1. Jennifer Taylor, ARNP Otolaryngology Seattle Children’s Hospital

2. Learning Objectives  Ear development in utero  Parts of the ear: Outer ear, middle ear, inner ear  Ear Exam: use of otoscope, tympanometry, positioning of patient  Other findings: congenital anomalies of the ear such as tags, pits, microtia  When to refer

3. Development of Ear in Utero  Structural ear development starts in the first 20 weeks’ gestation  Sensorineural part of the auditory system develops primarily after 20 weeks' gestational age  Auditory system functional at 25 weeks  25 weeks gestation to 5/6 months old most critical time for hair cells (sensorineural hearing)

4. Parts of the Ear

5. Outer Ear  Auricle (also referred to as pinna), ear canal, outer part of tympanic membrane  Protects tympanic membrane  Produces cerumen  Directs sound through ear canal  Can be reshaped if necessary during the fIrst few months of life d/t circulating estrogen (must start before 6 weeks of age)

8. Middle Ear  Air filled cavity behind tympanic membrane  Location of three smallest bones in body Malleus (hammer) Incus (anvil) Stapes (stirrup)  Opening of Eustachian tube

10. Describing the Tympanic Membrane Front of Face Right Ear

15. Inner Ear  Semicircular canals  Vestibule  Cochlea

17. Inner Ear cont’d  Associated with hearing and balance.  Tubes filled with fluid encased within the temporal bone of the skull.  Bony tubes (bony labyrinth ) contain a set of cell membrane lined tubes.  Filled with perilymph fluid, which the membranous labyrinth tubes are filed with endolymph. This is where the cells responsible for hearing are located (the hairy cells of Corti).

19. Ear Exam  Positioning  Tools  Cartilaginous development of the ear lobe, position of ears, shape of auricle (normal/abnormal), preauricular sinus or skin tags. External auditory canal patent.

20. Ear Exam cont’d  Pull downward and backward. This process will move the acoustic meatus in line with the canal. Hold the otoscope like a pen/pencil and use the little finger area as a fulcrum. This prevents injury should the patient turn suddenly.  Inspect the external auditory canal.  Inspect tympanic membrane  Inspect posterior ear and mastoid bone

21. Ear exam  Air inflation otoscopy (pneumatic- otoscope) is very useful to evaluate middle ear disease. Assess the mobility of tympanic membrane by applying positive and negative pressures with the rubber squeeze bulb.

22. Normal Ear exam  Normal:  Auditory canal: Some hair, often with yellow to brown cerumen.  Tympanic membrane Pinkish gray in color, translucent and in neutral position. Malleus lies in oblique position behind the upper part of drum. Mobile with air inflation.

23. Causes for Hearing Loss or Abnormal Ear Development  Genetics  Environmental: born premature, exposed to ototoxic medications  Infectious: CMV, TORCH, meningitis, family hx, craniofacial abnormalities, birth weight <1.5kg, neonatal hyperbilirubinemia, Apgar <4 at 1 minutes, <6 at 5 minutes, prolonged NICU stay or ECMO or mechanical vent, exposure to ototoxic meds.

27. When to refer  Hearing loss  Suspect hearing loss with behavioral issues, speech issues, ask about newborn hearing screen  Congenital anomaly of ear

29. Ronna K. Smith, MN, ARNP Otolaryngology Seattle Children’s Hospital

30. Objectives  Definition of OME and AOM by current standards and visualization  Current national guidelines for diagnostic criteria of AOM  Pharmacology for AOM and OME  Referral guidelines to Otolaryngology and indications for PE tube placement  Hands-on practice with otoscopy and identification of signs of AOM and OME

31. Otalgia  Differential diagnosis AOM OME OE TMJ dysfunction Bruxism Dental pain, teething? Tonsil or throat pain

32. Diagnoses  Otitis media: acute, chronic, recurrent  OME: middle ear effusions

33. Acute Otitis Media  Commonly defined as inflammation of the middle ear  Results in rapid onset of symptoms: otalgia, fever, irritability, anorexia, or vomiting  Often associated with upper respiratory infection

34. Acute Otitis Media  One of the most common reasons for young children to visit the primary care provider  Morbidity and mortality common before the introduction of antibiotics/vaccines  80-90% of children have had at least one episode of AOM by the age of 10  Peak incidence between 6-18 months

35. Acute Otitis Media  Factors influencing incidence: Age under 2 years, male gender, certain ethnic backgrounds Eustachian tube function Daycare Older siblings Exposure to cigarette smoke Allergy Craniofacial disorders Immune function

