 A sinus (Latin a hollow; a bay

or gulf) is a blind track (usually

lined with granulation tissue)
leading from an epithelial
surface into the surrounding
tissues.

Sin
us (acq

uired)
 A fistula (Latin = a pipe or
tube) is an abnormal
communication between the
lumen or surface of one organ
and the lumen or surface of
another, or between vessels
https://surgeryonline.wordpress.com/2008/10/17/sinuses-and-fistulas/
drKallya
n
1/27/2017 1
 This patient, 8 YRS
OLD GIRL, non-local
PRESENTED
WITH----
 Pain and sense of
something moving in
Rt ear for 1 wk and
H/O past ear
discharge on and off.
 Pain and discharge
behind the ear as
well.
2
 Hard of hearing
drKallya 1/27/2017
n
 Ext. auditory canal wall
is wet and odematous
with muco-purulent
discharge
 Central perforation on
TM *
 Conductive deafness *
 And behind the ear –
discharging sinus
 Fistula sign -ve

3
drKallya 1/27/2017 4
n
Ear Exam with Maggot
Speculum held

drKallya 1/27/2017 6
n
 On
Exam
 One discharging sinus
 Pain not much but we
got a number of
MAGGOTS ? Inside
the cavity.
 We took one ear
swab c/s- Proteus
mirabilis
 One X-ray Mastoid
and CT temporal
bone
 Systemic exam: NAD drKallya 1/27/2017 7
n
What features do you
expect t o get on
systemic/general exam f o r
this girl?
 Anaemia, tachycardia
 Fever
 Features of intracranial complications like
 Neck rigidity, kernig’s sign,
vertigo, nystagmus
 Neck: any mass or abscess

drKallya 1/27/2017 8
Focus on Nose and t hroat

 Rhinitis/ DNS/ sinusitis

 Adenoids/ NPC
 Pharyngitis/tonsillitis

 Any other pathology or source of

infection?
 Nutritional status is very important

drKallya 1/27/2017 9
n
 Diagnosis

 Chronic suppurative
otitis Media (CSOM)
 with chronic Mastoiditis
with maggots
infestation and hearing
loss

drKallya 1/27/2017 1
n 0
 CT scan f i n d i n g what you may find?

Loss of normal air cells

on mastoid.
Cavitation or osteolytic
lesion
 Or, just loss of normal
aeration in mastoid air cell
system

Figure. Acute incipient mastoiditis in a 3-

year-old girl with suspected right acute
mastoiditis showing increased attenuation
of the entire right middle ear with no
osseous defects. Note the normal aeration
of the tympanum and mastoid cells on Abnormal Norma
the left side.
https://pubs.rsna.org/doi/full/10.1148/rg.232025076 1/27/2017l 10
drKallya 1/27/2017 12
n
 Nasal decongestant
 Many patients do not use it because it is
not for ear
 Some patients use it in the ear mistakenly
 Proper explanation is necessary

drKallya 1/27/2017 14
n
 DEFINITION:  Usually it is a
non- specific
 Otitis Media is inflammation of type of
the middle ear that is usually inflammation
associated with the buildup of and
fluid.
 The fluid may or may not be occasionally it
 infected. may be of
specific type –
 Acute Chronic e.g. Tubercular
> 3 weeks

-
 Why O t i t i s Mediais so
important ?
 It is a very common disease encountered by ENT
Doc, GPs and paediatrician.
 In fact, it is the most common cause of
hearing loss in young children.
 Hearing loss is one of the most common
morbidities in Malaysia.
 It may give rise to serious consequences.
drKallya 1/27/2017 16
n
 MIDDLE EAR

 Biconcave disk shaped cavity

 Height 15mm / 13 mm
antero- postero
 2 mm at centre narrowest
point
 contains
 Air & 3 small bones or
ossicles
 Malleus, Incus, Stapes
 Chorda tympani nerve
 2 muscles- Tensor
tympani, Stapedius drKallya
n
1/27/2017 17
Intra-tympanic muscles/ ossicles
 Tensor Tympani

attached to
Maleus.

