2008 학생강의

분당차병원 이비인후과 부교수 이창호

Otology 2008 Curriculum

 Otitis Mdia – Middle ear anatomy

 SNHL – Cochlea Anatomy

 Audiometry - CHL vs SNHL

 Temporal Bone
 Facial nerve
 Vertigo - Vestibular anatomy
 http://niceear.co.kr/pk 강의록
 http://www.emedicine.com/ 참고서적
Otologic Symptom
 Hearing loss – 공통
 Inflammation
 Otalgia
 Otorrhea
 Associated
 Vertigo dizziness 로 최근에는 HL 보다 더 빈번해짐 .
 Facial nerve paralysis
 잡음
 Tinnitus
SNHL 에 동반되는 잡음 증상
 Earfullness
Inflammation 에 동반되는 잡음 증상
고막 tympanic membrane
9-10 x 8-9 x 0.1 mm 의 회
백색 (pearly white) 또는
담홍색의 얇은 막 . 100
mmHg(ca 130 dB) 에도 견
딤.
Outer squamous epithelium,
middle fibrous layer,
inner mucosal layer

주요 명칭 : annulus, pars
tensa, cone of light, pars
flaccida (Shrapnell’s
membrane), short process
of malleus, handle of
malleus, umbo,
Figure 2.2 Right ear.
Structures of the middle
ear seen after removal
of the tympanic
membrane.
9=pyramidal eminence;
co=cochleariform
process;
f=facial nerve;
j=incudostapedial joint.
Figure 4.3 Right ear.
Secretory otitis
media. Air bubbles
can be seen anterior
to the handle of the
malleus and also in
the posteroinferior
quadrant.
Figure 4.5 Left ear. Secretory
otitis media with an
apparently dense transudate
that gives the tympanic
membrane the characteristic
dark yellow color. An air-fluid
level can be appreciated at
the posterosuperior
quadrant. The tympanic
membrane is diffusely
hyperemic. If the condition is
not resolved by medical
treatment, a ventilation tube
should be inserted.
Figure 6.5 Right ear. Grade I
atelectasis with the malleus
slightly medialized. An
epitympanic retraction pocket is
also seen. Middle ear effusion
with yellowish color can be
appreciated. Pure tone
audiogram revealed a 40dB
conductive hearing
loss(Fig.6.6), whereas the
tympanogram was type B, I.e.,
typical of middle ear
effusion(Fig.6.7). In this case,
the insertion of a ventilation
tube is indicated to avoid
further retraction of the
tympanic membrane, to aerate
the middle ear, and to improve
hearing.
Figure 7.1 Left ear. The
tympanic membrane is
very thin due to atrophy of
the fibrous layer. A
posterosuperior marginal
perforation is seen. This
perforation is risky because
the skin of the external
auditory canal can easily
advance into the middle
ear, forming a
cholesteatoma. In this
case, a myringoplasty
using an endomeatal
approach is indicated.
Figure 7.4 Right ear. Large
perforation of the posterior
quadrants. Normal middle ear
mucosa. The incudostapedial
joint is intact. The oval window
with the annular ligament
surrounding the footplate can be
seen. The pyramidal eminence,
the stapedius tendon, the round
window, and Jacobson’s nerve
running on the promontory are
visible. The remaining anterior
quadrants of the tympanic
membrane are tympanosclerotic
and rigid, blocking the mobility of
the malleus.
Figure 2.1 Right ear. Normal
tympanic membrane.
1=Pars flaccida; 2=short
process of the malleus;
3=handle of the malleus;
4=umbo; 5=supratubal
recess; 6=tubal orifice;
7=hypotympanic air cells;
8=stapedius tendon;
c=chorda tmpani; I=incus;
p=promontory; o=oval
window; R=round window;
T= tensor tympani;
A=annulus.
Summary

 P/E of TM – behind TM
What is Otology
인턴이 바라본 과별 특성
 내과 : 양반이란 느낌이남 . 화가나도 점잖게 말하려고
노력 . 지적임 .
외과 : 정말 다양한 인간들이 모인 과 . 갈곳없는 사람
부터 엑설런트한 사람까지 . 착한사람부터 왕싸가지까
지 . 다양한 인간들
정형외과 : 말할 가치도 없다
이비인후과 : 속이 진짜 좁은 사람들이 모임
마취과 : 귀차니즘 남자 모임
진단검사과 : 귀차님즘 여자 모임
 When There was no ENT
 George Wahington
 Inflammatory quinsy – Peritonsillar abscess
 Elisha Cullen Dick, one of the physicians present
proposed a tracheotomy
 Instead the doctors prescribed bleeding - total
loss of five pints of blood.
 Washington died from either a streptococcal
infection of the throat, or a combination of
shock from the loss of blood, asphyxia, and
dehydration
 . 베토벤바이러스

Meniere’s disease – Recurrent Vertigo leading to Hearing Loss

.Gogh
ENT – Social Disease

 Recurrent Vertigo lasting hours

 Hearing fluctuation

 Meniere - French doctor, mid 19C

 Van Goch - Meniere’s disease? Schizo?
 Incidence: 2/1000
 1/3 - socially disturbed

Van Gaugh - Syphilitic Meniere’s dis. Victim?

