MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU „TVOŘÍME BUDOUCNOST MEDICÍNY“ Ear II ENT Clinic of Masaryk university, Brno Faculty St. Ann Hospital Head: Ass.prof. Gál Břetislav, MD, Ph.D. Pekařská 53, Brno , 656 91 Disorder of the ear congenital anomalies inflammations tumors injuries Microotia III. St. Microotia Treacher-Collins syndrome Most affected individuals have underdeveloped facial bones, particularly the cheek bones, and a very small jaw and chin (micrognathia). Conductive Hearing loss in about half of all affected individuals; - defects or by underdevelopment of the external meatus. People with Treacher Collins syndrome usually have normal intelligence. Apendices praeauriculares Apostasis auriculae Blunt attachment angle Herpes zoster oticus (part of Ramsey-Hunt syndrome) acute finding – after 3 days – after 10 days Perichondritis Chronic polychondritis – alergy- cauliflower ear Spinocellular cancer of auricle Othematoma (fresh injury; after 14 days; after some months) Earwax (Cerumen) Foreign body in external meatus - insect Insect, ventilation tube Foreign body in external meatus bead, piece of wood, blood Exostosis in ext. meatus right Erysipelas bullosa auricullae Inflammation of external meatus Furunculus of external meatus Middle ear cavity inflammations According to course, extension, localization Acute – Catarrhus tubotympanalis acutus – Otitis media acuta Chronic – Non suppurative – otitis media chronica secretorica (OMA, celistvý bubínek) – suppurative (permanent perforation) ▪ Otitis media chronica simplex – mostly mesotympanal ▪ Otitis media chronica with polyps, granulations ▪ Otitis media chronica cum ostitide ▪ Otitis media chronica cum cholesteatomate Catarrhus tubotympanalis acutus Symptoms – feeling of fulness in the ear, pressure, hearing disorder. Retracted ear drum, without perforation, tympanometry curve type C. Th: treatment of upper airway inflammations, aeration od middle ear cavity. retracted ear drum Otitis media acuta Infection - way: epipharyngeal, hematogenic, injury. Pneumococcus, haemophilus infl., Moraxella catarrhalis 1. Stage of tubal occlusion – Blood vessel injection, without reflex, mild pressure, hearing disorder 2. Stage of exudation – Gradual bulging of ear drum, pain, fever, nausea, vomiting 3. Stage of suppuration – ear drum without contours, spontaneous perforation 4. Stage of reparation – small secretion, ear drum with contours, defect healing with scar Otitis med. ac. l. sin. – gradual changes on ear drum Otitis media acuta Paracentesis (myringotomy) Otitis med. ac. sin. with myringotomy and following restitution Otitis media chronica secretorica ▪ Presence of secretion behind whole ear drum without symptoms of acute inflammations. Time – longer as 3 months. ▪ Pathogenesis – dysphunction of eustachian tube - restructuring of epithelium middle ear cavity – secretion in middle ear cavity – risk of ear drum retraction. ▪ Dg – otoscopy, tympano B or C2 curve, conductive hearing loss ▪ Therapy – conzesvative – stimulation of palate muscles, aeration of midlle ear cavity, antihistaminics, treatment of inflammations of upper airway – surgery. – adenotomy, myringotomy, TVT Otitis media chronica suppurativa Form ▪ Mesotympanal ▪ Epitympanal ▪ Mixed Causes ▪ Recurrences of acuta inflamm. of middle ear cavity ▪ Eustachian tube dysfunction ▪ Chronic inflammation of upper airway Central perforation Otitis media chronica suppurativa mesotympanalis Depend of phasis of inflammation, exacerbation – symptoms as in acute inflammation: ▪ Conductive hearing loss, ▪ Ear drum perforation, in pars tensa, ear discharge – purulent, without smell, ▪ Without temperatures and pain. ▪ Microbiology – usually mixed microbes – Escherichia, Klebsiella, koky, pseudomonads and mycosis. Otoscopy: pars tensa - central perforation, changed middle ear epithelium, polyps, granulations. Central perforation in antero-inferior quadrant Otitis media chronica suppurativa mesotympanalis Treatment ▪ Treatment of upper airway inflammation, improvement of nasal patency tube function. ▪ Local antibiotics , combination with s corticosteroids . ▪ Polyps and granulations removed surgically , ev. in 3-6 months myringoplasty, ev. Reconstruction of ossicle chain. Prognosis Favorite Complications rare Otitis media chronica epitympanalis ▪ Localization in epitympanal cavity; ▪ Frequently connected with cholesteatoma and osteitides ▪ Possible destruction of ossicular chain, bone of middle ear cavity, Theory of genesis 1. Tube Dysfunction – pocket in Schrapnellově membrane – perforation –cholesteatoma 2. Direct growth of epithelium through defect of ear drum into middle ear 3. Embryogenetic theory – congenital cholesteatoma Symptoms: smelly discharge, hearing disorder, occasionally ear pain, ev. paresis n.VII Otoscopy – perforation in pars flaccida Therapy – surgery with removal of cholesteatoma Polyp in otitis med. chronica, Defect of epitympanl space after removal of cholesteatoma Subtotal perforation of ear drum Complications of middle ear inflammation In antibiotic era rare ▪ Otologic – mastoiditis, petrositis, paresis , n. VII labyrinthitis ▪ Intracranial – abscessus epiduralis, subduralis, meningitis, brain and cerebellar abscess Mastoiditis Inflamation of processus mastoideus temporal bone. Osseal septums are melted (radiologic diagnosis). ▪ Usually complication of middle earcavity inflam. ▪ Rarely hematologic spread or injury Mastoiditis - forms ▪ acute (in 2–4 weeks after mediootitis, 50 % of all mastoiditis); ▪ subacute ▪ latents Mastoiditis - symptoms ▪ Acute mastoiditis: fever, palpating pain, retroauricular infiltration, apostasis auriculae or antalgic head position, purulent discharge from ear chanal , worsening of hypacusis, tinnitus, worsening of general condition ▪ Subacute and latent mastoiditis (mild symptoms): some pain – feeling of pressure, hypacusis Bezolds absces in child Mastoiditis Diagnosis: ▪ History of disease ▪ Otoscopy – posterior wall drop, signs of inflam. Middle ear ▪ Audiometry – decrease of both bone and air conduction ▪ CT – destruction of septums, cavity ▪ Increase of inflam. markers Possible complications: ▪ Tromboflebits sinus sigmoideus ▪ Intracranial Nitrolební komplikace (epidurální, subdurální absces, meningitida, mozkový, mozečkový absces) treaatment: ▪ Broad spectrum antibiotics ▪ Mastoidectomy Sanation and rekonstruction surgery inf chronic inflammation and its consequences ▪ Sanation surgery – aim – remove infection focus in temporal bone, potencial risk of life threatening intracranial complicatins ▪ Rekonstructive surgery – aim – reconstruction of hearing function Surgery for otitis media – Sanation surgery Approach – Schwartze - via planum mastoideum into antrum – Stake - via atticus into antrum – Zaufal – via posterior wall into aditus ad antrum and from this antreriorly and posteriorly Sanation surgery – atticotomy – meatoantrotomy – atticoantrotomy – tympanomastoidektomy Status post mastoid- ectomiam Status post atticoantro- tomiam (radical- conservative surgery) Relation between external meatus and trepanation cavity Scared thickened ear drum after otitis Ear drum with atrophic scar and calcification after otitis Injury perforation Surgery treatment - reconstructive surgery (tympanoplasty) Division according to Wulstein I. Myringoplasty II. Columelisation of incus III. Columelisation (stapes) IV. Ekranisation (shade of round window) V. Fenestration of labyrinth Tympanoplasty - type I. Myringoplasty Tympanoplasty II. Columalisation of incus Tympanoplasty type III.a damaged incus and maleus, stapes intact, sound conducted by prosthesis PORP, underlayed by cartilage PORP partial ossicular replacement prosthesis PORP Tympanoplasty type III.b damaged incus and maleus, stapes without suprastructures, sound conducted by prosthesis TORP, underlayed by cartilage. Connection directly between basis stapedis and ear drum. TORP Total ossicular replacement prosthesis Tympanoplasty type III.c Columelisation damaged incus, maleus, stapes intact, connected directly to ear drum - myringostapedopexis Tympanoplasty typ IV. Ecranisation (round window shielded) Tympanoplasty type V. Fenestration (new window created into labyrinth) Syndrome Van den Hoeve de Klein osteogenesis imperfecta fixatio stapedis on both sides blue sclera („the white of the eye“) Otosclerosis vs. tympanosclerosis Stapedotomy K-PISTON STAPES PROSTHESIS Clip piston maleovestibulopexis Stapedotomia Hypacusis perc. l. utr. St.p. stapedotomiam l.dx. Possibility for improvement of hearing by surgery and prosthetics Middle ear implant System for direct bone conduction External bone hearing aid Middle ear surgery Hearing aid for air conduction BONEBRIDGEBAHA Improvement of hearing Sound- bridge Implantable hearing aids Cochlear implants Bone conduction implants Middle ear implants (MEI) BONEBRIDGE BC-FMT = Bone Conduction Floating Mass Transducer First implantation of BONEBRIDGEin Czech rep.  Patient with Treacher-Collins syndrome and atresia meatus acust. ext.  Normal bone conduction, full „cochlear reserve“ bothsided  Surgery: ENT Clinic St.Ann Faculty hospital 29.8.2014 Preparation Estimation of cutaneous flap thickness (until 7 mm) Incision Creation of bed in sinodural angle Fixation of FMT transducer Fixation of FMT Closing the wound Hearing function before and after surgery Vibroplasty - sound bridge A cochlear implant system two main components. The externally worn audio processor detects sounds and sends them to the internal implant, which is placed just under the skin behind the ear. The sound is encoded in processor, electric signal is sended into internal implant and through flexible electrode, which is introduced into the cochlea stimulates directly neurons of auditory nerve. Electric signals are led into the brain, where they are interpreted as sound. Vibrant soundbridge – middle ear implant hearing system. Vibroplasty The externally worn audio processor receive and detects sounds and convert them into electrical signals, which are sent to the internal implant. Electrical signals are led into FMT, which change it into mechanical vibration and directly stimulate ossicles or round window niche or different vibratory structures. Labyrinthine Concussion (Commotio labyrinthi) damage to the inner ear due to head trauma with no well-defined injury or skull fracture, resulting in sensorineural hearing loss with or without vestibular symptoms acceleration-deceleration movement of the membranous labyrinth against the bony labyrinth, or the compression and vibration forces generated by a blunt force trauma. It is suggested that these actions result in “hemorrhaging sites and microcirculation disturbances in the cochlea, destroying the sensory epithelium due to rupture of vessels in the membranous labyrinth