ANATOMY AND PHYSIOLOGY OF

THE EAR

NILSON L. GELBOLINGO, M.D.

ENT-ORL-HNS

1
Main Components of the Hearing
Mechanism
Outer Ear
Middle Ear
Inner Ear
Central Auditory
Nervous System

2
Outer ear

3
 Outer Ear
Auricle (Pinna)
Collects sound
Helps in sound
localization
Most efficient in
directing high
frequency sounds
to the eardrum

4
Outer Ear
External auditory canal
Approximately 1¼ inch in
length

Lined with cerumen glands

Outer 1/3rd cartilage; inner
2/3rds mastoid bone
Increases sound pressure at
the tympanic membrane by as
much as 5-6 dB (due to
acoustic resonance)

5
Middle Ear

6
 Middle Ear
Small, air-filled cavity
Lies between the tympanic
membrane laterally and the
promontory medially
Transmits sound from OE to
the IE
Contains: Tympanic
membrane, 3 ossicles,
eustachian tube, 2 muscles

7
Middle Ear
Tympanic membrane
Thin membrane
Forms boundary
between outer and
middle ear
Vibrates in response
to sound
Changes acoustical
energy into
mechanical energy

8
 Middle Ear
A: Malleus
B: Incus
C: Stapes
Ossicles are smallest
bones in the body
Act as a lever system
Footplate of stapes
enters oval window
of the cochlea

9
 Middle Ear
Stapedius muscle
Connects the stapes to the middle ear wall
Contracts in response to loud sounds; known as the
Acoustic Reflex

10
 Middle Ear
Tensor tympani muscle
Runs along the roof of the ET
Attaches to the handle of the malleus

11
Middle Ear
Eustachian Tube
Lined with mucous
membrane; connects
middle ear to back of the
throat (nasopharynx)
Equalizes air pressure
Normally closed except
during yawning or
swallowing
Not a part of the hearing
process

12
 Inner Ear
Also called as labyrinth
2 main divisions: bony and membranous
3 regions: SSC, Vestibule, Cochlea

13
 Inner Ear

Cochlea - Snail-shaped
organ with a series of fluid-
filled tunnels; converts
mechanical energy into
electrical energy

14
Oval Window located at the footplate
of the stapes; when the footplate
vibrates, the cochlear fluid is set into
motion
Round Window functions as the
pressure relief port for the fluid set into
motion initially by the movement of the
stapes in the oval window

15
 Organ of Corti

The end organ of

hearing; contains
stereocilia and hair
cells.

16
 Hair Cells
Frequency-specific
High pitch sounds = base of cochlea
Low pitch sounds = apex of cochlea
When the basilar membrane moves, a shearing
action between the tectorial membrane and the
organ of Corti causes hair cells to bend

17
Vestibular System
Consists of three semi-
circular canals
Shares fluid with the
cochlea
Controls balance
No part in hearing process

18
 Central Auditory System

signals from cochlea to brain

Fibers of the auditory nerve are present in the
hair cells of the inner ear
Auditory Cortex: Temporal lobe of the brain
where sound is perceived and analyzed

19
20
How Sound Travels Through The Ear...

Acoustic energy, in the form of sound waves, is channeled into

the ear canal by the pinna. Sound waves strike the tympanic
membrane, causing it to vibrate like a drum, and changing it
into mechanical energy. The malleus, which is attached to the
tympanic membrane, starts the ossicles into motion. (The
middle ear components mechanically amplify sound). The
stapes moves in and out of the oval window of the cochlea
creating a fluid motion. The fluid movement within the
cochlea causes membranes in the Organ of Corti to shear
against the hair cells. This creates an electrical signal which
is sent via the Auditory Nerve to the brain, where sound is
interpreted!
21
QUESTIONS?

22
 Audiology

NILSON L. GELBOLINGO, M.D.

ENT ORL HNS
 Definition
The science which involves evaluation of hearing and
rehabilitation of individuals with hearing impairment
Goals:
To locate the cause and type and degree of hearing loss
Assess effect of hearing loss on speech, understanding, learning
Social interaction and day to day activities
Differentiate cochlear from retrocochlear lesion
 Definition of Terms
Sound
Change in pressure (particle displacement) within an elastic medium
Intensity
Loudness
Unit of measure: decibel
Frequency
Number of cycles (complete oscillations) of a vibrating body per unit of