 However, despite his wide circle of friends
and family, Vincent van Gogh
was a depressive, with a history of
gonorrhoea
and syphilis. In 1888, he cut off his ear, and h
homeopath Paul Ferdinand Gachet,
whose treatment and friendship led to the
most productive time in Vincent’s ‘cold
and lonely’ life.
 Great Human
 He said
 My misfortune is doubly painful to me because it
will result in my being misunderstood.
 For me there can be no recreation in the
company of others, no intelligent conversation,
no exchange of information with peers; only the
most pressing needs can make me venture into
society.
 I am obliged to live like an outcast.

Sensorineural HL
Otitis Media
Introduction

 most common diseases of childhood

 most frequent disease managed with
antibiotics in children.
 소아 항생제 남용의 주범이라는 불명예 .
Terminology

 Otitis media : inflammation of middle ear

without etiology or pathogenesis
 AOM : rapid onset of signs and symptoms of
acute infection in the middle ear : at least one
sign and one symptom
-Sign:erythema, white, yellow opacification,
bulging, otorrhea
-Symptoms:fever, otalgia, irritability, ear pulling,
balance disturbance, hearing loss
 OME : fluid within middle ear without symptoms
 MEE : fluid within middle ear (term
encompasses both AOM and OME)
Guidelines

 AOM Guideline
 Pediatrics 2004, 113:1451-1465.

 OME Guideline
 Pediatrics 2004, 113:1412-1429.
 Otolaryngol Head Neck Surg 2004, 130:S95-
118.
Definition of AOM
 Visualization of the tympanic membrane
withidentification of an MEE and
inflammatory changes is necessary to
establish the diagnosis with certainty.
 To visualize the tympanic membrane
adequately it is essential that cerumen
obscuring the tympanic membrane be
removed and that lighting is adequate.
Pitfalls in AOM Dx

 Crying baby
 Hyperemic TM (Color)
 Flat fluctuating B Impedance audiometry
(Mobility)
 
 Thickening of TM
 Needs brighter light source
COM plications of OM

 Infectious Complicaionts
mortality rate 2% > antibiotic era> 0.01%

 Acute and chronic mastoiditis,

 Petrositis

 Intracranial infection.
still fatal
COM plications of OM

The noninfectious sequelae - Major causes of

hearing loss

 Chronic perforation of the tympanic

membrane,
 Ossicular erosion,
 Labyrinthine erosion,
 Tympanosclerosis
Subperiosteal Abscess
AOM
Acute Otitis Media
AOM History
: ER Situation
 J.D., a previously healthy girl at 6 months of age
with a 3-day history of increasing irritability
and fevers.
 History revealed that she had upper
respiratory tract symptoms for 3 days that
included nasal congestion, rhinorrhea, dry
cough, decreased appetite and low-grade
fevers. The parents became concerned the night
before presentation when she became very
irritable, appeared to be in pain, and vomited
once after bottle-feeding. The girl was seen
pulling on her ears and was inconsolable prior to
arrival at the pediatrician's office. She had no
previous medical problems and was not taking
AOM History  Physical exam demonstrated a
6-month old girl who was crying
in her mother's arms. She was
alert but not cooperative. She
had a temperature of 38.5’C.
 Examination of the ears revealed
a right tympanic membrane
that was bulging,
erythematous, and didn't move
with pneumotoscopy. The nasal
mucosa was congested and the
patient was mouth breathing.
The remainder of the physical
exam was unremarkable.
 She was diagnosed with acute
otitis media and prescribed a
10-day course of amoxicillin at
40mg/kg/day. Within 24 hours,
her symptoms were improving
and she began to feed normally.
 Pathogenesis of Secretory Otitis in URI
URI (Rhinitis)

Hyperplasia and Edema of

edema of adenoids Nasal obstruction tubal mucosa

Accumulation Middle ear

of secretion in hypoventilation Ascending
nasopharynx infection
Negative middle
ear pressure

Ascending infection Epithelial changes

Pathogenesis of Acute Otitis Media
 Abnormal function of E-tube

 Ascending infection of respiratory

mucosa

 Allergy, ciliary dysfunction, etc

 Pathology of Acute Otitis Media

AOM initially results in edema, capillary engorgement

and infiltration into the submucosa of the pneumatized
spaces of the middle ear.

As the infection becomes more chronic, edema is

replaced with fibrosis and acute inflamatory cells are
replaced with lymphocytes.
 한글책 P.119 중이염 병태생리의 특징

 중이염을 일으키는 세균으로는 Streptococus, H.

influenza ……
 … 혈행성보다는 …대부분은 이관을 통한 직접적인
병의 전파 = ascending infection
 가장 중요한 것은 E-tube dysfunction 으로서 특
히 삼출성 중이염
 .. 아데노이드 …비인강에서 세균의 reservoir, 이
관의 기계적 폐쇄
 Retraction, Atelectasis, Adhesive OM 등의 단
계
Disorders Possibly Associated with
AOM
 Cleft palate Why?
 Submucous Cleft Palate, Bifid Uvula
 Craniofacial anomalies

 Allergy (possible)

 Congenital or acquired immune dysfunction

 Ciliary dysfunction
Prevalence of Acute Otitis Media

 Sex : boy > girl

Race : American Indians and Eskimos >
American White > Hispanics >
Blacks
Low socio-economic status
Day-care child, milk feeding
Winter season, URI
Genetics
Incidence of Acute Otitis Media
 1. By age 12 mo > 1 episode in 2/3
children
2. By age 3 year > 3 episodes in 46%
> 1 episode in 95%
3. AOM in adults: less common but
not rare
Age factors of AOM
 Incidence↓ in newborn period
Highest incidence: 6-24 months
Less common after 7 years old
P.120

