1. Infections of the middle ear M.Rogha M.D. Isfahan university of medical sciences 1

2.  Acute Otitis Media (AOM)  “acute onset of symptoms, evidence of a middle ear effusion, and signs or symptoms of middle ear inflammation.”  Otitis Media with effusion (OME)  “Presence of MEE without signs or symptoms of infection, previously named: secretory, serous, or glue ear. ” 2

3. 3 Difficult to treat AOM (20%) Recurrent AOM: three or more episodes in the previous six months or four or more in the preceding twelve months. Treatment failure AOM: a lack of improvement in sign and symptoms within 48-72 hours of AB treatment.

4.  31 million visits to physicians annually in U.S.  Most common diagnosis for an AB prescription in children.  Diagnosed > 5 million times a year.  3-5 billion $/year in U.S.  50,000 deaths / year worldwide. 4

5. ● Age <2 years ● Bottle propping ● Chronic sinusitis ● Ciliary dysfunction ● Cleft palate and craniofacial anomalies ● Child care attendance ● Down syndrome and other genetic conditions ● First episode of AOM when younger than 6 months of age ● Immunocompromising conditions 5

6.  Specific  Otalgia  Otorrhea  Dizziness  Hearing loss  Non-specific  Fever (50%)  Vomiting/diarrhea  Anorexia  Irritability 6

7.  Otoscopic findings  Bulging TM  Yellow, white, or bright red color  Opacification of eardrum  Impaired visibility of ossicular landmarks 7

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10. Bacterial  Streptococcus pneumoniae  Haemophilus influenzae  Moraxella catarrhalis Viral  RSV  Influenzae A & B  Parainfluenzae 1,2, & 3  Rhinovirus  Adenovirus  Enterovirus  Coronavirus 10

11. Mastoid abscess Facial nerve palsy Labyrinthitis Extra/sub dural abscess Meningitis Brain abscess Lateral sinus thrombophlebitis Petrositis

12.  Heptavalent pneumococcal conjugate vaccine  Reduction of otitis office visits  Reduction of antibiotic prescriptions  Influenza vaccine  Goal: decrease number of URI  Breast feeding  Prophylaxis  3 episodes in 6 months or 4 episodes in 1 yr  1 episode  Cause of resistance in the community 12

13.  80% will resolve within 3 days without treatment, 95% in 5 days  Antibiotics may improve short term symptoms, although evidence for any gain in medium to long term outcome is lacking  Countries with lower rates of antibiotic prescribing for acute otitis media do not have an increase in the number of complications

14.  Culture & sensitivity  Simple analgesia  Paracetamol  Ibuprofen(some evidence superior)  Antihistamine & decongestant??  Aural toilet  Myringotomy  Bulging drum  Facial palsy  Incomplete resolution

15.  No antibiotic if no fever; analgesic and reassurance  Amoxycillin 30-40mg/kg/d 3DDx10d  Amoxycillin clavulanate  Cefuroxime 30mg/kg/d 2DDx10d  Clarithromycin 15mg/kg/d 2DDx10d  Azithromycin 10mg/kg OD x 5d,5mg/kg ODx5d  Cotrimoxazole 10mg/kg/d 2DDx10d (Trimetho)

16.  Eliminate cause  Long term low dose antibiotics  Amoxycillin/cotrimoxazole  Myringotomy + grommet  Adenoidectomy  Treat allergy  Pneumococcal vaccine

17.  Persistence/reappearance of pain  Persistence/reappearance of discharge  Persistent fever  Symptoms & signs of complications:  Vertigo/Nystagmus/Ataxia  Facial palsy/diplopia  Headache, vomiting, drowsiness  Abscess behind ear/in neck

18.  Infants & young children  Follows measles, influenza, pneumonia   -haemolytic streptococci  Otorrhoea without pain  Foul smelling discharge  Sensorineural deafness  Large perforation

20.  Chronic infection of the middle ear with a non-healing perforation of the tympanic membrane  Otorrhea (ear drainage) for 6-12 weeks  Middle ear mucosa becomes edematous, polypoid, or ulcerated  The tympanic cavity usually contains granulation tissue  Most common infecting organisms are Pseudomonas aeruginosa, Staphylococcus aureus, Proteus species, Klebsiella pneumoniae, and diphteroids  Annual incidence approximately 40 cases/100,000 population

21.  Patients present with hearing loss and otorrhea  Pain, vertigo, fevers, facial nerve palsy, mental status changes or fetid drainage signify impending intra- temporal or intra-cranial complications

24.  Cholesteatomas are epidermal inclusion cysts of the middle ear and/or mastoid with a squamous epithelial lining  Contain keratin and desquamated epithelium  Term “cholesteatoma” coined by Johannes Muller in 1838  Misnomer because the cysts don’t contain cholesterol  Can be congenital or acquired  Natural history is progressive growth with erosion of surrounding bone due to pressure effects and osteoclast activation

26.  Epidermal inclusion cysts usually present in the anterior superior quadrant of the middle ear near the Eustachian tube orifice  Michaels found epidermoid formation in 37 of 68 temporal bones of fetuses at 10 to 33 weeks' gestation. (Michaels L: An epidermoid formation in the developing middle ear; possible source of cholesteatoma, Otolaryngol 15:169, 1986)  Diagnosed as a pearly white mass behind an intact tympanic membrane in a child who does not have a history of chronic ear disease

27. Pathogenesis  Invagination  Basal cell hyperplasia  Migration (through a perforation)  Squamous metaplasia

28.  Retraction pocket cholesteatoma usually within the pars flaccida or posterior superior tympanic membrane (invagination Theory)  Secondary to ETD  Keratin debris collects within a retraction pocket Normal TM Mucoid effusion and primary acquired cholesteatoma Mesotympanic cholesteatoma

30.  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

32.  History, physical examination, high resolution CT scan of the temporal bone Axial SectionCoronal Section

36.  Ototopical antibiotics  Surgical repair of the TM perforation  Repair of the ossicular chain if necessary

37.  Antibiotic only otic drops Floxin ( ofloxacin )  Antibiotic with steroid otic drops Ciprodex ( ciprofloxin and dexamethasone ) Cipro HC ( ciprofloxin and hydrocortisone ) Cortisporin ( neomycin, polymyxin, and hydrocortisone)  Ophthalmic antibiotic preparations Tobradex ( tobramycin and dexamethasone ) The concentration of antibiotic in ototopical drops is 100-1000x greater than what can be achieved systemically.

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

41.  Ototopical antibiotics  Surgical repair of the TM perforation  Repair of the ossicular chain if necessary  Often requires mastoidectomy

42.  Intact (bony ear) canal wall mastoidectomy  Canal wall down mastoidectomy  Radical Mastoidectomy  Modified Radical Mastoidectomy

43. Tympanoplasty with mastoidectomy and hydroxyapatite bone cement ossicular reconstruction

45.  Acute mastoiditis  Sub-periosteal abscess  Cholesteatoma  Labyrinthitis  Facial paralysis  Meningitis  Epidural/subdural abscess  Brain abscess  Sigmoid sinus thrombosis  Otitic Hydrocephalus

46.  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.

49.  Patients appear more ill than expected  fever, new onset vertigo, sensorineural hearing loss, fetid drainage, facial nerve weakness, proptotic ear  lethargy and mental status changes  CT and MRI are indicated  CT is superior for evaluating the bony details of the middle ear and mastoid space  MRI is more sensitive for diagnosing suspected intracranial complications.  Broad spectrum antibiotics and surgery are required