Unit of measure: hertz

Human ear: 20-20,000 Hz
 Definition of Terms
Pure Tone
Single-frequency sound; rarely occur in nature
Complex Sound
More than one frequency
Noise
Aperiodic complex sound
Resonant frequency
Frequency at which mass vibrates with least amount of external force
EAC: 3000 Hz
Tympanic membrane: 800-1600 Hz
Middle ear: 800 Hz
Ossicular chain: 500-2000 Hz
 Types of hearing loss
Conductive
Disorders of conductive mechanisms (of the external ear and middle
ear)
Sensorineural
Relates to cochlear nerve and central auditory pathways
Mixed Hearing loss
Combination of the two
 Patients to be tested
People complaining of hearing loss
Possibility of significant hearing loss
People about to undergo ear surgery
Those using ototoxic drugs
People working in noisy environments
High risk children
Hereditary or familial hearing loss
Craniofacial deformities
Low birth weight, prematurity
 Tuning Fork Test
A simple test. May be both qualitative and quantitative
Using the tuning fork:
Tuning forks come in different frequencies: 256, 512, 1024 Hz
Made up of two (2) tines and one (1) stem
Best to use 512 or 1024 Hz
These are frequencies involved in normal speech
Low frequencies are more vibratory than sound producing
Intensity will depend on how and what surface the fork is struck on
Gently strike on the palm, elbow, or knee
Never against a solid object to avoid overtones
 Types of Tuning Fork Tests
Weber Test
Vibrating tuning fork is placed at any midline structure
Vertex
Nasal bone
Incisors
The patient attempts to localize which side the sound is heard

Normal or equal degree of hearing loss

Rinne Test
Comparison between air conduction and bone conduction of both
ears
Place the struck tuning fork over the mastoid first, then later hold the
fork next to the ear and ask patients which is louder
The tuning fork is first applied to the mastoid and one waits until it is
no longer heard, then the tines are placed next to the ear
 Pure Tone Audiometry
Usually done in a sound proof room
Audiometer produces single tones in different frequencies
 Pure Tone Audiometry
Objective: To measure the hearing THRESHOLD
Lowest intensity level in decibels (dB) at which a sound can e heard at a
certain test frequency
Method:
Always test the better ear first
Air conduction tested using earphones; bone conduction uses special
conductor attached over the mastoid bone
Frequencies (Hz) used: 250, 500, 1000, 2000, 4000, 8000
A tone at certain frequency is given at a certain intensity. This is increased
by increments of 10dB until patient responds. Upon response, the tone is
decreased by 5dB to find the threshold.
 Pure Tone Audiometry
Recording the Data
AUDIOGRAM
frequencies
Color code used: red is for right; blue is for left
Air conduction units or symbols are connected by solid lines while
bone conduction units are connected by broken lines
 Interpreting the data
Normal threshold:
Both AC and BC occur
in normal range with
no more than 10dB gap
between them
Conductive hearing loss
AC dips vs. BC, latter
remaining in the normal
range
Sensorineural hearing loss
Both AC and BC drop
below normal with an
air-bone gap less than
10dB
Mixed Hearing Loss
Both AC and BC drop
below normal with air-
bone gap greater than
10dB
 Degree of hearing loss
According to WHO:
0-25 dB Normal Hearing Threshold
26-40 Mild Hearing Loss
41-55 Moderate Hearing Loss
56-70 Moderately Severe Hearing Loss
71-90 Severe Hearing Loss
>90 dB Profound Hearing loss
 Tympanometry
is an examination used to test the condition of the middle ear
and mobility of the eardrum (tympanic membrane) and the
conduction bones by creating variations of air pressure in the
ear canal.

Tympanometry is an objective test of middle-ear function.

Type A: normal
Type As: otosclerosis,
scarred TM, malleus
fixation
Type Ad: flaccid TM,
disarticulation
Type B: fluid in the ME,
perforated TM, ME atelectasis
Type C: Eustachian tube dysfunction
THANK YOU!!!
 Inner Ear Diseases

NILSON L. GELBOLINGO, MD, FPSOHNS

 Diseases of the inner ear
Diseases of the inner ear presents with signs and symptoms
related
to the Cochlea, Vestibular symptoms, or Both.
Generalizations:
Sudden onset usually present with vestibular symptoms
Gradual onset usually present with less or no vertigo
Etiologic agents may affect
Either the cochlear or vestibular system
Some affect one rather than both ears
 Cochlear Diseases based on onset, laterality and vestibular
symptoms ONSET LATERALITY VESTIBULAR
SYMPTOMS
Presbycusis Gradual Bilateral (-)
Infection Sudden Uni or bilateral (+)
Noise-induced Gradual Uni or bilateral (-)
Ototoxicity Sudden Bilateral (+/-)
Trauma Sudden Unilateral (+)
Barotrauma Sudden Unilateral (+)
Systemic Disease Gradual Bilateral (-)

disease Fluctuant Unilateral (+)