37. AOM: Symptoms and Presentation  Fever (~50%), irritability, waking at night  Anorexia, vomiting, diarrhea, balance problems, decreased hearing  Often preceded by URI symptoms (~50%), increased incidence in winter months

38. AOM: Diagnosis  “Diagnostic certainty” requires the presence of: Acute onset of symptoms Presence of effusion-bulging TM or poor mobility Evidence of inflammation (AAP Clinical Practice Guideline, 2004, updated 2013)

42. AOM: Microbiology in the post- Prevnar era  Strep pneumoniae-can vary in pcn resistance  non-typeable H. Influenzae MOST are beta-lactamase positive Associated purulent conjunctivitis makes H. Flu more likely  M. catarrhalis (nearly 100% beta- lactamase positive)

43. AOM: Treatment  60-80% of acute OM will clear spontaneously (Rosenfeld, 1995) 60% in 24 hours, 80% in 72 hours  Some studies suggest resolution rate is higher and complication rate lower if antimicrobials are used.  S. pneumoniae is often the cause of persistent otitis and is associated with a large number of otitis complications

44. AOM: Treatment  High dose amox has been the main recommendation for s. pneumoniae (>50% of cases of AOM historically)  Daycare, <2 yrs, abx in prev 3 mos=more likely to have resistant s.pneumoniae  Post-Prevnar: less s. pneumoniae, more non-typeable h. influenzae  High dose amox is STILL the first line (AAP, 2013) because of safety profile, high likelihood of effectiveness.

45. AOM: Treatment  The ‘observation’ option: Limit management to symptom relief in selected patients Caregiver must have means of communication Must be a system for re-evaluation Child should be healthy >6 months of age

46. Antibiotic Choice  First line: high dose Amoxicillin (80-90 mg/kg/day)  “Treatment failure” means persistence of symptoms-pain, fever. Persistence of effusion does NOT mean treatment failure  2 nd line: Augmentin with high amoxicillin concentration  If allergic to penicillin: Cefdinir, azithromycin, clarithromycin, erythromycin  For true treatment failure: Rocephin injections for 1-3 days.

47. Pain Management of pain should be addressed regardless of antibiotic use.  Analgesics Oral analgesics: Tylenol, Ibuprofen Benzocaine/antipyrene (Auralgan) drops Herbal drops, garlic drops, warm oil  Warm compresses  Distraction  Codeine

48. AOM: Complications  Hearing loss (temporary, conductive) COMMON  Perforation of tympanic membrane-less common, but not unusual  Uncommon: cholesteatoma, retraction pocket, ossicular discontinuity and fixation, mastoiditis, labrynthitis, facial paralysis, sensory neural hearing loss, intracranial infection.

49. AOM: When to Refer  3 episodes in 6 months, or 4 in one year  Persistent middle ear fluid (3-6 months, +/- hearing loss)  Severe bouts of otitis media or complicating issues, eg febrile seizures,  Multiple medication allergies making medical therapy difficult  Developmental delay, heightened concern for speech/language

50. Follow up  Middle Ear Effusion commonly persists after AOM 60-70% of cases will have MEE at 2 weeks post AOM 40% will have MEE 1 month after AOM 10% after 3 months (Teele, et al)  2 week follow up: hx of frequent OM, young infant, hx of prolonged OM, immunocompromised  1 month follow up: most children  If effusions are still present, but no acute signs….retreat? Refer for hearing test? Consider allergy management?

51. Otitis Media with Effusion: Basic Principles  Middle ear effusion (MEE) without signs and symptoms of acute infection  May occur spontaneously because of poor eustachian tube function, or may follow acute otitis media  May be acute or chronic  More common than AOM: up to 90% of children have had an episode of OME by school age

52. Otitis Media with Effusion: Basic Principles  Potential impacts: hearing, speech, language, learning, quality of life  Often accompanies upper respiratory infections  TM is typically retracted or neutral- not bulging  Symptoms: hearing loss, intermittent discomfort

53. OME: Diagnosis  Pneumatic otoscopy is primary diagnostic method. Tympanometry very helpful.  White or amber colored discoloration to TM  TM is often opaque  Decreased or absent mobility  Absence of acute OM s/s: pain, fever, inflammation, bulging of TM  This should NOT be treated as AOM!

