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AY 2010-2011

Subject ENTTopic Otorrhea

Date 13 October 2010

Lecturer Dr. Brendan Ferrolino

Transcriber Jmie Pages 14

Editor

Source: ppt. past tranx, book

abnormal discharge from the ear Characteristic (you must identify the appearance of the discharge as you examine and as you take the history, in able to

determine the pathology)1. Consistency serous, mucoid, purulent (transudate to exudates)2. Color clear, whitish, yellowish, bloody3. Amount scanty, copious/ profuse4. Odor non-foul, foul smelling (commonly ignored characteristic)

Possible Sources (anatomy and histology of ear canal must be considered)

1. External Ear Canal stratified squamous epitheliuma. Bony portion

formed by the tympanic part of the temporal bone

Otorrhea 1 of 16

Auricle

Temporalbone

External Auditory Meatus

Malleus

Incus

Semicircular Canals

Vestibular nerve

Cochlea

Stapes

Tympanic membrane

Eustachian Tube

I. X-SECTION OF THE EAR

OTOSCOPIC EXAMINATION In performing otoscopic examination, you must first stabilize the ear by holding it so the patient won’t feel pain as the

speculum is being inserted. The mobile cartilaginous part of the ear must be pulled upward and backward before inserting the speculum Very basic , helps in determining the problem Mainstay for the investigation of the middle ear disease normally otoscopy will reveal nothing more of the middle ear than the lateral aspect of the tympanic membrane. Tympanic membrane mobility provides the clues to the condition and ventilation of the tympanic cavity

OUTLINEI. X-Section of the ear ii. Pathogenesis c. Chronic suppurative

II. Otorrhea iii. Sequences of event d. TuberculosisIII. External Ear Disorder iv. Diagnosis Vi. microbiology

A. Diffuse Otitis Externa v. Types Vii. managementB. Furuculosis 1. Suppurative viii. Antimicrobial agentsC. Herpes Zoster Oticus a. Aerotitis – Barotrauma ix. Acute otitis mediaD. Other External Ear Disorders b. Otitis Media with Effusion x. Recurrent otitis media

IV. Middle Ear Disorder 2. Non-Suppurative xi. CholesteatomaA. Otitis Media a. Acute Suppurative V. Complications of Otitis Media i. Eustachian tube dysfunction b. Acute necrotizing

II. OTORRHEA

Tensor Tympani muscle

skin is very thin and adherent the periosteum sothere is not much subcutaneous tissue accounting for the temperature and pain sensitivity of the medial canal skin and can influence the pathogenesis and course of ear canal diseases such as necrotizing otitis externa.

b. Cartilaginous portion Forms the lateral 2/3 of the external auditory canal Angled downward and forward relative to the bony medial third. So at otoscopy, the ear is pulled

upward and backward. Has skin appendages such as hair follicles

2. Middle Ear Canal columnar, ciliated with mucous secreting goblet cells 3. Tissue/Bone Necrosis suppurative inflammation ( necrosis of the external, middle or even the mastoid )4. CSF Leak tear in dura mater due to trauma (blood or fluid comes out)

Pathogenesis off External Ear Otorrhea*usually patient’s are very religious in cleaning their ear which is wrong! normally the ear canal cleans itself as its skin desquamates

and move laterally, mm everyday,, so if ear is clean the migration is impeded, and pushed inside, so the canal is then filled with cerumen, etc.. so cotton bud tip must not be inserted all the way inside as the ear canal is only an inch long. it is the most common predisposing factor leading to trauma and irritation

Canal Skin Irritation or Trauma ↓

Bacterial Infection and Inflammation (canal becomes very narrow since it is swollen)

Diffuse - transudate Circumsribed -pus (localized only in outer portion of canal

involving the hair follicles)

A. Diffuse Otitis Externa Also known as swimmer’s ear (after swimming, water gets into the ear, so the skin gets very soft and subtle , so as you clean

it with cotton buds the skin is macerated or peels off, and is pushed inside the canal, exposing the deeper layers to contamination of the normal flora )

Otorrhea 2 of 16

III. EXTERNAL EAR DISORDER

Parts1. Auricle (pinna)

o shape defined by the elastic cartilaginous plateo no actual subcutaneous tissue in this region

2. External Auditory Canal (external acoustic meatus, ear canal)o lateral two-third consists of fibrocartilaginous framework that is angled downward and forward relative

to the bony medial thirdo bony portion (medial 3rd of the ear canal) is formed by the tympanic part of the temporal boneo bony ear canal grows less than the cartilaginous ear canalo bony ear and cartilaginous ear equal length by 5-6 yearso ear canal in adults: 2.5 cm long

medial boundary of the external ear is the tympanic membrane Anatomical Relations

o Anterior Temporomandibular jointo Anteriorly and Inferiorly Parotid Glando Posterior Mastoido Superiorly Temporalis muscle and Squamous part of the temporal bone

Function: Acoustic antenna which transmit sound waves to the sensitive middle ear structures in a discriminating way

Amplification of sound does not involve an increase in the amplitude of sound waves but is based on resonance (vibration) [naaalala nio pa ba sabi sa Physics? Sound is made by the vibration of molecules sa object.]

