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Embryology. Anatomy of tympanic cavity. Middle ear cleft. Anatomy of tympanic cavity. . . Anatomy of tympanic cavity. . Tensor tympani muscle. Stapedius muscle. ????????????????? Eustachian tube. Ventilation (????????????????????????)Protection (????????????????????????????? nasopharynx ???????????????)Excretion (?????????????????????????????????????????????????).
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1. Diseases of the middle ear
2. Embryology
4. Anatomy of tympanic cavity
5. Anatomy of tympanic cavity
7. Anatomy of tympanic cavity
9. ????????????????? Eustachian tube Ventilation (????????????????????????)
Protection (????????????????????????????? nasopharynx ???????????????)
Excretion (?????????????????????????????????????????????????)
10. Physiology 1.?????????(Amplifying sound) : 25 dB
- ?????????????????????????????????????????????? stapes footplate
- ???????????????? (physical laws of leverage)
????????????????????????? incus ????????????????????????
handle of malleus
- ??????????????????????
2. ??????????????? (Ear protection)
- Tensor tympani m.
- Stapedius m.
11. Nerve supply
Tympanic plexus/ Jacobson’s plexus
Blood supply
- anterior tympanic a.
- stylomastoid a.
- superficial petrosal a.
- inferior tympanic a.
12. ????????????????????????????????
13. I.?????????? (Otalgia) ???????????????????????????????????
Acute otitis media ??????????????????????
???????????????????
CN VII ??????????????? ????????????????????????????????? ??????????????????????????? ????????????????????
CN IX ??????????????????????? ????????? ??????????????????? ??????????????????????????????? ???????????????????????????????????????????????????
14. I.?????????? (Otalgia) [Cont.] ?????????????????????????????????
??????????????????
?????????????????????????????, ????????????????????????????, ????????????????????, ????????????????, ????????????????????, preauricular sinus, cyst
?????????????????????????
??????????????????????????????, ????????????????????????, ????????????????????
?????????????????????? ???? ??????, ??????????????, ??????????????
??????????? : acute otitis media ???????????????, ????????????????????????????????, barotraumas, ????????
15. ?????????????????????????????????????
CN V
CN VII
CN IX
CN X
?????????????????????? Cervical nerve 2,3
16. II.???????????? (Otorhea) ?????????????????????
Serous
Mucoid
Pururent
Bloody
Clear
17. III.?????????? (Itching) ???????????????
????????????????? (Otomycosis)
?????????????????????????????????????
??????????????????????????????
????????????????? ??????????????? ?????????? ???? immunocompromise host
??????????????? Aspergillus nigra (80-90%) ???????? black spore ?????????? Candida albicans
?????????? ??????? ?????
18. IV. ??????????? ????????????????? ?????????????????????????????????
?????????????????????????????????????????????????????????????????????????????
19. Diseases of the middle ear Congenital diseases
Trauma
Infections
Diseases of Otic capsule
Tumors : squamous cell carcinoma, Glomus tumor (chemodectoma)
20. congenital
21. Congenital diseases Abnormal ossicles : incus and malleus
Conductive hearing loss
Crouzon’s syndrome :
atresia of external ear or ossicle abnormality
Conductive hearing loss
Trachercollins :
small maxilla and mandible with external and internal ear abnormality
Dehiscence of the facial nerve canal
22. Dehiscence of the facial nerve canal 6 – 30 % , facial n. above oval window or above the promontory
clinical manifestations :
Conductive HL both ears
External ear abnormality
Diagnosis by otoscopy. Audiogram , CT-scan
Treatment : exploratory tympanotomy
23. Congenital : treatment Objective of surgical treatment
Functioning ossicular mechanism
Opening ear canal
Functioning the tympanic membrane
24. Neoplasm
25. Neoplasm of middle ear Squamous cell carcinoma
Glomus tumor (chemodectoma)
26. Trauma
27. Cause
Tympanic membrane perforation
ex: Cotton tipped swab (most common), stone
Air/fluid compression
Inflation of Eustachian tube
Fracture base of skull
Lightening strike
Thermal and chemical cause
28. Clinical manifestation
Pain (? improve)
Purulent discharge (infection)
??????
Tinnitus
Vertigo
+/- bleeding
29. Treatment
Remove foreign body (forceps) ?????????blood clot ??10???
