Diseases of the middle ear and eustachian tube Yard.Doç.Dr.Müzeyyen Doğan

Otitis Media Most common reason for visit to pediatrician Most common reason for visit to pediatrician Tympanostomy tube placement is 2nd most common surgical procedure in children Tympanostomy tube placement is 2nd most common surgical procedure in children Development of multidrug-resistant bacteria Development of multidrug-resistant bacteria

Otitis Media - History Egyptian mummies have perforations of TM and mastoid destruction Egyptian mummies have perforations of TM and mastoid destruction Prehistoric Iranian population has evidence of middle ear disease Prehistoric Iranian population has evidence of middle ear disease

Middle Ear Structures 1- Malleus 2- Incus --Ossicles 3- Stapes 4- Tympanic Membrane (Eardrum) 5- Round Window 6- Eustachian Tube

Middle Ear Structures 1- Malleus 2- Incus --Ossicles 3- Stapes 4- Tympanic Membrane (Eardrum) 5- Round Window 6- Eustachian Tube

Eustachian Tube Connects middle ear and nasopharynx Connects middle ear and nasopharynx Lumen shaped like two cones with apex directed toward middle Lumen shaped like two cones with apex directed toward middle Mucosa has mucous producing cells and ciliated cells Mucosa has mucous producing cells and ciliated cells

Eustachian tube Adults Adults ant 2/3- cartilaginous ant 2/3- cartilaginous post 1/3- bony post 1/3- bony 45 degree angle 45 degree angle isthmus 1-2 mm isthmus 1-2 mm nasopharyngeal orifice 8-9 mm nasopharyngeal orifice 8-9 mm Children Children longer bony portion 10 degree angle isthmus larger nasopharyngeal orifice 4-5 mm in infants

Eustachian tube Usually closed Usually closed Opens during swallowing, yawning, and sneezing Opens during swallowing, yawning, and sneezing Opening involves cartilaginous portion Opening involves cartilaginous portion Tensor veli palatini responsible for active tubal opening Tensor veli palatini responsible for active tubal opening No constrictor function No constrictor function

Eustachian tube Protection from nasopharyngeal sound and secretions Protection from nasopharyngeal sound and secretions clearance of middle ear secretions clearance of middle ear secretions ventilation (pressure regulation) of middle ear ventilation (pressure regulation) of middle ear

Pathology Edema, capillary engorgement, and PMN infiltration Edema, capillary engorgement, and PMN infiltration Epithelial ulceration and granulation tissue Epithelial ulceration and granulation tissue Fibrosis, influx of chronic inflammatory cells Fibrosis, influx of chronic inflammatory cells Increased columnar and goblet cells Increased columnar and goblet cells Osteitis Osteitis Edema and polypoid changes Edema and polypoid changes

Otitis Media - Definition Inflammation of the middle ear May also involve inflammation of mastoid, petrous apex, and perilabyrinthine air cells

Otitis Media - Classification Acute OM - rapid onset of signs & sx, < 3 wk course Acute OM - rapid onset of signs & sx, < 3 wk course Subacute OM - 3 wks to 3 mos Subacute OM - 3 wks to 3 mos Chronic OM - 3 mos or longer Chronic OM - 3 mos or longer

OM - Epidemiology Age Age Race Race Day care Day care Seasons Seasons Genetics Genetics Breast-feeding Breast-feeding Smoke exposure Smoke exposure Medical conditions Medical conditions

OM - Epidemiology Increasing incidence? Increasing incidence? Increases after newborn period Increases after newborn period 2/3 with AOM by one year of age 2/3 with AOM by one year of age 1/2 with >3 episodes by three years 1/2 with >3 episodes by three years most common in mos most common in mos

OM - persistent middle ear effusion (MEE) High incidence of MEE, avg of 40 days High incidence of MEE, avg of 40 days Children less that 2 years much more likely to have persistent MEE Children less that 2 years much more likely to have persistent MEE White children with higher incidence of MEE White children with higher incidence of MEE

Otitis Media - Race Higher incidence in: Higher incidence in: Eskimos Eskimos Native Americans Native Americans Australian and African aborigines Australian and African aborigines

OM - Day Care Greater risk of AOM in children < 3 years Greater risk of AOM in children < 3 years Home care best, large group day care worst Home care best, large group day care worst more exposures with wider range of flora more exposures with wider range of flora increased URI’s increased URI’s more frequent visits to MD to decrease parental leave time from work more frequent visits to MD to decrease parental leave time from work

OM - Breast-feeding Decreases incidence of URI and GI disease Decreases incidence of URI and GI disease Inverse relationship between incidence of OM and duration of breast-feeding Inverse relationship between incidence of OM and duration of breast-feeding Protective factor in breast-milk? Protective factor in breast-milk?

