Diseases of the middle ear

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Diseases of the middle ear
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Anatomy of tympanic memb.
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Anatomy of tympanic cavity
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Anatomy of tympanic cavity
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Diseases of the middle ear

• Congenital diseases
• Trauma
• Infections
• Diseases of Otic capsule
• Tumors squamous cell carcinoma

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Congenital diseases

• Abnormal ossicles incus and malleus
• Conductive hearing loss
• Crouzons syndrome
• atresia of external ear or ossicle abnormality
• Conductive hearing loss
• Treacher collins
• small maxilla and mandible with external and
  internal ear abnormality
• Dehiscence of the facial nerve canal

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Dehiscence of the facial nerve canal

• 6 30 , facial n. above oval window or above
  the promontory
• clinical manifestations
• Conductive HL both ears
• External ear abnormality
• Diagnosis by otoscopy. Audiogram , CT-scan
• Treatment Surgical treatment

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• Objective of surgical treatment
• Functioning ossicular mechanism
• Opening ear canal
• Functioning the tympanic membrane

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Trauma
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Traumatic rupture of tympanic membrane

• Most common Cotton tipped swab, branch, stone
• sudden air/fluid compression
• Inflation of Eustachian tube
• fracture base of skull
• Lightening strike
• Thermal and chemical cause
• May only create
• superficial flap laceration of external ear canal
  
• penetrate the TM
• involve ossicular chain, tympanic portion of
  facial n.
• clinical manifestation
• pain , purulent discharge, tinnitus , vertigo

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Traumatic rupture of tympanic membrane

• Treatment
• Remove foreign body
• Oral antibiotic
• ?????????????????????
• ????????????????????? 3 ????? ????????????????????
  ?

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Fracture of temporal bone

• Blunt trauma
• Sharp angle to the side of head as oppose to 90
• Cause the injuries of
• Soft tissue of external auditory canal
• Middle ear
• Otic capsule
• Fracture of temporal bone 3 types
• 1. Longitudinal fracture ( 70-90 )
• 2. Transverse fracture (20-30)
• 3. Mixed fracture

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Longitudinal fracture

• Direct lateral blunt trauma in parietal region
• Involved TM, roof of middle ear, ant. Petrous
  apex
• Clinical manifestation
• Facial palsy trauma, edema (delayed) gt direct
  interruption n. (involved geniculate ganglion)
• CHL (disruption ossicles)
• SNHL (gt3000-4000 Hz) (uncommon)
• bleeding in external canal

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Transverse fracture

• Severe blow to the occipital portion of skull or
  frontal portion of head
• Clinical manifestation
• Death from the blow itself immediately
• Severe SNHL
• Loss of vestibular function
• Facial paralysis (50)
• Bleeding in middle ear canal hemotympanium
• CSF otorrhea ? eustachain into nasopharynx
• vertigo

Inner ear / otic capsule injury
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• Facial palsy (labyrinthine segment)
• Incomplete palsy ? self limiting
• Complete palsy ? facial nerve decompression
  within 21 days

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Mixed fracture

• Diminished of a pure longitudinal of transverse
  fracture
• Fracture line extended in any direction of base
  of skull
• Complete evaluation of the entire patient must be
  done

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Traumatic disconnection of the osicular chain

• Cause head injury or surgical complication
• incudostapedial joint
• Diagnosis
• Trauma hx ? CHL but TM is normal
• air-bone gap 60 dB
• Tympanogram high compliance , no stapedial
  reflex
• Treatment
• Reposition long process of incus ? stapedial
  head
• Interposition

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Otoscerlosis

• Spongy bone formation of otic capsule ? ankylosis
  of footplate of stapes
• FgtM , 20-30 years old
• Related with familial history
• Associated conditions Van der Hoevee syndrome
  , Pagets disease

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Otoscerlosis

• Clinical manifestation (cont)
• Promontory ? flamingo pink (schwartze s sign)
• Bilateral
• ?????? , CHL , Paracusis
• Audiogram
• cahart notch of conduction curve
• Air conduction loss
• early low frequency gt high frequency
• late low frequency high frequency

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Otoscerlosis

• Treatment
• 1. fluoride supplement
• 2. ??????????????
• 3.Surgical treatment Stapedectomy (90
  success)
• wide air-bone gap
• loss of air conduction 60 dB
• bone conduction 30 dB
• Contraindication
• 1. narrow air-bone gap
• 2. ?????????????????????????????????

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• Complication (2-3)
• SNHL
• Facial nerve injury
• Perilymph fistula

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Otitis Media
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Otitis Media - Definition

• Inflammation of the middle ear
• May also involve inflammation of mastoid, petrous
  apex, and perilabyrinthine air cells

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Otitis Media - Classification

• Acute OM - rapid onset lt 3 wk course
• Subacute OM 3 wks to 3 mo
• Chronic OM 3 mo or longer

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Acute Otitis Media(AOM)
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EPIDEMIOLOGY

• Peak incidence in the first two years of life
  (esp. 6-12 months)
• Boys more affected girls
• 50 of children 1 yr of age will have at least 1
  episode.
• 1/3 of children will have 3 or more infections by
  age 3
• 90 of children will have at least one infection
  by age 6.
• Occurs more frequently in the winter months

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RISK FACTORS

• Intrinsic factor
• - Age
• - Allergies
• - Craniofacial abnormalities (cleft palate)
• - Immunocompromised host

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RISK FACTORS

• Extrinsic factor
• - Seasons
• - Upper Respiratory Infections
• - ?????????????????????????????

