ACUTE OTITIS MEDIA infection of the middle ear

Middle ear infection

1. ACUTE OTITIS MEDIA Dr Tembo Paul. M.D BSc.Hb , MBChB (UNZA)

2. DEFINITION Acute inflammation of the middle ear cavity TYPES: Acute suppurative otitis media Acute necrotizing otitis media Otitis media with effusions Recurrent otitis media Aero-otitis media( otitic barotrauma)

3. Acute Suppurative Otitis Media(A.S.O.M) An acute inflammation of the middle ear caused by pyogenic organisms Middle ear ( in this case means middle ear cleft = eustachian tube, middle ear, additus , antrum and mastoid air cells)

4. …. CAUSES OF A.S.O.M Usually ascending viral infections of the upper respiratory tract .Bacteria; strep.pneumoniae (30᷁%), B-lactamase producing organisms( H.Influenza , M.Catarrhalis ), others like strep pyogenes, staph. Aureus, pseudomonas aureginosa .

5. … ROUTES OF INFECTION Eustachian tube Via lumen of tube ie along subepithelial peritubal or surrounding lymphatics Via external ear-direct trauma exposes middle ear Blood borne- uncommon route

6. … PREDISPOSING/RISK FACTORS Recurrent attacks of common cold, U.R.T infections and exanthematous fevers Infections of tonsils and adenoids Chronic rhinitis and sinusitis Nasal allergy Tumours of nasopharynx, packing nose or nasopharynx in epistaxis

7. … Cleft palate (effect on tensor velli palatini ) Low socioeconomic groups More common in infants and young children because eustachean tube is more horizontal, shorter and wider than in adults N/B: anything altering normal functioning of eustachian tube is a predisposing factor

8. … PATHOLOGY AND CLINICAL FEATURES ASOM is divided into five stages; Stage of Tubal occlusion ; Occlusion due to oedema and hyperemia of nasopharyngeal end of tube Creates negative intratympanic pressure thus resulting in retraction of tympanic membrane Some secretions-not clinically appreciable Symptoms : Deafness(conductive), ear ache Signs : Horizontal handle of malleus, prominent lateral process of malleus, loss of light reflex

9. … 2. Stage of Pre-Suppuration Invasion of occluded tube by pyogenic organisms causing inflammation Inflammatory exudate seen in middle ear and membrane congestion Symptoms : marked ear ache (disturbs sleep), tiredness during day, deafness, tinnitus, high degree fever Signs : congestion of pars tensa , cart wheel appearance, reddening of pars flaccida , tuning fork shows conductive deafness

10. … 3. Stage of Suppuration Marked formation of pus Tympanic membrane bulges to point of rupture Symptoms : excruciating ear ache, increased deafness, fever (102-103 ⁰F) , vomitting , convulsions Signs : red and bulging tympanic membrane Yellow spot on membrane(signifies imminent rupture), nipple like protrusion of tympanic membr4ane with yellow spot on summit, tenderness over mastoid antrum, clouding of air cells on mastoid X-Ray

11. … 4. Stage of Resolution Characterized by ; Rupture of tympanic membrane with release of pus and subsidence of symptoms Inflammation begins to resolve NB: at this point, IF proper Tx was stated early or infection was mild, resolution starts to take place without rupturing of membrane Symptoms : reduced earache, reduced fever, child smiles Signs : blood tinge discharge on external auditory canal, small perforation, subsiding hyperemia of membrane, tympanic membrane returns to normal colour

12. … 5. Stage of Complication Features depend on virulence Spread of infection leads to; Acute mastoiditis Subperiosteal abcess Facial paralysis Labyrinthitis Periostitis Extradural abcess Meningitis Brain abcess / lateral sinus thrombophlebitis

13. … TREATMENT Principles of Mx Relief of symptoms Drain pus Prevent recurrence of infection

14. … A. Relief of Symptoms AIM: relieve eustachean tube of oedema and promote ventilation of middle ear Decongestant- nasal drops( ephedrine 0.1% adults, 0.05% children) can cause rebound congestion if overused, oxymetazoline (not used in children <6 years, xylometazoline ( otrivion ) Oral nasal decongestant Pseudoephedrine(30mg BD)+/- antihistamine(easy administration than nasal drops which require meticulous positioning) side effects: sympathomimetic effect therefore not preffered iii) analgesia and antipyretic ( paracetamol) iv) Dry local heat relieves pain