Bilateral 30%
 Vestibular disorders based on dizziness, hearing and vestibular status
DIZZINESS HEARING LOSS VESTIBULAR STATUS
Episodic Fluctuant Decreased
Vestibular neuronitis Acute, aggravated by head No loss Decreased
movement

Acute labyrinthitis Acute Severe sensorineural Decreased

hearing loss

Benign Positional Recurrent related to No loss Normal

position and aggravated by
head movement
Acoustic Neuroma Progressive Progressive sensorineural Decreased
hearing loss

Vertebrobasilar Acute and aggravated by Compatible with Normal

insufficiency head movement presbyacousis
 Cochlear diseases

A. Acoustic trauma
Temporary or permanent loss of hearing related to a
brief exposure to a
sudden loud sound (>90dB) such as an explosion
Usually recovers within 2 weeks if temporary
 Cochlear diseases
B. Noise induced hearing loss
Results from exposure to high level of sound for extended period
Requires noise level of 90dB continuously for 5 hours a day for 2
years
Treatment:
Prevention is the most important
Hearing aid may be used
Medical management
 Cochlear diseases
Permissible Noise Exposure
Duration/day (hrs) Sound level (dBA)
8 90
6 92
4 95
3 97
2 100
1.5 102
1 105
0.5 110
<0.25 115
 Cochlear diseases
C. Ototoxic drugs
Aminoglycosides
- damage hair cells via interference with protein synthesis
A. Vestibulotoxic drugs
Streptomycin
Gentamycin

B. Cochleotoxic drugs
Dihydrostreptomycin
Kanamycin
Neomycin
Tobramycin
vancomycin
Ototoxic drugs (continuation)
Diuretics
- affects enzyme synthesis of stria vascularis
Salicylates
Antiprotozoals
Examples: quinine, chloroquine
Cisplatin
Other drugs
 Cochlear diseases
D. Sensorineural hearing loss associated with systemic disorders
Congenital syphilis
Diabetes
Collagen diseases
Hypothyroidism
Leukemia

Hand-Schuller-Christian disease
Sarcoidosis
 Cochlear diseases
E. Inner ear/Barotrauma
Inability of the Eustachian tube to open up and equalize
Occurs with atmospheric pressure increase
Sudden changes in pressure cause rupture of the tympanic
membrane

F. Ischemia
Due to spasm, thrombosis or hemorrhage of the internal auditory
artery
 Vestibular disorders
Definition:
Vertigo
Dizziness a more general term and includes light headedness

Patient evaluation
History
Evaluation of symptoms
Common complaints (vertigo, nausea and vomiting)
 Vestibular disorders
Investigation of vestibular
functions:
Clinical examination
Test of stance and gait

Search for spontaneous

nystagmus
Positional testing Dix-Hallpike
test
 Vestibular disorders
Test of vestibular function

Caloric test Electronystagmography Rotational tests

 Vestibular disorders
Differentiating Central and Peripheral cause of Vertigo
Peripheral Central

Duration Intermittent Persistent

Hours to days Weeks to months
Signs/symptoms negative present

fixation Suppresses nystagmus No effect

Spontaneous nystagmus fatigable Non-fatigable

Induced nystagmus Fatigable Non-fatigable

Duration < 1 min Duration < 1 min
Follow COWS
 Vertigo
Peripheral causes of vertigo with Hearing Loss

Etiology not known

Due to increased endolymph
Rare in childhood
Triad: intermittent SNHL, tinnitus, vertigo
Severe vertigo in later stages
Patient is normal in between attacks
Treatment
Medical
Surgical
 Vertigo
Peripheral causes of vertigo without Hearing Loss
1. Vestibular neuritis
Vertigo lasting for days
May or may not have history of viral infection
Clinical exams: normal PTA but decreased calorics
Treatment:
- steroids
- antivertigo agents
- antidepressants
 Vertigo
2. Benign Positional Vertigo
Brief (<1min) of severe vertigo
pathogenesis otoconia of utricle is loose and moves with changes in
position (cupolithiasis)
Etiology closed head injury, degenerative changes, stapes surgery
Provoked by positional tests
Treatment:
-
- antivertigo agents
3. Acoustic Neuroma
Vertigo
Schwannoma of the eight nerve
SNHL is progressive and persistent
Vertigo less prominent
Unilateral
Tests:
PTA
CT scan (>1.5cm in size)
MRI (<1cm in size)
ABR
Treatment:
Surgical excision
 Vertigo
Central causes of vertigo
1. Tumors
2. Multiple sclerosis
3. Epilepsy
4. Vascular problems:
Posterior inferior cerebellar artery occlusion
Basilar migraine
Vertebrobasilar insufficiency
thank you!
EXTERNAL EAR DISEASES

NILSON L. GELBOLINGO, M.D.

