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PRESENTATIONS OF MIDDLE EAR DISEASE. Elizabeth Rose Royal Victorian Eye and Ear Hospital Royal Children’s Hospital. A “look and learn” lecture. Middle-ear conditions Management of otitis media Differential diagnosis of ear pain Clinical cases An invitation! (Or Two!).

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PRESENTATIONS OF MIDDLE EAR DISEASE

Elizabeth Rose

Royal Victorian Eye and Ear Hospital

Royal Children’s Hospital


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A “look and learn” lecture

  • Middle-ear conditions

  • Management of otitis media

  • Differential diagnosis of ear pain

  • Clinical cases

  • An invitation! (Or Two!)


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OTITIS MEDIAA SPECTRUM OF DISEASE

  • acute otitis media

  • chronic otitis media with effusion

  • atelectasis of the tympanic membrane

  • chronic adhesive otitis media

  • chronic suppurative otitis media

    • tubotympanic (“safe”)

    • atticoantral (“unsafe”)

      and may be acontinuumof disease


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ACUTE OTITIS MEDIA(AOM)

  • the presence of a middle-ear effusion

  • signs and symptoms of infection

    • fever, irritability, pain, otorrhoea


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Management of AOM

  • Pain relief

    Decongestants (oral/topical) and antihistamines

    • do not make the eustachian tube function better

    • do relieve the symptoms of a blocked nose


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Antibiotic therapy

  • if severe symptoms

    - pain

    - perforation

  • ≤ 2years of age

  • immune deficiency

  • cochlear implant

  • follow-up not possible


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Antibiotic therapy

  • Recommended treatment is:

    amoxicillin 50mg/kg/day in 3 doses

    • Can give up to 100mg/kg/day

    • Continue for 5 days

  • If no improvement in 2 days change to amoxicillin/clavulanate


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Penicillin allergy

  • trimethoprim-sulfamethoxazole

  • clindamycin

  • ceftriaxone IM, but will often need continuing oral medication


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Antibiotic therapy

  • older children who can be accurate about their symptoms should be treated symptomatically

  • if no improvement after 2 days consider treatment with antibiotics


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CHRONIC OTITIS MEDIA WITH EFFUSION(COME)

  • the presence of a middle ear effusion

  • asymptomatic apart from some hearing loss


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CHRONIC SUPPURATIVE OTITIS MEDIA(CSOM)“deafness and discharge”

  • persistent disease

  • insidious onset

  • severe destruction

  • irreversible sequelae


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1. tubotympanic disease(“safe”)

central perforation

2. atticoantral disease(“unsafe”)

cholesteatoma

the presence of keratinising squamous epithelium in the middle ear


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MANAGEMENT OF CHRONICOTITIS MEDIA WITH EFFUSION(and also retraction/atelectasis of the tympanic membrane)


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AKA

  • grommets

  • tubes

  • pressure equalisation tubes

  • middle ear ventilation tubes


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COME

Who should have middle ear ventilation tubes?


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1. COME for 4 months at least, with hearing loss

2. COME in a child ‘at risk’ regardless of the hearing

3. COME and structural damage to the tympanic membrane


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1. Hearing loss

  • median hearing loss is mild but there is a wide range

  • no data on the criteria for what is a significant hearing loss


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50% of children with persistent OME have hearing thresholds at

20 dB


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20% of children with persistent OME have hearing thresholds at

>35 dB


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2. An ‘at risk’ child has an increased risk of developmental difficulties due to:

physical

sensory

cognitive

behavioural

factors not related to the OME


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‘At risk’

  • Suspected or diagnosed speech and language delay or disorder

  • Autism-spectrum disorder and other pervasive developmental disorders

  • Blindness or uncorrectable visual impairment


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Management of the ‘at risk’ child may include:

  • speech and language therapy along with management of the OME

  • hearing aids for hearing loss independent of the OME


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Children with persistent OME who:

  • are not ‘at risk’

  • do not have significant hearing loss

  • donothave structural abnormalities of the eardrum or middle ear

    should be examined every three months



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PAIN

(Otalgia)


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DIFFERENTIAL DIAGNOSIS OF EAR PAIN

A.External auditory canal

  • trauma ( e.g. from cotton bud abuse)

  • auricular haematoma

  • foreign body

  • otitis externa

  • external auditory canal tumour


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DIFFERENTIAL DIAGNOSIS OF EAR PAIN

B. Middle ear

  • acute otitis media

  • bullous myringitis

  • chronic suppurative otitis media

  • middle ear tumour


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DIFFERENTIAL DIAGNOSIS OF EAR PAIN

C. Referred pain

  • oropharynx (IXth nerve)

    • tonsillitis/post-tonsillectomy

    • carcinoma, including posterior tongue

  • laryngopharynx(Xth nerve)

    • pyriform fossa

  • upper molar teeth, TMJ, parotid gland(Vc)

    • impacted wisdom teeth

    • changes to bite from new dentures

  • cervical spine(C2, C3)

    • pain is often worse at night


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DISCHARGE

(Otorrhoea)








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YOUARE INVITED!

1. ENT clinics at RVEEH


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All clinical years students

Every week day afternoon

(and some mornings)


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ContactRehana De Jong

9929 8666

RehanaDeJong@eyeandear.org.au


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YOUARE INVITED!

2. Hedley Summons Otolaryngology Prize



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Take-home message 1remember referred otalgia


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Take-home message 2more is missed in medicine by not looking than by not knowing


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ENT clinic Fifth Floor Outpatients

9929 8666

RehanaDeJong@eyeandear.org.au