Innervationso Sensory

1. Great Auricular Nerve (from the cervical plexus)2. Auriculotemporal Nerve (from the third division of the trigeminal)

o potions of the concha and ear canal are supplied by the auricular branch of the vagus nerve Complications: perichondritis ( if it spreads to the auricular cartilage)

Necrotizing otitis externa in predisposed patients as a result of superinfection with Pseudomonas after cleaning, it is treated locally for 1-2 days with 70% alcohol, which is applied hourly to a self-expanding foam or gauze

wick inserted into the ear canal. This treatment provides disinfection, reduces local swelling by fluid absorption and exerts a cooling action that relieves pain.

Signs and Symptomso Pain (present with an acute infection) and Tenderness - touch, chewing

*swallowing is not affected, it is only with the act of opening when pain is felt this is because the outer portion of the canal skin is behind the TMJ so as one opens the mouth the condyle moves also allowing the cartilaginous portion to move.

o Scanty discharge

Etiologic Organism (usually there is multiple organism causing swimmer’s ear)o Pseudomonas o Proteuso Staphylococcus

o Streptococcuso Gram negative

Treatment (never let the patient clean his ears as it only

aggravates the problem)o Gentle cleaning (first and most

important step which involves removing the debris and drying the ear canal)

o Ear wick + Topical Antibiotic Drops (antibiotic must not reach the deeper portion, so an ear wick is inserted – an elongated gauze which also helps to open the ear canal, and it is place for 48 hours and ear drops is placed )

o Analgesics/Antipyretics (given until infection subsides)

o Oral Antibiotics (is not usually given, only given if inflammation has reached the soft tissue inside the ear, or when enlarge lymphnodes are already palpated)

*remember approach is not always the same so you have to do otoscopy and the rest of physical exams and history

Fig.2 Appearance of a swollen ear canal, verynarrow lumen due to the edema and swelling

of the skin, with dry secretion and scanty discharge

Ear wick

Pathogenesis: An inflammatory condition of the external auditory canal involving the canal skin (eczema. Dermatitis due to a mechanical injury, toxicity or allergy) gives rise to an acute bacterial infection of the skin with a mixed flora that includes gram-negative organisms (P. aeruginosa, P. mirabilis) and anaerobes. A warm , moist climate promotes the development of a diffuse otitis externa

Itching- main initial symptoms Diagnosis:

Otoscopy: appears dry, cracked and scaly Bacteriologic exam: necessary only in cases with persistent or recurrent infection or if the diagnosis is uncertain

Complications: perichondritis, cellulites or abscess formation Necrotizing otitis media in predisposed patient

Steroid- and antibiotic-containing ear drops should be used for no more than two weeks due to the risk of sensitization, antibiotic resistance, and the development of a fungal infection. These are contraindicated in patients with a fungal infection of the ear canal, antibiotic hypersentivity, or a perforated tympanic membrane.

AY 2010-2011

Subject ENTTopic Otorrhea

Date 13 October 2010

Lecturer Dr. Brendan Ferrolino

Transcriber Jmie Pages

Editor

B. Furuculosis

*Infection of the pilosebaceous glands, appear as small abscess, skin easily ruptures so discharge comes out Also known as Circumscribed Otitis Externa

Signs and Symptoms* symptoms basically the same with diffuse otitis externa, but the ear canal are not really occluded, just the outer portion

o Pain and Tenderness -touch, chewing (can cause mild hearing loss and rarely leads to otorrhea)

o Purulent discharge -if ruptured Etiologic Organism: Staphylococcus aureus ( as

it is very common in superficial skin infection) Treatment

o Gentle cleaning o Incision and drainage (for abscess that have

clearly become demarcated)o Analgesics/Antipyreticso Oral Antibiotics (only if infection results to

cellulites around the ear)

C. Herpes Zoster Oticus*not a common condition but is very disturbing for the patient

vesiculo-pustular lesions with swelling and erythema of the skin which is very painful (the vesicles initially contains clear fluid but yellowish and bloody as it ruptures due to the bacteria it contains, painful since the facial nerve that supplies the ear canal and pinna has sensory innervations in the ear])

external ear canal is narrowed due to swelling

there may be ipsilateral facial paralysis due to involvement of Geniculate Ganglion of CN VII (infection is not the problem as it resolves after two weeks but it is the resulting facial paralysis)

Treatmento Analgesic Wound Careo Antibiotic Antiviral

A circumscribed lesion caused by an acute bacterial infection of the cartilaginous portion of the ear canal Pathogenesis: local mechanical trauma and contamination of the ear canal (e.g. from an ear plug, dusty environment, bath

water, or attempted self-cleaning of the ear) lead to obstruction of the hair follicles or glandular ducts, followed by a staphylococcal infection of the pilosebaceous units.

