ear tubes. the ear aom vs. ome acute otitis media –pus behind tm –acute infection –multiple...

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!