OM - smoke exposure Induces changes in respiratory tract Induces changes in respiratory tract Increased otorrhea, chronic and recurrent AOM in children with hx of parental smoking Increased otorrhea, chronic and recurrent AOM in children with hx of parental smoking

OM - Medical Conditions Cleft palate Cleft palate decreases after repair decreases after repair Craniofacial disorders Craniofacial disorders Treacher-Collins Treacher-Collins Down’s syndrome Down’s syndrome Ciliary dysfunction Ciliary dysfunction Immune dysfunction Immune dysfunction AIDS steroids, chemo IgG deficiency Obstruction Obstruction NG tubes NT intubation adenoids malignancy

Pathology Eustachian tube abnormalities Eustachian tube abnormalities Impaired opening Impaired opening shorter tube shorter tube Impaired immunity Impaired immunity children have poorer immune response children have poorer immune response less cytokines in nasopharynx in children with OM less cytokines in nasopharynx in children with OM Inflammatory mediators Inflammatory mediators Bacterial products induce inflam response with IL-1, IL-6, and TNF Bacterial products induce inflam response with IL-1, IL-6, and TNF Allergy Allergy

Microbiology S. pneumoniae % S. pneumoniae % H. influenzae % H. influenzae % M. catarrhalis % M. catarrhalis % Group A strep - 2-4% Group A strep - 2-4% Infants with higher incidence of gram negative bacilli Infants with higher incidence of gram negative bacilli

Virology RSV - 74% of middle ear isolates RSV - 74% of middle ear isolates Rhinovirus Rhinovirus Parainfluenza virus Parainfluenza virus Influenza virus Influenza virus

Chronic MEE Previously thought sterile Previously thought sterile 30-50% grow in culture 30-50% grow in culture over 75% PCR + over 75% PCR + Usual organisms Usual organisms

Diagnosis Acute OM Acute OM preceding URI preceding URI fever, otalgia, hearing loss, otorrhea fever, otalgia, hearing loss, otorrhea may have assoc constitutional sx may have assoc constitutional sx Chronic MEE Chronic MEE poss asymptomatic hearing loss “plugged” “popping”

Diagnosis Pneumatic otoscopy is gold standard Pneumatic otoscopy is gold standard Color - opaque, yellow, blue, red, pink Color - opaque, yellow, blue, red, pink Position - bulging, retracted Position - bulging, retracted Mobility - normal, hypomobile, neg pressure Mobility - normal, hypomobile, neg pressure Assoc pathology - perfs, cholesteatoma, retraction pockets Assoc pathology - perfs, cholesteatoma, retraction pockets Head & neck exam Head & neck exam

Diagnosis Audiogram Audiogram document CHL, SNHL, baseline, preop document CHL, SNHL, baseline, preop sooner if high risk sooner if high risk Impedance Impedance Acoustic reflexes Acoustic reflexes

Treatment - AOM Adults and older children - observation? Adults and older children - observation? Antibiotics - consider drug resistance patterns Antibiotics - consider drug resistance patterns Amoxil - not for B lactamase + Amoxil - not for B lactamase + TMP-SMT - not for group A strep TMP-SMT - not for group A strep Need high middle ear concentrations Need high middle ear concentrations

Antibiotics First line First line Amoxil mg/kg divided tid Amoxil mg/kg divided tid Ceftin - B lactam stable Ceftin - B lactam stable Augmentin - B lactam stable Augmentin - B lactam stable Bactrim, Pediazole Bactrim, Pediazole Second line Second line Augmentin Augmentin Ceftin Ceftin Rocephin Rocephin Macrolides - Zithromax, Biaxin Macrolides - Zithromax, Biaxin

Treatment - Recurrent AOM Chemoprophylaxis Chemoprophylaxis Sulfisoxazole, amoxicillin, ampicillin, pcn Sulfisoxazole, amoxicillin, ampicillin, pcn less efficacy for intermittent propylaxis less efficacy for intermittent propylaxis Myringotomy and tube insertion Myringotomy and tube insertion decreased # and severity of AOM decreased # and severity of AOM otorrhea and other complications otorrhea and other complications may require prophylaxis if severe may require prophylaxis if severe Adenoidectomy Adenoidectomy 28% and 35% fewer episodes of AOM at first and second years 28% and 35% fewer episodes of AOM at first and second years

Treatment - OME MEE > 3 mos or assoc hearing loss, vertigo, frequency, ME pathology, discomfort MEE > 3 mos or assoc hearing loss, vertigo, frequency, ME pathology, discomfort Antibiotics Antibiotics shown to be of benefit, 75% PCR + bacterial DNA shown to be of benefit, 75% PCR + bacterial DNA Antibiotics + steroid Antibiotics + steroid 21% improvement compared to abx alone 21% improvement compared to abx alone Myringotomy & tympanostomy +/- adenoidectomy Myringotomy & tympanostomy +/- adenoidectomy

Tympanostomy tube insertion Recurrent MEE with excessive cumulative duration Recurrent MEE with excessive cumulative duration Recurrent AOM - >3/6 mos or >4/12 mos Recurrent AOM - >3/6 mos or >4/12 mos Eustachian tube dysfunction Eustachian tube dysfunction Suppurative complication Suppurative complication

Complications Intratemporal Intratemporal hearing loss hearing loss TM perforation TM perforation CSOM CSOM retraction pockets retraction pockets cholesteatoma cholesteatoma mastoiditis mastoiditis petrositis petrositis labyrinthitis labyrinthitis adhesive OM adhesive OM tympanosclerosis tympanosclerosis ossicular dyscontinuity and fixation ossicular dyscontinuity and fixation facial paralysis facial paralysis cholesterol granuloma cholesterol granuloma necrotizing OE necrotizing OE Intracranial Intracranial meningitis extradural abscess subdural empyema focal encephalitis brain abscess lateral sinus thrombosis otitic hydrocephalus

adhesive OM

TM perforation

CSOM (dry)

CSOM

cholesteatoma

tympanosclerosis