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Overview of Middle Ear Infection in Children - Coggle Diagram
Overview of Middle Ear Infection in Children
Complications of untreated OM
Intratemporal complications
Permanent Hearing Loss
Cause problems with speech and language development
Cause permanent hearing loss if not treated,occurring in about 2 out of every 10,000 children who have otitis media
Usually conductive, resulting from tympanic membrane rupture and/or changes in the ossicular chain due to fixation or erosion caused by the chronic inflammatory process.
TM perforation (acute and chronic)
Tear in the tympanic membrane leading to a connection between the external auditory canal and the middle ear
Cholesteatoma
Definition: An abnormal collection of skin cells deep inside the ear.
O/E: White mass behind the TM.
Benign, but will grow large enough to erode the middle ear structures and the mastoid bone behind the middle ear
A persistent hole in the eardrum, chronic otitis media can also lead to a cholesteatoma
Labyrinthitis
Occurs through fistulization of the otic capsule or invasion through the oval and round windows
Most common extracranial complications
Serous labyrinthitis is a pre-suppurative condition in which the labyrinth undergoes inflammatory changes in association with acute suppurative otitis media
Purulent (suppurative) labyrinthitis rarely can develop
Definition: Inflammation of the labyrinth
Facial paralysis
Rare complication of acute suppurative otitis media, with estimated incidence of about 0.005% (Ellefsen & Bonding, 1996).
Pre-antibiotic era, with an estimated incidence of around 0.5–0.7% (Ellefsen & Bonding, 1996).
Possible cause: Alterations in the middle ear microenvironments, such as elevated pressure or acute inflammation, retrograde infection or due to reactivation of viruses within bony facial canal wherein facial nerve physiology may be directly affected (John & Derald, 1985).
72.2% patients with facial paralysis had full recovery (Jose et al. 2014).
Direct spread of the infection from the middle ear
Definition: Loss of facial movement due to nerve damage
Intracranial complications
Bacteral Meningitis
ETD facilitates migration of these bacteria to the middle ear, causing inflammation and infection (otitis media), which in turn could lead to further complications.
Signs of meningitis, including fever, neck stiffness and mental status changes, although some of these symptoms and signs may be absent initially ( Friedland et al, 2012).
Definition: An inflammation (swelling) of the protective membranes covering the brain and spinal cord
Brain abscess
In the past, the mortality rate of otogenic brain abscess was 14 to 35% , but has now decreased to 3% (Bartochowska, 2013).
Accumulation of pus in the cerebrum or cerebellum developing with encephalitis, caused by pyogenic microorganisms originating from inflammatory processes in the middle ear cavity.
Acute and chronic otitis media equally cause otogenic brain abscess (Barry et al. 1999).
An infection can spread from a nearby area, and this accounts for 14–58% of brain abscesses
Introduction :fountain_pen:
What is Otitis Media?
The most common diseases in young children worldwide
Can be associated with hearing loss and life-long sequelae but it may resolve spontaneously without complications
An inflammatory diseases of middle ear
Epidemiology
Based on prevalence surveys, WHO estimated that 28 thousand deaths every year are attributable to complications of OM
Chronic Suppurative OM most often occur in certain ethnic groups. It may be affected up to 12% Eskimo and 8% American Indian children followed by whites and blacks
Very common in children in age of 5 years old
Acute otitis media affects 11% of people each year with half occurring in those below five years old
Types of OM
OM with effusion
Inflammation of the middle ear with liquid collected in the middle ear
Asymptomatic
Chronic suppurative OM
TM is perforated and otorrhea is present
Acute OM
The rapid onset of signs and symptoms of inflammation in the middle ear
Causes of OM
Eustachian Tube Dysfunction
Mucosal damage
negative pressure in the middle
ear in relation to the nasopharynx.
