1. DISORDERS OF MIDDLE EAR
ENT531
By :
Rydaa Hibah
Ghada Reyof
Nora

2. Acute Supportive Otitis Media

3. It is an acute inflammation of middle ear by pyogenic organisms .
Middle ear implies middle ear cleft , i.e eustachian tube , middle ear , attic , aditus , antrum and mastoid air cells.

4. Etiology
It is more common especially in infants and children of lower socioeconomic group .
Typically the disease follows viral infection of upper respiratory tract but soon the pyogenic organisms invade the middle ear .

5. Routes of infection
1- Via eustachian tube ; it is the most common route . Infiction travels via the lumn of the tube or along subepithelial peritubal lymphatics .
2- Via external ear ; trumatic perforations of tympanic membrane due to any cause open a route to middle ear infection .
3- Blood – borne ; this is an uncommon route .

6. Predisposing factors
Any thing that interferes with normal functioning of Eustachian tube predisposes to middle ear infection . It could be;
1- recurrent attacks of common cold , upper respiratory tract infection and exanthematous fevers like measles, diphtheria or whooping cough .
2- infections of tonsils and adenoids .
3- chronic rhinitis and sinusitis .
4- Nasal allergy.
5- Tumors of nasopharynx, packing of nose or nasopharynx for epistaxis.
6- cleft palate.

7. Pathology
ASOM is a bacterial disease caused by pus forming organisms. Pathogenic bacteria have been isolated from the nasopharynx in up to 97% of children with ASOM. The bacterial infection may be a primary infection, or secondary following a viral acute non-suppurative otitis media. Bacteria enter the middle ear cleft via the eustachian tube, a tympanic membrane perforation or are blood-borne. Common organisms include:
Streptocococcus pneumoniae .
Haemophilus influenzae
Moraxella catarrhalis

8. Clinical features
Deafness - a conductive hearing loss which progresses
Pain - due to accumulation of pus and pressure necrosis of the tympanic membrane
Otorrhoea - occurs after episodes of pain, and is due to perforation of the tympanic membrane and release of pus
Pyrexia - children are typically fretful with a high (>39 degrees c) pyrexia
Tympanic membrane - is initially dull, then becomes hyperaemic. Evenually becomes full, angry and red, and finally perforates if unresolved

10. Treatment 1- Antibacterial therapy 2- Decongestant nasal drop
- Amoxicillin or Augmentin
2- Decongestant nasal drop
- Ephedrine nose drops
3- Oral nasal decongestants.
- Pseudoephedrine
4- Analgesics and antipyretics.
5- Dry local heat.

11. Treatment
6- Myringotomy
- It is incising the drum to evacuate pus and is indicated when
drum is bulging and there is acute pain
there is an incomplete resolution despite antibiotics when drum remains full with persistent conductive deafness
there is persistent effusion beyond 12 weeks

12. Recurrent Acute Otitis Media

13. Recurrent Acute Otitis Media
What is it: occur after acute upper respiratory infection, the child being free of symptoms between the episodes. Recurrent middle infections may sometimes be superimposed upon an existing middle ear effusion Age group: Infants and children between the age of 6 months and 6 years may get recurrent episodes of acute otitis media. Occur: four to five times in a year. Causes: recurrent sinusitis,velopharyngeal insufficiency, hypertrophy of adenoids, infected tonsils, allergy and immune deficiency,Feeding the babies in supine position without propping up the head may also cause the milk to enter the middle ear directly that can lead to middle ear infection.

14. Management:
1. Finding the cause and eliminating it, if possible. 2. Antimicrobial prophylaxis. -Amoxicillin (20 mg/kg for 3–6 months) - Sulfisoxazole. 3. Myringotomy and insertion of tympanostomy tube. -If the child has 4 bouts of acute otitis media in 6 months or 6 bouts in 1 year, insertion of a tympanostomy tube is recommended. 4. Adenoidectomy with or without tonsillectomy. 5. Management of inhalant or food allergy

15. Otitis Media With Effusion

16. This is an insidious condition characterized by accumulation of non-purulent effusion in the middle ear cleft.
The effusion is thick and viscid but sometimes it may be thin and serous. The fluid is nearly sterile. commonly seen in school-going children.

17. pathogenesis
1. Malfunctioning of Eustachian tube. Eustachian tube fails to aerate the middle ear and is also unable to drain the fluid.
2. Increased secretory activity of middle ear mucosa.

