PROF IAIN BRUCE PAEDIATRIC OTOLARYNGOLOGIST & ADULT OTOLOGIST

ACUTE PAEDIATRIC EAR PRESENTATIONS

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I BRUCE, ACUTE PAEDIATRIC OTOLOGY

A CHILD WITH EARACHE…

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

UNCOMPLICATED AOM

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

ACUTE OTITIS MEDIAAcute otitis media (AOM) is one of the most common medical conditions of childhood

Defined as the presence of inflammation in the middle ear, associated with an effusion and accompanied by the rapid onset of symptoms and signs of middle ear inflammation

Should be distinguished from glue ear, where the presence of effusion in the middle ear is not associated with these acute features

By 3 years, approximately 50% to 85% of all children will have had at least 1 episode of AOM and 33% will have had 2 or more episodes

A subgroup has recurrent AOM (rAOM), defined as having 3 or more episodes over the past 6 months, or 4 or more episodes over the past year

The peak age-specific incidence lies between 6 and 15 months

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

ACUTE OTITIS MEDIA

Otalgia or symptoms suggestive of otalgia, such as ‘pulling’, ‘tugging’ or ‘rubbing’ the ear

In younger children the presenting symptoms can be much less specific and include fever, irritability and poor feeding

A history of altered mental state or lethargy may suggest the development of an intracranial complication

Findings on otoscopy are an erythematous and bulging tympanic membrane

Besides otoscopy, clinical evaluation should seek to identify extracranial, intratemporal and intracranial complications, as suggested by fluctuation of the soft tissues overlying the mastoid bone, a protruding ear, altered conscious level, cranial neuropathies and signs of meningism

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

COMPLICATIONS OF AOM

The identification of RFs for developing a complication of AOM is difficult due to the low incidence of complications, but there are a few recognised predisposing factors:

1. Bacterial virulence of the infecting agent, with the most commonly identified causal bacteria being Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis

Streptococcus pyogenes, Pseudomonas aeruginosa, anaerobes and Staphylococcus aureus are often involved in AOM with complications

2. Extent of pre-existing cell tracts and dehiscence in the temporal bone may present a pathway for pathogens

3. Inadequate host defences (e.g. immunodeficiency)

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

ACUTE MASTOIDITIS

Clinical presentation: postauricular swelling, skin erythema, loss of postauricular sulcus and protrusion of the auricle

Acute mastoiditis (AM) is the most common complication of AOM, incidence about 1-2 / 10,000 children

Characterised by inflammation of the mastoid air-cell system, osteitis and possible extension into the surrounding structures

Sagging of the wall of the posterosuperior ear canal can be seen on otoscopy

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

ACUTE MASTOIDITIS

Clinical images removed

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

COMPLICATIONS OF AOM

Intratemporal Intracranial Extracranial

Acute mastoiditis Lateral sinus thrombosis Bezold’s abscess

(along sternocleidomastoid muscle)

Facial nerve palsy Extra- and subdural abscess Citelli’s abscess

(posterior to the mastoid)

Subperiosteal abscess Meningitis Luc’s abscess

(along root of zygoma)

Bacterial labyrinthitis Intracranial sepsis Septic emboli

Apical petrositis

(Gradenigo’s syndrome)

Otitic hydrocephalus

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

COMPLICATIONS OF AOM

Lateral sinus thrombosis on CT scan- Positive Delta sign of the right sigmoid sinus

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

INTRACRANIAL SEPSIS

Otogenic infection can spread to involve intracranial structures

Meningitis, intracranial abscess formation, subdural empyema and epidural abscess

Symptoms of AOM and/or AM + headache, nausea & vomiting, altered mental state (drowsiness), diplopia, seizures and extremity weakness

Antibiotic treatment, immunisations, increase in social welfare and wide access to healthcare have led to a significant decrease in the incidence and mortality of these complications

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

FACIAL NERVE PALSY

Facial nerve runs through the middle ear (ME), so susceptible to inflammatory damage in AOM

6-10% of population have a dehiscence of the facial nerve canal in ME

Incidence of facial nerve palsy (FNP) in AOM = 12.6% - 16.7%

Myringotomy with, or without, ventilation tube insertion is common for FNP complicating AOM

Combined with a cortical mastoidectomy when there is concurrent AM

A role for steroid treatment is established in idiopathic facial nerve palsy, BUT no consensus exists regarding steroid use in FNP complicating AOM

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

LABYRINTHITIS

Suppurative (bacterial) labyrinthitis is rare, and must be distinguished from serous labyrinthitis, where there is a non-purulent inflammation of the labyrinth

Presenting features including hearing loss, tinnitus, vertigo and nystagmus

Suppurative labyrinthitis should be suspected when symptoms are severe and/or progressive and is often associated with other complications

Suppurative labyrinthitis treatments include myringotomy and ventilation tube insertion in AOM and cortical mastoidectomy in AM

Recovery rates for inner ear function after suppurative labyrinthitis are poor with most patients having a resultant profound hearing loss (71% - 100%)

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

APICAL PETROSITIS

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

EXTRACRANIAL COMPLICATIONS OF ARM

I BRUCE, ACUTE PAEDIATRIC OTOLOGY

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