Infections of the middle ear

M.Rogha M.D.Isfahan university of medical sciences

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Acute Otitis Media (AOM) “acute onset of symptoms, evidence of a middle

ear effusion, and signs or symptoms of middle ear inflammation.”

Otitis Media with effusion (OME) “Presence of MEE without signs or symptoms of

infection, previously named: secretory, serous, or glue ear. ”

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Difficult to treat AOM (20%)

Recurrent AOM: three or more episodes in the previous six months or four or more in the preceding twelve months.

Treatment failure AOM: a lack of improvement in sign and symptoms within 48-72 hours of AB treatment .

31 million visits to physicians annually in U.S. Most common diagnosis for an AB

prescription in children. Diagnosed > 5 million times a year. 3-5 billion $/year in U.S. 50,000 deaths / year worldwide.

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● Age <2 years● Bottle propping● Chronic sinusitis● Ciliary dysfunction● Cleft palate and craniofacial anomalies● Child care attendance● Down syndrome and other genetic conditions● First episode of AOM when younger than 6 months of age● Immunocompromising conditions

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Specific Otalgia Otorrhea Dizziness Hearing loss

Non-specific Fever (50%) Vomiting/diarrhea Anorexia Irritability

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Otoscopic findings Bulging TM Yellow, white, or bright red color Opacification of eardrum Impaired visibility of ossicular landmarks

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Bacterial Streptococcus

pneumoniae Haemophilus

influenzae Moraxella

catarrhalis

Viral RSV Influenzae A & B Parainfluenzae 1,2, &

3 Rhinovirus Adenovirus Enterovirus Coronavirus

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Mastoid abscess

Facial nerve palsy

Labyrinthitis

Extra/sub dural abscess

Meningitis

Brain abscess

Lateral sinus thrombophlebitis

Petrositis

Heptavalent pneumococcal conjugate vaccine Reduction of otitis office visits Reduction of antibiotic prescriptions

Influenza vaccine Goal: decrease number of URI

Breast feeding Prophylaxis

3 episodes in 6 months or 4 episodes in 1 yr <6 months with >1 episode Cause of resistance in the community

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80% will resolve within 3 days without treatment, 95% in 5 days

Antibiotics may improve short term symptoms, although evidence for any gain in medium to long term outcome is lacking

Countries with lower rates of antibiotic prescribing for acute otitis media do not have an increase in the number of complications

Culture & sensitivity Simple analgesia

Paracetamol Ibuprofen(some evidence superior)

Antihistamine & decongestant?? Aural toilet Myringotomy

Bulging drum Facial palsy Incomplete resolution

No antibiotic if no fever; analgesic and reassurance Amoxycillin 30-40mg/kg/d 3DDx10d Amoxycillin clavulanate Cefuroxime 30mg/kg/d 2DDx10d Clarithromycin 15mg/kg/d 2DDx10d Azithromycin 10mg/kg OD x 5d,5mg/kg ODx5d Cotrimoxazole 10mg/kg/d 2DDx10d (Trimetho)

Eliminate cause

Long term low dose antibiotics

Amoxycillin/cotrimoxazole

Myringotomy + grommet

Adenoidectomy

Treat allergy

Pneumococcal vaccine

Persistence/reappearance of pain Persistence/reappearance of discharge Persistent fever Symptoms & signs of complications:

Vertigo/Nystagmus/Ataxia Facial palsy/diplopia Headache, vomiting, drowsiness Abscess behind ear/in neck

Infants & young children

Follows measles, influenza, pneumonia

-haemolytic streptococci

Otorrhoea without pain

Foul smelling discharge

Sensorineural deafness

Large perforation

Chronic infection of the middle ear with a non-healing perforation of the tympanic membrane

Otorrhea (ear drainage) for 6-12 weeks Middle ear mucosa becomes edematous,

polypoid, or ulcerated The tympanic cavity usually contains

granulation tissue Most common infecting organisms are

Pseudomonas aeruginosa, Staphylococcus aureus, Proteus species, Klebsiella pneumoniae, and diphteroids

Annual incidence approximately 40 cases/100,000 population

Patients present with hearing loss and otorrhea

Pain, vertigo, fevers, facial nerve palsy, mental status changes or fetid drainage signify impending intra-temporal or intra-cranial complications

Cholesteatomas are epidermal inclusion cysts of the middle ear and/or mastoid with a squamous epithelial lining

Contain keratin and desquamated epithelium Term “cholesteatoma” coined by Johannes

Muller in 1838 Misnomer because the cysts don’t contain

cholesterol Can be congenital or acquired Natural history is progressive growth with

erosion of surrounding bone due to pressure effects and osteoclast activation

Epidermal inclusion cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice

Michaels found epidermoid formation in 37 of 68 temporal bones of fetuses at 10 to 33 weeks' gestation. (Michaels L: An epidermoid formation in the developing middle ear; possible source of cholesteatoma, Otolaryngol 15:169, 1986)

Diagnosed as a pearly white mass behind an intact tympanic membrane in a child who does not have a history of chronic ear disease

Pathogenesis

Invagination Basal cell

hyperplasia Migration (through a

perforation) Squamous

metaplasia

Retraction pocket cholesteatoma usually within the pars flaccida or posterior superior tympanic membrane (invagination Theory)

Secondary to ETD Keratin debris collects within a retraction

pocket

Normal TM Mucoid effusion and primaryacquired cholesteatoma

Mesotympanic cholesteatoma

Migration Theory – most accepted Originates from a tympanic membrane perforation As the edges of the TM try to heal, the squamous

epithelium migrates into the middle ear

History, physical examination, high resolution CT scan of the temporal bone

Axial Section Coronal Section

Ototopical antibiotics Surgical repair of the TM perforation Repair of the ossicular chain if

necessary

Antibiotic only otic drops

Floxin (ofloxacin) Antibiotic with steroid otic drops

Ciprodex (ciprofloxin and dexamethasone) Cipro HC (ciprofloxin and hydrocortisone)

Cortisporin (neomycin, polymyxin, and hydrocortisone)

Ophthalmic antibiotic preparations Tobradex (tobramycin and dexamethasone)

The concentration of antibiotic in ototopical drops is 100-1000x greater than what can be achieved systemically.

Paper patch myringoplasty Fat myringoplasty Underlay tympanoplasty (medial graft technique)

Ototopical antibiotics Surgical repair of the TM perforation Repair of the ossicular chain if

necessary Often requires mastoidectomy

Intact (bony ear) canal wall mastoidectomy

Canal wall down mastoidectomy Radical Mastoidectomy Modified Radical Mastoidectomy

Tympanoplasty with mastoidectomy and hydroxyapatite

bone cement ossicular reconstruction

Acute mastoiditis Sub-periosteal

abscess Cholesteatoma Labyrinthitis Facial paralysis Meningitis Epidural/subdural

abscess Brain abscess Sigmoid sinus

thrombosis Otitic

Hydrocephalus

Due to antibiotics, the incidence of complications has greatly declined.

Complications are usually associated with some degree of bone destruction, granulation tissue formation, or the presence of a cholesteatoma.

Complications arise most commonly by infection spreading by direct extension from the middle ear or mastoid cavity to adjacent structures.

Patients appear more ill than expected fever, new onset vertigo, sensorineural hearing

loss, fetid drainage, facial nerve weakness, proptotic ear

lethargy and mental status changes CT and MRI are indicated

CT is superior for evaluating the bony details of the middle ear and mastoid space

MRI is more sensitive for diagnosing suspected intracranial complications.

Broad spectrum antibiotics and surgery are required