Otitis Media and Eustachian Tube Dysfunction

1. Otitis Mediaand Eustachian Tube Dysfunction R. Kent Dyer, Jr., M.D. Hough Ear Institute Oklahoma City, Oklahoma USA

2. Incidence of Otitis Media (OM) • Most common disease of childhood after viral URI • 15 million cases of Acute OM/year in U.S. • Cost of treatment: >$5 billion/year

3. Viral or Bacterial Insult Edema Leukocyte Infiltration Purulent Exudate/Granulation Tissue ET Obstruction vs. Resolution Fibrosis Pathology of Acute Otitis Media

4. Pathogenesis of Otitis Media • Infection (viral vs. bacterial) • Abnormal eustachian tube function • Allergy (minor role) • Neoplasm (nasopharyngeal carcinoma) • Sinusitis

5. Eustachian Tube Function • Protection from nasopharyngeal secretions • Ventilation • Clearance of middle ear secretions

6. Otitis Media Classification • Classified according to: • Duration of disease Acute, subacute, chronic • Quality of effusion Serous, mucoid, purulent • Tympanic membrane appearance

7. Acute Otitis Media Tympanic membrane: • Opaque • Bulging/injected • Reduced mobility • Purulent effusion

8. Otitis Media with Effusion Tympanic membrane: • Translucent or opaque • Gray/pink • Reduced mobility • Effusion present +/- air

9. Chronic Mucoid OM (Glue Ear) Tympanic membrane: • Opaque/gray • Retracted, reduced mobility • Thick effusion, no air • Hearing loss (>20dB HL)

10. Tympanosclerosis • White plaques in Lamina Propria • Hyaline deposition • Significant conductive hearing loss possible

11. Obliterative Tympanosclerosis

12. Atelectasis • Collapse or retraction of tympanic membrane • Often associated with ossicular pathology • Long-standing eustachian tube dysfunction

13. Attic Retraction • Isolated collapse of Pars Flaccida • May lead to cholesteatoma

14. Cholesteatoma • Accumulation of squamous epithelium in middle ear & mastoid • Osteolytic enzymes • Often accompanied by chronic otorrhea

16. Chronic Suppurative Otitis Media • TM Perforation • +/- cholesteatoma • Otorrhea

17. Diagnosis of Otitis Media

18. Ear Examination

19. Pneumatic OtoscopyEssential for Diagnosis of OM Keys: • Air tight seal • Adequate visualization of TM

20. Instrumentation

21. Tympanometry • Useful for confirming diagnosis (if pneumatic exam inadequate) • Type C (negative peak) Suggests ET dysfunction • Type B (flat) + effusion

22. Acute Otitis Media Microbiology: • S. pneumoniae 20-30% PCN resistant • H. influenza 30-60% B-Lactamase + • M. catarrhalis 90-95% B-Lactamase +

23. Acute Otitis Media(Day 2)

24. Acute Otitis Media(1 Week)

25. Chronic Serous Otitis Media Microbiology: • 50% of effusions culture + for bacteria • S. pneumoniae, H. influenza, M. catarrhalis

26. Serous Otitis Media

27. Chronic Suppurative Otitis Media Microbiology: • P. aeruginosa • S. aureus • Diphtheroids • Klebsiella

28. Management of Acute Otitis Media • Amoxicillin 90mg/kg/day • Mild PCN allergy (rash) • Cephalosporin • Severe PCN allergy (anaphylaxis) • Azithromycin • Clarithromycin

29. 2nd Line Therapy for Otitis Media • Amoxicillin/Clavulanate • Oral Cephalosporin (2nd or 3rd generation) • Macrolide • Ceftriaxone (IM)

30. When to Consider 2nd Line Rx • Group day care • Antibiotic Rx within last 30 days • Failure of antibiotic prophylaxis • Refractory AOM Failure to improve with 72 hours

31. Management of Persistent OM • Watchful waiting 90% of effusions will resolve within 3 months • Additional 2nd line antibiotics • Intranasal steroids • Eustachian tube inflation Valsalva vs. Otovent • Nasal endoscopy

32. Factors to Considerwith Long-standing Effusions • Degree of hearing loss (>20dB HL) • Vertigo/imbalance • Tympanic membrane changes (retraction) • Speech & language delay • Behavioral changes • Frequency & severity of AOM

33. Plan of Therapy Amoxil

34. Plan of Therapy Amoxil If No Improvement in 72 hrs.

35. Plan of Therapy Amoxil 2nd Line Antibiotic If No Improvement in 72 hrs.

36. Plan of Therapy Amoxil 2nd Line Antibiotic If No Improvement in 72 hrs. If Persistent Effusion

37. Plan of Therapy Amoxil 2nd Line Antibiotic 2nd Line Antibiotic/Monitor (up to 3 months) If No Improvement in 72 hrs. If Persistent Effusion

38. Amoxil 2nd Line Antibiotic 2nd Line Antibiotic/Monitor (up to 3 months) Modify Risk Factors (when possible) & Check Hearing Status If No Improvement in 72 hrs. If Persistent Effusion Plan of Therapy

39. Amoxil 2nd Line Antibiotic 2nd Line Antibiotic/Monitor (up to 3 months) Modify Risk Factors (when possible) & Check Hearing Status Tympanocentesis usually not indicated If No Improvement in 72 hrs. If Persistent Effusion Plan of Therapy

40. Indications for Tympanostomy Tubes • >5 episodes of AOM in 6-9 months • Persistent ME effusion x 3 months • Complication of OM • Failure of antibiotic prophylaxis Acute Mastoiditis

41. Indications for Tympanostomy Tubes • Craniofacial anomaly • Structural changes to TM • Speech & language delay

42. Serous Otitis Media w/Retraction

43. Choice of Tubes • Short-lasting (6-12 mo.) • Intermediate (12-18 mo.) • Long-lasting (>18 mo.)

44. Lumen Shaft Medial flange Straight Vent Tube

45. Flanges Lumen Grommet/Bobbin Style

46. T TYPE Vent tube Medial Flange Shaft TUBE INDUCED PERFORATION “GOODE T - TUBE” - Xomed

47. Post-tube Otorrhea • Usually secondary to URI or water exposure • Topical antibiotic usually adequate 5-7 days (Floxin, Ciloxin, Ciprodex)

48. Water Precautions • Cotton + Vaseline when bathing • Plug • Ear Band-It when swimming

49. Refractory Otorrhea Consider fungal etiology • Clotrimazole gtts • Amphotericin B powder • Cresylate • Debridement of ear canal • Water Precautions No H2O2!!!

50. Tube Removal • Removal recommended if tube persists >24 months • Risk of TM perforation 12-25% if tube retained >2 years