Transcript Controversy on Otitis Media

Otitis media with effusion
Chunfu Dai M.D & Ph.D
Otolaryngology Department
Eye Ear Nose & Throat Hospital
Fudan University
Background
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Otitis media is a multifactorial disease
process involving immunology, infectious
disease, anatomic considerations, social
and socioeconomic issues, and genetics,
among other factors.
Approximately 70% of children below the
age of 3 will develop an episode of otitis
media.
Background
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65-95% of children by the age of 7 years
will experience one or more episodes of
acute otitis media.
It remains the commonest cause for visit
to the doctor in the pediatric population.
Background
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Myringotomy was performed in eighteenth
and nineteenth centuries to treat otitis media.
During the preantibiotic era, the primary
concern was the potential for intracranial
complications of acute otitis media
In 1954, Armstrong’s reintroduction of the
tympanostomy tube, after that, few true
advances in the treatment of otitis media was
developed.
Definition
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OME is an inflammatory condition of the
middle ear and mastoid air cell system
characterized by accumulation of fluid in
the middle ear without signs or symptoms
of acute infection.
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Other names:
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Secretory otitis media,
Serous otitis media,
Glue ear,
Nonpurulent otitis media,
Catarrhal otitis media.
Pathogenesis
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Dysfunction of Eustachian
tube
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Obstruction of Eustachian
tube
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Mechanic obstruction
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Non mechanic obstruction
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enlarged adenoid, tumor,
enlarged inferior turbinate
Weakness of related muscle,
Clearance and defense
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Immotile cilia syndrome
Pathogenesis
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Infection
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PCR detects the middle ear fluid, positive findings was
70%
S pneumonia, haemophalus influenzae, haemolytic
streptocuccus
Immunity
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Middle ear is a isolated immune system
Inflammatory mediators
Specific antibody, immunologic complex
Antigen may from adenoid or nasopharygeal lymph
Classification of Otitis media
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Otitis meda with effusion: the presence of
middle ear effusion.
If the middle ear effusion is present for 8
weeks or longer, it is classified chronic
otitis media with effusion
Microbiology of otitis media
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Bacteria can be isolated from one third of
patient who have OME. The most common are S
pneumonia, H influenzae, and M catarrhalis
(using traditional culture method).
By using PCR, these three bacteria were
detected in approximately 70% of Chronic
middle ear effusion.
Diagnosis
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It is usually asymptomatic.
Hearing loss
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Kid can not concentrate
himself
Turn on TV in loudness
If one ear is normal, the
above symptoms will be
ignored
Fullness
Otalgia
Tinnitus
Diagnosis
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The diagnosis is made at
physical exam.
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TM may retracted, dull, and
opaque.
The color of TM may range
from light pink to amber even
dark blue.
The presence of air bubbles or
air fluid levels makes the
diagnosis more evident.
Diagnosis
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Tympanometry
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Middle ear pressure more negative than -200 (type C)
or a flat tympanometry curve (type B) is classified as
a failure.
A child fail test without marked HL (less than 20 dB)
should be retest 2 months later.
10-14% of patients with low compliance
tympanograms have only tympanic membrane
retraction or thickening without effusion.
While occlusion of the probe by cerumen or the
child’s crying can cause invalid results.
检查
Diagnosis
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Hearing test
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Rinne test: negative
Audiogram: conductive hearing loss, no more than 40
dB
Tympanogram: B type or C type
Lateral nasopharyngeal radiograph: hypertroph
of adenoid
Nasopharyngeal exam: to exclude spaceoccupation lesion
Differentiated diagnosis
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Nasopharyngeal carcinoma:
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Unilateral OME
EBV-VCA-IgA
Nasoendoscope
CT or MRI
Biopsy
CSF (cerebrospinal fluid) leakage
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Head trauma
Meningitis
CT or MRI
Differentiated diagnosis
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Perilymphatic fluid fistula
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Secondary to stapes surgery or barotrauma
Vertigo
Hearing test: sensorineural hearing loss or mixed
hearing loss
Cholestrol granuloma (heamotympanum)
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Advanced stage of OME
Tympanic membrane: blue
CT: soft tissue in mastoid or middle cavity
Differentiated diagnosis
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Atelectatic Otitis media
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Sequela of OME
Conductive hearing loss
TM contacts with ossicular chain, promotory
Diagnosis of otitis media
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Differentiate diagnosis of AOM and OME
will benefit our treatment, as the latter
condition is usually not treated unless it
becomes chronic
Diagnosis of otitis media
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OME is a relatively asymptomatic middle
ear effusion.
