Acute otitis media (AOM) secretory otitis media (OME)

Acute otitis media and secretory otitis media or glue ear for medical students

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Acute Otitis Media
Secretory Otitis Media
Prof. Dr. Ausaf Ahmed Khan
MBBS. DLO. FCPS. FRCS(Glasg)
Member IWGEES (International Working Group
of Endoscopic Ear Surgery)
Head of ENT / Head and Neck Surgery
Hamdard College of Medicine & Dentistry
Hamdard University. Karachi, Pakistan

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Acute Suppurative Otitis Media
Definition
Etiology
Pathogenesis
Clinical features
Differential diagnosis
Treatment

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ClassificationofOtitisMedia
(according to the duration of illness)
Acute OM rapid onset of signs &
symptoms, < 3 wk course
Subacute OM Symptoms lasting for
3 wks to 3 months
Chronic OM Illness persisting for
3 monthsor longer

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Acute Suppurative Otitis Media
Definition
It is the acute suppurative inflammation of the
mucosal lining of the middle ear cleft
Duration of illness should be < 3 wks.
Normal TM A.O.Media

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Acute Suppurative Otitis Media
The infection affects infants and children more
commonly than the adults …..
The type of inflammatory reaction and its
progress depends on the ;
virulence of the organisms,
age and resistance of the patient,
therapy with the antibiotics

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Roleofeustachiantube
in pathogenesis of ME infections
The ET doesnotopensregularlyon swallowing
due to one of the following factors;
1.Obstruction of the tubal lumen by hypertrophied
adenoidsin a child (or adult)
2.Swelling of the tubal mucosa due to chronic inflammation
of the neighboring structures such as the sinuses or
tonsils or allergy
3.An inadequate tensor palatimuscle
4.Infiltration of the tube by a malignant tumorof the
nasopharynx

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Air in the ME
is resorbed
Negative
pressure
in ME
Acts an irritant to
the ME mucosa
ME is no longer aerated
ET dysfunction
Changes occur in the ME
Consequences
of
the
Eustachian
tube
blockage

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Etiologyof the A.O.M.
Predisposingfactors
1.General factors
2.Local factors ;
In the Nose.
In the Throat.
In the Tympanic membrane itself.
Excitingfactors
Viruses and bacteria

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Predisposing factors
General
1.Age
Increase incidence in Infants and children.
Most common in 6 –11 months age child.
2.Weather
Winter & spring
3.Racial factors
More in white races, native Americans, Eskimos
4.Socioeconomic condition
poor communities
5.Daycarevs. Homecare

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6.Poor hygiene
7.Breast feeding
Decrease risk of URTI & GI disturbances
Inverse relationship b/w incidence of OM & breast feeding
8.Swimming & divingin contaminated water
9.Systemic diseases
Typhoid, measles & mumps
10.Immunodeficiency states
AIDS, steroids, chemotherapy, IgG deficiency
Predisposing factors
General

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Predisposing factors
Local
In the nose
Rhinitis & Sinusitis
Excessive nasal
blowing
After anterior nasal
packing
NG tube insertion
In the pharynx
Adenoid hypertrophy
and infection
Pharyngitis
Nasopharyngeal
tumors
After post-nasal
packing

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In the throat
Acute tonsillitis
Cleft palate
Palatal paralysis
In the T. M.
After traumatic
perforation
After myringotomy
Predisposing factors
Local

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Exciting factors
A viral infection may
predispose secondary
bacterial infection.
RSV
Rhinovirus
Influenza virus
Parainfluenza virus
Organisms (in order of
decreasing frequency):
Hemophilus influenzae
Pneumococci (in infants)
Streptococci (in adults)
Moraxella catarrhalis
Stpahylococcus aureus
Others
In 90% of cases the infection is mono-microbial.

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Pathology
An acute infection can spread very rapidly to
involve the whole lining of the ME cleft
The successive stages in the pathogenesis are;
1.Stage of Tubo-tympanitis
2.Stage of catarrhal inflammation
3.Stage of suppuration
4.Stage of resolution or complication

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Pathology
1. Stage of tubo-tympanitis.
There is tubul occlusion &
engorgement and edema of
the lining of the Middle Ear
cleft
Normal TM
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication

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Pathology
2. Stage of catarrhal inflammation
There is exudation from the lining of the ME
mucosa and collection of fluid in the ME and
Mastoid air cells.
The exudate is serous in nature at this stage
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication

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Pathology
3. Stage of Suppuration
In this stage there is collection
of the purulent fluid in the ME
cleft due to secondary
bacterial infection.
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication

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Early stage of AOM.
Redness, edema and
bulging in Pars flaccida
Increased redness, edema
and marked outward bulge
of the pars flaccida
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication

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Pathology
4. Stage of resolution or complication
Resolution occur by appropriate antibiotic therapy/
surgical drainage
If treatment is not given adequately
the pus may find its way outside or
may causes mastoiditis and other complications.
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication

