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					              Otitis Media
               Dr John Curotta



Head of ENT Surgery
The Children‟s Hospital at Westmead
    What is Otitis Media?
• AOM = Acute OM

• OME = OM with Effusion (= „glue ear‟)

• CSOM = Chronic Suppurative Otitis
         Media ( = a hole in the ear drum
                     which discharges)
 Ear drum without a hole
     2 types of fluid in middle ear:

• 1. Pus   -> Acute OM = AOM

• 2. Mucous -> Effusion = OME
 Ear drum with hole ( >6 weeks)
1. Simple hole: connects outer ear to
  mucous making lining of middle ear
(“like a nostril”) usually dry, but
  sometimes runny. = “SAFE‟ ear

2. Hole with skin of ear drum growing in
   = “UNSAFE” ear
         “UNSAFE” ear
              Also called:
• CHOLESTEATOMA
• Chol est e at oma
• „Kol-est-ee-at-oma „

• Means skin growing into ear, not out
   What is „UNSAFE‟ about skin
            growing in ?
• Skin is not normally in the ear and mastoid
• Lowest layer of skin makes an enzyme which
  eats away the bone
• This erodes Bones of hearing
               Bone covering inner ear
               Bone between ear and brain

             Deaf – Dizzy – Brain Abscess
   What makes you suspect an
        UNSAFE ear ?
• Persistent discharge

• The SMELL……Sneakers taken off after a
  week in the wet.




• That is ..soggy dirty mouldy skin…
         Cholesteatoma
• ALWAYS needs surgery

• Surgery: delicate / long / often repeated
           (very little pain and discomfort)
  !
          „Remote‟ Kids
Usually get early on :

• „Safe‟ Hole in ear drum ------

• Often Runny ears
    Northern Territory OM Survey
               2007
1300 children, 6 mo – 30 months old

•   25% AOM
•   5% AOM + perforation
•   15% CSOM
•   10% had completely normal ears.
       NT OM Survey 2007
By 6 months age   98% OME

By 12 months age
• 90 % AOM
• 35% AOM + Perforation
• 20% CSOM
    „Town‟ and „city‟ Kids
• Usually get what any other town/city
    kids get…….Glue ear.

• BUT because it is a hidden condition -
     …….may NOT get diagnosed !
 Job of Nurses for Ears
1. Runny ears: DRY the runny ears
               Maximise hearing
               Optimise learning

2. Glue ears: DIAGNOSE
              Maximise hearing
              Optimise learning
     RISK factors for Otitis Media
•   Boys
•   Brother/sister with OM
•   Early start to AOM (<6mo)
•   Not breast fed
•   Poor housing
•   Smoker at home
              PREVENTION
  Vaccination against Strep pneumoniae
                                (pneumococcus)
• PREVENAR works under 2 yrs age

• PNEUMOVAX works after 2 yrs age

• ( Hib – „Haemophilus influenzae Type b‟ vaccine
          is NO good for ears
          as they get „H influenzae Non-typeable )‟
      Pneumococcal Vaccination
           “PREVENAR”
• 239,000 operations for grommets in Australia
  in past 10 years

• Since Prevenar introduction in 2005
  grommets reduced by:
    <1 yr…23%
   1-2 yrs..16%
   2-3 yrs.. 6%
Study effect early Pn Vaccination
    ‘Remote’ NT Kids - 2009
• Minimal benefit in reduction Otitis Media
                       (unlike town/city kids)

Probably need
• Pneumococcal vaccine with wider spread
• Vaccine for Haemophilus infections of ears
• Vaccinate mothers
  Diagnose „GLUE Ear‟

• SCREEN

           vs

                • SUSPECT
    Aim of NSW Otitis Media
            Strategy
• is to screen all kids

• Eliminates guesswork



• But:      Do they all get screened?
           Hearing Testing

             Tiny Tots

• SWISH for all newborns
• NSW 99% cover ….Who is most likely
                     to miss out ?
Usual Tymps: unreliable under 6 months
           Hearing Testing
            Baby – to - 4 yrs old

VROA / Behavioural…test overall /
                    better ear hearing

Usual Tymps: „Reliable‟
           Hearing Testing
              • Over 4 yrs

• PTA + Tymps generally reliable
                AOM
           = pus in middle ear

• Body‟s immune +/- antibiotics kill
  bacteria BUT the mucous can take
  weeks to clear out
  POM = Fluid in ear since
        infection
• POM : “Persisting” Otitis Media
 i.e. after AOM, up to 12 weeks

   Once fluid is there > 12 weeks,
 Then call it : OME or „Glue ear‟
     Fluid in middle ear