Diagnosis: Inspection and palpation: tragal tenderness accompanied by a circumscribed, very painful swelling in the cartilaginous portion of the ear canalOtoscopy: pronounced swelling of the ear canal with debris in the residual lumen. Frequently the tympanic membrane cannot be seen, but it is normalSimple hearing test: The ear canal may be swollen shut, causing some degree of conductive hearing lossBacteriologic examination: the purulent center of the lesion (pus pocket) can be opened with small, blunt hook to obtain a smear

Complications: perichondritis ( if it spreads to the auricular cartilage)Necrotizing otitis externa in predisposed patients as a result of superinfection with Pseudomonas

after cleaning, it is treated locally for 1-2 days with 70% alcohol, which is applied hourly to a self-expanding foam or gauze wick inserted into the ear canal. This treatment provides disinfection, reduces local swelling by fluid absorption and exerts a cooling action that relieves pain.

o Surgery ( reserved for those who already have degeneration of facial nerve)

D. Other External Ear Disorders

1. OtomycosisChief complaint of the patient: ITCHINESS (The problem is not pain but itchiness accounting for secondary infection due to the manipulation inside the ear)*Refers to patient that have fungal infection of the ear. Most cases with otitis externa have fungal infection, either before or after the episode of acute infection.

Fig. Whitish debri Fig. With hyphae in the ear canal + debri.

2. Impacted CerumenChief Complaint: BLOCKED HEARING in the AFFECTED SIDE (cerumen is normal in the outer portion, the abnormality relies in the amount of cerumen produce, and as it is pushed inside the px complains of blocked hearing. )

HERPES ZOSTER OTICUS Also known as Ramsay Hurt Syndrome Pathogenesis: caused by reactivation of the dormant varicella-zoster virus (VZV) in ganglion cells. Involves CN VII and/or VIII (and occasionally IX and X) Symptoms: px initially experience ear pain or burning on one side in the absnce of physical findings

Vesicles erupt a few days after symptom onset Followed by hearing loss, vestibular complaints such as vertigo and disequilibrium and often by facial nerve palsy

Diagnosis: diagnosiss can be made clinicallyInspection: vesicles along the meatus and concha and occasionally and pinna. Accompanying lymphadenitis of the high cervical lymph nodes

Signs and symptoms Confirmation by the direct electron microscopic detection of VZV in vesicular aspirate or by ATleast a four-fold titer increase on

serologic testing. Differential Diagnosis: Bullous otitis externa

Otitis media, mastoiditis, labyrynthitis, cholesteatoma, aand tumors of the ear and lateral skull base – other causes of 7th and 8th CN lesion

Complications: secondary bacterial infection (usually with staphylococci and pseudomonas speciesZoster meningoenehalitis which results from the intracranial spread of the VZVPost-zoster neuralgia – late complication, esp. in older patient

OtomycosisPathogenesis: cerumen often harbors saprophytic fungi that have no specific pathologic significance. A warm, most climate is conducive to fungal infections, which are most common during summer months.Symptoms: manifested by severe itching and a feeking of fullness in the affected earDiagnosis: Otoscopy- white, yellow or black membrane lining the swollen erythematous skin of the ear canal

Bony portion affected most exclusivelyMycelia identified in direct samplesMicrobiologic exam- to determine the causative agent

Course: runs refractory course and has a tendency to recurComplications: perforation and subsequent otitis mediaTreatment: clean and dry the ear canal

Local antimycotics Salicylate-containing solution- in the uppermost epithelial layer, to enhance the antifungal action of specific medications Systemic antimycotic therapy is necessary only in immune-suppressed patients

Impacted Cerumen Physiology: cerumen or earwax is producedby the cerumen and sebaceous glands in the skin of the ear canal. It forms a protective film in

which fatty acids, lysozymes and the creation of an acid mileu effectively protect the skin of the ear canal. Self- cleansing of the ear canal, with natural removal of accumulated cerumen, is normally accomplished by epithelial migration from the tympanic membrane toward the external meatus.

Pathophysiology: Cerumen impaction may result from a disturbance of the normal self-cleansing mechanism or or from excessive cerumen secretion. The cerumen plug consists mainly of secretions from the cerumen glands mixed with sebum, exfoliative debris, and contaminants. Imprudent cleaning of the ear canal can interfere with the self-cleansing mechanism and displace the cerumen toward the tympanic membrane. Obstruction of the ear canal by cerumen may be caused by the impaction or swelling of a cerumen plug. This occurs after contact with water. With ageing, drying of the meatal skin and changes in the secretions can lead to the formation of a hard cerumen that tends to be retained in the ear, especially with a narrow canal.

