OTITIS MEDIA Flashcards
What do we call ear pain?
Otalgia
What is otitis media?
Inflammation of the middle ear
What are the three types of otitis media?
Acute suppurative otitis media (ASOM)
Otitis media with effusion (OME) - Glue ear
Chronic suppurative otitis media (CSOM)
What is the difference between acute suppurative otitis media (ASOM) and otitis media with effusion (OME)?
Acute suppurative otitis media is an ongoing viral or bacterial infection of the middle ear.
Otitis media with effusion is often preceded by ASOM, however typically there is no ongoing infection, but rather just the fluid left behind. This will be causing hearing loss and some mild discomfort.
What are the three ways that microorganisms may colonise the middle ear?
Via the Eustachian tube
Via a perforation in the tympanic membrane
Via haematogenous spread (very rare)
What are the bacteria commonly responsible for acute suppurative otitis media?
Streptococcus pneumoniae
Haemophilus influenzea
Moraxella catarrhalis
Which group of patients are most commonly affected by acute suppurative otitis media?
Children
What are the typical clinical features of acute suppurative otitis media?
Recent upper respiratory infection
Otalgia
Conductive hearing loss (not predominant symptom unlike in OME)
Pyrexia
Very young patients may present with ear pulling and restlessness
Opaque ear drum
Middle ear effusion
Discharge (suppuration)
Bulging of ear drum
What is the natural course of uncomplicated acute suppurative otitis media?
Untreated ASOM usually leads to ischaemia of part of the tympanic membrane and a perforation results, leading to discharge and eventual resolution of symptoms.
Acute suppurative otitis media is normally a self-limiting disease and therefore NICE advises against giving antibiotics unless there are certain indications. What are the indications for prescribing antibiotics?
Those who are systemically unwell but do not require admission (eg children under 3 months with temp of 38˚)
Those who are high risk of serious complications because of significant heart, lung, kidney, liver, or neuromuscular disease; or who are immunocompromised.
Those symptoms have lasted for 4 days or more and are not improving.
Signs of a perforated tympanic membrane - either visualized or because of large amounts of green yellow discharge
Acute suppurative otitis media is normally a self-limiting disease and therefore NICE advises against giving antibiotics unless there are certain indications. If a patient meets this criteria, what antibiotic should be prescribed?
Amoxicillin for 5 days
Acute suppurative otitis media is normally a self-limiting disease and therefore NICE advises against giving antibiotics unless there are certain indications. If a patient meets this criteria but are allergic to penicillin, what antibiotic should be prescribed?
Erythromycin or clarithromycin
What are the complications of acute suppurative otitis media?
Otitis media with effusion (glue ear)
Sensorineural hearing loss - toxic effects on the cochlear
Dizziness - infection may involve labyrinth
Facial nerve palsy - in 4% of the population the facial nerve is not in a bony casing but rather open in the middle ear.
Mastoiditis - persistent infection or abscess
Neck abscess - Bezold’s abscess tracks down sternocleidomastoid muscle
Intracranial complications - meningitis, brain abscess, subdural or extradural collections, infection thrombosis of lateral sinus
What proportion of children will have had a bout of otitis media with effusion by their 4th birthday?
80%
Why are children so susceptible to otitis media with effusion?
Because of the angle and length of their Eustachian tubes.
Also the adenoids make them more susceptible to effusion.
In which children are recurrent bouts of otitis media with effusion more common?
Those with Eustachian tube dysfunction:
Cleft palate
Larger adenoids
Recurring tonsillitis
Atopy
What are the clinical features of otitis media with effusion?
Main symptom is conductive hearing loss
Mild discomfort
Blocked nasal airway
Middle ear effusion
Dull grey tympanic membrane
Retracted ear drum
How would you investigate someone with the signs and symptoms of otitis media with effusion and what results would you expect?
Normally no investigations necessary
A pure tone audiogram would reveal a conductive hearing loss.
A tympanogram will show a flattened trace.
How would you initially manage a patient with otitis media with effusion?
Active observation for several months. Self-limiting illness and 90% of children will have complete resolution within a year. You review periodically for 3 months.
The normal management of otitis media with effusion is watchful waiting. Which patients would you refer for an ENT opinion?
Children with Down syndrome
Children with cleft palate
Hearing loss that is affecting child’s developmental, social or educational status
Severe bilateral hearing loss - better ear has hearing level of 30dB or worse
Persistent foul smelling discharge suggestive of cholesteatoma
What are the surgical options that an ENT specialist may advise for a child with otitis media with effusion?
Insertion of grommets (ventilation tubes)
Adenoidectomy
How long do patients have to be admitted for to have grommets inserted?
They don’t, normally a day case.
How do patients who have had grommets put in get rid of them after the effusion has drained?
They fall out naturally as part of the desquamative processes of the ear drum, within 6-12 months
What should parents of children with grommets be advised?
Hearing will return immediately and may initially feel like everything is too loud
Normal school activities should be encouraged.
Avoid immersing child’s head in soapy water
Not a contraindication to swimming - although advise against diving to any significant depth (due to pressure)
Not a contraindication to flying
What are the possible complications of grommet insertion?
Otorrhoea - ear discharge
Infection
Tympanosclerosis
Perforation of tympanic membrane
Cholesteatoma
Bleeding
What are the two types of chronic suppurative otitis media?
With or without cholesteatoma (also called unsafe or safe respectively)
What are the main features of chronic suppurative otitis media without cholesteatoma?
Perforation of pars tensa
Intermittent non offensive discharge
What are the main features of chronic suppurative otitis media with cholesteatoma?
Perforation of pars flaccida
Impaired hearing
Foul smelling discharge
How would you manage someone with chronic suppurative otitis media?
Refer to ENT specialist
Advise keeping ear dry
What is cholesteatoma?
A disease characterised by destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process, which originate from the tympanic membrane.
What is the most common presentation of someone with a cholesteatoma?
Prolonged foul smelling ear discharge, on the back of several bouts of suppurative ear disease. Often accompanied by otalgia.
Where should you look carefully in someone with a suspected cholesteatoma?
Attic region of the tympanic membrane.
What investigations should you do for someone who has a suspected cholesteatoma?
PTA - shows a conductive hearing loss
Ear swab - will often reveal Pseudomonas
Fine cut temporal bone CT - soft tissue within the middle ear and often erosion of bone and ossicles.
MRI will reveal any intracranial complications
What are the possible complications of cholesteatoma if left untreated?
Hearing loss - both conductive (erosion of ossicles) and sensorineural (invasion of cochlear)
Dizziness - erosion of vestibular apparatus
Facial nerve paralysis - either through direct invasion or compression
Mastoiditis/petrositis - will block the usual drainage pathways
Neck abscesses
Intracranial complications - meningitis, brain abscess, subdural or extradural collections, infection thrombosis of lateral sinus. (A lot more common with cholesteatoma than with ASOM)
How do you manage someone with cholesteatoma?
Depends on how early it is found:
Conservative:
Microsuction to remove keratinous debris with topical antibiotics
Surgical:
Normally mastoidectomy under general anaesthetic and more if the erosion has spread further.
