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Diseases of the middle ear

Embryology. Anatomy of tympanic cavity. Middle ear cleft. Anatomy of tympanic cavity. . . Anatomy of tympanic cavity. . Tensor tympani muscle. Stapedius muscle. ????????????????? Eustachian tube. Ventilation (????????????????????????)Protection (????????????????????????????? nasopharynx ???????????????)Excretion (?????????????????????????????????????????????????).

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Diseases of the middle ear

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    1. Diseases of the middle ear

    2. Embryology

    4. Anatomy of tympanic cavity

    5. Anatomy of tympanic cavity

    7. Anatomy of tympanic cavity

    9. ????????????????? Eustachian tube Ventilation (????????????????????????) Protection (????????????????????????????? nasopharynx ???????????????) Excretion (?????????????????????????????????????????????????)

    10. Physiology 1.?????????(Amplifying sound) : 25 dB - ?????????????????????????????????????????????? stapes footplate - ???????????????? (physical laws of leverage) ????????????????????????? incus ???????????????????????? handle of malleus - ?????????????????????? 2. ??????????????? (Ear protection) - Tensor tympani m. - Stapedius m.

    11. Nerve supply Tympanic plexus/ Jacobsons plexus Blood supply - anterior tympanic a. - stylomastoid a. - superficial petrosal a. - inferior tympanic a.

    12. ????????????????????????????????

    13. I.?????????? (Otalgia) ??????????????????????????????????? Acute otitis media ?????????????????????? ??????????????????? CN VII ??????????????? ????????????????????????????????? ??????????????????????????? ???????????????????? CN IX ??????????????????????? ????????? ??????????????????? ??????????????????????????????? ???????????????????????????????????????????????????

    14. I.?????????? (Otalgia) [Cont.] ????????????????????????????????? ?????????????????? ?????????????????????????????, ????????????????????????????, ????????????????????, ????????????????, ????????????????????, preauricular sinus, cyst ????????????????????????? ??????????????????????????????, ????????????????????????, ???????????????????? ?????????????????????? ???? ??????, ??????????????, ?????????????? ??????????? : acute otitis media ???????????????, ????????????????????????????????, barotraumas, ????????

    15. ????????????????????????????????????? CN V CN VII CN IX CN X ?????????????????????? Cervical nerve 2,3

    16. II.???????????? (Otorhea) ????????????????????? Serous Mucoid Pururent Bloody Clear

    17. III.?????????? (Itching) ??????????????? ????????????????? (Otomycosis) ????????????????????????????????????? ?????????????????????????????? ????????????????? ??????????????? ?????????? ???? immunocompromise host ??????????????? Aspergillus nigra (80-90%) ???????? black spore ?????????? Candida albicans ?????????? ??????? ?????

    18. IV. ??????????? ????????????????? ????????????????????????????????? ?????????????????????????????????????????????????????????????????????????????

    19. Diseases of the middle ear Congenital diseases Trauma Infections Diseases of Otic capsule Tumors : squamous cell carcinoma, Glomus tumor (chemodectoma)

    20. congenital

    21. Congenital diseases Abnormal ossicles : incus and malleus Conductive hearing loss Crouzons syndrome : atresia of external ear or ossicle abnormality Conductive hearing loss Trachercollins : small maxilla and mandible with external and internal ear abnormality Dehiscence of the facial nerve canal

    22. Dehiscence of the facial nerve canal 6 30 % , facial n. above oval window or above the promontory clinical manifestations : Conductive HL both ears External ear abnormality Diagnosis by otoscopy. Audiogram , CT-scan Treatment : exploratory tympanotomy

    23. Congenital : treatment Objective of surgical treatment Functioning ossicular mechanism Opening ear canal Functioning the tympanic membrane

    24. Neoplasm

    25. Neoplasm of middle ear Squamous cell carcinoma Glomus tumor (chemodectoma)

    26. Trauma

    27. Cause Tympanic membrane perforation ex: Cotton tipped swab (most common), stone Air/fluid compression Inflation of Eustachian tube Fracture base of skull Lightening strike Thermal and chemical cause

    28. Clinical manifestation Pain (? improve) Purulent discharge (infection) ?????? Tinnitus Vertigo +/- bleeding

    29. Treatment Remove foreign body (forceps) ?????????blood clot ??10??? Oral antibiotic ?????????????????????(infection) ????????: ???????????????????????? 90%?????????????????? ????????????????????? 3 ????? ?????????????????????? ????????????????????????Thermal and chemical cause????????? ??????????????? ?????????????????????