 항생제…치명적인 합병증은 줄었으나…전음성

난청과 같은 후유증은 오히려 증가
 …10% 에서 만성화
 …classification 전부…
 .. 유소아에서 더 많다…소아의 이관이 어른에
비하여 작고 더 짧으며 또한 수평의 위치… . 소
아기의 비인강 조직… .
Pathogens of AOM
- Up to 50% : culture positive

S. pneumoniae
H. influenzae
B. catarrhalis
Group A streptococcus
* Increased appearance of
β-lactamase producing pathogens
Clinical Stages of AOM
Stage of hyperemia
Stage of exudation
Stage of suppuration
Stage of coalescence
Diagnosis of AOM
쉽게 진단이 가능하다
-Specific Sn & Sn
prodrome, otalgia, fever,
otorrhea, hearing loss
- Physical examination
hyperemia of TM, bulging,
otorrhea,
- Audiologic and other Lab studies
 Treatment of AOM
AOM – Medical disease
OME – Not a Medical disease
Rest
Antibiotics
Other symptomatic drugs
Myringotomy ?
Local treatment
Antibiotics in Acute Otitis Media

Clinical improvement within 72 hrs

Choice of antimicrobials
Poor response
- change of antimicrobials
surgical intervention
Antibiotics in Acute Otitis Media

Drug Total daily dose

Amoxicillin 25-30
Ampicillin 50-100
Amoxicillin/clavulanate 40
Cefaclor 40
Erythromycin/sulfixasole 50 (mg/kg)
Otitis Media, Atelectasis and
Eustachian Tube Dysfunction

Changho Lee, MD
Department of Otolaryngology
Bundang CHA University
 Pathophysiology of Chronic Otitis
Media

Aucte Inflammation and Edema

Genetic Predisposition E-tube dysfunction

Chronic Inflammation and Fibrosis

Mucosal edema
Increased secretory Goblet cell

Chronic otitis Media

Chronic Otitis Media
Progression of OME to
Chr Suppurative OM

 Chronic otitis media

 Non – intact Tympanic membrane
 Transfer of EAC bacteria to Middle ear
 Granulation tissue formation
 Chronic Suppurative Otitis Media
COM vs OME : TM
COM vs OME :
Naming and Classification
 COM without  cOME
Cholesteatoma  = MEE
 = COM with perforation
 = Chronic suppurative
 Subclassification
OM
 Air-fluid
 Fluid
 COM with  Mucoid = Glue
Cholesteatoma  Purulent

Atelectasis
Adhesive OM
COM vs OME : TM - Diagnostic

 Perforation : easy  Effusion under Intact

TM
 Missing
 Atelectasis  AOM : easy to dx
 Cholesteatoma  OME : tricky dx for GP
COM vs OME : Symptomatology

 Hearing loss : CHL +-  Asymptomatic in

SNHL children except AOM
 Otorrhea >> Otalgia Otalgia
 URI, Alcohol, Water
 Adult
 Earfullness Very
uncomfortable
 Comlications in  HL
cholesteatoma
 Vertigo
 FN paralysis
COM vs OME : Audiometry

 PTA & AB gap  PTA ?

 Impedance
Audiometry

 Pneumatic Otoscope
COM vs OME : Bacteriology

 AOM/OME  CSOM
 Strep. Pneumonia  P. aeruginosa
 H. influ  Staph aureus
 Gr p A Sterp.  Corynbacterium
 M. cat  Kleb. Pneumoniae
 Anaerobes  Anaerobes
COM vs OME: Treatment

 1st: Otorrhea controle  Hearing Preservation

& Protection until
 Tympanopalsty + grow-up
Mastoidectomy
 long time surgery  Medical Mx – Acute
stage
 Indication: Easy to  VT insertion
say  Easy procedure but
repeated until growth
COM Classification

 OME - (chronic) Otitis media with Effusion

 COM without Cholesteatoma

 COM with Perforation

 Adhesive OM ?
 COM with Cholesteatoma
COM Classification

 OME - (chronic) Otitis media with Effusion

 COM without Cholesteatoma

 COM with Perforation

 Adhesive OM ?
 COM with Cholesteatoma
COM Classification

 OME - (chronic) Otitis media with Effusion

 COM without Cholesteatoma

 COM with Perforation

 Adhesive OM ?
 COM with Cholesteatoma
Microsurgery Video
Surgical mx of COM

 수술의 이름은 ?

 Tympanoplasty
 Mastoidectomy

 TM OP (Tympanomastoidectomy)
Otitis Media with Effusion, OME
Middle Ear Effusion, MEE
or whatever it may be called
 Middle Ear Effusion

•Effusion is the liquid resulting from OM, can

occur in all area of the pneumatized temporal
bone.