ENT ORL - HNS
 Preauricular sinus
Seen as a small pit along the
anterior margin of ascending
limb of helix
The tract usually blends with
the perichondrium of auricle
Sinus tract is usually superior
and lateral to facial nerve and
parotid gland
Subcutaneous cyst formation
in the area is common

2
 Preauricular sinus (synonyms)

Preauricular pit
Preauricular sinus
Preauricular tract
Helical fistula
Preauricular cyst
 Preauricular sinus theories

Embryological fusion: Incomplete fusion of

Hillocks
Ectodermal infolding: Isolated ectodermal
infolding
Incomplete closure of dorsal part of first
pharyngeal groove: (accepted)
 Pinna (Embryology)
Begins during the 6th week of gestation
Begins from 6 hillocks (Hillocks of His)
3 hillocks arise from caudal border of I
arch
Other 3 arise from the cephalic border
of II arch
6
 Management
Complete removal with the tract
Leaving behind remanant leads to recurrence

7
 Perichondritis
-Inflammation of the
perichondrium

Etiology:
* Ear Piercing
* Trauma
* Surgery
Causative Organisms:
1. Pseudomonas
2. Staphylococcus
Treatment
* Anti-Biotics
* I & D for Abscess formation
 Cerumen
Product of the sebaceous and ceruminous
glands of the external ear
Types: wet or dry
Functions:
1. lubrication
2. prevents dryness
3. antibacterial
4. protection
 Cerumen

Symptoms
1. ear fullness
2. ear pain or otalgia
3. hearing loss

Treatment
1. removal by direct visualization
2. irrigation
 Otitis externa
Types:
1. acute circumscribed otitis externa/
furunculosis
2. diffuse otitis externa
3. malignant otitis externa
Predisposing factors:
1. change in pH of canal skin
2. environmental changes
3. mild trauma
 Otitis externa
Principles in management:
1. careful cleaning of the canal by suction or cotton
wipes
2. evaluation of discharge, canal wall edema and TM,
if possible
3. selection of appropriate medications
 1. Acute circumscribed otitis externa

-Furunculosis
Cause: infection of sebaceous follicle of EAC usually
by Staph. aureus
Signs/ symptoms:
- pain
- tenderness on manipulation
- decreased hearing
- purulent ear discharge
- circumscribed swelling
 Acute circumscribed otitis externa

Otitis externa Otitis media

pain Very severe Not as severe
Tenderness on present absent
manipulation

fever Usually absent Usually present

Hx of URTI (-) (+)
Hx of ear (+) (-)
manipulation
hearing Not impaired impaired
Mastoid x-ray normal mastoiditis
 Acute circumscribed otitis externa

Treatment:
(+) abscess formation drainage;
antibiotics
(-) abscess formation local heat;
analgesics;
antibiotics
 2. Diffuse otitis externa

Secondary to acute or
chronic otitis media
Ear manipulation
Etiologic agents:
- Pseudomonas other
gram-negative organisms
 Diffuse otitis externa
Signs/ symptoms:
1. pain
2. tenderness on manipulation
3. scanty ear discharge
4. diffuse swelling of whole ear canal
5. decreased hearing occasionally

Treatment
1. mechanical cleaning
2. cotton wick application
3. topical antiobiotics
 3. Malignant otitis externa

Causes: P. aeruginosa
1. diabetic patients
2. immunocompromised and debilitated
patients
3. elderly patients
Course:
- very destructive
- spread via fissures of Santorini to
parotid gland
- osteomyelitis of temporal bone
 Malignant otitis externa
Signs/ symptoms:
1. pain on manipulation
2. TMJ pain
3. deep tenderness on palpation beneath the ear
4. otoscopy: intact TM; bone & cartilage
destruction; granulation tissues
5. cranial nerve problem especially VII ominous sign
6. intracranial complications
 Malignant otitis externa
Treatment
1. local debridement
2. IV gentamycin and carbenicillin
3. persistence or extension of infection local
excision
 Otomycosis
Causes:
1. ear cleaning with
contaminated implements
2. diabetics
3. immunocompromised patients
4. normal flora affected

