THE DEVELOPING EAR

Jennifer Taylor, ARNP

Otolaryngology

Seattle Children’s Hospital

Learning Objectives

Ear development in utero Parts of the ear: Outer ear, middle ear,

inner ear Ear Exam: use of otoscope,

tympanometry, positioning of patient Other findings: congenital anomalies of

the ear such as tags, pits, microtia When to refer

Development of Ear in Utero

Structural ear development starts in the first 20 weeks’ gestation

Sensorineural part of the auditory system develops primarily after 20 weeks' gestational age

Auditory system functional at 25 weeks 25 weeks gestation to 5/6 months old

most critical time for hair cells (sensorineural hearing)

Parts of the Ear

Outer Ear

Auricle (also referred to as pinna), ear canal, outer part of tympanic membrane

Protects tympanic membrane Produces cerumen Directs sound through ear canal Can be reshaped if necessary during the

fIrst few months of life d/t circulating estrogen (must start before 6 weeks of age)

Middle Ear

Air filled cavity behind tympanic membrane

Location of three smallest bones in bodyMalleus (hammer)Incus (anvil)Stapes (stirrup)

Opening of Eustachian tube

Describing the Tympanic Membrane

Front of F

aceRight Ear Right Ear

Inner Ear

Semicircular canals Vestibule Cochlea

Inner Ear cont’d Associated with hearing and balance. Tubes filled with fluid encased within the

temporal bone of the skull. Bony tubes (bony labyrinth ) contain a set

of cell membrane lined tubes. Filled with perilymph fluid, which the

membranous labyrinth tubes are filed with endolymph. This is where the cells responsible for hearing are located (the hairy cells of Corti).

Ear Exam

Positioning Tools Cartilaginous development of the ear

lobe, position of ears, shape of auricle (normal/abnormal), preauricular sinus or skin tags.  External auditory canal patent.

Ear Exam cont’d

Pull downward and backward. This process will move the acoustic meatus in line with the canal. Hold the otoscope like a pen/pencil and use the little finger area as a fulcrum. This prevents injury should the patient turn suddenly.

Inspect the external auditory canal. Inspect tympanic membrane Inspect posterior ear and mastoid bone

Ear exam

Air inflation otoscopy (pneumatic-otoscope) is very useful to evaluate middle ear disease. Assess the mobility of tympanic membrane by applying positive and negative pressures with the rubber squeeze bulb.

Normal Ear exam Normal: Auditory canal: Some hair, often with yellow to

brown cerumen. Tympanic membrane

Pinkish gray in color , translucent and in neutral position. 

Malleus lies in oblique position behind the upper part of drum.

Mobile with air inflation.

Causes for Hearing Loss or Abnormal Ear Development

Genetics Environmental: born premature, exposed to

ototoxic medications Infectious: CMV, TORCH, meningitis, family hx,

craniofacial abnormalities, birth weight <1.5kg, neonatal hyperbilirubinemia, Apgar <4 at 1 minutes, <6 at 5 minutes, prolonged NICU stay or ECMO or mechanical vent, exposure to ototoxic meds.

When to refer

Hearing loss Suspect hearing loss with behavioral

issues, speech issues, ask about newborn hearing screen

Congenital anomaly of ear

EARACHE: OTITIS MEDIA AND BEYOND

Ronna K. Smith, MN, ARNPOtolaryngology

Seattle Children’s Hospital

Objectives Definition of OME and AOM by current standards

and visualization Current national guidelines for diagnostic criteria of

AOM Pharmacology for AOM and OME Referral guidelines to Otolaryngology and

indications for PE tube placement Hands-on practice with otoscopy and identification

of signs of AOM and OME

Otalgia

Differential diagnosisAOMOMEOETMJ dysfunctionBruxismDental pain, teething?Tonsil or throat pain

Diagnoses

Otitis media: acute, chronic, recurrent OME: middle ear effusions

Acute Otitis Media

Commonly defined as inflammation of the middle ear

Results in rapid onset of symptoms: otalgia, fever, irritability, anorexia, or vomiting

Often associated with upper respiratory infection

Acute Otitis Media

One of the most common reasons for young children to visit the primary care provider

Morbidity and mortality common before the introduction of antibiotics/vaccines

80-90% of children have had at least one episode of AOM by the age of 10

Peak incidence between 6-18 months

Acute Otitis Media Factors influencing incidence:

Age under 2 years, male gender, certain ethnic backgrounds

Eustachian tube functionDaycareOlder siblingsExposure to cigarette smokeAllergyCraniofacial disordersImmune function

