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Serous Otitis media and Grommets
Otitis media with effusion, also known as glue ear, is the accumulation of fluid in the middle ear caused by eustachian tube dysfunction or infection. It is a common cause of hearing loss in children. Diagnosis is made through pneumatic otoscopy or tympanometry showing reduced mobility of the ear drum. Treatment involves initial watchful waiting, with myringotomy tubes placed for persistent or recurrent cases to improve ventilation and clear fluid. Complications can include ear drainage, tube displacement, blockage, or retained tubes.
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Serous Otitis media and Grommets
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- 3. • Otitis mediawith effusion is the accumulation of mucus within the middle ear and sometimes the mastoid air cell system. • Sero-mucinous otitis media/ GLUE EAR • Leading cause of childhood hearing loss • Chronic >/= 3 months.
- 4. • OME isoften asymptomatic and may go undetected, its incidence and prevalence has been difficult to establish accurately. • Point prevalence of OME on screening tests of up to 20%. • The highest incidence of OME is around 1 year of age • By age 3 years, almost all children would have experienced 1 episode. PREVALANCE
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- 6. MICROORGANISM S • Virus –RSV, Rhinovirus, adenovirus • Streptococcus pneumoniae • Hemophilus influenzae • Moraxella catarrhalis • BIOFILMS – causes recurrent episodes of OME.
- 7. BIOFILMS • Biofilms areorganized, heterogeneous bacterial communities. • Embedded in a matrix rich in polysaccharides, nucleic acids, and proteins known as the extracellular polymeric substances (EPSs). • P. aeruginosa, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
- 8. BIOFILMS • Biofilms inmiddle ear mucosa and adenoids causes recurrent persistent OME. • RESISTANCE - 1. Increased biomass prevents phagocytosis. 2. EPS provides a physical barrier to complement, antibody and immune cells. 3. Slowdown in metabolic rates that make the cells less susceptible to antibiotics.
- 9. HISTORY • GENERALLY ASYMPTOMATIC •HEARING LOSS • FULLNESS IN EAR • PROBLEMS WITH BALANCE. • FEVER • OTALGIA • IRRITABILITY/INCONSOLABLE CRYING • MALAISE • CHANGES IN EATING HABITS • OCCASIONAL TUGGING AT THE EAR
- 10. 1. Otoscopy 2. Pneumaticotoscopy to see the mobility of tympanic membrane 3. Otomicroscopy. EXAMINATION
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- 13. • Assessment ofTM and its mobility. • Primary diagnostic tool for OME. presence or absence of MEE. • Distinctly impaired mobility of the TM on pneumatic otoscopy is highly predictive of MEE. PNEUMATIC OTOSCOPY
- 14. PNEUMATIC OTOSCOPY Clean EACof cerumen and other debris Pneumatic otoscope positioned with Good air tight seal Slight positive and negative pressure applied NORMAL TM – Brisk movement OME – Impaired mobility NO MOVEMENT – Perforation / Patent tube
- 15. • Tympanometry providesinformation about TM mobility and the presence or absence of MEE. • Compared to pneumatic otoscopy, tympanometry is easier to perform and has a comparable sensitivity but a lower specificity for diagnosing OME. TYMPANOMETRY
- 16. TYMPANOMETRY • TYPE A– Sharp peak and normal middle ear pressure. • Normal • TYPE B – Flattened without discernable peak. • S/O MEE • Low ear canal volume – incorrect probe placement / wax • High volume – TM perforation • TYPE C – Sharp peak with negative middle ear pressure. • Intermediate probability of MEE.
- 17. AUDIOMETRY • In OMEair conduction thresholds are elevated relative to normal bone conduction thresholds:air-bone gap • Conductive hearing loss (20-40 dbHL) • To rule out pre-existing sensori- neural hearing loss X-RAY MASTOID • shows clouding of air cells due to fluid
- 18. MEDICAL MANAGEMENT • WATCHFUL WAITINGfrom the onset of effusion/diagnosis for 3 months in an uncomplicated case. • DECONGESTANTS- to relieve eustachian tube edema • ANTIALLERGIC MEASURES • ANTIBIOTICS-in case of acute episode and upper respiratiory tract infections • MIDDLE EAR VENTILATION- valsalva manoeuvre,chewing gum.
- 19. SURGICAL MANAGEMENT 1) Myringotomywith aspiration of middle ear fluid : • Incision is performed in the anterior-inferior quadrant • of the pars tensa. • Radial – SOM ; Circumferential – ASOM • Laser assisted myringotomy.
- 21. SURGICAL MANAGEMENT 2) Myringotomywith insertion of ventilation tube 3) Adenoidectomy in >4 years old ,if <4 year old adenoidectomy only if there is a distinct indication (chronic adenoiditis and nasal obstruction) 4) Eustachian Tube Dilatation.
- 22. TYMPANOSTOMY TUBE Improves middle ear ventilation Providespassage for fluid clearance Mechanical disruption of Biofilms in middle ear
- 23. AAO – HNFRECOMMENDED Clinicians should offer bilateral tympanostomy tubes to children with bilateral OME >3mo AND documented hearing difficulties Clinicians should offer bilateral tympanostomy tubes to children with recurrent AOM who have unilateral or bilateral OME at the time of assessment
- 24. AAO - HNFOPTIONAL • Unilateral or bilateral Chronic OME with symptoms attributable to OME that includes vestibular symptoms, poor scholastic performance, behavioural problems, ear discomfort • At risk children with unilateral or bilateral OME unlikely to resolve quickly or persistence for > 3mo.
- 25. TYPES OF VENTILATION TUBES • Shepardand Shah Grommets stay in situ for a shorter period of time(extrusion rates high within first 6 months). • T-tubes are designed to stay for a longer period of time Shah Grommet
- 27. COMPLICATIONS • Displacement intomiddle earOPERATIVE • Otorrhea(50%) • Extrusion of tube Early post- operative • Myringosclerosis • Tympanic membrane perforation • Tube block • Retained tube Late post operative
- 28. OTORRHEA • MC postop complication (50%) • Due to acute URI or as a result of chronic biofilm infection of tube. • Prevention – • Saline washouts of middle ear • Single application of antibiotic- steroid ear drops during tube insertion • Prolonged use of oral/topical antibiotics in early postop
- 29. TUBE COMPLICATIONS EARLY EXTRUSIONRETAINED TUBE TUBE BLOCK • Infection in middle ear • Improper insertion • Atrophy of TM • Tube retained for > 3 years / after resolution of middle ear infection. • Surgically removed • Followup to see healing of perforation. • Due to dried blood, mucus, granulation or polyps • Removed using pick, suction or ear drops. • Replacement if failed.
Editor's Notes
- #7 Biofilms,communities of sessile bacteria,resistant to disruption and with a low metabolic rate-adhere to mucosal surface with impaired host resistance-chronic inflammatory conditions
- #17 Jerger/Fiellau-Nikolajsen’s modification compliance curves. In ears with negative pressure the curve has the same shape, but is displaced to the left, the negative side of the X-axis. When the pressure is between -100 and -199 daPa it is called a type C1 curve and when between -200 and -400 a type C2 curve. In middle ears filled with fluid the tympanic membrane will act more stiffly, i.e., more sound is reflected (less admittance) and the curve will be very low or flat (a type B tympanogram) (Figure 1). Type B tympanogram has a high predictive value for fluid in the middle ear (97%-93%), and a type A tympanogram signifies a middle ear without fluid[15,16]. The C tympanograms are in a stage between normal and not normal. Often C1 is classified as normal, and often C2 means negative pressure with a mix of fluid and air in the middle ear[15].