Acute Otitis Media

DEFINITION

Acute otitis media is an infection of the middle ear, the area of the ear directly behind the tympanic membrane (ear drum). Acute otitis media is one of the most commonly diagnosed childhood illnesses and is responsible for more than 30 million clinic visits a year in the United States.

Acute otitis media usually starts when germs that cause colds or sore throats (either bacterial or viral infections) spread to the middle ear. Once in the ear, the infection can cause a buildup of pus or fluid behind the eardrum. The pressure on the eardrum can lead to significant pain in some children.

Physicians diagnose acute otitis media using an otoscope, an instrument placed in the opening of the ear that allows the doctor to look at the eardrum. Inflammation of the eardrum can indicate an infection. Lack of movement of the eardrum can also indicate infection. If there is fluid or pus behind the eardrum, it usually does not move easily.



SIGNS AND SYMPTOMS

- Fever
- Ear pain or pulling at one or both ears
- Irritability
- Decreased appetite
- Fluid coming from one or both ears

These symptoms can occur for other reasons, so it is important for children with these symptoms to be evaluated by a physician.

TREATMENT

Acute otitis media may be treated with antibiotics if there is a bacterial infection. When children have recurrent or chronic (persisting long-term) otitis media, it may be necessary to have a tympanostomy tube placed in the eardrum. The tube falls out naturally after several months and the hole heals naturally. Treatment depends on the characteristics of each child, so it is important for your child to have an evaluation if these symptoms develop.

WHEN TO CALL THE DOCTOR

Although quite rare, ear infections that don't go away or severe repeated middle ear infections can lead to complications, including spread of the infection to nearby bones. So kids with an earache or a sense of fullness in the ear, especially when combined with fever, should be evaluated by their doctors if they aren't improving.

Other conditions can also result in earaches, such as teething, a foreign object in the ear, or hard earwax. Consult your doctor to help determine the cause of the discomfort and how to treat it.
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Chronic Otitis Media

The Middle Ear and Its Structures

The middle ear is a hollow chamber in the bone of the skull. It is separated from the outside world by a thin membrane about half-an-inch in diameter, the eardrum. The middle ear area is lined by the same kind of mucous membrane that lines nose and mouth. It is connected to the back of the nose, just above the soft upper portion of the mouth, by a narrow passage called the eustachian tube.

The eustachian tube lies closed until the swallowing movement pulls it open and allows fresh air to enter the middle ear. The fresh air is needed to replace oxygen that has been absorbed by the middle ear lining. The fresh air equalizes the middle ear pressure with the air pressure outside the head. Some people hear this burst of fresh air as a pop or click.

Suspended within the middle ear is a chain of three small bones, the ossicles, which conduct sound vibrations from the eardrum across the middle ear into the fluid-filled inner ear. Inside the inner ear these vibrations are converted to nerve signals that are carried by the auditory nerve to the brain.

The mastoid bone is an extension of the air space of the middle ear. It is made up of small interconnected air spaces similar to a honeycomb. Its function is not clear, but it is often involved in chronic ear infections. Within it lie the structures of the inner ear responsible for balance and facial expression.

What is Chronic Otitis Media?

Chronic Otitis Media (COM) is the term used to describe a variety of signs, symptoms, and physical findings that result from the long-term damage to the middle ear by infection an inflammation. This includes the following:

- Severe retraction or perforation of the eardrum (a hole in the eardrum)
- Scarring or erosion of the small, sound conducting bones of the middle ear
- Chronic or recurring drainage from the ear
- Inflammation causing erosion of the bony cover or the facial nerve, balance canals, or cochlea (hearing organ)
- Erosion of the bony borders of the middle ear or mastoid, resulting in infection spreading to the meninges (the coverings of the brain) or brain
- Presence of cholesteatoma
- Persistence of fluid behind an intact eardrum

How Does Chronic Otitis Media Occur?

If the eustachian tube becomes blocked by swelling or congestion in the nose and throat, by swelling of the mucous membrane in the middle ear, or by swelling of the mucous membrane of the eustachian tube itself, the air pressure in the middle ear cannot equalize properly. A negative pressure develops, and if the obstruction is prolonged, fluid may be drawn into the air space of the middle ear from the mucosa. This may occur with a cold or flu virus and is a common cause of ear infections in children (serous otitis media). Serous otitis media usually resolves without treatment, but may require a course of antibiotics or steroids. It is a common reason for placement of tubes in children and adults.

