flacida. As this enlarges, squamous epithelium builds up and can’t escape => cholesteatoma formation.

23
Q

How does cholesteatoma present?

A
  1. Foul discharge ± deafness
  2. Headache
  3. Pain
  4. Facial paralysis
  5. Vertigo (indicate CNS complication)

Common in 5-15 year olds.

24
Q

What are the complications of cholesteatoma?

A
  1. Meningitis
  2. Cerebral abscess
  3. Hearing loss
  4. Mastoiditis
  5. Facial nerve dysfunction
    * cholesteatoma is locally destructive around and beyond pars flaccida due to release of lytic enzymes
25
Q

What is mastoiditis?

A

Middle ear infection => destroys our cells in mastoid bone ± abscess formation

=> antibiotics for otitis media can prevent mastoiditis

Signs:
=> fever
=> tenderness
=> swelling
=> redness behind pinna (mastoid)
=> protruding auricle

Imaging: CT

Treatment: Admit for IV antibiotics, myringotomy ± definitive mastoidectomy

26
Q

Surgery for chronic suppurative otitis media:

=> surgery considered if aural antibiotics and aural cleaning fails and persistent perforation / discharge continues, conductive hearing loss, chronic mastoiditis, or cholesteatoma formation

A
  1. Myringoplasty:
    => repair of tympanic membrane alone - perforation patched using a graft (temporals fascia or tragal perichondrium) => acts as a scaffold for tympanic membrane to grow over. 90% success rate
  2. Mastoidectomy:
    => For patients with mastoiditis or advanced cholesteatoma, mastoid surgery or tympanoplasty eradicates source of chronic infection, excise cholesteatoma and reconstruct hearing mechanism
27
Q

What are the risk factors for otitis media?

A
  1. URTI (autumn/ winter)
  2. Bottle-feeding
  3. Passive smoking
  4. Dummy / pacifier
  5. Presence of adenoids
  6. Asthma
  7. Malformations e.g. cleft palate

Paeds Respiratory / ENT (15 decks)

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