DISEASES of the MIDDLE EAR

When the eardrum is of

normal transparency, the
Incus and the Stapes are
visible in the background

Cone of Light:
Anteroinferior

Wall of Ear Canal

Margin of the
Eardrum
Transformer Mechanisms:

Eustachian Tube

Middle Ear
Incus
Blood Supply:

Proximal: from Malleus

Distal: from Stapes
Vulnerable to Ischemia

Children – more prone to ear

effusion as a result URTI due to:

Shorter route

Less inclination

More horizontal

Narrower diameter

† MIDDLE EAR EFFUSION

Most common cause of hearing loss in school age children

Eustachian tube dysfunction is a major underlying factor Sensory of Tympanic Membrane:

Often has no symptoms other than hearing loss 1. Tympanic branch of the
Glossopharyngeal nerve
2. Facial Nerve
3. Trigeminal Nerve
4. Auriculotemporal branch of
the Vagus

Hyperemic; Less transparent

† OTITIS MEDIA WITH EFFUSION

 Multiple air bubbles indicate the
Eustachian tube is returning to normal
function & the effusion is resolving

† ADHESIVE OTITIS MEDIA

The middle ear effusion has been completely absorbed, with loss of middle ear space and
erosion and loss of the long process of the Incus.

The eardrum is firmly adherent to the bony wall of the middle ear.

There is moderate to severe hearing loss.

Adhesive Otitis Media!

1. Sticky serous fluid
2. Bluish in color: Middle ear
† In these 2 ears, the eardrum has
subepithelial capillary
become severely retracted. The network absorbs fluid
pressure of the eardrum on the 3. Negative pressure builds up
Incus is causing it to he eroded away. as a result of absorption
(Refer to arrow). 4. Tiny ossicles become dead
bone due to prolonged
† This is also called Atelectasis of the decrease in blood flow
Eardrum and is sometimes the result 5. Sticky glue
6. can lead to Atelectasis of
of prolonged OME (Glue Ear).
the Ear drum - never pops
up with Valsalve
* Do Tympanoplasty instead

† VENTILATION TUBE

Ventilation Tube

>6 weeks without response to
treatment

Do a tiny incision in Pars Tensa
of tympanic membrane

Danger of making the hole too
big thus persistence of
perforation

Due to the use of Polyvinyl
Chloride, the body will treat it
as a Foreign body and will try
to wall it off by own tissue as a
normal reaction to the foreign
body

A collar of skin will be formed
around the neck of the
ventilation tube forming a
thickened skin to try to force
the ventilation tube out

† MYRINGOTOMY – “Myringo” meaning Eardrum

Incision must be parallel to the radial arrangement of the
tympanic membrane

TM very tense incise release pressure apposed
Pars flaccida healing occurs
† MIDDLE EAR DISEASE
† ACUTE PURULENT OTITIS MEDIA

Streptococcus pneumonia-most frequent Acute Otitis Media symptoms

H. Influenza-frequent pathogen in children <5 years old in Children:

Classic symptoms: pain, fever, malaise, hearing loss
Severe Bulging due to fluid and
pus build up

Acute Purulent Otitis Media Child crying all night

Bulging tympanic membrane

Purulent nasal discharge Eardrum rupture meaning release
of pressure

Child suddenly stops crying

Acute Otitis Media *Better drain early!

When the purulent fluid is removed from the middle ears of children with Acute Otitis Media, the
following bacteria are cultured:

Streptococcus pneumoniae 40-50% of cases (7% are resistant to sulophonamides)

Haemophilus influenzae 20-30% of cases (H. influenzae is not sensitive to erythromycin)

Moraxella catarrhalis 20% of cases (previously Branhamella catarrhalis)

Streptococcus pyogenes 4% of cases (7% are resistant to sulphonamides)

Other bacteria 10-15% of cases (Staphylococci, Klebsiella, etc.)

Viruses 5% of cases

Bulging eardrum covered

with edematous keratin
 The middle ear infection has progressed.
The eardrum is bulging outwards due to pressure
build up of pus in the middle ear. This is usually
very painful–unrelenting, exquisite pain!
In these 3 eardrums, a blister
containing serous fluid has formed
under the outer layer of the eardrum.
When these dry out, they form a
“cast” which then migrates out the
ear canal.

Ear canal is full of pus

Eardrum has ruptured. Pus drains into the ear

canal which often becomes completely coated
with pus. The pain goes away. Prompt medical
treatment usually allows the eardrum to heal.

† TYMPANOSCLEROSIS

A white deposit in the eardrum. It is a common complication of ventilation tubes

in the eardrum but can also occur after repeated episodes of Acute Otitis Media
and after prolonged OME. It does not usually interfere with hearing. Clinically, if
it is present it is a sign of significant previous middle ear disease. In this ear, an
effusion is present, and the clear patch in the eardrum probably indicates the
site of previous ventilation tube. (refer to arrow)

† CHRONIC OTITIS MEDIA

Pseudomonas aeruginosa, Proteus vulgaris

Most common anaerobes – Bacteroides sp.

Otorrhea and hearing loss are common

Pain is uncommon and may be a serious sign
† CHOLESTEATOMA

Keratinizing squamous epithelium entrapped in the middle ear and mastoid

Cholesteatoma at the top of the eardrum. (The

attic or pars flaccida). The eardrum is thickened
and these is a mucoid effusion in the middle ear

Visible through a large perforation in the

eardrum this cholesteatoma surround the
malleus and occupies much of the middle ear.

† COMPLICATIONS of ACUTE OTITIS MEDIA and MASTOIDITIS

1. Extension by bone erosion – usual route for chronic disease and cholesteatoma
2. Preformed pathways – usual route in the acute process
3. Extension by Osteothrombophlebitis

† EXTRACRANIAL COMPLICATIONS
1. Subperiosteal abscess
2. Facial nerve paralysis
3. Labyrinthitis
4. Petrositis – Gradenigo’s Syndrome
6th CN palsy
Pain due to irritation of the 5th CN
Middle ear suppuration
† COMPLICATION of MASTOIDITIS

† INTRACRANIAL COMPLICATION
1. Extradural abscess
2. Lateral sinus thrombosis
3. Meningitis
4. Otitic hydrocephalus
5. Subdural abscess
6. Brain abscess

MENINGITIS

Most common intracranial complication of suppurative otitis media

Stiffness of neck, fever, nausea, vomiting, headache

(+) Kernig’s sign, (+) Brudzinski’s sign

↑CHON ↓ sugar in the CSF

BRAIN ABSCESS

Cerebellar abscess – ataxia,dysdiadochokinesia, intention tremors, past pointing

Temporal lobe abscess – seizures, aphasia

OTITIC HYDROCEPHALUS

↑ ICP

Normal CSF finding

Inability of arachnoid granulations to absorb CSF that is formed

† CT SCAN – preferred method for diagnosing middle ear and mastoid diseases

Thanks: Cecile Ong’s notes

Toodles!