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

2. 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

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

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

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

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

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

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

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

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

11. Obliterative Tympanosclerosis

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

13. Attic Retraction Isolated collapse of Pars Flaccida
May lead to cholesteatoma

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

15. 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.

16. Chronic Suppurative Otitis Media
TM Perforation
+/- cholesteatoma
Otorrhea

17. Diagnosis of Otitis Media

18. 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.

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

20. Instrumentation

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

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

23. Acute Otitis Media (Day 2)

24. Acute Otitis Media (1 Week)

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

26. Serous Otitis Media

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

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

29. 2nd Line Therapy for Otitis Media
Amoxicillin/Clavulanate
Oral Cephalosporin (2nd or 3rd generation)
Macrolide
Ceftriaxone (IM)

30. 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

31. 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

32. 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

33. Plan of Therapy
Amoxil

34. Plan of Therapy
Amoxil
If No Improvement in 72 hrs.

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

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

37. 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

38. 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

39. 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

40. 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

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

42. Serous Otitis Media w/Retraction

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

44. Straight Vent Tube
Shaft
Lumen
Medial flange

45. Grommet/Bobbin Style
Lumen
Flanges

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

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

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

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

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