Acute otitis media

ASOM, AOM

1. ACUTE OTITIS MEDIA Dr. Ajay Manickam JUNIOR RESIDENT RG KAR MEDICAL COLLEGE HOSPITAL

2. Acute otitis media Acute inflammation of the muco periosteal layer of the middle ear cleft Inflammation typically occur in <6 weeks 60%-70% of children have >1 episode before 1st birthday Early onset < 6 months is associated with recurrent AOM and chronic OME

3. Routes of infection 1. Via Eustachian Tube - most common -inf . travels via lumen of tube peritubal lymphatic's 2. Via External Ear traumatic perforation of tympanic membrane 3 . Blood Borne -uncommon

4. Predisposing factors Recurrent common cold , URTI, exanthematous fevers (like measles , diphtheria, whooping cough) Infection of tonsils & adenoids Chronic rhinitis & sinusitis Nasal allergy Tumours of nasopharynx Cleft palate 

5. Eustachian tube & AOM In children ET is at an angle of 10° while in adults it is at an angle of 45°. ISTHMUS is a narrowing in the ET, at the junction of the cartilaginous and bony part. It is only present in adults .

6. Infectious organisms Streptococcus pneumonia (30%) Haemophilus influenzae (20%) Moraxella catarrhalis (12%) Others: Streptococcus pyogenes, Staphylococcus aureus and Pseudomonas Fungal less common – aspergillus & candida Bacterial otitis media from super infection of viral also possible

7. Pathophysiology

8. Stage of tubal occlusion SYMPTOMS : Deafness Ear ache SIGNS : R etraction of the TM. Loss of cone of light. Tuning Fork Test - conductive deafness

9. Otoscopy – Stage 1 TM retracted Foreshortened handle of malleus No cone of light Prominent lateral process of malleus

10. Stage of pre suppuration SYMPTOMS : Marked ear-ache(throbbing nature) Deafness & tinnitus High degree fever & restlessness SIGNS : Congested pars tensa Cart Wheel appearance of T.M Tuning fork test conductive loss  

11. Otoscopy - Stage 2 Cart wheel appearance of the TM No cone of light

12. Stage of suppuration Symptoms - EXCRUCIATING PAIN, Deafness, Fever 102-103 °F, Vomiting, Convulsions   Signs - T.M appears red & bulging Yellow spot on T.M, Tenderness over mastoid antrum, X-ray mastoid - clouding of air cells

13. Signs – Stage 3 Bulging out tympanic membrane Loss of anatomical land marks Clouding of mastoid aircells

14. Stage of resolution   Pathology - T.M ruptures, releases pus, symptoms subside & resolution starts, Mild infection/Early antibiotics resolution no rupture of TM Symptoms - Ear-ache relieved, Fever comes down Signs - EAC contain blood-tinged discharge or mucopurulent, Small perforation of T.M

15. Complication Highly virulent organisms/ low immunity disease spreads beyond middle ear resulting in A cute mastoiditis Sub periosteal abscess F acial paralysis L abyrinthitis P etrostitis M eningitis B rain abscess

16. Medical Management Systemic Antibiotic Nasal decongestants (systemic + topical) H1 anti-histamines Analgesic + anti-pyretic Aural toilet for ear discharge Hot fomentation for severe earache Review after 48 hours

17. 48 hours review 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 No effusion: no further treatment Effusion persists: treat as Otitis Media with Effusion Presence of abscess or coalescent mastoiditis: do cortical mastoidectomy

18. Myringotomy INDICATIONS : Symptoms are not relieved by antibiotics TM bulges significantly TM perforation is too small Incomplete resolution Persistent effusion beyond 12 weeks

19. Myringotomy Myringotomy is a surgical procedure in which a tiny incision is created in the eardrum to relieve pressure caused by fluid or to drain pus from the middle ear.

20. Underlying predisposing factor Chronic rhinitis Chronic sinusitis Chronic tonsillitis Chronic adenoiditis