Diseases of the Middle

ear

DR MUBARAK MOHAMED
ENT LECTURER
Outline

 Anatomy of the middle ear

 Acute infections of the middle ear

 Anatomy
 Middle ear is space in the temporal bone
which is lined by mucosa and filled with air
 Middle ear + Eustachian tube + aditus +
antrum + mastoid aircells = middle ear cleft
 Middle ear extends much beyond the limits of
tympanic membrane which forms its lateral
boundary and is sometimes divided into
 Epitympanum or the attic(above the parsa tensa)
 Mesotympanum(opposite the pars tensa)
 Hypotympanum( below the level of pars tensa)
 The middle ear is formed of six-sided box with
 a roof
 a floor
 Medial
 Lateral
 Anterior and
 Posterior wall
 Roof
 is formed by a thin plate of bone called tegmen tympani
 this bone separates tympanic cavity from the middle cranial fossa

 Floor
 Formed by thin plate of bone which separates tympanic cavity from the jugular bulb
 This bone can be congenitally absent
 Medial wall
 Formed by inner ear labyrinth
 Mostly by the basic coil of the cochlea which is called promontory
 Oval window is fixed by footplate of stapes
 Round window or the fenestra cochleae is covered by secondary tympanic membrane

 Lateral wall
 Formed mostly by the tympanic membrane and lesser extent by outer bony attic wall
called the scutum
 Anterior wall
 Has a thin plate of bone which separates the cavity from the internal carotid artery
 It has 2 openings; the lower one for the Eustachian tube and the upper one for the canal
of tensor tympani muscle

 Posterior wall
 Lies close to the mastoid air cells
Mastoid Antrum

 It is a large, air-containing space in the upper part of mastoid and communicates

with the attic through aditus

 Roof is formed by the tegmen antri which is a continuation of the tegmen

tympani and separates it from the middle cranial fossa
Mastoid Air cell system

 The mastoid consists of bone cortex with a “honeycomb” of air cells underneath.
 Depending on development of air cell, three types of mastoid have been described
I. Well-pneumonised or cellular: mastoid cells are well developed and intervening
septa are thin

II. Diploeitc: Mastoid consists of marrow spaces and a few air cells

III. Sclerotic or acellular: There are no cells or marrow spaces

Pneumotization of the air cells

 Sclerotic = absent  Diploic = partial  Pneumatic = complete

Contents of the Middle Ear

 Air filled space and lined by mucosa

 Three ossicles ( Malleus, incus and stapes)

 Two muscles ( tensor tympani and stapedius)

 Nerves ( tympanic plexus and chorda tympani)

Ossicles of the middle ear
 3 in number( malleus , incus and stapes)

 The Malleus
 Most lateral Ossicle
 Attached to the tympanic membrane
 Has head, neck, handle(manubrium) and lateral and an anterior process

 The incus
 Has a body and a short process, both which lie in the attic, and a long process which hangs vertically and attaches to
the head of stapes

 The stapes
 has a head, neck, anterior and posterior crura and a footplate.
 Footplate is held in the oval window by annular ligament
 Function
 Conduction of sound energy from the tympanic membrane to the oval window and then to the inner ear
fluid
 Blood supply: Branches from external carotid artery( maxillary and postauricular mainly)

 Venous drainage to pterygoid venous plexus and superior petrosal sinus

 Lymphatic drainage: lymphatic from middle ear drain into retropharyngeal and parotid nodes,
and from Eustachian tube drain into retropharyngeal group

 Innervation: Tympanic plexus(formed by tympanic branch of glossopharyngeal and sympathetic

fibers from plexus around the internal carotid artery)
Infections of the middle ear
Acute Otitis Media(Acute suppurative
otitis media)
 ASOM: is the acute infection(<3wks) of the middle ear cleft causing
inflammation of the middle ear space.

