cleft commonly seen in children and usually consequent to an upper respiratory tract infection Eustachian tube dysfunction- MOST COMMON Viral rhinitis Any form of rhinitis/ sinusitis Other causes of ET dysfunction Traumatic perforation of tympanic membrane Barotraumatic otitis media Hematogenous Upper respiratory tract infections are more common Eustachian tube is more short, wide and horizontal in children compared to adults Adenoid tends to hypertrophy and obstruct the ET orifice in the nasopharynx Feeding habits in an infant- nasopaharyngeal reflux more common Recurrent URTI Tonsils and adenoid infection Chr rhinitis and sinusitis Nasal allergy Cleft palate Tumours of nasopharynx Peak incidence at the age of 3-18 months 60% of children below 1 year of age- variable severity 80% of children below 3 years of age Boys>girls Native Americans> African Americans Rural>Urban: Reason? Usually starts as a viral infection. Ex: RSV, Rhinovirus, CMV, measles, EBV. Streptococcus pneumoniae ( 30-50%) H. influenzae ( 20-30%) Moraxiella catarrhalis ( 10-20%) Streptococcus pyogenes Pathology Tubal occlusion (hyperemia) Pre-suppuration Suppuration Resolution or Complications Pathology URTI leads to ET mucosal edema ET gets occluded Air in the middle ear cleft gets absorbed Vacuum (negative pressure in middle ear) Transudation Symptoms Blocked feeling in the ear following URTI Mild ache/ discomfort Signs Retracted drum Hyperemia Pathology Bacterial infection Exudation of fluid Increased mucus secretion and decreased drainage Accumulation of non-purulent fluid in middle ear Increased congestion Symptoms Irritable child Increasing ear-ache and deafness Autophony Signs Cart-wheel appearance of the TM Bulging drum Fluid level/ air bubbles seen through TM Pathology Suppuration Accumulation of pus in the middle ear under tension Acute coalescent/ masked mastoiditis Non resolved AOM- if no resolution by one month Recurrent ASOM CSOM- tubotympanic disease (TM perforation persists > 3 months) Symptoms Unexplained cause of crying in a child Fever, toxic symptoms Severe otalgia Deafness Signs Grossly congested and edematous TM Bulging of TM- >posteriorly Pus pointing +/- Pathology Accumulation of pus in the middle ear under tension Later- rupture of the TM and release of pus (discharge) Symptoms At the peak of otalgiamucopurulent, blood stained ear discharge Otalgia subsides with onset of discharge Signs RupturePulsatile ear discharge Light house sign Pin-hole perforation Pathology With drainage of the pus and Host defense/ treatment Inflammation resolves Pin-hole perforation heals Symptoms Acute symptoms subside Ear becomes dry Eventually hearing is restored Signs Pin-hole perforation without discharge Later healed perforation Pathology Infection fails to resolve due to Pneumatised mastoid with infection extending Organism- virulent Resistance of host- poor Treatment- inadequate Or if the TM fails to perforate Acute mastoiditis Symptoms Ear symptoms persist or increase Spiky temperature Swelling post-auricular region Signs Persistent ear discharge and congestion Mastoid tenderness and swelling Treatment usually started with clinical diagnosis Investigate if not resolving or if impending complications suspected Ear swab for C/S X-ray mastoids X-ray PNS/ nasopharynx Audiological assessment CT scan of temporal bone and intracranium- with contrast Treat URTI Broad spectrum antibiotics like amoxycillin/ ampicillin/ augmentin/ erythromycin etc.- Orally as syrup/ tablets High dose (meningitic dose) and parenteral if complications suspected Nasal decongestants Analgesics No role for topical antibiotics Indications TM fails to perforate Severe otalgia Non-resolving symptoms If impending complications suspected Tympanocentesis- Needle aspiration of the fluid Myringotomy Curvilinear incision on the TM at the site of most prominent bulgeusually posteriorly drainage of pus Or widen the pin-hole perforation- better drainage Cortical mastoidectomy To eradicate the diseased mucosa in the mastoid antrum and the air cells Acute otitis media usually due to streptococcus pneumoniae associated with exanthematous fevers like measles, chicken pox, etc. Extensive destruction of the middle ear structures Total perforation Ossicular discontinuity Higher incidence of mixed hearing loss Treatment is same as AOM Acute inflammation of the muco- periosteum of mastoid antrum and mastoid air cells, usually a result of ASOM, characterized by coalescence of the mastoid air cells and collection of pus under tension (empyema) within the mastoids Following ASOM, infection in the middle ear spreads into the mastoid antrum and cells Mucosal odema blocks the aditus- no drainage of mastiod antrum Mucopus in mastoids collect under tension HYPERAEMIC DE-CALCIFICATION gives rise to soft bone COALESCENCE DUE TO INTERCELLULAR BONE DESTRUCTION---EMPYEMA Pneumatized mastoidmore cells-- more mucosa Organismvirulent Resistance of the hostpoor Treatmentinadequate or inappropriate Failure of tympanic membrane to perforate in ASOM or perforation is too small for complete drainage EMPYEMA OF MASTOID Spread of infection to other structures in/ out of mastoid--- intracranial/ extracranial complications Extra-cranial Intra-cranial Mastoid abscess Meningitis Facial paralysis Extradural Labyrinthitis abscess Petrositis Subdural abscess Septicemia Brain abscess Osteomyelitis of Lateral sinus temporal bone thrombophlebitis Otitic hydrochephalus Cortical venous thrombophlebitis Following ASOM Increasing pain and discharge in the ear Post-aural painful swelling,fever, malaise and lassitude Features of complications Post-auricular swelling due to cellulitis/ abscess Mastoid tenderness positive Pinna is pushed forwards and downwards Sagging of the canal skin Congested bulging drum with no perforation or with small perforation Pulsatile ear discharge Ear swab for culture and sensitivity Pure tone audiogram if possible X-ray mastoidsSchullers view---shows clouding of the mastoid air cells and coalescence CT scan of the temporal bone and intracranium with contrast--if complications are suspected intravenous antibiotics Penicillin group with metronidazole preferred Early stagemyringotomy/ widening of perforation may be tried I&D if mastoid abscess is present followed by Emergency exploration of mastoid and cortical mastoidectomy Treatment of complications Injury to the middle and/or inner ear due to sudden negative middle ear pressure caused by sudden descent during flight or sudden deep diving Predisposed by pre-existing ET dysfunction Higher the altitudelower the atmospheric pressure Ascent- passive movement of air out of ET Sudden descentmiddle ear pressure is negative compared to atmospheric pressure Locking of the tube occurs if pressure difference Early locking in case of ET dysfunction Retraction of TM Transudation Exudation Micro-hemorrhage Traumatic perforation Ossicular discontinuity Round window rupture Inner ear damage Otalgia Blocked sensation/ deafness Tinnitus Vertigo Ear dischargeblood stained initially Congested retracted drum Fluid level/ air bubbles in middle ear Rupture TM Nystagmus +/- Conductive or mixed hearing loss Pure tone audiogram Impedance audiometry Microscopic otological examination Usually resolves within few weeks Analgesics/ and decongestants Labyrinthine sedatives/ steroids if inner ear damage suspected Persistent fluidmyringotomy grommet insertion Persistant perforationmyringoplasty