PRESENTATIONS OF MIDDLE EAR DISEASE

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PRESENTATIONS OF MIDDLE EAR DISEASE

• Elizabeth Rose
• Royal Victorian Eye and Ear Hospital
• Royal Childrens Hospital

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A look and learn lecture

• Middle-ear conditions
• Management of otitis media
• Differential diagnosis of ear pain
• Clinical cases
• An invitation! (Or Two!)

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OTITIS MEDIAA SPECTRUM OF DISEASE

• acute otitis media
• chronic otitis media with effusion
• atelectasis of the tympanic membrane
• chronic adhesive otitis media
• chronic suppurative otitis media
• tubotympanic (safe)
• atticoantral (unsafe)
• and may be a continuum of disease

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ACUTE OTITIS MEDIA(AOM)

• the presence of a middle-ear effusion
• signs and symptoms of infection
• fever, irritability, pain, otorrhoea

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Management of AOM

• Pain relief
• Decongestants (oral/topical) and antihistamines
• do not make the eustachian tube function better
• do relieve the symptoms of a blocked nose

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Antibiotic therapy

• if severe symptoms
• - pain
• - perforation
• 2 years of age
• immune deficiency
• cochlear implant
• follow-up not possible

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Antibiotic therapy

• Recommended treatment is
• amoxicillin 50mg/kg/day in 3 doses
• Can give up to 100mg/kg/day
• Continue for 5 days
• If no improvement in 2 days change to
  amoxicillin/clavulanate

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Penicillin allergy

• trimethoprim-sulfamethoxazole
• clindamycin
• ceftriaxone IM, but will often need continuing
  oral medication

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Antibiotic therapy

• older children who can be accurate about their
  symptoms should be treated symptomatically
• if no improvement after 2 days consider treatment
  with antibiotics

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CHRONIC OTITIS MEDIA WITH EFFUSION(COME)

• the presence of a middle ear effusion
• asymptomatic apart from some hearing loss

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CHRONIC SUPPURATIVE OTITIS MEDIA(CSOM)deafness
and discharge

• persistent disease
• insidious onset
• severe destruction
• irreversible sequelae

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• 1. tubotympanic disease (safe)
• central perforation
• 2. atticoantral disease (unsafe)
• cholesteatoma
• the presence of keratinising squamous epithelium
  in the middle ear

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MANAGEMENT OF CHRONICOTITIS MEDIA WITH
EFFUSION(and also retraction/atelectasis of the
tympanic membrane)
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AKA

• grommets
• tubes
• pressure equalisation tubes
• middle ear ventilation tubes

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COME

• Who should have middle ear ventilation tubes?

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• 1. COME for 4 months at least, with hearing loss
• 2. COME in a child at risk regardless of the
  hearing
• 3. COME and structural damage to the tympanic
  membrane

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1. Hearing loss

• median hearing loss is mild but there is a wide
  range
• no data on the criteria for what is a significant
  hearing loss

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50 of children with persistent OME have hearing
thresholds at 20 dB
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20 of children with persistent OME have hearing
thresholds at gt35 dB
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• 2. An at risk child has an increased risk of
  developmental difficulties due to
• physical
• sensory
• cognitive
• behavioural
• factors not related to the OME

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At risk

• Suspected or diagnosed speech and language delay
  or disorder
• Autism-spectrum disorder and other pervasive
  developmental disorders
• Blindness or uncorrectable visual impairment

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Management of the at risk child may include

• speech and language therapy along with management
  of the OME
• hearing aids for hearing loss independent of the
  OME

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Children with persistent OME who

• are not at risk
• do not have significant hearing loss
• do not have structural abnormalities of the
  eardrum or middle ear
• should be examined every three months

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PRESENTATIONS OF MIDDLE EAR DISEASE
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PAIN

• (Otalgia)

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DIFFERENTIAL DIAGNOSIS OF EAR PAIN

• A. External auditory canal
• trauma ( e.g. from cotton bud abuse)
• auricular haematoma
• foreign body
• otitis externa
• external auditory canal tumour

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DIFFERENTIAL DIAGNOSIS OF EAR PAIN

• B. Middle ear
• acute otitis media
• bullous myringitis
• chronic suppurative otitis media
• middle ear tumour

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DIFFERENTIAL DIAGNOSIS OF EAR PAIN

• C. Referred pain
• oropharynx (IXth nerve)
• tonsillitis/post-tonsillectomy
• carcinoma, including posterior tongue
• laryngopharynx (Xth nerve)
• pyriform fossa
• upper molar teeth, TMJ, parotid gland (Vc)
• impacted wisdom teeth
• changes to bite from new dentures
• cervical spine (C2, C3)
• pain is often worse at night

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DISCHARGE

• (Otorrhoea)

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HEARING LOSS
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FACIAL PARALYSIS
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HEADACHE
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VERTIGO
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TINNITUS
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NO SYMPTOMS
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YOU ARE INVITED!

• 1. ENT clinics at RVEEH

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All clinical years students

• Every week day afternoon
• (and some mornings)

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ContactRehana De Jong

• 9929 8666
• RehanaDeJong_at_eyeandear.org.au

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YOU ARE INVITED!

• 2. Hedley Summons Otolaryngology Prize

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All clinical years students from University of
Melbourne

• Coming in September!

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Take-home message 1remember referred otalgia
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Take-home message 2more is missed in medicine by
not looking than by not knowing
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ENT clinic Fifth Floor Outpatients

• 9929 8666
• RehanaDeJong_at_eyeandear.org.au