Acute inflammation of the muco-periosteal lining of the middle ear cleft commonly seen in children and usually consequent to an upper respiratory tract infection

Eustachian tube dysfunction- MOST COMMON• Viral rhinitis• Any form of rhinitis/ sinusitis• Other causes of ET dysfunction

Traumatic perforation of tympanic membrane

Barotraumatic otitis media Hematogenous

Upper respiratory tract infections are more common

Eustachian tube is more short, wide and horizontal in children compared to adults

Adenoid tends to hypertrophy and obstruct the ET orifice in the nasopharynx

Feeding habits in an infant- nasopaharyngeal reflux more common

Recurrent URTI Tonsils and adenoid infection Chr rhinitis and sinusitis Nasal allergy Cleft palate Tumours of nasopharynx

Peak incidence at the age of 3-18 months

60% of children below 1 year of age- variable severity

80% of children below 3 years of age Boys>girls Native Americans> African

Americans Rural>Urban: Reason?

Usually starts as a viral infection. Ex: RSV, Rhinovirus, CMV, measles, EBV.

Streptococcus pneumoniae ( 30-50%) H. influenzae ( 20-30%) Moraxiella catarrhalis ( 10-20%) Streptococcus pyogenes

Pathology

Tubal occlusion (hyperemia) Pre-suppuration Suppuration Resolution or Complications

Pathology URTI leads to ET

mucosal edema ET gets occluded Air in the middle

ear cleft gets absorbed

Vacuum (negative pressure in middle ear)

Transudation

Symptoms Blocked feeling in

the ear following URTI

Mild ache/ discomfortSigns

Retracted drum Hyperemia

Pathology Bacterial infection Exudation of fluid Increased mucus

secretion and decreased drainage

Accumulation of non-purulent fluid in middle ear

Increased congestion

Symptoms Irritable child Increasing ear-ache and deafness Autophony

Signs Cart-wheel appearance of the TM Bulging drum Fluid level/ air bubbles seen through

TM

Pathology Suppuration Accumulation of

pus in the middle ear under tension

Acute coalescent/ masked mastoiditis Non resolved AOM- if no resolution by

one month Recurrent ASOM CSOM- tubotympanic disease (TM

perforation persists > 3 months)

Symptoms Unexplained cause of crying in a child Fever, toxic symptoms Severe otalgia Deafness

Signs Grossly congested and edematous

TM Bulging of TM- >posteriorly Pus pointing +/-

Pathology Accumulation of

pus in the middle ear under tension

Later- rupture of the TM and release of pus (discharge)

Symptoms At the peak of otalgia—mucopurulent,

blood stained ear discharge Otalgia subsides with onset of

dischargeSigns

Rupture—Pulsatile ear discharge ‘Light house sign’

Pin-hole perforation

Pathology With drainage of

the pus and Host defense/

treatment Inflammation

resolves Pin-hole perforation

heals

Symptoms Acute symptoms subside Ear becomes dry Eventually hearing is restored

Signs Pin-hole perforation without

discharge Later healed perforation

Pathology Infection fails to resolve due to

• Pneumatised mastoid with infection extending

• Organism- virulent• Resistance of host- poor• Treatment- inadequate

Or if the TM fails to perforate Acute mastoiditis

Symptoms Ear symptoms persist or increase Spiky temperature Swelling post-auricular region

Signs Persistent ear discharge and congestion Mastoid tenderness and swelling

Treatment usually started with clinical diagnosis

Investigate if not resolving or if impending complications suspected

Ear swab for C/S X-ray mastoids X-ray PNS/ nasopharynx Audiological assessment CT scan of temporal bone and

intracranium- with contrast

Treat URTI Broad spectrum antibiotics like amoxycillin/

ampicillin/ augmentin/ erythromycin etc.- Orally as syrup/ tablets

High dose (meningitic dose) and parenteral if complications suspected

Nasal decongestants Analgesics No role for topical antibiotics

Indications TM fails to perforate Severe otalgia Non-resolving symptoms If impending complications suspected

Tympanocentesis- Needle aspiration of the fluid

Myringotomy• Curvilinear incision on the TM at the site of

most prominent bulge—usually posteriorly—drainage of pus

• Or widen the pin-hole perforation- better drainage

Cortical mastoidectomy• To eradicate the diseased mucosa in the

mastoid antrum and the air cells

Acute otitis media usually due to streptococcus pneumoniae associated with exanthematous fevers like measles, chicken pox, etc.

