How to Treat Otitis Media
Malignant otitis externa was first described as a severe infection of the external auditory canal 16 . It usually (but not always 101 ) affects elderly diabetics, resulting in unremitting pain, purulent discharge and invasion of cartilage, nerve, bone and adjacent soft tissue. The causative agent is usually Pseudomonas aeruginosa, but other organisms including fungi have been incriminated. The condition frequently goes on to ninth, tenth, eleventh and twelfth cranial nerve palsies and meningitis and death may result. Histopathological changes in the temporal bones of two patients who had been diagnosed clinically as having malignant otitis externa and were thought to have died of this condition 123 were those of severe otitis media and osteomyelitis of the jugular foramen secondary to it. It seems likely that the manifestations of malignant otitis media are due to the spread of inflammation from the tympanic cavity and mastoid air spaces to the petrous apex through bone marrow spaces...
Otitis media is one of the most common of all diseases, particularly in young children. The disease is usually caused by bacterial infection, Haemophilus influenzae and Gram-positive cocci usually being incriminated in the acute form and Gram-negative bacilli in the chronic form. The clinical forms of the acute and chronic conditions correspond to the pathological changes, but intermediate or mixed states are frequent. Perforation of the tympanic membrane may occur at any phase of otitis media, but an effusion, accompanied by all of the other manifestations of chronic otitis media, is often present behind an intact tympanic membrane, a condition known as serous otitis media. The appearances of the middle ear mucosa in acute otitis media may be seen in the bone chips removed at mas-toidectomy. There is congestion and oedema of the mucosa of the mastoid air cells. Haemorrhage may be severe and the mucosa and air cells are filled with neutrophils. Pus destroys bone, the actual...
Inflammation and infection of the middle ear, called otitis media, is a result of blockage of the Eustachian tubes that run from the back of the throat to the middle ear. Fluid gathers and pressure builds up, causing pain. Symptoms are a throbbing pain and sometimes fever. If there is a sudden sharp pain and pus drains from the ear, the eardrum has been perforated. Ear infection In a study, 86 of the children affected with ear infections were relieved of the condition when foods they were allergic to were removed from the diet, taking several months for the infection to clear totally. Most common offenders are milk, wheat, eggs, peanuts, and soy products. Allergies cause an inflammation and swelling of the middle ear, which allows fluid to become trapped and infection to fester. Craniosacral manipulation by an osteopath has cured middle ear infection caused by restriction of the respiratory apparatus. While fluid is not able to drain because of the restriction, it stagnates and...
Otosclerosis occurring with other pathologies has received little attention in the literature although these concomitant occurrences can be clinically relevant. We studied the clinical and histopathological characteristics of 182 cases of otosclerosis from our human temporal bone collection, and found 81 (44 ) to have associated pathologies. Clinical pathological findings included vestibular symptoms and findings (e.g. Meniere's syndrome), otitis media in various forms, and to a lesser extent labyrinthine anomalies, tumors and other associated pathologies. Whether these coexisting pathologies are coincidental (usually) or causative as in the case of Meniere's syndrome with extensive otosclerosis, appropriate diagnosis and treatment of the patient with otosclerosis requires recognition of these potential clinical pathological relationships. The entire collection of the temporal bone bank at the University of Minnesota was searched for those bones with otosclerosis. Out of 1,884...
Complications of meningitis include hydrocephalus, cerebral infarction, subdu-ral effusion or empyema, cerebritis and cerebral abscess. Sterile subdural fluid collections are not uncommon in the setting of meningitis and do not usually require surgical intervention. However, if seeded with bacteria, they can be transformed into infected collections (empyemas), which require drainage. Paranasal sinusitis, mastoiditis, otitis media, calvarial osteomyelitis and orbital cellulitis are other causes of empyema. On CT and MRI, both effusions and empyemas appear as peripherally enhancing extra-axial low-intensity fluid collections. They are most frequently located along the frontal and temporal lobes. Empyemas are typically unilateral, have a thick rim of enhancement, and may also have internal septations and locula-tions. Cerebritis can be seen in underlying brain parenchyma in both effusions and empyemas, and has the appearance of local edema (hypodensity on CT, and low T1 and high T2...
Tympanoplasty has many variations, but is essentially a mature set of procedures. Future progress will require research to achieve more successful control of chronic otitis media and to manage the processes of wound healing in the middle ear. The advantages and disadvantages of the underlay technique are listed in Table 3-2. 19. Leighton SE, Robson AK, Anslow P, Milford CA. The role of CT imaging in the management of chronic suppurative otitis media. Otolaryngol Clin North Am 1993 18 23-29.
Head and neck manifestations, particularly in the si-nonasal complex, are common and can affect as many as 90 of patients at presentation 50 (see Chap. 2). They include severe rhinorrhoea, sinusitis, otitis media and destruction of the nasal septum and cartilage to produce a saddle-nose deformity. By contrast, oral lesions are less common and affect only about 5 of patients 69 . They include oral ulceration, delayed healing of extraction wounds, tooth mobility and loss of teeth. Perforation of the palate is usually as a direct extension of si-nonasal disease. Extraorally, head and neck manifestations include swelling and desquamation of the lips, parotid gland enlargement, and cranial nerve palsies.
