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ENT (Diseases of the MIddle Ear)

Terms in this set (110)

What Drains the middle ear into the nasopharynx?
The Eustachian tube
What is the position of the The Eustachian tube in infancy?
Horizontal, which is why children get more ottitis media
What is the position of the The Eustachian tube in late childhood
More vertical in late childhood
**What does dysfunction of tube the eustachian tube
Otitis media
Otitis media with effusion (OME)
Barotitis
Patulous tube (PET)
Tube remains open causing echoing of the pt's h eartbeat, breathing, and speech (autophony)
What is an easy way to assess TM in integrity and eustachian tube patency?
Valsalva maneuver
What is another way to assess TM Mobility?
Tympanogram
What is the function of the Eustachian Tube?
Connects the middle ear to the nasopharynx providing ventilation and drainage; normally closed, opening only during swallowing or yawning
What happens in ETD?
Air trapped in middle ear becomes absorbed and negative pressure results
What causes Eustachian Tube Dysfunction (ETD)?
Any process that causes swelling of the tube lining such as viral URI or allergies
How does Eustachian Tube Dysfunction (ETD) present?
Often associated with URI and allergies

Sense of aural fullness and hearing loss

"POPPING" or "CRACKLING" sound with swallowing or yawning

PE: TM retraction with decreased mobility
What are the treatment options for Eustachian Tube Dysfunction (ETD)?
Leave it alone: Most cases of simple ETD caused by a cold, or changes in altitude will self-resolve in time without any specific treatments

Swallow and chew: ETD is improved by swallowing, chewing gum, drinking, or yawning.

Systemic or intranasal decongestants
- Pseudoephedrine 60 mg po every 4-6 hrs

Allergic patients ONLY IF THE HAVE ETD AND ALLERGIES:
- Antihistamines: not helpful for ETD, but may help with associated symptoms
- Intranasal corticosteroids: beclomethasone 2 sprays/nostril bid x 2-6 weeks
What are ways to prevent Eustachian Tube Dysfunction (ETD)?
Avoid air travel, rapid altitudinal changes, and underwater diving during active disease
Middle ear is gas-filled and separate from the outside world. When environmental pressures change, must be equalized in middle ear space via eustachian tube

If equalization does not occur, the TM retracts severely with eventual fluid and possible blood secretion into space and TM rupture

Air travel

Diving

Blast injuries


What is this called?
Barotrauma
What are the symptoms of Barotrauma?
1) Aural fullness

2) Pain

3) HL

4) Tinnitus

5) Nausea** (more serious)

6) Vomiting** (more serious)
How is the diagnosis of barotrauma made?
Clinically
What will I see on Physical Exam with Barotrauma?
1) TM retraction

2) Hemotympanum

3) Perforation
How can I prevent barotrauma?
Avoid air-travel/diving, when ears won't clear from a cold or allergies
What is an ABSOLUTE contraindication to diving?
TM perforation
What can a patient use as far as medications prior to flying can reduce obstruction around eustachian tube and allow for easier equalization to prevent barotrauma:
Pseudoephedrine 30 mg taken 30 minutes prior to flight/descent
What should I do for a baby to prevent barotrauma?
Feed during ascent and descent
Should an adult sleep during descent/ascent of a plane?
NO
If a repeated episodes in persons who must fly often, what can be done for prevention of barotrauma?
Ventilating tubes may be needed are useful
Should a diver dive fast or slow?
Descend/ascend slowly
Will most barotrauma heal spontaneously?
Yes! with time and patience, including edematous and/or hemorrhagic TM's - eustachian tube function should be restored however!
Can Decongestants and antihistamines be of benefit in barotrauma?
Not much unless there is an allergy component
When would antibiotics be useful in barotrauma?
ONLY if TM perforation and contamination of middle ear
When should I refer my patient with barotrauma to ENT?
When they have severe otalgia or hearing loss, tinnitus, vertigo, or persistence beyond 4-5 days
This is presence of middle ear fluid + inflammation
Acute
This recurrence soon after treatment of AOM
Recurrent Otitis media
This is presence of fluid WITHOUT signs of illness or inflammation
Otitis Media with Effusion (OME)
This is described as the following:


Inflammatory response to bacteria or viruses causing malfunctioning of the eustachian tube

Infection of the upper respiratory tract leads to mucosal inflammation, which diminishes the diameter of the eustachian tube

