Otitis Media

Otitis Media, College of Medicine, King Faisal University
Al Ahsa
Saudi Arabia

1. Otitis media Abdullatif Sami Al Rashed College of Medicine, King Faisal University Al Ahsa , KSA

2. ACUTE SUPPURATIVE OTITIS MEDIA

3. Introduction more common especially in infants and children of lower socioeconomic group . the disease follows viral infection of upper respiratory tract but soon the pyogenic organisms invade the middle ear . Breast or bottle feeding in a young infant in horizontal position, Swimming and diving are risk factors Streptococcus pneumoniae (30%), Haemophilus influenzae (20%) and Moraxella catarrhalis

4. CLINICAL FEATURES 1. Stage of tubal occlusion: Symptoms. Deafness and otalgia no fever. Signs. Tympanic membrane is retracted with handle of malleus assuming a more horizontal position, prominence of lateral process of malleus loss of light reflex. Tuning fork tests show conductive deafness.

5. CLINICAL FEATURES 2. Stage of presuppuration Symptoms. Severe otalgia affects the sleep, throbbing in nature . Deafness and tinnitus but complained only by adults. children runs high degree of fever and is restless. Signs . congestion of pars tensa . Leash of blood vessels appear along the handle of malleus and at the periphery of tympanic membrane imparting it a cart -wheel appearance. then, whole of tympanic membrane including pars flaccida becomes uniformly red. Conductive hearing loss .

6. CLINICAL FEATURES 3. Stage of suppuration . Symptoms. Otalgia becomes very severe. Deafness increases, Children may run fever of 39-40 C A/W vomiting and convulsions. Pain disappear when there is discharge Signs. Tympanic membrane appears red and bulging with loss of landmarks . Handle of malleus may be engulfed by the swollen and protruding tympanic membrane and may not be discernible . A yellow spot may be seen on the tympanic membrane where rupture is clear. Tenderness may be elicited over the mastoid antrum . X -rays of mastoid will show clouding of air cells because of exudate.

7. CLINICAL FEATURES 4. Stage of resolution . Symptoms. evacuation of pus, relieve otalgia , fever comes down and child feels better. Signs. External auditory canal may contain blood- tinged discharge which later becomes mucopurulent . small perforation is seen in anteroinferior quadrant of pars tensa . Hyperaemia of tympanic membrane subside with return to normal colour and landmarks.

8. CLINICAL FEATURES 5. Stage of complication. If virulence of organism is high or resistance of patient poor, resolution may not take place and disease spreads beyond the confines of middle ear. It may lead to: acute mastoiditis , labyrinthitis subperiosteal abscess , extradural abscess, brain abscess facial paralysis meningitis

9. TREATMENT Antibiotics: amoxicillin (40 mg /kg /day in three divided doses ) When there is discharge we give topical antibiotic Decongestant nasal drops: Ephedrine Oral nasal decongestants: Pseudoephedrine Analgesics: paracetamol Ear toilet. If there is discharge in the ear Myringotomy : indicated when Failure of medical TTT drum is bulging and there is acute pain, persistent effusion more the an 12 weeks.

10. OTITIS MEDIA WITH EFFUSION

11. ETIOLOGY Adenoid hyperplasia Chronic rhinitis and sinusitis Chronic tonsillitis Benign and malignant tumours of nasopharynx Unresolved acute otitis media Viral

12. CLINICAL FEATURES Hearing loss Delayed and defective speech Discomfort in the ear or very mild pain

13. CLINICAL FEATURES Otoscopic findings Tympanic membrane is often dull and opaque loss of light reflex Yellow, grey or bluish in colour . blood vessels may be seen along the handle of malleus Tympanic membrane having retraction. may appear full or slightly bulging in its posterior part due to effusion . Mobility of the tympanic membrane is restricted

14. TESTS Tuning fork tests show conductive hearing loss. Audiometry. conductive hearing loss of 20– 40 dB Impedance audiometry (tympanometry). It is useful in infants and children. B Curve: reduced compliance and flat curve with a shift to negative side. X-ray mastoids. There is clouding of air cells due to fluid.

15. TREATMENT Decongestants . Antihistaminics or sometimes steroids in cases of allergy . Antibiotics . Valsalva manoeuvre , Children can be given chewing gum to encourage repeated swallowing to open the tube . Myringotomy and aspiration of fluid with Grommet insertion Tympanotomy or cortical mastoidectomy required for removal of loculated thick fluid or associated with cholesterol granuloma

16. SEQUELAE OF CHRONIC OTITIS MEDIA with effusion Atrophy of tympanic membrane and atelectasis of the middle ear . Ossicular necrosis Most commonly, long process of incus gets necrosed . Tympanosclerosis Hyalinized collagen with chalky deposits may be seen Retraction pockets and cholesteatoma Cholesterol granuloma

17. CHRONIC SUPPURATIVE OTITIS MEDIA

18. TYPES Tubotympanic . Also called the safe or benign type. There is no risk of serious complications . Atticoantral . Also called unsafe or dangerous type. risk of serious complications is high.