 Stapedius:

attached to Stapes

drKallya 1/27/2017 18
n
T YM PAN ICMEMBRANE
( i nner vi ew ) C hor dat ym
pani ner ve

drKallya 1/27/2017 19
n
 MIDDLE EAR RELATIONS
Above:
Temporal lobe of
brain
Ext. Labyrint
auditory Middle(
h
canal ear Medially),

( Laterally) VII Nerve

post-medially

Jugular
bulb
( Below)

1/27/2017 21
drKallyan
Facial nerve Mastoid antrum

 Attico-antral
 Marginal
perforation

 Central
perforation
 Mostly anterior

drKallya 1/27/2017 2
 TYPES OF OTITIS
1. ACUTE SUPPURATIVE OTITIS MEDIA (ASOM)
MEDIA
3-6 WEEKS
2. CHRONIC SUPPURATIVE OTITIS MEDIA
(CSOM) > 2- 6 WEEKS
3. CHRONIC NON-SUPPURATIVE OTITIS
MEDIA
ALSO CALLED
OTITIS MEDIA WITH EFFUSION (OME) OR
SECRETORY OTITIS MEDIA (SOM)

SPECIAL TYPE-
 Why does it occur?
Aetiology-
Is middle ear a
closed cavity?
 Closed except
Eustachian
tube

Directly via
TM

E
T

drKallyan 1/27/2017
24
 H o w i n f e c t i o n enters the middle
ear c a v i t y /
 Through the
eustachian
tube

 Through a
perforated ear
drum

 If negative
pressure
generates inside
middle ear.
• Middle ear pr essur e i s normal
atmospheric pressure.
• When climbing up, at hi gh al t i t ude,
pressure outside drops but inside
middleear s t i l l remains high.

• I f f a i l s t o equalize, i t may lead t o

i nj ur y and inflammation in middle ear

drKallyan 1/27/2017
26
 Why does it
occur?
1.Extension of a
nasopharyngitis via
submucosal lymphatics
2.Direct spread via an infected
surface exudate
Common precursors
Sinusitis Nasopharyngitis
Pharyngitis / Flu
Nasopharyngeal tumour
Rupture of TM trauma
Swimming and diving
Chlorinated water Operations
at nearby site Excessive nose
blowing etc.
Pathology?
Tubal occlusion
Engorgement and oedema of
ME lining
Exudation
Serous first
Later mucopurulent
Bulging of TM
Rupture by pressure
necrosis

Mastoidit
is & Subperiosteal
abscess

drKallya 1/27/2017 27
n
 ACUTE SUPPURATIVE OTITIS
MEDIA
(ASOM)
Bacteriology

 A wide range of bacteria

 Haemolytic streptococcus
 Strep. Pneumoniae
 Staph aureus
 Haemophylus influenzae

drKallya 1/27/2017 28
n
 C l i n i c a l features
Phase 1 Fullness of ear Deafness/
autophony Retraction of
Acute tubal TM at very early stage
obstruction

Phase 2 Deafness increase Bubbling

Acute infection Before sound in ear Earache
rupture stabbing Constitutional
of tympanic cavity features: Fever, headache,
malaise etc

Intratympanic
pressure suddenly Otorrhoea,
falls after Relief of pain
rupture

Phase 3 Pain and tenderness on

mastoid region Constitutional
Acute mastoiditis disturbances increase 30
drKallyan 1/27/2017
D i f f e r e n t i a l diagnosis

 Furuncle of  Discharge
external ear  Pain
 Diffuse  Swelling
otitis  Reduced hearing
externa
 Malignant  EAC walls significantly inflammed
 TM usually normal or intact.
otitis externa
 Discharge not from ME
 Herpetic  Pain on moving on tragus or
lesions auricle
 DM

drKallya 1/27/2017 30
n
Investigations

 Diagnosis is mainly
clinical
 You can consider:
 Blood test
 Pus for culture/sensitivity
 X-ray mastoid
 Occasionally CT scan

drKallya 1/27/2017 31
n
Treatment
Symptomatic Local medications

 Rest  Nasal decongestant drop

 Analgesic  Before perforation
 Sedative  Myringotomy:
 Local heat sometimes

Antibiotic
 A broad spectrum
antibiotic should be
started until C/S report is
ready.
 Oral or IV
 After perforation
 Topical antibiotic drop
 Aural toileting
 Occassionally
Mastoidectom
y
Chronic Suppurative Otitis Media

