Acute Otitis Media

Earache with conductive hearing loss and fever accompanying a head cold characterize acute otitis media. The drum is red and the landmarks are obscured; drum distension and pulsation may be seen.

Otitis media is common in children, probably due to their short, wide eustachian tube and the presence of adenoids which may be infected near the orifice. Rupture of the tympanic membrane in acute otitis media is not uncommon and muco-purulent otorrhea ensues with a pulsatile discharge. Penicillin is invariably curative, and complications are rare.

The middle-ear infection frequently settles without otorrhea, but if the drum does rupture, a pulsating muco-purulent discharge filling the meatus is diagnostic of otitis media. A swab for culture and sensitivity is taken in these cases, although the ear usually becomes dry within 48 hours of penicillin therapy, and the perforation closes in most cases with little or no scarring.

Acute mastoiditis, previously serious and common, is almost unheard of where antibiotics are available. Myringotomy and cortical mastoidectomy are operations of the past for acute otitis media.

Otitis media with effusion after the acute attack is the main complication today.

Fig. 2.85 Acute otitis media with bulging and hyperemia of the posterior-superior quadrant of the tympanic membrane. This is the typical early appearance of acute otitis media photographed with a fiberoptic camera.

Fig. 2.86 Glomus jugulare tumor. A

photograph, via the fiberoptic endoscope, showing a glomus jugulare tumor presenting, as is characteristic, with a hyperemia in the lower half of the drum. Middle-ear fluid is often present, and a meniscus is also seen (arrow).

The histology of a glomus jugulare tumor (Fig. 2.86) is similar to the carotid body tumor, with which it may coexist. If the glomus tumor occupies the middle ear, it can be removed via a tympanotomy or mastoidectomy approach. When the jugular foramen is involved with loss of the cranial nerves IX, X, and X (often XII from the anterior condylar foramen is also affected), the treatment is difficult. A surgical approach to the skull base is needed via the mastoid and neck, with a neurosurgical exposure if there is an intracranial extension.

If the tumor is surgically inaccessible, radiotherapy does slow the growth of an already very slow-growing tumor, and has an important place in the management, particularly in the more elderly patient. Microembolism under radiographic control of the vessels supplying the tumor is a further modality used in the treatment of these very vascular lesions, prior to surgery.

Stapes Crura Fracture

Fig. 2.87 Bleeding. Bleeding from the ear or a red or "blue" drum (see Fig. 2.76), if the tympanic membrane does not rupture, may also follow a base-of-skull fracture with bleeding into the middle ear.

Fig. 2.88 Injury to the ear ossicles.

This may follow head injury. Dislocation of the incudostapedial joint is commonest (approx. 75%) (arrow), but fracture of the stapes crura and disruption of the stapes footplate also occur.

Barotrauma causing marked middle-ear pressure change, e.g., from diving or flying, may also disrupt the stapes footplate ligament or rupture the round window, causing perilymp fluid from the inner ear to pass into the middle ear (arrow)—a perilymph fistula. A fluctuating sensorineural hearing loss and vertigo ensue.

Fistulae often heal spontaneously, but a persistent perilymph leak needs to be sealed surgically.

Otosclerosis: Hearing Loss Due to Fixation of the Stapes Bone

Otosclerosis: Hearing Loss Due to Fixation of the Stapes Bone

Perilymph Fistula

Fig. 2.89 Otosclerosis. This is a common cause of bilateral symmetrical conductive hearing loss in adults.

The stapes footplate is ankylosed in the oval window by thick vascular bone. This curious bony lesion is usually an isolated middle-ear focus. It may be associated, however, with osteogenesis imperfecta tarda, and blue sclerae are occasionally seen with otosclerosis.

Otosclerosis is familial and more common in women (otosclerotic hearing loss increases during pregnancy, which may account for the apparently higher incidence in women). Patients frequently notice paracusis, in which there is improved hearing with background noise. The cause of otosclerosis remains unknown.

