Otitis Media

1. Otitis Media Dr John Curotta Head of ENT Surgery The Children’s 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 -> Acute OM = AOM 2. Mucous -> Effusion = OME

4. Ear drum with hole ( >6 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 SMELL……Sneakers 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 (<6mo) 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: <1 yr…23% 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 / Behavioural…test overall / better ear hearing Usual Tymps: ‘Reliable’

22. Hearing Testing Over 4 yrs PTA + Tymps generally reliable

23. AOM = pus in middle ear Body’s 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 > 12 weeks, ? Then call it : OME or ‘Glue ear’

25. Fluid in middle ear AOM POM OME 0 weeks >12 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: Shepard………………6 mo Medium: Reuter Bobbin………12 mo Large: Sheehy Collar Button.18 mo Larger: T – Tubes……………24 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 > 20% area TM (large is bad) in between…….(nuisance) small < 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 It’s the GERMS in the water

39. Looking after grommets Clean water…OK shower, beach, well-maintained pool (Chlorine : High end + pH : Low end of range) Some Remote WA - No School…No Pool

40. Looking after grommets AVOID Bath water Spa’s 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 virus…dries 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