AOM: Symptoms and Presentation

Fever (~50%), irritability, waking at night Anorexia, vomiting, diarrhea, balance

problems, decreased hearing Often preceded by URI symptoms

(~50%), increased incidence in winter months

AOM: Diagnosis “Diagnostic certainty” requires the

presence of:Acute onset of symptomsPresence of effusion-bulging TM or poor

mobilityEvidence of inflammation

(AAP Clinical Practice Guideline, 2004, updated 2013)

AOM: Microbiology in the post-Prevnar era

Strep pneumoniae-can vary in pcn resistance

non-typeable H. InfluenzaeMOST are beta-lactamase positiveAssociated purulent conjunctivitis makes H.

Flu more likely

M. catarrhalis (nearly 100% beta-lactamase positive)

AOM: Treatment

60-80% of acute OM will clear spontaneously (Rosenfeld, 1995)60% in 24 hours, 80% in 72 hours

Some studies suggest resolution rate is higher and complication rate lower if antimicrobials are used.

S. pneumoniae is often the cause of persistent otitis and is associated with a large number of otitis complications

AOM: Treatment High dose amox has been the main

recommendation for s. pneumoniae (>50% of cases of AOM historically)

Daycare, <2 yrs, abx in prev 3 mos=more likely to have resistant s.pneumoniae

Post-Prevnar: less s. pneumoniae, more non-typeable h. influenzae

High dose amox is STILL the first line (AAP, 2013) because of safety profile, high likelihood of effectiveness.

AOM: Treatment The ‘observation’ option:

Limit management to symptom relief in selected patients

Caregiver must have means of communication

Must be a system for re-evaluationChild should be healthy >6 months of age

Antibiotic Choice First line: high dose Amoxicillin (80-90

mg/kg/day) “Treatment failure” means persistence of

symptoms-pain, fever. Persistence of effusion does NOT mean treatment failure

2nd line: Augmentin with high amoxicillin concentration

If allergic to penicillin: Cefdinir, azithromycin, clarithromycin, erythromycin

For true treatment failure: Rocephin injections for 1-3 days.

Pain

Management of pain should be addressed regardless of antibiotic use.

AnalgesicsOral analgesics: Tylenol, IbuprofenBenzocaine/antipyrene (Auralgan) dropsHerbal drops, garlic drops, warm oil

Warm compresses Distraction Codeine

AOM: Complications Hearing loss (temporary, conductive)

COMMON Perforation of tympanic membrane-less

common, but not unusual Uncommon: cholesteatoma, retraction

pocket, ossicular discontinuity and fixation, mastoiditis, labrynthitis, facial paralysis, sensory neural hearing loss, intracranial infection.

AOM: When to Refer

3 episodes in 6 months, or 4 in one year Persistent middle ear fluid (3-6 months,

+/- hearing loss) Severe bouts of otitis media or

complicating issues, eg febrile seizures, Multiple medication allergies making

medical therapy difficult Developmental delay, heightened

concern for speech/language

Follow up Middle Ear Effusion commonly persists after AOM

60-70% of cases will have MEE at 2 weeks post AOM

40% will have MEE 1 month after AOM10% after 3 months (Teele, et al)

2 week follow up: hx of frequent OM, young infant, hx of prolonged OM, immunocompromised

1 month follow up: most children If effusions are still present, but no acute

signs….retreat? Refer for hearing test? Consider allergy management?

Otitis Media with Effusion: Basic Principles

Middle ear effusion (MEE) without signs and symptoms of acute infection

May occur spontaneously because of poor eustachian tube function, or may follow acute otitis media

May be acute or chronic More common than AOM: up to 90% of

children have had an episode of OME by school age

Otitis Media with Effusion: Basic Principles

Potential impacts: hearing, speech, language, learning, quality of life

Often accompanies upper respiratory infections

TM is typically retracted or neutral-not bulging

Symptoms: hearing loss, intermittent discomfort

OME: Diagnosis Pneumatic otoscopy is primary diagnostic

method. Tympanometry very helpful . White or amber colored discoloration to TM TM is often opaque Decreased or absent mobility Absence of acute OM s/s: pain, fever,

inflammation, bulging of TM This should NOT be treated as AOM!

Document….

Laterality: which side is it on? Mobility with pneumatic otoscopy Retraction pockets? Appearance of ossicles Be sure to document the duration of the

effusion if possible

OME: Treatment Observation: Document laterality, when

effusion was first observed and symptoms. Follow up periodically.