    31. Fracture of temporal bone Longitudinal fracture ( 70-90% ) fracture ??? long axis ??? petrous bone ????????????????? temperoparietal ????? Conductive hearing loss( ????????????????? / hemotympanum (otoscope = ?????????????) Deformity ????????? (???????????) Facial palsy (30%) ????????????????? geniculate ganglion Cerebrospinal otorrhea ? into nasopharynx

    32. Transverse fracture (20-30%) Fracture ????????????? long axis ????????? petrous ??????????????? frontal ???? occipital ????? Sensorineuronal hearing loss Vertigo (?????????? compensation ???????????????) Hemotympanum(???????) Facial palsy (70%) most=labyrinthine segment Incomplete palsy = compression ?????? ?????? ???????????? Complete palsy = acute/ nerve damage / ???????? nerve decompression ?? 21 ???

    33. Mixed fracture (10%) ?????????????? 2 ??????????? ???????????????

    34. Traumatic disconnection of the ossicular chain ??????????????????????????????? incudostapedial joint ????? Conductive hearing loss Otoscope : ?????????? Audiogram : air-bone gap ?????? 60 dB Tympanogram : high compliance ,????? stapedial reflex ???????? Reposition ??? long process ??? incus ?????? stapedial head Interposition ??? incus ????????????????? incus ????????????????? malleus??? stapes ???????????????

    35. Otitis barotrauma ??????????????????????????????????????????????????????? ???? ????????????????? ???????????? ?????????????????????????????????????????????????????????? ?????????????????????????????????? ??????????????????????????

    36. ????????? ??????????????????? ??????????????? ???????? ????? ????? ???????????? Blood filled bleb ???????? ?????????

    37. ?????????? ???????????????????????????? > ????????????? ????????????????????????????????????????????????????????? ???????????? Eustachian tube??????? tensor veli palatini ???????????????????????????????? ??????????????????????????????????????????????????????? 90 mmHg tensor veli palatini ???????????????? ???? eustachian tube block

    38. ????? ????? ???????????????????????? Hemotympanum ????????????????? ?????????? (???????????>??) ??????????? otitis barotrauma ??????????????????????????? eustachian tube ???????????? ex: allergic rhinitis, URI

    39. ???????? ???????????? ????? : ?????? ? ????? (???????????????????????????) ? ????????????????? (>100-500mmHg) ? ???????????????????????????????? ? ???????????????????????????????? Alternobaric vertigo = ??????????????????????? (??????????????????????)

    40. ?????????? Frenzel maneuver ?????????????????????? ????? ??????????????????? ?????? ??????? Valsava maneuver ???????????????????????????????? ?????????????????????????????????????????????????????????????????????? ???????????????? ??? ?????????????????????????????????????????????????????????? ???? ??? nasal decongestant , pseudoephedine (1hr before landing) , oxymetazoline(before landing) ?????????????? barotrauma ????? ??????????????????????????? ??????????????????????? ??????????????????????????????????????????????????????????Myringotomy , ventilation tube??? ???????????

    41. ???????? ???????????????????????????????? ????????????????????????? ? ?? oval window ? ???????? perilymph ??? ? ??? round window ???? ? ????? valsava maneuver ? perilymph ????????????????? ? ????????? membrane ?? otic capsule ???? round, oval window membrane ? perilymph fistula ? ???????????? , ??????????

    42. Decompression sickness ??????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????? ???????????????????????????????????????????????alveoli ????????????????????????????? ???? air embolism ????????????????????????????? ????? ?????? ?????????? ????? ???? ??????????????? ?????? ?????????? ????????????? ????????????????? ??? ??????? ?????????????????????????????????????? 30 ??? (????????????????????????????????????????????????????) ???????? : hyperbaric treatment

    43. Nitrogen narcosis ????? : ????? alcohol intoxification (Euphoria, ?????, ?????????????) ??????? : ?????????????????????????????????????? Oxygen toxicity ????? : ???????? ??????? ?????????? ???????????????? ??????????????????????? ?????????