Fig. 2.89 Otosclerosis. This is a common cause of bilateral symmetrical conductive hearing loss in adults.

The stapes footplate is ankylosed in the oval window by thick vascular bone. This curious bony lesion is usually an isolated middle-ear focus. It may be associated, however, with osteogenesis imperfecta tarda, and blue sclerae are occasionally seen with otosclerosis.

Otosclerosis is familial and more common in women (otosclerotic hearing loss increases during pregnancy, which may account for the apparently higher incidence in women). Patients frequently notice paracusis, in which there is improved hearing with background noise. The cause of otosclerosis remains unknown.

Paracusis Otosclerosis
Fig. 2.90 The stapes. The smallest bone in the body. It is, like the other ossicles, adult size at birth.
Teflon Prosthesis

Fig. 2.91 The stapedectomy opera- prosthesis, of which teflon (left) and tion. The operation for hearing loss due teflon-wire are coiniTiorHy used. to otosclerosis involves removal or perforation of the ankylosed stapes bone and replacement with a mobile prosthesis. This very successful operation was devised by John Shea of Memphis, Tennessee, United States, in 1957, and was a great advance in surgery, with good hearing achieved in over 90% of cases.

The diagram shows the attachment of the stapes prosthesis to the long process of the incus; the distal end of the prosthesis is placed through the opening made in the ankylosed stapes footplate. The lower diagram shows the exposure of the middle ear for stapedectomy. The drum is reflected anteriorly, hinging on the long process of the malleus. The stapes superstructure and part of the footplate are removed, and the prosthesis inserted. (M: malleus; I: incus;VIII: vestibulo cochlear nerve.)

Stapedectomy Prosthetic Diagram

Fig. 2.93 Stapedectomy—opening in the fixed footplate. An opening is made in the fixed footplate (arrow). The white marks to the right of this opening into the inner ear are the otoliths.

The prosthesis is attached to the long process of the incus, and the distal end of the prosthesis is placed into the inner ear.

Fig. 2.93 Stapedectomy—opening in the fixed footplate. An opening is made in the fixed footplate (arrow). The white marks to the right of this opening into the inner ear are the otoliths.

The prosthesis is attached to the long process of the incus, and the distal end of the prosthesis is placed into the inner ear.

Inner Ear Loss

Fig. 2.95 Fat-wire prosthesis. The wire loop is closed on the incus (top arrow) and a fat graft (middle arrow) seals the oval window. The bone covering the facial nerve (bottom arrow). It is important for the stapedectomy prosthesis to be closed like a ring on the finger on the long process of the incus.

This ensures that the prosthesis will not slip, but also that pressure does not predispose to incus necrosis. The lentiform nodule on the incus is preserved and is a further factor ensuring that the prosthesis/incus attachment is secure.

Fig. 2.95 Fat-wire prosthesis. The wire loop is closed on the incus (top arrow) and a fat graft (middle arrow) seals the oval window. The bone covering the facial nerve (bottom arrow). It is important for the stapedectomy prosthesis to be closed like a ring on the finger on the long process of the incus.

This ensures that the prosthesis will not slip, but also that pressure does not predispose to incus necrosis. The lentiform nodule on the incus is preserved and is a further factor ensuring that the prosthesis/incus attachment is secure.

Fig. 2.97 Conductive hearing loss very similar to otosclerosis is seen with Paget's disease. The bony changes seen with Paget's disease, however, tend to affect the entire ossicular chain and not specifically the stapes.

Surgery for conductive hearing loss with Paget's disease is usually not advisable and hearing aids are to be preferred.

Hearing Aids Inside Out

Hearing Aids Inside Out

Have you recently experienced hearing loss? Most probably you need hearing aids, but don't know much about them. To learn everything you need to know about hearing aids, read the eBook, Hearing Aids Inside Out. The book comprises 113 pages of excellent content utterly free of technical jargon, written in simple language, and in a flowing style that can easily be read and understood by all.

Get My Free Ebook


Post a comment