The preoperative discussion is of paramount importance and should contain the following elements (1) an explanation with diagram that the underlying problem in the ear with chronic otitis media with or without cholesteatoma is eustachian tube dysfunction (2) an explanation that this dysfunction is not going to be corrected, but that the disease caused by this problem will be corrected and (3) an explanation that the goal of the operation is not hearing improvement but hearing maintenance and prevention of complications.
JNA in adolescent boys is associated with prior self-limited bleeding before a more brisk event occurs. May cause nasal obstruction, initially unilateral. Nasopharyngeal carcinoma (NPC) is seen in teenage African-American boys in the United States. Nasal obstruction and ipsilateral serous otitis media or firm cervical lymph nodes are noted on exam.
Lesions located at the petrous-temporal bone apex (osteitis or meningitis associated with otitis media) irritate the ophthalmic division of the trigeminal and abducens (VI) nerve. Forehead pain is accompanied by ipsilateral lateral rectus palsy and a Horner's syndrome if sympathetic fibres are also involved. Tumours and trauma can also produce this syndrome.
Acute otitis media is the most frequent diagnosis in children presenting with fever. Diagnosis in a screaming child requires diagnostic skill beyond mere assessment of tympanic membrane erythema. Drum appearance and membrane mobility are important signs. Conjunctival suffusion may be one of the diagnostic clues to Kawasaki disease. It is important to evaluate for pharyngitis (eg, group A streptococcus, EBV), peritonsillar abscess, retropharyngeal abscess, and rhinosi-nusitis (eg, upper respiratory allergic diathesis). Drooling may suggest upper airway obstruction, including retropharyngeal abscess.
In an infant with otitis media, meningitis must be ruled out.The finding of a source of infection (eg, acute otitis media) in a highly febrile infant does not remove the onus on clinician to rule out serious deep infection. Although data suggest that a patient with one focus of infection is unlikely to have a second source of infection, the first diagnosis source does not protect patient from a second, more serious, source.
The burden of disease is borne disproportionately by the poor. In addition, the impact of disease on education is greatest for the poor. In the preceding review we saw examples where lack of breast feeding, or otitis media infection led to cognitive impairments only for children of the least educated mothers. There are also examples where the impact of one condition is greater for children suffering from other problems of health or nutrition 105, 106 . Conversely, preschool health interventions tend to provide the greatest benefit to disadvantaged children. For example, long-term educational benefits of a nutritional supplementation program in Guatemala were found only for those children of low socio-economic status. Many other examples exist in the literature on school-age children. For example, giving breakfast to children in Jamaican schools improved cognitive function on the same day to a greater extent for children with chronic malnutrition 107 . Similarly, gender differences in...
Pharyngeal carcinomas show a strong male predilection. While most patients with non-keratinising nasopharyngeal carcinoma are older than 50 years in endemic areas, there is a bimodal age distribution with a peak presentation in the 2nd and 6th decades in intermediate- and low-incidence areas 8, 43, 63, 77, 175 . The causative and aetiological role of EBV is well established in invasive and in situ nasopharyngeal carcinomas, irrespective of the ethnic origin of the patient and the histological subtype 31, 158 . However, environmental factors seem to play a role, since the incidence of non-keratinising na-sopharyngeal carcinoma decreases among second and third generation Chinese living in non-endemic areas 83 . Nasopharyngeal carcinomas arise in the lateral walls of the nasopharynx in the area of the Rosenmuller fossa and presenting symptoms may be nasal obstruction, epistaxis, post-nasal drip, tinnitus and cranial nerve palsy. Hearing loss and unilateral otitis media are related to...
Patients with cervical spine involvement may be initially asymptomatic. As the disease progresses neck pain may appear. Suboccipital headaches aggravated by neck movements are common, and electrical-like sensation in the torso or extremities that is precipitated by neck flexion or extension may appear. This is frequently referred to as Lhermitte'ssign. Some patients develop earache and occasionally facial pain due to compression or irritation of the sensory fibers of the greater auricular nerve or the spinal trigeminal nucleus. Neurological findings are less common than pain but may be present in up to one-third of the patients. Gait dysfunction (unstable gait, wide-based gait), decreased upper extremity dexterity and weakness, and sphincter dysfunction may develop due to cervical myelopathy.
How old is patient Although meningitis, otitis media, gastroe-sophageal reflux disease, abuse, and other causes of irritability can occur at any age, special considerations in neonates (0-2 months of age) include colic, neonatal abstinence syndrome, metabolic disorders, and anatomic abnormalities. Colic usually begins in second or third week of life and subsides by 3-4 months of age. Persistent crying in a neonate younger than 2 weeks of age or in an older infant is unlikely to be colic.