Symptoms: pressure sensation in the ear with concomitant hearing loss. Some may also complain of vertigo or tinnitus Diagnosis: Otoscopy- obstruction of ear canal by a yellowish-brown to black material, variable consistency Particular attention is given to tympanic membrane perforations and previous temporal bone fractures or otologic surgery. Differential diagnosis: choleastoma, tumor, foreign bodies and crusted blood Complications: Otitis externa Treatment: removal of cerumen and cerumen plugs using a hook or curette

Aural irrigation Otomicroscope- used in supervising the instrumental cleaning of the ear canal.

3. Aural Polyp*Mass is seen in the ear canal, can

present with bleeding *biopsy must be done to determine if its

benign or malignant

4. Psoriasis*Scaly, whitish discoloration

* bounded laterally by the ear drum* important structure: Ossicular chain

Eustachian tube* A very small confined chain that is important for hearing and balance

IV. MIDDLE EAR DISORDER

MIDDLE EAR Occupies a central position in the temporal bone consists of:

1. Tympanic cavity bounded laterally by the tympanic membranea. Tympanic Cavity

o allows for unrestricted mobility of the tympanic membraneb. Tympanic Membrane

o Function▪ gather sounds like the microphone▪ provides sonic shielding of the round window membrane

o consists of pars tensa and pars flaccid2. System of temporal bone air cells

o mucosa lined air cells of the temporal bone

3. Eustachian Tubeo connects the tympanic cavity/middle ear with the nasopharynxo Equalize static air pressure

air-filled cavity subdivided into:1. Tympanic cavity2. Mastoid air cells

communicate with the nasopharynx via the Eustachian tube Function:

1. Impedance matching2. equalize static pressure

A. OTITS MEDIA inflammation of the middle ear Classification based on Duration of Symptoms

1. Acute < 3 weeks2. Subacute3. Chronic > 3 months

Abnormal Eustachian Tube: most important prognostic factor in pathogenesis(It can be affected in all age groups especially in neonates up to elder, what happens in the Eustachian tube reflects what happens to the ear drum)

i. Eustachian Tube Dysfunction in Otitis Media1. Obstruction

The lateral third is bony the medial 2/3 is cartilaginous, so it is very soft so when it collapse it closes unabling it to functionas a drainage and for ventilation

a. Functional▪ collapse of tube▪ inability to open▪ as in cleft palate, cranio-facial deformity, Pierre-Robin, Downs, Crouzons

b. Mechanical▪ Intrinsic - inflammation (URTI), allergy

( infection and inflammation from the nose, nasopharynx and adenoids that obstructs the eustatian tube)

▪ Extrinsic - tumor, adenoid

2. Abnormal Patency▪ patulous (always open) - loss of weight ▪ leads to “reflux” otitis media (reflux from secretion of the nasopharynx which is not sterile as the

middle ear so bacteria can access the middle ear through it)

Eustachian Tube connects middle ear with nasopharynx ( in the nasopharynx, airway passes, adenoids is also located

just beside the opening, in children it is usually enlarged until 2-3 yrs old.) lined by columnar ciliated secretory epithelium normally closed opens on contraction of Tensor Veli Palatini muscle which is attached to the palate *if one has

congenital anomaly of the palate he usually have ventilation problem. Eustachian tube can also be affected by tumors, recurrent infection of sinuses Anatomical difference of the Eustachian Tube of Infants VS Adults

*infants are really prone to development of Otitis mediaInfants Adults

Shorter and horizontally oriented Longer and angulated (45˚)Prone to reflux from nasopharynx Drains betterPoor function of Tensor Veli Palatini

*Because of its anatomical location, reflux of milk intake in infants goes to the middle ear initiating the inflammatory process.

Functions1. Drains the middle ear secretion

▪ by mucociliary clearance of respiratory epithelium2. Protects the middle ear from nasopharyngeal secretions and sound pressure

▪ opens only by contraction of TVP3. Ventilates the middle ear for optimum hearing

▪ most important function, if pressure inside is not equal to the environment, there is an effect in the eardrum affecting the hearing.

▪ If pressure is too high= eardrum bulges▪ If the pressure is too low= eardrum retraction

*it also creates barrier in ascending infectionsIn cases of otitis media always keepin mind what happens in the Eustachian tube nasopharynx, nasal cavity, status of paranasal sinuses.

