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Otitis Media in Adults

May 06 | 3:30 PM

Otitis media (OM) is an umbrella term for a group of complex infective and inflammatory conditions affecting the middle ear. A malfunction of the eustachian tube, which helps to equalise pressure between the outer and middle ear, is frequently the cause of middle ear infections.These are less prevalent in adults than in children, although the former can have more serious consequences, including hearing loss if left unchecked.Dr. Pranshu Mehta, Consultant ENT Surgeon & Facial Aesthetics, Delhi, joins us LIVE on Medflix to help us diagnose adult onset OM and manage it effectively.

[Music] hello everyone uh i am doctor branch and first of all i'd like to thank dr nikki for welcoming me and welcoming each and every one who's present here right now so today i'm gonna be talking about otitis media exactly acute protective media and attacks how it is different from the ones uh which we see in kids in infants and how to deal with it what's the difference how important is it to recognize the correct cause and [Music] so without uh further wasting any of the time let's just start quickly i'll just put the presentation so i'll start with aom in the darts first of all what is a1 what is aom or what do you understand by a1 acute otitis media or sometimes people can refer it to as just otitis media just otitis media so any inflammation of the middle ear cavity any inflammation let it be infective let it be non-infective any inflammation [Music] any inflammation of the middle ear cavity is ortitis media now this acute just makes it a condition where the patient has severe and acute onset of pain whenever the patient presents with severe pain in the ear without discharge it's acute lattice media we usually confuse it with only being the infective cases however ome or otitis media with effusion so once we understand that it will be easier for us to understand a1 so acute protitis media will not only label it as infective cases we'll try to consider both cases here tonight which ones the otitis media which does not have any infection and the otitis media which has infection that is usually what we call as aom acuteotitis media which is infective in nature and the one which is non-infective okay so we'll consider both today let's move to the next slide okay so point is first of all we have to understand what is the etio patho physiology we have to understand the etiopathophysiology of this disease aol now to understand this we have to understand all the things the etiology the pathology and the physiology that is why this word is such an amazing word etio pathophysiology so let's focus on one thing first this is pinna this is the eac or the external auditory canal this is the tympanic membrane then we have what we call as the middle ear the middle ear now this middle ear is connected to the nasal cavity through eustachian tube et or the eu station tube and this nasal cavity has the septum has turbinates this opening of eustachian tube is located posteriorly in the koana posteriorly basically it's in the nasopharynx nasopharynx okay so now to understand now to understand that otitis media is inflammation of this part can you see it this part the tympanic cavity the middle ear this is otitis media so here there is no infection in the external part of the ear no infection as such only of the tymbanic membrane it's of the middle ear so as a part of the middle ear the timbering membrane also shows us some of the signs and those are the things which we can actually view because the rest of the middle ear is nothing but it is what it is inside the temporal bone so the only thing which you can view is this tn tempering memory okay so continuing with this now what happens is we'll talk about what can happen in adults that can lead to a1 or how am usually develops like what are the what is the series of events that will lead to development of aom or acute otitis media now consider it this way consider it this way this is your nose this is the septum here are the turbinates the nasopharynx you can see the koana and then there's nasopharynx over there there is the opening of eustachian tube over here it is going and connecting middle ear cavity this is eac this is the ear pin now now you have cough or you have cold either cuff or cold or both or rhinitis or allergic rhinitis or anything which causes edema or swelling in the mucosa of the nose it causes edema in the nose so first thing that occurs is edema in the mucosa of the nose whenever this occurs there is also watery discharge there is also watery discharge now these two things sometimes cause the blockage of this opening of use station tube now whenever there is blockage of use station cube the pressure difference here the pressure in the middle ear cavity and the pressure outside becomes different and because of this locking of eustachian cube new station tube locking occurs it gets locked because pressure here is less pressure here is more sometimes sometimes pressure here is more pressure here is less so there is a pressure difference now whenever there is locking what happens is see i'll show there is secretion in the middle ear cavity that secretion you'd usually would have been cleared through the