Bacterial infections of the lower respiratory system are less common than those of the upper system, largely because they are stopped by body defenses at the portal of entry. Lower tract infections, however, are generally much more serious. An earache or sore throat is unlikely to be life threatening, but their causative organisms can endanger life when they infect the lung. Distinctive patterns of signs and symptoms are produced by the different kinds of organisms that infect the lower respiratory system. The pneumonias are inflammatory diseases of the lung in which fluid fills the alveoli. They top the list of infectious killers in the general population of the United States, and they are important as nosocomial, meaning hospital-acquired, infections. Whooping cough, tuberculosis, and Legionnaires' disease are other distinctive types of infection. body defenses, innate immunity, p. 372
Hearing deficits are also commonly associated with syndromic craniosynostoses. Conductive hearing loss secondary to eustacian tube dysfunction and chronic otitis media are the most common causes. Apert syndrome, in particular, may be associated with hearing deficits related to stapedial footplate fixation in addition to middle-ear disease. Audiologic testing should be routinely performed, in order to diagnose these problems early so that appropiate therapy can be undertaken.
Tuberculous otitis media is an unusual form of chronic otitis media, which is generally associated with active pulmonary tuberculosis. In the initial stages multiple perforations of the tympanic membrane develop. Granulations in the middle ear may appear pale and are often profuse. Complications, especially involvement of the facial nerve, are more frequent than in the commoner form of chronic otitis media. The diagnosis is usually made by histopathological examination of biopsy material from middle ear contents. This is often delayed because surgeons are reluctant to take biopsies from cases of chronic otitis media that seem fairly typical.
Particularly echovirus 9, may also cause rashes. Rarely, a rash may be due to a reaction to an antibiotic or other drug but this seldom occurs early in the course of the disease. Focal neurological signs, seizures, and cranial nerve palsies resulting from rhomboencephalitis are seen in some patients with listerial infection.86 Pneumococcal meningitis is associated with otitis media, a history of skull fracture, alcoholism, or sickle cell disease, and up to 50 will have pneumonia. Staphylococci or gram negative bacilli often cause meningitis complicating the implantation of neurosurgical devices such as shunts. In those with immune suppression, including AIDS, simultaneous infection with more than one organism may occur. If there is a history of meningitis, there is probably a dural fistula from previous head injury or, much more rarely, the patient suffers from an inherited complement-deficiency state.
Patients should understand that they should not place any foreign objects into their ear canal including Q-Tips. Ceruminolytics should be used to remove cerumen. Patients who are prone to swimmer's ear (otitis externa) should keep the ear canal dry by placing two drops of alcohol in the ear canal.
Many factors considered to be significant by previously published reports were absent in our scoring system. The most notable of these was the status of the stapes in determining outcome. Because the superstructure presents no acoustical advantage, this result seems logical. Another factor noticeably absent from the OOPS index was the diagnosis that led to the surgical intervention. We listed cholestea-toma, chronic otitis, atelectasis, perforation, conductive hearing loss, and any combination of the above as diagnostic parameters. No single diagnosis predicted outcome, unlike the Austin Kartush system. Another factor absent from the OOPS index was magnitude of the preoperative air-bone gap. Although common sense would dictate that a better hearing ear would have fewer comorbidities, and thus a better surgical outcome, than an ear with poorer hearing, there was no trend in the data to support this. As a number of patients undergoing ossiculoplasty have incus necrosis from previous...
The bacteriology of cranial EDA correlates with the underlying cause of infection. Cases associated with para-nasal sinusitis, otitis and mastoiditis reflect the organisms of the underlying infection, most often hemolytic or microaerophilic streptococci and anerobes. Post-traumatic and or post-operative cases are most often caused by staphylococci.
A normal or near-normal mucosa predicts a favorable outcome. Likewise, an intact ossicular chain improves the prognosis for hearing improvement. Tympanosclerosis, a hyaline degeneration in the middle ear, is frequently seen in ears with chronic otitis media. Although tympanosclerosis rarely affects the success of the TM graft, it may contribute to ossicular fixation. Stape-dial fixation by tympanosclerosis, although rare, requires a second operation. Ossicular erosion or necrosis usually involves the incus. The status of the stapes can often be determined and is the most important ossicular variable in hearing improvement.
Indications for a CWU mastoidectomy include complications of acute otitis media, chronic otitis media, cholesteatoma, exposure of structures within or deep to the temporal bone, cerebrospinal fluid otorrhea, facial nerve trauma, and neoplasm of the temporal bone.6 A canal-wall-down procedure should be performed if the disease is in the only hearing ear, severe complications of otitis media or cholesteatoma are present, the surgeon is unable to remove cholesteatoma completely with the posterior canal wall intact, the eustachian tube is nonfunctional, or the patient is noncompliant or a poor anesthesia risk. A contracted or sclerotic mastoid cavity is a relative indication for wall-down surgery.7
Children with hearing or visual impairment are also at increased risk of psychiatric disorder. This is compounded by developmental delay in many cases. Children with fluctuating hearing impairments (often due to otitis media with effusions) are at greater risk of behavioural problems as well as language and reading delays. (28) The risk of developmental delay differs between deaf children of deaf as compared with hearing parents. In the former, parents are more able to attune themselves to the child's developmental needs using the modalities of vision and touch, allowing these children to develop attachments, symbolic play and (sign) language at the same rate as hearing children of hearing parents.(28) Early development in blind infants is facilitated by mothers who are attuned to and can respond to their infant's often subtle cues and give a continual sense of their presence using voice and touch. (28)
University hospital, indicated that the prevalence and clinical severity due to hMPV infections are slightly lower than those of RSV infections during the winter season 32 . Most of the hMPV-positive patients were children 2 years old without any underlying illnesses. hMPV was found significantly less frequently than RSV in children 2 months old. Of the 31 hMPV-posi-tive children 2 years old, only 4 (31 ) were 2 months old, whereas 43 (35 ) of the 122 hRSV-positive children 2 years old were also 2 months old. Others have found that the mean age of patients infected with hMPV was slightly lower than that compared to RSV 39 . Of the hMPV-posi-tive patients who were 5 years old, most had other diseases (e.g., cystic fibrosis, leukemia, and non-Hodgkin lymphoma) or had recently received bone marrow or kidney transplantation, indicating an association with immunosuppression. Two severely immunocompromised patients died due to progressive respiratory failure with hMPV as the sole pathogen...