 Suppurative * Pus formation

- * Frank pus
or
Saf Unsafe sometimes
e * Muco-
Attico-antral purulent

Tubo-
Tympani
c drKallya 1/27/2017 34
n
 MIDDLE EAR RELATIONS
 Facial nerve
 8th nerve
 Vth and VI th nerve
at apex of petrous
pyramid.
• Cerebellum
posteromedially
• Eustachian tube:
anteriorly

drKallya 1/27/2017 35
n
5T
and 6th ner ve
rHe l ai tni o n t o petrous
apex of t e m p o r a l
bone

drKallya 1/27/2017 36
n
Tubo- Tympanic

 Regarded as safe
 Results as a
consequence of
an ASOM
 Lack of attention and
re-infection either
from nasopharynx or
through the
perforation allow
acute infection to
persist or to recurred.
drKallya 1/27/2017 38
n
 Pathology

 Perforation of Tympanic ▪
membrane can be of any TM
size and shape.
 Large and kidney-shaped (sub-
total)
 Small to pinhole size
 Situated in Pers
Tensa, frequently
anteriorly.
 Ossicular chain
usually remains
intact.
drKallyan
1/27/2017 39
•Mucosa of Middle Ear looks velvety,
pink and oedematous.
•Occassionally a polypus can be
formed from ME mucosa.
•Normal pavement epithelium can be
replaced by collumnar secreting cells
by metaplasia or by extension of
epithelium from ET.
•The mastoid is usually cellular and
may show some changes simillar to
ME and can act as a reservoir of
infection

drKallya 1/27/2017 40
n
Tubo- Tympanic

 4 Stages:
 Active stage
 Quiescent stage: H/O otorrhoea in
recent past
 Inactive stage: Dry for several months
 Healed stage

drKallya 1/27/2017 41
n
Attico-antral
 Associated
with
Cholesteatoma.
 Regarded as unsafe
or dangerous.
 Granulation tissue may
or may not be.
 A continuous process
with exacerbations
with infection.
drKallya 1/27/2017 42
n
 Cholesteatoma : An epidermoid cyst
containing desquamated sheets of keratin & lined
by keratinised squamous epithelium.

 Definition –
 Cholesteatoma is a three dimensional epidermal and
connective tissue structure, usually in the form of a sac and
frequently conforming to the architecture of the various
spaces of the middle ear, attic, and mastoid. This structure
has the capacity for progressive and independent growth at
the expense of underlying bone, displacing or replacing the
middle ear mucosa, and has a tendency to recur after
removal.

 - Abramson (Cholesteatoma – First International Conference,

Birmingham, 1977)
drKallyan 1/27/2017 43
 A cholesteatoma is a hamartomatous like
keratin-producing squamous epithelial lesion
that is constructed very much like an onion,
in layers. The bulk of these tumors consists
of desquamated skin deposited into a core
of shed dead cells called the matrix.

https://pedsinreview.aappublications.org/content/20/4/134

drKallya 1/27/2017 44
n
 What i s keratin?
 Keratin is one of a family of
fibrous structural proteins. Keratin
is the protein that protects
epithelial cells from damage or
stress. It is the key structural
material making up the outer
layer of human skin, hair and nail.
 Keratin is formed by keratinocytes
 Any intervention in this normal
migration process can lead to
abnormal accumulation of
keratin and desquamated
epithelium. drKallya
n
1/27/2017 45
 Theories of cholesteatoma (OCNA 2006)

 Middle ear cholesteatoma occurs as two

principle different entities
 o Congenital
 o Acquired
  Primary acquired or attic retraction
pocket cholesteatoma
Secondary acquired cholesteatoma Occurs
secondary to epithelial migration into the
middle ear at the site of a tympanic
membrane perforation or iatrogenically
implanted during an otologic procedure.
drKallya 1/27/2017 46
n
 Primary acquired cholesteatoma
  Four predominant theories
 Invagination (whitmack’s)
 Basal cell hyperplasia or papillary ingrowth (Reudi)
 Metaplasia (Sade)
 Epithelial invasion
  The invagination theory is currently regarded as
one of the primary mechanism of the formation of
primary acquired attic cholesteatoma

drKallya 1/27/2017 47
n
Cholesteatoma formation

Congenital

Arising from embryonic epithelial tissue and

may involve mastoid, petrous and otic
capsule resulting in VII palsy, deafness and
vestibular dysfunction.