Medications: antibiotics and oral steroids may help in the short term, but effusion often recurs after course is complete.

Allergy treatment Tympanostomy tube placement for

persistent effusions, hearing loss ‘glue ear’ prolonged OME

Decision to Treat/Refer: Evaluate risk of developmental delays

Speech delayOME causing hearing lossAlready has DD

Evaluate likelihood of spontaneous resolutionFamily hx of needing tubesFamily hx of allergy, kid w/allergyTime of year

Otitis Media with Effusion

For children not at risk for developmental delaysObservation for 3 monthsHearing testing if OME lasts beyond 3 monthsLanguage testing if hearing loss occursFollow up every 1-3 months until OME is goneDecrease environmental risk factors (tobacco

smoke)Optimize listening and learning until effusion

resolves

Otitis Media with Effusion

In the setting of other developmental delaysEarly referral to OTONeeds hearing examMay have earlier recommendation for tubesConsider social setting—foster care, etc.

OME Treatment No evidence to support use of

decongestants, antihistamines, or steroids

No evidence to support long term effects of antibiotics - there has been some evidence of occasional short term benefit

Consider 10 day course of antibiotic and/or 5 day course of oral steroid as an option when tube placement is only other option

Ear Tubes (Pressure equalization-PE- or Tympanostomy tubes

The decision to place tubes is based on many factors…

-quality of life

-season, age

-presence of hearing loss/speech delay

-other co-morbid factors

-parents have reached ‘otitic exhaustion’

Bobbin or grommet style: last 6-12 months‘t-tube’ lasts 2 years

Care of PE tubes

Ok for swimming/bathing Treat drainage topically

No ototoxic drugsClear drainage and pump the tragus

Older kids and diving? F/U with audiology after extrusion F/U with surgeon ?

WHAT NOT TO MISS…

Ashley Sapin, ARNPOtolaryngology

Seattle Children’s Hospital

Why does my child have fluid behind their ear?

Persistent Effusions in “Non-complainers”

Why are these not okay?May be causing hearing lossPotential for retraction of the TM

and sequelae from chronic retraction

The longer fluid is present, the less likely it is to resolve spontaneously and more likely it is to have a negative impact

May be indicator of nasopharyngeal mass

Things to Note About Middle Ear Effusions

Anything obvious to treat?Allergic rhinitisSinusitis/RhinosinusitisChild drinking liquids while laying down

What do the effusions look like?Air bubbles?Air-fluid level?Color/texture of middle ear fluid?Position of eardrum?

When to Refer for Persistent Effusion

• In the presence of cognitive or sensory deficit– Speech and language acquisition and pronunciation– Reading– Behavioral- Poor focus or attention, abnormal family/peer interactions– Vestibular disturbance

• When the effusion has been present for 3 or more months– If hearing loss accompanies effusion, may be indication for ear tubes

• Underlying medical diagnosis– Abnormal ciliary function

• Primary ciliary dyskinesia• Cystic fibrosis

– Craniofacial abnormality or syndrome• Cleft palate• Submucous cleft palate• Trisomy 21• Craniofacial microsomia

Perforations & Retraction Pockets

Tympanic Membrane Perforation

Common Causes Abnormal middle ear pressure

○ Middle ear effusions○ Barotrauma

Foreign body○ Tympanostomy tubes○ Traumatic injury

Tympanic Membrane Perforation

Treatment If acute perforation with infection/otorrhea

○ Dry ear precautions○ Treat with antibiotic ear drops

Sulfacetamide-prednisolone Ciprodex Ofloxacin (+/- dexamethasone) Do NOT use gentamycin, tobramycin, or

cortisporin drops (ototoxic!)○ If in 1 month, no improvement and/or recurrent

otorrhea- ENT referral If vertigo or facial nerve involvement

○ Urgent ENT referral If chronic perforation

○ Non-urgent ENT referral

Retraction Pockets Cause

Eustachian tube dysfunction Potential Problems

Hearing loss○ Reduction of TM mobility○ Ossicular erosion

Granulation tissue formation Cholesteatoma formation

OrdersAudiogram (ENT will order)Referral to ENT

Retraction Pockets

Treatment Possibilities Watchful waiting Treat infection (if present) with

antibiotic ear drops Trial of steroid nasal spray if

allergic component Surgical intervention

○ Ear tube placement○ Excision of squamous debris

Cholesteatoma

Cholesteatoma Causes

Congenital- occur during fetal formation

Acquired○ Tympanic membrane perforation-

entryway for skin into middle ear○ Eustachian tube dysfunction○ Basal cell hyperplasia resulting from

infection○ Metaplasia resulting from chronic

irritation from middle ear infection

Cholesteatoma

SymptomsSensation of fullness in earHearing loss in affected ear- may be reported

by patient or found on audiogramDizzinessIntermittent or continuous otorrhea despite

treatmentFacial muscle weakness on affected sidePainful or painlessThere may be no symptoms at all…

