1. ACUTE AND CHRONIC OTITIS MEDIA
Prof. İlhan TOPALOĞLU M.D
Otolaryngology Department
Yeditepe University, School of Medicine

2. Objectives
To define acute otitis media (AOM) and chronic otitis media (COM)
To understand the clinical presentation and diagnostic evaluation of AOM and COM
To define the various types of cholesteatoma and how they develop.
To provide an overview of the management of AOM and COM.

3. Acute Otitis Media (AOM)
The diagnosis of AOM requires:
History of acute onset signs and symptoms
Presence of middle ear effusion (MEE)
Signs and symptoms of middle ear inflammation
The presence of MEE is indicated by:
A bulging tympanic membrane
Limited or absent tympanic membrane mobility
Air-fluid level behind the TM
- Otorrhea (drainage from the ear)
Signs of middle ear inflammation include:
Erythema of the tympanic membrane
- Otalgia (ear pain)

4. Acute Otitis Media (AOM)

5. Etiology of Acute Otitis Media
S. pneumoniae %
H. influenzae %
M. catarrhalis %
S. pyogenes (gr. A) 2%
S. aureus %
No growth up to 35%

6. Recurrent Acute Otitis Media
Multiple bouts of acute otitis media with complete resolution between episodes
4 episodes in 6 months or 6 episodes in 1 year is an indication for tympanostomy tube placement

7. Otitis Media with Effusion (Chronic non-suppurative Otitis Media)
Middle ear filled with serous or mucoid fluid
No purulence
Often present after acute otitis media is treated appropriately with antibiotics
Most will clear within 3 months

8. Etiology of OME 50% sterile to culture
Molecular techniques find bacterial products
When culture +, similar to AOM

9. Medical Treatment of OME
Observation – many European countries wait 6-9 months prior to placement of ear tubes
Antibiotics
Meta-analysis shows beneficial short-term resolution of OME
Unclear long-term impact
Audiogram at 3 months with persistent effusion to determine impact on hearing

10. Tympanostomy Tubes
In the US, chronic OME >3mos with hearing loss and/or speech delay is an indication for tympanostomy tube placement
Not just there to “drain fluid”
Bypass Eustachian tube to ventilate middle ear

11. Middle Ear Atelectasis
Lack of middle ear ventilation results in negative pressure within the tympanic cavity
The ear drum retracts onto structures within the middle ear
The result of long standing Eustachian tube dysfunction
The drum loses structural integrity and becomes flaccid
Contact between the drum and the incus or stapes can cause bone erosion at the IS joint
Can sometimes be treated with tympanostomy tubes

12. Middle Ear Atelectasis

13. Middle Ear Atelectasis
Patient is at risk for cholesteatoma due to skin accumulation within retraction pockets
Drum contact with the incus and/or stapes cause erosion of the incudostapedial (IS) joint
TM is flaccid and non-vibratory – affects hearing
Early atelectasis may be treatable with tympanostomy tubes
Severe atelectasis requires removal of the flaccid ear drum and replacement using cartilage (cartilage tympanoplasty)
This adds rigidity to the drum at the expense of vibratory capacity

14. Chronic otitis media (COM) with and without cholesteatoma

15. Definition
COM: unresolved inflammatory process of the middle ear and mastoid associated with TM perforation, otorrhea and hearing loss.

16. Etiology Unresolved middle ear infection
Dysfunction of Eustachian tube
Chronic inflammation in nose and pharynx
Dysfunction of immune system

17. Chronic otitis media Chronic infection of the middle ear
Perforation of the tympanic membrane
Patients present with hearing loss
Otorrhea (ear drainage)
Middle ear mucosa becomes edematous, polypoid, or ulcerated
The tympanic cavity usually contains granulation tissue

19. Near Total TM Perforation
These more severe perforations. The middle ear structures can be easily seen. Note the malleus handle, umbo, incudostapedial joint, stapedius muscle, stapes in the oval window, and round window. A perforation of this size is likely to require surgical repair.

