Otology - Middle ear problems 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 - often follow an URTI. Children have a shorter eustachian tube.
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) - purulent and blood stained if perforation 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 Consider delayed abs if <3 months old, <2 years and bilateral
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?
Extracranial: Mastoiditis - persistent infection or abscess Facial nerve palsy - in 4% of the population the facial nerve is not in a bony casing but rather open in the middle ear. Labrynthitis Intracranial: Meningitis (via labrynth), Brain abscess, subdural or extradural collections, Infection thrombosis of lateral sinus Systemic: Bacteraemia Septic arthritis IE Other: Otitis media with effusion (glue ear) Sensorineural hearing loss - toxic effects on the cochlear Dizziness - infection may involve labyrinth Neck abscess - Bezold’s abscess tracks down sternocleidomastoid muscle
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. Occurs when effusion is present after regression of acute OM symptoms.
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
Risk factors otits media with efusion
PARENTAL SMOKING
Boys
Older siblings
Down’s syndrome
Cleft palate
Atopy
Bottle feeding
What are the clinical features of otitis media with effusion?
Main symptom is conductive hearing loss Mild discomfort - may describe as itching 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
Whats important to investigate in adults with otitis media?
Post nasal space should be visualised to exclude a tumour obstructing the eustachian tube oriface (esp if unilateral)
What are the surgical options that an ENT specialist may advise for a child with otitis media with effusion?
Insertion of grommets (ventilation tubes which balance the pressure between middle ear and outside) + myringiotomy
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).
Occurs when eardrum has bursen and then failed to heal due to continued inflammation.
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 - likely steroid eardrops and aural toilet.
May do a myringoplasty (fix ear drum) / cortical mastoidectomy
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. Due to the prolonged low middle ear pressure which can allow development of a retraction pocket in pars tensa - when it enlarges can see the growth of squamous epithelium resulting in chilesteatoma.
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. Recurrent ear infections.
Where should you look carefully in someone with a suspected cholesteatoma?
Attic region of the tympanic membrane. - intracranial complications of meningits and cerebral abscess
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.
Risk of recurrence so requires careful followup
Whats tympanosclerosis?
Scarring on the eardrum (also looks white like cholesteatoma). Caused by grommet, otitis media, glue ear.
Management of tympanosclerosis
Tympanoplasty
What is mastoiditis
Supportive infection extends from middle ear to mastoid air cells (beware of intracranial spread). Is why abx is given if fever >48 hours.
Presentation mastoiditis
Inspection/palpatation reveals tender mastoid (+erythema) + swelling
Fever
Forward displacement of ear
Red/bulging tympanic membrane
Management mastoiditis
AV abx
Surgical - mastoidectomy
