Otitis Media Dr John Curotta Head of ENT Surgery The Children’s Hospital at Westmead

Otitis Media

Dr John Curotta

Head of ENT Surgery

The Children’s Hospital at Westmead

What is Otitis Media?• AOM = Acute OM

• OME = OM with Effusion (= ‘glue ear’)

• CSOM = Chronic Suppurative Otitis

Media ( = a hole in the ear drum

which discharges)

Ear drum without a hole

2 types of fluid in middle ear:

• 1. Pus -> Acute OM = AOM

• 2. Mucous -> Effusion = OME

Ear drum with hole ( >6 weeks)

1. Simple hole: connects outer ear to mucous making lining of middle ear

(“like a nostril”) usually dry, but sometimes runny. = “SAFE’ ear

2. Hole with skin of ear drum growing in

= “UNSAFE” ear

“UNSAFE” ear Also called:

• CHOLESTEATOMA

• Chol est e at oma

• ‘Kol-est-ee-at-oma ‘

• Means skin growing into ear, not out

What is ‘UNSAFE’ about skin growing in ?

• Skin is not normally in the ear and mastoid • Lowest layer of skin makes an enzyme which

eats away the bone• This erodes Bones of hearing Bone covering inner ear Bone between ear and brain

Deaf – Dizzy – Brain Abscess

What makes you suspect an UNSAFE ear ?

• Persistent discharge

• The SMELL……Sneakers taken off after a week in the wet.

• That is ..soggy dirty mouldy skin…

Cholesteatoma• ALWAYS needs surgery

• Surgery: delicate / long / often repeated

(very little pain and discomfort) !

‘Remote’ KidsUsually get early on :

• ‘Safe’ Hole in ear drum ------

• Often Runny ears

Northern Territory OM Survey 2007

1300 children, 6 mo – 30 months old

• 25% AOM

• 5% AOM + perforation

• 15% CSOM

• 10% had completely normal ears.

NT OM Survey 2007

By 6 months age 98% OME

By 12 months age

• 90 % AOM

• 35% AOM + Perforation

• 20% CSOM

‘Town’ and ‘city’ Kids• Usually get what any other town/city

kids get…….Glue ear.

• BUT because it is a hidden condition -

…….may NOT get diagnosed !

Job of Nurses for Ears 1. Runny ears: DRY the runny ears Maximise hearing Optimise learning

2. Glue ears: DIAGNOSE Maximise hearing Optimise learning

RISK factors for Otitis Media

• Boys

• Brother/sister with OM

• Early start to AOM (<6mo)

• Not breast fed

• Poor housing

• Smoker at home

PREVENTION

Vaccination against Strep pneumoniae

(pneumococcus)• PREVENAR works under 2 yrs age

• PNEUMOVAX works after 2 yrs age

• ( Hib – ‘Haemophilus influenzae Type b’ vaccine is NO good for ears as they get ‘H influenzae Non-typeable )’

Pneumococcal Vaccination“PREVENAR”

• 239,000 operations for grommets in Australia in past 10 years

• Since Prevenar introduction in 2005 grommets reduced by: <1 yr…23% 1-2 yrs..16% 2-3 yrs.. 6%

Study effect early Pn Vaccination

‘Remote’ NT Kids - 2009• Minimal benefit in reduction Otitis Media

(unlike town/city kids)

Probably need• Pneumococcal vaccine with wider spread• Vaccine for Haemophilus infections of ears• Vaccinate mothers

Diagnose ‘GLUE Ear’

• SCREEN

vs

• SUSPECT

Aim of NSW Otitis Media Strategy

• is to screen all kids

• Eliminates guesswork

• But: Do they all get screened?

Hearing Testing

Tiny Tots

• SWISH for all newborns• NSW 99% cover ….Who is most likely to miss out ?Usual Tymps: unreliable under 6 months

Hearing Testing

Baby – to - 4 yrs old

VROA / Behavioural…test overall /

better ear hearing

Usual Tymps: ‘Reliable’

Hearing Testing

• Over 4 yrs

• PTA + Tymps generally reliable

AOM = pus in middle ear

• Body’s immune +/- antibiotics kill bacteria BUT the mucous can take weeks to clear out

POM = Fluid in ear since infection

• POM : “Persisting” Otitis Media

i.e. after AOM, up to 12 weeks

Once fluid is there > 12 weeks,

Then call it : OME or ‘Glue ear’

