Otitis Media

Dr John Curotta

Head of ENT Surgery

The Children’s Hospital at Westmead

What is Otitis Media?• AOM = Acute OM

• OME = OM with Effusion (= ‘glue ear’)

• CSOM = Chronic Suppurative Otitis

Media ( = a hole in the ear drum

which discharges)

Ear drum without a hole

2 types of fluid in middle ear:

• 1. Pus -> Acute OM = AOM

• 2. Mucous -> Effusion = OME

Ear drum with hole ( >6 weeks)

1. Simple hole: connects outer ear to mucous making lining of middle ear

(“like a nostril”) usually dry, but sometimes runny. = “SAFE’ ear

2. Hole with skin of ear drum growing in

= “UNSAFE” ear

“UNSAFE” ear Also called:

• CHOLESTEATOMA

• Chol est e at oma

• ‘Kol-est-ee-at-oma ‘

• Means skin growing into ear, not out

What is ‘UNSAFE’ about skin growing in ?

• Skin is not normally in the ear and mastoid • Lowest layer of skin makes an enzyme which

eats away the bone• This erodes Bones of hearing Bone covering inner ear Bone between ear and brain

Deaf – Dizzy – Brain Abscess

What makes you suspect an UNSAFE ear ?

• Persistent discharge

• The SMELL……Sneakers taken off after a week in the wet.

• That is ..soggy dirty mouldy skin…

Cholesteatoma• ALWAYS needs surgery

• Surgery: delicate / long / often repeated

(very little pain and discomfort) !

‘Remote’ KidsUsually get early on :

• ‘Safe’ Hole in ear drum ------

• Often Runny ears

Northern Territory OM Survey 2007

1300 children, 6 mo – 30 months old

• 25% AOM

• 5% AOM + perforation

• 15% CSOM

• 10% had completely normal ears.

NT OM Survey 2007

By 6 months age 98% OME

By 12 months age

• 90 % AOM

• 35% AOM + Perforation

• 20% CSOM

‘Town’ and ‘city’ Kids• Usually get what any other town/city

kids get…….Glue ear.

• BUT because it is a hidden condition -

…….may NOT get diagnosed !

Job of Nurses for Ears 1. Runny ears: DRY the runny ears Maximise hearing Optimise learning

2. Glue ears: DIAGNOSE Maximise hearing Optimise learning

RISK factors for Otitis Media

• Boys

• Brother/sister with OM

• Early start to AOM (<6mo)

• Not breast fed

• Poor housing

• Smoker at home

PREVENTION

Vaccination against Strep pneumoniae

(pneumococcus)• PREVENAR works under 2 yrs age

• PNEUMOVAX works after 2 yrs age

• ( Hib – ‘Haemophilus influenzae Type b’ vaccine is NO good for ears as they get ‘H influenzae Non-typeable )’

Pneumococcal Vaccination“PREVENAR”

• 239,000 operations for grommets in Australia in past 10 years

• Since Prevenar introduction in 2005 grommets reduced by: <1 yr…23% 1-2 yrs..16% 2-3 yrs.. 6%

Study effect early Pn Vaccination

‘Remote’ NT Kids - 2009• Minimal benefit in reduction Otitis Media

(unlike town/city kids)

Probably need• Pneumococcal vaccine with wider spread• Vaccine for Haemophilus infections of ears• Vaccinate mothers

Diagnose ‘GLUE Ear’

• SCREEN

vs

• SUSPECT

Aim of NSW Otitis Media Strategy

• is to screen all kids

• Eliminates guesswork

• But: Do they all get screened?

Hearing Testing

Tiny Tots

• SWISH for all newborns• NSW 99% cover ….Who is most likely to miss out ?Usual Tymps: unreliable under 6 months

Hearing Testing

Baby – to - 4 yrs old

VROA / Behavioural…test overall /

better ear hearing

Usual Tymps: ‘Reliable’

Hearing Testing

• Over 4 yrs

• PTA + Tymps generally reliable

AOM = pus in middle ear

• Body’s immune +/- antibiotics kill bacteria BUT the mucous can take weeks to clear out

POM = Fluid in ear since infection

• POM : “Persisting” Otitis Media

i.e. after AOM, up to 12 weeks

Once fluid is there > 12 weeks,

Then call it : OME or ‘Glue ear’