This results in inadequate ventilation and leads to backflow of secretions from the throat up into the middle ear, causing an accumulation of microorganisms that precipitates infection
Acute Otitis Media (AOM)
What is most common illness affecting children between the ages of 3-6 years?
Acute Otitis Media (AOM)
T or F. 70% to 90% of cases resolve spontaneously, without the use of antibiotic therapy
True

"Despite this, antibiotic prescriptions for AOM have increased"
What are the modifiable Risk factors for Acute Otitis Media?
Bottle/pacifier use (creates reversal in secretion flow)

Day-care attendance

Exposure to second-hand smoke
What are the Nonmodifiable Risk factors for Acute Otitis Media?
Atopic states lead to deficiency of IgA, which can impair ability to fight off AOM
Also leads to a buildup of secretions in the nasopharynx that causes congestion of the eustachian tube
Cleft palate and trisomy 21 can lead to abnormal development of the palate and/or eustachian tube
What is the clinical presentation of young children (unable to express their symptoms verbally) with Acute Otits Media?
Fever, irritability, crying, drainage from ears, altered sleeping habits

**Ear pulling without other symptoms is not associated with infection of TM!
What is the clinical presentation of Older children/adults with Acute Otitis Media?
Sudden onset pain in affected ear, TTP, and fever
What are the physical exam findings of Acute Otitis media?
Erythematous, bulging TM without landmarks
What are the common pathogens of Acute Otitis Media?
1) S. pneumoniae (25%)

2) H. influenzae (50%)

3) M. catarrhalis (12.5%)
What viruses cause Acute Otitis Media?
1) RSV

2) Influenza

3) Parainfluenza viruses
What is the only way to find out definitively what caused the Acute Otitis Media?
Is by Tympanocentesis, generally reserved for patients with resistant cases of AOM for which no definitive treatment has been effective
We want to eliminate infection as quickly as possible, often by using antibiotics
Get out of that mindset!
Why do we want to get out of the habit of throwing antibiotics at AOM?
In otherwise healthy children, AOM due to the 3 most common pathogens listed above have spontaneous resolution rates of 20%, 50%, and 80%, respectively, without antibiotic use
What is the preferred treatment for Acute Otitis Media?
Antipyretics/analgesics
- Ibuprofen, acetaminophen
***When would I ONLY observe a patient with AOM for 48-72 hours?
1) >2 yo,

2) Healthy with nonsevere illness (mild otalgia and fever <102.2 F), and

3) Able to follow-up and start antibiotics if unsuccessful
What is the DOC for AOM?
Amoxicillin because of its 25-year history of clinical success, acceptability, limited side effects, and relatively low cost
How would I treat an adult with AIM?
Amoxicillin OR amox-clavulanate 875 mg bid or 500 mg tid x 10 days
How would I treat a child for AOM with Amoxicillin?
80-90 mg/kg/day x 10 days
Again, spontaneous improvement in 48-72 hrs will occur in
MOST CASES
***When would I treat Acute Otitis Media?
1) No improvement after 48-72 hrs of observation,

2) < 2 yo,

3) More severe symptoms, bilateral disease, or otorrhea
What would I give my patient if the have a PCN allergy?
Non-type 1 reaction: Cefdinir 300 mg bid OR Ceftriaxone (Rocephin) 2 g IM/IV once
What would I give my patient if the have a severe PCN allergy?
Azithromycin x 5 days
What is the SNAP Approach - Safety-Net approach to Antibiotic Prescriptions?
Based on clinical suspicion of AOM, give a prescription, but urge that it be filled only if the child does not respond to analgesics after 2 days or if the condition worsens
Why do we use the SNAP Approach ?
- Proven to reduce the number of filled prescriptions

- It minimizes the use of antibiotics and provides the caregiver with a sense of security that the prescription can be filled immediately if the child's condition worsens
*What is the number one symptom of AOM, but often goes untreated
Otalgia
**How do I address the Otalgia in AOM?
Oral analgesics
**What must I do with a patient with AOM if they are immunocompromised or persistent or recurrent infection?
Tympanocentesis
**What must I do if a patient has severe otalgia or complications of AOM occur (mastoiditis, meningitis)
Myringotomy
**By avoiding antibx for conditions that do not warrant their use, we eliminate the risk of possible side effects and misuse. What are the side effects?
Nausea, vomiting, diarrhea (15%), oral thrush, rash,
Clostridium difficile infection
Allergic/Anaphylactic reaction (5%)
What are some examples possible nonadherence and misuse problems with giving antibiotics?
Patients given antibx for nonbacerial infections or self-limiting conditions (Z-pak fixes everything!)

