ear tubes. the ear aom vs. ome acute otitis media –pus behind tm –acute infection –multiple...
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Ear Tubes
The Ear
AOM vs. OME
• Acute Otitis Media– Pus behind TM– Acute infection– Multiple severe
complicaitons• Mastoiditis• Meningitis• Brain abscess• Facial paralysis
– Treat with antibiotics– Ear tubes if recurrent
• Otitis Media with Effusion– Fluid behind TM
– May result from AOM
– Less sever complications• Hearing loss
• Scarring/atrophy of TM
• Tympanosclerosis
– Do not treat with antibiotics
– Ear tubes if persistent or chronic
Acute Otitis Media
Types of TM Findings
Normal TM
Serous otitis media
Mucoid Otitis Media
Acute Otitis Media
• Peak incidence AOM is between 6 and 18 months– AOM affects 40%-50% of children by age 1 – By age 3 years majority (>80%) of children have had 1
episode of AOM• ~ 40% of pediatric office visits in first 5 years related to
otitis media • ~5-10% of well visits associated with diagnosis of OME
Acute Otitis Media Diagnosis
Certain diagnosis of AOM meets all 3 of the criteria:• Presence of Purulent Middle Ear Effusion• Rapid onset• Signs and symptoms of middle-ear inflammation
– Otalgia
– No pain with pulling of ear
– TMJ pain
– Difficulty sleeping due to pain
Acute Otitis Media Diagnosis
• Pulling at the Ears (not reliable):– Zero percent of children with ear pulling as the primary sign had an ear
infection – Ear pulling + fever: only 15% had ear infections– Why do kids pull their ears?
• Itching• Teething• Exploration• Comfort• Habit• Pain
• Is ear pulling associated with ear infection. Baker RB. Pediatrics. 1992 Dec;90(6):1006-7
• Diagnostic accuracy and the observation option in acute otitis media: the Capital Region Otitis Project. Gurnaney H, Spor D, Johnson DG, Propp R. Int J Pediatr Otorhinolaryngol. 2004 Oct;68(10):1315-25
Acute Otitis Media Diagnosis
Presence of Purulent Middle Ear Effusion
• Exam- Unobstructed ear canal and good light!
• Bulging of the tympanic membrane• Limited or absent mobility of the
tympanic membrane– Pneumotoscopy– Tympanometry
• Air-fluid level behind the tympanic membrane
• Otorrhea (purulent)
Misdiagnosis of Acute OM
• Over-reliance on history• TM color does not predict AOME-crying makes most
tympanic membranes red
• Failure to evaluate tympanic membrane mobility (pneumatic otoscopy)
• Poor light from otoscope (bulb & battery)
• Failure to remove cerumen
• Inappropriate sized speculum
• Lack of experience
Acute Otitis Media
• Improving diagnostic accuracy:– Pneumatic otoscopy
– Otomicroscopy
Acute Otitis Media Treatment• Why do we treat AOM?
– Quality of Life
– Suppurative Complications
• Once treated, when do we follow-up?– If asymptomatic, follow-up is to ensure
resolution of fluid– This process can take up to 3 months (74%)
• Intracranial Complications:– Meningitis
– Extradural abscess
– Subdural empyema
– Lateral sinus thrombosis
– Brain abscess
– Otitic hydrocephalus
• Extracranial Complications:– Mastoiditis
– Petrositis
– Facial Paralysis
– Perforation of the TM– Hearing loss
• CHL• SNHL
– Labyrinthitis
Acute Mastoiditis
• May or may not be associated with subperiosteal abscess
• Protrusion of the auricle may be secondary to osteitis of the mastoid cortex without erosion/ abscess
Coalescent Mastoiditis
Tubes for Acute Otitis Media
• Recalcitrant- persistent acute infection despite antibiotics
• Recurrent– 3/6 or 4/12 or 6/12 total duration– Parental concern– Day care– At risk populations– Time of year
• Adenoidectomy if recurrent bacterial URI/sinusitis
• Complications
AOM vs. OME
• Acute Otitis Media– Pus behind TM– Acute infection– Multiple severe
complicaitons• Mastoiditis• Meningitis• Brain abscess• Facial paralysis
– Treat with antibiotics– Ear tubes if recurrent
• Otitis Media with Effusion– Fluid behind TM
– May result from AOM
– Less sever complications• Hearing loss
• Scarring/atrophy of TM
• Tympanosclerosis
– Do not treat with antibiotics
– Ear tubes if persistent or chronic
Otitis Media with Effusion
• Tympanic membrane
characteristics
– Translucent or opaque
– Gray, white, yellow, or pink
color
– Neutral or retracted position
– Reduced mobility, responds to
negative pressure on pneumatic
otoscopy
– Effusion present
Resolution of Middle Ear Fluid
Otitis Media with Effusion Treatment
• Intervention based on severity of hearing loss, child’s developmental status, parent preference – Aggressive management of “at-risk” population
• Watchful waiting for at least 3 months in “non at-risk” population– “Paradise Tube Article” studies only healthy, non at-risk
children
– Nasal steroids may help
– Nasal decongestants/antihistamines of no proven use
– Antimicrobials/steroids not indicated
Paradise JL., et al: Tympanostomy Tubes and Developmental Outcomes at 9 to 11 Years of AgeN Engl J Med. 363 (3):248-261, 2007.
Otitis Media with Effusion Treatment
• Audiogram if fluid > 3 months– If normal hearing periodic re-evaluation until clear; more
aggressive intervention if hearing loss, behavior problems or TM changes
• Surgery- Tubes with or without adenoids– Tubes initially only
• Adenoidectomy if nasal obstruction or infection problems or if past hx of tubes
– Repeat surgery--adenoidectomy +/-tubes
AOM vs. OME
• Acute Otitis Media– Pus behind TM– Acute infection– Multiple severe
complicaitons• Mastoiditis• Meningitis• Brain abscess• Facial paralysis
– Treat with antibiotics– Ear tubes if recurrent
• Otitis Media with Effusion– Fluid behind TM
– May result from AOM
– Less sever complications• Hearing loss
• Scarring/atrophy of TM
• Tympanosclerosis
– Do not treat with antibiotics
– Ear tubes if persistent or chronic
• Radial incision
• Anterior/inferior quadrant
Ear Tube Placement
Post-Operative Care
• Ear drops for 2-7 days – If fluid present
– Floxin, Ciprodex, Saline
– Never “Cortisporin” or gentamicin
• See at 2-4 weeks– Audiometry
– Clean tube is occluded
– Replace tube if unsuccessful
• See every 6-12 months until extrusion/healing
Complications
• Early Complications– Tube occlusion– Extrusion– Otorrhea– Impaction into middle
ear– Hearing loss
• Delayed Complications– Otorrhea
– Perforation
– Retention
– Myringosclerosis
– TM atrophy
– Hearing loss
– Tympanosclerosis
– Cholesteatoma
Questions?
Thank You!
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