Otitis Media
An infection of the middle ear or the area behind the eardrum is termed otitis media. Symptoms include pain, fever, irritability, and
hearing loss.
The middle ear is the compartment behind the eardrum which houses the three bones, the malleus, incus and stapes bones. The
eustachian tube connects the middle ear to the back of the nose. Normally the eustachian tube is collapsed but when we swallow or
yawn, the muscles around the tube contract and the tube opens allowing air to enter the middle ear. The eustachian tube is responsible
for maintaining an air containing middle ear space when the eardrum is intact.
The adenoids are aggregates of lymphoid tissue located behind the nose near the eustachian tube opening. Lymphoid tissue is a collection
of white blood cells that are part of our immune system. Adenoids are particularly enlarged from the ages of three to five and they
shrink soon thereafter. In some children, the adenoids remain enlarged. Enlarged adenoids can lead to excessive mouth breathing because
of obstruction of the nose. They can also obstruct the eustachian tube openings preventing the equilibration of middle ear pressure to
atmospheric pressure.
Acute Otitis Media
Acute otitis media is the term used to describe an infection involving the middle ear that starts rather suddenly. Typically the child or
adult experiences pain, irritability, fever, and hearing loss. On examination a reddened bulging eardrum is seen. This type of infection
usually is preceeded by a cold. Inflammation around the eustachian tube in the back of the nose occurs and bacteria can enter the middle
ear via the eustachian tube. Treatment involves antibiotics given by mouth for seven to ten days.. The typical course involves the
persistence of fluid in the middle ear for up to six weeks following treatment. No further antibiotic treatment is required.
If the pain and fever do not resolve within 48 hours of starting the antibiotics, the medication should be changed. If pain and fever
continue despite changing the antibiotics, consideration should be given to seeing a specialist.
Chronic Otitis Media
Chronic otitis media is the term used to describe the persistence of middle ear fluid after an acute infection. A mild hearing loss results. For children, even a mild hearing loss may impair the development of speech and language skills. For this reason tympanostomy tubes can be surgically placed to ensure drainage of accumulated middle ear fluid.. An adenoidectomy may also be useful for patients who have recurrent episodes of otitis media, chronic mouth breathing and snoring problems.
Left untreated a middle ear infection over time can rupture the eardrum and cause drainage from the ear canal. At this stage the infection usually has already involved the mastoid bone. The infection can then spread to involve the bones behind the eardrum, facial nerve, inner ear, and brain.
Hearing loss can result from both the eardrum perforation and from infection causing erosion of the middle ear bones. The ossicles may also lose their ability to vibrate and become more fixed in the presence of chronic infection. The best form of treatment that can be offered is surgery to repair the eardrum perforation and to replace the ossicles. There are two techniques that can be used to close a hole in the eardrum.
One involves placing a graft taken from the covering of the temporalis muscle underneath the perforation. This is also called an underlay technique.
In very unusual circumstances, clear watery discharge can be noted after insertion of a tymapanostomy tube. This drainage can be associated with headaches and concomitant drainage from the nose. These symptoms should raise the suspicion for an encephalocele (herniated brain) or meningocele (herniated covering of the brain) into the mastoid bone.
Tympanostomy tubes
In adults, these tubes can be surgically placed in an office setting. For children, this procedure can be done in a same-day surgery setting. This involves a general anesthetic gas that is inhaled by mask. Typically, the procedure lasts from 15 to 30 minutes. The eardrum is visualized with an operating microscope, an incision is made, and any middle ear fluid is suctioned away. A tube is then inserted and topical antibiotic drops are added. The child is then awakened from general anesthesia and sent home the same day.
These tubes are naturally extruded into the ear canal from six months to two years after insertion. The small hole left in the eardrum usually heals spontaneously 95 % of the time. On rare occasion a persistent hole may remain and require a patch to be placed.
There is no limitation on activity level after having tubes placed other than to keep water out of the ear. Water entering the middle ear can cause an otitis media. A middle ear infection can still occur with the tubes in place but accumulated middle ear fluid easily drains out. Patients with tubes in place can go swimming as long as an ear mold is worn.
In very unusual circumstances, clear watery discharge can be noted after insertion of a tymapanostomy tube. This drainage can be associated with headaches and concomitant drainage from the nose. These symptoms should raise the suspicion for an encephalocele (herniated brain) or meningocele (herniated covering of the brain) into the mastoid bone. Surgery is required to reduce the herniation.
Adenoidectomy
This is a surgical procedure to remove the adenoids. This involves general anesthesia delivered via a tube placed in the windpipe. Through the mouth and using a mirror the adenoids are removed and open blood vessels are cauterized. Patients usually go home the same day. Complications of otitis media
Most cases of otitis media resolve with prompt administration of antibiotics. On occasion despite prompt treatment, the infection can spread into the mastoid and cause mastoiditis. If the infection is serious, a mastoidectomy with administration of antibiotics may be required. Left untreated the mastoiditis can lead to a facial paralysis, dizzyness, hearing loss, meningitis, and even a brain abscess. Prompt treatment can not be underemphasized.
In order to allow a better understanding of otitis media, it is important to understand the anatomy of the area. Sound entering the ear
canal causes vibrations of the tympanic membrane (eardrum). The eardrum is attached to one of three ossicles (bones) found in the
middle ear, called the malleus. The malleus bone transmits the mechanical vibrations to another ossicle, the incus, which in turn transmits
the vibrations to the smallest of the three ossicles, the stapes. The stapes bone vibrates and sends the message to the inner ear. The
inner ear is made of a bony labyrinth filled with fluid and membranes. As the stapes vibrates, the fluid in the inner ear is set into motion.
The cilia on the ends of hair cells within the inner ear are bent and an electrical signal is generated and travels along the (cochlear)
hearing nerve and then back to the brain. The inner ear is composed of the cochlea, which is responsible for hearing and the semicircular
canals that transmit balance information back to the brain.
An alternative is to place the graft over the perforation, a technique called a lateral graft technique.
Experienced surgeons can usually perform this type of surgery in about two hours.