•Three types of effusion

serous - thin, watery
purulent - pus-like liquid
mucoid - thick, viscous
Amber, retraction pocket
 Middle Ear Effusion, MEE
Effusion is the liquid resulting from OM, can
occur in all area of the pneumatized temporal
bone.
Three types of effusion
serous - thin, watery
mucoid - thick, viscous
purulent - pus-like liquid
Most common cause of pediatric hearing loss !
Pathogens of Middle Ear Effusion
- Up to 50% : culture positive

S. pneumoniae
H. influenzae
B. catarrhalis
Group A streptococcus
Symptoms of MEE

Mostly asymptomatic
Conductive hearing loss
Otalgia, unsteadiness, tinnitus
if looked for
TM Findings of MEE

 Retraction
 Prominent malleus short process
 Shortening of malleus handle

 Amber color
 Air-fluid level
 Result of AOM Treatment

After 10-day courses

of effective antibiotic
treatment, up to 50%
of children will be
clinically well, but
have persistent effusion

Teele DW, Ann Otol Rhinol Laryngol 1980;89[Suppl 68]:5

Incidence of MEE after AOM

1. After AOM
40% with MEE at 1 month
20% with MEE at 2 months
10% with MEE at 3 months
2. Asymptomatic MEE:
peak at the age of two
prevalent in winter season
Natural Course of MEE

 It the patient remains asymptomatic,

the effusion can be followed, because it
may take up to 3 months to resolve after
a single episode of AOM.
The natural history & management of acute & subacute
effusions differ greatly from that of effusion present 2-3
monts or longer.
Course Plotting is Very Important for
Management
OM Prone = Recurrent AOMs Media

- intervention other than episodic treatment

Chemoprophylaxis:
half daily dose, h.s.
Myringotomy and/or
ventilating tube insertion
Adenoidectomy
Surgical mx of OME
Tympanostomy Tube

Protects middle ear from effusion.

But the only cure for OME is growing up.
VT under General Anesthesia
 Preoperative LAB
 Admission
 Many surgeons do T&A OP together.
 Repeated VT insertion is necessary for young
children.

 Makes VT procedure very painful procedure for

family
 중이염의 한방 치료 ?
 한약 먹인 걸 자랑하는 부모들 .
 병든 아이의 부모를 노리는 상술 .
레이저 튜브 클리닉

 분당차병원 이비인후과의 소아중이염클리닉은 전국에

서 가장 많은 튜브 시술을 행하고 있습니다 .
 이는 무조건 전신마취를 실시하는 일반 타병원과 달리
' 레이저 튜브 수술 ' 을 통해 전신마취율을 1/10 로 감
소 , 더불어 수술만족도는 최대한 높였습니다 .

 - 레이저 중이염 수술과 동시에 튜브를 삽입할 수 있는

국내 최초의 레이저 시스템입니다 .
 - 어린이도 전신마취가 필요한 경우는 20% 정도입니
다.
 - 입원이 필요 없습니다 .
LT with/without VT insertion
Laser Myringotomy Laser Myringotomy and VT insertion

 Blood sample 할 시간 동안 마칠 수 있는 레이저 튜브

 Video
Case : Laser myringotomy

 심 0 호 M/4Y 2M
 
 CC Known OME, persistent
 
 Brief Hx
4M/yr PO antibiotics for 3 years for OME
분당 SNUH VT schedule, PreOP LAB for GA
done
Visit for 2nd opinion
 
  
Case : Laser myringotomy
 Mx
 L glue on laser myringotomy --> VT insertion
 R pus on laser myringotomy --> VT hold
 비디오

 FU course of R (LM)
R no recurrence of MEE for 3 months without VT
GA was avoided.
Surgeon did not have to issue the safety of GA
Patient was happy
Adenoidectomy for MEE
Adenoid in Skull lateral
Postoperative 3 Mo.
Adenoid seen from
nasopharynx
Several Medical Mx Options for
Physiologic MEE with symptoms
No proof they are significantly more
effective that observation on prognosis

3. Another course of a different antimicrobials

4. Another course for the origianl antimicrobial, but for a
longer time
5. Topical (Intranasal)/ Systemic decongestants or systemic
antihistamines
6. Systemic/Topical (Nasal) Steroids
7. E-tube / Middle ear inflation with Valsalva or direct ET
inflation
 Aid in the Diagnosis of OME

Problems in very young children

Pneumatic otoscope
Conductive hearing loss
Tympanogram
type “B” or “C”
Tympanic aspiration
Impedance Audiometer

 Probe contains
 Air pump
 -400 ~ 200 mmH2O
 Speaker
 226Hz/ 85dB for Tympanometry
 250-6000 Hz for Stapedial reflex
 Microphone
 Immitance analyzer
 Tympanometry

 A
 As
 Otosclerosis
 C
 Peak shift, ET
dysfunction
 D
 Ad
 Healed perf
 B
Tympanometry FIg
Normal BOX
Dx?
Management strategies for cOME

Antibiotics
Antihistamines / decongestants
Mucolytics
Eustachian tube inflation
Myringotomy with/without tube insertion
Adenoidectomy
Allergy management
Intranasal or systemic steroids
 Antibiotics Trial has limited
 role for cOME
Result of Additional watchful waiting without
surgery & Antibiotics
 - 1M 6-32%
 (Rosenfed RM, Otol Head Neck Surg 106:378, 1992)
 -3M 20%
 -12M 26%
 -30M 31%
 (Mandel EM, Ped Infect Dis J 11:270, 1992)
 Extended observation are of little benefit.
Child Impact of cOME

 Total time with MEE in children

 3 yrs observation : 50%
 12 yrs observation : 6 yrs of OME
 (Maw R Br Med J 306:756. 1993)
 Mild Conductive HL
- 27dB HL
- > 35dB HL in 20%
- (Fria JJ, Arch otol 111:10, 1985)
- Prolonged MEE associated with HL may interfere
with speech and language development.
Unfavorable Prognosis
factor
 Otitis-prone (recurfrent episodes of AOM,
Otorrhea)
 Bilateral OME
 Age <2yrs
Early onsert of OM
 Group daycare attendance
Passive smoker exposure
Fall or early winter
Favorable Prognosis

