Acute suppurative otitis media

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1. Acute Suppurative
Otitis Media (ASOM)
Dr. Krishna Koirala

2. Definition
Pyogenic infection of middle
ear cleft lasting for < 3 weeks
Routes for infection

Via Eustachian tubeVia Eustachian tube

Via Tympanic membrane Via Tympanic membrane
perforationperforation

Hematogenous (rare)Hematogenous (rare)

3. Predisposing Factors
1. Breast feeding in supine position
2. Recurrent upper respiratory tract
infection
3. Nasal allergy
4. Chronic rhinitis & sinusitis
5. Tumours of nose & nasopharynx
6. Cleft palate

4. Bacteriology
1.Haemophilus influenzae
2.Streptococcus pneumoniae
3.Staphylococcus aureus
4.Moraxella catarrhalis
5.Beta hemolytic Streptococci
(causative agent in acute necrotizing
otitis media)

5. Stages of ASOM
1) Stage of Hyperemia/Tubal
occlusion

Mild earacheMild earache

T.M. retracted initially and T.M. retracted initially and
congested later congested later

Cartwheel appearance: Cartwheel appearance: blood blood
vessels radiating out from handle vessels radiating out from handle
of malleusof malleus

6. Cart wheel appearance

7. 2) Stage of Exudation
High fever High fever
Severe earache Severe earache
DeafnessDeafness
Marked congestion and bulging Marked congestion and bulging
of T.M.of T.M.
Mastoid tenderness Mastoid tenderness
P.T.A. : high frequency conductive P.T.A. : high frequency conductive
deafness deafness
due to due to mass effectmass effect of pus of pus

8. Stage of Exudation

9. 3) Stage of Suppuration
Ear discharge Ear discharge
Increased deafnessIncreased deafness
Decreased fever Decreased fever
Decreased earacheDecreased earache

10. Otoscopy
Pinhole perforation of pars tensa + Pinhole perforation of pars tensa +
otorrhea otorrhea
Light house sign: Light house sign: intermittent intermittent
reflection of light reflection of light
Decreased mastoid tenderness
High (mass effect) + low frequency
(stiffness effect ) Conductive deafness
Clouding of air cells in mastoid X-ray

11. Light House sign

12. Clouding of mastoid air
cells

13. 4) Stage of Coalescent
Mastoiditis
Otorrhea > 2 weeks, otalgia & deafness
Mastoid reservoir sign : pus fills up on
mopping
Sagging of postero-superior canal wall
due to peri-osteitis
Ironed out appearance of skin over the
mastoid due to thickened periosteum
Mastoid cavity in X-ray

14. 5) Stage of Resolution

Ear discharge stopsEar discharge stops

Hearing improvesHearing improves

perforation starts healing upperforation starts healing up

15. 6) Stage of Complications
Sub-periosteal abscess
Vertigo
Headache + blurred vision +
projectile vomiting
Fever + neck rigidity + irritability
Drowsiness
Paralysis of Cranial nerve(s)

16. Treatment of ASOM
1.Antibiotic (Co-amoxyclav, Cefuroxime)
2.Nasal decongestants (systemic +
topical)
3.H1 anti-histamines
4.Analgesic + anti-pyretic
5.Aural toilet for ear discharge
6.Heat application for severe earache

17. Review after 48 hours
Earache + fever persists:
Change to higher antibioticChange to higher antibiotic
If T.M. is bulging If T.M. is bulging ®® perform perform
myringotomy and send ear discharge myringotomy and send ear discharge
for C/Sfor C/S
Earache + fever subside:
Continue same treatment for 10-14 Continue same treatment for 10-14
daysdays

18. Review after 3 months
No effusion

No further treatmentNo further treatment
Effusion persists

Treat as Otitis Media with Effusion Treat as Otitis Media with Effusion
(OME)(OME)
Presence of abscess or coalescent
mastoiditis

Cortical mastoidectomyCortical mastoidectomy

19. Myringotomy in A.S.O.M.
Curvilinear incision
made in postero-
inferior quadrant
Incision is curvilinear
& not radial (as in
OME), to cut the fibres
of TM (to keep the
opening patent for
longer duration)

20. Why incision in PIQ?
Less vascular area
T.M. bulge is
maximum
Ossicles not
damaged
Easily accessible

21. Sub-periosteal
abscess & fistula

22. Pathology
Production of pus under tension ®
hyperemic decalcification
(halisteresis) + osteoclastic
resorption of bone ® sub-
periosteal abscess ® penetration
into periosteum + skin ® fistula
formation

23. Sub-periosteal abscess
formation

24. Sub-periosteal fistula:
discharging

25. Sub-periosteal fistula:
dry

26. Types of sub-periosteal abscess
Post-auricular
Bezold
Citelli
Zygomatic
Luc
Retro-mastoid
Parapharyngeal & Retropharyngeal

27. Types of sub-periosteal abscess

28. Post-auricular abscess
Commonest
Present behind the ear
Pinna pushed forwards & downwards

29. Bezold’s & Citelli’s
abscesses
Bezold: neck
swelling
over sternocleido-
mastoid muscle
Citelli: neck
swelling
over posterior
belly of
digastric muscle

30. Bezold’s abscess

31. Luc: swelling in external auditory
canal
Zygomatic: swelling antero-superior
to pinna + upper eyelid edema
Retro-mastoid: swelling over
occipital bone
Parapharyngeal & Retropharyngeal:
due to spread of pus along the
Eustachian tube

32. Gradenigo’s Syndrome
Giuseppe Gradenigo (1859 – 1926)

33. Defining Triad
Persistent otorrhea despite adequate
cortical mastoidectomy
Retro-orbital pain due to trigeminal
nerve involvement
Diplopia: convergent squint due to
lateral rectus palsy by injury to
Abducent nerve in Dorello’s canal at the
petrous apex

34. Etiology : Coalescent mastoiditis
involving petrous apex along postero-
superior & antero-inferior tracts in
relation to bony labyrinth
Diagnosis:
C.T. scan temporal bone for bony C.T. scan temporal bone for bony
detailsdetails
 MRI to differentiate b/w bone MRI to differentiate b/w bone
marrow & pusmarrow & pus
Treatment: Modified radical
mastoidectomy & clearance of
petrous apex cells

35. Cortical
Mastoidectomy

36. Antiseptic dressing

37. Draping

38. Infiltration

39. Marking of incision

40. Wilde’s post-aural
incision

41. Incision deepened

42. Musculoperiosteal flap
elevated

43. Cortical mastoidectomy
begun

44. Exposure of mastoid
antrum

45. Widening of aditus

46. Aditus widened

47. Final Cavity

48. Drain put in mastoid
cavity

49. Mastoid dressing