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Causes

• In children lt6 weeks
• - Streptococcus pneumoniae
• - Haemophilus influenzae(non-typeable)
• - Staph aureus
• - Group A Streptococcus
• - Moraxella catarrhalis
• - Escherichia coli
• - Klebsiella and Enterobacter
• - Pseudomonas aeruginosa
• - Nonpathogens

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Causes

• In Adult
• - Streptococcus pneumoniae
• - Haemophilus influenzae
• - Moraxella catarrhalis
• - Group A Streptococcus
• - Staph aureus
• - Nonpathogens

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??????????????

• ?????????????????????? 1-2 ???
• ???????????? ??????????????????????????????
• ?????????????????????????????????
• ???
• ????????????????????
• ?????????????????
• ????????

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Symptom

• ????????? ????
• ??????????????????????????????????
• Pneumatic otoscope ? ?????????????????

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Stage of acute otitis media

• Stage 1 Hyperemia
• swelling and redness of tympanic membrane ,
  mucosa in middle ear , eustachian tube , mastoid
• ??????????????????? ?????????????????????????????
  ????????? ??????????????????? ?????
  ????????????????????

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Stage of acute otitis media

• Stage 2 Exudation
• tympanic membrane ?????????????????????????
• ?????? ??????????????????????????????
  ??????????????????????????????????????????????

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Stage of acute otitis media

• Stage 3 Suppuration
• Ruptured tympanic membrane , Otorrhea
• ???????????????? ??????? ?????????????????????????
  

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Stage of acute otitis media

• Stage 4 Coalescense
• ???????????????????????? ???? mastoid
• Decalcification , osteoclastic reaction ???
  mastoid ????????????????????????????????
• ???????????????1 ???????????? 2 ???????
  ?????????? ?????? ????? ????????????????
  ???????????????????? 2
• Coalescense mastoiditis

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• Stage 5 Resolution
• ????????????? ???????????????????????? tympanic
  membrane ???????????????????? ????????????????????
  ?
• Stage 6 Complication
• ?????????????????? ???? coalescence
• Extracranial , Intracranial complication

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Stage 5
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???????????

• ????????????????
• ??????????????? ???? ?????????????????????????????
  ????????
• ??????????? pneumatic otoscope ???????????????????
  ??????????????
• X-Ray ?????????????????????????????

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??????????????? Acute Otitis Media

• ????????????????????????????????????
  (extracranial)
• - Subperiosteal abscess
• - Petrositis
• - Labyrinthitis
• - Facial paralysis

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??????????????? Acute Otitis Media

• ???????????????????????????????????
  (intracranial)
• - Meningitis
• - Extradural abscess
• - Lateral sinus thrombosis
• - Brain abscess
• - Subdural abscess
• - Focal otitis encephalitis
• - Otitic hydrocephalus

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Treatment

• ?????????? ??????? amoxicillin
• Dosage 40 mg/kg/day tid 10-14 day
• ?????????? 48-72 ??????? ?????????????????????????
  ????????? amoxycillin-clavulanate ???
  cephalosporins
• ??????????????????????? penicillin
  ???????????????? erythromycin or
  trimethoprim-sulfamethoxazole

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Treatment

• ???????(decongestant) ???????? eustachian tube
  ?????????????? ????????
• ??????????(antihistamine) ???????????????????????
  ???? ????????????????????
• ???????????????? ?????? ???????? ?????? ???????
• ?????????????????????????????? (Tympanocentasis)
  
• ??????????????????(myringotomy) ??????????????

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• ????????????? lt 6 wk ? ?????? ATB ??????? gram
  neg
• ??????????????????????????????????????????????????
  ???

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Chronic Otitis Media
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Definition

• ??????? ????????????????? ??? ?? perforation
  ?????????
• ?? recurrent infect
• Via perforation
• Via eustachian tube mixed organism

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Chronic Otitis Media

• Common organism
• P aeruginosa (48-98)
• S aureus (15-30)
• Klebsiella (10-21)
• Classification
• Safe Ear
• Unsafe Ear

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???????????

• ?????????????? (safe ear)
• ???????????????????????? ????????????
  ????????????????
• ????????????????? (central perforation)
• Drainage ?? ??? perforation, Eustachian tube ?
  ????????? complication, ????????????????

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Chronic Otitis Media
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Chronic Otitis Media
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Chronic Otitis Media
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• ??????????? (unsafe ear)
• ??????????????????? ??????????????????????????????
  ???
• Perforation ???????????????????????? (marginal)
  ???? attic(epitympanic recess perforation)
• ??????????????????? ????????????? ? ??? ?
• ??????????????????????
• ????????, ??????????, ???????????????????,
  ????????

