复旦大学耳鼻喉资料-26

Otitismediawitheffusion,ChunfuDaiM.D&Ph.DOtolaryngologyDepartmentEyeEarNose&ThroatHospitalFudanUniversity,Background,Otitismediaisamultifactorialdiseaseprocessinvolvingimmunology,infectiousdisease,anatomicconsiderations,socialandsocioeconomicissues,andgenetics,amongotherfactors.Approximately70%ofchildrenbelowtheageof3willdevelopanepisodeofotitismedia.,Background,65-95%ofchildrenbytheageof7yearswillexperienceoneormoreepisodesofacuteotitismedia.Itremainsthecommonestcauseforvisittothedoctorinthepediatricpopulation.,Background,Myringotomywasperformedineighteenthandnineteenthcenturiestotreatotitismedia.Duringthepreantibioticera,theprimaryconcernwasthepotentialforintracranialcomplicationsofacuteotitismediaIn1954,Armstrongsreintroductionofthetympanostomytube,afterthat,fewtrueadvancesinthetreatmentofotitismediawasdeveloped.,Definition,OMEisaninflammatoryconditionofthemiddleearandmastoidaircellsystemcharacterizedbyaccumulationoffluidinthemiddleearwithoutsignsorsymptomsofacuteinfection.,Othernames:Secretoryotitismedia,Serousotitismedia,Glueear,Nonpurulentotitismedia,Catarrhalotitismedia.,Pathogenesis,DysfunctionofEustachiantubeObstructionofEustachiantubeMechanicobstructionenlargedadenoid,tumor,enlargedinferiorturbinateNonmechanicobstructionWeaknessofrelatedmuscle,ClearanceanddefenseImmotileciliasyndrome,Pathogenesis,InfectionPCRdetectsthemiddleearfluid,positivefindingswas70%Spneumonia,haemophalusinfluenzae,haemolyticstreptocuccusImmunityMiddleearisaisolatedimmunesystemInflammatorymediatorsSpecificantibody,immunologiccomplexAntigenmayfromadenoidornasopharygeallymph,ClassificationofOtitismedia,Otitismedawitheffusion:thepresenceofmiddleeareffusion.Ifthemiddleeareffusionispresentfor8weeksorlonger,itisclassifiedchronicotitismediawitheffusion,Microbiologyofotitismedia,BacteriacanbeisolatedfromonethirdofpatientwhohaveOME.ThemostcommonareSpneumonia,Hinfluenzae,andMcatarrhalis(usingtraditionalculturemethod).ByusingPCR,thesethreebacteriaweredetectedinapproximately70%ofChronicmiddleeareffusion.,Diagnosis,Itisusuallyasymptomatic.HearinglossKidcannotconcentratehimselfTurnonTVinloudnessIfoneearisnormal,theabovesymptomswillbeignoredFullnessOtalgiaTinnitus,Diagnosis,Thediagnosisismadeatphysicalexam.TMmayretracted,dull,andopaque.ThecolorofTMmayrangefromlightpinktoamberevendarkblue.Thepresenceofairbubblesorairfluidlevelsmakesthediagnosismoreevident.,Diagnosis,TympanometryMiddleearpressuremorenegativethan-200(typeC)oraflattympanometrycurve(typeB)isclassifiedasafailure.AchildfailtestwithoutmarkedHL(lessthan20dB)shouldberetest2monthslater.10-14%ofpatientswithlowcompliancetympanogramshaveonlytympanicmembraneretractionorthickeningwithouteffusion.Whileocclusionoftheprobebycerumenorthechildscryingcancauseinvalidresults.,检查,Diagnosis,HearingtestRinnetest:negativeAudiogram:conductivehearingloss,nomorethan40dBTympanogram:BtypeorCtypeLateralnasopharyngealradiograph:hypertrophofadenoidNasopharyngealexam:toexcludespace-occupationlesion,Differentiateddiagnosis,Nasopharyngealcarcinoma:UnilateralOMEEBV-VCA-IgANasoendoscopeCTorMRIBiopsyCSF(cerebrospinalfluid)leakageHeadtraumaMeningitisCTorMRI,Differentiateddiagnosis,PerilymphaticfluidfistulaSecondarytostapessurgeryorbarotraumaVertigoHearingtest:sensorineuralhearinglossormixedhearinglossCholestrolgranuloma(heamotympanum)AdvancedstageofOMETympanicmembrane:blueCT:softtissueinmastoidormiddlecavity,Differentiateddiagnosis,AtelectaticOtitismediaSequelaofOMEConductivehearinglossTMcontactswithossicularchain,promotory,Diagnosisofotitismedia,DifferentiatediagnosisofAOMandOMEwillbenefitourtreatment,asthelatterconditionisusuallynottreatedunlessitbecomeschronic,Diagnosisofotitismedia,OMEisarelativelyasymptomaticmiddleeareffusion.Pneumaticotoscopefrequentlyshowseitheraretractedorconcavetympanicmembrane.Inaddition,anair-fluidlevelorbubbles,orbothmaybeobservedthroughatranslucenttympanicmembrane.,Managements,Principles:dischargemiddlefluidDrainage,ventilationEliminatepathogenesis,Managements,NonsurgicaltreatmentAntibioticsSteroidImprovementofnosecongestion,Managements,SurgicaltreatmentTympanocentesisMyrigotomyTympanotomywithPTmastoidectomy,ManagementofAOMalternativemedicaltreatment,Corticosteroid(orallyorintranasally),Antihistamine,decongestantsOrallycorticosteroidandintranasallycorticosteroidhelpclearchronicmiddleeareffusion.However,thereisnoevidenceofefficacyintreatmentofAOM.AntihistamineanddecongestantsareusedinthetreatmentofOME,itdoesnotbenefitAOM.Childrenwhohavenasalcongestionandallergicrhinitistheremaybearoleforthesepreparation.,Otitismediawitheffusion,ThenaturehistoryofthisdiseaseisforspontaneousresolutioninthemajorityofcaseMorethe80%resolutionby2month.Itisthesmallnumberofchildrenwhocontinuetohaveeffusionafter2-3monthsthatareconcern.Atrialofantibioticswouldbeappeartobeappropriateinthosechildrenwhohavenotreceivedantibioticsrecently.OMEisprobablyunderdiagnosis.,Otitismediawitheffusion,ChronicOMEisdefinedasaneffusionpersistingformorethan3monthsduration.Adenseeffusiontypicallymayconferuptoa30dBhearingloss.ChronicOMEmayhavearoleindevelopmentofretractionpockets,ossicularchainerosion,andcholesteatomaformation.,Otitismediawitheffusion,Meta-analyseshavecometoconclusionthatantibioticshaveasmallbutdistinctadvantageoverplacebointhetreatmentofpersistentOME.Whentheeffusionischronic,surgicalinterventionshouldbeconsidered,especiallywhenantibiotictherapyfail.Theprimarysurgicaltherapyremainsplacementoftympanostomytubesforpressureequalizationanddrainageofmiddleear.,Surgicaltreatmentforotitismedia,Placementoftympanostomytubes.Middleeareffusionformorethan3monthsormore.OMEassociatedwithhearinglossof30dBChronicsevereTMretraction.ImpendingintracranialcomplicationRecurrentotitismediawithmorethan3episodewithina6monthsperiod,ormorethan4episodewithina12monthperiod.,Surgicaltreatmentforotitismedia,AdenoidectomyindicationsforadenoidectomyChildrenwithchronicotitismediawhoarecandidatesfortympanostomytubeplacementChildrenhavesymptomsforchronicadenoidhypertrophy,Childrenrequiremultiplesetsoftympanostomytube.Ithasbeendemonstratedthatadenoidectomymayacceleratetheresolutionofchronicotitismediaregardlessofthesizeoftheadenoidpad.,Surgicaltreatmentforotitismedia,AdenoidectomyWithsignificantrisksinchildrenyoungerthan3yearsofagethatusuallyoutweightitsbenefit.Adenoidectomybeaconsiderationinthechildolderthan3yearsofageatthetimeofinsertionofasecondsetoftube.,Surgicaltreatmentforotitismedia,Laser-assistedmyringotomy(background)Ithasbeenadvocatedforthemanagementofacuteotitismedia(unresponsivetomedicalmanagement)andchronicotitismediawitheffusion,barotrauma,transtympanicinnerearperfusion.Ahistoryofallergies,thepresenceofathicktympanicmembraneandorhighviscocityfluidareallcontraindicationsforlaserassistedtympanostomy,Surgicaltreatmentforotitismedia,Itcanprovidesymptomreliefandavoidplacementoftympanostomytubebyalleviatinginfectionandinflammationorimprovingmiddleearventilation.FenestrationcreatesaroundopeningintheTMwithinaafractionofasecondandisusuallybloodless.Itgenerallylast2-4weeks,Surgicaltreatmentforotitismedia,Laser-assistedmyringotomy(techniquerequirement)Spotsizerangedfrom1.8-2.8