Etiologic agents:
- Aspergillus
- Candida
 Otomycosis
Signs/ symptoms
1. itchiness
2. diffuse swelling of EAC
3. mycelia or sporangia
4. discharge
5. decreased hearing occasionally
 Otomycosis
Treatment
1. clean ear thoroughly
2. clean again with antiseptic solution
3. dessicating agent
4. topical fungicidal preparations
5. keep ear dry and avoid ear manipulation
 Foreign bodies
A. Animate
- cockroaches, ants, ticks
- severe discomfort and
pain
- management
kill first prior to
removal (ether, oily
substance)
B. Inanimate
- may or may not produce
symptoms
- stones, seeds, wads of
paper
- remove with proper
instruments
 Trauma
A. Injury to auricle
* without tissue loss
- bruises
- hematoma evacuation to
avoid

* with tissue loss

- conservative in removal of
tissue
 Trauma
B. Traumatic rupture of
Tympanic membrane
Etiologies:
1. secondary to probing
2. too forceful syringing of ear
3. forceful change of pressure in
the EAC
Signs/ symptoms:
- sudden pain and bleeding with
decreased hearing
 Trauma
B. Traumatic rupture of TM
Treatment:
1. most heals spontaneously
2. cauterize edges
3. cigarette paper as scaffold
4. myringoplasty
 OTITIS MEDIA

Nilson L. Gelbolingo, M.D. FPSO-HNS

 OTITIS MEDIA
One of the most common childhood diseases
Leading cause of hearing loss in children
Most frequent indication for antimicrobial or
surgical therapy in children
 DEFINITION
Inflammation within the middle ear cleft beginning
behind an intact tympanic membrane (TM).

Acute otitis media (AOM)

> signs & symptoms of acute infection
- fever
- pain
- bulging TM
- middle ear effusion
 EPIDEMIOLOGY
2/3 of all infants have at least one ear
infection before 2 years old

Highest age-specific incidence:

between 6 & 18 months of age
 PREDISPOSING FACTORS
Young age
Male gender
Heredity
Poor economic & social conditions
Season of the year
Environmental factors
- smoking
- attendance at a daycare center
- food allergies
- bottle- feeding
 MICROBIOLOGY
Organisms
- Streptococcus pneumoniae
- Haemophilus influenza
- Moraxella catarrhalis
- Group A Streptococcus
- Staphylococcus aureus
 OTHER ORGANISMS
Mycobacterium tuberculosis
- painless, watery otorrhea through
single or multiple perforations

Chlamydia trachomatis
Pathophysiology
AOM common before 6 years of age
- maturation effect/ changes in the immune
system
- maturation of the Eustachian tube (ET)

Infancy Adulthood
ET angle 16 45
ET length 18 mm 35 mm
 Swelling of ET (Allergy/ Infection)

Resultant absorption of ET

Absorption of air in ME

Negative pressure in ME

Exudation of fluid

Trapping of secretion with proliferation of bacteria

ACUTE OTITIS MEDIA

 NEW THEORY

Abnormally patent/ compliant ET

Bacterial entry into ME

ACUTE OTITIS MEDIA

 STAGES OF AOM
Stage of hyperemia
Symptoms
- sense of ear fullness
- mild hearing loss
- fever
- earache
Sign
- hyperemic TM
 STAGES OF AOM
Stage of exudation
Symptoms
- marked hearing loss
- fever
- severe earache
Sign
- TM thickened & bulging
 STAGES OF AOM
Stage of suppuration
TM perforates
Symptoms
- decrease intensity of
symptoms
- marked hearing loss
Sign
- TM perforation
 STAGES OF AOM
Stage of coalescence
1% to 5% of cases persistence
of infection
Symptom
- continued ear discharge
Signs
- pain & mastoid tenderness
- fever
- leukocytosis
X-Ray: decalcification &
destruction of mastoid cell
partition
 DIAGNOSIS
Otoscopy
Classic sign
- redness & bulging of TM

Tympanometry
Demonstrates effusion
(type B tympanogram)
ACUTE OTITIS MEDIA
 DIAGNOSIS
Tympanocentesis
not routinely done
confirm diagnosis by demonstrating
bacteria on culture
Radiographic imaging
reserved for cases with possible
suppurative complications
 MANAGEMENT
Antimicrobial therapy
Mainstay of treatment
Amoxicillin
- 1st line treatment given x 10 days
- alternative drugs:
TMP-SMZ
Erythromycin-Sulfisoxazole
 MANAGEMENT
2nd line drugs:
Amoxicillin-Clavulanate
Cefuroxime
Cefixime
Cefprozil
Loracarbef
Cefpodoxime
Cefaclor
 MANAGEMENT
Adjunct medical therapy
decongestants & antihistamines