20. Clinical presentations
Hearing loss
Air conduction threshold is within 30 dB means TM proferation with intact ossicular chain
İf air conduction threshold is more than 30 dB is associated with discontinuity of ossicular chain

21. Ossicular erosion is frequent in COM
It most commonly affect the lenticular process of the incus and head of the stapes
Necrosis following vascular thrombosis

22. Clinical presentations
Otorrhea
Frequently, malodorous associated with cholesteatoma

23. Pathology
Middle ear mucosa is lined by secretory epithelium forming glandlike structure.
Hyalinization or tympanosclerosis
A healing response
It occurs during quiescent periods
It is formed by fused collagenous fibers
It is hardened by the deposition of calcium and phosphate crystals
Conductive hearing loss is associated with masses restricting ossicular mobility

24. Chronic otitis media Most common infecting organisms are
Pseudomonas aeruginosa,
Staphylococcus aureus,
Proteus species,
Klebsiella pneumoniae,
Diphteroids

25. Cholesteatoma

26. Cholesteatoma
Cholesteatomas are epidermal inclusion cysts of the middle ear and/or mastoid with a squamous epithelial lining
Contain keratin and desquamated epithelium
Natural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation

27. Classification
Congenital cholesteatoma
Acquired cholesteatoma

28. Congenital cholesteatoma
Diagnosis criteria:
Patients without previous history of ear disease, with normal and intact TM
The temporal bone pneumatization should be normal

29. Congenital cholesteatoma
Epidermal inclusion cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice
Diagnosed as a pearly white mass behind an intact tympanic membrane in a child who does not have a history of chronic ear disease

30. Acquired Cholesteatoma
Pathogenesis
Invagination
Basal cell hyperplasia
Migration (through a perforation)
Squamous metaplasia

31. Invagination Theory
Retraction pocket cholesteatoma usually within the pars flaccida or posterior superior tympanic membrane
Secondary to ETD
Keratin debris collects within a retraction pocket
Epytympanic cholesteatoma
Mesotympanic cholesteatoma

32. Migration Theory Most accepted
Originates from a tympanic membrane perforation
As the edges of the TM try to heal, the squamous epithelium migrates into the middle ear

33. Acquired cholesteatoma

34. Diagnosis History, physical examination, CT scan of the temporal bone
Axial Section
Coronal Section

35. Cholesteatoma Imaging

36. Cholesteatoma Imaging

37. Ototopical Medications
Antibiotic only otic drops
Siprogut (ciprofloxin )
Ophthalmic antibiotic preparations
Exocin (ofloxacin)
Steroid only otic drops
Cebedex (dexamethasone)
Norsol (prednisolon)
The concentration of antibiotic in ototopical drops is x greater than what can be achieved systemically.

38. Tympanoplasty Paper patch myringoplasty Fat myringoplasty
Underlay tympanoplasty (medial graft technique)

39. Underlay Tympanoplasty

40. Ossicular Chain Reconstruction

41. Mastoidectomy Intact (bony ear) canal wall mastoidectomy
Canal wall down mastoidectomy
Radical Mastoidectomy
Modified Radical Mastoidectomy

42. Mastoidectomy
Tympanoplasty with mastoidectomy and hydroxyapatite bone cement ossicular reconstruction

43. Complications of Otitis Media
EKSTRA CRANIAL
Facial paralysis
Acute or coalescent mastoiditis
Petrositis
Sub-periosteal abscess
Post-auricular fistula
Bezold abscess
Labyrinthitis

44. Complications of Otitis Media
INTRA CRANIAL
Meningitis
Epidural abscess
Subdural abscess
Brain abscess
Sigmoid sinus thrombosis
Cavernous sinus thrombosis
Otitic Hydrocephalus
Encephalitis
Cerebellitis

45. Complications of Otitis Media
Due to antibiotics, the incidence of complications has greatly declined.
Complications are usually associated with some degree of bone destruction, granulation tissue formation, or the presence of a cholesteatoma.
Complications arise most commonly by infection spreading by direct extension from the middle ear or mastoid cavity to adjacent structures.

46. Acute mastoiditis with sub-periosteal abscess
Infection in the mastoid has eroded through the mastoid cortex forming a “subperiosteal abscess.” This condition requires antibiotics and surgical drainage.

47. Brain Abscess