drKallya 1/27/2017 48
 The invagination theory
Blocked or long standing
Eustachian tube
dysfunction.
Impaired
ventilation in middle
ear

Negative middle ear

pressure structural
weakening of the
tympanic membrane
Development of
retraction pockets
pars flaccida, having the
weaker structural support, is
the most common site of
formation of a retraction drKallya 1/27/2017 49
n
Proprogressive
retraction.
impairment of epithelial
migration and cleaning
of keratin debris

accumulation of
keratin debris in the cytokine mediated
enlarging pocket inflammatory response --
> epithelial proliferation
local release of
collagenases

Bacterial expand by invading into

proliferation and surrounding middle ear
super-infection of soft tissue structures
and bone
accumulated debris drKallyan 1/27/2017
5
0
CT scan temporal bone:
cholesteatomatous invasion into
ME

drKallya 1/27/2017 52
n
 Cholesteato
ma
progression
 A small lesion can be extruded into EAM and
whole process can be stoped.
 Protrusion of finger-like processes of the cyst
into the tympanic cavity.
 Filling of the Tymp. cavity.
 Encroachment of mastoid structure and
progresses by osteolysis.
 Interfarence with ventilation
 Effusion drKallya 1/27/2017 53
n
Cholesteatoma
progression
 Active infection of keratotic
mass
 Formation of granulations ,
polypi & cholesterol
granuloma
 Increased exudation
 Infective necrosis of thin
bony barriers
 Spread of infection
 Fistulization of labyrinth
drKallya 1/27/2017 54
C l i n i c a l features

 Race : More in
 Indians
Age Common in Children here.
: Equally in male and female
 Sex : History
Premorbid history of recurrent AOM,
traumatic perforation, or placement of
ventilation tubes. Typically, they deny
pain or discomfort.

drKallya 1/27/2017 56
Predisposing factors
 Living in crowded conditions
 Daycare facility attendance
 Being a member of a large family
 parental education, passive smoke, socioeconomic
status, and the annual number of upper respiratory
tract infections
 Swimming/bathing in S. pools
 Malnutrition
 Rhino-sinusitis, adenoids, tonsillitis
 Cranio-facial anomelies

drKallya 1/27/2017 57
C l i n i c a l features
 Without complications: Pt. usually presents
with * persistent or recurrent ear discharge.
 Hard of Hearing
 Earache sometimes
 Bleeds
 Tinnitus
 In case of unsafe variety discharge may be
Scanty but foul smelly( malodourous)
*Maggots (Myiasis)

drKallya 1/27/2017 58
With complications
 Headache,
 Earache,
 Vertigo,
 Facial paralysis
 Fever with chill and rigor
 Features of Intracranial complication
like meningitis, abscess etc.
Diagnosis
 Very simple
 Otorrhoea, recurrent or persistent
 Ear Drum perforation
 More discharge, less smell, central or
ant. Hole ? -------usually safe.
 Less / scanty discharge, foul smell, attic
or post-superior perforation? –Unsafe.
 One may see greyish white or pearly sheets
of cholesteatoma/ polypi/ granulations
Facial Paralysis

drKallya 1/27/2017 61
n
1/27/ 01 drKallya 61
2 7 n
drKallya 1/27/2017 63
n
 Complications

Extracranial
 Direct spread
through bone:
 Osteitis, caries,
Erosion
 Venous spread-
Thrombophlebitis
 Spread via
Labyrinth-
labyrinthitis
 Facial paralysis
Complications
 Osteomyelitis of
the Temporal
 Blood stream
infection- venous
sinus thrombosis,
septicaemia, pyaemia,
metastatic abscess,
 Subperiosteal abscess
 Postauricular,
Zygomatic,
Pharyngeal

drKallya 1/27/2017 66
n
Complications-intracranial
 Pachymeningitis
 Leptomeningitis
 Thrombophlebitis of sigmoid
sinus
 Sub-dural , extradural abscess
 Brain lesions-encephalitis
Brain abscess-cerebral,
cerebellar
Common Organism

