Elizabeth Rose Royal Victorian Eye and Ear Hospital Royal Childrens Hospital Dorlands Medical Dictionary A look and learn lecture Middleear conditions Management of otitis media ID: 914082
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Slide1
PRESENTATIONS OF MIDDLE EAR DISEASE
Elizabeth RoseRoyal Victorian Eye and Ear HospitalRoyal Children’s Hospital
Dorland’s Medical Dictionary
Slide2A “look and learn” lecture
Middle-ear conditionsManagement of otitis media Differential diagnosis of ear painClinical cases
Slide3Normal TM
http://me.hawkelibrary.com/new/main.php?g2_itemId=315
Slide4Translucent
(can see through it)
Handle of the malleus
Incus
Stapedius tendon
Round window niche
Normal TM
http://me.hawkelibrary.com/new/main.php?g2_itemId=315
Slide5OTITIS MEDIAA
SPECTRUM OF DISEASEacute otitis media
chronic otitis media with effusionatelectasis of the tympanic membranechronic adhesive otitis mediachronic suppurative otitis mediatubotympanic (“safe”)atticoantral (“unsafe”)
and may be a
continuum
of disease
Slide6Acute otitis media
Otitis media with effusion
Normal
Usual
sequence after
AOM
http://me.hawkelibrary.com/new/main.php?g2_itemId=187
http://me.hawkelibrary.com/new/main.php?g2_itemId=315
(all accessed 12-03-13)
http://me.hawkelibrary.com/new/main.php?g2_itemId=524
Slide7Acute otitis media
Perforation
with discharge (
otorrhoea
)
Normal (perforation heals)
Persistent perforation
But
AOM may also lead to a
perforation
of the TM
http://me.hawkelibrary.com/new/main.php?g2_itemId=369
http://me.hawkelibrary.com/new/main.php?g2_itemId=524
http://otitismedia.hawkelibrary.com/aom/3_2_CSOM_Otorrhea
http://otitismedia.hawkelibrary.com/normal/tm_2
Slide8Acute otitis media
Otitis media with effusion
Cholesteatoma
Atelectasis and adhesions
with continuing Eustachian tube dysfunction
… and more severe problems
http://hawkelibrary.com
http://me.hawkelibrary.com/new/main.php?g2_itemId=524
http://me.hawkelibrary.com/new/main.php?g2_itemId=187
http://me.hawkelibrary.com/new/main.php?g2_itemId=1225
http://me.hawkelibrary.com/new/main.php?g2_itemId=1486
Slide9http://www.dr-li.net/Hearing%20Health.html
Slide10Diagnosis of acute otitis media
(Therapeutic Guidelines)
A history of acute onset of symptoms and signsotalgia, ear pulling, otorrhoea, fever, anorexia, vomitingAND
2. Middle ear effusion (otorrhoea if a TP perforation)
AND
3. signs and symptoms of
middle ear inflammation
,
characterised
by redness of the tympanic membrane.
Slide11Management of AOM
Pain reliefDecongestants (oral/topical) and antihistamines
do not make the eustachian tube function better Not recommended
Slide12Management of AOM
Who should be treated with antibiotics?
Slide13Antibiotic therapy
if severe symptomspain/fever
perforationbilateral diseasepossible suppurative complicationmastoiditisMeningitis or other intracranial complication≤ 2 years oldIndigenous (ATSI , Maori and Pacific Islanders)
immune deficiency
cochlear implant
only hearing ear
Slide14Antibiotic therapy
Recommended treatment is: amoxicillin 45mg/kg/day in 3 doses
Can give up to 100mg/kg/dayContinue for 10 daysIf no improvement in 2 days change to amoxicillin/clavulanate
Slide15If an
allergy to penicillin
cefuroxime child 3 months to 2 years: 10 mg/kg up to 125 mg; 2 years or more: 15 mg/kg up to 500 mg orally, 12-hourly for 5 days
Slide16Antibiotic therapy
older children who can be accurate about their symptoms should be treated symptomaticallyif no improvement after 2 days consider treatment with antibiotics
Slide17CHRONIC OTITIS MEDIA WITH EFFUSION(COME)
the presence of a middle ear effusionasymptomatic apart from some hearing loss
Slide18CHRONIC OTITIS MEDIA WITH EFFUSION
Normal OME
Slide19AOM COME
http://me.hawkelibrary.com/new/main.php?g2_itemId=524
Slide20AOM COME
TM bulging
Cannot see lateral process
of the
malleus
Opaque
White from the pus in the ME
Inflammation/prominent
vessels
TM is retracted
Malleus handle is more prominent
Opaque
Yellow from effusion
https://sydneyentclinic.com/sean-flanagan/patient-resources-2/patient-resources/hearing-loss/glue-ear-middle-ear-infections-and-grommets/
https://www.drrahmatorlummc.com/serousotitismedia.htm
Slide21MIDDLE-EAR EFFUSION
https://www.emaze.com/@AOOROWLL
https://www.drrahmatorlummc.com/serousotitismedia.htm
Middle ear full of fluid
Air-fluid level
Slide22CHRONIC ADHESIVE OTITIS MEDIA
TM is thin and adheres to the
ossicles
, often with erosion
https://www.medical.theclinics.com/article/S0025-7125(18)30068-3/fulltext
Slide23TYMPANIC MEMBRANE PERFORATIONS
https://journals.sagepub.com/doi/abs/10.1093/innovait/inp007?journalCode=inoa
https://dontforgetthebubbles.com/otitis-media/
Likely to have hearing impairment
Hearing may be normal
Slide24CHRONIC SUPPURATIVE OTITIS MEDIA
(CSOM)“deafness and discharge”
persistent diseaseinsidious onsetsevere destructionirreversible sequelae
Slide251.