eustachian tube opening and this middle ear would have been ventilated this middle ear would have been ventilated by air travelling by air traveling to the middle ear cavity through the eustachian tube opening so the air would have gone in to the middle ear cavity through this eustachian tube that is what we do in well silver maneuver right in valsalva we do a forceful exploration against a closed glottis closed nostril and closed mouth so the only opening where air can enter is the eustachian when it enters and opens our middle ear cavity now this eustachian tube gets blocked because of either edema in the mucosa which is lining this or there is a mucous plug or phlegm a mucous plug formed because of phlegm or because of watery discharge and temporarily this is blocked off so whenever this is blocked off this air can not cannot further enter into the middle ear to ventilate the ear so first thing that will happen is happen is ventilation of ventilation of middle ear is lost so whenever the ventilation of middle ear is lost there is negative pressure in the middle ear now this negative pressure what it does now if this is blocked here this negative pressure in the middle here the middle ear cavity is made up of bone which is lined by mucosa everywhere but there is only a few places where there is no bone and there are windows what are those windows one is tympanic membrane the most important one then there is a oval window and a round window on the medial wall of the middle ear where foot plate of stapes is present or covering the oval window and round window is open so whenever there is negative pressure this sucks in or pulls in the tympanic membrane tympanic membrane gets pulled in or sucked in then the mucosa also can be pulled in or sucked in and can even lead to formation of polyp not only this it starts secreting more secretions these secretions could be watery could be mucoid now whenever these secretions increase what will happen it will start collecting now it is collecting there will be a stage this collection will be filled in the eustachian tube but it will not be drained and the person will start feeling heaviness or feeling of blockage blockade proper blockage in the ear now if you are lucky enough to get the patient at this time and examine the patient see you will see fluid till here and air above so sometimes in patients of aom you get to see a tympanic membrane where you can see fluid and air so you can see a air fluid level air and fluid now this air fluid level is there because of what because patient has gone into eustachian tube dysfunction that has led to collection of watery or mucoid secretions mucoid secretions in the middle ear cavity and it has not completely occupied till now it has not completely occupied the middle ear cavity it just started to collect so here you can see a proper air fluid ratio now what will happen if it further keeps on collecting let's just see what happens so if the fluid keeps on collecting there'll be a time that a little air will be left and tympanic membrane is somewhere here so you won't be able to see the air right now but when you lie down like this or go like this this air will move just like the air in the water bottle moves if this is coke and if you've seen it if you tilt the bottle the air bubbles move right same thing will happen here but middle ear cavity is not as simple as it looks there are ventilation pathways and there are pathways through which the air can go or water can go or move so sometimes they the air bubbles will come here and get stuck and if you are lucky enough to examine the patient this time what you will see is a tympanic membrane with the retracted pars tensor past tensor will be completely retracted and there will be air bubbles there will be air bubbles so that is a typical picture of otitis media with effusion sometimes we call it as cirrus cotitus media or other names for this condition is glue ear see these conditions usually are not considered as acute otitis media these are just otitis media with diffusion but i am considering these as acute conditions because whenever this happens patient has severe pain due to stretching of the tympanic membranes timbering membrane is just like a balloon or a membrane which is stretched to its limit so whenever it will be stretched it has no endings it will pain so it pains now the question is what happens and how does it get affected infected so this is tympanic membrane this is your middle ear this is eustachian tube cavity this is nose suppose there is secretion which is caught up in the ear it is already optitis media with diffusion but no infection now if the patient has any microbe in the nasal cavity or in upper respiratory tract and that infection because of any cuff because of any sneeze or because of any forceful exploration travels up it will get a pre-made environment a very good niche which will have abundant proteins bit of glucose and which will act as a very good place for it to grow so this ome can any day get converted into infected case and once it gets infected that's what you call as acute otitis media acute otitis media so if i was to ask or i would to tell you about acute protitus media i'll say it always starts with eustachian tube dysfunction that could be due to rhinitis