SignsWhite mass behind intact tympanic membraneTympanic membrane perforation or retraction

pocketFocal granulation tissue on tympanic

membrane

Cholesteatoma

Treatment Imaging

○ CT○ MRI

Antibiotics if needed Surgical Intervention

○ 1st-Tympanomastoidectomy○ 2nd- May need additional surgery

Re-examination of middle ear space to confirm no regrowth of skin cells

Ossicular repair or prosthesis

Possible Complications Brain abscess Meningitis Labrynthitis Facial paralysis Deafness

Tympanosclerosis/Myringosclerosis

Calcification affecting connective tissue of tympanic membrane

Causes Previous otitis media Previous ear tubes Trauma to eardrum

May look like cholesteatoma- it isn’t Children with asymptomatic myringosclerosis

do not need ENT referral If symptomatic- then refer to ENT

Conductive hearing loss○ Surgical removal

Remove plaques (frequently refix to ossicles)

Middle ear reconstruction○ Hearing aids

Persistent Ear Drainage

Potential CausesAcute tympanic membrane rupture with acute otitis

mediaChronic tympanic membrane perforationAOM with patent ear tubesOtitis externa

○ Bacterial○ Fungal

Retained tympanostomy tubeCholesteatoma

(Remember, color of drainage may vary- serous, yellow, white, green, bloody…it can all be “normal” for otorrhea)

Persistent Ear Drainage Questions to ask

Any recent illness/co-morbid conditions?Frequency/recurrence of drainage?Do otic antibiotics help? Is there pain? (1-10, progressive, improve with drainage) Is there pruritis?Has child been swimming frequently/recently?Pain with external ear palpation?How is the patient’s hearing?Does the patient have ear tubes?

○ How long have these tubes been in place?○ When were they last seen by their ENT?

Retained Tympanostomy Tubes

Retained Tympanostomy Tubes Duration of Pressure Equilization (PE) tubes?

Armstrong/Reuter-Bobbin/Baxter○ Generally last 6-12 months ○ Should be in no longer than 2 years*

Soft T-Tubes○ Generally last 1-2 years○ Should be in no longer than 3 years*

Why remove retained PE tubes?○ Chronic TM perforation○ Infection of the PE tubes○ Persistent drainage○ Granulation tissue○ Most people outgrow the need for them

*There are always exceptions to this

CERUMEN AND FOREIGN BODIES: TAKE IT OR LEAVE

IT

Jennifer Hart, ARNP, CPNP

OtolaryngologySeattle Children’s Hospital

What the Wax?!?

Cerumen is the substance that is secreted by your ear canal

It protects the external auditory canal and the tympanic membrane

It contains antibacterial properties

Types of Cerumen Cerumen can be

sticky, hard or flakey

Multi colored: white, caramel, brown, black

When To Remove Cerumen

Only when it is a problemIf you suspect otitis media and can’t see TMIf there is hearing loss associated with

impactionIf there is pain due to impaction*If none of these exist, LEAVE IT ALONE

Home Methods

Q-Tips NO!!!! Debrox- yes Mineral/Olive Oil-yes ½ strength hydrogen peroxide- OK Ear Candling NO!!!! Wipe the bowl of the pinnae with warm

wet wash cloth

Safe removal

In clinic irrigation with warm water*caution do not shoot water directly down

the ear canalLoop curette, only if able to safely stabilize

childIf unable to clear refer to OTO but start on

home routine(Debrox, oil, ½ strength peroxide)

Fun With Foreign Bodies

When to Remove and when to Refer Remove if:

The object is easy to grasp with minimal chance of trauma or anxiety for the child.

You are able to safely restrain the child.If it is causing acute pain.

Why to Refer?

OTO has better equipmentBinocular microscope SuctionMultiple curettes and probesExperience to do this safely, with minimal

trauma and dramaAble to make the call for sedation

Remember

Don’t put anything smaller than your elbow in your ear. If you can put your elbow in your ear go ahead and use it to clean your ear.