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Prof. Mohammed Attallah College of Medicine King Saud University ORL Course 431 ORL Department King Abdulaziz University Hospital Done by: 428-C2

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Normal Middle Ear Cavity

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Eustachian tube in short The normal middle ear cavity has 2 openings. Eustachian tube opens into the nasopharynx. Functions: Aeration of ME cavity Ventilation Equalizing the pressure in the middle cavity. Any malfunction in eustachian tube can lead to abnormality in the middle ear. It can be obstructed by edema. Most common is perforation of tympanic membrane.

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Chronic otitis media 1. Chronic non-suppurative otitis media: Otitis media with effusion (OME, glue ear, secretory). Adhesive otitis media. Without perforation, meaning no super-added infection. 2. Chronic suppurative otitis media (more common): Tubotympanic (safe). Atticontral (unsafe). Associated with perforation.

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CSOM Long standing infection of part or whole of middle ear cleft, characterized by ear discharge, and permanent perforation. Perforation becomes permanent when its edges are covered by squamous epithelium and doesnt heal spontaneously.

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Etiology (from 427 ENT) Upper respiratory tract infections. Eustachian tube dysfunction. Environmental (hot and humid weather). Genetic. Previous OM (either AOM or OME).

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Classifications of CSOM According to site of perforation: 1. Safe (tubotympanic, anteroinferior): central perforation on TM. On otoscopy: ruminants of TM around perforation are found. 1. Unsafe (atticoantaral, posterosuperior): unsafe because its associated with cholesteatoma: Marginal is at the margin of TM. Attic (pars flaccida).

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Pathology (from 427 ENT) 1. Signs of suppurative infection: Discharge (ottorhea) and perforation. Chronic inflammatory in the mucosa and bone (osteitis). 2. Signs of healing attempts (if there is damage to mucosa): Granulation tissue and polyps. Fibrosis and typmanosclerosis. 3. Cholesteatoma (in unsafe type).

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Symptoms (from 427 ENT) 1. Ottorhea: Intermittent, profuse, odorless in safe type (mucopurulent discharge). Persistent, scanty, odorous in unsafe type (odor is due to involvement of the bone). 2. Deafness: conductive (expect in case of cholesteaome, where it can cause SNHL). 3. Tinnitus. N.B. any other symptom means complication.

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Investigations in CSOM 1. Audiology: to assess hearing loss. Conductive, sensory, or mixed hearing deafness. 2. Radiology: for all CSOM, to test: a) Ossicles. b) Condition of ME cavity. c) Most importantly, dura level. Tegmen tympani is a very thin bone, separating ME cavity from middle cranial fossa, allowing cholesteatoma to extend intra-cranially. check CT scan pre-operatively to assess the extension, because neurosurgeons may then be needed. Low dura: Dural level may be normally low, and you may unknowingly go into the brain. So you have to check radiology! d) Facial nerve. (35% of facial nerve has normal dehiscence) 3. All the others: blood, urine, etc. (mostly for anesthesiologists)

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Management of CSOM 1. Surgery in 3 forms depending on the case (of choice): a. Tympanoplasty: closure operation. b. Mastoidectomy: remove the necrotic tissue. c. Tympanomastoidectomy: cortical mastoidectomy with tympanoplasty. 2. Medical treatment: as a form of preparation to the operation; limited use in CSOM.

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Healed Tympanic Membrane with tympanosclerosis. Tympanosclerosis indicates previous perforation that healed, and is harmless and shouldnt be treated. Should be mentioned in the patients file, to avoid pseudoreaction or shopping patient: patient rotates around doctors seeking help. you can see the head of malleus, the light reflex, right sclerotic mass presenting perforation.

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Safe and Unsafe perforation in chronic otitis media

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TOTAL perforation in CSOM: 75% of TM has been lost. It goes with safe and not associated with cholesteatoma. Problem with total perforation is failure adaptation or anterior failure: Graft should be put 2 mm under the normal skin. In total perforation, uptake of graft is less anteriorly.

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Malingoplasty: only close the perforation. Tympanoplasty type I: Close the TM perforation with graft from temporalis fascia. Examine the ossicles for continuity with each other and mobility (if ossicles are immobile, patient cant benefit from typmanoplasty). Prevents re-infection.

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Cortical mastoidectomy operation as the possible operation in chronic suppurative otitis media.

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Types of mastoidectomiy Cortical: Opening the mastoid area, and clearing all the granulation (infected) tissue. Proper cortical if : visualize the long process of incus, lateral semicircular canal, sigmoid sinus, seradural angle, dura plate, tip of mastoid, and area where facial nerve is most likely there. (posterior meatal wall) Cortical is done when the infection is limited to the mastoid, and there is no cholesteatoma. Modified radical. Radical.

