Transcript The Right Patients for Tonsillectomy

Ear Tubes
The Ear
AOM vs. OME
• Acute Otitis Media
• Otitis Media with Effusion
– Pus behind TM
– Acute infection
– Multiple severe
complicaitons
– Fluid behind TM
– May result from AOM
– Less sever complications
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Mastoiditis
Meningitis
Brain abscess
Facial paralysis
– Treat with antibiotics
– Ear tubes if recurrent
• Hearing loss
• Scarring/atrophy of TM
• Tympanosclerosis
– Do not treat with antibiotics
– Ear tubes if persistent or
chronic
Types of TM Findings
Serous otitis media
Normal
TMMedia
Acute
Otitis
Mucoid Otitis Media
Acute Otitis Media
• Peak incidence AOM is between 6 and 18 months
– AOM affects 40%-50% of children by age 1
– By age 3 years majority (>80%) of children have had 1
episode of AOM
• ~ 40% of pediatric office visits in first 5 years related to
otitis media
• ~5-10% of well visits associated with diagnosis of OME
Acute Otitis Media Diagnosis
Certain diagnosis of AOM meets all 3 of the criteria:
• Presence of Purulent Middle Ear Effusion
• Rapid onset
• Signs and symptoms of middle-ear inflammation
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Otalgia
No pain with pulling of ear
TMJ pain
Difficulty sleeping due to pain
Acute Otitis Media Diagnosis
• Pulling at the Ears (not reliable):
– Zero percent of children with ear pulling as the primary sign had an ear
infection
– Ear pulling + fever: only 15% had ear infections
– Why do kids pull their ears?
• Itching
• Teething
• Is ear pulling associated with ear infection.
Baker RB. Pediatrics. 1992 Dec;90(6):1006-7
• Exploration
• Comfort
• Diagnostic accuracy and the observation option in
• Habit
acute otitis media: the Capital Region Otitis Project.
• Pain
Gurnaney H, Spor D, Johnson DG, Propp R.
Int J Pediatr Otorhinolaryngol. 2004 Oct;68(10):1315-25
Acute Otitis Media Diagnosis
Presence of Purulent Middle Ear
Effusion
• Exam- Unobstructed ear canal and good
light!
• Bulging of the tympanic membrane
• Limited or absent mobility of the
tympanic membrane
– Pneumotoscopy
– Tympanometry
• Air-fluid level behind the tympanic
membrane
• Otorrhea (purulent)
Misdiagnosis of Acute OM
• Over-reliance on history
• TM color does not predict AOME-crying makes most
tympanic membranes red
• Failure to evaluate tympanic membrane mobility (pneumatic
otoscopy)
• Poor light from otoscope (bulb & battery)
• Failure to remove cerumen
• Inappropriate sized speculum
• Lack of experience
Acute Otitis Media
• Improving diagnostic
accuracy:
– Pneumatic otoscopy
– Otomicroscopy
Acute Otitis Media Treatment
• Why do we treat AOM?
– Quality of Life
– Suppurative Complications
• Intracranial Complications:
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Meningitis
Extradural abscess
Subdural empyema
Lateral sinus thrombosis
Brain abscess
Otitic hydrocephalus
• Once treated, when do we follow-up?
• Extracranial
Complications:
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Mastoiditis
Petrositis
Facial Paralysis
Perforation of the TM
Hearing loss
• CHL
• SNHL
– Labyrinthitis
– If asymptomatic, follow-up is to ensure
resolution of fluid
– This process can take up to 3 months (74%)
Acute Mastoiditis
• May or may not be associated
with subperiosteal abscess
• Protrusion of the auricle may
be secondary to osteitis of the
mastoid cortex without
erosion/ abscess
Coalescent Mastoiditis
Tubes for Acute Otitis Media
• Recalcitrant- persistent acute
infection despite antibiotics
• Recurrent
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3/6 or 4/12 or 6/12 total duration
Parental concern
Day care
At risk populations
Time of year
• Adenoidectomy if recurrent
bacterial URI/sinusitis
• Complications
AOM vs. OME
• Acute Otitis Media
• Otitis Media with Effusion
– Pus behind TM
– Acute infection
– Multiple severe
complicaitons
– Fluid behind TM
– May result from AOM
– Less sever complications
•
•
•
•
Mastoiditis
Meningitis
Brain abscess
Facial paralysis
– Treat with antibiotics
– Ear tubes if recurrent
• Hearing loss
• Scarring/atrophy of TM
• Tympanosclerosis
– Do not treat with antibiotics
– Ear tubes if persistent or
chronic
Otitis Media with Effusion
• Tympanic membrane
characteristics
– Translucent or opaque
– Gray, white, yellow, or pink
color
– Neutral or retracted position
– Reduced mobility, responds to
negative pressure on pneumatic
otoscopy
– Effusion present
Resolution of Middle Ear Fluid
Otitis Media with Effusion Treatment
• Intervention based on severity of hearing loss, child’s
developmental status, parent preference
– Aggressive management of “at-risk” population
• Watchful waiting for at least 3 months in “non at-risk”
population
– “Paradise Tube Article” studies only healthy, non at-risk
children
– Nasal steroids may help
– Nasal decongestants/antihistamines of no proven use
– Antimicrobials/steroids not indicated
Paradise JL., et al: Tympanostomy Tubes and Developmental Outcomes at 9 to 11 Years of Age
N Engl J Med. 363 (3):248-261, 2007.
Otitis Media with Effusion Treatment
• Audiogram if fluid > 3 months
– If normal hearing periodic re-evaluation until clear; more
aggressive intervention if hearing loss, behavior problems
or TM changes
• Surgery- Tubes with or without adenoids
– Tubes initially only
• Adenoidectomy if nasal obstruction or infection problems or if past
hx of tubes
– Repeat surgery--adenoidectomy +/-tubes
AOM vs. OME
• Acute Otitis Media
• Otitis Media with Effusion
– Pus behind TM
– Acute infection
– Multiple severe
complicaitons
– Fluid behind TM
– May result from AOM
– Less sever complications
•
•
•
•
Mastoiditis
Meningitis
Brain abscess
Facial paralysis
– Treat with antibiotics
– Ear tubes if recurrent
• Hearing loss
• Scarring/atrophy of TM
• Tympanosclerosis
– Do not treat with antibiotics
– Ear tubes if persistent or
chronic
Ear Tube Placement
• Radial incision
• Anterior/inferior quadrant
Post-Operative Care
• Ear drops for 2-7 days
– If fluid present
– Floxin, Ciprodex, Saline
– Never “Cortisporin” or gentamicin
• See at 2-4 weeks
– Audiometry
– Clean tube is occluded
– Replace tube if unsuccessful
• See every 6-12 months until extrusion/healing
Complications
• Early Complications
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Tube occlusion
Extrusion
Otorrhea
Impaction into middle
ear
– Hearing loss
• Delayed Complications
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Otorrhea
Perforation
Retention
Myringosclerosis
TM atrophy
Hearing loss
Tympanosclerosis
Cholesteatoma
Questions?
Thank You!