Primary Care Otolaryngology

otitis media

Intravenous antibiotics may initially be used to treat patients with acute mastoiditis. Surgery, including PE tube placement or mastoidectomy, may be necessary in patients who do not respond to medical therapy. Other less common, but potentially devastating, complications of otitis media include epidural and brain abscesses, sigmoid sinus thrombosis, and facial nerve paralysis. A collection of pus can occur just outside the dura (termed an epidural abscess) , or with- in the brain itself (a brain abscess) , and surgical drainage is required. The

Figure 5.4. Otoscopic view of left eardrum with

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cholesteatoma involving the pars flaccida. The white material is keratin filling the canal.

sigmoid sinus can become infected and thrombosed , and can serve as a nidus of infection . This classically leads to showers of infected emboli , causing “picket fence fevers.” Facial nerve paralysis in the setting of acute otitis media is believed to be caused by inflammation around the nerve, and thus generally responds to appropriate intravenous antibiotic therapy as well as drainage of the pus. This can be done via either a myrin- gotomy (an incision in the eardrum) or, if necessary, a mastoidectomy . Cholesteatoma As mentioned above, some patients do not outgrow their eustachian tube dysfunction, and they go on to suffer from chronic negative middle ear pressure. This can result in retraction of the superior part of the ear drum, known as pars flaccida, back into the middle ear space. The outside of the eardrum is actually lined with squamous epithelium , which desquamates and produces keratin. Over time, the keratinous debris can get caught in the pars flaccida retraction pocket . This can continue to accumulate, expanding the pocket, and is then called a cholesteatoma, which often gets infected. Patients with cholesteatoma usually present with chronic ear drainage, often due to Pseudomonas or Proteus bacteria . These patients may be put on ototopical antibiotic drops, and their drainage may get better, only to return when the treatment is stopped. If the cholesteatoma is left untreated, it will continue to grow and erode bony structures. Possible sequelae include hearing loss secondary to necrosis of the long process of the incus; erosion into the lateral semicircular canal, causing dizziness; subperiosteal abscess; facial nerve palsy ; meningitis; and brain abscess.

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