 A
A child
 seen in the spring
 with unilateral OME
 who has no history of AOM
 And is cared for at home by nonsmoking
parents
 Factors influencing decisions
for or against surgery for OME
Favors Alternative to
Factor Favors Surgery Surgery
Epidemiology
Laterality of OME Bilateral Unilateral
Age of child 2 years or younger Older than 2 years
History of AOM Otitis prone Infrequent episodes
Daytime environment Group daycare Home care
Frequent smoke
Passive smoke exposure No smoke exposure
Spring or early
Current season Fall or early winter summer
 Factors influencing decisions
for or against surgery Favors
for OME
Alternative to
Factor Favors Surgery Surgery

Impact on child
Normal
Hearing Bilateral hearing loss hearing

Speech delay or No speech

Speech and language misarticulation impairment

Normal
Behavioral Abnormal behavior behavior
 Factors Influencing Decisions
for or against Surgery for OME
Favors Alternative to
Factor Favors Surgery Surgery

Miscellaneous
Otoscopic Air bubbles or air-fluid
appearance Structural changes of TM level

Antibiotic
tolerance Multiple drug allergies Antibiotics well tolerated
Baseline risk for
Other
OM High risk population Normal risk
indications for
surgery on
pharynx or Present (T&A) Absent
ears
P.121 MEE

 .. 이통이나 발열 등의 급성 증상 없이…
 ..glue ear, serous or secretory otitis
media….
 .. 조기진단이 어려울 수 있다 ..
 진단법으로는 1)…2)…3)
 치료목적…청력의 회복… . 만성화에 의한 합병
증의 예방
 고막절개…전하방부…
END
Traumatic TM Perforation
Figure 7.22 Left ear.
Posttraumatic perforation in
the posterosuperior
quadrant. The characteristic
radial tear, running in the
same direction as the fibers
of the tympanic membrane,
is apparent. Hemorrhagic
points separating the
epidermal layer from the
fibrous layer are visible.
These tiny hemorrhages are
typical of posttraumatic
perforations. This type of
tympanic membrane
perforation has a very high
incidence of spontaneous
healing.
Traumatic TM perforation

 10830933
 2004.6.22 2A 구타
. 남편
 6.25 PTA, SA
 Patch applied
 8.18
recommended
Tympanoplasty
Traumatic TM perforation -
Audiometry
L Traumatic TM perforation

 10470692 김옥 O
 2004.6.9 R TM
trauma
 2004.6.18 Infolding
correction + Patch
 2004.6.21 Patch
removal d/t otorrhea
 2004.8.13
Tympanoplasty,
Postauricular
TM Trauma
Traumatic TM perforation R

 10834524 원교 O
Fig
Traumatic TM perforation

 Acute stage: blood clot

 Mx: Antiseptic mx only
 Small perforation
 Spontaneous closure
 Surgical closure if persistent perforation
3 mo after trauma
 Emergecy if post perforation & vertigo
Small Post Perforation
Small Post Perforation
Goals of Therapy for COM

 Primary
 Dry ear
 Resolution of otorrhea
 Safe ear
 Prevention of complication
 Secondary
 Hearing improvement
Middle ear atelectasis and
adhesive OM
Middle ear atelectasis

 d/t Long-standing eustachian tube dysfunction.

 TM retracted onto the promontory and the
ossicles of the middle ear
 But not adherent to the medial wall of the
middle ear
 Intact mucosal lining of the middle ear
 Partial or complete obliteration of middle ear
space
  
Adhesive otitis media

 TM :
 adherent to the ossicles and promontory
 mucosal surfaces are not present.
 Erosion of the Ossicles
 long process of the incus and the stapes
suprastructure
Incidence of atelectasis in
OME
 Bilateral OME,
 5% of untreated ears
 2% of ears treated with VT
  
 Possibility - repeated bouts of AOM lead to
weakening and thinning of the
membrane?
  
Pathology of Atelectasis

 Sadé and Berco

 Destruction of the collagen-containing
fibrous layer of the tympanic membrane

 cf. TSP - also collagen destruction

  
Four states of TM retraction

 Stage I Retracted tympanic membrane

 stage II Retraction with contact onto the
incus
 stage III Middle ear atelectasis
 stage IV Adhesive otitis media
  
 Atelectasis may be reversible with VT
 May be a precursors to cholesteatomas
  
Diseases Masquerading as CSOM

 Inflammatory  Foreign body

 Wegener’s  Neoplastic
grnulomatosis  Nasopharyngeal
 Sarcoidosis angiofibroma
 Infectious  Parapharyngeal tumor
 Tuberculosis
 Malignant otitis externa
 Inverted papilloma
P.135 COM surgery

 수술전 검사… . 모두
 Tympanoplasty with mastoidectomy,
tympanomastoidectomy
 Tympanoplasty… 재료… temporalis fascia
 Complications of TM OP: 모두 …
Perforation
 Tympanosclerosis

Whitish plaques
in lamina propria
or submucosa
Hyaline degeneration
with calcification
Untreated TM Pathology
Cholesteatoma

 AOM 보다 더 무서운 Cholesteatoma

 학생강의 생략
Complications of
Cholesteatoma
 COMPLICATIONS AND EMERGENCY STATES OF CHRONIC
OTITIS MEDIA WITH CHOLESTEATOMA

    Hearing loss: conductive, sensorineural, mixed type

   Labyrinthe fistula: mainly horizontal semicircular canal,
rarely cochlea
   Facial nerve paralysis: acute or chronic
   Intracranial infections
   Brain hernia or cerebrospinal fluid leakage
Mechanism fo Bone Resorption in
COM
 Increased number and activity of osteoclasts.