Patulous Eustachian Tube Etiopathogenesis: when there is weight loss, there is a diminished amount of fat and connective tissue surrounding the

eutaschian tube leading to a permanently open connection may be established bet. the nasopharynx and tympanic membrane

Symptoms: aural fullness, vague hearing problems without objective hearing loss, occasional roaring tinnitus. Diagnosis: Otoscopy

Hearing tests NormalEndoscopic exam

Treatment: treat the underlying causeSubmucous injection of collagen- if symptoms are persistent and very distressful

ii. Pathogenesis of Otitis Media▪ Factors

1. Infection (URTI)2. Eustachian tube dysfunction3. Immunologic status4. Allergy5. Environment6. Social Factors

▪ Especially true in infants and young children (esp. those in enrolled in daycare centers)

iii. Sequences of Events in Otitis Media

Upper Respiratory Tract Infection↓

Mucosal Congestion↓

Eustachian Tube Dysfunction↓

Persistent Negative Middle Ear Pressure

Otitis Media with Effusion Eustachian Tube suddenly opens↓

Nasopharynx secretions insuffiated↓

Bacterial Otitis Media

*when there is negative pressure there is effusion due to transudation of fluid from the blood vessel, capillaries and mucosa to the middle ear space causing clear whitish secretion. * persistent negative pressure caused the eardrum to retracts causing atelectasis of the eardrum, so in some cases the Eustachian tube suddenly opens,allowing the secretions from nasopharynx which contains bacteria to go in the middle ear causing bacterial otitis media- thick yellowish secretion with intact eardrum

iv. Diagnosis of Otitis Media1. Clinical History (concise) 2. PE Findings (otoscopic findings)3. Pneumatic otoscopy (otoscope+bulb)4. Audiometry and Tympanometry

v. Types of Otitis Media1. Suppurative

a. Aerotitis - Barotrauma▪ Barotrauma

- when pressure difference outside and inside the middle ear is more than 90 mmHg- differences in atmospheric pressure when you ride an airplane.

During Ascent▪ during ascent there is passive opening of Eustachian tube▪ atmospheric pressure is less than middle ear pressure▪ Eustachian tube opens up easily to equalize pressure (When the plane takes off there is passive opening of the Eustachian tube since the pressure

withing the atmospheric pressure is lower and the pressure within the ear is higher, so air moves from the middle ear and goes out the eustachian tube, so no problem as it can easily open up)

During Descent▪ during descent, there is no passive opening of the Eustachian tube▪ atmospheric pressure is greater than the middle ear pressure

▪ eardrum retracts▪ Eustachian tube closes and TVP needs to open (but during landing there is problem with the opening of the Eustachian tube, since the

atmospheric pressure is higher than the middle ear and it impinges with the openingof the Eustachian tube so that it closes. So Longer problem in hearing during landing. And kids cry during the flight because of the pain due to change in pressure. )

b. Serous Otitis Media or Otitis Media with Effusion▪ Acute or Chronic▪ Closed ET results in fluid transudation from blood vessel▪ Causes: allergy, sinusitis, enlarged adenoid, rhinitis ,nasopharyngeal tumor▪ Chief complaint: HEARING LOSS▪ Work-up needed: check the nose, sinuses, and nasopharynx▪ Treatment: Antihistamines - Decongestants

AntibioticsMucolyticsAllergy ManagementEustachian tube inflationMyringotomy with ventilation tubeAdenoidectomy

>CHRONIC OME: Chronic Otitis Media with Effusion▪ mucoid to purulent effusion in middle ear▪ intact, thickened, opaque eardrum

2. Non-suppurativea. Acute Suppurative

BAROTRAUMA A rapid change in air pressure can have acute traumatic effects on the tympanic membrane and middle ear due to a

negative pressurein the tympanic cavity. The Teed scale classifies barotraumas into five grades of severity based on otoscopic findings:

I- erythema of the pars flaccidII- erythema of the entire tympanic membraneIII- Hematoma of the tympanic membraneIV- HematotympanumV- Rupture of the tympanic membrane

Etiopathogenesis: barotraumas is caused mainly by compression events associated with airplane landings or diving. When the ambient pressure rises and there is inadequate pressure equalization through the Eustachian tube, a negative pressure will develop in the tympanic cavity relative to the environment. This can lead to swelling and bleeding of the middle ear mucosa.the tympanic membrane is retracted inward, and the round window bulges into the middle ear. This can result in a perforation of the tympanic membrane or round window membrane

Symptoms: initial symptom is severe ear painConductive hearing loss (unnoticed due to pain)Vertigo and nystagmus (in some cases)

Diagnosis: HistoryOtoscopy: reveals tympanic membrane changes, a middle ear effusion, or a rupture of the tympanic membrane, depending on the grade of injury

Complications: during diving- cold water can enter the middle ear, causing caloric irritation of the vestibular organ with associated vertigo, loss of orientation and possible vomiting.

Bacterial infectionPermanent cochleovestibular dysfunction

Treatment: Paracentesis to relieve the negative pressureMedication including nonsteroidal-anti-inflammatory agents or steroids to reduce the swellingBed rest

Otitis Media with Effusion Refers t o an inflammation effusion behind an intact tympanic membtrane that is not associated with acute otologic

symptoms or systemic signs. Classification: Acute- last up to 3 weeks

Subacute – up to 3 months Chronic – more than 3 mos.