Supportive therapy
analgesics
antipyretics
local heat
 MANAGEMENT
Amoxicillin x 7 to 10 days as effective as:

Ceftriaxone IM, single dose

Azithromycin x 5 days

Rosenfeld RM et al, J Pediatr 1994, 124 355-367

Mc Cracken GH Jr, Pediatr Infect Dis J 1999, 18 1141-6
MANAGEMENT

Tympanocentesis
important in the following situations:
- AOM in a critically ill or septic child
- AOM with poor response to antibiotic
- Suppurative complications from AOM
- AOM in a newborn or in a child with
primary or secondary immunodeficiency in
whom an unusual organism may be present
 MANAGEMENT
Myringotomy
promptly relieves pain due to severe
AOM
little effect on remission of infection
 MANAGEMENT

If with tympanic membrane perforation

oral + topical antibiotics

 COMPLICATIONS
Mechanisms of Extension
preformed pathways
hematogenous
thrombophlebitis
bony erosions
 COMPLICATIONS

» Extracranial

» Intracranial
 COMPLICATIONS
Extracranial complications
TM perforation
tympanosclerosis
hearing loss
serous labyrinthitis
facial nerve paralysis
mastoiditis
subperiosteal abscess
 COMPLICATIONS
Intracranial complications
meninigitis
lateral sinus thrombosis
otitic hydrocephalus
abscess
focal otitic encephalitis
 PREVENTION
Environmental factors
risk factors identified environmental

discourage bottle-feeding
choose a daycare center with smaller
settings & with good ventilation
 PREVENTION
Vaccines
Pneumococcal vaccine
- effective in reducing the number of episodes of
AOM in children >2 y.o.
Hemophilus influenzae type B vaccine
- most ear infections caused by non-
typable strains
 PREVENTION
Vaccines
33% to 36% reduction in AOM cases
during the period when influenza
virus was in the community

no effect during the remainder of the

year
THANK YOU
OTITIS MEDIA WITH EFFUSION

Nilson L. Gelbolingo, M.D. FPSO-HNS

OTITIS MEDIA WITH EFFUSION (OME)
Definition
Presence of fluid
behind an intact
TM without
signs/symptoms
of acute
infection
OTITIS MEDIA WITH EFFUSION (OME)

Synonyms
Glue ear
Fluid in the ear
Serous or secretory otitis media
Non-suppurative otitis media
OTITIS MEDIA WITH EFFUSION (OME)
Epidemiology
60% have OME before 2 y.o.
80% had at least 1 episode prior to school
entry
25% discovered incidentally at well-child
check-ups
OTITIS MEDIA WITH EFFUSION (OME)
Sequelae
Adverse effects on:
Cognitive
Auditive
Linguistic
Communicative skills
OTITIS MEDIA WITH EFFUSION
OTITIS MEDIA WITH EFFUSION (OME)
Pathogenesis
ET dysfunction attributed to:
Allergy
Sinusitis
Rhinitis
Adenoid hypertrophy
Nasopharyngeal tumors
OTITIS MEDIA WITH EFFUSION (OME)
Symptoms
Ear fullness
Decreased hearing
Tinnitus
Signs
Early: TM appears dull, retracted, with
bubbles or air-fluid level
Late: TM appears dull, retracted, with
yellowish hue
OTITIS MEDIA WITH EFFUSION (OME)
Diagnosis
Pneumatic otoscopy
In the absence of the above otoscopic findings,
pneumatic otoscopy must be performed
Diagnosis: absence of movement of TM
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
OTITIS MEDIA WITH EFFUSION (OME)
Diagnosis
Tympanometry
Used to confirm the diagnosis of OME by
demonstration of type B curve
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 OTITIS MEDIA WITH EFFUSION
(OME)
Diagnosis
Pure tone audiometry
Should be performed in cooperative
children to assess their hearing levels
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
OTITIS MEDIA WITH EFFUSION (OME)
Management
OME after an episode of AOM
60% chance of spontaneous resolution at 1
month post-infection
80% at 2 months
90% at 3 months
 OTITIS MEDIA WITH EFFUSION
(OME)
Chronic OME (>3 months)

Months Cure Rates

3 22%

12 26%

30 31%
OTITIS MEDIA WITH EFFUSION (OME)
Therapy
OME lasting <12 weeks should be observed OR treated
with antibiotics
Observation should consist of follow-up visits every 2
weeks for the first month and monthly thereafter until the
disease resolves
Antibiotic therapy should consist of either Amoxicillin or
Co-trimoxazole given for 2 weeks
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
OTITIS MEDIA WITH EFFUSION (OME)
Therapy:
OME lasting > 12 weeks should be treated with
myringotomy and VT insertion OR antibiotics if
these have not been given
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
OTITIS MEDIA WITH EFFUSION (OME)