could be due to anatomical changes and what are the anatomical changes that can cause eustachian tube dysfunction hypertrophy of edenoids it is common in which age children and hence aom is more common in which age group okay so here goes the first poll aom is most commonly found in which population infants young adults or elderly so we've got approximately 30 seconds let's see i hope now you would have understood and you would answer based on the understanding so i'll i'm seeing that there are around 54 votes 55 till now so it's gonna end okay people 30 people voted for infants 25 people voted for young adults three people for elderly see i just say i would have gone with if i was the one one thing i told you gestation tube dysfunction will occur usually because of what recurrent rhinitis or cold okay this is something that can happen in both young people and adults both but anatomical obstruction occurs mostly because of adenoids it mostly occurs because of adenoid hypertrophy and when do you see a denied hypertrophy usually up to 9 or up to 11 years of age and most common in infants and children not in young adults then what else can cause phlegm to travel up sometimes it's the obstruction sometimes if the eustachian tube is too much petalus means it's too open it's too wide then also the fluid or infection can easily travel up and petalus eustachian tube is found in elderly because of fat loss so young adults they need a wrong answer i would say if kids or children or a child was an option it could have been a good option but here answer should have been infant so it's more common in infants and the other reason it's more common in infants is the eustachian tube is placed at an angle of 45 degrees with the horizontal in adults but in children it is almost flat like an infant it will be like this as he or she is turning into an adult in person it will keep on going at an angle and adult it will achieve 45 degree angle so what happens is whenever they drink milk whenever they take their feed there are more chances of this milk regurgitating and going into this eustachian tube and causing acute otitis media in infants and that is the reason all the mothers are told that to feed their baby in upright position or whenever they are done feeding the kid to keep them in upright position on their shoulder and to pat their back so that they burp and only the gas is the thing which comes up because of burping and not the food because if they vomit or regurgitate while they're lying down in supine position it will easily enter the eustachian tube leading to eustachian tube dysfunction causing aom in the middle ear okay so this is mostly what is happening this is the pathophysiology now we have seen the pathophysiology and we have also seen like it should be common in which people infants but here we are talking about adults how and why and where something is happening in adults that is causing aom and how it is different and how it is difficult also to treat so first of all in adults there are multiple reasons that this disease can occur but it is rare first of all something which i think some of the people attending the seminar also might be involved in smoking so how does smoking affect and cause otitis media with effusion or acute protitis media at all see what happens is first of all the nose and the eustachian tube and even the middle ear cavity anterior inferior part which part antero inferior part is lined by respiratory epithelium or pseudostratified columnar epithelial because it has celia also and it is responsible for moving the fluids or secretions in one direction that is from the anterior inferior part of the middle ear to the eustachian tube to the nasopharynx and from the nasopharynx to the pharynx this is normal movement now whenever people smoke that creates or causes first of all increases temperature reduces humidity these two factors alter the ph also because of some chemical changes and once these things occur the nasal cycle or the movement of the the exact term to be used over here is the mucosal layer movement it seizes it stops now when this stops the drainage of eustachian tube stops this leads to eustachian tube dysfunction because now it is not pushing or draining the secretions and draining everything into nasopharynx which it used to do so a simple thing like smoking and when i see smoking it not only include includes cigarettes or bds or hookahs it also includes e-smoking that is vapes even they cause this so that leads to eustachian cube dysfunction and trust me all the cases these days presenting to us with aom one day or the other turn into csom whether active or inactive and are taken for surgeries and these surgeries are never successful in the long run because for making this surgery a success when we are keeping a graft the ventilation of middle ear is very important and correct functioning of the eustachian tube is very important which is lost in people who are smokers so once it's lost it is causing the patient a failure in the surgery in the long run so even imagine somebody smoking he's got eustachian tube dysfunction he does not even know that he's got a perforation in the ear which has got infected now he has seen a doctor and is being treated for that he gets the surgery done and again