Cantekin EL, Mandel EM, Bluestone CD, et al. Lack of efficacy of a decongestant-antihistamine combination of otitis media with effusion in children. N Engl J Med 1987 316 432. 96. Mandel EM, Rockette HE, Bluestone CD, et al. Efficacy of amoxicillin with and without decongestant antihistamine for otitis media with effusion in children. N Engl J Med 1987 316 432.
The second-generation drugs demonstrate their most reliable activity against gram-negative organisms, including Enterobacteriaceae. Haemophilus spp. and sexually transmitted disease (STD) agents, such as Neisseria gon-orrhoeae, Chlamydia trachomatis, Ureaplasma ure-alyticum, and Moraxella catarrhalis (formerly Neisseria catarrhalis causes otitis media) are also susceptible. The antipseudomonal activity of ciprofloxacin, norfloxacin, ofloxacin, and lomefloxacin is due to their piperazine moiety resistance to these agents, however, is becoming more prevalent.
Nal otitis,4 and postinflammatory acquired atresia.10 The pathophysiology of acquired soft tissue canal stenosis is unknown because there are currently no experimental animal models. It is believed that the canal passes through several stages before developing the soft tissue stenosis. In the first stage of development, some type of insult (e.g., infectious, traumatic) produces granulation tissue of the ear canal, tympanic membrane, or combination of the two sites. The granulation tissue becomes infected and the tissue proliferates. This stage is considered the active or immature phase. Eventually, a mature stage ensues whereby the granulation tissue forms a well-developed fibrous plug lined by squamous epithelium. The disease process ceases to continue when the atresia reaches the lateral end of the bony canal.15
Patients who require skin grafting are predisposed to infection and accumulation of debris. Skin grafts do not contain the normal apocrine and sebaceous glands, which normally cleanse and protect the ear canal from infection. In addition, patients with soft tissue stenosis may be prone to postoperative infection because of their previous history of chronic otitis externa. Therefore, patients undergoing canaloplasty for acquired stenosis should be examined at least every 6 months for the first 2 years after the ear canal is healed.
The external auditory canal has a unique property in that is has a self-cleaning mechanism to keep the canal free of debris. In the normal ear canal, epithelial migration moves material laterally from the medial end of the canal. If such a mechanism did not exist, the lumen of the canal would gradually become occluded by keratin debris, and the transmission of sound would be impaired. Exostosis and chronic or recurrent external otitis are two of several conditions that may impair the self-cleansing mechanism of the ear canal.
The anterior hypotympanotomy is indicated for the removal of cholesteatoma primarily involving the hypotympanum and sinus tympani, which develop as a complication of adhesive otitis media or an atelectatic drum.1 As a result of the cholesteatoma removal and chronic eustachian tube dysfunction, the middle ear frequently heals with fibrosis, despite the best efforts to preserve a middle ear air space. Following a hypotympanotomy, the middle ear
Otitis media in children and purulent exacerbations of chronic bronchitis respond well to TMP-SMX because of its activity against both susceptible Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) the latter organism is now a much less frequent pathogen in otitis because of the use of the Hib vaccine.
Mid-face hypoplasia is also characteristic of this syndrome, resulting in a depressed nasal bridge, mandibular prognathism and a class III malocclusion, along with maxillary arch constriction. This results in a V-shaped maxillary dental arch, dental crowding and thickening of the alveolar ridges. Consistent with these deformities, there is often a posterior cross-bite and an anterior open bite. There is often delay of dental eruption and frequent supernumerary teeth. The palate is short, highly arched and often has a median furrow. The incidence of cleft palate is also high, occurring in 30 of those afflicted 11 . This results in eustachian tube dysfunction and frequent otitis media. Congenital stapedial foot plate anomalies, along with frequent middle-ear infections, result in an increased risk of hearing deficits. The soft palate is longer and thicker than in normal subjects. The nasopharynx is also reduced in size, placing these patients at risk of airway obstruction.
