Acute Suppurative Otitis Media

1. Acute Suppurative Otitis Media Dr. Vishal Sharma

2. Definition Pyogenic infection of middle ear cleft lasting for < 3 weeks. Routes for infection: • Via Eustachian tube • Via Tympanic membrane perforation • Haematogenous (rare)

3. Predisposing Factors 1. Breast feeding in supine position 2. Recurrent upper respiratory tract infection 3. Nasal allergy 4. Chronic rhinitis & sinusitis 5. Tumours of nose & nasopharynx 6. Exposure to cigarette smoke 7. Cleft palate

4. Bacteriology • Haemophilus influenzae • Streptococcus pneumoniae • Staphylococcus aureus • Moraxella catarrhalis •  - Hemolytic streptococci (causes acute necrotizing otitis media)

5. Stages of A.S.O.M.

6. 1. Stage of Hyperaemia • Synonym: Stage of tubal occlusion • Mild earache • T.M. retracted in early stage • T.M. congested later stage • Cartwheel appearance: radiating blood vessels from handle of malleus

7. Cart wheel appearance

8. 2. Stage of Exudation • High fever • Severe earache • Deafness • Marked congestion + bulging of T.M. • Mastoid tenderness • P.T.A.: high frequency conductive deafness due to mass effect of pus

9. Stage of Exudation

10. Stage of Exudation

11. Stage of Exudation

12. Stage of Exudation

13. Nipple sign (impending perforation) Localized protrusion of tympanic membrane due to destruction of fibrous layer by continuous pressure of pus

14. 3. Stage of Suppuration Symptoms: • Ear discharge (blood-stained  purulent) • Increased deafness • Decreased fever • Decreased earache

15. Blood stained otorrhoea

16. Signs & Investigations • Pinhole perforation + otorrhoea • Light house sign: intermittent reflection of light • Decreased mastoid tenderness • High (mass effect) + low frequency (stiffness effect of thick periosteum) Conductive deafness • Clouding of air cells in mastoid X-ray

17. Light House sign

18. Pinhole perforation

19. Clouding of mastoid cells

20. 4. Stage of Coalescent Mastoiditis • Otorrhoea > 2 weeks, otalgia & deafness • Mastoid reservoir sign: pus fills up on mopping • Sagging of postero-superior canal wallcaused by peri-osteitis due to pus in adjacent mastoid antrum • Ironed out appearanceof skin over mastoid due to thickened periosteum • Mastoid cavity in X-ray & CT scan

21. Pathogenesis Aditus Blockage  Failure of drainage  Stasis of secretions  Hyperemic decalcification  Resorption of bony septa of air cells  Coalescence of small air cells to form cavity  Empyema of mastoid cavity

22. Pathogenesis

23. Mastoid reservoir sign

24. Sagging of posterior wall

25. Ironed out appearance

26. Mastoid cavity

27. Mastoid cavity

28. 5. Stage of Resolution • Otorrhoea stops • Normal hearing • Healed perforation

29. Stage of Resolution

30. Sterile exudate in middle ear

31. 6. Stage of Complications • Sub-periosteal abscess • Vertigo • Headache + blurred vision + projectile vomiting • Fever + neck rigidity + irritability • Drowsiness • Gradenigo syndrome (apex petrositis)

32. Treatment of A.S.O.M. • Systemic Antibiotic • Nasal decongestants (systemic + topical) • H1 anti-histamines • Analgesic + anti-pyretic • Aural toilet for ear discharge • Heat application for severe earache • Review after 48 hours

33. Amoxicillin-clavulanate duo: 625 mg B.D. Ciprofloxacin: 500mg B.D. Doxycycline: 100 mg B.D. Cefadroxil: 500 mg B.D. Cefaclor: 500 mg T.I.D. Cefuroxime: 250 mg B.D. Cefixime: 200 mg B.D. Cefpodoxime: 200 mg B.D. Azithromycin: 500 mg O.D. Clarithromycin: 250 mg B.D.

34. Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD Loratidine: 10 mg OD Levocetrizine: 5 mg OD Desloratidine: 5 mg OD Topical:Azelastine spray (0.1%): 1-2 puff BD

35. Nasal Decongestants Systemic decongestants  Phenylephrine  Pseudoephedrine Topical decongestants  Xylometazoline  Oxymetazoline  Saline

36. Anti-cold preparations PsE = Pseudoephedrine; PhE = Phenylephrine

37. Topical Decongestants • Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION) • Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P) • Xylometazoline 0.1 %: 3 drops TID (OTRIVIN) • Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P) • Saline 2 %: 3 drops TID • Saline 0.67 %: 2 drops BD (NASIVION-S)

38. On review after 48 hours • Earache + fever persists:change to higher antibiotic. If T.M. is bulging  perform myringotomy. Send ear discharge for C/S. • Earache + fever subside:continue same treatment for 10-14 days • Review after 3 months

39. On review after 3 months • No effusion: no further treatment • Effusion persists:treat as Otitis Media with Effusion • Presence of abscess or coalescent mastoiditis: do cortical mastoidectomy

40. Myringotomy in A.S.O.M. Curvilinear incision made in postero-inferior quadrant. Incision is curvilinear & not radial (as in OME), to cut fibres of TM. This keeps opening patent for long time.

41. Why make incision in PIQ?  Least vascular area  T.M. bulge is maximum  Ossicles not damaged  Easily accessible

42. Sub-periosteal abscess & fistula

43. Pathology Production of pus under tension  hyperaemic decalcification (halisteresis) + osteoclastic resorption of bone  sub-periosteal abscess  penetration of periosteum + skin  fistula formation

44. Sub-periosteal abscess formation

45. Sub-periosteal fistula: dry

46. Sub-periosteal fistula: wet

47. Types of sub-periosteal abscess • Post-auricular • Bezold • Citelli • Zygomatic • Luc • Retro-mastoid • Parapharyngeal & Retropharyngeal

48. Types of sub-periosteal abscess

49. Post-auricular abscess Commonest. Present behind the ear. Pinna pushed forward & downward.

50. Bezold & Citelli abscesses Bezold: neck swelling over sternocleido- mastoid muscle Citelli:neck swelling over posterior belly of digastric muscle