Attachment asom

otorhinolaryngology

1. Dr. P. Hemalatha. MS. ENT Acute Suppurative Otitis Media

2. Viral Otitis Media Ciliated columnar epithelium sloughs leaving basal germinal layer of non ciliated cuboidal cells In ET, swelling and hyperemia with increased production of mucus cause temroary closure of tubal orfice With oxygen absorption,negative intratympanic pressure cause accumulation of transudate causing non inflammatory sterile otitis media. Subclinical mucoperiosteal hyperemia accounts for conductive hearing loss during colds Bacterial otitis media differentiated from viral otitis media by fever, hearing impairment, positive culture.

3. Acute Suppurative Otitis Media Acute Suppurative inflammation of mucoperiosteal lining of middle ear cleft lasting for 3 weeks and end result is normal with no loss of tympanic mucosal. 2peaks-one at 3 years and 2 nd at 6 years when child starts going to school Infantile Otitis media – bacteria can easily access middle ear due to short patent Eustachian tube.

4. 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

5. Bacteriology Haemophilus influenzae Streptococcus pneumoniae type 3 Staphylococcus aureus Moraxella catarrhalis  - Hemolytic streptococci (causes acute necrotizing otitis media )

6. Pathogenesis 1 st response to invading microorganism is Hyperemia Hyperemia followed by outpouring from dilated permeable capillaries-fibrin rbc wbc. Due to accumulation of exudate intratympanic pressure increases, ear perforated causing mucopurulent discharge and relief of pain, the epithelium becomes progressively thickened and secretory. Thickened mucosal obstruct drainage of secretions in epitympanum causing venous stasis, local acidosis, dissolution of bony walls (halisteresis) and formation of mucoperiosteal vascular granulation tissue. As host resistance overtakes the microbial invasion, resolution occur with decrease in aural discharge. Small central perforation closes immediately. Granular mucoperiosteum thickening recede slowly. Conductive hearing loss recover with decrease in fluid of middle ear and reduction of thickened mucoperiosteum.

7. 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

8. Cart wheel appearance

9. 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

10. Stage of Exudation

11. Stage of Exudation

12. Stage of Exudation

13. Stage of Exudation

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

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

16. Blood stained otorrhoea

17. 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

18. Light House sign

19. Pinhole perforation

20. Clouding of mastoid cells

21. 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

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

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

34. Topical Decongestants Oxymetazoline 0.05 %: 2-3 drops BD Oxymetazoline 0.025 %: 2 drops BD Xylometazoline 0.1 %: 3 drops TID Xylometazoline 0.05 %: 2 DROP BD Saline 2 %: 3 drops TID Saline 0.67 %: 2 drops BD

35. 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

36. 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

37. 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.

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

39. Thank you