Epidemiology: common in pre-school-age chil;dren Symptoms: In children- Hearing loss , Speech and language delay and perceptual impairment (may occur in bilateral cases)

In adult- clogged or pressure sensation, pain (rarely present, popping or sloshing sound, hearing loss and pressure sensation (very troublesome unlike in children)

Complications: acute otitis media, labyrinthitis Treatment:

Acute:- improve nasal breathing and euustachian tube function with:Short-term use of decongestant nose dropsMoisturizing and hygienic measuresTopical steroidsInflation of a balloon with noseValsava maneuver

Chronic: paracentesis Myringotomy

Stages1. Hyperemia

▪onset of disease▪ear fullness, earache, fever▪Physical Examination: congestion and retraction of eardrum▪Treatment

a. Bed Restb. Analgesicsc. Decongestant

2. Exudation▪ fluid under pressure in the middle ear▪ more severe ear pain, fullness and fever▪ Physical Examination: red, thickened bulging ear drum▪ Treatment

a. Antibioticsb. Decongestantc. Analgesicsd. Myringotomy

3. Suppuration▪ ear drum ruptures▪ profuse otorrhea maybe blood-tinged▪ relief of pain and fever▪ hearing loss worsens▪ Treatment

a. Clean ear canal of dischargeb. Systemic antibioticsc. Ear drop if discharge lessens

▪ disease process may stop at this stage

4. Coalescence and Surgical Mastoiditis▪breakdown of mastoid air cells with pus accumulation▪post aural pain and mastoid tenderness, fever▪sagging bony canal wall▪Treatment

a. Antibioticsb. Mastoidectomy

5. Stages of Complications▪ pathways for spread

a. Bone erosionb. Thrombophlebitisc. Preformed openingd. Surgical openinge. Hematogenous

6. Stage of Resolution▪may occur at any stage

b. Acute Necrotizing▪ in acutely ill young children, low resistance▪ Etiology: β Hemolytic Streptococcus▪ Profuse, foul otorrhea▪ Large eardrum perforation with necrotic middle ear▪ Treatment

a. IV Antibioticsb. Mastoidectomy

c. Chronic Suppurativeo chronic inflammation of middle ear and mastoid

▪ non-intact ear drum▪ discharge present▪ Treatment

a. Aural cleaningb. Treat predisposing factor (allergy, infection)c. Topical antibioticsd. Surgery

Safe DangerousCentral perforation Marginal, attic, totalMucoid-purulent, non-foul, profuse otorrhea Purulent, foul, scanty otorrhea

Mucosa, edematous, with small granulation Large polyp and granulationConductive hearing loss Mixed hearing lossX-ray; no cholesteatoma X-ray; with cholesteatomaTreatment: medical + surgery to preserve hearing Treatment: surgery for complications

d. Tuberculous

vi. Microbiology in Otitis Media1. Acute Otitis Media and Otitis Media with Effusion

a. S. pneumoniae (AOM: 35%)b. H. influenza (AOM: 23%)c. Moraxella catarrhalisd. Others

2. Chronic Suppurative Otitis Mediaa. P. aeruginosab. S. aureusc. Anaerobesd. Others: E.coli, H. influenza, Proteus, Strep

3. No growth in Cultureso Non-bacterial organism (virus, chlamydia)o Anaerobic organismo Immune response to pollens, antigeno Prior antibiotic treatmento Effect of host enzymes vs bacteria

(lysozymes, immunoglobulins)vii. Management

Chronic SuppurativeOtitis Media Chronic tympanic membrane perforation- does not healspontaneously after a few weeks Classification:

a. Dry- without active inflammatory signs such as pain, discharghe, and swelling of the mucosab. Wet or draining form- presence of discharge

Etiopathogenesis:a. Chronic inflammation secondary to E.T. dysfunctionb. Genetic and constitutional factors that affect the healing capacity and resistance of the mucosac. Special anatomic characteristics of the middle ear spaces such as pneumatization and relative sizesd. Nature, pathogenecity, virulence and resistance of the infecting organisms

Symptoms: presents with chronic otorrhea- mucopurulent dischargePain only felt on recurrenceChronic drainage- odorless, stringy mucus

Diagnosis: HistoryOtoscopy- in dry ear, central perforation in the tympanic membrane that does not involve the fibrocartilaginous ringWet ear, with secretions, inflamed and swollenValsava maneuver

Complications: mastoiditis or abscess formation (rare and atypical) Conductive hearing loss with cochlear hearing loss

Treatment: cleaning and dryingEar drops containing ototoxic substance – aminoglycoside antibioticstympanoplasty

Microbiological Findings in Middle Ear Aspirates from 38 infants and children (51 ears) with Chronic Suppurative Otitis Media