 There are many metabolites and cytokines

known to activate osteoclasts locally. PGE2,
OPGL, and MCSF are some of the most potent
osteoclast-activating metabolites. Cytokines and
growth factors such as IL-1, IL-6, TNF-α, EGF,
PTH-rP, and TGF-β seem to play an important
role in middle ear infections and cholesteatoma.
tPA and collagenase also may play a role of local
invasion of cholesteatoma. Recent evidence
suggests that bacterial biofilms within
chronically infected cholesteatomas may
contribute to their aggressiveness by local
elaboration of lipopolysaccharide.
중이 middle ear

이관을 통하여 비인강과

연결되는 함기강
고막 tympanic
membrane
이소골 ossicle
이내근 intratympanic
m.
기능
외이도를 통하여 고막
에
고막 tympanic membrane
9-10 x 8-9 x 0.1 mm 의 회
백색 (pearly white) 또는
담홍색의 얇은 막 . 100
mmHg(ca 130 dB) 에도 견
딤.
Outer squamous epithelium,
middle fibrous layer,
inner mucosal layer

주요 명칭 : annulus, pars
tensa, cone of light, pars
flaccida (Shrapnell’s
membrane), short process
of malleus, handle of
malleus, umbo,
중이강 middle ear space

Tympanum:
mesotympanum,
protympanum,
epitympanum,
hypotympanum,
aditus,
mastoid antrum,
mastoid air
cells
이소골

추골 , 방망이뼈 ,
malleus
침골 , 다듬이뼈 ,
incus
등골 , 등자뼈 ,
stapes
 The Ossicular Chain(1)
 A Malleus
 B Incus
 C Stapes
 Ossicles are smallest
bones in the body, fully
formed at birth
 Act as a lever system
 Footplate of stapes
enters oval window of
the cochlea
이내근 intratympanic muscles

고막장근 tensotympani
m.
삼차신경지배
등골근 stapes m.
안면신경지배
기능
큰소리에 수축하여
내이를 보호하는 역할
stapedial reflex
이관 Eustachian tube, E-
tube 중이의 전상부에서 시작하여 비인강의
Rosenmüller fossa 에 열린다 .
약 37 mm 의 길이로 외측 1/3 을 골부 , 내
측 2/3 은 연골부이다 .
연하운동 , 하품 등으로 구개거근 (levator
veli palatini m.) 의 수축으로 열려 중이 내외
의 압력의 평형을 이룬다 .
 Middle ear physiology
 The middle ear acts as a Impedance
matching transformer
 Air to Fluid (Cochlea)
 중이가 없다는 가정 하에서 공기와 물 사이의 에너지 전
달 효율은 약 0.1%
 Provides a pressure gain
 Amplification 31.5-36.5dB 한글책
Sound Amplification

 학생 교과서 54
Passive Amplification of
middle ear
 1. Ratio of vibratory area
• X 17-20 = 25dB
of TM vs stapes , At:As
 2. Lever action of the
ossicular chain , lm:ls • X 1.3 = 2.5dB
 3. Buckling effect of TM
(=Shearing)
• X 2-3 = 4-9dB

 Cf. dB=20log(P2/p1)
• =31.5-36.5dB
Tympanic cavity

 Round window effect

 Sound wave 의 RW 의 직접 전달방지
 Round window niche
 Perpendicular to TM
 Phase difference
 Oval window vs Round window
Buckling Effect

 Catenary effect, Shearing effect

 포유류 ( 고양이 ) 고막의 일반적 특징
 Tensor Tympani + TM surface tension
 Cone shape TM
 집음력
 복원력
Tensor tympani &
Shearing Effect

 Shearing effect 를 좀 더 부연 .
 고막의 표면장력과 tensor tympani 의 긴장도
의 평형점에서 고막의 원추형 단면을 가지게 되
고,
 malleus handle 이 그 안에 위치 .
Eustachian Tube
Eustachian Tube(1)
 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, but status can
influence hearing ability
 유아이관과 성인이관과의 차이

유아 이관은
협부가 불완전 ,
상대적으로 수평위
짧고
굵다 .
E Tube - Introduction

 Bartholomeus Eustachius
   Medical 2/3 Cartilage, Lateral 1/3 Bone
 평상시는 폐쇄 , 연하운동 , 하품 시만 열림
  
Eustachian Tube Function
 1. Ventilation
 of the middle ear
 2. Protection
 from nasopharyngeal
secretions and sound
pressure
 3. Clearance
 of middle ear infection.
4 Paratubal muscles

 Tensor veli palatini :

 only active dilator
 Levator veli palatini
 Salpingpharyngeus
 Tensor tympani
4 Paratubal muscles Fig
Tensor Veli Palatini

The only one muscle

that opens
cartilaginous E-tube
Closure of the tube :
passive
Normally closed at rest,
opened by swallowing,
yawning, and sneezing
 E-tube of children is different to adult

by its;
short length
relatively wide diameter
more horizontal angle
Comparison between
Infant and Adult Eustachian
 = Why more susceptible to OME?
tubes
  
 18 years of development and growth
 Lengthens rapidly during early childhood
 Adult size by age 7
  
 Child – Passive conduit for nasal secretions
 Easy reflux of NP secretions to middle ear
 Adult - Active tubal opening
  
