1. Ear Tubes

2. The Ear

3. AOM vs. OME Acute Otitis Media –Pus behind TM –Acute infection –Multiple severe complicaitons Mastoiditis Meningitis Brain abscess Facial paralysis –Treat with antibiotics –Ear tubes if recurrent Otitis Media with Effusion –Fluid behind TM –May result from AOM –Less sever complications Hearing loss Scarring/atrophy of TM Tympanosclerosis –Do not treat with antibiotics –Ear tubes if persistent or chronic

4. Acute Otitis Media Types of TM Findings Normal TM Serous otitis media Mucoid Otitis Media

5. Acute Otitis Media Peak incidence AOM is between 6 and 18 months –AOM affects 40%-50% of children by age 1 –By age 3 years majority (>80%) of children have had 1 episode of AOM ~ 40% of pediatric office visits in first 5 years related to otitis media ~5-10% of well visits associated with diagnosis of OME

6. Acute Otitis Media Diagnosis Certain diagnosis of AOM meets all 3 of the criteria: Presence of Purulent Middle Ear Effusion Rapid onset Signs and symptoms of middle-ear inflammation –Otalgia –No pain with pulling of ear –TMJ pain –Difficulty sleeping due to pain

7. Acute Otitis Media Diagnosis Pulling at the Ears (not reliable): –Zero percent of children with ear pulling as the primary sign had an ear infection –Ear pulling + fever: only 15% had ear infections –Why do kids pull their ears? Itching Teething Exploration Comfort Habit Pain Is ear pulling associated with ear infection. Baker RB. Pediatrics. 1992 Dec;90(6):1006-7 Diagnostic accuracy and the observation option in acute otitis media: the Capital Region Otitis Project. Gurnaney H, Spor D, Johnson DG, Propp R. Int J Pediatr Otorhinolaryngol. 2004 Oct;68(10):1315-25

8. Acute Otitis Media Diagnosis Presence of Purulent Middle Ear Effusion Exam- Unobstructed ear canal and good light! Bulging of the tympanic membrane Limited or absent mobility of the tympanic membrane –Pneumotoscopy –Tympanometry Air-fluid level behind the tympanic membrane Otorrhea (purulent)

9. Misdiagnosis of Acute OM Over-reliance on history TM color does not predict AOME-crying makes most tympanic membranes red Failure to evaluate tympanic membrane mobility (pneumatic otoscopy) Poor light from otoscope (bulb & battery) Failure to remove cerumen Inappropriate sized speculum Lack of experience

10. Acute Otitis Media Improving diagnostic accuracy: –Pneumatic otoscopy –Otomicroscopy

11. Acute Otitis Media Treatment Why do we treat AOM? –Quality of Life –Suppurative Complications Once treated, when do we follow-up? –If asymptomatic, follow-up is to ensure resolution of fluid –This process can take up to 3 months (74%) Intracranial Complications: –Meningitis –Extradural abscess –Subdural empyema –Lateral sinus thrombosis –Brain abscess –Otitic hydrocephalus Extracranial Complications: –Mastoiditis –Petrositis –Facial Paralysis –Perforation of the TM –Hearing loss CHL SNHL –Labyrinthitis

12. Acute Mastoiditis May or may not be associated with subperiosteal abscess Protrusion of the auricle may be secondary to osteitis of the mastoid cortex without erosion/ abscess

13. Coalescent Mastoiditis

14. Tubes for Acute Otitis Media Recalcitrant- persistent acute infection despite antibiotics Recurrent –3/6 or 4/12 or 6/12 total duration –Parental concern –Day care –At risk populations –Time of year Adenoidectomy if recurrent bacterial URI/sinusitis Complications

15. AOM vs. OME Acute Otitis Media –Pus behind TM –Acute infection –Multiple severe complicaitons Mastoiditis Meningitis Brain abscess Facial paralysis –Treat with antibiotics –Ear tubes if recurrent Otitis Media with Effusion –Fluid behind TM –May result from AOM –Less sever complications Hearing loss Scarring/atrophy of TM Tympanosclerosis –Do not treat with antibiotics –Ear tubes if persistent or chronic

16. Otitis Media with Effusion Tympanic membrane characteristics –Translucent or opaque –Gray, white, yellow, or pink color –Neutral or retracted position –Reduced mobility, responds to negative pressure on pneumatic otoscopy –Effusion present

17. Resolution of Middle Ear Fluid

18. Otitis Media with Effusion Treatment Intervention based on severity of hearing loss, child’s developmental status, parent preference –Aggressive management of “at-risk” population Watchful waiting for at least 3 months in “non at-risk” population –“Paradise Tube Article” studies only healthy, non at-risk children –Nasal steroids may help –Nasal decongestants/antihistamines of no proven use –Antimicrobials/steroids not indicated Paradise JL., et al: Tympanostomy Tubes and Developmental Outcomes at 9 to 11 Years of Age N Engl J Med. 363 (3):248-261, 2007.

19. Otitis Media with Effusion Treatment Audiogram if fluid > 3 months –If normal hearing periodic re-evaluation until clear; more aggressive intervention if hearing loss, behavior problems or TM changes Surgery- Tubes with or without adenoids –Tubes initially only Adenoidectomy if nasal obstruction or infection problems or if past hx of tubes –Repeat surgery--adenoidectomy +/-tubes

20. AOM vs. OME Acute Otitis Media –Pus behind TM –Acute infection –Multiple severe complicaitons Mastoiditis Meningitis Brain abscess Facial paralysis –Treat with antibiotics –Ear tubes if recurrent Otitis Media with Effusion –Fluid behind TM –May result from AOM –Less sever complications Hearing loss Scarring/atrophy of TM Tympanosclerosis –Do not treat with antibiotics –Ear tubes if persistent or chronic

21. Radial incision Anterior/inferior quadrant Ear Tube Placement

24. Post-Operative Care Ear drops for 2-7 days –If fluid present –Floxin, Ciprodex, Saline –Never “Cortisporin” or gentamicin See at 2-4 weeks –Audiometry –Clean tube is occluded –Replace tube if unsuccessful See every 6-12 months until extrusion/healing

25. Complications Early Complications –Tube occlusion –Extrusion –Otorrhea –Impaction into middle ear –Hearing loss Delayed Complications –Otorrhea –Perforation –Retention –Myringosclerosis –TM atrophy –Hearing loss –Tympanosclerosis –Cholesteatoma

26. Questions? Thank You!