If the eustachian tube blockage persists, chronic changes in the tissue of the middle ear begin to occur. First, the mucous secretions become thicker, and therefore less likely to drain. Then the membranes themselves begin to thicken and become inflamed. The defense mechanisms of the eustachian tube and middle ear become compromised and bacteria normally present in the nose may enter the middle ear and cause a painful condition called acute otitis media. This responds to antibiotic treatment, but may require placement of tubes.

The negative pressure in the middle ear or alternating periods of negative, normal and positive pressure may deform the eardrum. In the long term, the eardrum may become severely distorted, thinned, or even perforated. These changes may cause hearing loss and a sensation of pressure. When there is a hole in the eardrum, the natural protection of the middle ear from the environment is lost. Water and bacteria entering the middle ear from the ear canal can cause inflammation and infection. Drainage from the ear is a sign of a perforation.

Inflammation and infection in time can cause erosion of the ossicles and the walls of the middle and inner ear. The patient may experience hearing loss, imbalance, or weakness of facial movement on the affected side. In rare instances, the infection may extend deeper into the head, causing meningitis or brain abscess.

A cholesteatoma, or skin cyst, is essentially skin in the wrong place. Epidermal skin from the ear canal or outside surface of the eardrum, like that on the back of the hand, does not belong in the middle ear. If it is trapped by a deformed eardrum or migrates through a perforation, it tends to grow out of control and can cause significant damage to the structures of the middle ear and mastoid.

How Do I Know If I Have Chronic Otitis Media?

Warning signs of chronic otitis media include:

- Persistent blockage of fullness of the ear
- Hearing loss
- Chronic ear drainage
- Development of balance problems
- Facial weakness
- Persistent deep ear pain or headache
- Fever
- confusion or sleepiness
- Drainage or swelling behind the ear

Chronic otitis media generally occurs gradually over many years in patients with longstanding or frequent ear trouble. However, it can occasionally develop over several months in a patient with no previous history of ear disease. Any of the above symptoms should prompt an evaluation by an ENT or otologist/neurotologist.

How is Chronic Otitis Media Treated?

The first step in treating otitis media is a thorough evaluation by a physician. This will include a history and examination of the ear, nose, and throat. Depending on the individual situation, further testing will include a hearing test, tympanometry (a test that measures the pressure in the middle ear) and CT or MRI scan.

Treatment depends upon the stage of the disease. Initially, efforts to control the causes of eustachian tube obstruction, such as allergies or other head and neck infectious problems, may prevent progression of chronic otitis media. Uncomplicated chronic ear fluid is treated with antibiotics, steroids, and/or placement of ventilation tubes. Many children with chronic or recurrent ear infections have ventilation tubes inserted in their eardrums to allow normal air exchange in the middle ear until the eustachian tube matures.

Once the disease has progressed to the point of significant damage to the eardrum or ossicles, more intensive treatment is needed. If active infection is present in the form of ear drainage, antibiotic eardrops are prescribed. Occasionally, these may be supplemented with oral antibiotics.

Once the active infection is controlled, surgery is usually recommended. There are three objectives of surgery for COM:

* Eradication of the disease
* Remodeling of the middle ear and mastoid bone, located just behind the external ear, to prevent recurrence
* Preservation or improvement in hearing

Surgeries to achieve these objectives include tympanoplasty, mastoidectomy, or typanomastoidectomy. The ENT doctor or otologist makes an incision within the ear canal or behind the external ear. Part of the mastoid bone is then drilled away to gain access to the middle ear space. The abnormal tissues are removed. If possible, efforts are made to rebuild the eardrum and the sound-conducting bones. It is sometimes necessary, however, to complete the hearing reconstruction at a later date (a second stage) rather than at the same time as removal of the infected or damaged parts. Patients are usually discharged from the hospital on the same day or one day after surgery.

