DISEASES OF MIDDLE EAR

Students should be able to:
DISEASES OF MIDDLE EAR
LEARNING OBJECTIVES
1. Recognize the clinical manifestations of diseases of middle ear and
their basic management.
2. Understand when to refer the patient to the concerned speciality.
3. Able to follow guidelines for treatment of discharging ear.
4. Discuss the management of OTITIS MEDIA
ASOM,CSOM,OME,OTOSCLEROSIS
OTITIS MEDIA
DEFINITION
Inflammation of the middle ear cleft
OTITIS MEDIA - CLASSIFICATION
Acute OM - rapid onset of signs & symptoms < 3 wks course
Subacute OM - 3 wks to 3 months
Chronic OM - 3 months or longer
OTITIS MEDIA
SIGNS AND SYMPTOMS

SPECIFIC SIGNS
Otalgia
Otorrhea
Hearing Loss
Vertigo
NONSPECIFIC SIGN
Fever
Irritability
Lethargy
Anorexia
Vomiting
Diarrhea
STAGES OF SUPPURATIVE AOM
Stage of tubal occlusion.
Stage of pre suppuration.
Stage of suppuration.
Stage of resolution.
Stage of complication.
STAGE OF TUBAL OCCLUSION
SYMPTOMS:
Deafness.
Otalgia.
No fever.

SIGNS:
Retracted tympanic membrane.
Prominence of lateral process of malleus
Loss of light reflex
STAGE OF PRESUPPURATION
SYMPTOMS:
Otalgia
No fever
SIGNS:
Redness and outward bulging of pars flaccida.
Dilation of blood vessels most apparent.

STAGE OF SUPPURATION
SYMPTOMS:
Severe otalgia
Persistent fever.
Conductive deafness
SIGNS:
Edematous TM.
No landmarks seen.
bulge to the point of rupture.
Obvious outward

STAGE OF RESOLUTION
SYMPTOMS:
No otalgia.
Mild hearing loss.
No fever.
SIGNS:
Inflammation resolved.
Blood stained discharge in auditory canal.
SEROUS OTITIS MEDIA (OME)
An effusion in the middle ear resulting from incomplete
resolution of acute otitis media or obstruction of the eustachian
tube

usually sterile
may contain pathogenic bacteria.
More common in children.
Predisposing Factors:
o Eustachian tube obstruction
inflammatory processes in the nasopharynx
allergic manifestations
hypertrophic adenoids
benign or malignant neoplasms.
SYMPTOMS - OME
Asymptomatic
o or
Patient may experience
-ear discomfort
-hearing loss
-tinnitus
-possibly vertigo
-feeling of ear fullness
SIGNS
Tympanic membrane retraction--mild
Displacement of the light reflex--Distorted
Accentuation of the landmarks--Prominent
Transudate from the blood vessels in the mucous membrane
develops in the middle ear
o amber or gray appearance of tympanic membrane
o immobility of the tympanic membrane
An air-fluid level or bubbles of air may be seen through the tympanic
membrane.
Conductive hearing loss occurs
DIAGNOSTIC TESTS FOR SOM

Otoscopy
Pneumatic otoscopy--- diagnostic clinical test
Tympanometry – type B--diagnostic investigation
PTA – conductive loss
Type A
DIAGNOSIS
Acute OM
o preceding URI
o fever, otalgia, hearing loss, otorrhea
o may have assoc. constitutional symptoms
Chronic MEE (OME)
o asymptomatic
o hearing loss
o “plugged”
o “popping”
The position of the tympanic membrane is a key for
differentiating acute otitis media and otitis media with effusion.

Acute OM
o Bulging
o Thickened
o yellow middle ear effusion
Chronic MEE (OME)
o typically retracted or in the neutral position
o Thickened
o Amber or grayish middle ear effusion
Acute OM
Chronic MEE (OME)
MANAGEMENT OF OTITIS MEDIA
TREATMENT
Medical
Aural toilet
Suction Cleaning
Topical Antibiotics
Systemic Antibiotics
o depending on the culture and sensitivity
DECONGESTANTS
ANALGESICS AND ANTIPYRETICS

MANEUVERS TO OPEN ET
VALSALVA MANOEUVRE
It is a simple method in which the patient closes his nostrils & mouth
at the same time & attempts to exhale forcefully.
In this way the ends of Eustachian tubes where they connect with
throat can be opened.
SURGICAL MANAGEMENT
Myringotomy with or without ventilation tube insertion.
Laser assisted myringotomy / tympanostomy
Mastoidectomy and related procedures.
Myringoplasty or tympanoplasty.
GROMMET / VENTILATION /TYMPANOSTOMY TUBES

INDICATIONS OF MYRINGOTOMY/ VENTILATION TUBE
INSERTION
Impending rupture of TM.
Infection not responding to medical treatment.
Infection in immature or immuno-compromised host.
Pain or vertigo.
Prolonged serious hearing loss which may compromise speech and
IQ development.
Recurrent otitis media.
COMPLICATIONS
Injury to incudostapedial joint or stapes.
Injury to jugular bulb with profuse bleeding.
Middle ear infection.
Failure to resolve the ear infection.
Persistent perforation after the tube falls out of the ear drum.
Chronic ear drainage.
Infection.
Hearing loss.
Scarring of the ear drum.
Foreign body reaction to the tube itself.
MASTOIDECTOMY & RELATED PROCEDURES
MASTOIDECTOMY
-The purpose of these procedures is to eradicate DISEASE present in
the inaccessible parts of the temporal bone.
- Middle ear.
- Mastoid.
- Attic/Antrum.
-Increase the Air Reservior
Adenoidectomy and/or tonsillectomy
for the treatment of otitis media with effusion is controversial, some
studies support it while others do not.

OTOSCLEROSIS
INTRODUCTION
7-10% Caucasian temporal bones
1% Caucasians with symptoms
Other races lesser incidence
Otosclerosis is an autosomal dominant disorder of the otic capsule,
limited to the temporal bone.
Has simple autosomal dominant inheritence with incomplete
penetrance. - 70%
Age of onset of hearing loss ranges from teens to the forties
Pregnancy can accelerate the otosclerotic process.
Mostly Involves Foot Plate of Stapes- Fistula Ante Fenestrum
CLINICAL FEATURES
Slowly progressive hearing loss

Bilateral, asymmetric
Ages 15 to 45
Women 2:1
o pregnancy/estrogen therapy
PHYSICAL EXAMINATION
Otomicroscopy
o normal
o Schwartze’s sign
Tuning forks
o 512 Hz Conductive Deafness
DIFFERENTIAL DIAGNOSIS
Tympanosclerosis
Incus/malleus fixation
ossicular discontinuity
congenital footplate fixation
Middle ear pathology causing CD

AUDIOLOGIC EVALUATION SHOULD INCLUDE
Impedance audiometry
Pure tone audiogram
Speech audiometry

IMPEDANCE AUDIOMETRY DIAGNOSTIC
MANAGEMENT

Amplification
- Refuse surgery
- Poor surgical candidate
- Following improvement of CHL
Medical therapy
- Sodium fluoride
- Vitamin D
- Calcium carbonate
Stapes surgery
STAPES SURGERY
Stapedotomy/ Stapedectomy
Insertion of prosthesis

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