    44. Disease of otic capsule

    45. Spongy bone formation of otic capsule ? ankylosis of footplate of stapes Associated conditions : Van der Hoevee syndrome , Pagets disease

    46. Otosclerosis Clinical manifestation (cont) F>M , 20-30 years old Promontory ? flamingo pink (schwartze s sign) Bilateral, Related with familial history ?????? , CHL , Paracusis Audiogram Air conduction loss early : low frequency > high frequency late : low frequency = high frequency cahart notch of conduction curve

    48. Treatment 1. fluoride supplement 2. ?????????????? 3.Surgical treatment : Stapedectomy (90% success) Conductive hearing loss Air-bone gap of at least 30 dB Good cochlear reserve Contraindication 1. narrow air-bone gap 2. ?????????????????????????????????

    50. Complication (2-3%) SNHL Facial nerve injury Perilymph fistula

    51. Infection

    52. Otitis Media - Definition Inflammation of the middle ear May also involve inflammation of mastoid, petrous apex, and perilabyrinthine air cells

    53. Otitis Media - Classification Acute OM - rapid onset : < 3 wk course Subacute OM : 3 wks to 3 mo Chronic OM : 3 mo or longer

    54. Acute Otitis Media (AOM)

    55. RISK FACTORS Intrinsic factor - Age(??? ) - Allergies - Craniofacial abnormalities (cleft palate) - Immunocompromised host Extrinsic factor - Seasons - Upper Respiratory Infections - ????????????????????????????? - l??????????????

    56. Causes ???????????????????? Nasopharynx ?????? submucosal lymphatic ???????????????????????????????????????????? ????????????? ?????????? Sinus ???????????????????????

    57. Causes In Children <6 weeks - Streptococcus pneumoniae - Haemophilus influenzae(non-typeable) - S. aureus - Group A Streptococcus - Moraxella catarrhalis - E. coli - Klebsiella and Enterobacter - Pseudomonas aeruginosa - Nonpathogens ***

    58. Causes In Adult 3k - Streptococcus pneumoniae *** - Haemophilus influenzae - Moraxella catarrhalis - Group A Streptococcus - S. aureus - Nonpathogens

    59. Clinical manifestation Phase 1 : Acute tubal obstruction ?????? ??????????????? ???????? Retraction ????????? Phase 2 : Acute infection of tympanic cavity - ??????????????: ??? ????? ????????????? ???????????????????????? ?????????????????????????????? capillary ???? handle of malleus ???????????????????????????? - ??????????????: ?? Otorrhea ????????????????? Phase 3 : Retention of pus in mastoid process

    60. Stage of acute otitis media Stage 1 Hyperemia swelling and redness of tympanic membrane , mucosa in middle ear , eustachian tube , mastoid Et ??????????????????? ?????????????????????????????????????? ??????????????????? ????? ????????????????????

    61. Stage 2 Exudation tympanic membrane ????????????????????????? ?????? ?????????????????????????????? ??????????????????????????????????????????????

    62. Stage 3 Suppurative Ruptured tympanic membrane , Otorrhea ??????????????????????? ?????????????????????????

    63. Stage 4 Coalescense ???????????????????????? ???? mastoid ??? ????? ??????? Decalcification , osteoclastic reaction ??? mastoid ???????????????????????????????? ???????????????1 ???????????? 2 ??????? ?????????? ?????? ????? ???????????????? ???????????????????? 2 Coalescense mastoiditis

    64. Stage 5 Resolution ????????????? ???????????????????????? tympanic membrane ???????????????????? ????????????????????? Stage 6 Complication ?????????????????? ???? coalescence Extracranial , Intracranial complication

    65. ??????????????? Acute Otitis Media ???????????????????????????????????? (extracranial) - Subperiosteal abscess - Petrositis - Labyrinthitis - Facial paralysis

    66. ??????????????????????????????????? (intracranial) - Meningitis - Extradural abscess - Lateral sinus thrombosis - Brain abscess - Subdural abscess - Focal otitis encephalitis - Otitic hydrocephalus

    67. ?????????? ??????? amoxicillin Dosage : 40 mg/kg/day tid : 10-14 day 2-3 ?????????? 48-72 ??????? ???????????????????? (??????????...)?????????????? amoxycillin-clavulanate ??? cephalosporins ?????????????????????? penicillin ????????????????????? Macrolide ???? erythromycin ????????? Sulfaniazine ???? trimethoprim-sulfamethoxazole

    68. Treatment ?????? ???????????????? ?????? ???????? ?????? ??????? ???????(decongestant) ???????? eustachian tube ?????????????? ???????? ??????????(antihistamine) ??????????????????????? ???? ???????????????????? ?????????????????????????????? (Tympanocentasis) ??????????????????(myringotomy) ??????????????

