CDP: Middle Ear

Acute otitis media

Acute otitis media

Most cases of AOM occur in young children- age 6-24 months

Incidence decreases significantly after age 5

Acute otitis media most common pathogens

Streptococcus pneumoniae, Haemophilus infuenzae, Moraxella catarrhalis

Acute otitis media risk factors

Peak age- 6-12 months

Attending day care

Exposure to 2nd hand smoke

Pacifier use

Not being breastfed

Acute otitis media pathophysiology

Antecedent event (viral URI) -> inflammatory edema in the respiratory mucosa of the nose, nasopharynx, and Eustachian tube -> obstruction of Eustachian tube flow -> optimal environment for bacterial proliferation

Acute otitis media signs and symptoms

Otalgia

Fever

Conductive hearing loss

Otorrhea (likely indicative of TM perforation)

Ear tugging (in infants/toddlers)

Symptoms typically develop AFTER a recent URI

Acute otitis media: normal physical exam

A normal tympanic membrane is mobile, slightly convex, translucent, and intact

Mobility can be assessed with pneumatic otoscopy

Acute otitis media: abnormal physical exam

Bulging tympanic membrane

Fluid-filled middle ear (effusion)

Decreased TM mobility on pneumatic otoscopy

Perforation of the TM with purulent discharge

Acute otitis media diagnosis

clinical with history and otoscopic exam

Acute otitis media additional testing

only necessary in patients with complicated presentations, which occurs when the infection spreads to adjacent structures leading to:

Mastoiditis

Facial nerve paralysis

Meningitis

Brain abscess

Acute otitis media management

Observation can be done in children based on age and severity

Acute otitis media antibiotic regimen

Amoxicillin (antibiotic of choice in children)

Augmentin (antibiotic choice in adults)

Cefdinir, Cefuroxime, Cefpodoxime

Azithromycin

Duration is typically 5-10 days based on age and AOM severity

Treatment time for patients <2 or adults with severe infection

10 days of antibiotics

Acute otitis media management: tympanostomy tubes

may be offered in children with recurrent AOM (>4 per year)

Chronic suppurative otitis media

Caused by chronic middle ear mucosal inflammation with tympanic membrane perforation

Chronic suppurative otitis media most common pathogens

Pseudomonas aeruginosa, Staphylococcus aureus, Proteus vulgaris, Klebsiella pneumoniae

Chronic suppurative otitis media risk factors

History of multiple episodes of AOM

Early otitis media (occurring in the first few months of life)

Chronic serous otitis media

Chronic suppurative otitis media pathophysiology

Generally results from AOM that is not diagnosed/treated properly

Can also occur due to chronic otitis media with effusion & following traumatic perforations

Chronic suppurative otitis media signs and symptoms

Chronic (> 6 weeks) purulent middle ear discharge (Otorrhea)

Otorrhea can be persistent or intermittent

Conductive hearing loss

Perforated TM with purulent middle ear drainage on otoscopy

Chronic suppurative otitis media diagnosis

clinical based on history and findings on otoscopy

Chronic suppurative otitis media diagnostic studies

cultures of purulent drainage can be collected in patients with persistent/unresponsive disease

Chronic suppurative otitis media management

aural toilet

Empiric topical (otic drop) antibiotics x 2 weeks: Fluoroquinolones- Ciprofloxacin, Ofloxacin

Chronic suppurative otitis media management: consider systemic antibiotics in patients with

patients with persistent otorrhea after 3 weeks

Chronic suppurative otitis media patient education

Keep ear dry

Chronic suppurative otitis media management: treatment failure

persistent otorrhea after 3 weeks of initial topical treatment

Additional work-up is warranted at that point (culture, CT scan of the temporal bone, consideration of surgery)

Mastoiditis

Highest incidence in children younger than 2 years old

Mastoiditis etiology

Otitis media is the MCC of acute mastoiditis in children & adults

Mastoiditis most common pathogens

Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae, Moraxella catarrhalis

Mastoiditis risk factors

recurrent acute otitis media

Mastoiditis pathophysiology

Purulence/exudate from a middle-ear infection spreads to mastoid air cells through the aditus ad antrum

Mastoiditis complications

Can develop extracranial abscess and intracranial complications, including:

Meningitis

Intracranial abscess

Sigmoid sinus thrombosis/thrombophlebitis

Mastoiditis signs and symptoms

Typical s/sx of OM PLUS-

Postauricular tenderness, erythema, and edema

Protrusion of the auricle

Otalgia

Fever

Narrowing of EAC

Mastoiditis diagnosis

typically based on history and clinical characteristics

Mastoiditis diagnosis: consider a CT of the temporal bone if

Extracranial or intracranial complications are suspected

Severe illness or toxic appearance

Persistent AOM despite appropriate antimicrobial management (to rule out sub-acute/masked mastoiditis)