Benefits of M + VT
insertion
Alleviation of
hearing loss
Avoidance of ME
sequelae
OTITIS MEDIA WITH EFFUSION (OME)
Disadvantages of M + VT insertion
Tympanosclerosis (51%)
Persistent perforation (13%)
Risk of recurrent OME necessitating repeat
insertion (30% in 5 months)
Extra precaution and ear care which patient must
take
OTITIS MEDIA WITH EFFUSION (OME)
The following regimens are not recommended
for the routine treatment of OME in an
otherwise healthy child
Antihistamine-decongestant combination
Steroids
Mucolytic
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 Diagnosed Case of Unilateral
Otitis Media with Effusion

Observe up to Antibiotics
<12 weeks by history
12th week x2 weeks

Does OME resolve ? Does OME resolve ?

No Yes No

Antibiotics Observe up to
x2 weeks 12th week

Does OME resolve ? No Does OME resolve ?

Yes Myringotomy with Yes

VT insertion
 Diagnosed Case of Unilateral
Otitis Media with Effusion

>12 weeks by history

Yes Antibiotic Rx ? No

Antibiotics
Does OME resolve ?
x2 weeks

No Yes

Myringotomy with
VT insertion
Thank you !
CHRONIC SUPPURATIVE
OTITIS MEDIA

Nilson L. Gelbolingo, M.D. FPSO-HNS

CHRONIC SUPPURATIVE OTITIS MEDIA
Definition
chronic otorrhea (>3 months) through a non-
intact tympanic membrane
 PREVALENCE
2.5% 29.4%
- Bastos, 1990; Yabut, 1994

14% of OPD consultations

- UST, 1989

30% of emergency cases

62% of operated ears
- PGH, del Rosario, 1992
 INCIDENCE
History of acute & recurrent OM
Parental history of COM
Larger families & more settings
Higher crowding index
Attendance at large daycare centers
PATHOPHYSIOLOGY

» Complication of AOM

» Sources of pathogens
 MICROBIOLOGY
Aerobic pathogens:
Pseudomonas aeruginosa
Staphylococcus aueus
Proteus spp
Klebsiella pneumoniae
Diphtheroids
 MICROBIOLOGY
Anaerobic pathogens:
Peptococcus sp.
Peptostreptococcus sp.
Bacteroides sp.
Bacteroides melanogenicus
 CHRONIC CHANGES
Irreversible:
TM perforation
formation of granulation tissue
osteitis
osteogenesis
bone erosion
mucosal edema
subepithelial glandular formation
cholesterol granuloma
cholesteatoma
 DIAGNOSIS

Otoscopy

Audiologic evaluation

Radiologic imaging
 RECOMMENDATIONS ON THE
DIAGNOSIS OF CSOM

CSOM is diagnosed mainly by the presence

of a tympanic membrane perforation upon
otoscopy and a history of ear discharge for
more than 3 months.
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 RECOMMENDATIONS ON THE
DIAGNOSIS OF CSOM

Mastoid radiographs to evaluate the

degree of mastoid pneumatization must be
part of the initial diagnostic assessment.
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 RECOMMENDATIONS ON THE
DIAGNOSIS OF CSOM

Puretone audiometry must be performed as

part of the total diagnostic assessment.
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 RECOMMENDATIONS ON THE
DIAGNOSIS OF CSOM

Culture and sensitivity of ear discharge is not

part of the routine initial diagnostic
assessment.
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 RECOMMENDATIONS ON THE
TREATMENT OF CSOM

Aural hygiene is an essential part of the

treatment of CSOM in all patients.
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 RECOMMENDATIONS ON THE
TREATMENT OF CSOM
Topical antibiotics for 2 weeks or earlier if the
ear discharge had dried should be used for the
initial management CSOM.
For treatment failures, an additional 2 weeks
of antibiotic therapy should be tried
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 RECOMMENDATIONS ON THE
TREATMENT OF CSOM

Mastoidectomy must be performed on all

cases of CSOM with suppurative
complications.
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 RECOMMENDATIONS ON THE
TREATMENT OF CSOM

Mastoidectomy is indicated for cases of CSOM

with cholesteatoma formation.
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 RECOMMENDATIONS ON THE
TREATMENT OF CSOM

Mastoidectomy may be performed for those

who fail to respond to adequate treatment.
- Clinical Practice Guidelines of the Philippine Society
of Otorhinolaryngology Head & Neck Surgery
 Adult with otorrhea > 3 months

Otoscopy

TM perforation ?