18. Etiology 1- Malfunctioning of eustachian tube: A- Adenoid hyperplasia
b-chronic rhinitis and sinusitis
c-chronic tonsillitis: enlarged tonsils block the movement of soft palate
d-Tumors of nasopharynx
e-palatal defect eg: cleft palate
2- allergy
3-unresolved otitis media
4-viral infection

19. Clinical feature
Symptoms: The disease affects children of 5- 8 years of age. The symptoms include:
(1) Hearing loss: sometimes it’s the only symptom
(2 Delayed and defective speech. Because of the hearing loss
(3) Mild earaches: there may be a history of Upper respiratory tract infection

20. Clinical assessment Otoscopic findings:
Tympanic membrane is often dull and opaque with loss of light reflex.
May appear yellow, grey or bluish in color.
Thin leash of blood vessels may be seen along the handle of malleus or at the periphery of tympanic membrane and differs from marked congestion of acute suppurative otitis media.
Tympanic membrane may show retraction, it may appear full or slightly bulging in its posterior part due to effusion. Province of lateral process, decrease in mobility of T.M has bulging contour “difficult to assessing ossicular land mark

21. Hearing Tests:
Tuning fork:
Rinne’s Test:
If the air is louder than bone “positive” (normal)
If the bone is louder than air “negative” (conductive hearing loss),
Weber’s Test:
Sound heard in midline (normal)
Tests show conductive hearing loss
(patient hears better in the diseased ear)

22. (2) Audiometry:
There is conductive hearing loss of 20–40 dB. Sometimes, there is associated sensorineural hearing loss due to fluid pressing on the round window membrane. This disappears with evacuation of fluid.
(3) Impedance audiometry:
It is an objective test useful in infants and children, it gives information on how mobile the tympanic membrane is and the volume of the canal.
(4) Tympanometry (type B):
A flat or dome-shaped graph. No change in compliance with pressure changes. Seen in middle ear fluid or thick tympanic membrane.
(5) X-ray mastoids: There is clouding of air cells due to fluid accumulation.

23. Treatment
The aim of the treatment is to remove the fluid and to preventits recurrence again.
A. Medical :
1. Decongestants: such as nasal drops
2. Antiallergic measures: Antihistamine
3. Antibiotics:
Useful in cases of upper respiratory tract infections or unresolved acute suppurative otitis media.
4.Middle ear aeration:Valsalva manoeuvre.

24. B. Surgical:
When fluid is thick and medical treatment alone does not help, fluid must
be surgically removed.
1.Myringotomy and aspiration of fluid:
An incision is made in tympanic membrane and fluid aspirated with suction
ventilation tube insertion
2. Tympanotomy or cortical mastoidectomy.
3. Surgical treatment of causative factor:
Such as adenoidectomy or tonsillectomy

26. Aero-Otitis Media ( Otitic Barotrauma )

27. It Is a Non-Suppurative condition resulting from failure of eustachian tube to maintain middle ear pressure at ambient atmospheric level.

28. Boyle’s law Volume is inversely proportional to pressure in fixed mass of gas

29. Mechanism
During descent environmental pressure is higher than ME pressure, therefore we need to aerate the ME actively by VALSALVA manouvre/other methods If the tube does not open and the pressure gradient increases beyond 90 mm of Hg, tube gets locked Similar during deep sea diving & hyperbaric chamber

30. TM congested/ retracted
Clinical Features
Sever air ache
Hearing loss
TM congested/ retracted
Tinnitus

31. OTITIC BAROTRAUMA- EARLY

32. Treatment
The aim is to restore middle ear aeration. This is done in mild cases by decongestant nasal drops or oral nasal decongestant with antihistaminics are helpful.
In the presence of fluid or failure of the above methods, Myringotomy may be performed to “unlock” the tube and aspirate the fluid.

33. Ero-otitis can be prevented by the following measures:
Avoid air travel in the presence of upper respiratory infection .
Do not permit sleep during descent .
Autoinflation of the tube by Valsalva should be performed.
Use vasoconstrictor nasal spray and a tablet of antihistaminic and systemic decongestant, half an hour before descent
In recurrent barotrauma, attention should be paid to nasal polyps, septal deviation, nasal allergy and chronic sinus infections.

34. Chronic Otitis Media

35. Chronic Suppurative Middle Ear Infection CSOM
Long-standing infection of a part or whole of the middle ear cleft characterized by ear discharge and a permanent perforation.
TUBOTYMPANIC
(MUCOSAL DISEASE)
ATTICOANTRAL
(CHOLESEATOMA)

36. Tubotympanic Type
The disease starts in childhood and is therefore common in that age group
It is the sequelae of acute otitis media usually following exanthematous fever and leaving behind a large central perforation.

