Transcript Ear III
بسم هللا الرحمن الرحيم CHRONIC OTITIS MEDIA Classification of Chronic Otitis Media • Chronic Non Suppurative Otitis Media – Otitis media with effusion “OME” – Adhesive otitis media • Chronic Suppurative Otitis Media “CSOM” – Tubotympanic (Safe) – Atticoantral (Unsafe) OTITIS MEDIA WITH EFFUSION DEFINITION Presence of non-purulent fluid within the middle ear cleft SYNONYMS • • • • • • • Secretory otitis media Middle ear effusion Sero-mucinous otitis media Catarrhal otitis media Glue ear Serous otitis media Non-suppurative otitis media PREVALENCE • Between 20% and 50% of children do have OME at some time between 3 and 10 years of age • Two peaks at 2 and 5 years of age RISK FACTORS • • • • • • • • Race Age Gender Season Nasopharyngeal anatomical abnormalities Cleft palate Smoking ? Allergy HISTOPATHOLOGY • Changes in the mucosa – Vasodilatation & mononuclear cell infiltration – Metaplasia of the epithelium to ciliated columnar – Mucus secreting gland formation • Formation of fluid in the middle ear – Transudate – Exudate – Secretion ETIOPATHOLOGY • Eustachian tube dysfunction • Chronic inflammation ETIOLOGY • Eustachian tube dysfunction – – – – Poor muscular function Adenoids Barotrauma Others • Infections – Unresolved AOM – Adenoiditis and other URTIs SYMPTOMS • Hearing impairment • ± Otalgia • Fluid sensation Diagnosis DIAGNOSIS DIAGNOSIS • Otoscopy • Tuning fork tests DIAGNOSIS • Otoscopy • Tuning fork tests • PTA DIAGNOSIS • Otoscopy • Tuning fork tests • PTA • Tympanometry DIAGNOSIS • Otoscopy • Tuning fork tests • PTA • Tympanometry • Myringotomy TREATMENT • Treatment of the cause if feasible • Observation • Medical treatment – Antibiotics – Decongestants, ?Auto-inflation – ?Steroids • Surgical – Myringotomy – Ventilation tubes (grommets) COMPLICATIONS OF VENTILATION TUBES INSERTION • Infection • Blockage • Extrusion • Tympanosclerosis • Perforation Iatrogenic Cholesteatoma FACTORS AFFECTING TREATMENT • • • • • • • • Age Duration Unilateral or bilateral Degree of hearing impairment Previous treatment Associated conditions Tympanic membrane changes Others SEQUELAE • Spontaneous resolution – 50% resolve within 3 months. Only 5% persists for more than 12 months • Tympanosclerosis • Scarring, retraction and atelectasis • Cholesteatoma Conclusion • OME is very common in children • Etiology is associated with ET dysfunction and or chronic infection • In adults: Nasopharyngeal pathology should be considered • Most cases resolve spontaneously • Conservative treatment is of doubtful value • VT insertion restore hearing in the selected cases Classification of Chronic Otitis Media • Chronic Non Suppurative Otitis Media – Otitis media with effusion “OME” – Adhesive otitis media • Chronic Suppurative Otitis Media “CSOM” – Tubo-tympanic (Safe) – Attico-antral (Unsafe) Chronic Adhesive Otitis Media • Formation of adhesion in the middle ear after reactivation and subsequent healing of either CSOM or OME Clinical Features • History of CSOM or OME • Deafness is usually the only symptoms • TM shows various structural changes Treatment • Observation • Surgical treatment • Hearing aid Classification of Chronic Otitis Media • Chronic Non Suppurative Otitis Media – Otitis media with effusion “OME” – Adhesive otitis media • Chronic Suppurative Otitis Media “CSOM” – Tubo-tympanic (Safe) – Attico-antral (Unsafe) CHRONIC SUPPURATIVE OTITIS MEDIA ETIOLOGY • Environmental • Genetic • Previous OM • Upper respiratory tract infections • Eustachian tube dysfunction