General Pediatrics, the University of Chicago

Yingshan Shi, M.D. (773) 702-6169 03/2001

Middle Ear Disorders

TM	Etiology	S & S	Dx & Tx	F-up
Normal		Oval, convex, translucent,, gray 10x11mm memberane
Acute OM	Strep Pneumoniae Strep pyogenes (GA)	Erythma, bulging and dark purple Intra-membranous hemorrhage
OM Infusion	40% OM with OME may last up 4 weeks 10-20% continue after 12 weeks^2
Congenital Inclusion cyst
Cholesteatomas benign tumor	Congenital Intramembranous Implantation after extrusion of tympanostomy tubes, squamous debris accumulates and keratin material invaginate into TM epithelium Risk: Retraction pockets Chronic OM Penetrating trauma	Tiny pearl-like cyst or golden colored spherical cystic mass Severe-intermittent or chronic foul-smelling cheesy otorrhea Growth over time and local destruction of 3 middle ear ossicles and cause TM perforation	-immidiate ENT referral or -F-up 6-8wks, not>months -Spontaneous desquamation If consistent-ENT referral DD- transient located effusion Dx Otomicroscopy Contrast thin-section high resolution CT- middle ear Audiograms Tx cyst excision tympanoplasty	Recurrence - 50% f-up q6-8mo for at least 1-2yr post-op otomicroscopy or CT- periodically for several years
Tympano sclerosis	Irritation from TM tubes or chronic inflammation		No significant hearing loss and no Tx except plaques occupy the entire TM
Retraction pockets	Risk -Eustachian tube dysfunction & -excessive negative middle ear pressure -T tubes for COME	Atrophic TM Non-fixed retraction-TM will briskly move when moderate negative pressure is applied Fixed- no movement Complication Permanent conductive hearing loss cholesteatoma	Fixed -ENT referral Mobile -f-up for short time application of Politzer's technique of introducing positive pressure using a 1-oz Devilbis bulb syringe or OCT devices such as Mathis middle ear insufflator or plastic tipped nasal aspirator dissection / tympanoplasty middle ear ventilation
Cholesterol granuloma	Idiopathic hemotympanum behind the eardrum Granulation tissue in the middle ear with inflammation and a chocolate brown, sterile middle ear effusion	-Fullness of the ear -Gun-metal blue colored middle ear effusion ,No trauma Hx -conductive hearing loss DD blue behind eardrum Trauma hemotympanum Esp. basilar skull Fx Blast trauma to TM Dehiscent or high-riding jugular bulb	-ENT referral or -F-up months- can sponta resolution If consistent-ENT referral Aspiration and tympanostomy tubes

	Complication and Management		Treatment
Otitis Externa	Cellulitis, Chondritis, Mastoiditis CT scan Oral IV S aureus, GA strep Augmentin Cefazolin-1^st H. Influenzae, Cefuroxime Cefuroxime S. pneumoniae Cefdinir Pseudomonas Quinolones Piperacilin Blue green discharge Ticarcillin Ciprofloxacin MRSAs Quinolones Vancomycin Ciprofloxacin Fugal Ceftazidime Furunculosis Lanced, Emla or injected local anesthetic for pain Topical and oral antibiotics Eczematous OE- atopic or lupus Chronic OE Cleaning, debridement Topical acidifying, topical antibiotics Fungal OE Aspergillus niger or Candida Debridement - once a weel Topical acidifying Clotrimazole 3 drops tid Clioquinol (Vioform) Necrotizing OE - most Pseudomonas Infection spread to the soft tissuem cartilage, bone, nerves, or parotid gland. High risk of meningitis and thrombosis. Risk: diabetes, immuno deficiency Piperacillin gentamicin or tobramycin pending culture results Cefepime and meropenem for resistant strains Cholesteatoma		Topical antibiotics: bid to qid 5-10 days. Polymyxin/neomycin 3 drops tid 10days, 10ml $34 Ofloxacin(Floxin) 5 drops bid 10 days, 10ml $81 Ciprofloxacin(CIPRO) 3drops bid 7 days, 10ml $87 Going to feel better in 24 hours, no more drainage in 3 days, completely normal in 5 days. Ototoxicity: usually with prolonged instillation or instilled in a perforated TM. Sensorineural hearing loss, tinnitus and vertigo. Quinolone - ofloxacin and ciprofloxacin with or without steroid are not associated with ototoxicity Skin allergic reaction for neomycin is 15-35% Topical steroid, mainly hydrocortisone- reduction of inflammation Using a cotton wick, soaking the wick many times with antibiotics. Putting drops directly after wick fallen out Pain control: codeine 0.5-1mg/kg/dose, max 30mg Acidifying agent will help: white vinegar half and half with rubbing alcohol. Not use to too inflamed ear cannel and TM perforation RTC in 2-3 days When to referral Failure to improve Constitutional symptoms, persistent ear drainage, granulation tissue Prevention Avoidance of excessive cleaning of the eat canal Use of eat plugs while swimming - makeshife ear plugs as well as plastic plugs a cotton ball smeared with Vaseline custom plugs made for the child with tubes Prophylactic treatment for recurrent OE Mixed vinegar and alcohol qd after swimming, 4-5 drops
Chronic Otorrhea	3 % of patients with tympanostomy tubes Otorrhea >3-4weeks Tympanostomy tube otorrhea bacterial and fungal granulation tissue tobacco smoke in the home allergies immune deficiencies ciliary dyskinesia GER Eustachian tube dysfunction Munchausen syndrome by proxy	Granulation tissue Bloody otorrhea histiocytosis X Tuberculosis cholesteatoma CT- not respond Tx in about 2 weeks to rule out cholesteatoma or neoplasia Nasopharyngoscopy	Ear plugs while swimming or bathing- clean them with white vinegar or hydrogen peroxide. Cotton balls coated with petroleum jelly serve well as earplugs Ear irrigation with half strength hydrogen peroxide using a bulb syringe Ototopical antibiotics- fluoroquinolone, aminoglycoside Prednisone 1mg/kg/day for 3 days for granulation and anti-inflammation Topical steroid: Cipro HC- ciprofloxacin-hydrocortisone dexamethasone Oral antibiotics- not for uncomplicated otorrhea, indicated for any suggestion with streptococcus infection to prevent the development of rheumatic heart disease Remove the tympanostomy tube as indicated Consider adenoidectomy for pathogens chronically colonize the nasopharynx

Ref:

1. Richard H. Schwartz, MD and Charles M. Myer III, MD Infectious Diseases in Children 8/2001: 12-16

2. Quinonez, JM.Media with effusion Pediatric Infections Forum 2003;5(3):3

3. The Child with Otitis Exterma. A supplement to Comtemporary Pediatrics 2002

4. Infectious Diseases in Children. A supplement to Contemporary Pediatrics 2003;vol20(10)