ACUTE SUPPURATIVE OTITIS MEDIA

BY:NEHIL NIGAM

CLASSIFICATION OF OTITIS MEDIA

Otitis media

suppurative

acute Chronic

Tubotympanic(safe

type)

Atticoantral (unsafe

type)

Non-suppurative

Acute Chronic

adhesive

OTITIS MEDIA

Inflammation of the middle ear.

Middle ear implies middle ear cleft, which includes:

Eustachian tubeMiddle earAtticAdditusAntrumMastoid air cells

Anatomy of ear

AETIOLOGY

•More common especially in infants and children of lower socioeconomic group.

•The disease typically follows viral infection of upper respiratory tract:

RhinovirusRSVInfluenza virusenterovirus

BACTERIOLOGY

•Streptococcus pneumoniae•Haemophilus influenzae•Moraxella catarrhalisAlso,•Streptococcus pyogens•Staphylococcus aureus•Pseudomonas aeruginosa

ROUTES OF INFECTION1. Via Eustachian tube.

2. Via external ear.

3. Blood-borne.

Ant. Cranial fossa

Middle cranial fossa

Posterior cranial fossa

Jugular fossa

Sphenoid sinus

nasopharynx

Understanding position of Eustachian tube:

Normal functions of Eustachian tube

• Normally Eustachian tube is closed.• Functions:

Ventilation and thus regulation of middle ear pressure

Protection against

Nasopharyngeal reflux of nasopharyngeal

sound pressure secretions

Clearance of middle ear secretions

Via Eustachian tube•Most common route.•In infants and young children, tube is:

Shorter Wider

More horizontal

Via External ear•Due to traumatic perforation of tympanic membrane.

Blood-borne

PREDISPOSING FACTORS

Anything that interferes with the normal functioningof Eustachian tube, predisposes to middle earinfection, like:1. Recurrent attacks of common cold2. URI3. Measles, diphtheria or whooping cough4. Infection of tonsils and adenoids5. Chronic rhinitis6. Sinusitis7. Nasal allergy8. Tumors of nasopharynx, packing of nose or

nasopharynx for epistaxis9. Cleft palate.10.Down syndrome

Acute tubal blockage

Absorption of middle ear gases

Negative pressure in middle ear

Transudate in middle ear/ haemorrhage

Prolonged tubal blockage

OME (thin watery or mucoid discharge)

Atelactatic ear/perforation

Retraction pocket/ cholesteatoma

Erosion of incudostapedial joint

PREDISPOSI

NG FACTORS

(A) incomplete unilateral cleft of the lip, (B) unilateral cleft of the lip, alveolus, and palate, (C) bilateral cleft of the lip, alveolus, and palate, (D) isolated (median) cleft palate.

Tensor veli palatini muscle

Torus tubarius

PATHOLOGY AND CLINICAL FEATURES

STAGE OF TUBAL OCCLUSION

STAGE OF PRESUPPURATION

STAGE OF SUPPURATION

STAGE OF RESOLUTION

STAGE OF COMPLICATIONS

STAGE OF TUBAL OCCLUSION

PATHOLOGY SYMPTOMS SIGNS

Tubal blockage due to edema and hyperemia of nasopharyngeal end of Eustachian tube

Deafness Earache

NOT markedGenerally no fever

T.M. retractedHandle of malleus – horizontalProminence of lateral process of malleusLoss of light reflexTuning fork test- conductive deafness

Normal tympanic membrane

As the drum becomes increasingly retracted, it drapes over the ossicular chain, and the incus and stapes head may be outlined.

STAGE OF PRESUPPURATION

PATHOLOGY SYMPTOMS SIGNS

Pyogenic organisms invade tympanic cavity

Hyperemia of lining of tympanic cavity

Inflammatory exudate in middle ear

Tympanic membrane-congested

Marked throbbing headacheAdults – deafness and tinnitusChildren – high degree of fever and restlesness

Congestion of pars tensaCartwheel appearance of pars tensaLater- congestion of whole tympanic membraneTuning fork test- conductive deafness found

Normal Congested tympanic membrane

STAGE OF SUPPURATIONPATHOLOGY SYMPTOMS SIGNS

Marked pus formation in middle ear

May extend upto mastoid air cells

Excruciating earache

Deafness increases

Children- fever 102-103 degree F

Vomiting

Convulsions

Redness and bulging in tympanic membrane

handle of malleus- engulfed

Yellow spot on T.M. where rupture imminent

X-ray of mastoid- clouding of air cells

STAGE OF RESOLUTIONPATHOLOGY SYMPTOMS SIGNS

T.M. – ruptures with release of pus

Hence subsidence of symptoms

Earache relieved

Fever – down

EAC- blood tinged discharge may be present

Small perforation in anteroinferior quadrants of pars tensa

Hyperemia of T.M. subsides- normal colour and landmarks

STAGE OF COMPLICATIONS

Acute MastoiditisPetrositis GRADENIGO’S

SYNDROMESub-periosteal abscessFacial paralysisLabyrinthitisExtradural abscessMeningitisBrain abscess or lateral sinus thrombophlebitis

• Gradenigo's syndrome, also called Gradenigo-Lannois syndrome and petrous apicitis

is a complication of otitis media and mastoiditis involving the apex of the petrous temporal bone.

SYMPTOMS: triad of symptoms consisting of  periorbital unilateral pain related to trigeminal

nerve involvement,  diplopia due to sixth nerve palsy (Dorello’s

canal) persistent otorrhea, associated with bacterial

otitis media with apex involvement of the petrous part of the temporal bone (petrositis).

retroorbital pain due to pain in the area supplied by the ophthalmic branch of the trigeminal nerve (fifth cranial nerve),

Bell's palsy caused by invo lvement of the facial nerve (seventh cranial nerve), and

otitis media.Other symptoms can include photophobia, excessive 

lacrimation, fever, and reduced corneal sensitivity.The syndrome is usually caused by the spread of an infection into the petrous apex of the temporal bone.

TREATMENT:Mastoid exploration.Exeneration of the cell tracts leading to petrous apex

TREATMENT

Acute otitis media

Antibacterial therapy

Earache and fever

Complete resolution

Good response

Persistent fluid but earache and

fever abate

Complete resolution

(no effusion)

Persistent effusion

Treat as otitis media with effusion

Complete resolution

Review after 48-72hours

Another antibacterial therapy therapy for 10 days or myringotomy and culture and specific antimicrobial

for 10 days Periodic checks for 12 weeks

DRUGS Antimicrobial agents: Amoxicillin Ampicillin co-amoxiclav Erythromycin Cephalosporins

Decongestant nasal drops: Ephedrine

Oral nasal decongestants:Pseudoephedrine

Analgesics:Paracetamaol

Ear toilet:

Dry local heat

Myringotomy: incising the drum to evacuate pus.

•Indications of myringotomy: Bulging drum and acute pain Incomplete resolution drum remains full with persistent

conductive deafness Persistent effusion beyond 12 weeks Onset of complications like facial nerve

paralysis or labyrinthitis Serous otitis media Non suppurative otitis media

PREVENTIONRoutine childhood vaccination against:pneumococci (with pneumococcal

conjugate vaccine), H. influenzae type B, and influenza decreases the incidence of AOM.

Infants should not sleep with a bottle, and elimination of household smoking may

decrease incidence.