the surgery fails and he has no clue that it's because of his smoking habit which has been there since some time so this smoking is something which is causing adults to have photitis media with diffusion or acute otitis media these days second thing whether the weather these days how is the weather affecting us the humidity these days in the northern parts of the country uh every part has a separate climate zone or weathers where like every month there's a different weather in different state of our country so i'm talking about the northern part of the country right now like daily for example the humidity has been as low as 20 to 27 it is so low that the evaporation is very high and what our nose has to do with evaporation so it's very simple it's physiology our nose is responsible for humidifying the air which we inhale okay so the less the humidity there is more evaporation from the nose what happens then our nasal secretions contain a few things what are those few things nasal secretions have water they have proteins they have immunoglobulins secretory immunoglobulins igg iga now whenever there is evaporation only this water content is lost proteins are not evaporated immunoglobulins are also proteins they are not evaporated imagine it just to be like this you're sitting somewhere infant is less than one year child was not in option infant in fact was in an option i had put passive smoking to yes passive smoking too can hamper your nasal secretions and nasal cycle sir i've gotten csm what is the cost for my fingerplasty see the cost may vary from 30 000 to 1 lakh to lag depending on where you go for an operation okay so moving on with the class okay so whether what happens is imagine sitting somewhere they sweat on your forehead and the sweat evaporates so quickly that you cannot even wipe it off what is left once you white once that sweat is evaporated you find salts over here now these salts what they do you try to rub them then what will happen is you will feel that gritty feeling and the two surfaces will be rubbing each other with these tiny particles in between causing very very minute injury to these surfaces similar to that our nose the nasopharynx and the throat there are proteins which are left now the nose is okay you will feel dry over here because of that but the pharynx the nasopharynx and as well as the oropharynx whenever you swallow this soft palate closes this velopharynx your tongue and this thing touches to push the food downwards so whenever these surfaces will touch or come in contact they will also rub against the remnants of proteins and other particles so it will happen here as well so whenever that happens the mucosa gets damaged there is some mucosal damage that again leads to abrasions and that can cause in this weather news station tube dysfunction if it happens around the eustachian tube because then after the injury there will be edema over it those people who are suffering from allergic rhinitis or have allergies their symptoms will aggravate during this time people will have dry or itchy throat why they'll have this because this season this dryness and itchiness will be because of rubbing of two surfaces which has proteins causing very minor damages and little edema this will cause granulations on the posterior pharyngeal wall posterior pharyngeal wall and these granulations are nothing but a pathogenomic in cases of allergic pharyngitis how do we identify allergic pharyngitis there are granulations which are pale so it's just edema there's no infection no inflammation as such but there's edema and granulations scattered all over the posterior pharyngeal world so this is what is happening because of the weather now talking about what bacterias are involved so in kids or in infants most commonly the ones which are involved are hemophilus influenzae streptococcus pneumoniae m catarrhalis then you have even staph aureus sometimes mrsa now this strange thing is even in adults there have been studies which are found out even in adults it is the same haemophilus influenzaes streptococcus pneumoniae and catarrhalis staphys it's the same absolutely same so there's not much difference in this now how do you recognize a patient that this patient has otitis media okay let's go to the slides how do we know that we examine and what we examine we examine the tympanic membrane the only thing you can examine is the tempering membrane patient will come to you with only one complaint sudden ear pain sudden sharp shooting ear pain once you examine the tm there will be no discharge in the external auditory canal but the tm will look this is first i'm showing you a normal tympanic membrane this is a tymbanic membrane which is normal of the left ear hence it is making an angle of 55 degrees with the horizontal okay now you see this a cone of light in the anterior inferior corner we can see the handle of malleus the lateral process is bulging out the point of bone which is bulging out so much that you can see that bone outside that is literal process of melees then if you track or trace it down to the center that is handle of melees and then the umbo and then cone of light this is how the normal timbering membrane looks now if it gets infected if the tymbanic cavity gets infected this is how it looks all i can