 2nd common disease in children

 Common microrganisms:
 S.pneumoniae(most common)
 H.influenza
 Moraxella catarrhalis
 Group B streptococcus (in infants)
Routes of infection

 Via Eustachian tube

 most common
 Eustachian tube in infant and young children is shorter, wider and more horizontal
 Breast and bottle feeding may force fluid in the middle ear
 Swimming and diving can also force fluid via the tube

 Via external ear: traumatic perforation

 Heamatological: Blood-borne ( rare route).

Predisposing factors
 Recurrent attacks of common cold, URTI, measles, diphtheria and whooping cough

 Infections of tonsils and adenoids

 Chronic rhinitis and sinusitis
 Nasal allergy
 Nasal packing
 Tumours of the nasopharynx
 Bottle feeding or supine baby feeding
 Gastroeosophageal reflux
 Craniofacial or skull base abnormalities
Pathogenesis

 The middle ear is lined by respiratory epithelium with ciliated cells mucus
secreting goblet cells and cells capable of secreting local immunoglobulins.

 Anatomic or physiological dysfunction of the Eustachian tube appears to play a

critical role in the development of otitis media

 The eustachian tube 3 physiologic functions with respect to the middle ear;
1. Protection of middle ear from nasopharyngeal secretions

2. Drainage of middle ear secretions into the nasopharynx

3. Ventilation of the middle ear to equilibrate pressures to be as the ambient

pressure
 When one or more of the ET functions is compromised, accumulation of fluid in
the middle ear and subsequent infections may occur

 Congestion of the mucosa of the ET can result in obstruction; secretions that are
constantly formed by the mucosa of the middle ear accumulate behind the
obstruction, and If a bacterial agent is present, a suppurative otitis media may
result
Clinical features
 Otalgia ( irritability and tugging of ears in
children)
 Aural fullness
 Decreased hearing
 Tinnitus
 Fever
 Otoscopic examinations: hyperemic or
thickened TM, fluid in middle ear
space( nonmobile or bulging TM, air fluid
levels,)
Diagnosis
 Acute otitis media is clinically
diagnosed by
 History
 Examination
 Audiogram( conductive hearing
loss)
Treatment

A. Antibiotics:
 Penicillins are the first line therapy for ASOM
 If patient is allergic to penicillins, erythromycin is the drug of choice
 Duration is for 7-10days
B. Analgesics and antipyretics: eg paracetamol

C. Decongestant nasal drops: Oxymetazoline or Ephedrine nasal drops for relieve

of Eustachian tube oedema and promote ventilation of middle ear.
D. Oral Nasal decongestants: eg pseudophrine
Otitis Media with Effusion(OME)

 Also called secretory(serous) otitis media

 Presence of persistent fluid in the middle ear space without evidence of infection
 Common in school going children

 Pathogenesis: two main mechanism are thought to be responsible

 Eustachian tube dysfunction
 Increased secretory activity of middle ear mucosa
Aetiology

I. Malfunctioning ET: can be caused by:

I. Adenoid hypertrophy
II. Chronic rhinitis and sinusitis
III. Palatal defects( paralysis or cleft palate)
IV. Benign and malignant tumors of nasopharynx

II. Allergy: Seasonal or perennial allergy

III. Unresolved acute otitis media
IV. Viral infections
Clinical features
 Symptoms:
 Hearing loss
 Ear fullness
 Delayed speech( children)
 Tinnitus

 Otoscopic examination: dull TM, non mobile TM, air

fluid level, loss of cone of light)
 Tuning fork: conductive hearing loss
 Tympanogram: flat curve
 Audiogram: conductive hearing loss(30-40db)
Treatment

 The aim of treatment is removal of fluid and prevention of it is recurrence

A. Medical
 Decongestants
 Antiallergic
 Nasal corticosteroid
 Antibiotics( can be useful in cases of URTI)
 Middle ear aeration( chewing gum , valsalva manoeuvre)
B. Surgical
 When fluid is thick, medical treatment is not helpful
 Fluid should be surgically removed

 Type of surgeries
a. Myringotomy and aspiration of fluid
b. Insertion of Ventilation tubes: either grommet or T-tube
c. Surgical treatment of causative factor: Adenoidectoy, tonsillectomy and FESS form
sinusitis.
Grommet
Thanks