Fluid in middle ear

AOM POM OME

0 weeks >12 weeks

Benefit of Hearing Testing

• Learning to talk

vs

• Learning in classroom

Hearing under 4-5 years

• One ear is enough to learn to talk and to get along at home

• So ‘general’ tests of hearing are OK

Hearing, over 4-5 yrs

• Unilateral OR Bilateral HL : very important to diagnose

• Poor hearing even in ONE ear is a major problem in classroom

Hearing over 5 yrs• This means at school

• Absolutely need both ears hearing

Unilateral hearing Loss• Very serious problem in class room

• Placement

• Background noise

• Direction

• Anything other than one-to-one talking

Grommets - time working

• Small: Shepard………………6 mo

• Medium: Reuter Bobbin………12 mo

• Large: Sheehy Collar Button.18 mo

• Larger: T – Tubes……………24 mo +

The bigger the grommet

• The longer it stays

• The bigger the risk of a larger perforation

• So, NO T-tubes in children

Grommets• The GOOD

• The BAD

• The UGLY

Grommets- The GOOD• Instant relief

• Consistent relief

• Helps balance too

• Reduces AOMs as well

Grommets-The BAD• Need admission to hospital

• Waiting list

• General anaesthetic

• How long effective

• Repeat grommets

Grommets-The UGLY• Limit water exposure - e.g. swimming

• Discharging grommet a problem

Social / hearing / extrude grommet

• Residual perforations, esp if large large > 20% area TM (large is bad)

in between…….(nuisance)

small < 10% area TM (small is good ! )

If not grommets – What ?

• Seating position……….counting chooks

• FM System

• Hearing Aid/s

• Room amplification

Looking after grommets

• Its not the water

• It’s the GERMS in the water

Looking after grommets

• Clean water…OK shower, beach, well-maintained pool (Chlorine : High end +

pH : Low end of range)Some Remote WA - No School…No Pool

Looking after grommets

AVOID• Bath water• Spa’s• Indoor heated pools• Creeks OR USE• Ear plugs and cap / head band

Infected grommets• Foreign material in the body - if infected

gets covered in “slime”

• Called “BIOFILM”

• Like the inside of water pipes etc

• Also plaque on teeth / infected catheters/ IV cannulas etc

BIOFILM• Bacteria exude a jelly to cover

themselves

• So, antibiotics cannot reach them

• To clean biofilm – must mechanically break it up – brush it / scrub it

If not possible – remove the device.

Discharge through Grommets ..How?

• Head cold Virus: Increase secretion in nose / sinuses / ears

• Secondary bacterial infection (like AOM)

• Overflow through grommet

Discharge through Grommets ..How?

• If virus…dries up when nose dries up

• If bacterial.. May / may not dry up with nose….

Antibiotic medicine or capsules (eg Amoxil) helps

Discharge through Grommets ..How?

• Bacteria which live on skin in outer ear can get into middle ear through the mucous discharge…..(pseudomonas) ..these are resistant to most oral antibiotics … Need DROPS

Ear Drops for Grommets

• Ciprofloxacin (= Ciloxan / Ciproxin HC) is always safe in ears

• Sofradex usually safe in infected ears

• Sofradex is unsafe in clean ears

Ear Drops for wax• 1. Sodium Bicarbonate Ear drops

( chemist makes them up) • 2. Waxsol drops• 3. Ear Clear Drops for Wax Removal

Then syringe. Never Cerumol - too harsh

Discharge through grommets

• If so much discharge ear drops cannot get in

• Use 3% Hydrogen Peroxide as drops first, to clean the ear, dab dry and then put in drops. (only for a day or so at a time)

(probably is breaking up Biofilm)

Wax or discharge in Ears

Gently syringe with dilute baby shampoo 1/2 teaspoonful in 1 cup warm water (= 1%) (or 1 tsp in 500ml)

• Finish by syringing Betadine (1 tsp in 100ml)

10 ml syringe with a cut-off scalp vein needle

Safe in perforations or grommets

References• Aboriginal Ear Health Manual – Harvey

Coates et al from WA

• Aboriginal Otitis Media ENT Program Evaluation Report 2002“

• Surgical Management of Otitis Media with Effusion in children” – Clinical Guideline, February 2008 - UK