15. … B. Drainage of Pus Ear Toilet- involves dry mopping with sterile cotton buds and wick moistened with a/biotic Myringotomy C. Prevent Recurrence of Infection A/biotic therapy: ampicillin(50mg/kg/day in 4 divided doses) and amoxicillin(40mg/kg/day)-covers s.pnemoniae and H.influenza NB: if pts allergic to drugs give ceflacor , cotrimoxazole , erythromycin NB: if B-Lactamase producing organisms use Amoxicillin, Clavulanate , augment with cefuroxime , axetil or cefixime . NB: whatever the cause the antibiotic should be continued for a minimum of 10 days until tympanic membrane regains normal appearance and hearing returns to normal

16. Acute Necrotizing Otitis Media Seen often in children suffering from measles, scarlet fever or influenza AETIOLOGY: B- Haemolytic Streptococcus Pathology: rapid destruction of whole of whole of tympanic membrane with its annulus, mucosa of promontory, ossicular chain and mastoid air cells.

17. … Clinical Features : profuse ottorhea , scars, secondary cholesteatoma MANAGEMENT Medical Mx : Early institution of A/biotics for at least 7-10 days Surgical Mx : cortical mastoidectomy

18. OTITIS MEDIA WITH EFFUSIONS (Synonyms: Serous otitis media, secretory otitis media, mucoid otitis media or “Glue Ear”) Insidious condition characterized by accumulation of non purulent effusion in the middle ear cleft Effusion thick serous and it is sterile Commonly seen in school going children

19. … PATHOGENESIS Two mechanisms responsible: Malfunctioning eustachian tube Increased secretory activity of middle ear mucosa AETIOLOGY Malfunctioning eustachian tube: caused by ; Adenoid hyperplasia Chronic Rhinitis and Sinusitis Chronic Tonsilitis

20. … d. Benign and malignant tumors of nasopharynx e. Palatal defects e.g cleft palate, palatal paralysis 2. Allergy 3. Unresolved Otitis Media 4. Viral Infections

21. … CLINICAL FEATURES Symptoms(5-8year olds affected): Hearing loss, Delayed and defective speech, mild ear aches Signs : otoscopic findings; Dull and opaque tympanic membrane, appears yellow grey or bluish in color, blood vessels seen on handle of malleus, or Blood vessels at periphery of tympanic membrane, membrane retraction, full bulging tympanic membrane, fluid level or air bubbles , mobility of tympanic membrane Hearing test findings: Tunning Fork test= conductive deafness, Audiometry: conductive deafness between 20-40DB , +/- sensorineural deafness Impedence Audiometry X Ray Mastoids: clouding of air cells due to fluid

22. … TREATMENT Medical: Decongestants Anti allergic measure Steroids/antihistamine use Find out allergy of person involved c) A/biotics d) Middle ear aeration

23. … 2. Surgical: Indicated when fluid is thick and medical treatment alone does not help, surgical removal must be done Myringotomy and aspiration of fluid Grommet insertion Tympanotomy /cortical mastoidectomy Sx treatment of causative factor e.g Adenoidectomy, Tonsilectomy and/or wash out of maxillary antra(done during myringotomy)

24. Recurrent Otitis Media Recurrent episodes 4-5 times per year of acute otitis media affecting 6month-6year old children Occurs after URTI and child is symptom free between episodes AETIOLOGY Recurrent sinusitis Velopharyngeal insufficiency Hypertrophy of adenoids Infected tonsils Allergy Immune Deficiency Feeding baby in supine without head support

25. … MANAGEMENT Finding cause and eliminating it Antimicrobiual Prophylaxis Myringotomy and insertion of tympanostomy tube Adenoidectomy +/- tonsilectomy Management of inhalant or food allergy

26. Aero-Otitis Media ( Otitic Barotrauma) It is a non suppurative condition resulting from failure of eustachian tube to maintain middle ear pressure at ambient atmospheric pressure AETIOLOGY Rapid descent during air flight, underwater diving or compression in pressure chamber MECHANISM reversal of normal functioning of eustachean tube where it allows easy and passive egress of air from the middle ear to pharynx if middle ear pressure is high.

27. … CLINICAL FEATURES Symptoms : Severe earache, hearing loss and tinnitus, vertigo(uncommon) Signs : tympanic membrane retraction ,congestion and rupture Middle ear shows air bubbles of hemorhagic effusions Hearing loss = conductive but sensorineural type of loss may be seen

28. … TREATMENT Aim is : Restore middle ear aeration PREVENTION Avoid air travel in presence of URTI or allergy Swallow repeatedly during descent No sleep during descent of plane( fx of swallowing is decreased during sleep) Autoinflation of tube by valsalva during descent helps Use vasoconstrictor nasal spray and antihistamine and systemic decongestant 30minutes before descent of plane