Otitis Media and Eustachian Tube Dysfunction R. Kent Dyer, Jr., M.D. Hough Ear Institute Oklahoma City, Oklahoma USA

Incidence of Otitis Media (OM) Most common disease of childhood after viral URI 15 million cases of Acute OM/year in U.S. Cost of treatment: >$5 billion/year

Pathology of Acute Otitis Media Viral or Bacterial Insult Edema Leukocyte Infiltration Purulent Exudate/Granulation Tissue ET Obstruction vs. Resolution Fibrosis

Pathogenesis of Otitis Media Infection (viral vs. bacterial) Abnormal eustachian tube function Allergy (minor role) Neoplasm (nasopharyngeal carcinoma) Sinusitis

Eustachian Tube Function Protection from nasopharyngeal secretions Ventilation Clearance of middle ear secretions

Otitis Media Classification Classified according to: Duration of disease Acute, subacute, chronic Quality of effusion Serous, mucoid, purulent Tympanic membrane appearance

Acute Otitis Media Tympanic membrane: Opaque Bulging/injected Reduced mobility Purulent effusion

Otitis Media with Effusion Tympanic membrane: Translucent or opaque Gray/pink Reduced mobility Effusion present +/- air

Chronic Mucoid OM (Glue Ear) Tympanic membrane: Opaque/gray Retracted, reduced mobility Thick effusion, no air Hearing loss (>20dB HL)

Tympanosclerosis White plaques in Lamina Propria Hyaline deposition Significant conductive hearing loss possible

Obliterative Tympanosclerosis

Atelectasis Collapse or retraction of tympanic membrane Often associated with ossicular pathology Long-standing eustachian tube dysfunction

Attic Retraction Isolated collapse of Pars Flaccida May lead to cholesteatoma

Cholesteatoma Accumulation of squamous epithelium in middle ear & mastoid Osteolytic enzymes Often accompanied by chronic otorrhea

Slide No. 32 – Cholesteatoma – Schematic View When a retraction pocket becomes large enough, the self-cleaning mechanism of the eardrum epithelium is altered. The usual process of epithelial migration and desquamation of death cells is interrupted, allowing large amounts of keratinous material to accumulate. The pressure induced by the expanding keratinous mass often associated with an infectious process accelerates the destructive expansion and lysis of the bony structures. This coronal schematic view of the ear canal and middle ear illustrates the pouching of the severe retractions, accumulation of debris and the destructive expansion involving the mastoid bone and middle ear ossicles. CHOLESTEATOMA A cholesteatoma is an epidermal inclusion cyst with expanding capabilities. It may not only involve the middle ear but through enlargement may involve and destroy adjacent structures. Several theories have been proposed about the pathogenesis of the cholesteatoma:  A) Retraction of the tympanic membrane with invagination, accumulation by trapping of keratinous material, expansion, and infection. B) Invasion by migration of the epithelium of the ear canal through a perforation and into the middle ear. C) Invasion and epithelial metaplasia of the basal cells of the external auditory meatus epithelium. D) Squamous transformation by metaplasia of the middle ear mucosa. E) Congenital. F) Iatrogenic (trapping of epithelium). There is enough evidence in the medical literature to support any of the theories. The most logical concept is to assume that the cholesteatomatous process may begin for any of those reasons. Still, clinically, by far the most observed process is the formation of cholesteatoma by the progressive retraction of the tympanic membrane. The progressive retraction forms a pocket where keratin accumulation begins inducing the formation of a cyst that expands prompting destruction of the osseous structures. Bony destruction may be due to osteoclastic action by the pressure of the cyst, or by a biochemical process induced by the epithelial walls of the cyst itself. The lytic bony process of the cholesteatoma is aggressive and may invade not only the ossicles but also the adjacent structures of the otic capsule. Extratemporal extension may invade intracranial or extracranial structures. The most common symptom of a cholesteatoma is loss of hearing. Cholesteatoma is not painful and otorrhea is infrequent. In children, the disease is diagnosed usually when the magnitude of the cyst is such that it becomes infected and produces a foul smelling otorrhea, resistant to medical treatment. At inspection, a retraction is recognized usually in the posterior superior aspect of the eardrum or the attic. There is accumulation of keratinous material and osseous defects, easy bleeding granulation tissue and polyps may be seen. Definitive treatment for cholesteatoma is surgical. Medical treatment with otic drops (antibiotics – anti-inflammatories) may be established to try to control the infectious process. Pseudomona aeruginosa, Bacteroides sp., and Peptostreptococcus are the most frequently isolated bacteria.