Oral antibiotic
?????????????????????(infection)
????????: ???????????????????????? 90%?????????????????? ????????????????????? 3 ????? ?????????????????????? ????????????????????????Thermal and chemical cause????????? ??????????????? ?????????????????????
31. Fracture of temporal bone Longitudinal fracture ( 70-90% )
fracture ??? long axis ??? petrous bone
????????????????? temperoparietal
?????
Conductive hearing loss(
????????????????? / hemotympanum (otoscope = ?????????????)
Deformity ????????? (???????????)
Facial palsy (30%) ????????????????? geniculate ganglion
Cerebrospinal otorrhea ? into nasopharynx
32. Transverse fracture (20-30%)
Fracture ????????????? long axis ????????? petrous
??????????????? frontal ???? occipital
?????
Sensorineuronal hearing loss
Vertigo (?????????? compensation ???????????????)
Hemotympanum(???????)
Facial palsy (70%) most=labyrinthine segment
Incomplete palsy = compression ?????? ??????
???????????? Complete palsy = acute/ nerve damage / ???????? nerve decompression ?? 21 ???
33. Mixed fracture (10%)
?????????????? 2 ??????????? ???????????????
34. Traumatic disconnection of the ossicular chain ???????????????????????????????
incudostapedial joint
?????
Conductive hearing loss
Otoscope : ??????????
Audiogram : air-bone gap ?????? 60 dB
Tympanogram : high compliance ,????? stapedial reflex
????????
Reposition ??? long process ??? incus ?????? stapedial head
Interposition ??? incus ????????????????? incus ????????????????? malleus??? stapes ???????????????
35. Otitis barotrauma ??????????????????????????????????????????????????????? ???? ????????????????? ????????????
?????????????????????????????????????????????????????????? ?????????????????????????????????? ??????????????????????????
36. ?????????
??????????????????? ??????????????? ????????
?????
?????
????????????
Blood filled bleb
????????
?????????
37. ??????????
???????????????????????????? > ?????????????
????????????????????????????????????????????????????????? ???????????? Eustachian tube??????? tensor veli palatini ????????????????????????????????
??????????????????????????????????????????????????????? 90 mmHg tensor veli palatini ???????????????? ???? eustachian tube block
38. ?????
?????
????????????????????????
Hemotympanum
?????????????????
?????????? (???????????>??)
??????????? otitis barotrauma ??????????????????????????? eustachian tube ???????????? ex: allergic rhinitis, URI
39. ????????
????????????
????? : ?????? ? ????? (???????????????????????????) ? ????????????????? (>100-500mmHg) ? ???????????????????????????????? ? ????????????????????????????????
Alternobaric vertigo = ??????????????????????? (??????????????????????)
40. ??????????
Frenzel maneuver
?????????????????????? ????? ??????????????????? ?????? ???????
Valsava maneuver
????????????????????????????????
?????????????????????????????????????????????????????????????????????? ???????????????? ??? ?????????????????????????????????????????????????????????? ???? ??? nasal decongestant , pseudoephedine (1hr before landing) , oxymetazoline(before landing)
?????????????? barotrauma ????? ??????????????????????????? ??????????????????????? ??????????????????????????????????????????????????????????Myringotomy , ventilation tube???
???????????
41. ????????
???????????????????????????????? ????????????????????????? ? ?? oval window ? ???????? perilymph ??? ? ??? round window ???? ? ????? valsava maneuver ? perilymph ????????????????? ? ????????? membrane ?? otic capsule ???? round, oval window membrane ? perilymph fistula ? ???????????? , ??????????
42. Decompression sickness ??????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????? ???????????????????????????????????????????????alveoli ????????????????????????????? ???? air embolism ?????????????????????????????
?????
??????
??????????
????? ???? ??????????????? ?????? ?????????? ????????????? ????????????????? ??? ???????
?????????????????????????????????????? 30 ??? (????????????????????????????????????????????????????)
???????? : hyperbaric treatment
43. Nitrogen narcosis
????? : ????? alcohol intoxification (Euphoria, ?????, ?????????????)
??????? : ??????????????????????????????????????
Oxygen toxicity
????? : ???????? ??????? ?????????? ???????????????? ??????????????????????? ?????????