Recommended duration of treatment is not followed
In rare cases, a patient may experience an "Amoxicillin rash". When would it show up?
>72 hours after beginning medication and having never taken penicillin previously.

Often itchy maculopapular or morbilliform rash
Is "Amoxicillin rash" a contraindication for future amoxicillin usage?
No. Nor should current regimen necessarily be stopped
What is the prognosis of acute otitis media?
At 2 weeks, 50% of patients will still have fluid in their ears

By 10 weeks, only about 10% will have residual fluid

In many children, the cycle then starts all over again, and they may have 5 or 6 bouts of AOM in as many months (recurrent acute otitis media)
So what is the definition of recurrent otitis media?
≥ Episodes of Acute Otitis Media in 6 months

≥ 4 Episodes of Acute Otitis Media in 1 year
With perforation with otorrhea, a small proportion of patients go on to develop _____________because of the failure of the TM to heal
3
chronic serous otitis media
Is there a non-pharmacologic treatment of recurrent otitis media?
Pressure equalization (PE) tubes

**Tubes are not intended to drain fluid, rather for pressure equalization
This is described:

Presence of middle ear fluid without acute signs of illness or inflammation

Characterized by hearing loss and/or aural fullness, and possibly a h/o recurrent episodes of AOM

Often antecedent URI, exacerbation of allergies, or airplane travel
Otitis Media with Effusion (OME) aka. Serous Otitis Media (SOM)


The point is this is not an infection
What is the clinical presentation of Otitis Media with Effusion (OME) aka. Serous Otitis Media (SOM)?
Hearing loss; audiometry with mild-mod Conductive Hearing Loss

In younger children: delayed speech development or behavioral problems

"blocked" feeling in ear

PE: dull gray or yellow TM with reduced mobility

TM retraction with fluid and/or bubbles visible
**What tests need to be ran with Otitis Media with Effusion (OME) aka. Serous Otitis Media (SOM)?
****Tympanometry is best means of diagnosis: Type C - flat configuration

Audiometry - CHL
What must be done with In ANY adult with persistent unilateral Otitis Media with Effusion (OME) aka. Serous Otitis Media (SOM)?
Must r/o nasopharyngeal carcinoma (CT/MRI)
How do most cases of Otitis Media with Effusion (OME) aka. Serous Otitis Media (SOM) resolve?
spontaneously without treatment
**Do Decongestants/antihistamines/nasal steroids make sense for Otitis Media with Effusion (OME) aka. Serous Otitis Media (SOM)?
Yes, BUT but no data supporting their benefit
What should I do if Otitis Media with Effusion (OME) aka. Serous Otitis Media (SOM) does not resolve?
PE tubes

Adenoidectomy
What is the rationale behind using Adenoidectomy in the treatment of Otitis Media with Effusion (OME) aka. Serous Otitis Media (SOM)?
- It relieves nasal obstruction, improves eustachian tube function and eliminates potential reservoir of bacteria

- Often performed at the same time as PE tube placement if the patient is getting his or her 2nd set of tubes
**Why should Unilateral OME in an adult suggest concern?
Early nasopharyngeal carcinoma is well known for its silent nature (usually the only sign is unilateral OME)

Nasopharyngeal examination is MANDATORY for any adult patient with unilateral OME Using a rigid or flexible endoscope!!!
***What are the complications of Otitis Media?
Perforation of TM

Chronic suppurative otitis media (CSOM)

Mastoiditis

Meningitis

Tympanosclerosis
What happens in a TM perforation?
Purulence must drain someplace, and often this is the path of least resistance
**How must I treat a perforation?
Combination of oral and topical antibiotics and meant to prevent Chronic suppurative otitis media (CSOM)
Why is Ofloxacin Otic such a good drug for a perforation?
Low acidity and low ototoxicity
What should I definitely NOT give a patient with a perforation?
-No aminoglycosides or alcohol