    69. ????????????? < 6 wk ? ?????? ATB ??????? gram negative ????????????????????????????????????????????????????? ????????????????????????????????????? middle ear ???????????????????? ???? ?? I&D ?????????? subperiosteal abscess

    70. Chronic Otitis Media

    71. Definition ??????? ?????????????????????????? 3 ????? ??? ?? perforation ????????? ?? recurrent infect Via perforation Via eustachian tube : mixed organism

    72. Risk factors Inadequate treatment of acute otitis media Chronic dysfunction of eustachian tube Persistant perforation of ear drum Irreversible change in middle ear(??????) Persisitant osteomyelitis in mastoid Persistant disease in nose ,sinuses ,nasopharunx (?????? ????? ???) Other factors

    73. Chronic Otitis Media Common organism P aeruginosa (48-98%) S aureus (15-30%) Klebsiella (10-21%) Classification Safe Ear Unsafe Ear

    74. ?????????????? (safe ear) Drainage ?? ??? perforation, Eustachian tube ? ????????? complication ???????????????? ???????????????????????? ???????????? ???????????????? ????????????????? ??? central perforation ???????????? - tympanosclerosis - cholesterol granuloma

    75. Chronic Otitis Media

    76. Chronic Otitis Media

    77. ??????????? (unsafe ear) Drainage ????? ???????????? ????????????? ??????????????????? ????????????????????????????????? Perforation ???????????????????????? (marginal) ???? attic(epitympanic recess perforation) ????? cholesteatoma ???????????? Mastoiditis Facial paralysis Meningitis Brain abscess

    78. Marginal Perforation

    79. Cholesteatoma

    81. ??????????????? Chronic Otitis Media Intratemporal complication - Mastoiditis - Petrositis - Labyrinthitis ? SNHL , vertigo - Facial paralysis from mastoiditis, cholesteatoma

    82. ??????????????? Chronic Otitis Media Intracranial complication (from cholesteatoma invaded into base of skull) - Meningitis - Extradural abscess - Brain abscess - Subdural abscess - Lateral venous sinus thrombosis

    83. Treatment 1. Medical treatment - ?????????? - ?????????????????????? ???????????????????????????? ???? solution of 50% peroxide and 50% sterile water Surgical treatment - Myringoplasty(only) -Tympanoplasty(+middle) - Mastoidectomy - Radical Mastoidectomy 9(ex mid mas)

    84. ???????? Antibacterial agent ?????? Chloramphenical Neomycin sulphate,polymycins,ofloxacin ??????????????????????????? ??????????????? ????????? ????????? ???????? Sofradex , Otosporin, Dexoph Antifungal ??????????????????????? propylene glycol ???????????????????? ????????????????????????????????????????? ???????????????????????????????? Amphotericin B ???????????????????

    85. ??????????????? ???????????? ????? aminoglycoside ex: neomycin, gentamycin ??????????? aminoglycoside ex: chloramphenicol, vasocidin opthamic solution ????????????????? ex: merthiolate (thimerosal) ??????????????? ex: cresylate, volsol, gentian violet, povidine iodine, chlorhexidine ????? steroid ex: hydrocortisone, dexamethasone ??????????????? ????? fluoroquinolone ex: ciprofloxacin, ofloxacin, levofloxacin

    86. ?????????????????????????? ????????????????????????????????????????? ?????????????????????????????????????????????????? ??????????????????????????????????????? ????????????????????????????????????? ???????????????????????????? steriod ????????????? contract dermatitis ??? ??????????????????????? steriod ??????????????????????????????????????????????????? ???????????????????????????????? ??????????????? ??????????????????????????? ?????????????????????????????????? ???????????????????????????????? ????????????????????????????????????????????????????????????????? ?????????????????? ???????????????????? ????????????????????????????? ???????????????????????? ??? ?????????? ????????????? ????????????