Mastoiditis management

Consultation with an otolaryngologist and/or neurosurgeon should occur EARLY in the disease course

uncomplicated mastoiditis management

first-line treatment is IV antibiotics with middle ear drainage with myringotomy & tympanostomy tube placement

ampicillin-sulbactam or piperacillin-tazobactam

If no clinical improvement in 48 hours -> mastoidectomy

complicated mastoiditis management

aggressive surgical management with mastoidectomy + IV antibiotics + myringotomy & Tympanostomy Tube placement is suggested

Mastoiditis prognosis

Most children appropriately treated early in the course recover without complications

Intracranial extension can result in permanent neurologic deficits or death

Tympanic membrane perforation

Overall incidence unknown- many heal spontaneously (the TM can regenerate)

Males > Females

Tympanic membrane perforation etiology

Otitis media

Barotrauma (sudden pressure changes- flying, diving, etc.)

Head trauma (including physical abuse)

Foreign objects in ear (Q tips!)

Tympanic membrane perforation signs and symptoms

Sudden onset of otalgia

Hearing loss

Bloody otorrhea

Tinnitus

Vertigo

Tympani membrane perforation physical exam

Otoscopy demonstrates a perforation in the TM

Do not perform pneumatic otoscopy with a TM perforation- can damage the middle ear!

Vestibular and hearing assessment should be performed to assess the patient's balance and hearing

Tympanic membrane perforation diagnostic studies

clinical diagnosis

Weber, Rinne, and audiogram (hearing test) may also demonstrate conductive hearing loss

Tympanic membrane perforation: Weber test

Normal= no lateralization

Conductive hearing loss= lateralization to affected side

Tympanic membrane perforation: Rinne test

Normal= AC > BC

Conductive hearing loss= BC > AC

Tympanic membrane perforation management: small tympanic perforations

generally heal spontaneously

Tympanic membrane perforation management if contaminated wound

Antibiotic otic drops indicated x 3-5 days

Ciprofloxacin, Ofloxacin

Tympanic membrane perforation management: large or marginal perforations

may require surgery-often fail to close spontaneously

Tympanic membrane perforation management: referral to ENT

Large or non-healing perforations

Significant or persistent hearing loss

Penetrating trauma to the middle ear

Vestibular symptoms (n/v, nystagmus, ataxia)

Suspicion of cholesteatoma

Tympanic membrane perforation management: emergent evaluation and admission is appropriate if

patients have sustained a perforation and have facial nerve paralysis or s/sx of basilar skull fracture

Cholesteatoma

Caused by congenital or acquired keratinizing squamous epithelium in the middle ear

acquired more common

Cholesteatoma risk factors

TM retraction (from Eustachian tube dysfunction)

TM perforation

Recurrent or chronic otitis media

Family history of chronic middle ear disease or cholesteatoma

Cholesteatoma signs and symptoms

Persistent foul-smelling otorrhea

Conductive hearing loss

Dizziness

Tinnitus

Facial nerve weakness or paralysis

Can also be asymptomatic

Cholesteatoma physical exam: congenital

Spherical white mass behind intact tympanic membrane

Cholesteatoma physical exam: acquired

Retraction pocket with accumulation of squamous debris

White mass behind a perforated TM

Cholesteatoma diagnosis

typically made per the patient's history and otoscopic exam

Cholesteatoma diagnosis: audiometry

important to assess for hearing deficits, as this may alter the surgical plan

Typically shows conductive hearing loss

Cholesteatoma diagnosis: CT of the temporal bone

typically performed to assess the extent of disease and any associated complications prior to surgical treatment

Cholesteatoma management: treatment of choice

mastoidectomy

Cholesteatoma management: long-term follow up

needed due to the possibility of a residual or recurrent lesion after surgery

Delayed treatment of cholesteatoma can lead to

gradual expansion of the cholesteatoma and can cause intracranial and extracranial complications (similar to mastoiditis)

Otosclerosis

abnormal bony overgrowth involving the footplate of the stapes

can cause acquired hearing loss

Otosclerosis etiology

Autosomal dominant disorder

Most patients present with conductive hearing loss between 20-45 years of age

Otosclerosis pathophysiology

bony overgrowth occurs in the otic capsule (bony outer wall of the inner ear in the temporal bone) -> involves the stapes footplate -> stapes becomes fixated and cannot conduct sound properly to the inner ear

Otosclerosis signs and symptoms

Gradual conductive hearing loss beginning in young adulthood
-Usually bilateral & asymmetric

Tinnitus

Vertigo (uncommon)

Otosclerosis physical exam

Otoscopic exam reveals a normal TM & no middle ear inflammation

Tuning fork tests will reveal conductive hearing loss (Weber and Rinne)

Otosclerosis diagnostic studies

Audiometry should be done to test for conductive hearing loss

CT scan of the temporal bone may be performed to assess the extent of otosclerosis and for preoperative planning

Otosclerosis management for patients with mild hearing loss

consider continued observation with hearing aids if needed with routine follow-up to determine if the condition is progressing

Otosclerosis management: surgical treatment

can be performed via stapedectomy with prosthesis placement