ACUTE AND CHRONIC OTITIS MEDIA Prof. İlhan TOPALOĞLU M.D Otolaryngology Department Yeditepe University, School of Medicine

Objectives To define acute otitis media (AOM) and chronic otitis media (COM) To understand the clinical presentation and diagnostic evaluation of AOM and COM To define the various types of cholesteatoma and how they develop. To provide an overview of the management of AOM and COM.

Acute Otitis Media (AOM) The diagnosis of AOM requires: History of acute onset signs and symptoms Presence of middle ear effusion (MEE) Signs and symptoms of middle ear inflammation The presence of MEE is indicated by: A bulging tympanic membrane Limited or absent tympanic membrane mobility Air-fluid level behind the TM - Otorrhea (drainage from the ear) Signs of middle ear inflammation include: Erythema of the tympanic membrane - Otalgia (ear pain)

Acute Otitis Media (AOM)

Etiology of Acute Otitis Media S. pneumoniae 25% H. influenzae 20-25% M. catarrhalis 10-20% S. pyogenes (gr. A) 2% S. aureus 1% No growth up to 35%

Recurrent Acute Otitis Media Multiple bouts of acute otitis media with complete resolution between episodes 4 episodes in 6 months or 6 episodes in 1 year is an indication for tympanostomy tube placement

Otitis Media with Effusion (Chronic non-suppurative Otitis Media) Middle ear filled with serous or mucoid fluid No purulence Often present after acute otitis media is treated appropriately with antibiotics Most will clear within 3 months

Etiology of OME 50% sterile to culture Molecular techniques find bacterial products When culture +, similar to AOM

Medical Treatment of OME Observation – many European countries wait 6-9 months prior to placement of ear tubes Antibiotics Meta-analysis shows beneficial short-term resolution of OME Unclear long-term impact Audiogram at 3 months with persistent effusion to determine impact on hearing

Tympanostomy Tubes In the US, chronic OME >3mos with hearing loss and/or speech delay is an indication for tympanostomy tube placement Not just there to “drain fluid” Bypass Eustachian tube to ventilate middle ear

Middle Ear Atelectasis Lack of middle ear ventilation results in negative pressure within the tympanic cavity The ear drum retracts onto structures within the middle ear The result of long standing Eustachian tube dysfunction The drum loses structural integrity and becomes flaccid Contact between the drum and the incus or stapes can cause bone erosion at the IS joint Can sometimes be treated with tympanostomy tubes

Middle Ear Atelectasis

Middle Ear Atelectasis Patient is at risk for cholesteatoma due to skin accumulation within retraction pockets Drum contact with the incus and/or stapes cause erosion of the incudostapedial (IS) joint TM is flaccid and non-vibratory – affects hearing Early atelectasis may be treatable with tympanostomy tubes Severe atelectasis requires removal of the flaccid ear drum and replacement using cartilage (cartilage tympanoplasty) This adds rigidity to the drum at the expense of vibratory capacity

Chronic otitis media (COM) with and without cholesteatoma

Definition COM: unresolved inflammatory process of the middle ear and mastoid associated with TM perforation, otorrhea and hearing loss.

Etiology Unresolved middle ear infection Dysfunction of Eustachian tube Chronic inflammation in nose and pharynx Dysfunction of immune system

Chronic otitis media Chronic infection of the middle ear Perforation of the tympanic membrane Patients present with hearing loss Otorrhea (ear drainage) Middle ear mucosa becomes edematous, polypoid, or ulcerated The tympanic cavity usually contains granulation tissue

Near Total TM Perforation These more severe perforations. The middle ear structures can be easily seen. Note the malleus handle, umbo, incudostapedial joint, stapedius muscle, stapes in the oval window, and round window. A perforation of this size is likely to require surgical repair.

Clinical presentations Hearing loss Air conduction threshold is within 30 dB means TM proferation with intact ossicular chain İf air conduction threshold is more than 30 dB is associated with discontinuity of ossicular chain

Ossicular erosion is frequent in COM It most commonly affect the lenticular process of the incus and head of the stapes Necrosis following vascular thrombosis

Clinical presentations Otorrhea Frequently, malodorous associated with cholesteatoma

Pathology Middle ear mucosa is lined by secretory epithelium forming glandlike structure. Hyalinization or tympanosclerosis A healing response It occurs during quiescent periods It is formed by fused collagenous fibers It is hardened by the deposition of calcium and phosphate crystals Conductive hearing loss is associated with masses restricting ossicular mobility

Chronic otitis media Most common infecting organisms are Pseudomonas aeruginosa, Staphylococcus aureus, Proteus species, Klebsiella pneumoniae, Diphteroids

Cholesteatoma

Cholesteatoma Cholesteatomas are epidermal inclusion cysts of the middle ear and/or mastoid with a squamous epithelial lining Contain keratin and desquamated epithelium Natural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation

Classification Congenital cholesteatoma Acquired cholesteatoma

Congenital cholesteatoma Diagnosis criteria: Patients without previous history of ear disease, with normal and intact TM The temporal bone pneumatization should be normal

Congenital cholesteatoma Epidermal inclusion cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice Diagnosed as a pearly white mass behind an intact tympanic membrane in a child who does not have a history of chronic ear disease

Acquired Cholesteatoma Pathogenesis Invagination Basal cell hyperplasia Migration (through a perforation) Squamous metaplasia

Invagination Theory Retraction pocket cholesteatoma usually within the pars flaccida or posterior superior tympanic membrane Secondary to ETD Keratin debris collects within a retraction pocket Epytympanic cholesteatoma Mesotympanic cholesteatoma

Migration Theory Most accepted Originates from a tympanic membrane perforation As the edges of the TM try to heal, the squamous epithelium migrates into the middle ear

Acquired cholesteatoma

Diagnosis History, physical examination, CT scan of the temporal bone Axial Section Coronal Section

Cholesteatoma Imaging

Cholesteatoma Imaging

Ototopical Medications Antibiotic only otic drops Siprogut (ciprofloxin ) Ophthalmic antibiotic preparations Exocin (ofloxacin) Steroid only otic drops Cebedex (dexamethasone) Norsol (prednisolon) The concentration of antibiotic in ototopical drops is 100-1000x greater than what can be achieved systemically.

Tympanoplasty Paper patch myringoplasty Fat myringoplasty Underlay tympanoplasty (medial graft technique)

Underlay Tympanoplasty

Ossicular Chain Reconstruction

Mastoidectomy Intact (bony ear) canal wall mastoidectomy Canal wall down mastoidectomy Radical Mastoidectomy Modified Radical Mastoidectomy

Mastoidectomy Tympanoplasty with mastoidectomy and hydroxyapatite bone cement ossicular reconstruction

Complications of Otitis Media EKSTRA CRANIAL Facial paralysis Acute or coalescent mastoiditis Petrositis Sub-periosteal abscess Post-auricular fistula Bezold abscess Labyrinthitis

Complications of Otitis Media INTRA CRANIAL Meningitis Epidural abscess Subdural abscess Brain abscess Sigmoid sinus thrombosis Cavernous sinus thrombosis Otitic Hydrocephalus Encephalitis Cerebellitis

Complications of Otitis Media Due to antibiotics, the incidence of complications has greatly declined. Complications are usually associated with some degree of bone destruction, granulation tissue formation, or the presence of a cholesteatoma. Complications arise most commonly by infection spreading by direct extension from the middle ear or mastoid cavity to adjacent structures.

Acute mastoiditis with sub-periosteal abscess Infection in the mastoid has eroded through the mastoid cortex forming a “subperiosteal abscess.” This condition requires antibiotics and surgical drainage.

Brain Abscess