Healing after surgery takes several months. In 90 percent of cases, surgery is successful in repairing the eardrum and a dry, healthy ear results. Hearing improvement is more difficult to predict and varies greatly depending on the severity of the disease, including the presence of cholesteatoma, ossicular erosion, mastoid disease, and eustachian tube function. If a hearing reconstruction was performed, it will take several weeks and months for hearing to begin improving. During this time middle ear packing and fluids are being reabsorbed and scar tissue is being formed to help stiffen the bones. In addition, the eardrum thins out. These factors contribute to a gradual hearing improvement. Routine checkups by the physician are recommended at least yearly after the healing is complete, and in some cases may be required two or more times yearly to maintain adequate local hygiene.

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Hemoptysis

Definition

Hemoptysis is the coughing up of blood or bloody sputum from the lungs or airway. It may be either self-limiting or recurrent. Massive hemoptysis is defined as 200-600 mL of blood coughed up within a period of 24 hours or less.

Description

Hemoptysis can range from small quantities of bloody sputum to life-threatening amounts of blood. The patient may or may not have chest pain.

Causes and symptoms

Hemoptysis can be caused by a range of disorders:

- Infections. These include pneumonia; tuberculosis; aspergillosis; and parasitic diseases, including ascariasis, amebiasis, and paragonimiasis.

- Tumors that erode blood vessel walls.

- Drug abuse. Cocaine can cause massive hemoptysis.

- Trauma. Chest injuries can cause bleeding into the lungs.

- Vascular disorders, including aneurysms, pulmonary embolism, and malformations of the blood vessels.

- Bronchitis. Its most common cause is long-term smoking.

- Foreign object(s) in the airway.

- Blood clotting disorders.

- Bleeding following such surgical procedures as bronchial biopsies and heart catheterization.

Diagnosis

The diagnosis of hemoptysis is complicated by the number of possible causes.

Patient history

It is important for the doctor to distinguish between blood from the lungs and blood coming from the nose, mouth, or digestive tract. Patients may aspirate, or breathe, blood from the nose or stomach into their lungs and cough it up. They may also swallow blood from the chest area and then vomit. The doctor will ask about stomach ulcers, repeated vomiting, liver disease, alcoholism, smoking, tuberculosis, mitral valve disease, or treatment with anticoagulant medications.

Physical examination

The doctor will examine the patient's nose, throat, mouth, and chest for bleeding from these areas and for signs of chest trauma. The doctor also listens to the patient's breathing and heartbeat for indications of heart abnormalities or lung disease.

Laboratory tests

Laboratory tests include blood tests to rule out clotting disorders, and to look for food particles or other evidence of blood from the stomach. Sputum can be tested for fungi, bacteria, or parasites.

X ray and bronchoscopy

Chest x rays and bronchoscopy are the most important studies for evaluating hemoptysis. They are used to evaluate the cause, location, and extent of the bleeding. The bronchoscope is a long, flexible tube used to identify tumors or remove foreign objects.

Imaging and other tests

Computed tomography scans (CT scans) are used to detect aneurysms and to confirm x-ray results. Ventilation-perfusion scanning is used to rule out pulmonary embolism. The doctor may also order an angiogram to rule out pulmonary embolism, or to locate a source of bleeding that could not be seen with the bronchoscope.

In spite of the number of diagnostic tests, the cause of hemoptysis cannot be determined in 20-30% of cases.

Treatment

Massive hemoptysis is a life-threatening emergency that requires treatment in an intensive care unit. The patient will be intubated (the insertion of a tube to help breathing) to protect the airway, and to allow evaluation of the source of the bleeding. Patients with lung cancer, bleeding from an aneurysm (blood clot), or persistent traumatic bleeding require chest surgery.

Patients with tuberculosis, aspergillosis, or bacterial pneumonia are given antibiotics.

Foreign objects are removed with a bronchoscope.

If the cause cannot be determined, the patient is monitored for further developments.

Prognosis

The prognosis depends on the underlying cause. In cases of massive hemoptysis, the mortality rate is about 15%. The rate of bleeding, however, is not a useful predictor of the patient's chances for recovery.


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Pneumothorax

A pneumothorax is air that is trapped next to a lung. Most cases occur 'out of the blue' in healthy young men. Some develop as a complication from a chest injury or a lung disease. The common symptom is a sudden sharp chest pain followed by pains when you breathe in. You may become breathless. In most cases, the pneumothorax clears without needing treatment. The trapped air of a large pneumothorax may need to be removed if it causes breathing difficulty. An operation is needed in some cases.