44. Disease of otic capsule
45. Spongy bone formation of otic capsule ? ankylosis of footplate of stapes
Associated conditions :
Van der Hoeve’e syndrome , Paget’s disease
46. Otosclerosis Clinical manifestation (cont)
F>M , 20-30 years old
Promontory ? flamingo pink (schwartze ‘s sign)
Bilateral, Related with familial history
?????? , CHL , Paracusis
Audiogram
Air conduction loss
early : low frequency > high frequency
late : low frequency = high frequency
cahart notch of conduction curve
48. Treatment
1. fluoride supplement
2. ??????????????
3.Surgical treatment : Stapedectomy (90% success)
Conductive hearing loss
Air-bone gap of at least 30 dB
Good cochlear reserve
Contraindication
1. narrow air-bone gap
2. ?????????????????????????????????
50. Complication (2-3%)
SNHL
Facial nerve injury
Perilymph fistula
51. Infection
52. Otitis Media - Definition Inflammation of the middle ear
May also involve inflammation of mastoid, petrous apex, and perilabyrinthine air cells
53. Otitis Media - Classification Acute OM - rapid onset : < 3 wk course
Subacute OM : 3 wks to 3 mo
Chronic OM : 3 mo or longer
54. Acute Otitis Media (AOM)
55. RISK FACTORS Intrinsic factor
- Age(??? )
- Allergies
- Craniofacial abnormalities (cleft palate)
- Immunocompromised host
Extrinsic factor
- Seasons
- Upper Respiratory Infections
- ?????????????????????????????
- l??????????????
56. Causes ???????????????????? Nasopharynx ?????? submucosal lymphatic
???????????????????????????????????????????? ????????????? ?????????? Sinus ???????????????????????
57. Causes In Children <6 weeks
- Streptococcus pneumoniae
- Haemophilus influenzae(non-typeable)
- S. aureus
- Group A Streptococcus
- Moraxella catarrhalis
- E. coli
- Klebsiella and Enterobacter
- Pseudomonas aeruginosa
- Nonpathogens ***
58. Causes In Adult 3k
- Streptococcus pneumoniae ***
- Haemophilus influenzae
- Moraxella catarrhalis
- Group A Streptococcus
- S. aureus
- Nonpathogens
59. Clinical manifestation Phase 1 : Acute tubal obstruction
?????? ??????????????? ???????? Retraction ?????????
Phase 2 : Acute infection of tympanic cavity
- ??????????????: ??? ????? ????????????? ???????????????????????? ?????????????????????????????? capillary ???? handle of malleus ????????????????????????????
- ??????????????: ?? Otorrhea ?????????????????
Phase 3 : Retention of pus in mastoid process
60. Stage of acute otitis media Stage 1 Hyperemia
swelling and redness of tympanic membrane , mucosa in middle ear , eustachian tube , mastoid
Et ??????????????????? ?????????????????????????????????????? ??????????????????? ????? ????????????????????
61. Stage 2 Exudation
tympanic membrane ?????????????????????????
?????? ?????????????????????????????? ??????????????????????????????????????????????
62. Stage 3 Suppurative
Ruptured tympanic membrane , Otorrhea
??????????????????????? ?????????????????????????
63. Stage 4 Coalescense
???????????????????????? ???? mastoid ???
????? ???????
Decalcification , osteoclastic reaction ??? mastoid ????????????????????????????????
???????????????1 ???????????? 2 ??????? ?????????? ?????? ????? ???????????????? ???????????????????? 2
Coalescense mastoiditis
64. Stage 5 Resolution
????????????? ???????????????????????? tympanic membrane ???????????????????? ?????????????????????
Stage 6 Complication
?????????????????? ???? coalescence
Extracranial , Intracranial complication
65. ??????????????? Acute Otitis Media ???????????????????????????????????? (extracranial)
- Subperiosteal abscess
- Petrositis
- Labyrinthitis
- Facial paralysis
66. ??????????????????????????????????? (intracranial)
- Meningitis
- Extradural abscess
- Lateral sinus thrombosis
- Brain abscess
- Subdural abscess
- Focal otitis encephalitis
- Otitic hydrocephalus
67. ?????????? ??????? amoxicillin
Dosage : 40 mg/kg/day tid : 10-14 day 2-3
?????????? 48-72 ??????? ???????????????????? (??????????...)?????????????? amoxycillin-clavulanate ??? cephalosporins
?????????????????????? penicillin ????????????????????? Macrolide ???? erythromycin ????????? Sulfaniazine ???? trimethoprim-sulfamethoxazole
68. Treatment ??????
???????????????? ?????? ???????? ?????? ???????
