Otitis Media with Effusion and Acute Otitis Media

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Otitis Media with Effusion and Acute Otitis
Media

• Wouter-J.F. ten Cate
• ORL Specialist

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Anatomy
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Normal Ear
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Middle Ear Effusion

• Fluid in the middle ear

Normal
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Epidemiology

• Middle ear effusion is the most common cause of
  acquired conductive hearing loss in children
• 60 of all children will have a middle ear
  effusion in their first year
• 90 of all children will develop a middle ear
  effusion

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Epidemiology

• The peak is between 3-6 years where 30 will have
  a a middle ear effusion
• Incidence drops to 2 at age 11
• Incidence relates positively to upper airway
  tract infections

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Persistent Middle Ear EffusionSynonyms

• Glue ear
• Otitis media with effusion (OME)
• Chronic seromucinous otitis media

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OME

• The diagnosis otitis media with effusion is made
  when fluid is present behind the ear drum for 12
  weeks or more

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Factors involved in the Aetiology of OME
Anatomic/Physiological dysfunction 1. Eustachian
tube dysfunction 2. Cleft palate submucous
cleft 3. Craniofacial dysplasia (trisomie 21)
Infection
Host Factors 1.Immature/impaired immunology 2.
Familial predisposition 3. Method of feeding
(breast or bottle) 4. Sex 5. Race
OME
Environmental Factors 1. Day-care attendance 2.
Smoking in households
Allergy
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Infection/Inflammation
Eustachian tube dysfunction
Hyperactive middle ear and tube mucosa
Negative middle ear pressure
OME
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Eustachian Tube

• Connects middle ear and nasopharynx
• Lumen shaped like two cones with apex directed
  toward middle, isthmus
• Mucosa has mucous producing cells and ciliated
  cells

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Eustachian Tube
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Eustachian Tube
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Nasopharynx
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Eustachian tube

• Children
• wide cartilaginous part
• longer bony portion
• 10 degree angle
• isthmus larger
• nasopharyngeal orifice 4-5 mm in infants

• Adults
• ant 2/3- cartilaginous
• post 1/3- bony
• 45 degree angle
• isthmus 1-2 mm
• nasopharyngeal orifice 8-9 mm

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Eustachian Tube

• Usually closed
• Opening involves cartilaginous portion
• Opens 1 x per minute in adult
• Opens 5 x per minute in a baby
• Duration of opening only a fraction of a second

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Eustachian Tube Physiology

• Pressure regulation (ventilation) of the middle
  ear
• Clearance of middle ear secretions
• Protection from nasopharyngeal sound, secretions,
  and pressure differences during breathing,
  swallowing etc.

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Eustachian Tube and Middle Ear Pressure

• Compensation the negative pressure changes due to
  of gas diffusion in the middle ear
• Dynamic equilibrium lies around zero

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The mastoid serves as
a pressure
buffer Small mastoids are correlated with
chronic middle ear disease
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Tube opening Active and Passive

• Active during swallowing, yawning, and sneezing
• Tensor veli palatini responsible for active tubal
  opening
• Passive From middle ear or nasopharynx through
  pressure difference (Valsalva, scuba diving)

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Tube Dysfunction

• Upper airway infection
• involves often Eustachian tube
• Adenoids disease
• enlarged or chronic infection or malignancy
• Anatomy
• Cleft palate
• Craniofacial dysplasia (trisomie 21)
• children
• Trauma
• adenoidectomy and temporal bone fracture
• Ciliary dysfunction

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Eustachian Tube Function Tests

• Valsalva
• Toynbee
• Politzer
• Tympanogram (indirect)

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Valsalva and Toynbee
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Valsalva Manoeuvre
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Tympanometry

• Compliance test of the tympanic membrane under
  different pressure levels in the outer ear canal

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Causes of Hyperactive Middle Ear Mucosa and Fluid
Exudate

• Bacterial and viral infection
• Allergy
• Negative middle ear pressure

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Infection and OME

• Previously thought sterile
• 30-50 grow in culture
• Over 75 PCR
• Usual upper airway infection organisms

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Clinic of Persistent Middle Ear Effusion

• Oft asymptomatic
• Hearing loss
• Plugged, popping ears, otalgia
• Delayed speech development
• Unclear speech / loud speech
• Additional pathology (adenoid disease)

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Diagnosis

• Oto(micro)scopy
• aerated/fluid
• position - bulging, retracted
• mobility - normal, hypomobile, neg pressure
  (pneumatic otoscope)
• associated pathology

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Otoscope
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Valsalva with MEE
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Middle Ear Effusion with Air Bubbles
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OME Typical
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OME
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Middle Ear Effusion?
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Further Diagnostics

• Audiogram
• document CHL, SNHL, baseline, preop
• sooner if high risk
• Impedance tympanometry

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Treatment - OME

• Antibiotics/nasal decongestants
• If unresponsive
  Myringotomy tympanostomy combined with
  treatment of associated condition if possible
  (adenoidectomy, allergic rhinitis)
• Valsalva training

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Adenoid Face
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Enlarged Adenoids
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Myringotomy
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After VT Placement
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Complications of VTs

• G/A complications.
• Otorrhoea 12
• TM perforation 0.5 -25
• Scarring/ atrophy/ tympanosclerosis of TM
• Cholesteatoma

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CAVE Middle Ear Effusion in Adults...
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NPC