The overall goals of treatment of chronic otitis media in order of priority are (1) to make the ear safe (2) to make the ear clean, dry, comfortable, and relatively free of maintenance and (3) to restore hearing. Otologists pursue these goals with medical and surgical treatment. Tympanoplasty is defined as a procedure to remove disease from the middle ear and to reconstruct with or without tympanic membrane grafting. Tympanic membrane grafting is a component of tympanoplasty when the disease involves the tympanic membrane for example, in cases of perforation or atelectasis. Tympanoplasty often includes reconstruction of the ossicular chain for hearing. Sometimes mastoidectomy is also performed either to remove disease or to provide exposure through a posterior tympanotomy approach.
Signs of connective tissue dysplasia such as hyperextensible finger joints, flat feet, inguinal and hiatus hernia, enlarged aortic root, and mitral valve prolapse can be detected in some cases. Foot abnormalities such as flat feet, a sandal gap, and long broad toes with recurrent paronychia of the first toes have also been reported. In a certain number of adult males, hypogonadal appearance with decreased body hair, gynaecomastia, and striae have been reported. Other occasional features associated with fragile X syndrome include torticollis, kyphoscoliosis, pectus excavatum, hyper-reflexia, and nystagmus. Epilepsy is reported in about 25 per cent of these individuals. In some cases an abnormal response of thyroid-stimulating hormone release in response to administration of thyrotropin-releasing hormone has been reported. Other medical conditions such as strabismus, otitis media, sinusitis, joint dislocation, orthopaedic problems, and apnoea may also affect subjects with fragile X...
Hodgkin lymphoma only rarely shows primary involvement of the nasopharynx 1274,1602,1756,1763,1922 . The patients usually present with nasal obstruction or otitis media, and frequently have low stage (stage I II) disease. Most of the tumours are of mixed cellu-larity and nodular sclerosis subtypes. The majority of cases involving the nasopharynx are associated with Epstein-Barr virus 1274,1756 . Please refer to 'Hodgkin lymphoma' in 'WHO classification of tumours Tumours of haematopoietic and lymphoid tissues' for details.
The goals of surgery in chronic otitis media are to produce a dry, safe ear to restore hearing and to preserve normal anatomic structures and contours when possible. Careful evaluation of the patient is necessary to determine the necessity and urgency of surgery. In patients with a unilateral dry, central perforation and minimal hearing loss, the main indication for surgery is to prevent further episodes of otorrhea, and surgery is elective. Patients with
Clues to the severity and overall morbidity resulting from infection may be obtained by asking whether hospitalization or intravenous antibiotics have been required to treat infections or whether oral antibiotics have generally been sufficient. The response to therapy should be evaluated carefully. Continued high fever or other symptoms suggesting a lack of response of culture-confirmed bacterial infection to antibiotics is more likely indicative of a significant immune deficiency than is the frequently seen pattern in which the fever and symptoms resolve promptly when antibiotic therapy is started (e.g., for otitis media) only to recur again shortly after the prescribed course of therapy is concluded. In many situations, the latter may actually represent a distinct new infection. This pattern is quite commonly seen in children in day care and in adults with frequent exposure to small children. Similarly, it is also important to distinguish inadequate or inappropriate therapy from...
Exostoses usually do not produce clinical symptoms. If the exostoses are large enough, patients may develop recurrent external otitis because the lesions may prevent the natural elimination of cerumen desquamated epithelium from the external canal. Conductive hearing loss is possible when the exo-stoses tamponades cerumen against the tympanic membrane or when the external canal is occluded by the exostoses. For similar reasons, osteomas and fibrous dysplasia of the external canal can also present with recurrent external otitis or conductive hearing loss.
Treating chronic otitis media in the pediatric population remains a major challenge. Recent advances in microbiologic evaluation and antimicrobial development provide accurate identification and effective eradication of most of the offending organisms. Nevertheless, recurrent ear infection and failure of medical management continue to require surgical intervention. In addition, cholesteatoma, congenital malformations, and cochlear implantation are some of the other indications for pediatric tympanomastoidectomy.
The goal of modern otologic surgery is to maintain or restore normal anatomy. This maxim, however, sometimes persuades surgeons performing tympa-nomastoid surgery to do anything to leave the canal wall intact, despite the fact that there are clear intraoperative reasons for removing it. First and foremost, in most patients having chronic otitis media with cholesteatoma, the mastoid cell system is usually significantly sclerotic, and therefore a properly done canal-wall-down (CWD) procedure results in a small, manageable mastoid bowl to maintain. Second, middle ear grafting is more than possible with a CWD procedure together with reconstruction of the middle ear and transformer mechanism when indicated and when feasible. Third, in ears with extensive cholesteatoma where disease itself and anatomic constraints indicate the need for a CWD procedure, residual disease usually results when the surgeon persists in attempting to remove disease with the wall intact. Additionally, in certain...
S. pneumoniae meningitis is associated with pneumonia, acute and chronic otitis media, alcoholism, diabetes mellitus, splenectomy, hypogammaglobulinaemia, head trauma, and CSF rhinorrhoea or otorrhoea resulting from dural leaks. Staphylococcal infection may complicate neurosurgical procedures and head trauma and also affects those with immunosuppression or endocarditis. Anaerobic organisms alone or as part of polymicrobial infections cause 1-2 of cases that complicate paranasal sinus and ear infections, skull fractures, neurosurgery, and immunosuppression.74 Tuberculosis remains a significant cause of meningitis in the United Kingdom and United States.75 Many other organisms may also cause meningitis, commonly of a more chronic nature, but which may rapidly develop into an acute emergency in those with compromised immune systems.