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Uses of cortical mastoidectomy As a pathway into the inner ear for cochlear implants. Therapeutic: Adhesive otitis media: when TM adheres to promontory, and there is no air in ME cavity. Air is put behind the TM membrane, leading to re-aeration and reopening of the eustachian tube. Compression of facial nerve. Labyrinth operations. Removal of emboli from the sigmoid sinus.

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Post auricular incision approach to middle ear and mastoid Elevate the meatal skin, take a graft from temporalis fascia, then enter the ME cavity.

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Complications of mastoidectomy Most commonly: facial never paralysis. Nowadays, this ugly complication is prevented by continuous monitoring in the OR. Mostly, steroid therapy is given. In severe cases, decompression of nerve is done.

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Facial paralysis as a complication of middle ear and mastoid surgery

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Otitis media with effusion (OME) Definition: TM is not perforated, while the ME cavity is filled with sterile, non-purulent fluid. Prolonged obstruction of eustachian tube: Air will be absorbed. Mucosa of ME cavity will change, and become secretory in nature. Due to eustachian tube blockage, fluid will accumulate in ME cavity.

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Otitis media with effusion (OME) Most common complication is conductive deafness. Treatment of conductive deafness in OME: Treat the underlying cause: open the eustachian tube by any means; e.g. systemic or local antihistamines, remove adenoid, leading to re-aeration of the middle ear. Sometimes we have to surgically re-aerate the ME cavity. Aeration is important, because if fluid continues to accumulate, it will become thick in nature (glue-like), and TM will adhere to promontory; condition known as adhesive OM. End stage of mal-treatment of OME is adhesive otitis media, and the treatment is very difficult.

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Adhesive otitis media (end stage) adherence of TM to promontory, leading to inability to elevate TM from promontory.

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Acute Otitis Media Stage IV Seen here that TM is congested (bulging). Presents with severe pain and conductive deafness.

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Acute Otitis Media Most common in infants, due to the eustachian tube shape; shorter, wider, and more horizontal. A. Early stages: 1. Eustachian tube blockage: Adenoid in the nasopharynx. Obstruction can lead to mal-aeration of middle ear, which contains air. 2. Mucosa of the middle ear is cuboidal in nature, not secretory. Permeate: Air absorbed, TM will move medially (refraction of TM), handle becomes shorter because its pulled upward and backwards, loss of light reflex in TM.

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B. Late stage: Prolonged malaeration of ME, mucosa changes its nature, becoming secretory. Starts to secrete fluid into ME cavity, leading to conductive deafness. Proper otoscopy of canal: Hair sign: visualizing the air-fluid level in TM (not seen anymore). At this stage, the patient has conductive deafness. (OME)

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Pathophysiology of Otitis Media (from 427 ENT) Eustachian tube occlusion: discomfort autophony, retracted drum due to negative pressure. Exudates inflammation: fever, earache (due to fluid accumulation), deafness and congested ear drum. Suppurative inflammation: bulging of drum due to increased pressure in tympanic cavity, increased severity of fever, congestion and bulging of the drum, deafness. TM rupture: due to increased pressure, otorrhea, high temperature, and ear ache will subside. Resolution. N.B. these stages take place if OM isnt treated. The fever of OM can be raised at any stage of OM.

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Stages of AOM Retrograde infection from nasopharynx: Stage I: congestion of blood vessels along the handle of malleus. Stage II: if not treated, congestion radiates to periphery. Stage III: The entire TM becomes red in color with bulging and severe pain. Stage IV: spontaneous rupture of TM, releasing fluid into EAC, the pain subsides.

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Management Medical (of choice): Admission, IV antibiotics, analgesics, antihistamines to re-open the eustachian tube. In some cases if there is bulging like the previous case; myringotomy is done to evacuate the ME cavity from its contents. If myringotomy was not done, TM may rupture, and its always better to surgically incise than rupture. Surgical: If there is bulging, we do ventilation tube insertion.

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Treatment (from ENT 427) 1. Antimicrobial treatment for 7 days: Amoxicillin + calvulonic acid = Augmentin. Trimethoprim / sulphamethoxazole. Cefaclore / cepxime. Erythromycin sulphisomoxazole. 2. Decongestants: Nasal drops or spray to iopen the eustachian tube by vasoconstriction. 3. Myringotomy: If the TM is bulging. For culture sensitivity if ibfection fails t resolve properly. 4. Ear toilet and local antibiotics.

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Ventilation tube insertion (surgical treatment of otitis media) Inserted in the anterioinferior quadrant of TM, to promote proper aeration of ME cavity, and to drain the fluid if present. Types of tubes: Shahmen: small, and doesnt cause any irritation. Golden: not used in KAUH, because its thick and heavy.

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Done by: Lama Al-Mansour