19. TUBOTYMPANIC TYPE After recurrent or untreated acute OM Pseudomonas aeruginosa , Proteus, Escherichia coli and Staphylococcus aureus , while anaerobes include Bacteroides fragilis and anaerobic Streptococci

20. TUBOTYMPANIC TYPE CLINICAL FEATURES: Otorrhea : nonoffensive , mucoid or mucopurulent , constant or intermittent Hearing loss. Conductive Perforation. Always central by otoscope Middle ear mucosa. It is seen when the perforation is large . Red, oedematous and swollen. Occasionally, a polyp may be seen

21. TUBOTYMPANIC TYPE INVESTIGATIONS Examination under microscope To check presence of granulations, in-growth of squamous epithelium from the edges of perforation, status of ossicular chain , tympanosclerosis and adhesions Audiogram . Conductive mainly but SNHL can A/W Culture and sensitivity of ear discharge Mastoid X-rays/CT scan temporal bone

22. TUBOTYMPANIC TYPE TREATMENT Ear toilet. Antibiotic ear drops containing neomycin Systemic antibiotics. They are useful only in acute exacerbation of CSOM Instructions to patients: keep water out of the ear during bathing, and swimming. Rubber inserts can be used. Hard nose blowing ( ينفخ بخشمه بقوه )can also push the infection from nasopharynx to middle ear and should b e avoided .

23. TUBOTYMPANIC TYPE TREATMENT Treat other causes such as adenoid or tonsill Aural polyp or granulations, if present , should be removed by surgical excision. Myringoplasty with or without ossicular reconstruction can be done to restore hearing when ear is dry

24. ATTICOANTRAL TYPE A/W: Cholesteatoma . Osteitis and granulation tissue Ossicular necrosis . Cholesterol granuloma SYMPTOMS Otorrhea ; Usually scanty, but always foul-smelling due to bone destruction . Hearing loss . Bleeding.

25. ATTICOANTRAL TYPE SIGNS Perforation either attic or posterosuperior marginal type Retraction pocket Cholesteatoma : Pearly-white flakes INVESTIGATIONS Examination under microscope Tuning fork tests and audiogram X-ray mastoids/CT scan temporal bone Culture and sensitivity of ear discharge

26. Only study the yellow color

27. ATTICOANTRAL TYPE TREATMENT: surgery is main TTT Mastiodectomy Canal wall down procedures Canal wall up procedures Hearing can be restored by myringoplasty or tympanoplasty

28. adhesive otitis media. Tympanic membrane is very thin and wraps the promontory and ossicles . There is no middle ear space, mucosal lining of the middle ear is absent and tympanic membrane gets adherent to the promontory . Retraction pockets are formed which may collect keratin plugs and form cholesteatoma . Erosion of the long process of incus and stapes superstructure is common in such cases

29. Complications of Suppurative Otitis Media

30. INTRATEMPORAL COMPLICATIONS (I) ACUTE MASTOIDITIS Pain behind the ear after ttt of OM Increased in its intensity or recurrence of pain Persistent fever Discharge profuse, pulsatile and increases in purulence after OM TTT Mastoid Tenderness. Perforation of tympanic membrane . Swelling over the mastoid Hearing loss Mastoid fistula

31. INTRATEMPORAL COMPLICATIONS (I) ACUTE MASTOIDITIS CBC, ESR, X Ray Mastoid, Ear swab Hospitalization of the patient, Antibiotics, Myringotomy .

32. INTRATEMPORAL COMPLICATIONS 2. Gradenigo syndrome triad of ( i ) external rectus palsy ( VIth nerve palsy), (ii) deep-seated ear or retro-orbital pain ( Vth nerve involvement) and (iii) persistent ear discharge CT scan and MRI For Dx . CT scan of temporal bone will show bony details of the petrous apex and the air cells MRI helps to differentiate diploic marrow-containing apex from the fluid or pus . TTT  Cortical , modified radical or radical mastoidectomy

33. INTRATEMPORAL COMPLICATIONS 3. FACIAL PARALYSIS Both OM and Facial palsy must be treated Nerve decompression + OM TTT 4. LABYRINTHITIS Fistula of labyrinth TTT  mastoid exploration to eliminate the cause + Systemic antibiotic Diffuse Serous Labyrinthitis and Diffuse suppurative Labyrinthitis TTT  same SNHL lecture + OM TTT

34. INTRACRANIAL COMPLICATIONS Of OTITIS MEDIA EXTRADURAL ABSCESS Persistent headache on the side of otitis media Severe pain in the ear General malaise with low-grade fever Pulsatile purulent ear discharge . Dx by contrast -enhanced CT or MRI . TTT  Cortical or modified radical or radical mastoidectomy with antibiotic cover

35. INTRACRANIAL COMPLICATIONS Of OTITIS MEDIA SUBDURAL ABSCESS Meningeal irritation symptoms Aphasia, hemiplegia and hemianopia . Jacksonian type of epileptic fits Raised intracranial tension Symptoms and signs Lumbar puncture should not be done as it can cause herniation of the cerebellar tonsils . TTT  A series of burr holes or a craniotomy is done to drain subdural empyema . Intravenous antibiotics are administered to control infection then AFTER THAT MASTIODECTOMY

36. INTRACRANIAL COMPLICATIONS Of OTITIS MEDIA MENINGITIS Fever, chills and rigors. Headache . Neck rigidity. Photophobia and mental irritability. Nausea and vomiting (sometimes projectile) . positive Kernig’s Sign (extension of leg with thigh flexed on abdomen causing pain) positive Brudzinski’s sign (flexion of neck causes flexion of hip and knee ) CT with contrast or MRI and LP for Dx TTT  antibiotics + OM TTT ( Mastoidectomy )

37. ANY ABSCESS you should TTT by: Antibiotic Craniotomy Drainage OM TTT ( Mastoidectomy )

38. THANK YOU