Should be compared with the incidence for that age group in the community, but the exposure history also needs to be taken into consideration. For example, a 40-year-old who lives alone and sits in front of a computer screen all day would be expected to have a different degree of exposure to infectious agents than a kindergarten teacher, day care worker, or pediatric office nurse. College students moving from home to the dormitory for the first time and military recruits often have sharp increases in infectious disease exposure. Similarly, a first-born baby at home often has a very different degree of exposure than a similar-aged child in day care or with many siblings. Generally, the frequency of respiratory infection among school-aged children in the United States is about six to eight upper respiratory infections per year, but as many as one a month while school is in session is not unusual. About half of these are primary bacterial infections or secondary bacterial sequelae, such...
Use of pacifiers beyond the age of two years is associated with a substantial increase in otitis media. Viral infections and other conditions that cause inflammation of the nasal mucosa play a role in some cases. Nasal allergies and exposure to air pollution and cigarette smoke are examples of nasal irritants. Administration of influenza vaccine to infants in day care facilities substantially decreases the incidence of otitis media during the flu season. Ampicillin or sulfasoxazole given continuously over the winter and spring are useful preventives in people who have three or more bouts of otitis media within a six-month period. Surgical removal of enlarged adenoids improves drainage from the eustachian tubes and can be helpful in preventing recurrences in certain patients. In those with chronically malfunctioning eustachian tubes, plastic ventilation tubes are sometimes installed in the eardrums so that pressure can equalize on both sides of the drum (see figure 23.7). In the United...
The disease processes in the pediatric patients are different from those in adults. Spontaneous improvement of chronic otitis media in an adult is uncommon, whereas it is the norm for young children to improve with age. It is frequently feasible to ''buy time'' with medical management and CWU procedures to wait for a child to become immunologically competent and their eustachian tubes to function better.1
Acute sinusitis is associated with the same bacteria as otitis media. Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis are the most commonly encountered pathogens. Thirty five percent of H influenzae and 75 of M catarrhalis strains produce beta-lactamases, making them resistant to penicillin antibiotics.
Unilateral serous otitis media with a firm ipsilateral cervical lymph node suggests NPC. Hypoesthesia over V2 or abnormalities of extraocular muscles suggests invasion of inferior orbital fissure, seen with advanced JNA. Blood pouring into the posterior oropharynx is suggestive of posterior bleeding. Excoriation of the nares on one side with foul odor suggests a foreign body. Evaluate for signs of atopy (eg, allergic shiners, Denny crease, mouth breathing).
Speech discrimination should be adequate. With a pure conductive loss, discrimination will improve to 100 if the stimulus can be made loud enough. patients should be in reasonable health, although advanced age is not a contraindication to surgery. Stapedectomy in very young children (younger than 5 years of age) may be contraindicated until it is demonstrated that they are not prone to otitis media.
Occasionally, a case with no apparent fixation will be encountered. When this happens, it is incumbent upon the surgeon to determine if there are any other causes of a conductive hearing loss. Malleus and incus fixation, or the presence of a serous otitis, are three obvious conditions to exclude.
Gomez is a 7-year-old Hispanic American boy whose mother and father are obese. He is in the clinic because of an ear infection. After the examination and explanation of his condition to his mother, the physician tells his mother that Gomez's BMI over the past 3 years has continued to go higher, and now is 22. Gomez is medically obese. The physician expresses concern for both the patient and his parents regarding the health impact of obesity, and the possible long-term complications from the disease. For the first time Gomez's mother expresses concern for the health of everyone in her family, especially Gomez.
The pharmacokinetics of ampicillin and amoxicillin are similar (Table 45.1). Both have good oral bioavailability ampicillin is also bioavailable after intramuscular injection. Concomitant ingestion of food decreases the bioavailability of ampicillin but not amoxicillin. Consequently, oral doses of ampicillin should be given on an empty stomach. Ampicillin achieves therapeutic concentrations in the cerebrospinal fluid only during inflammation. Therefore, ampicillin is effective treatment for meningitis caused by Listeria monocytogenes. Amoxicillin does not reach adequate concentrations in the central nervous system and is not appropriate for meningitis therapy. Other indications for ampicillin include serious infections like enterococcal endocarditis and pneumonia caused by p-lactamase-negative H. influenzae. Amoxicillin oral therapy is appropriate for clinically acute nonserious bacterial infections like otitis media and sinusitis. Amoxicillin also has use in mul-tidrug regimens for...
Wullstein1 and Zollner2 first introduced the term tympanoplasty in 1951 to describe surgical reconstruction of the middle ear hearing mechanism that had been impaired or destroyed by disease. Successful tympanoplasty requires a mobile tympanic membrane or graft and a secure sound-conducting mechanism between this mobile membrane and the inner ear fluids. since the introduction of the concept of hearing restoration in surgery for chronic otitis media, numerous materials have been used to recreate the sound-conducting mechanism. Aeration of a mucosal-lined middle ear is essential for sound conduction. If this can be accomplished, then the most biocompatible implant material with appropriate design and weight must be used for the optimal hearing restoration.