Extensive destruction of the middle ear structures• Total perforation• Ossicular discontinuity• Higher incidence of mixed hearing loss

Treatment is same as AOM

Acute inflammation of the muco-periosteum of mastoid antrum and mastoid air cells, usually a result of ASOM, characterized by coalescence of the mastoid air cells and collection of pus under tension (empyema) within the mastoids

Following ASOM, infection in the middle ear spreads into the mastoid antrum and cells

Mucosal odema blocks the aditus- no drainage of mastiod antrum

Mucopus in mastoids collect under tension HYPERAEMIC DE-CALCIFICATION gives rise

to soft bone COALESCENCE DUE TO INTERCELLULAR

BONE DESTRUCTION---EMPYEMA

Pneumatized mastoid—more cells--more mucosa

Organism—virulent Resistance of the host—poor Treatment—inadequate or

inappropriate Failure of tympanic membrane to perforate in

ASOM or perforation is too small for complete drainage

EMPYEMA OF MASTOID Spread of infection to other

structures in/ out of mastoid--- intracranial/ extracranial complications

Extra-cranial

Mastoid abscess Facial paralysis Labyrinthitis Petrositis Septicemia Osteomyelitis of

temporal bone

Intra-cranial Meningitis Extradural abscess Subdural abscess Brain abscess Lateral sinus

thrombophlebitis Otitic

hydrochephalus Cortical venous

thrombophlebitis

Following ASOM Increasing pain and discharge in the

ear Post-aural painful swelling,fever,

malaise and lassitude Features of complications

Post-auricular swelling due to cellulitis/ abscess

Mastoid tenderness positive Pinna is pushed forwards and

downwards Sagging of the canal skin Congested bulging drum with no

perforation or with small perforation Pulsatile ear discharge

Ear swab for culture and sensitivity Pure tone audiogram if possible X-ray mastoids—Schuller’s view---shows

clouding of the mastoid air cells and coalescence

CT scan of the temporal bone and intracranium with contrast--if complications are suspected

intravenous antibiotics Penicillin group with metronidazole

preferred Early stage—myringotomy/ widening of

perforation may be tried I&D if mastoid abscess is present followed

by Emergency exploration of mastoid and

cortical mastoidectomy Treatment of complications

Injury to the middle and/or inner ear due to sudden negative middle ear pressure caused by sudden descent during flight or sudden deep diving

Predisposed by pre-existing ET dysfunction

Higher the altitude—lower the atmospheric pressure

Ascent- passive movement of air out of ET Sudden descent—middle ear pressure is

negative compared to atmospheric pressure

Locking of the tube occurs if pressure difference

Early locking in case of ET dysfunction

Retraction of TM Transudation Exudation Micro-hemorrhage Traumatic perforation Ossicular discontinuity Round window rupture Inner ear damage

Otalgia Blocked sensation/ deafness Tinnitus Vertigo Ear discharge—blood stained initially

Congested retracted drum Fluid level/ air bubbles in middle ear Rupture TM Nystagmus +/- Conductive or mixed hearing loss

Pure tone audiogram Impedance audiometry Microscopic otological examination

Usually resolves within few weeks Analgesics/ and decongestants Labyrinthine sedatives/ steroids if

inner ear damage suspected Persistent fluid—myringotomy

grommet insertion Persistant perforation—myringoplasty