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Otitis Media

Otitis Media. Dr John Curotta Head of ENT Surgery The Children’s Hospital at Westmead. What is Otitis Media?. AOM = Acute OM OME = OM with Effusion (= ‘glue ear’) CSOM = Chronic Suppurative Otitis Media ( = a hole in the ear drum

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Otitis Media

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  1. Otitis Media Dr John Curotta Head of ENT Surgery The Children’s Hospital at Westmead

  2. What is Otitis Media? • AOM = Acute OM • OME = OM with Effusion (= ‘glue ear’) • CSOM = Chronic Suppurative Otitis Media ( = a hole in the ear drum which discharges)

  3. Ear drum without a hole 2 types of fluid in middle ear: • 1. Pus -> Acute OM = AOM • 2. Mucous -> Effusion = OME

  4. Ear drum with hole ( >6 weeks) 1. Simple hole: connects outer ear to mucous making lining of middle ear (“like a nostril”) usually dry, but sometimes runny. = “SAFE’ ear 2. Hole with skin of ear drum growing in = “UNSAFE” ear

  5. “UNSAFE” ear Also called: • CHOLESTEATOMA • Chol est e at oma • ‘Kol-est-ee-at-oma ‘ • Means skin growing into ear, not out

  6. What is ‘UNSAFE’ about skin growing in ? • Skin is not normally in the ear and mastoid • Lowest layer of skin makes an enzyme which eats away the bone • This erodes Bones of hearing Bone covering inner ear Bone between ear and brain Deaf – Dizzy – Brain Abscess

  7. What makes you suspect an UNSAFE ear ? • Persistent discharge • The SMELL……Sneakers taken off after a week in the wet. • That is ..soggy dirty mouldy skin…

  8. Cholesteatoma • ALWAYS needs surgery • Surgery: delicate / long / often repeated (very little pain and discomfort) !

  9. ‘Remote’ Kids Usually get early on : • ‘Safe’ Hole in ear drum ------ • Often Runny ears

  10. Northern Territory OM Survey 2007 1300 children, 6 mo – 30 months old • 25% AOM • 5% AOM + perforation • 15% CSOM • 10% had completely normal ears.

  11. NT OM Survey 2007 By 6 months age 98% OME By 12 months age • 90 % AOM • 35% AOM + Perforation • 20% CSOM

  12. ‘Town’ and ‘city’ Kids • Usually get what any other town/city kids get…….Glue ear. • BUT because it is a hidden condition - …….may NOT get diagnosed !

  13. Job of Nurses for Ears 1. Runny ears: DRY the runny ears Maximise hearing Optimise learning 2. Glue ears: DIAGNOSE Maximise hearing Optimise learning

  14. RISK factors for Otitis Media • Boys • Brother/sister with OM • Early start to AOM (<6mo) • Not breast fed • Poor housing • Smoker at home

  15. PREVENTION Vaccination against Strep pneumoniae (pneumococcus) • PREVENAR works under 2 yrs age • PNEUMOVAX works after 2 yrs age • ( Hib – ‘Haemophilus influenzae Type b’ vaccine is NO good for ears as they get ‘H influenzae Non-typeable)’

  16. Pneumococcal Vaccination“PREVENAR” • 239,000 operations for grommets in Australia in past 10 years • Since Prevenar introduction in 2005 grommets reduced by: <1 yr…23% 1-2 yrs..16% 2-3 yrs.. 6%

  17. Study effect early Pn Vaccination ‘Remote’ NT Kids - 2009 • Minimal benefit in reduction Otitis Media (unlike town/city kids) Probably need • Pneumococcal vaccine with wider spread • Vaccine for Haemophilus infections of ears • Vaccinate mothers

  18. Diagnose ‘GLUE Ear’ • SCREEN vs • SUSPECT

  19. Aim of NSW Otitis Media Strategy • is to screen all kids • Eliminates guesswork • But: Do they all get screened?

  20. Hearing Testing Tiny Tots • SWISH for all newborns • NSW 99% cover ….Who is most likely to miss out ? Usual Tymps: unreliable under 6 months

  21. Hearing Testing Baby – to - 4 yrs old VROA / Behavioural…test overall / better ear hearing Usual Tymps: ‘Reliable’

  22. Hearing Testing • Over 4 yrs • PTA + Tymps generally reliable

  23. AOM = pus in middle ear • Body’s immune +/- antibiotics kill bacteria BUT the mucous can take weeks to clear out

  24. POM = Fluid in ear since infection • POM : “Persisting” Otitis Media i.e. after AOM, up to 12 weeks Once fluid is there > 12 weeks,  Then call it : OME or ‘Glue ear’

