Otitis media treatment


Patients with chronic suppurative otitis media respond more to topical therapy than to systemic therapy. Topical quinolones are particularly effective in resolving otorrhoea without the risk of ototoxicity. There is no evidence that the addition of oral antibiotics confers increased benefit. Intravenous antibiotics, particularly the anti-pseudomonal drugs, are highly effective but too expensive. Antibiotics provide little benefit in mild cases of acute otitis media. But infants with frequent recurrences of acute otitis media may be considered for daily antibiotic prophylaxis. The addition of dexamethasone to a topical antibiotic increases the middle ear drainage. Steroids, decongestants, and antihistamines are not effective in the treatment of acute infection and may instead cause complications. Several complementary and/or alternative medicine therapies, such as homeopathy, acupuncture, herbal remedies, chiropractic treatments, and nutritional supplements, have been used by parents for the treatment of acute otitis. Suregry may be advised if the child's infection fails to respond to antibiotics, if the ear infections are chronic or hearing loss is indicated. The most common type of surgery is Myringotomy. Other optional surgeries include adenoidectomy and tonsillectomy. The doctor may suggest a stapedectomy, replacement of the stapes with a prosthesis in case of hearing loss.

1.Tympanoplasty


Tympanoplasty surgery is carried out for the closure of the tympanic perforation by a soft tissue graft with or without reconstruction of the ossicular chain. The specific type of tympanoplasty depends on the extent of damage to the ossicular chain. The sequential destruction of the malleus, incus and stapes requires progressively more medially placed tympanic grafts. Mastoidectomy and tympanoplasty may or may not be performed together in order to eradicate Chronic suppurative otitis media, particularly if cholesteatoma is absent. In both procedures, the middle ear is inspected and, the middle ear ossicles and mucosa may be removed if complete removal of infections warrants it. Tympanoplasty is performed to eradicate disease from the middle ear and to restore the hearing mechanism. Tympanoplasty is mainly classified into 2 primary types: lateral grafting and medial grafting. In the lateral graft technique, the graft material is laid laterally to the annulus after the remnant of squamous tissue is denuded, whereas in medial grafting, the annulus is raised and the graft slipped medially.
Mastoidectomy involves removing the mastoid air cells, granulations and debris using bone drills and microsurgical instruments.

2.Mastoidectomy (Basic)


In simple Mastoidectomy, external mastoid cortex is drilled away and the mastoid air cells are removed. There are two basic variations of Mastoidectomy surgery: canal-wall up and canal-wall down. The extent of the disease present and exposure required would predict which type of operation is performed. Both procedures involve many of the same basic steps and approach. The recovery for both is similar.

The bony posterior canal wall that separates the middle ear and mastoid cavities may be removed with drilling, in canal-wall-down Mastoidectomy (CWD), as opposed to intact canal- wall Mastoidectomy (ICW) in which the posterior canal wall is preserved and an opening through it is made to gain entry into the middle ear. The effectiveness of Mastoidectomy depends on patient selection and the timing of surgery. The CWD was the first type Mastoidectomy, but it has some disadvantages. They include: the need for frequent ear canal cleaning, water restrictions and possible hearing changes. The mastoid bowl or cavity created by a canal wall down Mastoidectomy will often fill with earwax. The earwax must be removed periodically in order to prevent infection. The wide opening into the outer ear is visible, although it is not necessarily ugly.

3.Mastoidectomy (MRM)


Modified Radical Mastoidectomy (MRM) is carried out for chronic ear infection, usually with cholesteatoma, where it has caused problems such as breakdown of the bone of the back wall of the ear canal or exposure of the balance organs of the inner ear. The aim of the operation is to remove cholesteatoma completely. A dry ear with good hearing is also anticipated. This technique is particularly useful for extensive cholesteatoma and semicircular canal fistula. It is a relatively safe method and may be used for alteration surgery or for operating when the other ear is completely deaf. Many surgeons prefer a canal wall up or combined approach tympanoplasty technique and reserve the MRM operation for patients where the canal wall up is not appropriate, like when disease enters corners of the middle ear that cannot be adequately accessed without removing the canal wall. The operation is done with an operating microscope, very delicate instruments and drill. It may be done through an incision just behind (post aural) or in front (endaural) of the ear. Some surgeons use a facial nerve monitoring device but most reserve this for cases such as difficult revision surgery.

4.Mastoidectomy (CWU for Cholesteatoma)


Chronic suppuration can occur with or without cholesteatoma. The treatment design for cholesteatoma invariably includes tympanomastoid surgery with adjunct medical treatment therapy. The canal wall up Mastoidectomy surgery does not remove the bone of the ear canal or create a cavity that is exposed to outside air, as is done for canal wall down Mastoidectomy. But the mastoid disease along with trabeculated bone is removed and tissues are closed back to their normal positions. This eliminates the need for mastoid bowl cleaning, and people usually return to normal activities. The ear looks about the same after surgery as it did before surgery. A CWU Mastoidectomy is often performed in conjunction with reconstruction or repair of the eardrum or the ossicles. One disadvantage of the CWU Mastoidectomy is the high recurrence or residual cholesteatoma, relative to the CWD Mastoidectomy. Residual or recurrent ear cholesteatoma may be hidden from ear canal inspection by the wall of the ear canal. So it is recommended perform a second look surgery several months after the first surgery.
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