Acute Suppurative Otitis Media and management

Acute otitis media

1. Acute Suppurative Otitis Media Dr. ANSHUL SINGLA

2. Definition Pyogenic infection of middle ear cleft lasting for < 3 weeks. Routes for infection: Via Eustachian tube Via Tympanic membrane perforation Haematogenous (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. Exposure to cigarette smoke 7. Cleft palate

4. Bacteriology Haemophilus influenzae Streptococcus pneumoniae Staphylococcus aureus Moraxella catarrhalis  - Hemolytic streptococci (causes acute necrotizing otitis media )

5. Stages of A.S.O.M.

6. 1. Stage of Hyperaemia Synonym: Stage of tubal occlusion Mild earache T.M. retracted in early stage T.M. congested later stage Cartwheel appearance: radiating blood vessels from handle of malleus

7. Cart wheel appearance

8. 2. Stage of Exudation High fever Severe earache Deafness Marked congestion + bulging of T.M. Mastoid tenderness P.T.A.: high frequency conductive deafness due to mass effect of pus

9. Stage of Exudation

10. Stage of Exudation

11. Stage of Exudation

12. Stage of Exudation

13. Nipple sign (impending perforation) Localized protrusion of tympanic membrane due to destruction of fibrous layer by continuous pressure of pus

14. 3. Stage of Suppuration Symptoms: Ear discharge (blood-stained  purulent) Increased deafness Decreased fever Decreased earache

15. Blood stained otorrhoea

16. Signs & Investigations Pinhole perforation + otorrhoea Light house sign: intermittent reflection of light Decreased mastoid tenderness High ( mass effect ) + low frequency ( stiffness effect of thick periosteum) Conductive deafness Clouding of air cells in mastoid X-ray

17. Light House sign

18. Pinhole perforation

19. Clouding of mastoid cells

20. 4. Stage of Coalescent Mastoiditis Otorrhoea > 2 weeks, otalgia & deafness Mastoid reservoir sign : pus fills up on mopping Sagging of postero-superior canal wall caused by peri-osteitis due to pus in adjacent mastoid antrum Ironed out appearance of skin over mastoid due to thickened periosteum Mastoid cavity in X-ray & CT scan

21. Pathogenesis Aditus Blockage  Failure of drainage  Stasis of secretions  Hyperemic decalcification  Resorption of bony septa of air cells  Coalescence of small air cells to form cavity  Empyema of mastoid cavity

22. Pathogenesis

23. Mastoid reservoir sign

24. Sagging of posterior wall

25. Ironed out appearance

26. Mastoid cavity

27. Mastoid cavity

28. 5. Stage of Resolution Otorrhoea stops Normal hearing Healed perforation

29. Stage of Resolution

30. Sterile exudate in middle ear

31. 6. Stage of Complications Sub-periosteal abscess Vertigo Headache + blurred vision + projectile vomiting Fever + neck rigidity + irritability Drowsiness Gradenigo syndrome (apex petrositis)

32. Treatment of A.S.O.M. Systemic Antibiotic Nasal decongestants (systemic + topical) H1 anti-histamines Analgesic + anti-pyretic Aural toilet for ear discharge Heat application for severe earache Review after 48 hours

33. Amoxicillin-clavulanate duo: 625 mg B.D. Ciprofloxacin: 500mg B.D. Doxycycline: 100 mg B.D. Cefadroxil: 500 mg B.D. Cefaclor: 500 mg T.I.D. Cefuroxime: 250 mg B.D. Cefixime: 200 mg B.D. Cefpodoxime: 200 mg B.D. Azithromycin: 500 mg O.D. Clarithromycin: 250 mg B.D.

34. Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD Loratidine: 10 mg OD Levocetrizine: 5 mg OD Desloratidine: 5 mg OD Topical: Azelastine spray (0.1%): 1-2 puff BD

35. Nasal Decongestants Systemic decongestants  Phenylephrine  Pseudoephedrine Topical decongestants  Xylometazoline  Oxymetazoline  Saline

36. Anti-cold preparations Name Chlorpheniramine Decongestant Paracetamol COLDIN 4 mg PsE 60 mg 500 mg SINAREST 4 mg PsE 60 mg 500 mg DECOLD 4 mg PhE 7.5 mg 500 mg SUPRIN 2 mg PhE 5 mg 500 mg PsE = Pseudoephedrine; PhE = Phenylephrine

37. Topical Decongestants Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION) Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P) Xylometazoline 0.1 %: 3 drops TID (OTRIVIN) Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P) Saline 2 %: 3 drops TID Saline 0.67 %: 2 drops BD (NASIVION-S)

38. On review after 48 hours 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

39. On 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

40. Myringotomy in A.S.O.M. Curvilinear incision made in postero-inferior quadrant. Incision is curvilinear & not radial (as in OME), to cut fibres of TM. This keeps opening patent for long time.

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

42. Sub-periosteal abscess & fistula

43. Pathology Production of pus under tension  hyperaemic decalcification ( halisteresis ) + osteoclastic resorption of bone  sub-periosteal abscess  penetration of periosteum + skin  fistula formation

44. Sub-periosteal abscess formation

45. Sub-periosteal fistula: dry

46. Sub-periosteal fistula: wet

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

48. Types of sub-periosteal abscess

49. Post-auricular abscess Commonest. Present behind the ear. Pinna pushed forward & downward.

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

51. Bezold’s abscess

52. Bezold’s abscess

53. Luc: swelling in external auditory canal Zygomatic: swelling antero-superior to pinna + upper eyelid oedema Retro-mastoid: swelling over occipital bone (? Citelli’s abscess) Parapharyngeal & Retropharyngeal: due to spread of pus along Eustachian tube

54. Retromastoid abscess

55. Gradenigo syndrome Giuseppe Gradenigo (1859 – 1926)

56. Defining triad  Persistent otorrhoea: despite adequate cortical mastoidectomy  Retro-orbital pain: Trigeminal nerve involvement  Diplopia: convergent squint due to lateral rectus palsy by injury to abducent nv in Dorello’s canal under Gruber’s petro-sphenoid ligament , at petrous apex

57. Persistent otorrhoea + Retro-orbital pain + Convergent squint

58. Right Convergent squint Right gaze Central gaze Left gaze

59. Etiology: Coalescent mastoiditis involving petrous apex along postero-superior & antero-inferior tracts in relation to bony labyrinth Diagnosis: 1. C.T. scan temporal bone for bony details. 2. M.R.I. to differ b/w bone marrow & pus Treatment: Modified radical mastoidectomy & clearance of petrous apex cells

60. C.T. scan & M.R.I.

61. Hearing preserving approaches to petrous apex Eagleton’s middle cranial fossa approach Frenckner’s subarcuate approach Thornwaldt’s retro-labyrinthine approach Dearmin & Farrior’s infra-labyrinthine approach Farrior’s hypotympanic sub-cochlear approach Lempert Ramadier’s peri-tubal approach Kopetsky Almoor’s peri-tubal approach

62. Hearing sacrificing approaches to petrous apex Trans-cochlear approach Trans-labyrinthine approach

63. Spread of pus

64. Post-auricular: Lateral spread Bezold: Inferior spread Citelli: Inferior spread Luc: Anterior spread Zygomatic: Superior spread Retro-mastoid: Posterior spread Parapharyngeal: Medial spread Retropharyngeal: Medial spread Gradenigo syndrome: Medial spread

65. Cortical Mastoidectomy

66. Antiseptic dressing

67. Draping

68. Infiltration

69. Marking of incision

70. Wilde’s post-aural incision

71. Incision deepened

72. Musculoperiosteal flap elevated

73. Bezold’s abscess

74. Aspiration of pus

75. Drainage of abscess

76. Drainage of abscess

77. Corical mastoidectomy begun

78. Exposure of mastoid antrum

79. Widening of aditus

80. Aditus widened

81. Final Cavity

82. Cortical Mastoidectomy

83. Drain put in mastoid cavity

84. Mastoid dressing

85. Healed post-aural scar

86. Thank you