Transcript Otitis Media with effusion

Infections of the middle ear
M.Rogha M.D.
Isfahan university of medical sciences
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Acute Otitis Media (AOM)
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Otitis Media with effusion (OME)
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“acute onset of symptoms, evidence of a middle
ear effusion, and signs or symptoms of middle ear
inflammation.”
“Presence of MEE without signs or symptoms of
infection, previously named: secretory, serous, or
glue ear. ”
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.
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Treatment
failure AOM: a lack of improvement in sign
and symptoms within 48-72 hours of AB treatment .
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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.
● 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
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Otalgia
Otorrhea
Dizziness
Hearing loss
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Non-specific
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Fever (50%)
Vomiting/diarrhea
Anorexia
Irritability
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Otoscopic findings
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Bulging TM
Yellow, white, or bright red color
Opacification of eardrum
Impaired visibility of ossicular landmarks
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Viral
Bacterial
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Streptococcus
pneumoniae
Haemophilus
influenzae
Moraxella
catarrhalis
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RSV
Influenzae A & B
Parainfluenzae 1,2, &
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Rhinovirus
Adenovirus
Enterovirus
Coronavirus
Mastoid abscess
Facial nerve palsy
Labyrinthitis
Extra/sub dural abscess
Meningitis
Brain abscess
Lateral sinus thrombophlebitis
Petrositis
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Heptavalent pneumococcal conjugate vaccine
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Influenza vaccine
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Goal: decrease number of URI
Breast feeding
Prophylaxis
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Reduction of otitis office visits
Reduction of antibiotic prescriptions
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
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Culture & sensitivity
Simple analgesia
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Paracetamol
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Ibuprofen(some evidence superior)
Antihistamine & decongestant??
Aural toilet
Myringotomy
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Bulging drum
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Facial palsy
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Incomplete resolution
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No antibiotic if no fever; analgesic and reassurance
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Amoxycillin 30-40mg/kg/d 3DDx10d
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Amoxycillin clavulanate
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Cefuroxime 30mg/kg/d 2DDx10d
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Clarithromycin 15mg/kg/d 2DDx10d
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Azithromycin 10mg/kg OD x 5d,5mg/kg ODx5d
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Cotrimoxazole 10mg/kg/d 2DDx10d (Trimetho)
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Eliminate cause
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Long term low dose antibiotics
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Amoxycillin/cotrimoxazole
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Myringotomy + grommet
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Adenoidectomy
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Treat allergy
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Pneumococcal vaccine
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Persistence/reappearance of pain
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Persistence/reappearance of discharge
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Persistent fever
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Symptoms & signs of complications:
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Vertigo/Nystagmus/Ataxia
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Facial palsy/diplopia
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Headache, vomiting, drowsiness
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Abscess behind ear/in neck
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Infants & young children
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Follows measles, influenza, pneumonia
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-haemolytic streptococci
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Otorrhoea without pain
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Foul smelling discharge
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Sensorineural deafness
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Large perforation
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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
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Patients present with hearing loss and otorrhea
Pain, vertigo, fevers, facial nerve palsy, mental status
changes or fetid drainage signify impending intratemporal or intra-cranial complications
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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
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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)
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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
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Invagination
Basal cell hyperplasia
Migration (through a
perforation)
Squamous metaplasia
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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 primary
acquired cholesteatoma
Mesotympanic
cholesteatoma
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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
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History, physical examination, high resolution
CT scan of the temporal bone
Axial Section
Coronal Section
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Ototopical antibiotics
Surgical repair of the TM perforation
Repair of the ossicular chain if necessary
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Antibiotic only otic drops
Floxin (ofloxacin)
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Antibiotic with steroid otic drops
Ciprodex (ciprofloxin and dexamethasone)
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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.
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Paper patch myringoplasty
Fat myringoplasty
Underlay tympanoplasty (medial graft technique)
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Ototopical antibiotics
Surgical repair of the TM perforation
Repair of the ossicular chain if necessary
Often requires mastoidectomy
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Intact (bony ear) canal wall mastoidectomy
Canal wall down mastoidectomy
 Radical Mastoidectomy
 Modified Radical Mastoidectomy
Tympanoplasty with mastoidectomy and
hydroxyapatite bone cement ossicular
reconstruction
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Acute mastoiditis
Sub-periosteal abscess
Cholesteatoma
Labyrinthitis
Facial paralysis
Meningitis
Epidural/subdural
abscess
Brain abscess
Sigmoid sinus
thrombosis
Otitic Hydrocephalus
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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.
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Patients appear more ill than expected
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CT and MRI are indicated
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fever, new onset vertigo, sensorineural hearing loss, fetid
drainage, facial nerve weakness, proptotic ear
lethargy and mental status changes
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