OtoRhinoLaryngology Portal

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Otitis Media with Effusion [OME]

Yellowish fluid filling the middle ear cavity.

Bulging eardrum with turbid middle ear effusion

complicating upper respiratory tract infection.

Thin straw-colured fluid filling middle ear cleft

with mild eardrum retraction.

Straw-coloured middle ear effusion.

Effusion with air bubbles.

A lesser effusion with air bubbles and significant eardrum retraction.

 

Blood-tinged effusion: consider barotrauma if no obvious source of infection. 

Eardrum retraction, more horizontally aligned lateral process,

and distorted cone of light reflex.

Pronounced pars flaccida retraction and the lesser pars tensa with yellowish effusion seen.

 

  

Middle ear effusion with a retracted tympanic membrane. 

 

Yellow middle ear effusion seen at upper segment of middle ear compartment.

 

 Retracted tympanic membrane in resolving OME. 

The normal cone of light is absent.

 

Watch video of OME @ YouTube

 

 Watch video of OME with bubbling air @ YouTube

 

Watch video of air bubbles dispersion upon nose blowing @ YouTube

 

Watch video of serous otitis media @ YouTube

 

 

 

 

 Video showing bluish middle ear fluid with transmitted pulsation.

OME with Myringosclerosis

Otitis Media with Effusion [OME] & Eardrum Retraction

                         Figure 1                                                Figure 2

 

This eardrum is retracted involving both of its pars flaccida and pars tensa.  There is middle ear effusion secondary to longstanding negative middle ear pressure.

 

Figure 1: Dull eardrum appearance with distorted cone of light reflex

Figure 2: An atrophic central pars tensa which draped onto the promontory

Otitis Media with Effusion [OME] & Retraction of Pars Tensa + Pars Flaccida

A rounded atrophic area is seen over antero-inferior segment

where ventilation tube/grommet was previously inserted.

Myringotomy and Grommet

Grommet/Ventilation Tubes

First two from left are for short-term while the rest are for long-term purpose.

 

Grommet - Shephard type.  (red arrow - inner flange, blue arrow - outer flange, black arrow - the neck part which fits into myringotomy slit and stablize the grommet in place.

 

Figure shows the typical site of grommet and its orientation in right eardrum. 




Cleft Palate as Predisposing Factor to Chronic Eustachian Dysfunction and OME Formation

Gross cleft palate in an adult.  Nasal regurgitation, bathing of Eustachian introitus with refluxate, and loss of tubal protection predispose to chronic Eustachian tube dysfunction, negative middle ear pressure, and glue ear formation.

Rhinogenic Otitis Media

 Tenacious mucopus being sucked out from right nasopharyngeal Eustachian tube opening.  This patient has pansinutitis and presented with irritable coughs of more than 4 weeks.

The similar tenacious mucopus from left nasopharyngeal Eustachian tube opening.

 

[Arrow - Eustachian tube opening, TT - torus tubarius, mp - mucopus]

Retracted Eardrum

Middle Ear Effusion: Suctioning of Tenacious Mucous

Arrow - tenacious mucous, TM - tympanic membrane, A - anterior, P - posterior, I - inferior, S - superior, (+) - lateral process of malleus, ST - suction tube.  Note: Patient in supine position under general anaesthesia.

 

Watch video of mucous suctioning after myringotomy @ YouTube 

Middle Ear Effusion Drainage Immediately After Grommet Insertion

Yellowish mucous seen draining through ventilation tube channel.

Grommet/Ventilation Tube In-situ

Grommet or ventilation tube in a well-sited placement.  The middle ear effusion has resolved and eardrum is no longer retracted.  It will eventually extruded due to self--migratory property of the eardrum epithelium.

Well seen inner flange of grommet (yellow arrow) beyond a transparent eardrum.  White arrow - outer flange of grommet, red arrow - patent lumen of grommet enabling middle ear ventilation and pressure equalization on either side.

Grommet surrounded by dried secretion drained from middle ear space.  Myringosclerosis is evident around the grommet.

 

Watch video of grommet in-situ @ YouTube

Self-Extrusion of Grommet/Ventilation Tube

 Extruded grommet at 2 o'clock position with normal looking eardrum at the background.

 

 Extruded grommet (asterisk) with retracted eardrum and recurrence of middle ear effusion.