Species No. of Isolates

Pseudomonas aeruginosa 34S. aureus (7β-lactamase inhibitor) 10Diphtheroids 10S. epidermidis 6Streptococcus, alpha 4S. pneumonia 3E. coli 2C. albicans 2H. influenza, non typable 2C. parapulosis 2Enterococcus species 2Pseudomonas maltophilia 2Proteus mirabilis 2S. pyogenes 1

viii. Antimicrobial Agents for Therapy of Acute Otitis Media (United States, 1994)

Approved Under Investigation

AmoxicillinAmoxicillin-clavulanateCefaclorCefiximeCefuroxime axetilCefprozilCefpodoximeLoracarbefTrimethoprim/sulfamethoxazoleErythromycin/sulfisoxazole

CeftibutenCeftriaxoneClarithromycinAzithromycin

ix. Acute Otitis MediaTreatment:

▪ chemoprophylaxis with antimicrobials amoxicillin 25 mg/kg HS cotrimoxazole 75 mg/kg HS

▪ myringotomy with tube insertion▪ adenoidectomy▪ pneumococcal vaccines

Acute Otitis Media Epidemiology: common disease in infants and small children but can occur in any age Pathogenesis: generally caused by infections that ascends to the middle ear through the E.T. Etiologic Organisms: S. pneumonia, H. influenza, catarrhalis Factors that increase risk: craniofacial anomalies

Previous episode of acute otitis media Presence of chronic serous otitis media

Parental smokingLeaving infants at day-care center

Factor that reduces risk: breastfeeding Symptoms: often preceeded by a viral infection of the upper respiratory tract

Severe earache- initial symptomFever within the 1st 24 hrs. IrritabilityVomitingDiarrheaAural discharge manifesting tympanic membrane perforation

Diagnosis: P.E. mastoid shows no swellingbut may be tenderOtoscopy – opaque thickened, erythematous and sometimes bulging tympanic membrane

Immobile tympanic membrane by pneumatic otoscopyFeatures of conductive hearing lossBacteriologic examination (done only in px with sponatneoius perforation or paracentesisParacentesis for bacteriologic exam (in immunocompromised px, treatment failures and complications)

Differential Diagnosis:otitis externa, chronic otitis media Course: spontaneous perforation of the tympanic membrane may occur. After the acute phase of the inflammation has

subsided, a residual inflammatory effusion will persist in the tympanic cavity for several weeks with associated conductive hearing loss.

Complications: acute mastoiditis Treatment: non-steroidal anti-inflammatory analgesics (acetaminophen) for pain relief

Decongestant nose drops IrrigationAntibiotic therapy – as a rule it is started right away though improvement may occur in 1-2 days w/o antibiotic.

- Should be continued 7-10 days

x. Recurrent Otitis Media▪ chemoprophylaxis with antimicrobials

amoxicillin 25 mg/kg HS cotrimoxazole 75 mg/kg HS

▪ myringotomy with tube insertion▪ adenoidectomy▪ pneumococcal vaccines

xi. Cholesteatoma

▪ accumulation of squamous epithelial debris▪ enlarges like a tumor▪ destroys bone by pressure necrosis and enzymatic action

▪ Typesa. Congenitalb. Acquired – due to COM

▪ retraction pocket

Recurrent Otitis Media Occurrence of 5 or more acute middle ear inflammations in 1 year, or 3 inflammmations in 6 mos. The middle ear heals between episodes, no effusion in the tympanic membrane Epidemiology: disease of infants and small children Etiopathogenesis: same as acute otitis media Symptoms, diagnosis and course: same as acute otitis media

Allergy should be excluded if the hx is suspicios for an allergic rxn Treatment: adenoidectomy can decrease the bacterial burden in the nasopharynx and improve Eustachian tuibe fxn.

Choleastatoma▪ 2 characteristics:

a. Keratinizing squamous epithelium is found in bony spaces at an abnormal locationb. Bone is destroyed through an inflammatory osteoclastic process

Types:a. Congenital or true – very rare and usually found behind an intact tympanic membrane.

- Can occur anywhere in the temporal boneb. Acquired – arises in connection with inflammations and ventilations problems of the middle ear

- Two forms: primary (pars flaccid choleastatoma) and secondary ( pars tensa cholesteatoma) Epidemiology: occurs in any age grp., rare in small children Pathogenesis: primary cause of acwuired is impairment of middle ear ventilation SymptomsL acwuired c. usually present as chronic otitis media

a. Dry, uninfected cholesteatoma – does not cause otalgia or otorrhea. Manifested clinically as functional deficits. Aural pressure- common initial symptomsignifying impaired middle ear ventilation Facial nerve palsy and vestibular dysfxn (rotary vertigo and disequilibrium)

b. Infected with discharge- present as chronic otitis media with otorrhea.Generally fetidWith hearing lossPain with acute exacerbationFacial nerve palsy or vestibular dysfxnAbscess formationMeningitis

diagnostic work-up: Otoscopy- white epithelial debris in a retraction pocket in the attic or in postsuperior quadrant of the tympanic membrane. Occasional bone erosion in the post superior canal wall.

