ent

2. DISEASES OF MIDDLEDISEASES OF MIDDLE
EAREAR
ByBy
Prof. Zainullah KakarProf. Zainullah Kakar
M.B.B.S, D.L.O, M.C.P.S. F.C.P.S.M.B.B.S, D.L.O, M.C.P.S. F.C.P.S.
Head of E.N.T. departmentHead of E.N.T. department

3. OTITIS MEDIAOTITIS MEDIA
• It is inflammation of the middle ear
mucosa.
• It may be divided into
• acute
• chronic.

4. ACUTE SUPPORATIVE OTITISACUTE SUPPORATIVE OTITIS
MEDIAMEDIA
It is acute inflammation of the mucosa of
middle ear cleft by pus producing
organisms.
• Route of infection
• Eustachian tube
• Perforation in tympanic membrane
• Blood borne infection

5. PATHOLOGYPATHOLOGY
• It is described into five stages
• Stage of tubotympanitis
• In this stage the middle ear cleft mucosa is
red and congested.

6. 22ndnd
stagestage
• Stage of acute serous
or catarrhal
inflammation
• In this stage serous
exudates starts.

7. 33rdrd
stagestage
• Stage of acute
supporative
inflammation
• Pus formation
starts in this stage

8. 44thth
stagestage
• Stage of resolution
• In this stage the condition settles.
• The pus is either absorbed or comes out
through perforation.

9. 55thth
stagestage
• Stage of complications
• If virulence of the organisms is high or
resistance of the patient is low the disease
may not resolve and spread beyond the
confines of the middle ear.

10. BACTERIOLOGYBACTERIOLOGY
• commonest organisms.
• Streptococcus Pneumoniae
• H influenzae

11. CLINICAL PICTURECLINICAL PICTURE
• Clinical picture depends on
– virulence of the infecting organisms,
– defense of the patient
– availability and effectiveness of the treatment.

12. SYMPTOMSSYMPTOMS
• The patient may present with one or
more than one of the following symptoms
• Otalgia
• Otorrhoea
• deafness

13. OTALGIAOTALGIA
pain in the ear extending to the mastoid region,
either unilateral or bilateral
mostly bilateral in children
pain is deep seated and is throbbing in nature.
Pain is at first due to engorgement of the
mucosa and later due to presence of pus under
pressure.
When the membrane ruptures and pressure is
relieved the pain settles.

14. DEAFNESSDEAFNESS
It is more prominent in bilateral cases
It is conductive

15. OTORRHEAOTORRHEA
If the tympanic membrane perforates there
will be blood stained pus discharge from
the ear.

16. SIGNSSIGNS
Signs depend on the
severity of the
disease
In early stage there
may congestion along
the handle of malleus
and periphery

17. 33rdrd
stagestage
In more severe cases
whole the tympanic
membrane is
congested and
bulging mainly
postariorly,
The land marks on the
membrane or absent.

18. Severe casesSevere cases
Finally the membrane appears as a doubled
roll, the dimple in the centre presenting its
attachment to the handle.
If the discharge is present it will be odorless,
may be blood stained and have shiny and
glossy appearance due to the presence of
mucus.
If the discharge is offensive it shows acute
attack on chronic case.

19. perforationperforation
In the cases of discharging one, the perforation is
usually posterior, small and central.
The marginal perforation is sign of acute attack on
a chronic case.
• The general signs like pyrexia are usually
present in children
• The hearing tests show conductive deafness.

20. NOSE AND THROATNOSE AND THROAT
• Signs of infection will be present in the nose or throat if it
is secondary to the upper respiratory tact infection.
• In infants and children the examination may be difficult
due to non-cooperation but the presence of
• undiagnosed pyrexia
• Crying or screaming (particularly at night),
• putting up the hand to the head or ear,
• rolling the head on pillow are signs which should suggest
that the ear should be examined for acute infection

21. INVESTIGATIONSINVESTIGATIONS
• Blood tests
• Audiometry

22. BLOOD PICTUREBLOOD PICTURE
Blood complete picture will show
leucocytosis.
Immunoglobulin electrophoresis is
necessary in recurrent cases.

23. AUDIOMETRYAUDIOMETRY
• Pure tone audiometry and compliance
audiometry are done only in early cases
and will show conductive deafness.

24. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
• furunculosis
• Referred pain

25. TREATMENTTREATMENT
• Medical treatment
• Surgical treatment

26. MEDICAL TREATMENTMEDICAL TREATMENT
• ANTIBIOTICS
• After taking swab from the ear nose or throat
antibiotics are started.
• Mostly used antibiotics are
– amoxicilline.
– co-trimaxazole,
– erythrocine
– cefaclor.
– It is given 5-10 days.
– Decongastant,.
– analgesics

27. SURGICAL TREATMENTSURGICAL TREATMENT
Myringotomy is done in those cases which are not
responding to medical treatment and there is still
pain and bulging membrane.
Myringotomy is preferred over spontaneous
rupture because the healing scar of
myringotomy is better than that of spontaneous
rupture.
•

28. MYRINGOTOMYMYRINGOTOMY
• It is a surgical
procedure in which
perforation is made in
the tympanic
membrane

29. MYRINGOTOMYMYRINGOTOMY
• INDICATIONS
• Acute supporative otitis media
• Secretory otitis media
• For diagnosis
• For aspiration of fluid
• For insertion of grommet
• -Ca nasopharynx for aspiration of fluids to find
malignant cells
• -For obtaining fluid for gram staining and c/s

30. INSTRUMENTSINSTRUMENTS

31. PROCEDUREPROCEDURE
• This operation is done
under general
anaesthesia.
• surgical microscope
is necessary After
aseptic measures
incision is given to the
tympanic membrane
in the postero inferior
portion.

32. MYRINGOTOMYMYRINGOTOMY
• This point is preferred
due to two reasons.
Posterior part is the most
bulging part and in
inferior portion trauma to
the ossicles and chorda
tympani nerve can be
avoided. The incision
should be 3-4 mm long.
The pus is sucked out

33. MYRINGOTOMYMYRINGOTOMY
• In secretory otitis
media the incision is
given in the anterior
half. Upper portion is
better than inferior
portion because
extrusion is more
common due to
heaping of epithelium
on one side.

34. COMPLICATIONSCOMPLICATIONS
A myringotome can result
in
• -Damage to the various
structures
• incus
• maleus
• incudo-stapedial joint,
• facial nerve
• chorda ttympani nerve.
• -Rare damage is to the
juglar bulb.

35. CHRONIC SUPPORATIVE OTITISCHRONIC SUPPORATIVE OTITIS
MEDIAMEDIA
• It is the chronic supporative inflammation of the mucosa
of middle ear.
It may be
Active with discharge of pus
• Quiescent when the pus ceases less than six months
• Inactive the discharge ceases for more than six months.
• Healed otitis media when the ear heals with healing of
the perforation of the tympanic membrane.

36. TYPESTYPES
• Clinically it is
divided into two
groups
• 1. Safe type or
tubotympanic type
• 2. Dangerous type or
atticoantral type
•

37. TYPESTYPES
• although the symptoms may be very
similar but they will be discussed
separately because of difference in their
management

38. SAFE OR TUBOTYMPANICSAFE OR TUBOTYMPANIC
SUPPORATIVE OTITIS MEDIASUPPORATIVE OTITIS MEDIA
• It is called safe type because does not
carry any great risk to the patient. The
disease is confined to mucosa and there
is no risk of bony erosion.
• It is called tubo-tympanic type because the
disease is confined to the antero-inferior
part of the middle ear cleft.

39. BACTERIOLOGYBACTERIOLOGY
• Pus shows multiple organisms both
aerobic and anaerobic.
• The common aerobic organisms are Ps.
aeruginosa, B.proteus, Esch. coli and
Staph. aureus.
• The anaerobic organisms are Bacteroids
fragilis

40. CLINICAL FEATURESCLINICAL FEATURES
• Main complaints of the patient are
• Discharge from the ear
• Deafness

41. DISCHARGEDISCHARGE
• Usually there is a profuse mucopurulent
discharge from the ear which may be
continuous or intermittent.
• It appears specially with
– upper respiratory tract infection
– entry of water into the ear.

42. DEAFNESSDEAFNESS
• Deafness is present in every case varies
from mild to moderate but severe is rare.

43. SIGNSSIGNS
Examination of the nose, sinuses and throat
is necessary because the etiological factor
is usually present there.

44. DISCHARGEDISCHARGE
• Meatus may be filled with pus. Pus is
profuse mucopurulent

45. DEAFNESSDEAFNESS
• Deafness is present
in every case from
mild type to moderate
but the severe type
which occurs due to
ossicular involvement
is rare.
• The deafness is
conductive in type.

