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Literature reading

OTITIS MEDIA WITH EFFUSION


Kartika Sudrajat
Supervisor:

Dr.Denese M S Rully, MKes, Sp.THT-KL

Dept. of Otorhinolaryngology Head & Neck Surgery


Hasan Sadikin General Hospital
2013
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INTRODUCTION
Otitis Media (OM)
Inflammation of the middle ear, without
reference to a specific etiology or pathogenesis
Otitis media (OM) is the most common reason for an
illness-related medical visit in preschool-age children

Otitis Media with Effusion (OME)


The presence of fluid in the middle ear without signs or
symptoms of acute ear infection
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ANATOMY

DEFINITION
Otitis Media with Effusion (OME)
Inflammation of the middle ear space resulting in a
collection of fluid behind an intact tympanic
membrane
OME often follows episode of Acute Otitis Media
Process : acute
subacute
chronic
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Acute OME
New onset middle ear effusion < 3 weeks

Subacute OME
Middle ear effusion 3 weeks 3 months

Chronic OME
Middle ear effusion > 3 months

SYNONYMS
Serous otitis media
Secretory otitis media
Allergic otitis media
Catarrhal otitis media
Non supurative otitis media
Mucoid otitis media
Secondary otitis media

Tubotympanic catarrh
Hydrotubotympanum
Exsudative catarrh
Tubotympanitis
Tympanic hydrops
Glue ear
Fluid ear
Middle ear efussion

EPIDEMIOLOGY
Studies :
Screening asymptomatic children (2-3 y.o) with
tympanometry 17-41 % have OME
Screening children (2-6 y.o) using tympanometry and
otoscopy 22-61 % have OME
Frequency of OME increases with age, reaching maximum
between 1-2 years
Most episodes of OME resolve spontaneously
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PATHOGENESIS

Risk Factors for Otitis Media

Viral upper respiratory infection


Allergic Rhinitis
Eustachian tube dysfunction
Cigarette smoking (passive)
Bottle fed, not breast fed
Male sex
Immunologic deficiency
Cilia dysfunction
Cleft palate disease
Genetic predisposition
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PATHOGENESIS
Normal opening of the proximal end
of the eustachian tube or
mucociliary clearance

Interfering process

Otitis Media with Effusion


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PATHOGENESIS
Mechanical

Functional

Intraluminal
Viral Rhinitis
Alergic Rhinitis

Extraluminal
Adenoid Hypertrophy
Nasopharingeal tumor

OBSTRUCTION OF
THE TUBE

Poor tensor Veli


Palatini muscle
Function

Negative pressure
Of the Middle ear

Increased tubal
compliance

Duration
Magnitude

AOM

Efussion
Transudation
Eksudation

OME
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PATHOGENESIS
Middle ear ventilation restored

Mucociliary transport effective


in moving the middle ear fluid
through the eustachian tube

Resolution of OME
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MICROBIOLOGY

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THE EUSTACHIAN TUBE


Essential in maintaining a healthy, well aerated
middle ear
Protects middle ear from pathogenic organism in
the nasopharynx
Equilibrates pressure across the tympanic
membrane
Allows drainage of secretions from the middle
ear to the nasopharynx

THE EUSTACHIAN TUBE


Infant
10 degrees off horizontal
13 to 18 mm long

>7 years
45 degrees angle, 2 to 2.5 cm
below the middle ear orifice
31 to 38 mm long
Shape of two cones
connected by the narrow end
(isthmus)

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THE EUSTACHIAN TUBE

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THE EUSTACHIAN TUBE


EVALUATION
o
o
o
o
o

The Valsava test


The Toynbee test
The Politzer test
Eustachian tube catheterization
The nine step inflation-deflation test

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The Valsava test

The Politzer test

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The Toynbee test

The nine step inflation-deflation


test

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Diagnosis
HISTORY
Decreased hearing
Aural fullness and or
pressure
Plugged
URTI, plane trip, scuba
diving

CHILDREN
Pull at the ears clogged
sensation
Poor hearing
Speech & language
developmental delay
ADULTS
Aural pressure
Hearing loss
Clicking
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PHYSICAL EXAMINATION

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PHYSICAL EXAMINATION
Poorly mobile tympanic
membrane in neutral
position, bulging, or
retracted
Color of tympanic
membrane :
yellow serous effusion
gray mucoid efusion
Air bubble (+)

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DIAGNOSTIC WORKUP
Pneumatic otoscopy
Sensitivity & spesificity
Tympanometry
> 90 %
Diagnostic miringotomy
Audiometric evaluation
Flexible fiberoptic nasopharyngoscopy
CT scan
Acoustic reflectometry

