4.1 Acute, Chronic, and Secretory Acute Otitis Media (AOM)

• Commonly children in between 3 to 7 years of age

• Viral (rhinovirus, RSV, adenovirus)—most resolve within 24 hours; or bacterial (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis)

• C/o: fever, rubbing ear, pain, hearing loss (HL); symptoms may improve when tympanic membrane (TM) ruptures/discharge

• Predisposing factors include: age (<7 years), non-breastfeeding, day care attendance, race, anatomy (e.g., cleft palate), immunodeficiency

• Rx: analgesia; consider antibiotics if failure to resolve after 24 to 48 hours or immediately if age <2 years or systemically unwell

4.1.1 Recurrent AOM

• Consider if 3 episodes in 6 months or ≥4 in a year

• Treatment options include watchful wait, long-term low-dose antibiotics (e.g., trimethoprim) or grommet insertion

4.2 Chronic Otitis Media

4.2.1 Various classifications; consider:

• Healed chronic otitis media (COM): healed perforation, tympanosclerosis

• Inactive mucosal COM: dry TM perforation, noninflamed middle ear (ME) mucosa

• Inactive squamous COM: TM retraction, not retaining debris or infected

• Active mucosal COM: TM perforation with mucopus, inflamed ME mucosa

• Active squamous COM: cholesteatoma

4.2.2 Tympanosclerosis

• Termed myringosclerosis when confined to TM

• May arise from abnormal healing in response to inflammatory episodes or trauma (e.g., post-myringotomy)

• See changes to lamina propria connective tissue component of TM and ME mucosa

• Inflammation damages collagen fibres, fibroblasts invade in reparative phase causing excess collagen synthesis and hyalinization; fibres fuse as indistinct mass

• Usually asymptomatic; large plaques in TM may cause conductive HL; may cause ossicular fixation in ME

4.2.3 TM Perforations

• Surgery indicated to prevent discharge/waterproofing; while repair may improve hearing (closure of air–bone gap) it also risks making hearing worse

• HL with perforation related to:

Size

Loss of baffling effect on round window

Reduced ratio of TM: footplate to overcome air:fluid impedance mismatch

Associated ossicular chain damage, e.g., if over incudostapedial joint

Position (umbo involvement = worse hearing)

• Success of surgery may relate to surgeon, eustachian tube (ET) function, smoking, discharging at time of surgery

• Traumatic perforations: water exclusion, most heal by 6 weeks

4.2.4 TM Retractions

• Classification attic retractions (pars flaccida)—Tos

I: dimple

II: onto malleus neck

III: bony erosion (of scutum)

IV: keratin accumulation/cholesteatoma

• Sadé’s Classification of pars tensa retractions

I: annular retraction

II: onto long process of incus

III: onto stapes/promontory

IV: adhesive to medial wall

• Rx: most asymptomatic and do not lead to cholesteatoma; watchful wait often best; consider ventilation tube insertion, treatment of sinonasal disease to improve ET function, excision of pocket with grafting (e.g., cartilage) and cortical mastoidectomy to increase air reservoir; little good evidence to support intervention