Ear III Prof. Mohammed Attallah College of Medicine King Saud University ORL Course 431 ORL Department King Abdulaziz University Hospital Done by: 428-C2
34
Embed
Prof. Mohammed Attallah College of Medicine King Saud University ORL Course 431 ORL Department King Abdulaziz University Hospital Done by: 428-C2.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Slide 1
Prof. Mohammed Attallah College of Medicine King Saud
University ORL Course 431 ORL Department King Abdulaziz University
Hospital Done by: 428-C2
Slide 2
Slide 3
Normal Middle Ear Cavity
Slide 4
Eustachian tube in short The normal middle ear cavity has 2
openings. Eustachian tube opens into the nasopharynx. Functions:
Aeration of ME cavity Ventilation Equalizing the pressure in the
middle cavity. Any malfunction in eustachian tube can lead to
abnormality in the middle ear. It can be obstructed by edema. Most
common is perforation of tympanic membrane.
Slide 5
Chronic otitis media 1. Chronic non-suppurative otitis media:
Otitis media with effusion (OME, glue ear, secretory). Adhesive
otitis media. Without perforation, meaning no super-added
infection. 2. Chronic suppurative otitis media (more common):
Tubotympanic (safe). Atticontral (unsafe). Associated with
perforation.
Slide 6
CSOM Long standing infection of part or whole of middle ear
cleft, characterized by ear discharge, and permanent perforation.
Perforation becomes permanent when its edges are covered by
squamous epithelium and doesnt heal spontaneously.
Slide 7
Etiology (from 427 ENT) Upper respiratory tract infections.
Eustachian tube dysfunction. Environmental (hot and humid weather).
Genetic. Previous OM (either AOM or OME).
Slide 8
Classifications of CSOM According to site of perforation: 1.
Safe (tubotympanic, anteroinferior): central perforation on TM. On
otoscopy: ruminants of TM around perforation are found. 1. Unsafe
(atticoantaral, posterosuperior): unsafe because its associated
with cholesteatoma: Marginal is at the margin of TM. Attic (pars
flaccida).
Slide 9
Pathology (from 427 ENT) 1. Signs of suppurative infection:
Discharge (ottorhea) and perforation. Chronic inflammatory in the
mucosa and bone (osteitis). 2. Signs of healing attempts (if there
is damage to mucosa): Granulation tissue and polyps. Fibrosis and
typmanosclerosis. 3. Cholesteatoma (in unsafe type).
Slide 10
Symptoms (from 427 ENT) 1. Ottorhea: Intermittent, profuse,
odorless in safe type (mucopurulent discharge). Persistent, scanty,
odorous in unsafe type (odor is due to involvement of the bone). 2.
Deafness: conductive (expect in case of cholesteaome, where it can
cause SNHL). 3. Tinnitus. N.B. any other symptom means
complication.
Slide 11
Investigations in CSOM 1. Audiology: to assess hearing loss.
Conductive, sensory, or mixed hearing deafness. 2. Radiology: for
all CSOM, to test: a) Ossicles. b) Condition of ME cavity. c) Most
importantly, dura level. Tegmen tympani is a very thin bone,
separating ME cavity from middle cranial fossa, allowing
cholesteatoma to extend intra-cranially. check CT scan
pre-operatively to assess the extension, because neurosurgeons may
then be needed. Low dura: Dural level may be normally low, and you
may unknowingly go into the brain. So you have to check radiology!
d) Facial nerve. (35% of facial nerve has normal dehiscence) 3. All
the others: blood, urine, etc. (mostly for anesthesiologists)
Slide 12
Management of CSOM 1. Surgery in 3 forms depending on the case
(of choice): a. Tympanoplasty: closure operation. b. Mastoidectomy:
remove the necrotic tissue. c. Tympanomastoidectomy: cortical
mastoidectomy with tympanoplasty. 2. Medical treatment: as a form
of preparation to the operation; limited use in CSOM.
Slide 13
Healed Tympanic Membrane with tympanosclerosis.
Tympanosclerosis indicates previous perforation that healed, and is
harmless and shouldnt be treated. Should be mentioned in the
patients file, to avoid pseudoreaction or shopping patient: patient
rotates around doctors seeking help. you can see the head of
malleus, the light reflex, right sclerotic mass presenting
perforation.
Slide 14
Safe and Unsafe perforation in chronic otitis media
Slide 15
TOTAL perforation in CSOM: 75% of TM has been lost. It goes
with safe and not associated with cholesteatoma. Problem with total
perforation is failure adaptation or anterior failure: Graft should
be put 2 mm under the normal skin. In total perforation, uptake of
graft is less anteriorly.
Slide 16
Malingoplasty: only close the perforation. Tympanoplasty type
I: Close the TM perforation with graft from temporalis fascia.
Examine the ossicles for continuity with each other and mobility
(if ossicles are immobile, patient cant benefit from
typmanoplasty). Prevents re-infection.
Slide 17
Cortical mastoidectomy operation as the possible operation in
chronic suppurative otitis media.
Slide 18
Types of mastoidectomiy Cortical: Opening the mastoid area, and
clearing all the granulation (infected) tissue. Proper cortical if
: visualize the long process of incus, lateral semicircular canal,
sigmoid sinus, seradural angle, dura plate, tip of mastoid, and
area where facial nerve is most likely there. (posterior meatal
wall) Cortical is done when the infection is limited to the
mastoid, and there is no cholesteatoma. Modified radical.