???????(decongestant) ???????? eustachian tube ?????????????? ????????
??????????(antihistamine) ??????????????????????? ???? ????????????????????
?????????????????????????????? (Tympanocentasis)
??????????????????(myringotomy) ??????????????
69. ????????????? < 6 wk ? ?????? ATB ??????? gram negative
?????????????????????????????????????????????????????
????????????????????????????????????? middle ear ???????????????????? ???? ?? I&D ?????????? subperiosteal abscess
70. Chronic Otitis Media
71. Definition ??????? ?????????????????????????? 3 ????? ??? ?? perforation ?????????
?? recurrent infect
Via perforation
Via eustachian tube : mixed organism
72. Risk factors Inadequate treatment of acute otitis media
Chronic dysfunction of eustachian tube
Persistant perforation of ear drum
Irreversible change in middle ear(??????)
Persisitant osteomyelitis in mastoid
Persistant disease in nose ,sinuses ,nasopharunx
(?????? ????? ???)
Other factors
73. Chronic Otitis Media Common organism
P aeruginosa (48-98%)
S aureus (15-30%)
Klebsiella (10-21%)
Classification
Safe Ear
Unsafe Ear
74. ?????????????? (safe ear) Drainage ?? ??? perforation, Eustachian tube ? ????????? complication
????????????????
???????????????????????? ???????????? ????????????????
????????????????? ??? central perforation
????????????
- tympanosclerosis
- cholesterol granuloma
75. Chronic Otitis Media
76. Chronic Otitis Media
77. ??????????? (unsafe ear) Drainage ????? ???????????? ?????????????
??????????????????? ?????????????????????????????????
Perforation ???????????????????????? (marginal) ???? attic(epitympanic recess perforation)
????? cholesteatoma
????????????
Mastoiditis
Facial paralysis
Meningitis
Brain abscess
78. Marginal Perforation
79. Cholesteatoma
81. ??????????????? Chronic Otitis Media Intratemporal complication
- Mastoiditis
- Petrositis
- Labyrinthitis ? SNHL , vertigo
- Facial paralysis from mastoiditis, cholesteatoma
82. ??????????????? Chronic Otitis Media Intracranial complication (from cholesteatoma invaded into base of skull)
- Meningitis
- Extradural abscess
- Brain abscess
- Subdural abscess
- Lateral venous sinus thrombosis
83. Treatment
1. Medical treatment
- ??????????
- ?????????????????????? ???????????????????????????? ????
solution of 50% peroxide and 50% sterile water
Surgical treatment
- Myringoplasty(only)
-Tympanoplasty(+middle)
- Mastoidectomy
- Radical Mastoidectomy 9(ex mid mas)
84. ???????? Antibacterial agent ?????? Chloramphenical
Neomycin sulphate,polymycins,ofloxacin
??????????????????????????? ??????????????? ????????? ?????????
???????? Sofradex , Otosporin, Dexoph
Antifungal ??????????????????????? propylene glycol ???????????????????? ????????????????????????????????????????? ???????????????????????????????? Amphotericin B ???????????????????
85. ??????????????? ????????????
????? aminoglycoside ex: neomycin, gentamycin
??????????? aminoglycoside ex: chloramphenicol, vasocidin opthamic solution
????????????????? ex: merthiolate (thimerosal)
??????????????? ex: cresylate, volsol, gentian violet, povidine iodine, chlorhexidine
????? steroid ex: hydrocortisone, dexamethasone
???????????????
????? fluoroquinolone ex: ciprofloxacin, ofloxacin, levofloxacin
86. ?????????????????????????? ????????????????????????????????????????? ??????????????????????????????????????????????????
???????????????????????????????????????
????????????????????????????????????? ???????????????????????????? steriod ????????????? contract dermatitis ???
??????????????????????? steriod ???????????????????????????????????????????????????