59. Document….  Laterality: which side is it on?  Mobility with pneumatic otoscopy  Retraction pockets?  Appearance of ossicles  Be sure to document the duration of the effusion if possible

61. OME: Treatment  Observation: Document laterality, when effusion was first observed and symptoms. Follow up periodically.  Medications: antibiotics and oral steroids may help in the short term, but effusion often recurs after course is complete.  Allergy treatment  Tympanostomy tube placement for persistent effusions, hearing loss  ‘glue ear’ prolonged OME

62. Decision to Treat/Refer:  Evaluate risk of developmental delays  Speech delay  OME causing hearing loss  Already has DD  Evaluate likelihood of spontaneous resolution  Family hx of needing tubes  Family hx of allergy, kid w/allergy  Time of year

63. Otitis Media with Effusion  For children not at risk for developmental delays Observation for 3 months Hearing testing if OME lasts beyond 3 months Language testing if hearing loss occurs Follow up every 1-3 months until OME is gone Decrease environmental risk factors (tobacco smoke) Optimize listening and learning until effusion resolves

64. Otitis Media with Effusion  In the setting of other developmental delays Early referral to OTO Needs hearing exam May have earlier recommendation for tubes Consider social setting—foster care, etc.

65. OME Treatment  No evidence to support use of decongestants, antihistamines, or steroids  No evidence to support long term effects of antibiotics - there has been some evidence of occasional short term benefit  Consider 10 day course of antibiotic and/or 5 day course of oral steroid as an option when tube placement is only other option

67. Ear Tubes (Pressure equalization-PE- or Tympanostomy tubes The decision to place tubes is based on many factors… -quality of life -season, age -presence of hearing loss/speech delay -other co-morbid factors -parents have reached ‘otitic exhaustion’

68. Bobbin or grommet style: last 6-12 months ‘t-tube’ lasts 2 years

69. Care of PE tubes  Ok for swimming/bathing  Treat drainage topically No ototoxic drugs Clear drainage and pump the tragus  Older kids and diving?  F/U with audiology after extrusion  F/U with surgeon ?

70. Ashley Sapin, ARNP Otolaryngology Seattle Children’s Hospital

71. Why does my child have fluid behind their ear?

72. Persistent Effusions in “Non-complainers”  Why are these not okay? May be causing hearing loss Potential for retraction of the TM and sequelae from chronic retraction The longer fluid is present, the less likely it is to resolve spontaneously and more likely it is to have a negative impact May be indicator of nasopharyngeal mass

73. Things to Note About Middle Ear Effusions  Anything obvious to treat? Allergic rhinitis Sinusitis/Rhinosinusitis Child drinking liquids while laying down  What do the effusions look like? Air bubbles? Air-fluid level? Color/texture of middle ear fluid? Position of eardrum?

74. When to Refer for Persistent Effusion In the presence of cognitive or sensory deficit – Speech and language acquisition and pronunciation – Reading – Behavioral- Poor focus or attention, abnormal family/peer interactions – Vestibular disturbance When the effusion has been present for 3 or more months – If hearing loss accompanies effusion, may be indication for ear tubes Underlying medical diagnosis – Abnormal ciliary function Primary ciliary dyskinesia Cystic fibrosis – Craniofacial abnormality or syndrome Cleft palate Submucous cleft palate Trisomy 21 Craniofacial microsomia

75. Perforations & Retraction Pockets

76. Tympanic Membrane Perforation  Common Causes Abnormal middle ear pressure ○ Middle ear effusions ○ Barotrauma Foreign body ○ Tympanostomy tubes ○ Traumatic injury

77. Tympanic Membrane Perforation  Treatment If acute perforation with infection/otorrhea ○ Dry ear precautions ○ Treat with antibiotic ear drops Sulfacetamide-prednisolone Ciprodex Ofloxacin (+/- dexamethasone) Do NOT use gentamycin, tobramycin, or cortisporin drops (ototoxic!) ○ If in 1 month, no improvement and/or recurrent otorrhea- ENT referral If vertigo or facial nerve involvement ○ Urgent ENT referral If chronic perforation ○ Non-urgent ENT referral

78. Retraction Pockets  Cause Eustachian tube dysfunction  Potential Problems Hearing loss ○ Reduction of TM mobility ○ Ossicular erosion Granulation tissue formation Cholesteatoma formation  Orders Audiogram (ENT will order) Referral to ENT

79. Retraction Pockets  Treatment Possibilities Watchful waiting Treat infection (if present) with antibiotic ear drops Trial of steroid nasal spray if allergic component Surgical intervention ○ Ear tube placement ○ Excision of squamous debris