Chronic Suppurative Otitis Media TM Perforation +/- cholesteatoma Otorrhea

Diagnosis of Otitis Media

Ear Examination Slide No. 6 – Ear Examination Normal Eardrum This slide shows a normal eardrum. The pars tensa is of normal color and transparency. In the upper portion of the eardrum, the pars flaccida can be easily inspected. Other structures that can be seen include the umbo, the long and short process of the malleus, and the fibrous annulus. Through the transparency of the eardrum, the long process of the incus, the anterior crura of the stapes, and the stapes tendon can be seen. The corda tympani whitish shadow can be seen in the posterior superior aspect.

Pneumatic Otoscopy Essential for Diagnosis of OM Keys: Air tight seal Adequate visualization of TM

Instrumentation

Tympanometry Useful for confirming diagnosis (if pneumatic exam inadequate) Type C (negative peak) Suggests ET dysfunction Type B (flat) + effusion

Acute Otitis Media Microbiology: S. pneumoniae H. influenza 20-30% PCN resistant H. influenza 30-60% B-Lactamase + M. catarrhalis 90-95% B-Lactamase +

Acute Otitis Media (Day 2)

Acute Otitis Media (1 Week)

Chronic Serous Otitis Media Microbiology: 50% of effusions culture + for bacteria S. pneumoniae, H. influenza, M. catarrhalis

Serous Otitis Media

Chronic Suppurative Otitis Media Microbiology: P. aeruginosa S. aureus Diphtheroids Klebsiella

Management of Acute Otitis Media Amoxicillin 90mg/kg/day Mild PCN allergy (rash) Cephalosporin Severe PCN allergy (anaphylaxis) Azithromycin Clarithromycin

2nd Line Therapy for Otitis Media Amoxicillin/Clavulanate Oral Cephalosporin (2nd or 3rd generation) Macrolide Ceftriaxone (IM)

When to Consider 2nd Line Rx Group day care Antibiotic Rx within last 30 days Failure of antibiotic prophylaxis Refractory AOM Failure to improve with 72 hours

Management of Persistent OM                                        Management of Persistent OM Watchful waiting 90% of effusions will resolve within 3 months Additional 2nd line antibiotics Intranasal steroids Eustachian tube inflation Valsalva vs. Otovent Nasal endoscopy

Factors to Consider with Long-standing Effusions Degree of hearing loss (>20dB HL) Vertigo/imbalance Tympanic membrane changes (retraction) Speech & language delay Behavioral changes Frequency & severity of AOM

Plan of Therapy Amoxil

Plan of Therapy Amoxil If No Improvement in 72 hrs.

Plan of Therapy Amoxil 2nd Line Antibiotic If No Improvement in 72 hrs.

Plan of Therapy Amoxil 2nd Line Antibiotic If No Improvement in 72 hrs. If Persistent Effusion

2nd Line Antibiotic/Monitor (up to 3 months) Plan of Therapy Amoxil 2nd Line Antibiotic 2nd Line Antibiotic/Monitor (up to 3 months) If No Improvement in 72 hrs. If Persistent Effusion

Plan of Therapy Amoxil 2nd Line Antibiotic 2nd Line Antibiotic/Monitor (up to 3 months) Modify Risk Factors (when possible) & Check Hearing Status If No Improvement in 72 hrs. If Persistent Effusion

Plan of Therapy Amoxil 2nd Line Antibiotic 2nd Line Antibiotic/Monitor (up to 3 months) Modify Risk Factors (when possible) & Check Hearing Status Tympanocentesis usually not indicated If No Improvement in 72 hrs. If Persistent Effusion

Indications for Tympanostomy Tubes >5 episodes of AOM in 6-9 months Persistent ME effusion x 3 months Complication of OM Failure of antibiotic prophylaxis Acute Mastoiditis

Indications for Tympanostomy Tubes Craniofacial anomaly Structural changes to TM Speech & language delay

Serous Otitis Media w/Retraction

Choice of Tubes Short-lasting (6-12 mo.) Intermediate (12-18 mo.) Long-lasting (>18 mo.)

Straight Vent Tube Shaft Lumen Medial flange

Grommet/Bobbin Style Lumen Flanges

TUBE INDUCED PERFORATION T TYPE Vent tube Medial Flange Shaft TUBE INDUCED PERFORATION “GOODE T - TUBE” - Xomed

Post-tube Otorrhea Usually secondary to URI or water exposure Topical antibiotic usually adequate 5-7 days (Floxin, Ciloxin, Ciprodex)

Water Precautions Cotton + Vaseline when bathing Plug Ear Band-It when swimming

Refractory Otorrhea Consider fungal etiology Clotrimazole gtts Amphotericin B powder Cresylate Debridement of ear canal Water Precautions No H2O2!!!

Tube Removal Removal recommended if tube persists >24 months Risk of TM perforation 12-25% if tube retained >2 years