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Otitis Media

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Otitis Media Dr John Curotta Head of ENT Surgery The Children s Hospital at Westmead What is Otitis Media? AOM = Acute OM OME = OM with Effusion (= glue ear ... – PowerPoint PPT presentation

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Title: Otitis Media


1
Otitis Media
  • Dr John Curotta
  • Head of ENT Surgery
  • The Childrens Hospital at Westmead

2
What is Otitis Media?
  • AOM Acute OM
  • OME OM with Effusion ( glue ear)
  • CSOM Chronic Suppurative Otitis
  • Media ( a hole in the ear
    drum
  • which
    discharges)

3
Ear drum without a hole
  • 2 types of fluid in middle ear
  • 1. Pus -gt Acute OM AOM
  • 2. Mucous -gt Effusion OME

4
Ear drum with hole ( gt6 weeks)
  • 1. Simple hole connects outer ear to mucous
    making lining of middle ear
  • (like a nostril) usually dry, but sometimes
    runny. SAFE ear
  • 2. Hole with skin of ear drum growing in
  • UNSAFE ear

5
UNSAFE ear
  • Also called
  • CHOLESTEATOMA
  • Chol est e at oma
  • Kol-est-ee-at-oma
  • Means skin growing into ear, not out

6
What is UNSAFE about skin growing in ?
  • Skin is not normally in the ear and mastoid
  • Lowest layer of skin makes an enzyme which eats
    away the bone
  • This erodes Bones of hearing
  • Bone covering inner ear
  • Bone between ear and brain
  • Deaf Dizzy Brain
    Abscess

7
What makes you suspect an UNSAFE ear ?
  • Persistent discharge
  • The SMELLSneakers taken off after a week in the
    wet.
  • That is ..soggy dirty mouldy skin

8
Cholesteatoma
  • ALWAYS needs surgery
  • Surgery delicate / long / often repeated
  • (very little pain and
    discomfort) !

9
Remote Kids
  • Usually get early on
  • Safe Hole in ear drum ------
  • Often Runny ears

10
Northern Territory OM Survey 2007
  • 1300 children, 6 mo 30 months old
  • 25 AOM
  • 5 AOM perforation
  • 15 CSOM
  • 10 had completely normal ears.

11
NT OM Survey 2007
  • By 6 months age 98 OME
  • By 12 months age
  • 90 AOM
  • 35 AOM Perforation
  • 20 CSOM

12
Town and city Kids
  • Usually get what any other town/city
  • kids get.Glue ear.
  • BUT because it is a hidden condition -
  • .may NOT get diagnosed !

13
Job of Nurses for Ears
  • 1. Runny ears DRY the runny ears
  • Maximise hearing
  • Optimise learning
  • 2. Glue ears DIAGNOSE
  • Maximise hearing
  • Optimise learning

14
RISK factors for Otitis Media
  • Boys
  • Brother/sister with OM
  • Early start to AOM (lt6mo)
  • Not breast fed
  • Poor housing
  • Smoker at home

15
PREVENTION
  • Vaccination against Strep pneumoniae

  • (pneumococcus)
  • PREVENAR works under 2 yrs age
  • PNEUMOVAX works after 2 yrs age
  • ( Hib Haemophilus influenzae Type b vaccine
  • is NO good for ears
  • as they get H influenzae
    Non-typeable )

16
Pneumococcal Vaccination PREVENAR
  • 239,000 operations for grommets in Australia in
    past 10 years
  • Since Prevenar introduction in 2005
  • grommets reduced by
  • lt1 yr23
  • 1-2 yrs..16
  • 2-3 yrs.. 6

17
Study effect early Pn Vaccination Remote NT
Kids - 2009
  • Minimal benefit in reduction Otitis Media
  • (unlike
    town/city kids)
  • Probably need
  • Pneumococcal vaccine with wider spread
  • Vaccine for Haemophilus infections of ears
  • Vaccinate mothers

18
Diagnose GLUE Ear
  • SCREEN
  • vs
  • SUSPECT

19
Aim of NSW Otitis Media Strategy
  • is to screen all kids
  • Eliminates guesswork
  • But Do they all get screened?

20
Hearing Testing
  • Tiny Tots
  • SWISH for all newborns
  • NSW 99 cover .Who is most likely
  • to miss out ?
  • Usual Tymps unreliable under 6 months

21
Hearing Testing
  • Baby to - 4 yrs old
  • VROA / Behaviouraltest overall /
  • better ear
    hearing
  • Usual Tymps Reliable

22
Hearing Testing
  • Over 4 yrs
  • PTA Tymps generally reliable

23
AOM
  • pus in middle ear
  • Bodys immune /- antibiotics kill bacteria BUT
    the mucous can take weeks to clear out

24
POM Fluid in ear since infection
  • POM Persisting Otitis Media
  • i.e. after AOM, up to 12 weeks
  • Once fluid is there gt 12 weeks,
  • ? Then call it OME or Glue ear