    87. OTITIS MEDIA WITH EFFUSION

    88. ?????????????????????????????????? characterized by a nonpurulent effusion of the middle ear that may be either mucoid or serous. typically do not involve pain or fever. can occur during the resolution of AOM once the acute inflammation has resolved. Child > adult ( especially 1-7 years old)

    90. Etiology ??????????? AOM ??????????? otitis barotrauma(?????????????????) Allergy ?????????????????????????? adenovirus ???? Rhinovirus

    91. Symptoms ???????? ??????????????? ???? delayed speech ??????*** (?????????????????????????) ???????????? ????? (1-2?????? ?????????????????????????????????????????) ??????????????????????????????? ????? valsava maneuver ???????????????????????????????????????????? ?????????????? ?????????????????????????????????????????????? ????????????????? ???? ???????????? (???????????? NCA)

    92. Signs TM retraction Short process malleus ??????? ?????????????????? ??????????????????????????? ?????????? / airfluid level (good prognosis) TM ????????? ??? Pneumatic otoscopy ????? TM ??????????? ??????????????????? ?? ?????????? ??? ????????????? ??????????????? bloody fluid serous fluid ????????????????? (glue ear )

    97. Complication 1. middle ear atelectasis(ET middle- tym) 2. cholesteatoma ( destructive and expanding keratinizing squamous epithelium in the middle ear ) 3. perforated TM 4. auditory deprivation (sensorineural hearing loss) 5. tympanosclerosis

    98. Investigation Tympanogram ?????????????? type B Audiogram(CHL) (bone conduction ???????) Low tone loss ( air conduction ????) Low and high tone air conduction ???? ? ??????????? flat type High tone air conduction ????

    99. Treatment Antibiotic-Amoxycillin, trimethoprim-sulfamethoxazole , Cephalosporin ( 2-4 Wk ,F/U q 1Wk) Steroid (nasal spray 2 Wk) Decongestant (?????????? ET tube ) valsava manuver (???????? ET tube ????? , increase pressure in middle ear ) ????????????????????????????????????????????? Myringotomy ?????????????? pressure equlization

    100. Myringotomy 1 anteroinferior 2 grommet tube ??????????????????????? ????????????? ??? middle ear (???????????????????????????????????????) ?????????????? -1 ??

    101. Indication: No response to antibiotic for 1 month ???????????????????? 3 ??????????? impending cholesteatoma adhesive otitis media ??????? middle ear atelectasis Severe conductive hearing loss cleft palate Tent to recurrent OME

    102. Complication Persistent otorrhea ??? ATB ???????????? TM perforation ?????????????? Granuloma ??? TM Ossicles dislocation

    103. Clinical practice guideline for otitis media with effusion (OME)

    104. OME= ??????????????????????????????????????????????????????????????? ?????????? ??????????????????????????????? ????????????????????? ???????????????????????????????????? ???????????????????????????????????????????????? ?????????????????????????????

    105. Guideline for OME ?????????? 1a : ???????????? pneumatic otoscopy ???????????? OME ???????????????? ??????????? ??????????????????? ?? air-fluid level ???????????? ?????????? 1b : ??? tympanometry ????????????????? OME ??? type B ?????????? 1c : ????????????????????????????????????????? ?????????? 2 : ?????????????????????????? ???????? ?????????????

    106. ?????????? 3 : ??????????????????????????????????????OME??????????????????????????????? ??????????????????????? ????????????? speech language therapy ??????????????? OME ????????????????? ??????????????????????????????? ?????????????????????????????????? ?????????? 4 : ??????????????????????????? OME ????????????????????????????????????????????????????????? ??????? AOM ????????????????? OME 75-90% ???????????? ?????????? 5 : ????????????????????? ????????????????? ??????????????????? steroid ????????????????????????????????????????????????