46. • In long-standing
cases there may be
sensori-neural
deafness also. The
sensori-neural
element is due to
absorption of the
toxins through the
round or oval
windows

47. PERFORATIONPERFORATION
• Meatus is cleared of pus by mopping or
suction to examine the meatus and
tympanic membrane.
• Otitis externa may be seen due to long
standing discharge.

48. Examination under MicroscopeExamination under Microscope
• This is very necessary to see the condition
of mucosa, granulations, formation or
status of the ossicles, tympanosclerosis,
adhesions or cholestaetoma sac.

49. PERFORATIONPERFORATION
• There is central
perforation in the pars
tensa may be small or
large or even subtotal
but always
surrounded by
remnants of the
tympanic membrane.

50. Tuning fork testsTuning fork tests
• These test show conductive deafness
• Rinne’s test
• Weber test
• Schwabach test

51. INVESTIGATIONSINVESTIGATIONS
Audiometry
• Hearing loss is usually conductive and
mild to moderate but sensori-neural loss is
also seen in long standing cases.
•

52. Radiological examinationRadiological examination
Xray pns water’s view to exclude sinusitis
• Mastoid xray will show cellular mastoid in
the start but in long standing cases
sclerosis or pneumatized with clouding of
air cells with out any bony destruction
which is a feature of attico-antral disease.

53. CULTURE AND SENSITIVITYCULTURE AND SENSITIVITY
TESTTEST
• Culture sensitivity of the pus is better to
select proper antibiotic.

54. COMPLICATIONSCOMPLICATIONS
• Complications in this type of chronic
supporative otitis are rare and they are not
serious one. The following complications
may be seen in this type.
• Otitis externa
• Polyp formation
• Ossicular problems
– Ossicular fixation
necrosis

55. OTITIS EXTERNAOTITIS EXTERNA
• Otitis externa
– It is seen in long standing case due to flow of
the pus

56. POLYP FORMATIONPOLYP FORMATION
Polyp is a smooth mass
of oedematous and
inflammed mucosa which
has protruded through the
perforation and presents
in the external auditory
meatus. This polyp is
pale in contrast to pink
fleshy polyp seen in
atticoantral type.

57. Ossicular problemsOssicular problems
• Ossicular fixation
• necrosis in long standing cases due to
ischaemic necrosis.

58. TREATMENTTREATMENT
• MEDICAL TREATMENT
• SURGICAL TREATMENT
• First of all it is necessary to eliminate
the infection of the upper respiratory tract.
It may require removal of tonsil or adenoid
or treatment of nose and sinuses.

59. MEDICAL TREATMENTMEDICAL TREATMENT
• Aural toilet
• Aural toilet has a very important role in the treatment of chronic
supporative otitis media.
It promotes the drainage of pus from the middle ear and make the
approach of the local drops easy to the diseased mucosa. There are
varios methods of aural toilet like
suction clearance,
dry mopping or
wet irrigation.
Dry mopping or suction clears the meatus and then the patient
performs valsalva test to push the debris in meatus, which is then
cleared. In children who are usually uncooperative it may be cleared
by syringing.
•

60. • Topical antibiotic application
• Topical antibiotic drops are used with better
results because there may be isolated pockets
with out any blood supply so the systemic
antibiotic can not reach there.
• After aural toilet the patient lies down with the
effected ear above and the drops are instilled.
The tragus depressed intermittently so that the
drops are pushed into the middle ear and the air
is sucked out. The patient should remain in this
position for some time.

61. • Systemic antibiotics
• They are helpful in acute exacerbations
but role in chronic is limited

62. PRECAUTIONSPRECAUTIONS
Water entry to the ear should be prevented
by plugging the ear during bathing.
Forceful blowing should also be prohibited
which pushes infected nasal secretions
through the Eustachian tube to the middle
ear.

63. SURGICAL TREATMENTSURGICAL TREATMENT
• Any aural polyp or granulation tissue
should be removed to facilitate pus
drainage and easy excess of drops.
• The polyps is always cut at the origin and
not avulsed as it may arise from facial
canal, horizontal canal or ossicles
resulting in damage of that structure.

64. RECONSTRUCTIVE SURGERYRECONSTRUCTIVE SURGERY
When the ear is dry the tympanic membrane
may be repaired by myringoplasty.
ossicular reconstruction can be done