Values in infants compared
with adults
 Length of tube
 Shorter
 Angle of tube to horizontal plane
 10° versus 45°
 Cartilage cell density
 Greater
 Elastic at hinge portion of cartilage
 Less
 Ostmann’s fat pad
 Relatively wider
Eustachian Tube Dysfunction

Obstruction
Abnormally patulous E-tube, APET
E Tube Function Test (ETF)
이관검사법
 Valsalva법
 Toynbee 법
 Frenzel 법
 Politzer 법
 Catheterization 법
ETF – Valsalva

 The Valsalva test is performed by visual

inspection of the tympanic membrane
while the eustachian tube and middle ear
are inflated by a forced expiration with
the mouth closed and the nose occluded
by the thumb and forefinger. The test is
positive when an intact tympanic
membrane is observed moving, or by air
heard through a perforated TM. A positive
valsalva test only indicates an
anatomically patent and probably
ETF - Toynbee

 Watching the ear drum as the

patient swallows with the nose
pinched off and then swallows
with the nose unobstructed.
 The first step normally causes
the ear drum to retract, while the
second step releases it
ETF – Politzer

 The Politzer test is performed by visual

inspection of the tympanic membrane
while compressing one naris into which
the end of a rubber tube attached to an
air bag has been inserted while the
opposite naris is compressed with digital
pressure. The patient is asked to repeat
the letter K or to swallow while air is
injected into the nasal cavity. When
positive, the overpressure that develops
in the nasopharynx is transmitted to the
Tests of middle ear function

 Tympanometry (Impedance audiometry)

 Equivalent volume measure
 Static acoustic immitance
 Eustachian tubefunction test
 Acoustic reflex measure
 Impedance Audiometry

 Middle Ear Analyzer

2. Tympanometry
226 Hz IA
Normal EAC Vol
 Child 0.5-1.0 ml
 Adult 0.6 – 2.0 ml
3. Acoustic(Stapedial) reflex
– WNL = 70-100 dB
• Reflex decay
• E-tube function test
Impedance Audiometer Fig
Result Parameters

 1. Ear Canal Volume, measured in cm3, indicates the volume from the
probe tip to the tympanic membrane at a pressure of +200 daPa.
 2. Compliance Peak, expressed in daPa, indicates the amplitude of the
peak. This value can vary from NP (no peak) to 6.0 cm3.
 3. Pressure Peak, measured in cm3, indicates the pressure at which
equalization occurs on both sides of the tympanic membrane. It also
indicates the pressure at which peak compliance or maximum mobility is
attained. This corresponds to the value on the horizontal axis of the graph.
 4. The Scale of Reference, measured in cm3, is dependent on the
amplitude of the tymp peak measurement. This scale is either 1.5 cm3 or
3.0 cm3. Should the peak measure 1.5 or less in amplitude, the scale
reading will be 1.5 cm3. If it is 1.6 or greater, the scale will read 3.0 cm3.
The change in scale size merely allows a greater distribution of the graph
on the chart. A tymp peak reading of "NP" will automatically cause the
scale reading to be 1.5, which is indicative of no peak.
 5. Normal Box indicates the range of pressure peak and compliance peak
values associated with normal middle-ear function. (-150 daPa to +100
daPa, 0.2 cm3 to 1.4 cm3 per ASHA, 32, Suppl. 2, 1990, 17-24).
 6. Gradient, expressed in daPa, is the tympanometric pressure width at
Classification of Otitis Media
 Definition:
 Otitis media is an inflamation of the
middle ear, without reference to a
specific etiology or pathogenesis

 Classification by;
duration of the disease
presence/absence of effusion
physical state of TM
presence of atelectasis/retraction pocket
Classification of Otitis Media
by Duration of
 Acute the Disease
< 3 weeks
Subacute : 3 weeks - 3 months
Chronic > 3 months
 The natural history & management of acute & subacute
effusions differ greatly from that of effusion present 2-3
monts or longer.

 AOM, MEE, cOME

Middle Ear Anatomy and
Auditory Physiology
How to describe
 1) 이경 (Otoscope) 을 통해 관찰한 정상 우측 고막소
견을 간단히 그리시오 . / 자세히 그리시오

 2) 환기관 삽입술 시 적절한 고막절개술

(myringotomy) 위치에 O 표 , 환기관 삽입을 하면
절대 안 될 위치에 X 표

 3) 중이염 수술시 고막천공을 통해 관찰한 우측고막 및

중이 소견을 그리시오
Figure 2.3 Right ear. Division
of the tympanic
membrane into four
quadrants:
A.S.=anterosuperior;
A.I.=anteroinferior;
P.S.=posterosuperior;
P.I.=posteroinferior. This
division facilitates the
description of different
pathologic affections of
the tympanic membrane.
 OM - Description of Tympanic
Membrane
intact
perforated;
central / marginal
tympanosclerosis
retracted / atelectatic
effusion
Method of TM evaluation

1. Position
Normal, retraction, bulging,
2. Color
Normal – pale grey, transluscent
Yellow or blue (r/o MEE), amber (MEE)
Dark pink / light red (AOM or Hyperemia d/t
crying, coughing, nose blowing)
Method of TM evaluation

3. Mobility
 Normal
 Movement only with negative pressure (E-tube
dusfunction)
 Only slight movement with both positive and
negative pressure (MEE)
 No movement (perforation or VT)
 Modified Fulghum Scale:
Otomicroscopy grading scale for OME