tubotympanic disease (“safe”)central perforation2. atticoantral disease
(“unsafe”)cholesteatomathe presence of keratinising squamous epithelium in the middle ear
Slide26TUBOTYMPANIC
(central perforation)
https://dontforgetthebubbles.com/otitis-media/
Central perforation with active discharge (
otorrhoea
)
Slide27ATTICOANTRAL DISEASE
CHOLESTEATOMA(marginal or attic perforation)
https://www.southlakeent.com/services-procedures/ears-hearing/ear-concerns/cholesteatomas
Erosion in the attic with keratin
Can see cholesteatoma in the
mesotympanum
as well
Likely to surround the
ossicles
(incus)
Slide28Cholesteatoma
A non-neoplastic accumulation of keratinising stratified squamous epithelium in the tympanic cavity (middle ear) or mastoid air cells
Resorbs (damages) underlying bonePotentially dangerous to the patient
Slide29CHOLESTEATOMA
Complications
Hearing loss Intracranial
.tympanic membrane .
ossicles
.inner ear
Vertigo
Tinnitus
Facial paralysis
https://www.vectorstock.com/royalty-free-vector/ear-anatomy-vector-23904762
Slide30MANAGEMENT OF CHRONIC
OTITIS MEDIA WITH EFFUSION(and also retraction/atelectasis of the tympanic membrane)
Slide31What are grommets?
Slide32https://jaydeeautocables.com.au/products/rubber-grommet-assortment-kit
Any tube with flanges
https://twen.rs-online.com/web/p/rubber-grommets/1879453/
https://venuspack.com.au/product-category/poly-bags-netting/tarpaulins/
Slide33?Young surfers
https://kialoa.com/blogs/talkstory/endearing-photos-of-young-surfers
https://diannewolfer.com/books/picture-books/granny-grommet-and-me/
Slide34Wallace and gromit
https://www.radiotimes.com/movies/is-wallace-and-gromit-on-netflix/
Slide35MIDDLE EARVENTILATION TUBES
https://slideplayer.com/slide/14431309/
Slide36AKA
grommetstubes pressure equalisation tubes
middle ear ventilation tubestympanostomy tubesNOT a drainage tube(it’s role in life is to ventilate!)
Slide37https://www.slideshare.net/bethfernandezaud/unit-3-review-30629514
Mucoid middle ear effusion
Slide38Ventilates
the middle ear
https://www.healthinfo.org.nz/index.htm?Ventilation-tubes-grommets.htm
Slide39COME
Who should have middle ear ventilation tubes?
(for OME)
Slide40Natural history
of OME after AOM
Slide411. COME for
4 months at least, with hearing loss
2. COME in a child ‘at risk’ regardless of the hearing3. COME and structural damage to the tympanic membrane
Slide421. 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
Slide43O
]
O
O
O
O
O
X
X
X
X
X
[
[
[
[
[
]
]
]
]
X
50%
of children with persistent OME have hearing thresholds at
20 dB
Slide44O
]
O
O
O
O
O
X
X
X
X
X
[
[
[
[
[
]
]
]
]
X
20%
of children with persistent OME have hearing thresholds at
>35 dB
Slide452. An
‘at risk’ child has an increased risk of developmental difficulties due to factors not related to the OME:
physicalsensory, e.g. blindnesscognitive, e.g. developmental delaybehavioural
Slide46https://www.pinterest.com.au/pin/350999364682083551/
Slide473. Structural damage to the tympanic membrane
https://app1.unmc.edu/medicine/heywood/otology/unit4-middle-ear-disease-diagnosis.cfm
Retraction of the tympanic membrane can get worse and damage the
ossicles
or become a cholesteatoma
Slide48Children with persistent OME
who:Do not have other risk factorsDo
not have significant hearing lossDo not have damage to the tympanic membrane or middle earCan be evaluated every three months
Slide49Take it to Telehealth - 1
remember referred otalgia
If the ear is normal seek the cause of the pain
Slide50Take it to Telehealth – 2
More is missed in medicine by not looking than by not knowing
https://www.thesun.co.uk/living/2712715/can-you-spot-the-dog-on-the-rug-hilarious-photos-show-animals-blend-into-the-background-when-it-suits-them/