Transcript Otitis Media and Eustachian Tube Dysfunction

Otitis Media
and Eustachian Tube Dysfunction
R. Kent Dyer, Jr., M.D.
Hough Ear Institute
Oklahoma City, Oklahoma USA
Incidence of Otitis Media (OM)

Most common disease of childhood after viral
URI

15 million cases of Acute OM/year in U.S.

Cost of treatment: >$5 billion/year
Pathology of Acute Otitis Media
Viral or Bacterial Insult
Edema
Leukocyte Infiltration
Purulent Exudate/Granulation Tissue
ET Obstruction
vs.
Resolution
Fibrosis
Pathogenesis of Otitis Media

Infection (viral vs. bacterial)

Abnormal eustachian tube function

Allergy (minor role)

Neoplasm (nasopharyngeal carcinoma)

Sinusitis
Eustachian Tube Function

Protection from
nasopharyngeal
secretions

Ventilation

Clearance of middle ear
secretions
Otitis Media Classification

Classified according to:
– Duration of disease
Acute, subacute, chronic
– Quality of effusion
Serous, mucoid, purulent
– Tympanic membrane appearance
Acute Otitis Media
Tympanic membrane:

Opaque

Bulging/injected

Reduced mobility

Purulent effusion
Otitis Media with Effusion
Tympanic membrane:

Translucent or opaque

Gray/pink

Reduced mobility

Effusion present +/- air
Chronic Mucoid OM (Glue Ear)
Tympanic membrane:

Opaque/gray

Retracted, reduced
mobility

Thick effusion, no air

Hearing loss (>20dB
HL)
Tympanosclerosis

White plaques in
Lamina Propria

Hyaline deposition

Significant conductive
hearing loss possible
Obliterative Tympanosclerosis
Atelectasis

Collapse or retraction of
tympanic membrane

Often associated with
ossicular pathology

Long-standing
eustachian tube
dysfunction
Attic Retraction

Isolated collapse of
Pars Flaccida

May lead to
cholesteatoma
Cholesteatoma

Accumulation of
squamous epithelium in
middle ear & mastoid

Osteolytic enzymes

Often accompanied by
chronic otorrhea
Chronic Suppurative Otitis Media

TM Perforation

+/- cholesteatoma

Otorrhea
Diagnosis of
Otitis Media
Ear Examination
Pneumatic Otoscopy
Essential for Diagnosis of OM
Keys:

Air tight seal

Adequate visualization
of TM
Instrumentation
Tympanometry

Useful for confirming
diagnosis (if pneumatic
exam inadequate)
– Type C (negative peak)
Suggests ET dysfunction
– Type B (flat)
+ effusion
Acute Otitis Media
Microbiology:

S. pneumoniae
20-30% PCN resistant

H. influenza
30-60% B-Lactamase +

M. catarrhalis
90-95% B-Lactamase +
Acute Otitis Media
(Day 2)
Acute Otitis Media
(1 Week)
Chronic Serous Otitis Media
Microbiology:

50% of effusions culture
+ for bacteria

S. pneumoniae, H.
influenza, M. catarrhalis
Serous Otitis Media
Chronic Suppurative Otitis Media
Microbiology:

P. aeruginosa

S. aureus

Diphtheroids

Klebsiella
Management of Acute Otitis Media

Amoxicillin 90mg/kg/day
– Mild PCN allergy (rash)
• Cephalosporin
– Severe PCN allergy (anaphylaxis)
• Azithromycin
• Clarithromycin
2nd Line Therapy for Otitis Media

Amoxicillin/Clavulanate

Oral Cephalosporin (2nd or 3rd generation)

Macrolide

Ceftriaxone (IM)
When to Consider 2nd Line Rx

Group day care

Antibiotic Rx within last 30 days

Failure of antibiotic prophylaxis

Refractory AOM
Failure to improve with 72 hours
Management of Persistent OM

Watchful waiting
90% of effusions will resolve
within 3 months

Additional 2nd line
antibiotics

Intranasal steroids

Eustachian tube inflation
Valsalva vs. Otovent

Nasal endoscopy
Factors to Consider
with Long-standing Effusions

Degree of hearing loss (>20dB HL)

Vertigo/imbalance

Tympanic membrane changes (retraction)

Speech & language delay

Behavioral changes

Frequency & severity of AOM
Plan of Therapy
Amoxil
Plan of Therapy
Amoxil
If No Improvement in 72 hrs.
Plan of Therapy
Amoxil
If No Improvement in 72 hrs.
2nd Line Antibiotic
Plan of Therapy
Amoxil
If No Improvement in 72 hrs.
2nd Line Antibiotic
If Persistent Effusion
Plan of Therapy
Amoxil
If No Improvement in 72 hrs.
2nd Line Antibiotic
If Persistent Effusion
2nd Line Antibiotic/Monitor (up to 3 months)
Plan of Therapy
Amoxil
If No Improvement in 72 hrs.
2nd Line Antibiotic
If Persistent Effusion
2nd Line Antibiotic/Monitor (up to 3 months)
Modify Risk Factors (when possible)
&
Check Hearing Status
Plan of Therapy
Amoxil
If No Improvement in 72 hrs.
2nd Line Antibiotic
If Persistent Effusion
2nd Line Antibiotic/Monitor (up to 3 months)
Modify Risk Factors (when possible)
&
Check Hearing Status
Tympanocentesis usually not indicated
Indications for Tympanostomy
Tubes

>5 episodes of AOM in
6-9 months

Persistent ME effusion
Acute Mastoiditis
x 3 months

Complication of OM

Failure of antibiotic
prophylaxis
Indications for Tympanostomy
Tubes

Craniofacial anomaly

Structural changes to
TM

Speech & language
delay
Serous Otitis Media w/Retraction
Choice of Tubes

Short-lasting (6-12 mo.)

Intermediate (12-18 mo.)

Long-lasting (>18 mo.)
Straight Vent Tube
Shaft
Lumen
Medial flange
Grommet/Bobbin Style
Flanges
Lumen
T TYPE Vent tube
Medial Flange
Shaft
TUBE INDUCED PERFORATION
“GOODE T - TUBE” - Xomed
Post-tube Otorrhea

Usually secondary to URI
or water exposure

Topical antibiotic usually
adequate 5-7 days
(Floxin, Ciloxin, Ciprodex)
Water Precautions

Cotton + Vaseline when
bathing

Plug

Ear Band-It when
swimming
Refractory Otorrhea
Consider fungal etiology

Clotrimazole gtts

Amphotericin B powder

Cresylate

Debridement of ear
canal

Water Precautions
No H2O2!!!
Tube Removal

Removal
recommended if
tube persists >24
months

Risk of TM
perforation 12-25%
if tube retained >2
years