Acute suppurative otitis media

This is very helpful for the first time reading the topic of middle ear infection.

1. Acute suppurative otitis media 6th semester mbbs Nischal shrestha

2. It is an acute inflammation of middle ear cleft by pyogenic organisms. Middle ear cleft includes Eustachian tube, middle ear, attic, aditus , antrum and mastoid air cells Aetiology : More common in infants and children of lower socioeconomic group. Typically disease follows viral infection of URT

3. Routes of infection Via Eustachian tube: most common route. Via External Ear: traumatic perforations of TM d/t any cause Blood borne: uncommon route Via lumen of tube Along sub-epithelial peritubal lymphatics Also ET in infants and young children is shorter, wider and more horizontal So breast or bottle feeding in horizontal position may force fluid through tube into middle ear Also swimming and diving can force water through tube into middle ear

4. Predisposing Factors Anything that interferes with normal functioning of ET, it could be: Recurrent attacks of common cold, URTI and exanthematous fevers like measles, diphtheria or whooping cough Infections of tonsils and adenoids Chronic rhinitis and sinusitis Nasal allergy Tumors of nasopharynx, packing of nose or nasopharynx for epistaxis Cleft palate: caused by anatomic problems in the muscles that open the tube.

5. Bacteriology - In infants and young children Streptococcus pneumoniae 30% Hemophilus influenzae 20% Moraxella catarrhalis 12% - Many strains of H. influenzae and M. catarrhalis are beta lactamase producing

6. Clinical features and pathophysiology The disease runs through following stages: Stage of tubal occlusion Stage of presuppuration Stage of suppuration Stage of resolution Stage of complication

7. 1. Stage of Tubal Occlusion Symptoms: Deafness and earache , but are not marked There is generally no fever Mucosa: edema and hyperemia of nasopharyngeal end of ET Blocks the tube Lining of middle ear absorbs the remaining air Negative intratympanic pressure Retraction of tympanic membrane

8. Signs > Otoscopy : TM is retracted with handle of malleus assuming a more horizontal position Prominence of lateral process of malleus Loss of cone of light > Tuning fork tests show conductive deafness

9. 2. Stage of presuppuration (exudation) Symptoms : Marked earache (throbbing type) which may disturb sleep Child runs high degree of fever and is restlessness Deafness and tinnitus , complained by adults, d/t fluid in middle ear Prolonged tubal occlusion Pyogenic organism invasion Signs of inflammation (hyperemia of its lining) Inflammatory exudation and congestion of TM

10. Signs From beginning, there is congestion of pars tensa and loss of landmarks Cartwheel appearance of TM as blood vessels appear along the handle of malleus and at periphery of TM Later, whole of TM including pars flaccida becomes uniformly red. This appearance is also termed angry looking TM. Tuning fork tests show conductive type of hearing loss

11. 3.

12. Symptoms : Excruciating ear pain Deafness increases Child may run fever of 102-103 °F. This may be accompanied by vomiting and even convulsion

13. Signs TM appears red and bulging with loss of landmarks Handle of malleus may not be perceptible d/t swollen TM A nipple like protrusion of TM with a yellow spot where rupture is imminent, on its summit may be seen ( in pre-antibiotic era when course of disease was allowed to progress Tenderness over mastoid area may be present X –rays of mastoid will show clouding of air cells because of exudate

14. Nipple like protrusion

15. Clouding of mastoid cells

16. 4. Stage of Resolution

17. > Symptoms : With evacuation of pus, earache is relieved, fever comes down and child feels better Signs : external auditory canal may contain blood tinged discharge which later becomes mucopurulent Usually small perforation is seen in anteroinferior quadrant of pars tensa . + ve light house sign: pus oozing out from perforated site in a pulsatile fashion Hyperemia of TM begins to subside with return to normal color and landmarks

18. Pinhole appearance

19. Light house sign

20. 5. Stage of complication If virulence of organism is high or resistant of pt. poor, resolution may not take place and disease spreads beyond the middle ear

21. Treatment Control infection Local therapy Treat related disease

22. Control infection: antibiotics To arrest and reverse inflammation Prevent suppuration and perforation Relieve symptoms and hasten resolution Reduce risk of complication Ampicillin 50mg/kg/day in 4 divided doses Amoxicillin 40mg/kg/day in 3 divided doses

23. Antibiotics Indicated in all cases with fever and severe earache m/c organism : S. pneumoniae and H. influenza. So effective drugs are ampicillin and amoxicillin Those allergic to penicillins , give  cefaclor , cotrimoxazole or erythromycin For beta lactamase producing H. influenza or M. catarrhalis , give  amoxicillin clavulanate , cefixime Therapy must be continued for a min of 10 days, till TM regains normal appearance and hearing returns to normal Early discontinuance with relief of earache & fever, or therapy in inadequate doses may lead to secretory otitis media and residual hearing loss

24. Local Therapy Before perforation Relieve earache and control inflammation Dry local heat to relieve severe earache Decongestant nasal drops (ephedrine, oxymetazoline , xylometazoline ) Oral nasal decongestant (pseudoephedrine) Analgesic and antipyretic (paracetamol)

25. Myringotomy Curvilinear incision made in postero -inferior quadrant. Done to relieve pressure caused by excessive build up of fluid, or to drain pus from Middle ear Incision is curvilinear & not radial (as in OME), to cut fibres of TM. This keeps opening patent for long time

26. Why to make incision in PIQ? Least vascular area T.M. bulge is maximum Ossicles not damaged Easily accessible

27. A tympanostomy tube is inserted into the eardrum to keep middle ear aerated for prolonged time and to prevent reaccumulation of fluid

28. Indications o f myringotomy Symptoms are not relieved by antibiotics TM bulges significantly TM perforation is too small Incomplete resolution( persistent conductive hearing loss) Persistent effusion beyond 12 weeks

29. Local Therapy after perforation Clear external acoustic canal – ear toilet Control infection Repair TM

30. Treat related diseases Chronic rhinitis Chronic sinusitis Chronic tonsillitis Adenoid vegetation

31. Acute otitis media Antibacterial therapy Review after 48-72 hours Earache and fever persist or increase Good response Another antibacterial therapy for 10 days or if TM is bulging  myringotomy and culture and specific antimicrobial for 10 days Continue same for 10 days Periodic checks for 12 weeks Complete resolution Complete resolution Persistent fluid but earache and fever subside Complete resolution (no effusion) Persistent effusion t/t as OME Abscess or coalescent mastoiditis Do cortical mastoidectomy