- No polymyxin/neomycin drops
How long should a patient be on oral antibiotics for a perforation?
10 days
Most heal uneventfully but, what do all perforations warrant?
ANTIBIOTICS, ORAL and Topical
***When should a patient be referred for ENT evaluation (CSOM) after a perforation?
If persists > 6 weeks
**This is is defined as chronic otorrhea (i.e., >6-12 wk) through a perforated tympanic membrane (TM)

Mucosal changes (degeneration and granulation tissue) and osseous changes (osteitis and sclerosis)
Chronic Suppurative Otitis Media (CSOM)
Is Chronic Suppurative Otitis Media (CSOM) bacterially the same or different from AOM?
Different (P aeruginosa, Proteus species, and S aureus along with other anaerobic bacteria)
What is the hallmark of Chronic Suppurative Otitis Media (CSOM)?
Purulent discharge that is continuous or intermittent, with increased severity during URI or following water exposure
Is Chronic Suppurative Otitis Media (CSOM) painful?
Pain is uncommon except during exacerbations
Why would a patient with Chronic Suppurative Otitis Media (CSOM) have conductive hearing loss?
destruction of ossicular chain, TM, or both
**What will always be present in Chronic Suppurative Otitis Media (CSOM)?
TM perforation
What is the treatment of Chronic Suppurative Otitis Media (CSOM)?
**Referral for ENT evaluation and management

Regular removal of debris, use of earplugs for water protection, and topical antibiotic drops during exacerbations

Definitive tx is surgical in most cases
This is a complication of Otitis Media that is an Extension of infection into mastoid air cells
Mastoiditis
What is the clinical picture of Mastoiditis?
Ear pain associated with a draining perforated TM

Postauricular tenderness , erythema, and edema

Fever, malaise

Protruding auricle & loss of postauricular crease
What should always be performed when mastoiditis is suspected?
CT!!!

Coalescence of the mastoid air cells due to destruction of their bony septa
What is the treatment of mastoiditis?
Immediate ENT referral - myringotomy, admission, and IV antibiotics

If no response from above tx within 24 hrs - mastoidectomy for debridement
This is a complication of otitis media that is described as:

Firm submucosal scarring that can appear as milky white patch(es) on the TM
Tympanosclerosis
What is Tympanosclerosis?
It is a disease limited to the middle ear with formation of hyaline deposits and calcification in the tympanic membrane
What causes tympanocsclerosis
Injuries to the eardrum and chronic disease in the middle ear can lead to formation of tympanosclerotic plates
What do the calcification in the tympanic membrane cause?
Conductive hearing loss due to decrease in mobility of the TM and even immobilization of the ossicular chain
What causes Cholesteatoma?
Chronic negative middle ear pressure
What is the main cause of Cholesteatoma?
Prolonged ETD, with resultant negative middle ear pressure that draws inward the upper flaccid portion of the TM (pars flaccida)
What will Physical Exam show with Cholesteatoma?
TM retraction pocket, perforation that exudes keratin debris, or granulation tissue
**What is the imaging modality of choice for Cholesteatoma?
Due to it's ability to demonstrate the bony anatomy of the temporal bone
What is the treatment of choice for Cholesteatoma?
Surgery
This is an Abnormal bony growth in the middle ear that results in hearing loss
---> Results in impedance of sound through the ossicular chain, producing Conductive hearing loss
Otosclerosis
How does Otosclerosis present?
Slow progressive unilateral or bilateral Conductive hearing loss

Onset in early life (3rd-4th decade)
What is the treatment of Otosclerosis?
Observation: unilateral disease and mild CHL

Nonsurgical: sodium fluoride/bisphosphonates to prevent progression of disease (controversial)

Amplification: those with normal cochlear function and speech discrimination

Surgery: stapes prosthesis (stapedectomy)
What can cause TM perforation?
Diving/Flying, overpressure from explosion or blow to ear, infection, myringotomy

Spontaneous healing occurs in most cases

Large perforations may require tympanoplasty

Persistent perforation may result from secondary infection by exposure to water

Pts should wear ear plugs while in water during healing period
Is Hemotympanum a serious condition?
May follow blunt trauma or extreme barotrauma

Spontaneous resolution over several weeks is the usual course
What should be considered if CHL > 30dB persists for > 3 months following trauma?
Disruption of ossicular chain
How is Disruption of ossicular chain treated?
Middle ear exploration with reconstruction of the ossicular chain and TM repair (usually restores hearing)
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