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Clinical features
Symptoms
Clinical features may vary and dependson the
stage of the disease.
Fullnessin the ear (in early stage)
Deep seated pain
Severepainas the pus builds up pressure in the ME
Deafness(is present in all stages)
Dischargefrom the ear (once TM is perforated)
Discharge is profuse, purulent or muco-purulent in nature,
sometimes blood-stained and often pulsatile
Pain decreases after discharge occurs

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Other constitutional symptoms;
Features of a recent URTIin most of the cases
Fever
Headache
Malaise
Clinical features
Symptoms

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Clinical features
Signs
In the early stage there is retractionof the TM
with prominent blood vessels along HOM.
Then increasedcongestionof the periphery of
the pars tensa and pars flaccida.
Congestionof the whole TM.
Presence of pusin the ME and normal features
of the TM are lost leading to bulgingof the TM.
After ruptureof the TM, pusdischargein EAC.

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Diagnosis
of A.O.M.
History of URTI in recent
past.
Complainsfever, otalgia,
deafness, discharge at
late stage
FindingsTM is red, dull,
bulging, pus behind the
TM
if perf occursit shows pus
in EAC & TM perforation.
Nose and throat shows
features of URTI
TForktests shows CD.
Impedancetest shows flat
line.
PTAshows CD.

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Differential diagnosis
Furuncle & Diffuse otitis externa
Pain is more superficially located
Discharge is serous
Tympanic membrane is not congested
Usually no / mild conductive deafness
Conditions causing referred otalgia
Ear examination is essentially normal
No hearing loss
Herpes zoster oticus
Vesicles are usually seen

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Management
Medical treatment
Bed rest, hot fomentation.
Analgesics/ antipyretics.
Antibiotics. (systemic/ topical)
Antihistamines & Decongestants
(have limited role).
Surgical treatment
Myringotomyif TM is bulging and about to
perforate or if complications occur.
Tympanoplastyat a later stage (if perf. persist)

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Antibiotics ofchoice
First line
Amoxicillin -60-90 mg/kg divided tid
Co-Amoxical (Augmentin) -B lactam stable
Ceftin -B lactam stable
Bactrim, Pediazole
Second line
Augmentin
Ceftin
Rocephin
Macrolides -Zithromax, Biaxin

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Myringotomy
Is the surgery in which a hole
is made in the T.M. to evacuate
the pus.
Done by a Myringotome (myringotomy knife)
Incision is given in the postero-inferior quadrant of
the pars tensa (in case of ASOM).
Pus is evacuated and may be send for C/S.
Antibiotic ear drops are given.

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Complications
Mastoiditis
Mastoid abscess
Post-aural abscess
Bezold’s abscess
Citellie’s abscess
Zygomatic abscess
Facial paralysis
Petrositis (Gradinego’s syndrome)
Ptosis, Diplopia & Mastoiditis
Intracranial complications

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SecretoryOtitisMedia
(Otitis Media with Effusion)
“ Collection of non-purulent fluid in middle ear
causing hearing impairment”

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Etiology of OME
ET obstruction (Adenoids, NPC).
Allergy.
Viral infection.
Unresolved acute otitis media.
Cleft palate.

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Clinical features
History
Deafness-unilateral or
bilateral.
Bubbling sensation /
crackles in ears.
Nasal blockade.
Mouth breathing.
ADENOIDS???

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Clinical features
Signs
Nose–Rhinitis/
adenoids/ /NPC.
Throat.
Ear; color change,
dull / retracted TM,
fluid behind the TM,
pneumatic otoscopy /
valsalva,
Rinne -ve both sides

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Adenoids
N.P.C.

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Investigations
X-rays post-nasal space for adenoids
Pure tone audiogram/ Speech
Discrimination
Tympanogram/ Impedance audiometry

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X-ray Post-nasal space

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Pure tone audiogram

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Audiogram

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Tympano
metry/
Impedance
audiometry

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Differential Diagnosis
Acute Otitis media
Tympanosclerosis
Atelactatic middle ear disease
Adhesive Otitis media

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Treatment
Adenoidectomy
Myringotomy
Grommet insertion

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Grommet is a ring inserted into a hole
through thin material, such as fabric

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Grommet insertion

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Complications of Secretory Otitis media
ATELACTASIS

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Complications of Secretory Otitis media
TYMPANOSCLEROSIS

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Complications of Secretory Otitis media
ADHESIVE O. MEDIA

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SOM: Summary
Bilat. deafness main complaint
Mouth breather due to adenoids
Dull, retracted, immobile TM
Bubbles behind TM/ enlarged adenoids.
A-B gap/ flat Tympanogram
Adenoidectomy/ BMT
Atelactasis/ tympanoscl/ adhesive otitis m.

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