see is something which is bulging out there is proper yellowish discoloration and congestion over it proper condition this is purely white this is congested so this is how a case of acute otitis media looks like this is infected this is another case this is the other ear because you can see the lateral process of malice is facing the other side here you can see small small blood vessels running from from the periphery to the center or from the center to the periphery this is called as the cartwheel appearance of tympanic membrane this is this is characteristic of infection inside the middle ear cavity okay this is cartwheel appearance now once you've seen this now we want to manage this case how do we manage this case okay so management there is a reason i have called it as management and not treatment because the first and foremost thing according to me okay before going to that i'll ask you another question let's see we'll run a few poles and then go to the management the middle ear cavity is lined by a dash type of epithelium single type 2 type or multiple you can consider this option to be as multiple types of epithelium okay 25 volts still counting okay so majority of the people have answered us two types of epithelium which is correct few of them feel that it's single type of epithelium uh it's actually two types this if this is the middle ear gravity here is the mastoid antrum the anterior inferior part anterior inferior part is lined by the respiratory epithelium which is nothing but pseudostratified or you can say ciliary columnar they have a celia this it's not stratified it's pseudo stratified it's basically for movement it it is responsible for moving the secretions out then the posterior part posterior superior is usually lined by flat cells flat cells cuboidal cells now this is the reason previously the csom was termed like tuber tympanic tubo tympanic that is tubal and tymbanic cavity or etico and etic is this part but now they've changed this and the correct terminology these days is mucosal type and squamosal type whether the squamous epithelium has started growing in or not whether it's only mucosa okay so this is one thing let's run another pole before going however i have already answered this let's still see how many of you think that smoking can make one prone for ear infections now this question i want everybody to answer it correctly if you have been listening to this lecture because by the end of this lecture i hope majority of the people will reduce the amount of cigarettes they consume so 96 are sure that it does one person say no it does not i hope i am thinking that it's the person who smokes and does not want to accept this okay now before moving to the management a very important question that will help you to understand the importance of a woman adults can aom be dangerous we have heard csom being safe and unsafe but can aom be dangerous i've made this pinna eac and middle ear cavity this middle ear cavity has pass in aom and this bus has the capability of causing pressure necrosis eroding the mucosa eroding the bone and in fact there is something called as venous channels venous channels through the emissary veins so through those veins this infection can travel anywhere okay for once forget the mystery veins just see if infection goes behind it affects mastoid if it goes up it enters cranial cavity if it goes medial it goes to the labyrinth it goes to the labyrinth patient suddenly starts developing vertigo if it goes down it enters jugular bulb if it goes here it enters sort of infra temporal fossa actually it will first involve the joint the temporal mandibular joint and then come to the temporal fossa so there are many ways where it can go now why it is dangerous because once it enters the cranial cavity if this is passed and it is coming up this is the bone here we have meninges biomatter arachnoid dura now if bus comes in lies here it will cause what just remember this diagram this diagram will help you in remembering many things and solving it if pus breaks the bone and comes and lies here it will cause extra dural abscess if it now breaks this and comes and lies here it will cause subdural abscess now if it comes here and now it is basically touching all three layers what is the inflammation of all three layers of meningitis called it will cause meningitis so it causes extra duralapses subdue relapses meningitis now if it comes further in involves the parenchyme of the brain it will cause brain abscess and what we will call this brain abscess we'll call it autogenic brain abscess because this originated from infection this infection originated from the brain autogenic brain axis now if from the parenchyma this goes and involves a venous sinus venous sinus it will cause venous thrombophlebitis right now imagine if this involves the lateral sinus where all the csf drains and that gets blocked it will cause hydrocephalus it will cause hydrocephalus now this hydrocephalus will be called as otic hydrocephalus why because this occurred because of year so it will become very easy people staying in air con are also prone for it because the humidity is decreased okay i have a very good uh thing which somebody has written people staying in air conditioners are also prone for eustachian tube