Otitis media with effusion Chunfu Dai M.D & Ph.D Otolaryngology Department Eye Ear Nose & Throat Hospital Fudan University

Background Otitis media is a multifactorial disease process involving immunology, infectious disease, anatomic considerations, social and socioeconomic issues, and genetics, among other factors. Approximately 70% of children below the age of 3 will develop an episode of otitis media.

Background 65-95% of children by the age of 7 years will experience one or more episodes of acute otitis media. It remains the commonest cause for visit to the doctor in the pediatric population.

Background Myringotomy was performed in eighteenth and nineteenth centuries to treat otitis media. During the preantibiotic era, the primary concern was the potential for intracranial complications of acute otitis media In 1954, Armstrong’s reintroduction of the tympanostomy tube, after that, few true advances in the treatment of otitis media was developed.

Definition OME is an inflammatory condition of the middle ear and mastoid air cell system characterized by accumulation of fluid in the middle ear without signs or symptoms of acute infection.

Other names: Secretory otitis media, Serous otitis media, Glue ear, Nonpurulent otitis media, Catarrhal otitis media.

Pathogenesis Dysfunction of Eustachian tube Obstruction of Eustachian tube Mechanic obstruction enlarged adenoid, tumor, enlarged inferior turbinate Non mechanic obstruction Weakness of related muscle, Clearance and defense Immotile cilia syndrome

Pathogenesis Infection Immunity PCR detects the middle ear fluid, positive findings was 70% S pneumonia, haemophalus influenzae, haemolytic streptocuccus Immunity Middle ear is a isolated immune system Inflammatory mediators Specific antibody, immunologic complex Antigen may from adenoid or nasopharygeal lymph

Classification of Otitis media Otitis meda with effusion: the presence of middle ear effusion. If the middle ear effusion is present for 8 weeks or longer, it is classified chronic otitis media with effusion

Microbiology of otitis media Bacteria can be isolated from one third of patient who have OME. The most common are S pneumonia, H influenzae, and M catarrhalis (using traditional culture method). By using PCR, these three bacteria were detected in approximately 70% of Chronic middle ear effusion.

Diagnosis It is usually asymptomatic. Hearing loss Fullness Otalgia Kid can not concentrate himself Turn on TV in loudness If one ear is normal, the above symptoms will be ignored Fullness Otalgia Tinnitus

Diagnosis The diagnosis is made at physical exam. TM may retracted, dull, and opaque. The color of TM may range from light pink to amber even dark blue. The presence of air bubbles or air fluid levels makes the diagnosis more evident.

Diagnosis Tympanometry Middle ear pressure more negative than -200 (type C) or a flat tympanometry curve (type B) is classified as a failure. A child fail test without marked HL (less than 20 dB) should be retest 2 months later. 10-14% of patients with low compliance tympanograms have only tympanic membrane retraction or thickening without effusion. While occlusion of the probe by cerumen or the child’s crying can cause invalid results.

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Diagnosis Hearing test Rinne test: negative Audiogram: conductive hearing loss, no more than 40 dB Tympanogram: B type or C type Lateral nasopharyngeal radiograph: hypertroph of adenoid Nasopharyngeal exam: to exclude space-occupation lesion

Differentiated diagnosis Nasopharyngeal carcinoma: Unilateral OME EBV-VCA-IgA Nasoendoscope CT or MRI Biopsy CSF (cerebrospinal fluid) leakage Head trauma Meningitis

Differentiated diagnosis Perilymphatic fluid fistula Secondary to stapes surgery or barotrauma Vertigo Hearing test: sensorineural hearing loss or mixed hearing loss Cholestrol granuloma (heamotympanum) Advanced stage of OME Tympanic membrane: blue CT: soft tissue in mastoid or middle cavity

Differentiated diagnosis Atelectatic Otitis media Sequela of OME Conductive hearing loss TM contacts with ossicular chain, promotory

Diagnosis of otitis media Differentiate diagnosis of AOM and OME will benefit our treatment, as the latter condition is usually not treated unless it becomes chronic

Diagnosis of otitis media OME is a relatively asymptomatic middle ear effusion. Pneumatic otoscope frequently shows either a retracted or concave tympanic membrane. In addition, an air-fluid level or bubbles, or both may be observed through a translucent tympanic membrane.