???????????????????????????????? ???????????????
??????????????????????????? ?????????????????????????????????? ????????????????????????????????
????????????????????????????????????????????????????????????????? ?????????????????? ????????????????????
????????????????????????????? ???????????????????????? ??? ?????????? ????????????? ????????????
87. OTITIS MEDIA WITH EFFUSION
88. ??????????????????????????????????
characterized by a nonpurulent effusion of the middle ear that may be either mucoid or serous.
typically do not involve pain or fever.
can occur during the resolution of AOM once the acute inflammation has resolved.
Child > adult ( especially 1-7 years old)
90. Etiology
??????????? AOM
??????????? otitis barotrauma(?????????????????)
Allergy
?????????????????????????? adenovirus ???? Rhinovirus
91. Symptoms ???????? ??????????????? ???? delayed speech
??????*** (?????????????????????????) ????????????
????? (1-2?????? ?????????????????????????????????????????)
??????????????????????????????? ????? valsava maneuver ????????????????????????????????????????????
??????????????
?????????????????????????????????????????????? ????????????????? ???? ???????????? (???????????? NCA)
92. Signs TM retraction
Short process malleus ???????
?????????????????? ???????????????????????????
?????????? / airfluid level (good prognosis)
TM ????????? ???
Pneumatic otoscopy ????? TM ???????????
??????????????????? ?? ?????????? ??? ?????????????
??????????????? bloody fluid serous fluid ????????????????? (glue ear )
97. Complication 1. middle ear atelectasis(ET middle- tym)
2. cholesteatoma ( destructive and expanding keratinizing squamous epithelium in the middle ear )
3. perforated TM
4. auditory deprivation
(sensorineural hearing loss)
5. tympanosclerosis
98. Investigation Tympanogram
?????????????? type B
Audiogram(CHL) (bone conduction ???????)
Low tone loss ( air conduction ????)
Low and high tone air conduction ???? ? ??????????? flat type
High tone air conduction ????
99. Treatment Antibiotic-Amoxycillin, trimethoprim-sulfamethoxazole , Cephalosporin ( 2-4 Wk ,F/U q 1Wk)
Steroid (nasal spray 2 Wk)
Decongestant (?????????? ET –tube )
valsava manuver (???????? ET tube ????? , increase pressure in middle ear )
????????????????????????????????????????????? Myringotomy ?????????????? pressure equlization
100. Myringotomy 1 anteroinferior
2 grommet tube ??????????????????????? ????????????? ??? middle ear
(???????????????????????????????????????)
?????????????? ˝-1 ??
101. Indication:
No response to antibiotic for 1 month
???????????????????? 3 ???????????
impending cholesteatoma
adhesive otitis media ??????? middle ear atelectasis
Severe conductive hearing loss
cleft palate
Tent to recurrent OME
102. Complication
Persistent otorrhea ??? ATB ????????????
TM perforation ??????????????
Granuloma ??? TM
Ossicles dislocation
103. Clinical practice guideline for otitis media with effusion (OME)
104. OME= ??????????????????????????????????????????????????????????????? ??????????
???????????????????????????????
?????????????????????
???????????????????????????????????? ???????????????????????????????????????????????? ?????????????????????????????
105. Guideline for OME ?????????? 1a : ???????????? pneumatic otoscopy ???????????? OME ???????????????? ??????????? ??????????????????? ?? air-fluid level ????????????
?????????? 1b : ??? tympanometry ????????????????? OME ??? type B
?????????? 1c : ?????????????????????????????????????????
?????????? 2 : ?????????????????????????? ???????? ?????????????
106. ?????????? 3 : ??????????????????????????????????????OME??????????????????????????????? ??????????????????????? ????????????? speech language therapy ??????????????? OME ????????????????? ??????????????????????????????? ??????????????????????????????????
?????????? 4 : ??????????????????????????? OME ????????????????????????????????????????????????????????? ??????? AOM ????????????????? OME 75-90% ????????????
?????????? 5 : ????????????????????? ????????????????? ??????????????????? steroid ????????????????????????????????????????????????
107. ?????????? 6 : ???????????????????? OME ??????? 3 ????? ?????????????? ???????????????????????????????????????
?????????? 7 : ??????????? OME ??? ??????????????????? 3-6 ????? ???????????????????????????????????????????????????????????????????????????