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Marginal Perforation
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??????????????? Chronic Otitis Media

• Cholesteatoma
• Mass of keratinizing stratified squmaous
  epithelium (skin) present in the middle ear
  and/or mastoid

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RISK FACTORS

• Inadequate treatment of acute otitis media
• Chronic dysfunction of eustachian tube
• Persistant perforation of ear drum
• Irreversible change in middle ear
• Persisitant osteomyelitis in mastoid
• Persistant disease in nose ,sinuses ,nasopharunx
• Other factors

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??????????????? Chronic Otitis Media

• Intratemporal complication
• - Mastoiditis
• - Petrositis
• - Labyrinthitis ? SNHL , vertigo
• - Facial paralysis from mastoiditis,
  cholesteatoma

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??????????????? Chronic Otitis Media

• Intracranial complication (from cholesteatoma
  invaded into base of skull)
• - Meningitis
• - Extradural abscess
• - Brain abscess
• - Subdural abscess
• - Lateral venous sinus thrombosis

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Treatment

• 1. Medical treatment
• - ?????????? ,???????? ????
• - ?????????????????? upper respiratory tract
  infection
• - ?????????????????????? ????????????????????????
  ???? ????
• solution of 50 peroxide and 50 sterile water
• 2. Surgical treatment
• - Tympanoplasty
• - Mastoidectomy
• - Radial Mastoidectomy

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OTITIS MEDIA WITH EFFUSION
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OTITIS MEDIA WITH EFFUSION

• characterized by a nonpurulent effusion of the
  middle ear that may be either mucoid or serous.
• typically do not involve pain or fever.
• can occur during the resolution of AOM once the
  acute inflammation has resolved.
• Child gt adult (1-7yr)

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OTITIS MEDIA WITH EFFUSION

• Etiology
• obstruction/dysfunction of Eustachian tube
• - URI / sinusitis
• - Adenoid hypertrophy
• - CA nasopharynx
• - ???? ET- ???? ????????????????
• - cleft palate (abnormal tensor veli palatini
  insertion)
• - kartagener syndrome

can occur dcan occur during the resolution of AOM
once the acute inflammation has resolved. uring
the resolution of AOM once the acute inflammation
hascan occur during the resolution of AOM once
the acute inflammation has resolved. resolved.

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• ??????????? AOM
• ??????????? otitis barotrauma
• Allergy

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Symptoms

• ???????? ??????????????? ???? delayed speech
• ?????? (?????????????????????????)
• ????? (1-2?????? ????????????????????????????????
  ?????????)
• ??????????????????????????????? ????? valsava
  maneuver ?????????????????????????????????????????
  ???
• ?????????????? ??????? autophonia
• ??????????????????????????????????????????????
  ????????????????? ???? ????????????

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Signs

• TM retraction ??????????????????
  ???????????????????????????
• Short process malleus ???????
• ?????????? / airfluid level (good prognosis)
• TM ?????????
• Pneumatic otoscopy ????? TM ???????????
• ??????????????????? ?? ?????????? ???
  ?????????????
• ??????????????? bloody fluid serous fluid
  ????????????????? (glue ear )

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Otitis Media with Effusion
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Otitis Media with Effusion
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Otitis Media with Effusion
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Otitis Media with effusion
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Otitis media with effusion
fluid accumulation within the middle ear
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Complication

• 1. middle ear atelectasis
• 2. cholesteatoma
• 3. perforated TM
• 4. auditory deprivation
• (sensorineural hearing loss)
• 5. tympanosclerosis

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investigation

• Tympanogram type B
• Audiogram
• Low tone air conduction ????
• Low and high tone air conduction ???? ? flat type
• High tone air conduction ????

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Treatment

• Antibiotic-Amoxycillin, trimethoprim-sulfamethoxaz
  ole , Cephalosporin ( 2-4 Wk ,F/U q 1Wk)
• Steroid (nasal spray 2 Wk)
• Decongestant (?????????? ET tube )
• valsava manuver (????????ET tube????? , increase
  pressure in middle ear )
• Myringotomy ?????????????? pressure equlization

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Myringotomy

• 1 anteroinferior
• 2 grommet tube ???????????????????????
  ????????????? ??? middle ear( ????????????????????
  ???????????????????)
• ?????????????? ½-1 ??

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Myringotomy

• Indication
• 1. No response to antibiotic for 1 month
• 2. ???????????????????? 3 ???????????
• 3. impending cholesteatoma
• 4. adhesive otitis media ??????? middle ear
  atelectasis
• 5. Severe conductive hearing loss
• 6. cleft palate
• 7 . Tent to recurrent OME

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Complication

• Presistent otorrhea ??? ATB ????????????
• TM perforation ??????????????
• Granuloma ??? TM
• Ossicles dislocation

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Question

• ????????????????????????????????? temporal bone
  ??? longitudinal ??? transverse ?????????? ?
• ?????????????????????????? safe ear ??? unsafe
  ear ?? COM ????????????????????????? ?
• ???????????????????? ??? SOM ??? ?
• ???????? staging ??? AOM ????????? ?
• ????? most common ??? COM ??? ?