SUMPh Nicolae Testemitanu Department Otorhinolaryngology Anatomy and physiology

SUMPh “Nicolae Testemitanu” Department Otorhinolaryngology Anatomy and physiology of the middle ear Associate Professor Diacova Svetlana

Tympanic membrane - TM, membrana tympani, myrinx • Delimits middle and external ear, in sulcus tympanicus in bottom of EAC • In adults TM – a board of ovale shape, translucid, 11 x 9 mm Position: oblique, in new-borns - horizontal. • Layers: 1. extern - skin 2. intern - mucous 3. meddle - fibrous 2 (radial şi circular). • Parts: 1. pars tensa (stretched part) 2. pars flaccida - relaxed, - without fibrous layer (membrana Shrapnelli) 1

Tympanic membrane - TM, membrana tympani, myrinx 3 Color - Gray – Perl Reference points: 1 - hammer handle ; 2 - short apophyses ; 3 - creases – anterior and posterior; 4 - umbo; 5 – light cone. 2 1 5 4

Tympanic membrane - TM, membrana tympani, myrinx Four quadrans: (line along hammer handle through umbo and perpendicular to that): 2 1 anterosuperior 2 posterosuperior 3 anteroinferior 4 posteroinferior 1 4 3

Middle ear Common system of pneumatic cavities : 1. tympanic cavity (cavum tympani); 2. auditory tube (Eustache); 3. antrum and procesus mastoideus

Timpanic cavity (cavum tympani) • Central position • Ventilation through auditory tube and nasofarinx • Communicates with antrum and mastoid cells – through aditus ad antrum • • • Lateral wall– tympanic membrane, Internal wall – labirintic (Promontorium) Anterior wall - tubar (auditory tube), Posterior wall - mastoidic, (aditus ad antrum) Superior wall - tegmen (tegmen tympani), fosa cranii media • Inferioar wall - jugular - (bulbus v. jugularis).

Timpanic cavity (cavum tympani) 3 parts • Superior part – supratympanal (attic or epitympanum). • Middle part - mezotympanum (mesotympanum). • Inferior part – hipotympanum Mucosa – cubic epithelium of one layer 3 ossicles: 1. malleus; 2. incus; 3. stapes. 2 muscles of tympanic cavity: m. Stapedius, m. Tenzor tympani.

Auditory tube (Eustachio) • Communicates with timpanic cavity and nasopharynx • In children: short, large, more horizontal, easy opens, in small children is opened. • Mucosa – voluminous respiratory ciliated epithelium with unique Goblet cells, that produce mucus • Functions: » aeration, » protection » drainage

Mastoidian process Contains pneumatic cells with the biggest cell - antrum. • Communicates with tympanic cavity - through aditus ad antrum. • In newborns – only antrum • Developing – during the first years of life Limits: • Superior - temporalis line, continuation of zygomaticus apophyses. • Anterior –posterior wall of EAC, in postero-super. part - spina suprameatum Henle, antrum’s proiection Antrum – the biggest cell, contains air. Tegmen of antrum delimits from dura mater of the middle cranian fossa 3 types of pneumatization of mastoidian apophyses : pneumatic, diploic, sclerozant.

Mastoidian apophyses • Behind the posterior wall- Sinus lateralis (sinus sigmoideus) – venous sinus of the jugular vein system. • Under inferior wall– bulbus v. jugularis int. • In anterior wall – n. Facialis, EAC • Behind superior wall – middle cranian fossa • Behind middle wall –semicircular canal

Definition. • OTITIS MEDIA (OM) – inflammaion of middle ear (which includes : tympanic cavity, auditory tube (Eustachio), antrum and mastoid cells).