dysfunction because the humidity is decreased correct specifically in this weather we should always try putting the ac or the air conditioners in wet or cool mode not in dry mode dry mode reduces humidity that is why people start getting their nose blocked even if there is no discharge no rhinitis nothing but they feel their nose is blocked when they sit in the ac or the air-conditioned environment right this is because this is happening oh but i just quickly finished what i started so always remember it like this extra durable abscess one infection comes here subdural abscess infection comes here involves all three meningitis infection comes in the parenchyma infection involves venous sinus venous thromboe phlebitis infection clogs the lateral sinus sinus thrombosis occurs because of the sinus thrombosis there is hydrocephalus what do we call it as other hydrocephalus so these things can occur these are otherwise you can call them as the cranial intracranial complications of csom or even a1 they can occur and that is how the infection spreads and this is the reason this is important we do not want the bus to stay in so what is the treatment first thing if there is no infection always prefer doing myringotomy my ring got me myrin got me nothing it's not a surgery it's nothing big a very sleek knife or by ringo tone what we use my ringo tom in the antero inferior quadrant we just create a hole that's it we just puncture it and come back the water comes out the secretions come out we can use suction sometimes and then what do we need to open we need to open the eustachian tube so for opening the eustachian tube where is the eustachian tube opening actually located in the nasopharynx so what we have to prescribe here is my pool question again so if a patient does not have any nasal symptoms would you still use xylometazoline 0.1 that is a nasal decongestant in aom cases yes or no so i hope this is one of the biggest issue i have with patients when a patient comes to with me with severe ear ache and i give them a nasal drop seventy percent of the people have answered it correctly the issue which i always have with my patients is that when they tell me they have pain in the ear why am i giving them a nasal drop because it is very important to make your patient understand what is happening here because for them they know nothing for them it's like earpin and you are prescribing us a nasal drop we don't have nasal issue sometimes if you don't explain i am telling you once you start practicing you will find people coming to you who will instill or driven in their ear or whatever year a nasal drop you would have given them in the ear because they had ear pain and you prescribed them a drop they did not know which drops to be used where and they'll be telling you that we we have been putting this here and there is no effect so it's always important to explain the condition to the patient second thing if it is infected it is always better to start the patient on antibiotic because if this infection is not treated well or uh substandard of antibiotic is given lower doses are given this can cause an issue what is the antibiotic of choice any day it's amox many people ask me for nasal infections throat infections uh what about macrolides azithromycin erythromycin no they work but not as effectively as amox so amoxicillin with or without clevelandic acid dosage is very very very important very very very important and hence is the next question what is the best suited doses a dosage of co mx amoxiclear that is amoxicillin with levolonic acid for mild year year mild middle ear infections 625 bdd i'm talking about mild cases 625 tds one gram bd or od one gram okay so people are already answering okay see i knew this and that's why i was keen on asking this question the correct dosage is tedious 625 why and how what is the dosage for plane amoks 500 it is tds correct or not everybody agrees to that if you agree to it leave a reaction or something okay everybody agrees right great what is cohomoxyclip co-amoxiclavis amox 500 plus 125 milligrams of clevelandic now what is cleveland doing is clevelandic in any means increasing the t half of amox no it is not among glyphonic acid is nothing but a beta beta lactamase right so that it breaks the lactomyses which are there it is not affecting the t half of amoxicillin in any condition so for amox to act we need to maintain a plasma t plateau in the therapeutic window if this is our therapeutic window we want the concentration to stay in between this or above this but not below so if this is achieved only after giving medicine exactly at its t half and colonic acid is not affecting the d half we have to give amoxicillin with levulonic acid or augmentin or moxie currency or any medicine in the same manner imagine it to be a mox only because the marks is just 500 so it has to be given in tedious or in some cases if people the compliance is good in people then it can be given as one milligram or one gram od and if you want to consider it by weight remember this 40 milligram per kg body weight per day for kids kids infants anyone can be 25 to 40 milligram per kg but this is i'm talking about amox we are just talking about amox so if the commonly used dosage which is available in market remember this also 