Managements Principles: discharge middle fluid Drainage, ventilation Eliminate pathogenesis

Managements Non surgical treatment Antibiotics Steroid Improvement of nose congestion

Managements Surgical treatment Tympanocentesis Myrigotomy Tympanotomy with PT mastoidectomy

Management of AOM alternative medical treatment Corticosteroid (orally or intranasally), Antihistamine, decongestants Orally corticosteroid and intranasally corticosteroid help clear chronic middle ear effusion. However, there is no evidence of efficacy in treatment of AOM. Antihistamine and decongestants are used in the treatment of OME, it does not benefit AOM. Children who have nasal congestion and allergic rhinitis there may be a role for these preparation.

Otitis media with effusion The nature history of this disease is for spontaneous resolution in the majority of case More the 80% resolution by 2 month. It is the small number of children who continue to have effusion after 2-3 months that are concern. A trial of antibiotics would be appear to be appropriate in those children who have not received antibiotics recently. OME is probably underdiagnosis.

Otitis media with effusion Chronic OME is defined as an effusion persisting for more than 3 months duration. A dense effusion typically may confer up to a 30 dB hearing loss. Chronic OME may have a role in development of retraction pockets, ossicular chain erosion, and cholesteatoma formation.

Otitis media with effusion Meta-analyses have come to conclusion that antibiotics have a small but distinct advantage over placebo in the treatment of persistent OME. When the effusion is chronic, surgical intervention should be considered, especially when antibiotic therapy fail. The primary surgical therapy remains placement of tympanostomy tubes for pressure equalization and drainage of middle ear.

Surgical treatment for otitis media Placement of tympanostomy tubes. Middle ear effusion for more than 3 months or more. OME associated with hearing loss of >30dB Chronic severe TM retraction. Impending intracranial complication Recurrent otitis media with more than 3 episode within a 6 months period, or more than 4 episode within a 12 month period.

Surgical treatment for otitis media Adenoidectomy indications for adenoidectomy Children with chronic otitis media who are candidates for tympanostomy tube placement Children have symptoms for chronic adenoid hypertrophy, Children require multiple sets of tympanostomy tube. It has been demonstrated that adenoidectomy may accelerate the resolution of chronic otitis media regardless of the size of the adenoid pad.

Surgical treatment for otitis media Adenoidectomy With significant risks in children younger than 3 years of age that usually outweight its benefit. Adenoidectomy be a consideration in the child older than 3 years of age at the time of insertion of a second set of tube.

Surgical treatment for otitis media Laser-assisted myringotomy (background) It has been advocated for the management of acute otitis media (unresponsive to medical management) and chronic otitis media with effusion, barotrauma, transtympanic inner ear perfusion. A history of allergies, the presence of a thick tympanic membrane and or high viscocity fluid are all contraindications for laser assisted tympanostomy

Surgical treatment for otitis media It can provide symptom relief and avoid placement of tympanostomy tube by alleviating infection and inflammation or improving middle ear ventilation. Fenestration creates a round opening in the TM within a a fraction of a second and is usually bloodless. It generally last 2-4 weeks

Surgical treatment for otitis media Laser-assisted myringotomy (technique requirement) Spot size ranged from 1.8-2.8mm and power from 7-22w, in general, thicker tympanic membranes required higher power or more than 1 laser discharge. Topic anesthesia in an office setting and general anesthesia in operating room or office-based procedure.

Surgical treatment for otitis media Laser-assisted myringotomy (related results) 2.4 and 2.6 mm spot size resulted in a greater percentage of patent fenestrations, long duration of fenestration was associated with higher cure rate Age of patient, type of fluid, wattage, preoperative tympanogram, or quadrant of TM undergoing fenestration are not predictors for duration of fenestration patency. .

Surgical treatment for otitis media The incidence of cure at 90 days for is greater than 60%, and the incidence of cure for OM treated in conjunction with adenoidectomy is greater than 80%. Reduced risk and cost, and more effective and satifaction from parents

Prognosis

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