Acute otitis media

AOM

1. ACUTE OTITIS MEDIA

2. DEFINATION INFLAMMATION OF MIDDLE EAR CLEFT OF RAPID ONSET AND INFECTIVE IN ORIGIN ASSOCIATED WITH A MIDDLE EAR EFFUSION AND A VARIED COLLECTION OF CLINICAL SYMPTOMS AND SIGNS. Key points: Inflammation of middle ear cleft Rapid onset Infective in origin Effusion varied collection of S/S

3. SUBGROUPS SPORADIC AOM : Occurs with upper RTI RESISTANT AOM : Persistence of symptoms and signs after 3-5 days of antibiotic treatment PERSISTENT AOM : Persistence or recurrence of signs and symptoms within six days of completion of course of antibiotics. RECURRENT AOM : 3 or more of AOM in 6 months or 4-6 AOM in 1 year.

4. AETIOLOGY VIRUS 60-90 % CASES RESPIRATORY SENSITIVE VIRUS(RSV) INFLUENZAE -A PARAINFLUENZAE HUMAN RHINO VIRUS ADENOVIRUS BACTERIAL H. INFLUENZAE MOREXELLA CATARRHALIS STREPTOCOCCUS PYOGENES STAPYLOCOCCUS AUREUS

5. ROUTES OF INFECTION EUSTACHIAN TUBE: Infection travels via the lumen of the tube following negative middle ear pressure. A long sub epithelial peritubal lymphatics. In infants and young children and native Americans - shorter, straighter and patulous. VIA EXTERNAL EAR : through pre-existing perforations or grommet following exposure to water. HAEMATOGENOUS : This is an uncommon route

6. RISK FACTORS GENETIC RISK FACTORS FAMILY HISTORY OF AOM HLA ASSOCIATION MATERNAL BLOOD GROUP- A POSITIVE ATOPY IMMUNOLOGICAL RISK FACTORS LOW IgG2 DEFECTIVE COMPLEMENT DEPENDENT OPSONISATION DECREASE CD4 COUNT ENVIRONMENTAL DAY-CARE ATTENDANCE OUT SIDE HOME WINTER SEASON USE OF PACIFIER POOR SOCIOECONOMIC STATUS OVERCROWDING PASSIVE SMOKE EXPOSURE COW MIKL ALLERGY SYNDROMIC ASSOCIATION TURNER’S SYNDROME DOWN SYNDROME CLEFT PALATE

7. CLINICAL FEATURES 1 . STAGE OF TUBAL OCCLUSION Oedema and hyperaemia of nasopharyngeal end of eustachian tube Absorption of air and negative intratympanic pressure. Retraction of tympanic membrane with some degree of effusion Symptoms : Deafness and earache not marked. Afebrile Signs : Tympanic membrane is retracted Handle of malleus assuming a more horizontal position, Prominence of lateral process of malleus Loss of light reflex.

8. 2. STAGE OF PRE-SUPPURATION Prolonged tubal occlusion Invasion of tympanic cavity by pyogenic organism Inflammatory exudates appears in the middle ear. Congestion of tympanic membrane Symptoms. Marked earache which may disturb sleep and is of throbbing nature. Deafness and tinnitus are also present but complained only by adults. High fever Restless in child. Signs. Congestion of pars tensa . Leash of blood vessels appear along the handle of malleus and at the periphery of tympanic membrane - cart-wheel appearance . Whole of tympanic membrane including pars flaccida becomes uniformly red.

9. 3. STAGE OF SUPPURATION Formation of pus in the middle ear and to some extent in mastoid air cells Bulging of TM to the point of rupture. Symptoms. Excruciating pain. More Deafness Fever of 102-103°F , accompanied by vomiting and even convulsions. Signs. Tympanic membrane appears red and bulging with loss of landmarks. Handle of malleus may be engulfed by the swollen and protruding tympanic membrane. A yellow spot may be seen on the tympanic membrane where rupture is imminent. In pre-antibiotic era, one could see a nipple-like protrusion of tympanic membrane with a yellow spot on its summit. Tender mastoid antrum .

10. 4. STAGE OF RESOLUTION Rupture of TM with release of pus and subsidence of symptoms. If proper treatment is started early or if the infection was mild- resolution without rupture of tympanic membrane. Symptoms: Earache is relieved Fever comes down and child feels better Signs : External auditory canal may contain blood-tinged discharge Later Mucopurulent . A small perforation is seen in antero-inferior quadrant of pars tensa .

11. 5. STAGE OF COMPLICATION Virulent organism Poor resistance of patient Disease spreads beyond middle ear. Acute mastoiditis, Subperiosteal abscess, Facial paralysis, Labyrinthitis, Petrositis, Extradural abscess, Meningitis, Brain abscess Lateral sinus thrombophlebitis.

12. MANAGEMENT DIAGNOSIS HISTORY – COLD AND COUGH 4-5 DAYS BACK SYMTOMATOLOGY - RAPID ONSET OALGIA HEARING LOSS OTORRHEA FEVER EXCESSIVE CRYING IRRITABILITY MALAISE VOMITING EAR PULLING CLINICAL EXAMINATION

13. TREATMENT PROPER ANTIBACTERIAL THERAPY : Amoxicillin Amoxicillin- clavulanate Cefaclor Co- trimoxazole Erythromycin Cefuroxime axetil Cefixime DURATION: Minimum of 10 days, Till tympanic membrane appears normal . Hearing returns to normal. If not - Secretory otitis media and residual hearing loss

14. DECONGESTANT NASAL DROPS Ephedrine nose drops oxymetazoline xylometazoline XYLITOL - A sweetner inhibites growth of pneumococcus

15. ORAL NASAL DECONGESTANTS Pseudoephedrine Phenylephrine Anti-histaminic Single or in combination. ANALGESICS AND ANTIPYRETICS Paracetamol Aceclofenac ibuprufen helps to relieve pain and fever EAR TOILET - If there is discharge in the ear EAR DROP - Steroid and antibiotic DRY LOCAL HEAT - h elps to relieve pain. VACCINATION - Mumps, Measles, Rubella H influenzae type B , Pneumococcal vaccine

16. MYRINGOTOMY INDICATION: (a) Drum is bulged and there is acute pain, (b) Incomplete resolution despite antibiotics , ear drum is full with persistent conductive deafness. (c) Persistent effusion beyond 12 weeks. SITE: Point of maximum bulge Antero-inferior quadrant

17. DD EARACHE, +/- BLOCKAGE SENSATION, +/- FEVER OTITS EXTERNA MYRIGITIS ACUTE MASTOIDITIS OME NECROTISING OTITS MEDIA RAMSEY HUNT SYNDROMDE DENTAL PAIN( ADULT )