No Yes

Reevaluate Active CSOM

 Active CSOM

Option: Mastoidectomy
Option: Audiometry

Cholesteatoma and/or suppurative

complications ?

No Yes

Aural hygiene; Mastoidectomy

Topical antibiotics x 2 weeks
Active CSOM without cholesteatoma Aural hygiene;
and/or suppurative complications Topical antibiotics x 2 weeks

Discharge resolved ?
TM healed ?

Alternative topical
No Yes
antibiotic x 2 weeks

Discharge resolved ? Observe

TM healed ?

No Consider mastoidectomy
and/or tympanoplasty
Thank You !
COMPLICATIONS OF OTITIS MEDIA

Dr. Nilson L. Gelbolingo

COMPLICATIONS OF OTITIS MEDIA

Extension of infection beyond the

confines of the middle ear and mastoid air
cells
pre-antibiotic era
COMPLICATIONS OF OTITIS MEDIA

Intratemporal / extracranial
extratemporal / intracranial
intratemporal and intracranial infections
coexist (50%)
COMPLICATIONS OF OTITIS MEDIA

most complications: subacute and

chronic infections
4 mechanisms of extension:
direct extension
preformed pathway
hematogenous
thrombophlebitis
COMPLICATIONS OF OTITIS MEDIA
INTRATEMPORAL COMPLICATIONS

TM perforation

pars tensa
INTRATEMPORAL COMPLICATIONS

Tympanosclerosis
INTRATEMPORAL COMPLICATIONS
Hearing Loss
A. Conductive type
- temporary
- presence of fluid in ME or TM perforation
B. Sensorineural
- permanent
- causes:
1. Spread of infection or inflammatory
products through the RW membrane
2. Labyrinthitis
INTRATEMPORAL COMPLICATIONS

Coalescent mastoiditis
Breakdown of mastoid bony trabeculae
Tx: mastoidectomy
INTRATEMPORAL COMPLICATIONS

Petrositis/ syndrome
Triad of:
a. Discharging ear
b. Retroorbital pain (CN V)
c. Diplopia (CN VI)
INTRATEMPORAL COMPLICATIONS
Facial Nerve Paralysis
Runs through the mastoid and middle ear cavities
40% to 50% dehiscent
AOM

COM
0 bone erosion by cholesteatoma or granulation
INTRATEMPORAL COMPLICATIONS

Subperiosteal abscess
types:
1. Post-auricular
2. Zygomatic/preauricular
3.
4. Parapharyngeal
INTRATEMPORAL COMPLICATIONS
Labyrinthitis
Direct extension into labyrinth in AOM
Bone erosion in CSOM
S/Sxs:
sudden/progressive/fluctuating hearing loss
Vertigo
N/V
tinnitus
INTRATEMPORAL COMPLICATIONS
Types

Type Vertigo Hearing Loss Pathology

Circumscribed Mild Conductive Erosion without
actual invasion of
the labyrinth with
a fistula
Serous Mild to Mixed Localized
moderate invasion with
toxins
Suppurative Severe Sensorineural Actual
penetration and
invasion by the
organisms
INTRATEMPORAL COMPLICATIONS

Tx:
- Acute cases high dose antibiotic +
myringotomy
- Chronic cases high dose antibiotic +
mastoidectomy
INTRACRANIAL COMPLICATIONS
Lateral Sinus Thrombophlebitis
Inflammation of the sinus adventitia and
penetration of the venous wall
Sxs:
septic fever (picket fence)
chills
pain
Tx: mastoidectomy with removal of infected
thrombus
INTRACRANIAL COMPLICATIONS
Meningitis
Most common IC complication, both AOM &
CSOM
Cause/s:
INTRACRANIAL COMPLICATIONS

Extradural abscess
Destruction of bone adjacent to the dura
Chronic OM with cholesteatoma
Sxs: severe otalgia and headache relieved by
abundant pulsatile drainage
INTRACRANIAL COMPLICATIONS
Subdural Abscess
Direct extension of extradural abscess or extension of
thrombophlebitis
Between arachnoid membrane and dura
S/sxs:
Fever
Headache
Seizures
Hemiplegia
Coma
INTRACRANIAL COMPLICATIONS
Brain abscess
Temporal lobe or cerebellar lobe
Usually associated with:
meningitis
sinus thrombosis
petrositis

S/sxs:
increased ICP
cerebellar signs
temporal lobe signs

Tx: neurosurgical exploration and mastoidectomy