ACUTE SUPPURATIVE OTITIS MEDIA

ASOM

1. ACUTE SUPPURATIVE OTITIS MEDIA (ASOM) Dr Harjitpal Singh Assistant Professor(ENT), Dr RKGMC, Hamirpur

2. OTITIS MEDIA Otitis media is a group of inflammatory diseases of the middle ear cleft . Middle ear cleft includes: Eustachian tube Middle ear Attic Additus Antrum Mastoid air cells

3. CLASSIFICATION OF OTITIS MEDIA

4. EPIDEMIOLOGY Peak incidence in the first two years of life (6-12 months) Boys are affected more than girls. 50% of children less than one year of age will have at least one episode. Occurs more frequently in the winter months.

5. ACUTE SUPPURATIVE OTITIS MEDIA It is an acute inflammation of middle ear cleft by pyogenic organisms.

6. AETIOLOGY More common especially in infants and children of lower socioeconomic group. The disease typically follows viral infection of upper respiratory tract: Rhinovirus RSV Influenza virus Enterovirus

7. Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Also , Streptococcus pyogens Staphylococcus aureus Pseudomonas aeruginosa BACTERIOLOGY

8. PREDISPOSING FACTORS Anything that interferes with the normal functioning of Eustachian tube, predisposes to middle ear infection, like: 1. Recurrent attacks of common cold 2. URI 3. Measles, diphtheria or whooping cough 4. Infection of tonsils and adenoids 5. Chronic rhinitis 6. Sinusitis 7. Nasal allergy 8. Tumors of nasopharynx , packing of nose or nasopharynx for epistaxis 9. Cleft palate.

9. ROUTES OF INFECTION Via Eustachian tube. Via external ear. Blood-borne .

10. ROUTES OF INFECTION ( cont ) Via Eustachian tube Most common route. In infants and young children, tube is : Shorter Wider More horizontal Via External ear Due to perforation of tympanic membrane . Blood borne

11. NORMAL FUNCTIONS OF EUSTACHIAN TUBE

12. PATHOLOGY AND CLINICAL FEATURES

13. STAGE OF TUBAL OCCLUSION

14. NORMAL TYMPANIC MEMBERANE

15. NORMAL TYMPANIC MEMBERANE

16. STAGE OF PRESUPPURATION

17. STAGE OF PRESUPPURATION ( cont )

18. STAGE OF SUPPURATION

19. Bulging out tympanic membrane Loss of anatomical land marks Clouding of mastoid aircells STAGE OF SUPPURATION ( cont )

20. STAGE OF SUPPURATION ( cont )

21. STAGE OF RESOLUTION

22. STAGE OF RESOLUTION ( cont )

23. STAGE OF COMPLICATIONS

24. GRADENIGO'S SYNDROME In 1904 the syndrome was introduced by Giuseppe Gradenigo It is also called Gradenigo-Lannois syndrome. It is due to petrous apicitis which is a complication of otitis media and mastoiditis involving the apex of the petrous temporal bone. SYMPTOMS: Tria d of symptoms consisting of 1) Periorbital unilateral pain related to Trigeminal nerve involvement , 2) Diplopia due to inflammation of the Abducens nerve in Dorello’s canal 3) Persistent otorrhea , associated with bacterial otitis media with apex involvement of the petrous part of the temporal bone ( petrositis ). Other symptoms can include photophobia , excessive lacrimation , fever , vomiting and reduced corneal sensitivity .

25. GRADENIGO'S SYNDROME ( cont ) The retroorbital or periauricular pain is due to inflammation/irritation of the first (ophthalmic) division of the trigeminal nerve Lateral rectus palsy due to Abducens nerve palsy leads to horizontal diplopia Sometimes there can be transient weakness of ipsilateral Facial Nerve. The classical syndrome related to otitis media has become very rare after the antibiotic era . TREATMENT : Mastoid exploration: Cortical, radical or modified radical mastoidectomy . Exeneration of the cell tracts leading to petrous apex I/V antibiotics

26. TREATMENT OF ASOM

27. TREATMENT OF ASOM ( cont ) Antibacterial therapy Decongestant nasal drops Oral nasal decongestans Analgesics and antipyretics Ear toilet Dry local heat Myringotomy

28. TREATMENT OF ASOM ( cont ) 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

29. MYRINGOTOMY Myringotomy is incision of the tympanic membrane & drainage of the middle ear . In case of acute otitis media the incision is a Curvilinear/circumferential one between umbo & posterior meatal wall starting from below up, so that the line of incision is not obscured by the draining fluid or blood.  After incision of the drum the middle ear is sucked out through the incision. Sometimes a grommet (ventilation tube) is inserted to prevent recurrence, which remains in place so long the Eustachian tube function does not return back to normal. For grommet insertion, incision is radial and in antero inferior quadrant. Complications:- Injury to the ossicles . Injury to the inner ear. Injury to the chorda tympani nerve

30. MYRINGOTOMY ( cont ) Incision for Grommet insertion Incision for fluid drainage

31. MYRINGOTOMY ( cont ) GROMMET

32. MYRINGOTOME

33. INDICATIONS OF MYRINGOTOMY Bulging drum and acute pain Incomplete resolution drum remains full with persistent conductive deafness Persistent effusion beyond 12 weeks Onset of complications like facial nerve paralysis or labyrinthitis Serous otitis media Non suppurative otitis media

34. PREVENTION Routine childhood vaccination against: pneumococci (with pneumococcal conjugate vaccine), H . influenzae type B, and influenza decreases the incidence of AOM. Infants should not sleep with a bottle, and elimination of household smoking may decrease incidence .

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