25
Fluid in middle ear
  • AOM POM OME
  • 0 weeks gt12
    weeks

26
Benefit of Hearing Testing
  • Learning to talk
  • vs
  • Learning in classroom

27
Hearing under 4-5 years
  • One ear is enough to learn to talk and to get
    along at home
  • So general tests of hearing are OK

28
Hearing, over 4-5 yrs
  • Unilateral OR Bilateral HL
    very important to diagnose
  • Poor hearing even in ONE ear is a major problem
    in classroom

29
Hearing over 5 yrs
  • This means at school
  • Absolutely need both ears hearing

30
Unilateral hearing Loss
  • Very serious problem in class room
  • Placement
  • Background noise
  • Direction
  • Anything other than one-to-one talking

31
Grommets - time working
  • Small Shepard6 mo
  • Medium Reuter Bobbin12 mo
  • Large Sheehy Collar Button.18 mo
  • Larger T Tubes24 mo

32
The bigger the grommet
  • The longer it stays
  • The bigger the risk of a larger perforation
  • So, NO T-tubes in children

33
Grommets
  • The GOOD
  • The BAD
  • The UGLY

34
Grommets- The GOOD
  • Instant relief
  • Consistent relief
  • Helps balance too
  • Reduces AOMs as well

35
Grommets-The BAD
  • Need admission to hospital
  • Waiting list
  • General anaesthetic
  • How long effective
  • Repeat grommets

36
Grommets-The UGLY
  • Limit water exposure - e.g. swimming
  • Discharging grommet a problem
  • Social / hearing / extrude grommet
  • Residual perforations, esp if large
  • large gt 20 area TM (large is bad)
  • in between.(nuisance)
  • small lt 10 area TM (small is good ! )

37
If not grommets What ?
  • Seating position.counting chooks
  • FM System
  • Hearing Aid/s
  • Room amplification

38
Looking after grommets
  • Its not the water
  • Its the GERMS in the water

39
Looking after grommets
  • Clean waterOK shower,
    beach,

    well-maintained pool
    (Chlorine High end
  • pH Low end of range)
  • Some Remote WA - No SchoolNo Pool

40
Looking after grommets
  • AVOID
  • Bath water
  • Spas
  • Indoor heated pools
  • Creeks
  • OR USE
  • Ear plugs and cap / head band

41
Infected grommets
  • Foreign material in the body - if infected gets
    covered in slime
  • Called BIOFILM
  • Like the inside of water pipes etc
  • Also plaque on teeth / infected catheters/ IV
    cannulas etc

42
BIOFILM
  • Bacteria exude a jelly to cover themselves
  • So, antibiotics cannot reach them
  • To clean biofilm must mechanically break it up
    brush it / scrub it
  • ? If not possible remove the device.

43
Discharge through Grommets ..How?
  • Head cold Virus? Increase secretion in nose /
    sinuses / ears
  • Secondary bacterial infection (like AOM)
  • Overflow through grommet

44
Discharge through Grommets ..How?
  • If virusdries up when nose dries up
  • If bacterial.. May / may not dry up with nose.
  • Antibiotic medicine or capsules (eg
    Amoxil) helps

45
Discharge through Grommets ..How?
  • Bacteria which live on skin in outer ear can get
    into middle ear through the mucous
    discharge..(pseudomonas)
    ..these are resistant to most oral antibiotics
    Need
    DROPS

46
Ear Drops for Grommets
  • Ciprofloxacin ( Ciloxan / Ciproxin HC) is always
    safe in ears
  • Sofradex usually safe in infected ears
  • Sofradex is unsafe in clean ears

47
Ear Drops for wax
  • 1. Sodium Bicarbonate Ear drops (
    chemist makes them up)
  • 2. Waxsol drops
  • 3. Ear Clear Drops for Wax Removal
  • Then syringe.
  • Never Cerumol - too harsh

48
Discharge through grommets
  • If so much discharge ear drops cannot get in ?
  • Use 3 Hydrogen Peroxide as drops first, to clean
    the ear, dab dry and then put in drops. (only for
    a day or so at a time)

  • (probably is breaking up Biofilm)

49
Wax or discharge in Ears
  • Gently syringe with dilute baby shampoo
  • 1/2 teaspoonful in 1 cup warm water ( 1)
  • (or
    1 tsp in 500ml)
  • Finish by syringing Betadine (1 tsp in 100ml)
  • 10 ml syringe with a cut-off scalp vein
    needle


  • Safe in perforations or
    grommets

50
References
  • Aboriginal Ear Health Manual Harvey Coates et
    al from WA
  • Aboriginal Otitis Media ENT Program Evaluation
    Report 2002
  • Surgical Management of Otitis Media with Effusion
    in children Clinical Guideline, February 2008
    - UK
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