Mainly Gr –ve organisms Gr +ve

Staphylococcus
aurius
 Ps. Aeruginosa
 Proteus mirabilis
 B. proteus
 Klebsiella
 Polymicribial
 Anaerobes/ Fungi
Investigations

 General------------
 Specific-
Ear swab for
C/S X-Ray
Mastoid
Biopsy, HPE
Audiometry
CT scan/MRI
And as per complication if
 Pure tone audiometry

drKallya 1/27/2017 69
Treatment

Objective

 To remove the disease

 To eradicate and prevent
infection
 Secondly, to improve or to
 Retain Hearing level

drKallya 1/27/2017 72
n
Treatment – t o remove disease

Medical Surgical
 Control of infection  Removal of
 Aural toileting polypi /
granulation
 Topical antibiotic drop
tissue /
 Nasal decongestant cholesteatoma
 Elimination of adjacent  Atticotomy to
foci Mastoidectomy of
of infection variable extent
 Systemic antibiotic depending on the extent
 Antihistamine/ T. toxoid of disease.
drKallya 1/27/2017 73
n
Treatment- For hearing

 Different types of
tympanoplasty
 Myringoplasty
 Ossiculoplasty

 Periodic follow-up
 How to take care of ear
 Good personal and home hygiene &
environment
drKallya 1/27/2017 74
n
 ADVICE TO PATIENT
 Pastikan telinga sentiasa kering
 Pastikan air tidak masuk kedalam telinga
 Jangan bersihkan telinga terlalu kerap
 Jangan masukan minyak ke dalam telinga
 Jangan makan makanan terlalu sejuk atau yang
boleh mengakibatkan alahan
 Jangan menghembus kedua-dua hidung dengan kuat
serentak.
 Rawatan cepat kalau ada selesma sumbat hidung.
 Jangan berenang/diving
drKallya 1/27/2017 75
n
Temporal bone
T EMPORAL BONE

drKallya 1/27/2017 77
n
TYMPANIC MEMBRANE

1/27/2017 drKallya 76
n
 TYMPANI C MEMBRANE

 SEPERATES EXT. EAR

FROM MIDDLE EAR
 PEARLY GREY-
 3 LAYERS: WHITE COLOUR
 OUTER EPITHELIAL
 MIDDLE FIBROUS LAYER HAVING CIRCULAR AND RADIAL
FIBRES & HANDLE OF MALLEUS
 INNER MUCOSAL LAYER
 CONE OF LIGHT: FROM UMBO ANTERO INFERIORLY
 Otitis media
• Otitis media is formally defined as inflammation
of the middle ear space, and it is one of the most
common illnesses in the paediatric population
worldwide.
 …………………..A Disease Spectrum
• Acute otitis media

Subacute

• Chronic Otitis
Media

06/20/13
Otitis Media with Effusion

(Secretory Otitis Media)

Glue Ear
Otitis Media with Effusion
in
Children
 Acute Otitis media
• As per American Association of Family
Physicians (AAFP.2009a) this is: acute
onset of signs and symptoms, the
presence of middle ear effusion
(bulging of the tympanic membrane, or
limited or absent mobility of the
tympanic membrane, or air-fluid level
behind the tympanic membrane, or
otorrhoea), and signs and symptoms of
middle ear inflammation (distinct
erythema of the tympanic membrane
or distinct otalgia.
 Chronic suppurative otitis media
CSOM

• Chronic suppurative otitis media causes recurrent or persistent

discharge (otorrhea) through a perforation in the tympanic membrane,
and can lead to thickening of the middle ear mucosa and mucosal
polyps. It usually occurs as a complication of persistent acute otitis
media (AOM) with perforation in childhood.
Otitis media with
effusion (OME, ‘glue
ear’
)Is presence of fluid in
the
middle ear behind an
intact tympanic
membrane without signs
and symptoms
acute infection. of an
(Boonacker)

It is o.ne of the most

common illnesses in the
paediatric population
06/20/13

worldwide.
 Otitis media with effusion

• This is presence of fluid in the

middle ear, without signs and
symptoms of acute ear infection
as diagnosed by (pneumatic)
otoscopy or tympanometry
(AAFP 2009b).
 Pathophysiology
Eetiology is still not fully understood.

