1. Non-Suppurative Otitis Media
Dr. Vishal Sharma

2. Types Otitis Media with effusion (O.M.E.) Adhesive otitis media
Tympanosclerosis
Baro-traumatic otitis media

3. Otitis Media with effusion
Presence of serous or mucoid effusion in middle ear cleft with no frank pus.
Synonyms:
Secretory / Serous otitis media
Seromucinous / exudative otitis media
Catarrhal otitis media
Glue ear

4. Etiology 1. Eustachian tube dysfunction
 Vacuum in M.E.  extravasation of fluid
 Lack of drainage of M.E. secretions
2. Upper respiratory tract allergy / viral infection
 Increase M.E. secretions
3. Low grade middle ear infection
 Inadequate treatment of A.S.O.M.

5. Causes for E.T. dysfunction
1. Eustachian Tube obstruction
Intrinsic edema = infection / allergy / trauma
Extrinsic = adenoid / nasopharyngeal tumour /
post – Radiotherapy scarring
Functional = floppy Eustachian tube
2. Patulous Eustachian tube: reflux of secretions

6. Causes for E.T. dysfunction
3. Palatal abnormality:
 cleft palate / palatal palsy
4. Muco-ciliary pathology:
 Infection / allergy / smoking
 Kartagener’s syndrome / Young’s syndrome
 Surfactant deficiency / Immune deficiency

7. Causes of E.T. dysfunction

8. Predisposing conditions
Child going to a nursery
Early weaning with formula milk
Parents who smoke
Recurrent respiratory infections
Crowded living condition
Poor nutrition
Cleft palate

9. Clinical Symptoms Mild deafness in a young child
Deafness increases during U.R.T.I.
Mild otalgia
Blocking sensation in ear
Delayed & defective speech due to deafness

10. Clinical signs 1. Otoscopy: Blue eardrum with restricted mobility
Retraction of T.M. in early stage
Bulging of T.M. in later stages
Fluid level + air bubbles seen behind T.M.
2. Tuning Fork Tests: conductive deafness

11. Otoscopy

12. Blue ear drum

13. Left retracted ear drum

14. Right air-fluid level

15. Left air-fluid level

16. Right air bubbles

17. Left air bubbles

18. Investigations

19. P.T.A.: low frequency conductive deafness
Pure Tone Audiometry
P.T.A.: low frequency conductive deafness

20. C curve in ear drum retraction
Impedance Audiometry
C curve in ear drum retraction

21. B curve in middle ear effusion
Impedance Audiometry
B curve in middle ear effusion

22. X-ray mastoid & Nasopharynx
clouding of mastoid air cells + adenoid mass

23. Medical treatment Antibiotic (Co-amoxyclav) for 2-4 weeks
Nasal decongestants (systemic + topical)
H1 anti-histamines
Auto-inflation of Eustachian tube by Valsalva maneuver
Analgesic for acute earache

24. Non-medical, Non-surgical treatment
Politzerization
Otovent balloon
Ear popper device
Eardoc device

25. Politzerization
Rubber tube attached to Politzer bag is put into one nostril & both nostrils pinched. Pt is asked to swallow repeatedly & Politzer bag is squeezed simultaneously.

26. Otovent balloon device

27. Technique of inflation

28. Otovent balloon device
Balloon is inflated by blowing air out of nose. When fully inflated, balloon neck is pinched off and nasal occluder is inserted into one nostril. Child is instructed to swallow as balloon is deflated into nasal cavity. Portion of air from balloon enters Eustachian tube & ventilates middle ear.

29. Ear Popper Device

30. Ear Popper Device
Based on Politzer Maneuver, EarPopper ™ Device delivers a safe, constant, regulated stream of air into nasal cavity. During swallowing, air is diverted to Eustachian tube clearing & ventilating middle ear.

31. EARDOC device

32. EARDOC device
EARDOC ™ generates & transmits special vibration waves which travel through temporal bone to reach middle ear & Eustachian tube. The waves ease middle ear pressure & drain trapped fluids. As a result edema & pain are reduced.

33. Surgical treatment
Myringotomy (Tympanocentesis) + grommet (Pressure Equalization tube) insertion:
Radial incision made in antero-inferior quadrant. For thick fluid, 2 incisions made in antero-inferior quadrant & antero-superior quadrant (Beer can principle).