80. Cholesteatoma

81.  Causes Congenital- occur during fetal formation Acquired ○ Tympanic membrane perforation- entryway for skin into middle ear ○ Eustachian tube dysfunction ○ Basal cell hyperplasia resulting from infection ○ Metaplasia resulting from chronic irritation from middle ear infection

82. Cholesteatoma Symptoms Sensation of fullness in ear Hearing loss in affected ear- may be reported by patient or found on audiogram Dizziness Intermittent or continuous otorrhea despite treatment Facial muscle weakness on affected side Painful or painless There may be no symptoms at all… Signs White mass behind intact tympanic membrane Tympanic membrane perforation or retraction pocket Focal granulation tissue on tympanic membrane

83. Cholesteatoma  Treatment Imaging ○ CT ○ MRI Antibiotics if needed Surgical Intervention ○ 1 st -Tympanomastoidectomy ○ 2 nd - May need additional surgery Re-examination of middle ear space to confirm no regrowth of skin cells Ossicular repair or prosthesis  Possible Complications Brain abscess Meningitis Labrynthitis Facial paralysis Deafness

84. Tympanosclerosis/Myringosclerosis  Calcification affecting connective tissue of tympanic membrane  Causes Previous otitis media Previous ear tubes Trauma to eardrum  May look like cholesteatoma- it isn’t  Children with asymptomatic myringosclerosis do not need ENT referral  If symptomatic- then refer to ENT Conductive hearing loss ○ Surgical removal Remove plaques (frequently refix to ossicles) Middle ear reconstruction ○ Hearing aids

85. Persistent Ear Drainage  Potential Causes Acute tympanic membrane rupture with acute otitis media Chronic tympanic membrane perforation AOM with patent ear tubes Otitis externa ○ Bacterial ○ Fungal Retained tympanostomy tube Cholesteatoma (Remember, color of drainage may vary- serous, yellow, white, green, bloody…it can all be “normal” for otorrhea)

86. Persistent Ear Drainage  Questions to ask Any recent illness/co-morbid conditions? Frequency/recurrence of drainage? Do otic antibiotics help? Is there pain? (1-10, progressive, improve with drainage) Is there pruritis? Has child been swimming frequently/recently? Pain with external ear palpation? How is the patient’s hearing? Does the patient have ear tubes? ○ How long have these tubes been in place? ○ When were they last seen by their ENT?

87. Retained Tympanostomy Tubes

88.  Duration of Pressure Equilization (PE) tubes? Armstrong/Reuter-Bobbin/Baxter ○ Generally last 6-12 months ○ Should be in no longer than 2 years* Soft T-Tubes ○ Generally last 1-2 years ○ Should be in no longer than 3 years* Why remove retained PE tubes? ○ Chronic TM perforation ○ Infection of the PE tubes ○ Persistent drainage ○ Granulation tissue ○ Most people outgrow the need for them * There are always exceptions to this

89. Jennifer Hart, ARNP, CPNP Otolaryngology Seattle Children’s Hospital

90. What the Wax?!?  Cerumen is the substance that is secreted by your ear canal  It protects the external auditory canal and the tympanic membrane  It contains antibacterial properties

92. Types of Cerumen  Cerumen can be sticky, hard or flakey  Multi colored: white, caramel, brown, black

93. When To Remove Cerumen  Only when it is a problem If you suspect otitis media and can’t see TM If there is hearing loss associated with impaction If there is pain due to impaction *If none of these exist, LEAVE IT ALONE

94. Home Methods  Q-Tips NO!!!!  Debrox- yes  Mineral/Olive Oil-yes  ½ strength hydrogen peroxide- OK  Ear Candling NO!!!!  Wipe the bowl of the pinnae with warm wet wash cloth

96. Safe removal  In clinic irrigation with warm water *caution do not shoot water directly down the ear canal Loop curette, only if able to safely stabilize child If unable to clear refer to OTO but start on home routine(Debrox, oil, ½ strength peroxide)

97. Fun With Foreign Bodies

98. When to Remove and when to Refer  Remove if: The object is easy to grasp with minimal chance of trauma or anxiety for the child. You are able to safely restrain the child. If it is causing acute pain.

100. Why to Refer?  OTO has better equipment Binocular microscope Suction Multiple curettes and probes Experience to do this safely, with minimal trauma and drama Able to make the call for sedation

101. Remember  Don’t put anything smaller than your elbow in your ear. If you can put your elbow in your ear go ahead and use it to clean your ear.