 

Extruded grommet (asterisk) at anterior-inferior recess and granulation polyp adjacent to a minute perforation (arrow).  Ear discharge is obvious.

 

 

Long-Term Ventilation Tube in the  Management of Chronic Eustachian Tube Dysfunction

 

Watch video of T-tube insertion @ YouTube

 

Further reading:

Raman R, Rahmat O. Branula used as T-tube introducer for middle ear effusion. J Laryngol Otol. 2008. Jun;122(6):635.

Grommet- Related Problems

       Epithelial crusts and blockage.        Earwax impaction surrounding grommet

                                                                 secondary to cotton-tip usage.

          Partially-inserted grommet                        Grommet surrounded by

      with visible inner flange superiorly.                       myringosclerosis.

Central scarring of a healed eardrum post-grommet extrusion.

Migration of grommet into middle ear with closure of myringotomy opening.  Green hue of grommet seen beyond the eardrum (arrow) - green-coloured Shepard type grommet was used earlier.

 Recurrent ear discharge during upper respiratory tract infection or in situation likes untreated nasopharyngeal carcinoma and in chronic mastoiditis. 

Otomycosis after bilateral myringotomy and grommet insertion.

OtoLAM Laser Myringotomy

Figure shows the result of OtoLAM laser myringotomy effect on dry paper.  Circular-shaped scanning laser beam was selected.  The sharpest image of the line (capillary on actual membrane) is the right focus required before the laser being triggered.  A clean-cut perforation was obtained as shown.

 

Pre-CO2 Laser Myringotomy of right tympanic membrane.

(Arrow - lateral process of malleus, S - superior, I - inferior, A - anterior, P - posterior).  NB: patient in supine position under general anaesthesia. 

 

 Post-CO2 Laser Myringotomy of right tympanic membrane.

 (Arrow - lateral process of malleus, S - superior, I - inferior, A - anterior, P - posterior).  NB: patient in supine position under general anaesthesia. 

 

Watch video of OtoLAM Laser Myringotomy @ YouTube

 

Watch another video of CO2-laser myringotomy @ YouTube

Adhesive Otitis Media

Adherent of eardrum onto middle ear surface or structures

(usually involving atrophic/thinned-out eardrum) in longstanding,

irreversible eustachian tube dysfunction.

 

Adhesive otitis media in a patient with untreated severe septal deviation and allergic rhinitis.  Treatment is directed at the underlying causes and ventilating the middle ear by inserting medium to long-term grommet.

 Recurrent secretory otitis media with atelectasis after grommet extrusion. 

Adhesive Otitis Media With An Intact Ossicular Chain

1 - lateral process of malleus, 2 - handle of malleus, 3 - long process of incus, 4 - stapedius tendon, arrow - incudostapedial joint, A - anterior, P - posterior.

Adhesive Otitis Media Resulting in Ossicular Resorption

Severe atelectatic and atrophic eardrum (pars tensa and pars flaccida) with resorption of the long process of incus.  The aetiology was untreated longstanding severe allergic rhinitis complicated by Eustachian tube dysfunction. 

M - malleus, arrow - head of stapes]

Missing long process of incus in longstanding severe adhesive otitis media.

[P -  Promontory, White arrow -  Chorda tympani nerve, Yellow arrow -  Facial nerve, red arrow -Capitulum of head of stapes]

Posterior Quadrant Atelectasis

 

 1 - Malleus, TM - Tympanic Membrane, A - Anterior, P - Posterior

 

Healed Eardrum Perforation with Severe Atelectasis

The appearance may mistakenly diagnosed as chronic suppurative otitis media in quiescent stage.  In reality, the atrophic healed segment of the perforated eardrum has completely draped the promontory and its proximity.

 

Watch video of Eardrum Perforation or Atelectasis? @ YouTube  

Eardrum Perforation within an Atelectatic Segment

                            At rest.                                          On Valsalva manouevre.

 

Perforation (arrow) within an atelectatic eardrum in a patient with longstanding Eustachian tube dysfunction.

 

Watch video of hidden perforation within a collapsed (atelectatic) eardrum segment @ YouTube.

Attic Perforation with Scanty Pus, Keratin & Tenacious Mucous

 

HIdden atttic perforation revealed after suctioning of the mucopus at attic area.  This is a classical presentation of secondary acquired cholesteatoma in unsafe type of chronic otitis media. 

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