Age - The shorten length of ET, narrower and more horizontal
Bacterial colonization of nasopharynx
Viral URTI
cough
Dense bacterial otopathogens loads in nasopharynx
Flu
Genetics
Cleft lip or Palate or both
Male genders
Polymorphism in immune pathways
Family history of Otitis Media
Impaired immunity
Allergy
Socioeconomic status
Education
Housing
Employment
Social & Environmental
Crowding
Hygiene
siblings
Daycare
Smoke exposure
poor nutrition
Pathophysiology of Otitis Media
1) Begins with inflammatory process at the upper respiratory tract infection involving the mucosa of the nose, nasopharynx, middle ear mucosa, and Eustachian tubes.
2) As inflammation occurs, edema (swelling in body tissues) happens in the small middle ear cavity, resulting the Eustachian tube to dysfunction too. This causes low ventilation rate in the ME cavity
3) Low ventilation rate in the cavity will increase negative pressure, causing exudate(fluid from ME walls), leading to mucosal accumulation in the cavity. This fluid will provide savoury atmosphere for bacterial growth.
4)In long term of bacterial growth will lead to purulence (discharge of pus) from the ME cavity, leading to CSOM
Before any discharge of perforation of TM, TM could be seen erthematous and bulging.
Diagnostic Criteria of OM
Acute OM
Rapid onset
Purulent effusion
Otalgia & fever
Bulging and erythematous TM, with purulent effusion behind it
Persistent Acute OM
Persistent signs and symotoms of AOM during antibiotic treatment OR relapse within 1 month of treatment completion
Recurrent Acute OM
3 or more episodes of acute OM within 6 to 18 months
Otitis media with effusion (OME)
Clear fluid behind the TM in the absence features of AOM
Reduce hearing
Occur following AOM episodes but can be present without preceding AOM
Chronic Suppurative Otitis Media (CSOM)
Post Acute OM
With or without cholesteatoma
Hearing loss
Active (producing discharge) or inactive (dry) perforation
Recurrent or persistent ear discharge (otorrhea) over 2 to 6 weeks through a perforated TM
Treatment & Management
ENT
AOM
Watchful waiting (70 to 90% of children with AOM have spontaneous resolution within 7 to 14 days) (Rosenfeld RM and Kay D, 2003)
Antihistamines, decongestants and myringotomy showed no benefits (Hendley JO, 2002)
Antibiotic e.g. amoxycillin
aged < 2 years with bilateral AOM
<6 months and > 2 years with severe symptoms (moderate to severe otalgia or fever)
At risk of complications like chronic suppurative otitis media or mastoiditis (e.g. Aboriginal children living in remote communities, children with immunodeficiency syndromes)
Those who have already had 48 hours of watchful waiting
Analgesic (painkiller)
OME
Active observation
Antihistamines and decongestants (no benefits)
Myringotomy or Tympanostomy with ventilation tube
Ventilation tubes beneficial for younger children in high infection load (attending daycare) and in older children with hearing loss >25dB in both ears for more than 12 weeks (Rovers MM et al. 2005)
Autoinflation (eg.Valsalva maneuver useful in older children with persistent OME
Oral and topical intranasal corticosteroids + antibiotics showed faster short term resolution of OME (Thomas CL et al. 2006)
CSOM
Tympanoplasty (using a soft-tissue graft)
Topical antibiotics (e.g. quinolones, aminoglycosides, polymyxins) are more effective than systemic antibiotics
Audiological
Hearing monitoring (important after ENT management)
Amplification (after medical clearance)
Air conduction HA
Open fit thin-tube BTE more suitable to keep the ears aerated
BTE with occluding earmolds may have adverse effect on ear discharge
Bone conduction HA
Showed beneficial for patient with CHL and reduce ear discharge
Conventional BCHA (non-surgical)
BC thresholds ≤ 50dB HL @ 250-6000Hz
Younger children
Implantable BCHA
Bone anchored hearing aids
BC thresholds ≤ 45 dB HL @
500 – 3000 Hz
Speech score more than 60%
Age 5 years and above
Audiant bone conductor (ABC)
BC thresholds ≤ 25 dB HL 3FA
Speech score more than 80%
Age 3 years and above
Assistive listening device (FM system)