Definition

A pneumothorax is air that is trapped between a lung and the chest wall. The air gets there either from the lungs or from outside the body.



Causes

Primary spontaneous pneumothorax. This means that the pneumothorax develops for no apparent reason in an otherwise healthy person. This is the common type of pneumothorax. It is thought to be due to a tiny tear of an outer part of the lung - usually near the top of the lung. It is often not clear why this occurs. However, the tear often occurs at the site of a tiny 'bleb' or 'bullae' on the edge of a lung. These are like small 'balloons' of tissue that may develop on the edge of a lung. The wall of the 'bleb' is not as strong as normal lung tissue and may tear. Air then escapes from the lung but gets trapped between the lung and the chest wall.

Most occur in healthy young adults who do not have any lung disease. It is more common in tall thin people.

About 2 in 10,000 young adults in the UK develop a spontaneous pneumothorax each year. Men are affected about four times more often than women. It is rare in people over the age of 40. It is also much more common in smokers compared to non-smokers. Cigarette smoke seems to make the wall of any bleb even weaker and more likely to tear.

About 3 in 10 people who have a primary spontaneous pneumothorax have one or more recurrences sometime in the future. If a recurrence does occur it is usually on the same side and usually occurs within three years of the first one.

Secondary spontaneous pneumothorax. This means that the pneumothorax develops as a complication (a 'secondary' event) of an existing lung disease. This is more likely to occur if the lung disease weakens the edge of the lung in some way. This may then make the edge of the lung more liable to tear and allow air to escape from the lung. So, for example, a pneumothorax may develop as a complication of COPD (chronic obstructive airways disease) - especially where lung bullae have developed in this disease. Other lung diseases that may be complicated by a pneumothorax include: pneumonia, tuberculosis, sarcoidosis, cystic fibrosis, lung cancer, and idiopathic pulmonary fibrosis.

Other Causes

An injury to the chest can cause a pneumothorax. For example, a car crash or a stab wound to the chest. Surgical operations to the chest may cause a pneumothorax. A pneumothorax is also an uncommon complication of endometriosis.

Symptoms

- The typical symptom is a sharp, stabbing pain on one side of the chest which suddenly develops.
- The pain is usually made worse by breathing in (inspiration).
- You may become breathless. As a rule, the larger the pneumothorax, the more breathless you become.
- You may have other symptoms if an injury or a lung disease is the cause. For example, cough or fever.

A chest x-ray can confirm a pneumothorax. Other tests may be done if a lung disease is the suspected cause.

What happens to the trapped air and small tear on the lung?

In most cases of spontaneous pneumothorax the pressure of the air that leaks out of the lung and the air inside the lung equalises. The amount of air that leaks (the size of the pneumothorax) varies. Often it is quite small and the lung collapses a little. Sometimes it can be large and the whole lung collapses. If you are otherwise fit and well, this is not too serious as the other lung can cope until the pneumothorax goes. If you have a lung disease, a pneumothorax may make any existing breathing difficulty much worse.

The small tear that caused the leak usually heals within a few days, especially in cases of primary spontaneous pneumothorax. Air then stops leaking in and out of the lung. The trapped air of the pneumothorax is gradually absorbed into the bloodstream. The lung then gradually expands back to its original size. Symptoms may last as short as 1-3 days in cases of primary spontaneous pneumothorax. However, symptoms and problems may persist longer, especially in cases where there is an underlying lung disease.

Tension pneumothorax
This is a rare complication. This causes shortness of breath that quickly becomes more and more severe. This occurs when the 'tear' on the lung acts like a one way valve. In effect, each breath in (inspiration) 'pumps' more air out of the lung, but the valve action stops air coming back into the lung to equal the air pressure. The volume and pressure of the pneumothorax increases. This puts pressure on the lungs and heart. Emergency treatment is needed to release the trapped air.

Treatment

No treatment may be needed. You may not need any treatment if you have a small pneumothorax. A small pneumothorax is likely to clear over a few days. A doctor may advise an X-ray in 7-10 days to check that it has gone. You may need painkillers for a few days if the pain is bad.