OM HIGH INCIDENCE • 80 - 90 % children – once in a life • 50 - 70 % - 3 and more episodes • 60 - 85 % children by 3 y. o. with bronchitis and pneumonia • 35 - 40 % children of the first 7 years of life with “respiratory infection” • 60 - 70 % children with hipertrophy of palatine amigdals and adenoides

OTITIS MEDIA relations between different forms Acute OM Recurrent OM Chronic Suppurative OM OM with effusion Adhesive OM

OM classification • Acute OM– acute inflammation of middle ear • OM with effusion - presence of liquid behind intact tympanic membrane • Recurrent OM - Recidive of acute OM 3 times in 6 months or 4 times in 12 months

OM classification • Adhesive OM – cicatrization of tympanic cavity , adherences formation • Chronic Suppurative OM - inflamatory chronic purulent procces in middle ear

OM OM with effusion Adhesive OM Lack of diagnostic and an adequate treatment Chronic Supurative OM with risc Of INTRACRANIAL COMPLICATIONS

OME – otitis media with effusion etiologic variabil procces with presence of effusion (exudate, liquid) behind tympanic membrane relativly intact are not caracteristic Acute infection signs: fever, intensive pain

EMO Middle ear containing serous mucous purulent Glue ear OM serous OME Mucous OM sero-mucous OM

OME 1. High Incidence • 60 % children 2. cognitiv –intelectual consequences • speech development retardation • psihoemoţional retardation in child Otologic consequences • Recurrent OM • Adhesive OM • Chronic Suppurative OM • OM with colesteatom with risc of intracranial complications • sensoro-neural hearing loss

OME Etiology • Caused by microbian or viral flora in a small quantity • The most frequent: • Streptococcus pneumoniae • Haemophilus influenzae • Moraxella catarralis

OME Pathogenesis Eustachian tube is opened Microbian toxins or Eustachian tube Alergic antigens = in auditory tube is closed =in tympanic cavity=stimulates „The vacuum”theory, • hiperplazia of epithelium, Is based on a postulat • Goblet cells proliferation , Of nasal obstruction as • paralises ciliar motions, Principal initiative • blocks evacuation moment of exudate from TC Mucous edema, hipersecretion and dereglation of exudate evacuation Leads to auditory tube obstruction.

OME Favorable factors • Early age • malnutrition • Artificial alimentation of a child during first year of life • Genetic anomalies of cranium and face, • Recurrent otitis media during first months • Allergy changes • prematurity • Frequent viral infections

OME Anatomic and functional features in children Auditory tube • shorter • larger • straight • opened Mucosa in nose and tympanic cavity • More irritated by bacteria, viruses, alergens • More easily develop cells, that produce mucous

OME Favorable factors in adults and older children Viral infection Nasal septum deviation sinusitis alergy nazopharingeal tumor proccesses as a complication of a hiperbarooxigenotherapy In pacients of these age groups predominate exudative serous proccesses.

OME In elder children • Hearing loss • Sensation of liquid in the ear • Ear noise Clinical signs In children af early age • iritability • Sleep disturbances • Inadecvate reaction to parents’ calling • Speech development retardation • psiho-emoţional retardation

OME Anamnesis Diagnostics Sleep disturbances Inadecvate reaction to parents’ calling, Speech development retardation Otoscopy TM gray-pink, dull Tragal reflex is not a semnificativ diagnostic sign Pneumootoscopy Impedance Audiometry & Audiometry TM gray-pink, dull, Motional decrease of MT type B of tympanogram Stapedian Reflex absence Conductive hearing loss (30 - 50 d. B)

Otoscopic OME signs NORM

EMO Impedansmetry • type B • Stapedian reflex is absent 0

OM Impedansmetry C A B - 100 mm H 2 O O 0 Types of tympanogram 1. Type A – norm 2. Type B - pathology (OM ? ) 3. Type C - pathologz (auditorz tube disfunction)

OME Audiometry Tonal audiometry • Conductive hearing loss • 10 – 15 % mixt hearing loss Play audiometry • Inadecvate reaction to sounds 30 – 50 d. B on the wholl frequence scale BAER inregistration • inregistration of curve on 35 -40 d. B • prolonged of latency of peak I OAE Inregistration Absence of otoemission to 30 d. B and presence of that to 60 d. B

OME Screening methods • Impedance Audiometry • OAE inregistration • BERA inregistration

OME Treatament methods antibacterial antialergic nasopharyngeal OME, acute General treatment OME, subacute Local treatment

OME Miringotomy

OME Timpanostomy