Non-Suppurative Otitis Media Dr. Vishal Sharma

Types Otitis Media with effusion (O.M.E.) Adhesive otitis media Tympanosclerosis Baro-traumatic otitis media

Otitis Media with effusion Presence of serous or mucoid effusion in middle ear cleft with no frank pus. Synonyms: Secretory / Serous otitis media Seromucinous / exudative otitis media Catarrhal otitis media Glue ear

Etiology 1. Eustachian tube dysfunction  Vacuum in M.E.  extravasation of fluid  Lack of drainage of M.E. secretions 2. Upper respiratory tract allergy / viral infection  Increase M.E. secretions 3. Low grade middle ear infection  Inadequate treatment of A.S.O.M.

Causes for E.T. dysfunction 1. Eustachian Tube obstruction Intrinsic edema = infection / allergy / trauma Extrinsic = adenoid / nasopharyngeal tumour / post – Radiotherapy scarring Functional = floppy Eustachian tube 2. Patulous Eustachian tube: reflux of secretions

Causes for E.T. dysfunction 3. Palatal abnormality:  cleft palate / palatal palsy 4. Muco-ciliary pathology:  Infection / allergy / smoking  Kartagener’s syndrome / Young’s syndrome  Surfactant deficiency / Immune deficiency

Causes of E.T. dysfunction

Predisposing conditions Child going to a nursery Early weaning with formula milk Parents who smoke Recurrent respiratory infections Crowded living condition Poor nutrition Cleft palate

Clinical Symptoms Mild deafness in a young child Deafness increases during U.R.T.I. Mild otalgia Blocking sensation in ear Delayed & defective speech due to deafness

Clinical signs 1. Otoscopy: Blue eardrum with restricted mobility Retraction of T.M. in early stage Bulging of T.M. in later stages Fluid level + air bubbles seen behind T.M. 2. Tuning Fork Tests: conductive deafness

Otoscopy

Blue ear drum

Left retracted ear drum

Right air-fluid level

Left air-fluid level

Right air bubbles

Left air bubbles

Investigations

P.T.A.: low frequency conductive deafness Pure Tone Audiometry P.T.A.: low frequency conductive deafness

C curve in ear drum retraction Impedance Audiometry C curve in ear drum retraction

B curve in middle ear effusion Impedance Audiometry B curve in middle ear effusion

X-ray mastoid & Nasopharynx clouding of mastoid air cells + adenoid mass

Medical treatment Antibiotic (Co-amoxyclav) for 2-4 weeks Nasal decongestants (systemic + topical) H1 anti-histamines Auto-inflation of Eustachian tube by Valsalva maneuver Analgesic for acute earache

Non-medical, Non-surgical treatment Politzerization Otovent balloon Ear popper device Eardoc device

Politzerization Rubber tube attached to Politzer bag is put into one nostril & both nostrils pinched. Pt is asked to swallow repeatedly & Politzer bag is squeezed simultaneously.

Otovent balloon device

Technique of inflation

Otovent balloon device Balloon is inflated by blowing air out of nose. When fully inflated, balloon neck is pinched off and nasal occluder is inserted into one nostril. Child is instructed to swallow as balloon is deflated into nasal cavity. Portion of air from balloon enters Eustachian tube & ventilates middle ear.

Ear Popper Device

Ear Popper Device Based on Politzer Maneuver, EarPopper ™ Device delivers a safe, constant, regulated stream of air into nasal cavity. During swallowing, air is diverted to Eustachian tube clearing & ventilating middle ear.

EARDOC device

EARDOC device EARDOC ™ generates & transmits special vibration waves which travel through temporal bone to reach middle ear & Eustachian tube. The waves ease middle ear pressure & drain trapped fluids. As a result edema & pain are reduced.

Surgical treatment Myringotomy (Tympanocentesis) + grommet (Pressure Equalization tube) insertion: Radial incision made in antero-inferior quadrant. For thick fluid, 2 incisions made in antero-inferior quadrant & antero-superior quadrant (Beer can principle).