Radical.
Slide 19
Uses of cortical mastoidectomy As a pathway into the inner ear
for cochlear implants. Therapeutic: Adhesive otitis media: when TM
adheres to promontory, and there is no air in ME cavity. Air is put
behind the TM membrane, leading to re-aeration and reopening of the
eustachian tube. Compression of facial nerve. Labyrinth operations.
Removal of emboli from the sigmoid sinus.
Slide 20
Post auricular incision approach to middle ear and mastoid
Elevate the meatal skin, take a graft from temporalis fascia, then
enter the ME cavity.
Slide 21
Complications of mastoidectomy Most commonly: facial never
paralysis. Nowadays, this ugly complication is prevented by
continuous monitoring in the OR. Mostly, steroid therapy is given.
In severe cases, decompression of nerve is done.
Slide 22
Facial paralysis as a complication of middle ear and mastoid
surgery
Slide 23
Otitis media with effusion (OME) Definition: TM is not
perforated, while the ME cavity is filled with sterile,
non-purulent fluid. Prolonged obstruction of eustachian tube: Air
will be absorbed. Mucosa of ME cavity will change, and become
secretory in nature. Due to eustachian tube blockage, fluid will
accumulate in ME cavity.
Slide 24
Otitis media with effusion (OME) Most common complication is
conductive deafness. Treatment of conductive deafness in OME: Treat
the underlying cause: open the eustachian tube by any means; e.g.
systemic or local antihistamines, remove adenoid, leading to
re-aeration of the middle ear. Sometimes we have to surgically
re-aerate the ME cavity. Aeration is important, because if fluid
continues to accumulate, it will become thick in nature
(glue-like), and TM will adhere to promontory; condition known as
adhesive OM. End stage of mal-treatment of OME is adhesive otitis
media, and the treatment is very difficult.
Slide 25
Adhesive otitis media (end stage) adherence of TM to
promontory, leading to inability to elevate TM from
promontory.
Slide 26
Acute Otitis Media Stage IV Seen here that TM is congested
(bulging). Presents with severe pain and conductive deafness.
Slide 27
Acute Otitis Media Most common in infants, due to the
eustachian tube shape; shorter, wider, and more horizontal. A.
Early stages: 1. Eustachian tube blockage: Adenoid in the
nasopharynx. Obstruction can lead to mal-aeration of middle ear,
which contains air. 2. Mucosa of the middle ear is cuboidal in
nature, not secretory. Permeate: Air absorbed, TM will move
medially (refraction of TM), handle becomes shorter because its
pulled upward and backwards, loss of light reflex in TM.
Slide 28
B. Late stage: Prolonged malaeration of ME, mucosa changes its
nature, becoming secretory. Starts to secrete fluid into ME cavity,
leading to conductive deafness. Proper otoscopy of canal: Hair
sign: visualizing the air-fluid level in TM (not seen anymore). At
this stage, the patient has conductive deafness. (OME)
Slide 29
Pathophysiology of Otitis Media (from 427 ENT) Eustachian tube
occlusion: discomfort autophony, retracted drum due to negative
pressure. Exudates inflammation: fever, earache (due to fluid
accumulation), deafness and congested ear drum. Suppurative
inflammation: bulging of drum due to increased pressure in tympanic
cavity, increased severity of fever, congestion and bulging of the
drum, deafness. TM rupture: due to increased pressure, otorrhea,
high temperature, and ear ache will subside. Resolution. N.B. these
stages take place if OM isnt treated. The fever of OM can be raised
at any stage of OM.
Slide 30
Stages of AOM Retrograde infection from nasopharynx: Stage I:
congestion of blood vessels along the handle of malleus. Stage II:
if not treated, congestion radiates to periphery. Stage III: The
entire TM becomes red in color with bulging and severe pain. Stage
IV: spontaneous rupture of TM, releasing fluid into EAC, the pain
subsides.
Slide 31
Management Medical (of choice): Admission, IV antibiotics,
analgesics, antihistamines to re-open the eustachian tube. In some
cases if there is bulging like the previous case; myringotomy is
done to evacuate the ME cavity from its contents. If myringotomy
was not done, TM may rupture, and its always better to surgically
incise than rupture. Surgical: If there is bulging, we do
ventilation tube insertion.
Slide 32
Treatment (from ENT 427) 1. Antimicrobial treatment for 7 days:
Amoxicillin + calvulonic acid = Augmentin. Trimethoprim /
sulphamethoxazole. Cefaclore / cepxime. Erythromycin
sulphisomoxazole. 2. Decongestants: Nasal drops or spray to iopen
the eustachian tube by vasoconstriction. 3. Myringotomy: If the TM
is bulging. For culture sensitivity if ibfection fails t resolve
properly. 4. Ear toilet and local antibiotics.
Slide 33
Ventilation tube insertion (surgical treatment of otitis media)
Inserted in the anterioinferior quadrant of TM, to promote proper
aeration of ME cavity, and to drain the fluid if present. Types of
tubes: Shahmen: small, and doesnt cause any irritation. Golden: not
used in KAUH, because its thick and heavy.