AOM       POM          OME
0 weeks             >12 weeks
     Benefit of Hearing Testing
• Learning to talk

         vs

• Learning in classroom
 Hearing under 4-5 years
• One ear is enough to learn to talk and to
  get along at home

• So „general‟ tests of hearing are OK
     Hearing, over 4-5 yrs
• Unilateral OR Bilateral HL :
  very important to diagnose

• Poor hearing even in ONE ear is a
  major problem in classroom
     Hearing over 5 yrs
• This means at school

• Absolutely need both ears hearing
    Unilateral hearing Loss
• Very serious problem in class room

•   Placement
•   Background noise
•   Direction
•   Anything other than one-to-one talking
    Grommets - time working
• Small:   Shepard………………6 mo

• Medium: Reuter Bobbin………12 mo

• Large:   Sheehy Collar Button.18 mo

• Larger: T – Tubes……………24 mo +
 The bigger the grommet
• The longer it stays

• The bigger the risk of a larger
  perforation

• So, NO T-tubes in children
             Grommets
• The GOOD

• The BAD

• The UGLY
    Grommets- The GOOD
•   Instant relief
•   Consistent relief
•   Helps balance too
•   Reduces AOMs as well
      Grommets-The BAD
•   Need admission to hospital
•   Waiting list
•   General anaesthetic
•   How long effective
•   Repeat grommets
   Grommets-The UGLY
• Limit water exposure - e.g. swimming
• Discharging grommet a problem
  Social / hearing / extrude grommet
• Residual perforations, esp if large
large > 20% area TM (large is bad)
      in between…….(nuisance)
small < 10% area TM (small is good ! )
If not grommets – What ?
•   Seating position……….counting chooks
•   FM System
•   Hearing Aid/s
•   Room amplification
  Looking after grommets
• Its not the water




• It‟s the GERMS in the water
 Looking after grommets
• Clean water…OK
  shower,
  beach,
  well-maintained pool
  (Chlorine : High end +
        pH : Low end of range)
Some Remote WA - No School…No Pool
    Looking after grommets
     AVOID
•   Bath water
•   Spa‟s
•   Indoor heated pools
•   Creeks
                OR USE
•   Ear plugs and cap / head band
      Infected grommets
• Foreign material in the body - if infected
  gets covered in “slime”
• Called “BIOFILM”
• Like the inside of water pipes etc
• Also plaque on teeth / infected
  catheters/ IV cannulas etc
             BIOFILM
• Bacteria exude a jelly to cover
  themselves
• So, antibiotics cannot reach them

• To clean biofilm – must mechanically
  break it up – brush it / scrub it
 If not possible – remove the device.
Discharge through Grommets ..How?

• Head cold Virus: Increase secretion in
  nose / sinuses / ears
• Secondary bacterial infection (like AOM)

• Overflow through grommet
Discharge through Grommets ..How?

• If virus…dries up when nose dries up

• If bacterial.. May / may not dry up with
  nose….
  Antibiotic medicine or capsules
  (eg Amoxil) helps
Discharge through Grommets ..How?

• Bacteria which live on skin in outer ear
  can get into middle ear through the
  mucous discharge…..(pseudomonas)
  ..these are resistant to most oral
  antibiotics …
  Need DROPS
     Ear Drops for Grommets
• Ciprofloxacin (= Ciloxan / Ciproxin HC)
  is always safe in ears

• Sofradex usually safe in infected ears

• Sofradex is unsafe in clean ears
      Ear Drops for wax
• 1. Sodium Bicarbonate Ear drops
  ( chemist makes them up)
• 2. Waxsol drops
• 3. Ear Clear Drops for Wax Removal

Then syringe.
            Never Cerumol - too harsh
   Discharge through grommets
• If so much discharge ear drops cannot
  get in 
• Use 3% Hydrogen Peroxide as drops
  first, to clean the ear, dab dry and then
  put in drops. (only for a day or so at a time)

  (probably is breaking up Biofilm)
Wax or discharge in Ears
Gently syringe with dilute baby shampoo
1/2 teaspoonful in 1 cup warm water (= 1%)
                             (or 1 tsp in 500ml)

• Finish by syringing Betadine (1 tsp in 100ml)

  10 ml syringe with a cut-off scalp vein needle

             Safe in perforations or grommets
           References
• Aboriginal Ear Health Manual – Harvey
  Coates et al from WA
• Aboriginal Otitis Media ENT Program
  Evaluation Report 2002“
• Surgical Management of Otitis Media
  with Effusion in children” – Clinical
  Guideline, February 2008 - UK