Aspirating (removing) the trapped air is sometimes needed. This may be needed if there is a larger pneumothorax or if you have other lung or breathing problems. As a rule, a pneumothorax that makes you breathless is best removed. It is essential to remove the air quickly in a 'tension' pneumothorax. The common method of removing the air is to insert a very thin tube through the chest wall with the aid of a needle. (Some local anaesthetic is injected into the skin first to make the procedure painless.) A large syringe with a three way tap is attached to the thin tube that is inserted through the chest wall. The syringe sucks out some air, the three way tap is turned, and the air in the syringe is then expelled into the atmosphere. This is repeated until most of the air of the pneumothorax is removed.

Sometimes a larger tube is inserted through the chest wall to remove a large pneumothorax. This is more commonly needed for cases of secondary spontaneous pneumothorax when there is underlying lung disease. Commonly, the tube is left is left place for a few days to allow the lung tissue that has 'torn' to heal.

Note: it can be dangerous to fly if you have a pneumothorax. Do not fly until you have the 'all clear' from your doctor following a pneumothorax. Also, do not go to remote places where access to medical care is limited until you have the 'all clear' from a doctor.

Treating Recurrences

Some people have repeated episodes of spontaneous pneumothorax. If this occurs, a procedure may be advised with the aim of preventing further recurrences. For example, an operation is an option if the part of the lung that tears and leaks air out is identified. It may be a small 'bleb' on the lung surface that can be removed. Another procedure that may be advised is for an irritant powder (usually a kind of talc powder) that can be put on the lung surface. This causes an inflammation which then helps the lung surface to 'stick' to the chest wall better.

A lung specialist will be able to give the pros and cons of the different procedures. The procedure advised may depend on your general health, and whether you have an underlying lung disease.

If you are a smoker and have had a primary spontaneous pneumothorax, you can reduce your risk of a recurrence by stopping smoking.

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Pleural effusion

A pleural effusion is a collection of fluid next to the lung. There are various causes. The effusion may cause you to become breathless. The fluid can be drained if necessary. Treatment is mainly aimed at the underlying cause.

Pleural Effusion

A pleural effusion means that there is a build up of fluid between a lung and the chest wall.

The pleura is a thin membrane that lines the inside of the chest wall and covers the lungs. There is normally a tiny amount of fluid between the two layers of pleura. This acts like lubricating oil between the lungs and the chest wall as they move when you breathe. A pleural effusion develops when this fluid builds up and separates the lung from the chest wall.

Symptoms

You may feel some chest pain but a pleural effusion is often painless. The amount of fluid varies. As the effusion becomes larger, it presses on the lung which cannot expand fully when you breathe. You may then become breathless.

You may also have symptoms of the condition that is causing the effusion. For example, cough, and fever if the cause is pneumonia.
What are the causes of a pleural effusion?

A pleural effusion is a complication of various conditions. The following are some of the more common causes of a pleural effusion (but there are other rarer causes too).

- Pneumonia (lung infection), tuberculosis, and tumours (cancers) may cause inflammation of the lung and pleura. This may cause fluid to build up into a pleural effusion.
- Some arthritic conditions may cause inflammation of the pleura in addition to joint inflammation. For example, pleural effusion is an uncommon complication of rheumatoid arthritis and systemic lupus erythematosis (SLE).
- Heart failure causes 'back pressure' in the blood vessels (veins) that take blood back to the heart. Some fluid may seep out of the blood vessels. Swelling of the legs with fluid is typical with heart failure, but a pleural effusion may also develop.
- A low level of protein in the blood also tends to allow fluid to seep out of the blood vessels. For example, cirrhosis of the liver and some kidney diseases may cause a low level of blood protein which allows a pleural effusion to develop.

Diagnose

A chest x-ray confirms a pleural effusion. If the cause of the effusion is known then no further tests may be needed. However, sometimes a pleural effusion is the first sign of an underlying condition. Further tests may then be advised to find the cause of the effusion. These may include lung tests, blood tests, and taking a sample of the fluid and pleura to examine in the laboratory.

Treatment

A large pleural effusion that makes you breathless can be drained. This is usually done by inserting a needle or tube through the chest wall. A local anaesthetic is injected into the skin and chest wall first to make the procedure painless.

A major part of treatment is usually directed to the underlying cause of the effusion. For example, antibiotics for pneumonia, chemotherapy or radiotherapy for cancers, etc. Therefore, treatment can vary greatly, depending on the cause of the effusion.

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