228.5 milligram tablet and syrup syrup is per 5 ml then there is 457 milligram per 5 mm then there is 625 which is a tablet then there is 642.9 also then there is one gram also so these are the different things available most commonly used for adults is 625 for kids it is 228.5 milligram per 5 ml this has 200 amox 28.5 milligram colonic this has 400 marks 57 milligram problem so as per the weight this is to be given so i'll quickly finish it off if it is non infective do my ring automay plus insert one ventilation tube so that middle ear gets ventilation because that was the whole purpose of it give a nasal decongestant nasal decongestant usually these days we prefer xylometazoline or hydroxy or oxyxyrometazoline 0.1 percent is the adult dose 0.05 percent is the kids pediatric dose give one anti-allergic whatever you prefer monterey and see that is modulus with levo citrus i prefer blastin with monte lucas other than this if it is infective antibiotic which is oral but if there are any signs of any complication mastoid or intracranial or anything admit the patient and start with iv so yes steroids can be used but nasal nasal steroids specifically in cases of otitis media with diffusion where you are not suspecting infection if there is acute pus in the middle ear cavity i will suggest initially avoid but once the infection subsides yes you can use international intranasal osteoids most commonly used ones are mometazone fluticasone fluticasone furate and propionate there are two so these can be used these are good option okay so i hope everybody is clear with otitis media in adults and why it needs uh correct diagnosis and correct treatment and correct guiding of the patient so that they understand that if they will not change their habits this can recur and sometimes this can be so bad that the person might require admission because this can lead to complications which are life-threatening so that's it for now if you have any questions kindly come up yes firstly thank you so much sir for the amazing presentation how to clean kids here first thing do not clean them if the kid is less than two to three years old just use olive oil olive oil drops two drops three drops or johnson and johnson baby oil those drops that will melt the wax and it will automatically come out so no point of cleaning it thank you and then does eustachian tube and encephalation has a rule eustachian tube insufficient [Music] may or may not have a role can have a role in otitis media with a fusion when there is no infection because you never know infection might be already at a point where tympanic membrane might rupture and you insufflate and you cause a rupture though it will immediately result in like starting the discharge and reducing the pain but we never know the infection can go into the labyrinth also rupturing the around in the round window then it's not useful if it is infected sir as infection can cause perforation of tm similarly can it affect over window not the over window it can affect the round window see over windows covered by foot plate of stapes which is made up of a bone so chances of it entering the oval window are less than entering the round window or more and hence the percolation through the round window only is what leads to labyrinthitis what is the duration of use of nasal decongestant nasal decongestants should be used judicially seven to ten days if required after seven days uh they can be used along with the intranasal steroid so that after seven days once you have already taken antibiotic cover for seven days then you start internally internal nasal steroids and you start tapering off your xylometers that is nasal decongestant so that the person does not develop dependence okay uh ashwini pattern thank you then alternate for amoxiclear okay if amoxicleave does not work or if there are uh there is no role for ear drops first of all and then if amoxicles does not work yes there are other antibiotics cephalosporins probably oral cerebellus foreign uh better to go for these instead of going for macrolides and if the infection is again severe go for uh injectables like safe track zone there's no role for ear drops is there any relationship between deviated nasal septum and alternatives alternatives i've already told then if a person is having etd what precautions to be taken to avoid a1 in this weather it's always important see we previously we used to make fun of yoga and all but jalan neeti is something which is amazing uh in allopathic medicine on in our medical culture we call it as nasal douching we take a normal saline in a syringe put it in the nostril and make sure that it comes out from the other as well as through the mouth that keeps all the mucoid secretions the proteins uh in a proper liquid manner like liquid state and makes sure it gets cleaned and there's no this thing like this does not occur again and again the infection does not occur so it cleans all the secretions dried up secretions so that can be done so uh it is better to avoid low humidity areas it is better to avoid dry ac air conditioned uh places it is better to avoid uh dust for those who have e3d it is better to avoid uh your smoking like cigarettes ugly is there any relationship between dns and aom yes dns if of the posterior part or even anterior