Fluid in middle ear

AOM POM OME

0 weeks >12 weeks

Benefit of Hearing Testing

• Learning to talk

vs

• Learning in classroom

Hearing under 4-5 years

• One ear is enough to learn to talk and to get along at home

• So ‘general’ tests of hearing are OK

Hearing, over 4-5 yrs

• Unilateral OR Bilateral HL : very important to diagnose

• Poor hearing even in ONE ear is a major problem in classroom

Hearing over 5 yrs• This means at school

• Absolutely need both ears hearing

Unilateral hearing Loss• Very serious problem in class room

• Placement

• Background noise

• Direction

• Anything other than one-to-one talking

Grommets - time working

• Small: Shepard………………6 mo

• Medium: Reuter Bobbin………12 mo

• Large: Sheehy Collar Button.18 mo

• Larger: T – Tubes……………24 mo +

The bigger the grommet

• The longer it stays

• The bigger the risk of a larger perforation

• So, NO T-tubes in children

Grommets• The GOOD

• The BAD

• The UGLY

Grommets- The GOOD• Instant relief

• Consistent relief

• Helps balance too

• Reduces AOMs as well

Grommets-The BAD• Need admission to hospital

• Waiting list

• General anaesthetic

• How long effective

• Repeat grommets

Grommets-The UGLY• Limit water exposure - e.g. swimming

• Discharging grommet a problem

Social / hearing / extrude grommet

• Residual perforations, esp if large large > 20% area TM (large is bad)

in between…….(nuisance)

small < 10% area TM (small is good ! )

If not grommets – What ?

• Seating position……….counting chooks

• FM System

• Hearing Aid/s

• Room amplification

Looking after grommets

• Its not the water

• It’s the GERMS in the water

Looking after grommets

• Clean water…OK shower, beach, well-maintained pool (Chlorine : High end +

pH : Low end of range)Some Remote WA - No School…No Pool

Looking after grommets

AVOID• Bath water• Spa’s• Indoor heated pools• Creeks OR USE• Ear plugs and cap / head band

Infected grommets• Foreign material in the body - if infected

gets covered in “slime”

• Called “BIOFILM”

• Like the inside of water pipes etc

• Also plaque on teeth / infected catheters/ IV cannulas etc

BIOFILM• Bacteria exude a jelly to cover

themselves

• So, antibiotics cannot reach them

• To clean biofilm – must mechanically break it up – brush it / scrub it

If not possible – remove the device.

Discharge through Grommets ..How?

• Head cold Virus: Increase secretion in nose / sinuses / ears

• Secondary bacterial infection (like AOM)

• Overflow through grommet

Discharge through Grommets ..How?

• If virus…dries up when nose dries up

• If bacterial.. May / may not dry up with nose….

Antibiotic medicine or capsules (eg Amoxil) helps

Discharge through Grommets ..How?

• Bacteria which live on skin in outer ear can get into middle ear through the mucous discharge…..(pseudomonas) ..these are resistant to most oral antibiotics … Need DROPS

Ear Drops for Grommets

• Ciprofloxacin (= Ciloxan / Ciproxin HC) is always safe in ears

• Sofradex usually safe in infected ears

• Sofradex is unsafe in clean ears

Ear Drops for wax• 1. Sodium Bicarbonate Ear drops

( chemist makes them up) • 2. Waxsol drops• 3. Ear Clear Drops for Wax Removal

Then syringe. Never Cerumol - too harsh

Discharge through grommets

• If so much discharge ear drops cannot get in

• Use 3% Hydrogen Peroxide as drops first, to clean the ear, dab dry and then put in drops. (only for a day or so at a time)

(probably is breaking up Biofilm)

Wax or discharge in Ears

Gently syringe with dilute baby shampoo 1/2 teaspoonful in 1 cup warm water (= 1%) (or 1 tsp in 500ml)

• Finish by syringing Betadine (1 tsp in 100ml)

10 ml syringe with a cut-off scalp vein needle

Safe in perforations or grommets

References• Aboriginal Ear Health Manual – Harvey

Coates et al from WA

• Aboriginal Otitis Media ENT Program Evaluation Report 2002“

• Surgical Management of Otitis Media with Effusion in children” – Clinical Guideline, February 2008 - UK