Paediatric ENT and Related Topics

Acute Otitis Media  Complications of Acute Otitis Media  Glue Ear/OME
Tonsils and Adenoids  Obstructive Sleep Apnoea     Airway Obstruction in Children

In acute otitis media (AOM) the whole middle ear cleft (from the eustachian tube to the mastoid air cells) is affected by an acute bacterial infection, which is sometimes described as an 'abcess in the middle ear'. Initially, there is a phase of eustachian tube obstruction with a sensation of fullness in the ear, as the infection develops, increasing pain is felt with deafness and in children particularly, a marked pyrexia and systemic symptoms. AOM may not be an obvious cause of illness in the very young. Resolution may occur with perforation through the tympanic membrane. Parents will notice a sudden discharge, often accompanied by resolution of pain. This normally heals up as the infection resolves.
 

Age - AOM is commonest in the very young (0-24 months) but may present at any age.

Predisposing factors

• URTI
• Rhinitis and sinusitis
• Tonsillitis
• Immine defficiency
• Flu

• Pneumococcus
• Strep Pyogenes
• Staph aueus
• Moraxella
• Haemophilus infuenzae

Usually, children will present unwell with a pyrexial illness and usually otalgia and depending on the age, complain of deafness.
The ear itself may be tender, including over the mastoid bone, but the skin over the mastoid should not be actually swollen or red.
Depending on the stage of the disease, the drum may be red and injected, or even bulging. After perforation it is often inpossible to see anything in the ear canal without suctioning the pus out, and this is not pracical outside an ENT clinic and this  is difficult in small children anyway. As the infection resolves, a perforation may be visible, often inferiorly. This may heal with a small scar, but often leaves remarkably little evidence of it's existence.

Treatment

The role of antibiotics in simple AOM is controversial. Many infections wil resolve on supportive treatment only. If antibitoic treatment is used, a broad spectrum antibiotic shoud be used such as Amoxil, erythromycin or a broad spectrum cephalosporin.
Nasal (ephedrine nose drops) and systemic (pseudoephedrine, Sudafed) decongestants may help, anti-pyrexials and analgesics are essential in children (paracetamol / Calpol, ibuprofen).
After the drum has perforated, a persistent discharge may be treated with topical antibiotic eardrops.
Myringotomy (incising the eardrum) is rarely necessary, except when there are complications of AOM such as facial palsy or acute mastoiditis.

Recurrent AOM

This can be a problem in some children. Possible treatment options include prophylactic low dose daily antibiotics (trimethoprim), insertion of grommets and adenoidectomy. An immune defficiency state should be considered as a cause. Generally, children grow out of this tendency in time, with or without help from the ENT surgeon.

• Becasue of it's anatomical position and relations, a purrulent infection in the middle ear space can have serious complications:

Superior: Thin bony plate (tegmen tympani) Dura, temporal lobe

Posterioir: Mastoid air cells linked to the middle ear through the Aditus , Sigmoid Venous sinus

Anterior: Tempro-mandibular joint (TMJ)

Inferior: Jugular Bulb, Soft tissues of the neck

Medial: Cochlea, bony labyrinth, facial nerve
 
 

Compications of AOM (Diagramatic)

 

Acute Mastoiditis

Typically after an episode of acute otitis media, the child will present with further pyrexia, pain and unilateral swelling over the mastoid bone. The ear is pushed forwards and the crease (post aural sulcus) between skull and pinna is filled in. What has happened is that pus in the middle ear and mastoid air cells has eroded through the bone overlying the mastoid to the subcutaneous tissues and an abscess forms (see diagram)

This requires admission to hospital and is a potentially life threatening infection. Untreated it may progress to any of the other complications of AOM listed here. Early cases respond to intravenous antibiotics alone, although a grommet is usually inserted at some stage to reduce the risk of further attacks of AOM. If IV antibiotics are ineffective, or there is a more serious complication such as lateral sinus thrombosis, then surgical drainage is required. As well as draining the abscess, a cortical mastoidectomy may also be performed.
 
 

More serious compications of AOM:

• Intracrainal / temporal lobe abscess
• Extradural abscess
• Meningitis
• Lateral / Sigmoid sinus thrombosis

These may present as neurosurgical emergencies with focal signs and severe illness rather than as Ear emergencies. Often a combined otolgical / neurosurgical approach is required to manage these cases.

Bacerial Laryrinthitis:

Actual purulent infection inside the cochlea and vestibule are fortunately very rare complications of ear disease. An acute infection will lead to hearing loss and severe vertigo as well as a pyrexial illness. Untreated, the infection will certainly spread centrally and become life threatening.

Neck Abscess:

Rarely, infection will track into the soft tissues of the neck producing an abscess. A Bezold's abscess tracks down sternomastoid sheath and a Citelli's abscess forms in the digastric triangle. Both are rare in the modern antibiotic era.

Facial Palsy:

The facial nerve is red in this diagram, it's branches in the middle ear (chorda tympani and the petrosal nerves) are in yellow
Normally the facial nerve runs along the medial wall of the middle ear in a bony canal. If this canal is dehiscent at any part of the middle ear (about 10% of population) then pus in the middle ear can cause a facial palsy. This normally resolves after the infection is treated, but it is usual for the infection to be drained surgically with a myringotomy to encourage early resolution and nerve recovery.
 
 

Otitis Media with Effusion (Glue Ear)

Function

The tonsils and adenoids form part of Waldeyer's ring, a collection of lymphoid tissue in the upper aero digestive tract. They contribute to immune function in early life but after about 3 years of age are of little value.

The adenoids sit in the nasopharynx on the postero-superior wall and the tonsils lie in the tonsillar fossa, between the anterior and posterior palatal arches. Although small at birth, gradual enlargement takes place in early life, probably as a result of exposure to infectious agents and the maximum size is reached at around 3-4 years of age. Thereafter, tonsils and adenoids undergo gradual shrinkage relative to the overall size of the pharynx, and unless there is a continued stimulus for their enlargement (e.g persistent infection), are generally very small in adult life

Adenoid size may be assessed with a mirror in clinic, nasal endoscopy, or by a lateral skull plain x-ray. Radiology can demonstrate adenoid enlargement and loss of the normal nasopharyngeal air space. If paediatric flexible nasal endoscopes are available in clinic, most children will allow this procedure.
 
 
 
 
 
 
 
 
 
 
 
 

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