Transcript The Right Patients for Tonsillectomy

Middle Ear
Differential Diagnosis of Ear Disease
External Ear
• Cerumen impaction
• Auricular hematoma
• Perichondritis
• Otiis Externa
• Otomycosis
• Foreign Body
•External ear canal
laceration
-temporal bone fracture
Middle Ear
• Acute otitis media
• Mastoiditis
•Serous/chronic otitis
media
• Hemotympanum
•Tympanic membrane
perforation
•Tympanic membrane
retraction
• Cholesteatoma
Inner Ear
• Sensorineural
hearing loss
• Vestibular neuritis
• Meniere’s Disease
• Vestibular
migraine
Anatomy of the ear
Conductive Hearing Loss
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 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%)
Complications of Acute OM
• Intracranial
Complications:
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Meningitis
Extradural abscess
Subdural empyema
Lateral sinus
thrombosis
– Brain abscess
– Otitic hydrocephalus
• Extracranial
Complications:
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Mastoiditis
Petrositis
Facial Paralysis
Perforation of the TM
Hearing loss
• CHL
• SNHL
– Labyrinthitis
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
Acute Mastoiditis Management
• IV antibiotics
• Incision and drainage of
subperiosteal abscess
• Myringotomy and tube
placement
• Cortical mastoidectomy
traditionally recommended
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
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 (chronic)
– 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
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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 (chronic)
Types of TM Findings
Serous otitis media
Normal
TMMedia
Acute
Otitis
Mucoid Otitis Media
Tympanic Membrane Perforation
Myringosclerosis
Tympanic Membrane Perforation
• Multiple causes
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Trauma (welder’s slag)
Tubes
Infection
Barotrauma
• Potential complications
− Otorrhea
− Hearing loss
− Cholesteatoma
• Treatment
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Auidiogram
Dry ear precautions
Ciprodex for otorrhea
Tympanoplasty if no
spontaneous resolution
(~6 months)
− 90-95% success rate
Tympanic Membrane Retraction
• Negative pressure pulls
TM inward
• Caused by eustachian
tube dysfunction
• Most likely in superior
TM (“Prussack’s space”)
• Loss of middle ear
volume
• Loss of amplification
• Physical exam:
− Microscope: can see
retraction
− Monocular otoscope:
oval/angled/rotated TM
− Angled/horizontal
malleus
• Complications:
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Serous otitis media
Hearing loss
Damage to ossicles
Cholesteatoma
Tympanic Membrane Retraction
Tympanic Membrane Retraction
Cholesteatoma
• Dermoid cyst in middle
ear space
• Recurrent
otorrhea/infection in one
ear
• Causes:
− Epithelial rest (congenital)
− Retraction of TM with
migration of epithelium into
middle ear
− Perforation/trauma
• Physical exam:
− Squamous debris and
granulation tissue
− “like a bomb went off”
− May see “pearl”
• Complications:
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Hearing loss
Destruction of ossicles
Facial paralysis
Intracranial extension
Vertigo
Cholesteatoma
• Work-up:
− Audiogram
− CT Temporal bones
without contrast
• Treatment:
− Ciprodex for otorrhea
− Dry ear precautions
− Surgery
 Mulitple surgeries
required
Inner Ear
Differential Diagnosis of Ear Disease
External Ear
• Cerumen impaction
• Auricular hematoma
• Perichondritis
• Otiis Externa
• Otomycosis
• Foreign Body
•External ear canal
laceration
-temporal bone fracture
Middle Ear
• Acute otitis media
• Mastoiditis
•Serous/chronic otitis
media
• Hemotympanum
•Tympanic membrane
perforation
•Tympanic membrane
retraction
• Cholesteatoma
Inner Ear
• Sensorineural
hearing loss
• Vestibular neuritis
• Meniere’s Disease
• Vestibular
migraine
• BPPV
Inner Ear Pathology
• Key symptoms:
• Treatment for HL
− Sensorineural hearin
gloss
− Hearing aids
− Tinnitus
− Hearing aids
− Vertigo
• Work-up:
− Audiogram
− MRI of internal auditory
canal with and without
contrast
− +/- CT temporal bones
− +/-ENG
− Hearing aids
− Cochlear implant
• Treatment for vertigo
− Meclizine
− Valium
− Vestibular exercises
Sensorineural Hearing Loss
Summary
• Ear pathology complex
• Symptoms, age, type of hearing loss can help
focus differential
• Remember that otoscope distorts exam
• Dry ear precautions always a good idea
• No shame in ENT referral
Questions?
Thank You!