histologically a chronic inflammatory condition

(Qureishi et al.
2014)
 Risk factors for developing OME
Non-medical risk factors:
young age (two to five years
old)
large family size
history of OME in sibling
 short duration or no
breast feeding
passive smoking
Medical risk factors:
history of AOM
 nasal obstruction
 history of acute adeno-
tonsillitis
craniofacial anomalies
such as CLP and DS
 Otitis media with
effusion (OME) is the can be associated with
most common cause of delayed language
acquired hearing loss in development and
childhood, especially behavioural problems
during a time of rapid
language development. (Simpson et al 2011)
And that’s why-
 Prevalence
• Prevalence of OME varies between 6.5% to 10.9% among
children in different countries.
• Approximately 90% of children have OME at some time
before school age, most often between six months and four
years of age.
• Malaysia survey 2005:
• the prevalence of OME was 5.1% in general population,
• Saim et al. reported a OME prevalence of 13.8% among
preschool children
 OME is a fluctuating condition with symptoms

that vary with time and age,

and

may persist in some children. It is often

underdiagnosed.
• Untreated OME may lead to
• hearing impairment,
• speech and language developmental delay, and
• poor school performance.
• Long term complications include
• adhesive otitis media, ossicular chain disruption,
retraction pockets and cholesteatoma.
 Young
children
• Symptoms suggestive of OME:-
• hearing impairment suspected by parents, caregivers, teachers
• speech or language delay
associated presentation such as

• Aural fullness
• recurrent otalgia,
• upper respiratory tract infection or acute otitis media
• poor school performance
• lack of concentration or attention * Ear clean
 Presentation
Children Adult
• often asymptomatic with fluctuating • sSame but may present early.
hearing loss.
• Hearing impairment commonest • May be associated with
presentation (90%) at home or other diseases e.g. NPC,
in school. conductive type.
other PNS tumours.
• Common associated presentations
are otalgia (60%), upper respiratory • Unilateral ?
tract infection/URTI (40%), AOM
(30%) and tonsillitis (18%).
 By doctor
As an incidental
finding Patients come
for other problems -
URTI, Rhinitis, Nose
block, lack of
attention, poor
performance,
imbalance.
 Rinne and Weber tuning fork tests

• Variable sensitivity and specificity in predicting

conductive hearing loss associated with OME.
• Not very reliable in children less than 12 years of
age.
 OME with thick
glue
Pre-op Post-op
34 dB 1/52, 14
dB
• Type B tympanogram is highly
suggestive of OME.
• Type C2 tympanogram combined with
absence of ASR may also suggest
OME.
 Types of tympanogram

Type A tympanogram Type B tympanogram Type C tympanogram

 Rinne and Weber tuning fork tests

• Variable sensitivity and specificity in predicting

conductive hearing loss associated with OME.
• Not very reliable in children less than 12 years of
age.
 Treatmen
• OME is a common t condition in children which is
usually mild with spontaneous resolution
occuring in 56% of cases at three Months.
• However, it can be recurrent and persistent after
that.

• NON-SURGICAL INTERVENTION
• Topical intranasal steroid is beneficial either alone
or with antibiotic
• Antihistamine or Decongestant
 Treatmen
t
• Hearing Aid: not a 1 line treatment
st

• offered to children with persistent bilateral OME

and hearing loss as an alternative to surgical
intervention where surgery is contraindicated or
not acceptable.
 Treatmen
t
• SURGICAL INTERVENTION
• Myringotomy with VT (Ventilation tube/ Grommet)
insertion
• To ventilate the middle ear.
• To improve hearing and minimise the risk of OME
recurrence.
• This will lead to normalisation of middle ear
pressure.
• Must be balanced between its risks and benefits.
 Treatmen
t
• Surgical Options:
• Myringotomy
• Myringotomy with VT
• Myringotomy with VT plus adenoidectomy
 Treatmen
• Surgical Options:
t
When?
• After 3 months of watchful waiting, if no
improvement.
• hearing impairment of more than 25 dB in the
better ear or
• structural changes to the tympanic membrane.