37. Microbiology Pseudomonas Aeroginosa  Proteus E. Coli 
Staphylococcus Aureus

38. Types Pathological changes
• Active :when the ear is actively discharging
• Inactive :when the ear is dry 
Pathological changes
• Perforation is almost always central
• Mucosa is inflammed, edematous
• Polyps may be seen
• Ossicular chain is usually intact
• Mastoid is usually cellular

39. Clinical Features 1. Ear discharge: 2. Perforation : 3. Hearing loss :
Non offensive, mucoid or mucopurulent. Constant or intermittent.
2. Perforation :
Central - anterior, posterior or inferior to handle of malleus.
3. Hearing loss :
Conductive type
4. Middle ear mucosa :
Pale pink and moist – normal
Red oedematous and swollen - inflammed

40. Rx option Suction clearance. Avoidance of water. 
Treat primary cause.
Antibiotics: Systemic and Topical (ear drop neomycin/gentamycin combined with steroid 
Surgical treatment: aural polyp or granulation, if present should removed before local treatment w/ abx
Reconstructive surgery: Myringoplasty -/+ Reconstruction of ossicles
• Closure of TM defect - Myringoplasty
• Reconstruction of ossicles – Ossiculoplaty

41. Atticoantral Type

42. CHOLESTEATOMA
Cholesteatoma is a destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or mastoid process.

43. The cholesteatoma is classified into:
1. Congenital
2. Acquired,
- primary
- secondary

44. 1. Congenital cholesteatoma. It arises from the embryonic
epidermal cell rests in the middle ear cleft or temporal bone.
A middle ear congenital cholesteatoma presents as a white
mass behind an intact tympanic membrane and causes conductive
hearing loss.
It may also spontaneously rupture through the tympanic membrane and present with a discharging ear indistinguishable from a case of chronic suppurative otitis media.

46. 2. Primary acquired cholesteatoma
2. Primary acquired cholesteatoma . It is called primary as there is no history of previous otitis media or a pre-existing perforation. Theories on its genesis are:
(A)  Invagination of pars flaccida: Persistent negative pressure in the attic causes a retraction pocket which accumulates keratin debris. When infected, the keratin mass expands towards the middle ear.
(B)  Basal cell hyperplasia: There is proliferation of the basal layer of pars flaccida induced by subclinical childhood infections.
(C)  Squamous metaplasia: Normal pavement epithelium of attic undergoes metaplasia, keratinizing squamous epithelium due to subclinical infections.

47. 3. Secondary acquired cholesteatoma
3. Secondary acquired cholesteatoma. In these cases, there is already a pre-existing perforation in pars tensa. This is often associated with posterosuperior marginal perforation or sometimes large central perforation. Theories on its genesis include:
(A) Migration of squamous epithelium: Keratinizing squamous epithelium of external auditory canal or outer surface of tympanic membrane migrates through the perforation into the middle ear.
(B) Metaplasia: Middle ear mucosa undergoes metaplasia due to repeated infections of middle ear through the pre-existing perforation.

48. EXPANSION OF CHOLESTEATOMA AND DESTRUCTION OF BONE
Once cholesteatoma enters the middle ear cleft, it invades the surrounding structures, first by following the path of least resistance, and then by enzymatic bone destruction.
Cholesteatoma has the property to destroy bone. It may cause destruction of ear ossicles, erosion of bony labyrinth and canal of facial nerve.

49. Symptoms of cholesteatoma:
Hearing loss.
Discharge from the ear with or without an odor.
Tinnitus.
Dizziness
Headache
Earache 
Fullness or pressure in ear.
Facial weakness or paralysis

50. Diagnosis The diagnosis can be made based on :
physical examination of the ear with an otoscope.
- The dead skin tissue can sometimes be seen
through the eardrum.
Radiologic findings through:
(CT) scanning is the diagnostic imaging modality of choice for these lesions, owing to its ability to detect subtle bony defects.
 (MRI) is used when very specific problems, such as the following, are suspected :
Dural involvement or invasion
Subdural or epidural abscess
Brain herniation into the mastoid cavity

51. Treatment Cholesteatoma is a persistent disease.
The standard treatment of cholesteatoma is to surgically remove the growth.
Types of surgeries are:
1- canal wall up
2- canal wall down
Antibiotics and ear drops to treat any infection.
Ototopical medications:
Antibiotic only otic drops:
Floxin.
Antibiotic with steroid otic drops:
Ciprodex

52. Thank you