Pneumatic otoscope frequently shows
either a retracted or concave tympanic
membrane.
In addition, an air-fluid level or bubbles,
or both may be observed through a
translucent tympanic membrane.
Managements
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Principles:
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discharge middle fluid
Drainage, ventilation
Eliminate pathogenesis
Managements
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Non surgical treatment
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Antibiotics
Steroid
Improvement of nose congestion
Managements
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Surgical treatment
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Tympanocentesis
Myrigotomy
Tympanotomy with PT
mastoidectomy
Management of AOM
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alternative medical treatment
Corticosteroid (orally or intranasally),
Antihistamine, decongestants
 Orally corticosteroid and intranasally
corticosteroid help clear chronic middle ear
effusion. However, there is no evidence of
efficacy in treatment of AOM.
 Antihistamine and decongestants are used
in the treatment of OME, it does not
benefit AOM.
 Children who have nasal congestion and
allergic rhinitis there may be a role for
these preparation.
Otitis media with effusion
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The nature history of this disease is for
spontaneous resolution in the majority of
case
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More the 80% resolution by 2 month. It is the
small number of children who continue to
have effusion after 2-3 months that are
concern.
A trial of antibiotics would be appear to be
appropriate in those children who have not
received antibiotics recently.
OME is probably underdiagnosis.
Otitis media with effusion
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Chronic OME is defined as an effusion
persisting for more than 3 months
duration.
A dense effusion typically may confer up
to a 30 dB hearing loss.
Chronic OME may have a role in
development of retraction pockets,
ossicular chain erosion, and cholesteatoma
formation.
Otitis media with effusion
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Meta-analyses have come to conclusion that
antibiotics have a small but distinct advantage
over placebo in the treatment of persistent OME.
When the effusion is chronic, surgical
intervention should be considered, especially
when antibiotic therapy fail.
The primary surgical therapy remains placement
of tympanostomy tubes for pressure equalization
and drainage of middle ear.
Surgical treatment for otitis
media
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Placement of tympanostomy tubes.
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Middle ear effusion for more than 3 months or
more.
OME associated with hearing loss of >30dB
Chronic severe TM retraction.
Impending intracranial complication
Recurrent otitis media with more than 3
episode within a 6 months period, or more
than 4 episode within a 12 month period.
Surgical treatment for otitis
media
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Adenoidectomy
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indications for adenoidectomy
Children with chronic otitis media who are
candidates for tympanostomy tube placement
 Children have symptoms for chronic adenoid
hypertrophy,
 Children require multiple sets of tympanostomy
tube.
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It has been demonstrated that adenoidectomy may
accelerate the resolution of chronic otitis media
regardless of the size of the adenoid pad.
Surgical treatment for otitis
media
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Adenoidectomy
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With significant risks in children younger than
3 years of age that usually outweight its
benefit.
Adenoidectomy be a consideration in the child
older than 3 years of age at the time of
insertion of a second set of tube.
Surgical treatment for otitis
media
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Laser-assisted myringotomy (background)
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It has been advocated for the management of acute
otitis media (unresponsive to medical management)
and chronic otitis media with effusion, barotrauma,
transtympanic inner ear perfusion.
A history of allergies, the presence of a thick
tympanic membrane and or high viscocity fluid are all
contraindications for laser assisted tympanostomy
Surgical treatment for otitis media
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It can provide symptom relief and avoid
placement of tympanostomy tube by
alleviating infection and inflammation or
improving middle ear ventilation.
Fenestration creates a round opening in the
TM within a a fraction of a second and is
usually bloodless. It generally last 2-4 weeks
Surgical treatment for otitis
media
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Laser-assisted myringotomy (technique
requirement)
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Spot size ranged from 1.8-2.8mm and power
from 7-22w, in general, thicker tympanic
membranes required higher power or more
than 1 laser discharge.
Topic anesthesia in an office setting and
general anesthesia in operating room or
office-based procedure.
Surgical treatment for otitis
media
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Laser-assisted myringotomy (related results)
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2.4 and 2.6 mm spot size resulted in a greater
percentage of patent fenestrations, long duration of
fenestration was associated with higher cure rate
Age of patient, type of fluid, wattage, preoperative
tympanogram, or quadrant of TM undergoing
fenestration are not predictors for duration of
fenestration patency.
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Surgical treatment for otitis media
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The incidence of cure at 90 days for is greater
than 60%, and the incidence of cure for OM
treated in conjunction with adenoidectomy is
greater than 80%.
Reduced risk and cost, and more effective and
satifaction from parents
Prognosis