In dry cholesteatoma, brownish-blackcrust in the sup. Canal wall Screening for complications: Hearing test, indicates conductive hearing loss

Facial nerve function test Fistula sign Imaging studies: CT scan

Treatment: Surgery necessary due to the bone destruction caused by cholesteatoma. a. Main goal: eradicate the destructive inflammatory process in the mastoid and tympanic cavity.b. It is also done to improve hearing

A. Extracranial1. Facial Nerve Paralysis

▪ peripheral type▪ affects upper and lower half of face

2. MastoiditisSubperiosteal Abscess▪ Types

a. Post-auricular (most common)b. Pre-auricularc. Bezold’s (tip of mastoid to neck)d. Parapharyngeale. Intracanal

3. Labyrinthitis▪ direct extension of infection or by bone erosion to inner ear

Types Vertigo Hearing LossCircumscribed Mild ConductiveSerous Moderate to Severe Mixed

V. COMPLICATIONS OF OTITIS MEDIA

MASTOIDITIS Inflammation of the aircells of the mastoid process. Present when the inflammatory process is focused on the mucous membranes and bony structures of the mastoid Etiopathogenesis: usually originates from an infection of the middle ear. Most frequent complication of otitis media. Can

also be cause by an inflammatory destructive process (Wegener diseasea0Important pathogenetic factors:

a. degree of mastoid pneumatizationb. virulence of the infecting organismc. host immune statusd. treatment for optitis media

Symptoms: fever, local pain Malaise, abdominal pain, anorexia in infants

Diagnosis: classical triad-a. Prominent auricle with retroauricular swellingb. Tenderness over the mastoidc. Otorrhea

Otoscopy- reveals the feat. Of acute or subacute otitis media w/ or w/o tympanic membrane perforations. Erythematous or swollen post. Wall of external auditory canal

CT scan- best diagnosis, demonstrates clouding of mastoid air cells and middle ear spaces and erosion of the mastoid boneElevation of inflammatory parameters (WBC, CRP, ESR

Treatment: mastoidectomyParacentesis and placement of myuringotomy tube for middle ear decompressionAntibiotics

Suppurative Severe Sensorineural4. Petrositis

▪ infected air cells at Petrous apex of temporal bone▪ Gradenigo’s Syndrome

- discharging ear- retro-orbital pain (CN VI)- diplopia (CN VI palsy)

B. Intracranial1. Extradural Abscess

▪ pus between bone and dura▪ severe otalgia and headache

Subdural Abscess▪ pus between dura and brain▪ fever, headache, seizures, hemiplegia, coma

2. Lateral Sinus Thrombophlebitis▪ extension of infection to lateral sinus – venous drainage from brain▪ “picket fence” fever, chills, headache and severe otalgia▪ Treatment

a. Mastoidectomy with ligation of internal jugular veinb. IV antibiotics

3. Meningitis▪ most common▪ stiff neck, fever, headache and vomiting, seizures, (+) Kernigs and Brudzinski signs▪ lumbar puncture – (+)▪ Treatment

a. High dose of antibioticsb. Mastoidectomy after adequate medical treatment

4. Brain Abscess▪ associated with meningitis, petrositis▪ lateral sinus thrombosis▪ Cerebellar

- aphasia, seizures, visual defects▪ Temporal

- ataxia, tremors, hypotonia, dysdiadokinesia▪ signs of increased intracranial pressure

▪ Stages of Brain Abscessa. Stage of encephalitis + signs of meningitisb. Stage of encapsulation (symptom free)c. Stage of expanding brain abscess (classic signs of increased intracranial pressure)d. Stage of rupture (leads to death)

5. Otitic Hydrocephalus▪ due to decreased absorption of CSF at arachnoid villi▪ signs of increased intracranial pressure

- papilledema, headache, otitis media- sterile CSF

▪ CT Scan: to rule out brain abscess▪ Treatment

- generally self limited- directed at otitis media and increased intracranial pressure

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Meningitis Etiology: result from a clinically overt otitis media, esp. with cholesteatoma. Can also arise from an occult process

involving the lateral skull base Can result from the spread of amiddle ear infection through performed channels (blood vessels, diploic veins)

through the labyrinth, through bone gaps caused by laterobasal fractures, or by contiguous spread from infected osteitis or cholesteatoma.

Symptoms: severe headache, fever, clouding of consciousness and nuchal stiffness Diagnosis: CT scan of the temporal bone with contrast agent administration and lumbar puncture Treatment: antibiotics, corticosteroids

Surgery – diagnostic to establish cause of infection and therapeutic to eradicate the infectiopus focus and eliminate its route of spread.

Course: otogenic meningitis can lead to inner ear disorder or even bilateral blindness