34. Surgical treatment
Laser or radio-frequency assisted myringotomy: grommet insertion not required
Cortical mastoidectomy: for refractory cases with loculated fluid in mastoid
Treatment for predisposing factors: adeno-tonsillectomy / antral wash / polypectomy

35. Myringotomy & grommet insertion

36. Myringotome

37. Right Myringotomy incision

38. Left Myringotomy incision

39. Myringotomy performed

40. Beer can principle

41. Glue like fluid

42. Shepard’s Grommet

43. Armstrong’s grommet

44. Donaldson grommet

45. Shah’s grommet

46. T-tube grommet

47. Grommet insertion

48. Right grommet in position

49. Left grommet in position

50. Grommet in ant-sup quadrant

51. T-tube grommet in situ

52. Grommet extrusion Grommet gets extruded on its own due to
endothelium growing
on its inner surface.
Extrudes after 6 - 9
months.

53. Grommet extrusion

54. Healed tympanic membrane

55. Complications of Grommet insertion

56. Tympanosclerosis

57. T.M. Perforation

58. T.M. Perforation

59. Granulation over grommet

60. Grommet lost inside

61. Radiofrequency assisted myringotomy

62. Cortical Mastoidectomy

63. Sequelae of O.M.E. T.M. atrophy & atelectasis Adhesive otitis media
Tympanosclerosis
Cholesterol granuloma
Ossicular necrosis
Retraction pocket & cholesteatoma

64. Prevention of O.M.E. Avoid irritants like cigarette smoke
Identify & avoid any allergens
Consider a smaller day care centre (< 6 children)
Wash hands & toys frequently
Use air filters & provide fresh air at home
Encourage breastfeeding
Use of pneumococcal vaccine

65. Adhesive Otitis Media
Pathology: TM atrophy + atelectasis (due to dissolution of fibrous layer) + adhesions in M.E. cavity, following chronic O.M.E.
Clinical Features:
1. Conductive deafness
2. Thin retracted T.M. with no mobility

66. Adhesive Otitis Media

67. Adhesive Otitis Media Treatment: 1. Hearing Aid
2. Surgery (long term results are poor)
a. Tympanotomy + release adhesions + put silastic sheet b/w promontory & TM.
b. Grommet insertion

68. Left grommet in position

69. Tympanosclerosis Deposition of hyaline (acellular + avascular
collagen) + calcium
deposits in submucosal
tissue of T.M. & M.E.
cavity following long-
standing otitis media

70. Tympanosclerosis Treatment: 1. Hearing Aid
2. Surgery (long term results are poor)
Remove tymapnosclerotic plaque & perform tympanoplasty

71. Barotrauma of middle ear

72. Pathogenesis E.T. has collapsible cartilaginous part & rigid bony part
Allows expulsion of air
from middle ear into E.T.
but not suction of air into
middle ear via ET.

73. Etiology
Failure of Eustachian tube to equalize rapid increase in pressure difference b/w middle ear & atmosphere, over a long period.
During ascent: middle ear pressure is more than Atmospheric Pressure  no barotrauma in normal middle ear
During descent: middle ear pressure is less than Atmospheric Pressure  barotrauma occurs

74. Pathology in normal Middle Ear Symptoms
Pressure Difference
Pathology in normal Middle Ear
Symptoms
- 60 mm Hg
Hyperaemia + edema + exudation + T.M. retraction
Otalgia, deafness, tinnitus
- 90 mm Hg (less in pt with cold)
Locking of E.T. (collapse of lumen), microscopic hemorrhage
Severe otalgia
- 100 to 400 mm Hg
T.M. rupture
Frank blood otorrhoea

75. Treatment Nasal decongestants + H1 anti-histamines
Politzerization for middle ear aeration
Myringotomy + grommet insertion done for:
refractory cases
presence of haemotympanum

76. Prevention 1. Avoid air travel during cold / nasal allergy
2. During descent while flying:
 Do repeated swallows (lozenges / gum)
 Do intermittent Valsalva maneuvre
 Avoid sleeping (as swallowing is decreased)
3. Pt with previous episode: take nasal decon-gestant + antihistamine 30 min before descent.

77. Thank You