?????????? 8 : ??????????????????????????????????????????????????????? ???????????????????????? ????????????????? ???? ??????????????????? ????????? AOM ???????????????
?????????? 9 : ????????????????????????????????????????????????????? ??????????????????????????? ?????? ???????????????????????????? ???????????????????????????????????????
108. ?????????? 10 : ????????????????????????????????????
?????????? 11 : ?????????????????????????????????? OME ??????????????????? amoxicillin ??????? 80-100 mg/kg/day oral 5-10 ??? ???? ceftriaxone 1 g/day IV 1 ????? ?????????????? erythromycin ??????? cotrimoxazole ???? ceftriaxone 50 mg/kg/day IM 3??? ????????????????????????????????? S.pneumoniae, beta-lactamase producing H.influenza ??? amoxicillin ????????? drug of choice ????
109. ???????????????????????????????????? 72 ??????? ???????????????? ????? ???????????????????????????????????????? ????????? tympanocentesis ???????????????????????? ???????????
Amoxicillin/clavulanate 80-100 mg/kg/day ????Ampicillin/ sulbactam 7 ???
oral cephalosporin (second, third generation) ????
New macrolide (clarythromycin, azithromycin)????
New quinolone (levofloxacin, gatifloxacin, noxofloxacin)
110. ???????????????? ???? Mycoplasma pneumaniae ???????????? hemorrhagic bullous myringitis ???????????????????????? macrolides, tetracyclin, new quinolone
Recurrent acute otitis media ??? ??????????????????????????????????? 48-72 ??????? ????????????????????????????????????????
111. ???????? ?????????????????
1. ????????????
2. ??????????
3. ???????????????
4. ?????????????
5. ????????????
112. ????????????????????????? 1. ??????????????????????????? ??????????????????????????????????
2. ?????????????????????????
3. ??????????????????????????
4. ???????????
5. ????????????????????????? ???????????????? ???????????????????
6. ???????????????????????? ???????????????????????? ?????????
113. ??????????? 1. ???????? ???????????????????????????????????????????????????
2. ???????? ??????????????????????????????????????????
3. ???????? ????????????? neomycin
4. ?????????????????????
114. ???????????????? 1. ??????????????????????????????? ???????????? ???? ?????????????????????? ??????????????????????? ???? ?????????
2. ?????????????????????????????????????????
3. ????????????????????? ?????????????? ?????????????? ?????????????? ??????????????????????????????????????????????????????????????
4. ?????????????????????????????????????? (?????? 8 – 10 ???) ??????????????????????????? ?????????????????????
115. 5. ???????????????????????? ??????????????????????????????????????? ???????????????????????? ???????????????????????????????????? ???????????????????????????
6. ??????????????????????????? 5 – 10 ???? ????????????????????????????????????????????????????????? (?????????????????????????????????????????????????????????)
7. ???????????????????????????? ???????????????????????????? ??????????????????????????????????????????????????????????? ??????????????????????????????????? 20 – 30 ???? ???????????????????????????
116. ?????????????????? 5% Sodium bicarbonate
Chloramphenical ear drop
Neomycin ear drop
Solfadex (Fremycitin+gramicidin+dexa)
117. Tarivid otic solution
3% ofloxacin
118. DEXOREN-S® [eye/ear drops]
chloramphenicol 0.5 % w/v, dexamethasone sodium phosphate 0.1 % w/v
119. Antibiotic+corticosteroid Neomycin + dexamethasone
120. Polymyxin B + neomycin + hydrocortisone
121. Sofradex
Grammicidine + framycetin + dexamethasone
122. ????????
Antifungal ??????????????????????? propylene glycol ???????????????????? ????????????????????????????????????????? ???????????????????????????????? Amphotericin B ???????????????????
123. ???????????? ??????????????????????????? (impact cerumen) ??????????????? ?????????????????? ????????????????????????????????? ??????????????. ???????????????????????????????? ?????? ???????????????? ?????????????????????????????????? ??????? 2.5% NaHCO3 ????? ????????????????????????????????????????????? ??????? ??????????. ?????????????????????? ??????????????????? 4 ????? ?????? 1 ??????? ??????????????????????? ear toilet.
124. Thanks you