Patients with Stickler syndrome may suffer hearing difficulties for two reasons. Firstly, the association with cleft and high arched palate leads to an increased incidence of serous otitis media causing a conductive hearing deficit. In some patients, a mild conductive element persists, despite treatment, because of ossicle defects or tympanic membrane abnormalities. Secondly, there can be an associated high tone sensorineural hearing loss that may be so subtle that many patients are unaware of the deficit. Baseline audiometry therefore has an important diagnostic role to reveal subtle asymptomatic high tone loss.
Bacteria reach the brain parenchyma via the bloodstream, by direct extension from an adjacent focus of infection or by implantation through wounds as a result of trauma or neurosurgery. In about 15 of cases the source of infection cannot be identified. Haematogenous spread has been implicated in approximately 25 of cases. The most common primary foci are endocarditis and pulmonary infections. Brain abscesses resulting from haematogenous spread are often multifocal and more frequently involve middle cerebral artery territory. Congenital cyanotic heart disease and pulmonary suppuration (for example, bronchiectasis or lung abscess) are associated with an increased frequency of brain abscess. Sinusitis, otitis, and dental abscess are the most commonly implicated foci of infection that result in direct spread of infection to the brain parenchyma and subdural space. With improved treatment of these conditions the incidence of suppurative complications has declined. Spread of infection...
Which are usually generalised but may be focal, nausea and vomiting, raised intracranial pressure even to the point of coning, and neck stiffness to suggest meningitis. There may be pyrexia and symptoms relating to the source of infection, such as otitis or sinusitis. Cerebral abscesses, therefore, must be included in the differential diagnosis of patients who present acutely with a wide range of neurological features. Faced with a patient in whom intracranial abscess is a possible diagnosis, the priority is to confirm the diagnosis and identify the source of infection and the responsible organism or organisms. Once vital functions have been stabilised, a full examination should be made for a focus of infection, such as otitis media or pelvic sepsis, and if found, cultures should be made and steps taken to eradicate the source. Blood cultures should be set up. Contrast-enhanced CT or MRI should be done as soon as possible. In addition to visualising the intracranial contents, note...
Antibiotics are used to treat a wide range of bacterial infections, ranging from otitis media and urinary tract infections to serious lower respiratory tract infections and bacteremia. The primary goal of treatment with an antibiotic is selection of a drug and dosing regimen that is active against the infecting micro-organism at the site of action. Thus, in addition to being active against the micro-organism, the drug and dosing regimen must provide adequate amounts of active drug for an adequate amount of time at the site of infection. There are a number of in vitro methods that allow one to determine concentrations of drug that should be effective. These sensitivity tests indicate the minimum inhibitory concentrations (MIC) and minimum bactericidal concentration (MBC) for drug-organism pairs. Patient immune defense system is also an important factor. If an antibiotic inhibits the growth of an organism, but does not kill it, the patient's immune
The Rion is manufactured by Rion Company in Japan. It is approved for implantation in Japan and is not available in the United States. Indications for the device include patients with conductive deafness and mild to moderate mixed hearing losses due to chronic otitis media, tympanosclerosis, or total loss of the sound conductive mechanism. The device's usage has been limited to patients with bilateral deafness. It is implanted in the ear with greater hearing loss (Fig. 29-6). The audiologic criteria for selecting candidates are (1) an average bone-conduction hearing threshold for speech frequencies not exceeding 50 dB (2) speech discrimination score
FIGURE 7-8 (A,B) Cholesteatoma developing in the hypotympanum and sinus tympani from adhesive otitis media may be removed using a transcanal hypotympanotomy. For the hypotympanotomy, the tympanomeatal flap is extended inferior and anterior. In a right ear the flap is made circumferentially from the 4 o'clock position to the 12 o'clock position. This allows bone removal from floor of the canal and posterior canal wall. FIGURE 7-8 (A,B) Cholesteatoma developing in the hypotympanum and sinus tympani from adhesive otitis media may be removed using a transcanal hypotympanotomy. For the hypotympanotomy, the tympanomeatal flap is extended inferior and anterior. In a right ear the flap is made circumferentially from the 4 o'clock position to the 12 o'clock position. This allows bone removal from floor of the canal and posterior canal wall.
Plaques of tympanosclerosis are patches of hyali-nized (calcified) scar that replace portions of the fibrous layers of the tympanic membrane following periods of inflammation from chronic otitis media. They probably interfere with healing by blocking vascularization of the graft. Tympanosclerosis can be removed from the medial surface of the tympanic membrane with an angled pick. It is also useful to score the medial surface of the tympanic membrane remnant to stimulate the respiratory epithelium to incorporate the graft.
Unfortunately, many cases are complicated by secondary infections caused by bacterial pathogens, mainly Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, and Haemophilus influenzae. These pathogens readily invade the body because measles damages the normal body defenses. Secondary infections most commonly cause earaches and pneumonia.