part can result in [Music] compensatory hypertrophy of inferior turbinate of the opposite side so that opposite side now will also be blocked so this can cause uh then thank you sushida all eam cases need nasal decongestants when there is no evidence of uita yes all cases of aom will require nasal decongestants that was one of my poll questions because if you do not give nasal decondition you have to understand the pathophysiology the basic thing why the secretions are pulling up or getting collected in the middle ear is because they are not being drained out and the drainage is only through one place that is you station tube so if you station dupe was working fine in the first place it would have never occurred so it's always better to give nasal decongestant yes okay the recording will be available ear drops do not usually have any any effect until unless you have done miringotomy place the ventilation tube in sleep in situ and then you are instilling antibiotic drops through that fungal infection of year can occur in kids who see uh there's a myth and i think most of the people will do it wrong using ear buds specifically airpods airports pro the ones which have a rubber tubing and at the end they create a packed seal so if you you've just come out of the shower and your ears have water and you start using your earplugs they entrap moisture over there whenever there's moisture there are this chance of growing of fungus so fungal infection auto microsis occurs in those people who either use cotton in their ear or earphones once their ear is wet so the ones who are prone for this and who have already had this infection once or twice i will say it's better while taking a shower take a cotton piece dip it in oil squeeze it put it once you've once you're done remove it and throw it so the oil creates a barrier which works tremendously so just plain cotton does not so remember that i think yeah there is [Music] role of steam yes the other i'd say uh there's a pattern if nasal decongestant wait for 10 minutes then it gives stabilization with the mucolitic agent like a eucalyptus oil capsule or something to inhale and exhale after five minutes through the nose five seconds so what happens is when you are exhaling the nose is made in such a way that this turbulence around the external layers and the air gushes into the sinuses and even [Music] who joined us on stage [Music] [Music] media does they play a [Music] is [Music] is [Music] across [Music] [Music] rapid fat loss um [Music] my question is how to use a nasal decongestant because is it essential that it should go along the lateral wall of the nose rather than putting it directly inside the nostril i didn't see uh anything is good depends from people to people it's always otherwise better to put it on the lateral wall of the nose a drop on both sides one on the little one on the medial but even the people who put it exactly in the center it reaches the nasopharyngeal wall directly and they complain that it reaches their throat as soon as they do it but it's always advisable to put it on [Music] and the second question is what's the role of steam in that how frequently it should be taken and is it recommended as such see steam not in cases of aom but in cases of photitis media with diffusion if there is being stuck in the eustachian tube so if you are taking stem inhalation that too with a mucolitic agent that can help in cleaning the mucus or uh it's acting as an expectorant so instead of just taking orally we are using that steam once the mucosa the edema mucosa has gone down because we have decongestated with the decongestant after five minutes of becoming use of nasality consistent we can take that student but not too hot people usually make a mistake of using steam which is too hot that can dry up the mucosa we don't want that thank you so much we still have a couple of more questions um uh can illustration could better be used to suction over you station tube opening see it depends if or there's already too much retraction of these tympanic membrane and you do suction it will further pull up it will further suck in the environment so it's always patient to patient personal person [Music] or uh hypertrophy of the inferior turbinates usually will not allow you to pass the stationary catheter all down there and even if you do even if you are able to do that it's a good thing because you should be able to do that if you're a practicing surgery but then i'll say it's not something i would prefer in the first place if somebody turns up i'll go with a more conservative approach for protectors for even use suction put a ventilation tube let it ventilate let the discharge come out that'll be a bit better thing to do in any case uh any role of nucleolitic tablets uh yes yes much lighting caps are useful in cases of autism with diffusion any day preferably many people give embrosol these days uh specifically in covet situations and is still 16 600 milligram effervescent tablets have been used with or without uh acetophylum so these things are being used and they are useful however the effect only comes after seven to ten days but not initially for uh anti-music any antiologics any second generation [Music] thank you so much

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