    107. ?????????? 6 : ???????????????????? OME ??????? 3 ????? ?????????????? ??????????????????????????????????????? ?????????? 7 : ??????????? OME ??? ??????????????????? 3-6 ????? ??????????????????????????????????????????????????????????????????????????? ?????????? 8 : ??????????????????????????????????????????????????????? ???????????????????????? ????????????????? ???? ??????????????????? ????????? AOM ??????????????? ?????????? 9 : ????????????????????????????????????????????????????? ??????????????????????????? ?????? ???????????????????????????? ???????????????????????????????????????

    108. ?????????? 10 : ???????????????????????????????????? ?????????? 11 : ?????????????????????????????????? OME ??????????????????? amoxicillin ??????? 80-100 mg/kg/day oral 5-10 ??? ???? ceftriaxone 1 g/day IV 1 ????? ?????????????? erythromycin ??????? cotrimoxazole ???? ceftriaxone 50 mg/kg/day IM 3??? ????????????????????????????????? S.pneumoniae, beta-lactamase producing H.influenza ??? amoxicillin ????????? drug of choice ????

    109. ???????????????????????????????????? 72 ??????? ???????????????? ????? ???????????????????????????????????????? ????????? tympanocentesis ???????????????????????? ??????????? Amoxicillin/clavulanate 80-100 mg/kg/day ????Ampicillin/ sulbactam 7 ??? oral cephalosporin (second, third generation) ???? New macrolide (clarythromycin, azithromycin)???? New quinolone (levofloxacin, gatifloxacin, noxofloxacin)

    110. ???????????????? ???? Mycoplasma pneumaniae ???????????? hemorrhagic bullous myringitis ???????????????????????? macrolides, tetracyclin, new quinolone Recurrent acute otitis media ??? ??????????????????????????????????? 48-72 ??????? ????????????????????????????????????????

    111. ???????? ????????????????? 1. ???????????? 2. ?????????? 3. ??????????????? 4. ????????????? 5. ????????????

    112. ????????????????????????? 1. ??????????????????????????? ?????????????????????????????????? 2. ????????????????????????? 3. ?????????????????????????? 4. ??????????? 5. ????????????????????????? ???????????????? ??????????????????? 6. ???????????????????????? ???????????????????????? ?????????

    113. ??????????? 1. ???????? ??????????????????????????????????????????????????? 2. ???????? ?????????????????????????????????????????? 3. ???????? ????????????? neomycin 4. ?????????????????????

    114. ???????????????? 1. ??????????????????????????????? ???????????? ???? ?????????????????????? ??????????????????????? ???? ????????? 2. ????????????????????????????????????????? 3. ????????????????????? ?????????????? ?????????????? ?????????????? ?????????????????????????????????????????????????????????????? 4. ?????????????????????????????????????? (?????? 8 10 ???) ??????????????????????????? ?????????????????????

    115. 5. ???????????????????????? ??????????????????????????????????????? ???????????????????????? ???????????????????????????????????? ??????????????????????????? 6. ??????????????????????????? 5 10 ???? ????????????????????????????????????????????????????????? (?????????????????????????????????????????????????????????) 7. ???????????????????????????? ???????????????????????????? ??????????????????????????????????????????????????????????? ??????????????????????????????????? 20 30 ???? ???????????????????????????

    116. ?????????????????? 5% Sodium bicarbonate Chloramphenical ear drop Neomycin ear drop Solfadex (Fremycitin+gramicidin+dexa)

    117. Tarivid otic solution 3% ofloxacin

    118. DEXOREN-S [eye/ear drops] chloramphenicol 0.5 % w/v, dexamethasone sodium phosphate 0.1 % w/v

    119. Antibiotic+corticosteroid Neomycin + dexamethasone

    120. Polymyxin B + neomycin + hydrocortisone

    121. Sofradex Grammicidine + framycetin + dexamethasone

    122. ???????? Antifungal ??????????????????????? propylene glycol ???????????????????? ????????????????????????????????????????? ???????????????????????????????? Amphotericin B ???????????????????

    123. ???????????? ??????????????????????????? (impact cerumen) ??????????????? ?????????????????? ????????????????????????????????? ??????????????. ???????????????????????????????? ?????? ???????????????? ?????????????????????????????????? ??????? 2.5% NaHCO3 ????? ????????????????????????????????????????????? ??????? ??????????. ?????????????????????? ??????????????????? 4 ????? ?????? 1 ??????? ??????????????????????? ear toilet.

    124. Thanks you

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