  25. Fluid in middle ear AOM POM OME 0 weeks >12 weeks

  26. Learning to talk vs Learning in classroom Benefit of Hearing Testing

  27. Hearing under 4-5 years • One ear is enough to learn to talk and to get along at home • So ‘general’ tests of hearing are OK

  28. Hearing, over 4-5 yrs • Unilateral OR Bilateral HL : very important to diagnose • Poor hearing even in ONE ear is a major problem in classroom

  29. Hearing over 5 yrs • This means at school • Absolutely need both ears hearing

  30. Unilateral hearing Loss • Very serious problem in class room • Placement • Background noise • Direction • Anything other than one-to-one talking

  31. Grommets - time working • Small: Shepard………………6 mo • Medium: Reuter Bobbin………12 mo • Large: Sheehy Collar Button.18 mo • Larger: T – Tubes……………24 mo +

  32. The bigger the grommet • The longer it stays • The bigger the risk of a larger perforation • So, NO T-tubes in children

  33. Grommets • The GOOD • The BAD • The UGLY

  34. Grommets- The GOOD • Instant relief • Consistent relief • Helps balance too • Reduces AOMs as well

  35. Grommets-The BAD • Need admission to hospital • Waiting list • General anaesthetic • How long effective • Repeat grommets

  36. Grommets-The UGLY • Limit water exposure - e.g. swimming • Discharging grommet a problem Social / hearing / extrude grommet • Residual perforations, esp if large large > 20% area TM (large is bad) in between…….(nuisance) small < 10% area TM (small is good ! )

  37. If not grommets – What ? • Seating position……….counting chooks • FM System • Hearing Aid/s • Room amplification

  38. Looking after grommets • Its not the water • It’s the GERMS in the water

  39. Looking after grommets • Clean water…OK shower, beach, well-maintained pool (Chlorine : High end + pH : Low end of range) Some Remote WA - No School…No Pool

  40. Looking after grommets AVOID • Bath water • Spa’s • Indoor heated pools • Creeks OR USE • Ear plugs and cap / head band

  41. Infected grommets • Foreign material in the body - if infected gets covered in “slime” • Called “BIOFILM” • Like the inside of water pipes etc • Also plaque on teeth / infected catheters/ IV cannulas etc

  42. BIOFILM • Bacteria exude a jelly to cover themselves • So, antibiotics cannot reach them • To clean biofilm – must mechanically break it up – brush it / scrub it  If not possible – remove the device.

  43. Discharge through Grommets ..How? • Head cold Virus: Increase secretion in nose / sinuses / ears • Secondary bacterial infection (like AOM) • Overflow through grommet

  44. Discharge through Grommets ..How? • If virus…dries up when nose dries up • If bacterial.. May / may not dry up with nose…. Antibiotic medicine or capsules (eg Amoxil) helps

  45. Discharge through Grommets ..How? • Bacteria which live on skin in outer ear can get into middle ear through the mucous discharge…..(pseudomonas) ..these are resistant to most oral antibiotics … Need DROPS

  46. Ear Drops for Grommets • Ciprofloxacin (= Ciloxan / Ciproxin HC) is always safe in ears • Sofradex usuallysafe in infected ears • Sofradex is unsafe in clean ears

  47. Ear Drops for wax • 1. Sodium Bicarbonate Ear drops ( chemist makes them up) • 2. Waxsol drops • 3. Ear Clear Drops for Wax Removal Then syringe. Never Cerumol - too harsh

  48. Discharge through grommets • If so much discharge ear drops cannot get in  • Use 3% Hydrogen Peroxide as drops first, to clean the ear, dab dry and then put in drops. (only for a day or so at a time) (probably is breaking up Biofilm)

  49. Wax or discharge in Ears Gently syringe with dilute baby shampoo 1/2 teaspoonful in 1 cup warm water (= 1%) (or 1 tsp in 500ml) • Finish by syringing Betadine (1 tsp in 100ml) 10 ml syringe with a cut-off scalp vein needle Safe in perforations or grommets

  50. References • Aboriginal Ear Health Manual – Harvey Coates et al from WA • Aboriginal Otitis Media ENT Program Evaluation Report 2002“ • Surgical Management of Otitis Media with Effusion in children” – Clinical Guideline, February 2008 - UK

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