Laryngoscope 2000 November;110(11):1857-1860

Evaluation of TM Mobility

 Pneumatic otoscopy
 Impedance Audiometry
 Bailey Fig 121-4
Tympanic Membrane

 Normal color : Pearly grey

 Pars flaccida, Pars tensa
 Histological 3 Layer
 Skin : Stratum cutaneum
 Elastic fiber : Stratum proprium
 Mucosa : Stratum mucosa

 Cf. Atrophic TM
Ossicles

 Malleus
 Head, Neck, Handle, Short process,
 Incus
 Long crus : lenticular process, IS joint
 Short crus
 Stapes
 Smallest bone in our body
 Oval window (Cochlea)
Middle ear structure OP memo

 Letf ear viewed externally

MIDDLE EAR CAVITY
 1. Lateral wall - Tympanic cavity proper : TM & Annulus
epitympanum: squamous temporal
bone & scutum
cf) Prussak’s space
 2. Medial wall - Promontory of LSCC
Promontory of Facial canal
Oval window niche
cochlear promontory
round window niche
cf) subiculum, Ponticulus
3. Anterior wall – Superior : E- Tube
opening (lateral portion of

ICA horizontal part)

Inferior : ICA

4. Posterior wall- anterior wall of

mastoid air cell
Facial recess,
pyramidal eminence,
Tympanic sinus
(lateral -> medial)
Lateral Wall of Tympanic Cavity
Fig
 Right ear viewd from
internally
 From medial
(internal) view
 2 Striated muscles of Middle
ear
 1) Protection of cochlea from noise
 2) Vocalization, body movement, tactile stim.
 1kHz 이하의 음의 전도를 저하시킴 .

 Acoustic reflex
 Stapedius
 CN7, stapedial b ranch of FN
 Tensor tympani
 CN 5 더 큰 소리
Tensor Tympani Fig

 Vivid view of malleus

and tensor tympani through thin TM 6 yrs pos
stapedectomy
with Lippy-Robinson prosthesis.
 Tenosr tympanii 가 shearing effect 를 보이
다가 , 완전히 도태되기 일보 직전의 모습
Stapedius muscle

 Smallest muscle in our body

 Pyramidal eminence
Middle ear mucosa

 flat, cuboidal, and columnar cell types

 Scanning electron micrograph of mucosa
overlying the center of thepromontory in
a human.
 Many nonciliated cells with surface
microvilli and few ciliated cells are shown.
Mastoid Pneumatization

 3-4 세 성인과 같은 모양

 Pneumatic
 Diploic
 Sclerotic
Other Structure in the
Temporal Bone
 Major Structure
 Carotid a, IJV,

 Surgical landmarks
 Sigmoid sinus, Dura
 Facial nerve,
 Sound
Three components of a sinusoid
physical terms range subjective terms
frequency 16 - 20000 Hz pitch
intensity 0 - 120 dB loudness
phase location of sound

Conversational range : 250-2000 Hz

Human Hearing
Localization & Bilateral
Hearing
Phase
Low frequencydifference
High frequency
Interaural Time Difference Interaural Level Difference
Air Conduction vs
Bone Conduction
 Air conduction:
 Headphone
 외이 , 중이 , 내이 전 감음기관을 통한 청력의 성적
 Ossicular chain to Oval window
 Bone conduction:
 Bone vibrator
 내이만을 통한 청력
 Skull vibration to Endolymph or Ossicle
 AB gap: BC 은 항상 AC 보다 우수하다 .
EAC : Auditory Aspect

 Resonance effect
 Amplification : 10dB – 15dB
Prevention of CSOM

 Primary
 Vaccinations
 Chemoprophylaxis
 Lifestyle modifications
 Secondary
 Treatment of otitis media
Xylitol Gum to Prevent AOM

 Randomized placebo controlled trials

 12% reduction in AOM
 Number needed to treat(NNT) = 8
 Uhari M. Pediatrics 1998
 No benefit in patients with PETs
 Legace E. J Fam Pract 1999
 자일리톨껌
 국내에 나와 있는 일반적인 자일리톨껌은 대략 검질  3-40%,  단맛을 내
는 설탕성분으로 자일리톨  6-70%  에  1-2%  정도의 향료등이 들어 있
습니다 . 

자일리톨껌의 메이커에 따라 다르지만 검질을 제외한 설탕부분을 자일리
톨로  100%  대체한 경우도 있고 설탕부분 중  5-60% 는 자일리톨로 나
머지  4-50% 는 말티톨을 비롯 이소말트나 솔비톨같은 기타 환원당으로 
구성 할 수도 있습니다 .   

자일리톨이 충치균에게 작용하는 무익회로를 기대하려면 
적어도 자일리톨이  50% 이상 함유되어 있는 무설탕껌이
어야 한다는 것이 자일리톨을 인증하는 각 나라 치과의사협회의 규정
입니다 .
 (http://www.xylitolstudy.co.kr)
Effectiveness of Avoidance

 Food allergy and recurrent OME

 78% incidence (N=104)
 Elimination diet
 86% reduction of OME
 Challenge diet
 96% recurrence of OME
 Other
 Smoking, daycare, bottle feeding
Steroid treatment of OME

 Systemic steroid + Antibiotic

 32% increased resolution of OME (NNT=3)
 Compared to antibiotics alone
 Inhaled Nasal Steroid + Antibiotic
 25% increased resolution of OME(NNT=4)
 Compared to Abx + placebo or Abx alone
Medical Treatment of Otorrhea

 Aural toilet
 Topical antiseptics
 Topical antimicrobials
 Systemic antimicrobials
. 틀린 그림