CLINICO-PATHOLOGICAL TYPES Tubo-tympanic Attico-antral PATHOLOGY • Signs of suppurative infection – Discharge & perforation – Chronic inflammatory reaction in the mucosa and the bone (ostietis) • Signs of healing attempts – Granulation tissue & polyps – Fibrosis & tympanosclerosis • Cholesteatoma (attico-antral type) CHOLESTEATOMA DEFINITION • The presence of a desquamating stratified squamous epithelium in the middle ear PATHOGENESIS OF CHOLESTEATOMA • Implantation (congenital or acquired) • Metaplasia • Epithelial migration CLASSIFICATION OF CHOLESTEATOMA • Congenital • Acquired – Primary – Secondary Effect of Cholesteatoma • Keratin encourages persistence of the infection • Matrix causes bone erosion Clinical Features of CSOM CLINICO-PATHOLOGICAL TYPES Tubo-tympanic Attico-antral (cholesteatoma) SYMPTOMS OF CSOM • Otorrhea – Intermittent, profuse & odorless in TT type – Persistent, scanty & malodorous in AA type • Deafness • Tinnitus N.B. Any other symptom means complication OTOSCOPIC EXAMINATION • Discharge – Present in TT type if active but may be absent – Usually is present in AA type • Perforation – Central: in TT type – Marginal or attic in AA type with cholesteatoma PERFORATION IN TT CSOM PERFORATION IN AA CSOM OTOSCOPIC EXAMINATION • Discharge – Present in TT type if active but may be absent – Usually is present in AA type • Perforation – Central: in TT type – Marginal or attic in AA type with cholesteatoma • Polyps, granulation tissue, tympanosclerosis Bacteriology Bacteriology Aerobes Pseudomonas aeruginosa Staphylococcus aureus Proteus Klebsiella and Escherichia coli Anaerobes Bacteroides Peptococcus Peptostreptococcus INVESTIGATIONS • Audiometry • Bacteriology • Imaging Congenital Cholesteatoma Cloudy middle ear in CSOM Cholesteatoma with attic erosion TREATMENT OF CHRONIC SUPPURATIVE OTITIS MEDIA • Depends on the type and presentation Active TT type Inactive TT type Attico-antral type (usually active) Conservative treatment Active TT type Inactive TT type Conservative Treatment •Treat any predisposing factor •Keep the ear dry TYMPANOPLASTY •Ear toilet •Antibiotics •Removal of polyps and granulations TYMPANOPLASTY An operation performed to eradicate disease in the middle ear cavity and to reconstruct the hearing mechanism MYRINGOPLASTY An operation performed tympanic membrane to repair the AIMS OF TYMPANOPLASTY • To close the perforation • To prevent re-infection • To improve hearing TREATMENT OF ATTICOANTRAL CSOM Removal of cholesteatoma by mastoid operation RADICAL MASTOIDECTOMY An operation in which the mastoid antrum and air cells, attic and middle ear are converted into common cavity, exteriorized to the external canal. The tympanic membrane, malleus and incus are removed leaving only the stapes in situ. MODIFIED RADICAL MASTOIDECTOMY An operation in which the mastoid antrum and air cells, attic and middle ear are converted into common cavity, exteriorized to the external canal. The tympanic membrane and ossicles remnants are retained AIMS OF RADICAL & MODIFIED RADICAL MASTOIDECTOMY • Safety • Dry ear • Preserve hearing Conclusion • In TT type the discharge is usually copious, intermittent and odorless. The perforation is central. Treatment is conservative (if there is active infection) followed by tympanoplasty to prevent re-infection and improve hearing. • In the AA type the discharge is usually scanty, persistent and of bad odor. The perforation is attic or marginal with cholesteatoma. Treatment is by mastoidectomy to provide safety and dry ear THANK YOU