Surgical treatment Laser or radio-frequency assisted myringotomy: grommet insertion not required Cortical mastoidectomy: for refractory cases with loculated fluid in mastoid Treatment for predisposing factors: adeno-tonsillectomy / antral wash / polypectomy

Myringotomy & grommet insertion

Myringotome

Right Myringotomy incision

Left Myringotomy incision

Myringotomy performed

Beer can principle

Glue like fluid

Shepard’s Grommet

Armstrong’s grommet

Donaldson grommet

Shah’s grommet

T-tube grommet

Grommet insertion

Right grommet in position

Left grommet in position

Grommet in ant-sup quadrant

T-tube grommet in situ

Grommet extrusion Grommet gets extruded on its own due to endothelium growing on its inner surface. Extrudes after 6 - 9 months.

Grommet extrusion

Healed tympanic membrane

Complications of Grommet insertion

Tympanosclerosis

T.M. Perforation

T.M. Perforation

Granulation over grommet

Grommet lost inside

Radiofrequency assisted myringotomy

Cortical Mastoidectomy

Sequelae of O.M.E. T.M. atrophy & atelectasis Adhesive otitis media Tympanosclerosis Cholesterol granuloma Ossicular necrosis Retraction pocket & cholesteatoma

Prevention of O.M.E. Avoid irritants like cigarette smoke Identify & avoid any allergens Consider a smaller day care centre (< 6 children) Wash hands & toys frequently Use air filters & provide fresh air at home Encourage breastfeeding Use of pneumococcal vaccine

Adhesive Otitis Media Pathology: TM atrophy + atelectasis (due to dissolution of fibrous layer) + adhesions in M.E. cavity, following chronic O.M.E. Clinical Features: 1. Conductive deafness 2. Thin retracted T.M. with no mobility

Adhesive Otitis Media

Adhesive Otitis Media Treatment: 1. Hearing Aid 2. Surgery (long term results are poor) a. Tympanotomy + release adhesions + put silastic sheet b/w promontory & TM. b. Grommet insertion

Left grommet in position

Tympanosclerosis Deposition of hyaline (acellular + avascular collagen) + calcium deposits in submucosal tissue of T.M. & M.E. cavity following long- standing otitis media

Tympanosclerosis Treatment: 1. Hearing Aid 2. Surgery (long term results are poor) Remove tymapnosclerotic plaque & perform tympanoplasty

Barotrauma of middle ear

Pathogenesis E.T. has collapsible cartilaginous part & rigid bony part Allows expulsion of air from middle ear into E.T. but not suction of air into middle ear via ET.

Etiology Failure of Eustachian tube to equalize rapid increase in pressure difference b/w middle ear & atmosphere, over a long period. During ascent: middle ear pressure is more than Atmospheric Pressure  no barotrauma in normal middle ear During descent: middle ear pressure is less than Atmospheric Pressure  barotrauma occurs

Pathology in normal Middle Ear Symptoms Pressure Difference Pathology in normal Middle Ear Symptoms - 60 mm Hg Hyperaemia + edema + exudation + T.M. retraction Otalgia, deafness, tinnitus - 90 mm Hg (less in pt with cold) Locking of E.T. (collapse of lumen), microscopic hemorrhage Severe otalgia - 100 to 400 mm Hg T.M. rupture Frank blood otorrhoea

Treatment Nasal decongestants + H1 anti-histamines Politzerization for middle ear aeration Myringotomy + grommet insertion done for: refractory cases presence of haemotympanum

Prevention 1. Avoid air travel during cold / nasal allergy 2. During descent while flying:  Do repeated swallows (lozenges / gum)  Do intermittent Valsalva maneuvre  Avoid sleeping (as swallowing is decreased) 3. Pt with previous episode: take nasal decon-gestant + antihistamine 30 min before descent.

Thank You