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Peadiatrics - Master Medicine > OTITIS MEDIA > Flashcards

OTITIS MEDIA Flashcards

1
Q

What do we call ear pain?

A

Otalgia

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2
Q

What is otitis media?

A

Inflammation of the middle ear

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3
Q

What are the three types of otitis media?

A

Acute suppurative otitis media (ASOM)

Otitis media with effusion (OME) - Glue ear

Chronic suppurative otitis media (CSOM)

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4
Q

What is the difference between acute suppurative otitis media (ASOM) and otitis media with effusion (OME)?

A

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.

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5
Q

What are the three ways that microorganisms may colonise the middle ear?

A

Via the Eustachian tube

Via a perforation in the tympanic membrane

Via haematogenous spread (very rare)

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6
Q

What are the bacteria commonly responsible for acute suppurative otitis media?

A

Streptococcus pneumoniae

Haemophilus influenzea

Moraxella catarrhalis

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7
Q

Which group of patients are most commonly affected by acute suppurative otitis media?

A

Children

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8
Q

What are the typical clinical features of acute suppurative otitis media?

A

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

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9
Q

What is the natural course of uncomplicated acute suppurative otitis media?

A

Untreated ASOM usually leads to ischaemia of part of the tympanic membrane and a perforation results, leading to discharge and eventual resolution of symptoms.

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10
Q

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?

A

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

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11
Q

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?

A

Amoxicillin for 5 days

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12
Q

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?

A

Erythromycin or clarithromycin

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13
Q

What are the complications of acute suppurative otitis media?

A

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

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14
Q

What proportion of children will have had a bout of otitis media with effusion by their 4th birthday?

A

80%

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15
Q

Why are children so susceptible to otitis media with effusion?

A

Because of the angle and length of their Eustachian tubes.

Also the adenoids make them more susceptible to effusion.

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16
Q

In which children are recurrent bouts of otitis media with effusion more common?

A

Those with Eustachian tube dysfunction:

Cleft palate

Larger adenoids

Recurring tonsillitis

Atopy

17
Q

What are the clinical features of otitis media with effusion?

A

Main symptom is conductive hearing loss

Mild discomfort

Blocked nasal airway

Middle ear effusion

Dull grey tympanic membrane

Retracted ear drum

18
Q

How would you investigate someone with the signs and symptoms of otitis media with effusion and what results would you expect?

A

Normally no investigations necessary

A pure tone audiogram would reveal a conductive hearing loss.

A tympanogram will show a flattened trace.

19
Q

How would you initially manage a patient with otitis media with effusion?

A

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.

20
Q

The normal management of otitis media with effusion is watchful waiting. Which patients would you refer for an ENT opinion?

A

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

21
Q

What are the surgical options that an ENT specialist may advise for a child with otitis media with effusion?

A

Insertion of grommets (ventilation tubes)

Adenoidectomy

22
Q

How long do patients have to be admitted for to have grommets inserted?

A

They don’t, normally a day case.

23
Q

How do patients who have had grommets put in get rid of them after the effusion has drained?

A

They fall out naturally as part of the desquamative processes of the ear drum, within 6-12 months

24
Q

What should parents of children with grommets be advised?

A

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

25
Q

What are the possible complications of grommet insertion?

A

Otorrhoea - ear discharge

Infection

Tympanosclerosis

Perforation of tympanic membrane

Cholesteatoma

Bleeding

26
Q

What are the two types of chronic suppurative otitis media?

A

With or without cholesteatoma (also called unsafe or safe respectively)

27
Q

What are the main features of chronic suppurative otitis media without cholesteatoma?

A

Perforation of pars tensa

Intermittent non offensive discharge

28
Q

What are the main features of chronic suppurative otitis media with cholesteatoma?

A

Perforation of pars flaccida

Impaired hearing

Foul smelling discharge

29
Q

How would you manage someone with chronic suppurative otitis media?

A

Refer to ENT specialist

Advise keeping ear dry

30
Q

What is cholesteatoma?

A

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.

31
Q

What is the most common presentation of someone with a cholesteatoma?

A

Prolonged foul smelling ear discharge, on the back of several bouts of suppurative ear disease. Often accompanied by otalgia.

32
Q

Where should you look carefully in someone with a suspected cholesteatoma?

A

Attic region of the tympanic membrane.

33
Q

What investigations should you do for someone who has a suspected cholesteatoma?

A

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

34
Q

What are the possible complications of cholesteatoma if left untreated?

A

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)

35
Q

How do you manage someone with cholesteatoma?

A

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.

Peadiatrics - Master Medicine (4 decks)

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