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TREATMENT
MEDICAL TREATMENT

ANTIBIOTICS

CORTICOSTEROIDS

DECONGESTANT-ANTIHISTAMINES

MUCOLYTIC AGENTS

PHYSICAL MANIPULATIONS
SURGICAL TREATMENT
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MEDICAL TREATMENT
The length of medical therapy before surgical
management is controversial
Avoidance or elimination to a specific prediposing
factors :
Barotrauma
Household smoking
Allergens
Hearing loss hearing amplification
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Antibiotics
Bacterial isolates in OME fluid (+)
Improve clearance of the effusion
Prophylactic dosing : daily dose used to treat acute
infection
Guideline from Agency for Health Care Policy &
Research, 1994 (OME child 1-3 y.o) : 3 months
antibiotic therapy
Avoid passive smoking, bottle feeding, another day
care
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Antibiotics

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Antihistamin - Decongestant
Antihistamin
Allergy as a cause of OME (+ allergen avoidance,
desensitization )
Decongestant
Analogy of comparing the middle ear and mastoid
system to a paranasal sinus
To help clear secretions and congestions
Some studies : no efficacy of this compounds in the
course of OME
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Corticosteroids
Reduce the inflamatory response in the nasopharynx
eustachian tube complex
Stimulate a surface active agent in the eustachian
tube to facilitate air & fluid movement
Short term success, no significant long-term efficacy

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Mucolytic agents
To alter the viscoelastic properties of the middle ear
mucus to improve mucous transport from the middle
ear the nasopharynx

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Physical Manipulations
Politzerization of the nose to blow open the
eustachian tube and reestablish middle ear
ventilation
o The Valsava test
o The Toynbee test
o The Politzer test

Bottle feeding in supine positions can let milk enter


& remain in the nasopharynx for extended periods
and lead to inflammation in that area
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SURGICAL TREATMENT
Early surgical intervention to prevent speech
and language delay & possible permanent
structural changes
Substantial hearing loss
Developmental delay or disabilities (visual
impairment)
Severe tympanic membran retractions
Balance disorders
Sensorineural hearing loss
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SURGICAL TREATMENT
Audiometric evaluation should be performed before
surgical intervention, to determine the CHL & detect
SNHL

SURGICAL TREATMENT
Myringotomy
Ventilation tubes
Adenoidectomy

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MYRINGOTOMY

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Myringotomy
Simple myringotomy heals in several days
To prevent early closure of the perforation :

Cauterization
Laser treatment

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Ventilation Tubes
o 2 or 3 mm myringotomy is
made in anterior superior or
anterior inferior quadrant
Tympanosclerotic portions are
poor sites
Avoid myringotomy at atrophic
area
o Suctioned out the middle ear
fluid
o Placed the ventilation tube
Any tympanic membrane
retraction at the incision site,
elevated with small suction
tube
o Otic drops for 2-3 days post op
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VENTILATION TUBE

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Ventilation Tubes
Factors to be considered to remove ventilation tube :
Age
Absence of nasopharyngeal abnormalities
Others factors which affect incidence of OME
After removal ventilation tube freshening the edges
of the perforation & placing a paper patch

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Ventilation Tubes
COMPLICATIONS OF VENTILATIONS TUBE
Post operative otorrhea
Long standing perforation
Hearing loss
Granulation tissue
Early occlusion of the tube lumen
Early extrution of a ventilation tube
Cholesteatoma

Adenoidectomy

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COMPLICATIONS OF OME
Hearing loss delayed of speech, language &
cognitive development
Impaired balance mechanisms
Structural change :
atelectasis
retraction pocket
erosion of incudostapedial joint
perforation of tympanic membrane
cholesteatoma
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OME IN ADULTS
Less common than in children serious condition
Etiology :
Nasopharyngeal carcinoma
Wegeners granulomatosis
Adenoid hypertrophy HIV infection
Nasogastric/nasotracheal tube
Barotrauma
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BAROTRAUMA
During transition from low to high pressure
Symptoms : otalgia, fullness, hearing loss, tinnitus
Extreme pressure changes perforated TM
Management :
Toynbee or Valsava maneuver
Pseudoephedrine/oxymetazoline before diving
Surgical therapy
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HIGH LIGHT
Inflammation of the middle ear space resulting in a
collection of fluid is present in the middle ear space and there is an
absence of the sign and symptoms of acute infection (no perforation of
the tympanic membrane is present)
Any process that interferes with normal opening of the eustachian tube of
the mucocliary clearance mechanism can cause OME
Diagnosis is made with pneumatic otoscopy. Tympanometry and
audiometry use d to confirm the diagnosis and asses hearing loss
OME resolves spontaneously in most cases

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THANK YOU !!

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