Following the introduction of tympanoplasty in the early 1950s by Wullstein16 and Zollner,17 all surgeries used an overlay graft. Wullstein's article, ''Tympanoplasty as an Operation to Improve Hearing in Chronic Otitis Media and Its Results,'' set the stage for this operation to improve hearing and protect the middle ear from the outside environment. At that time, this operation consisted of full-thickness and split-thickness skin grafts. By the end of the decade, graft eczema, desquamation, and a poor long-term take rate had prompted many surgeons to seed alternate grafting materials and techniques.18 In 1956 Sooy19 had reported the use of canal skin pedicle graft to close marginal perforations. In 1958 House and Plester, working independently, began using canal skin as a free overlay graft.20,21 In 1959 Shea, Austin, and Tabb, working independently, employed vein as an undersurface graft to repair tympanic membrane perforations.22 24 The vein graft tended to atrophy over a few...
The IBM is indicated for patients with chronic otitis media and mastoiditis, intractable cholestea-toma, cholesterol granuloma, or granulation tissue in the mastoid, middle ear, or attic, either as a first operation or, if there has been prior surgery, to revise where the earlier procedure has left an intact posterior canal wall or bridge. Because most patients with chronic otitis media and mastoiditis do have small, sclerotic, hypocellular mastoids, they are ideal candidates for the IBM.11 In the rare patient with a well-pneumatized mastoid, excellent results can be obtained by adding some techniques from combined-approach tympanoplasty to the intact-canal-wall tympanomastoidectomy. For the most difficult cases of severely contracted, sclerotic mastoids, however, an intact-canal-wall tympanoplasty may be unnecessarily hazardous even in the hands of experts and it does not offer much alleviation of open-cavity postoperative problems. The IBM techniques result in a very small cavity.
Because the temporal bones used in dissecting laboratories to teach techniques for intact-wall mas-toidectomy often come from patients who have died of nonotologic causes and may have well-pneuma-tized mastoids, students and practicing otolaryngol-ogists may become comfortable performing these procedures on well-pneumatized temporal bones, which are not to be seen in patients with chronic otitis media. The tight, sclerotic, hypocellular mas-toids with cholesteatoma in varying and difficult-to-reach places found in live patients make the procedure difficult in actual practice, and many young otolaryngologists then become frustrated with the approach, which seems to work less well in live bones than it did as they learned it as residents. They may abandon otologic surgery. The IBM procedure allows both otologic experts and other well-trained otolaryngologists to eradicate disease competently, with efficiency, accuracy, and safety. Exposure of a tight sclerotic mastoid is much easier,...
Most patients with chronic otitis media have small external ear canals that bulge into the anterior and often also the posterior canal. Generous canaloplasty, tailored to each patient, is usually required. Using self-retaining retractors, skin of the anterior canal is elevated in a laterally based flap, and skin of the posterior canal in a medially based flap. A highspeed cutting drill under suction irrigation is used to enlarge the circumference of the posterior canal, removing the spine of Henle and all overhangs to achieve a straight, direct, unobstructed approach to the tympanic annulus (Fig. 10-4).
Eustachian tube surgery is still in its infancy, but with experience there may be a significant role for laser treatment of refractory otitis media and tubal dysfunction in air travel and scuba diving. Surgery of the temporal bone and middle ear is expected to increasingly rely on minimally invasive techniques. It is anticipated that there will be improvements in patient outcomes, reductions in morbidity, and enhancements in our ability to maintain or restore function in the middle ear.
Lateral graft tympanoplasty provides a reliable technique for reconstruction of the middle ear and TM in chronic otitis media. Appropriate patient selection and counseling mandates a thorough understanding of the disease processes of chronic otitis media and detailed preoperative evaluation. Lateral graft techniques provide maximal exposure of the ear canal and middle ear space and have a very high graft success rate. Most of the potential complications can be avoided by strict adherence to proper surgical technique. Once mastered, it provides the otologic surgeon with a technique that can be reliably used to treat nearly all cases of chronic otitis media and restore middle ear function.
Complications using the self-treatment technique with the MicroWick were infrequent. Two patients had a permanent tympanic membrane perforation after the MicroWick and dexamethasone infusion that was repaired using an adipose tissue graft as an office procedure. Two patients developed acute otitis media, which responded to local treatment with antibiotic eardrops. Two patients had the MicroWick and tube spontaneously extrude from the eardrum during treatment. Two patients had severe unsteadiness after the MicroWick and gentamicin treatment that did not quickly respond to vestibular rehabilitation therapy.
Most affected children develop severe or profound mental retardation and lack speech. Typical facial features associated with this syndrome consist of a long face and prominent jaw, a wide mouth with widely spaced teeth, thin upper lip, mid-facial hypoplasia, deep-set blue eyes, blonde hair, flat occiput, and microcephaly. Other characteristic clinical features include ataxic movements, epilepsy (about 86 per cent) and or an abnormal EEG, inappropriate bouts of laughter, tongue-thrusting movement, hand-flapping, and mouthing behaviour. Upper respiratory tract infection and middle-ear infection are common after infancy and obesity has been reported in female adults.(38)