undergraduate lecture

1. Ahmad Nawaz Ahmad
Associate Professor & HOD
LNH & LNHMC
Otitis Media

2. Otitis Media

3. Clasification Suppurative Otitis
Media
Acute Otitis media infection of middle
ear cleft for short period of time less
than 3 months)
Chronic Otitis media is middle ear
infection for 3 months or more
characterized by recurrent middle ear
discharge and permanent perforation
> 3 months : Ballanger,1996
> 2 months : Djaafar, 2001
> 6 weeks : Rolland, 2002

4. INTRODUCTION
 Most common diseases of the middle ear are
inflammations and infections play a major role
 Otitis media is the most common reason for an
illness-related medical visit in preschool age
children.
(Bailey, 2006)
 Second most common diagnosis made by
pediatricians
(Linsk R et al,2002)

5. INTRODUCTION
 70% of children will have had one or
more episodes of acute otitis media by
their third birthday.
 Occurs mainly in children : newborn
period - 7 years
 Occurs equally in males and females
(Healy&Rosbe,Ballenger’s,2002)

6. INTRODUCTION
 Bondy et al : the proportion of children
with a diagnosis of otitis media was
highest (42% to 60%) in the 7 to 36
months range
 Other studies have shown the highest
incidence of acute otitis media, for both
sexes, was in the 6 to 11 months
(Bailey,2006)

7. INTRODUCTION
 Epidemiologic studies at the University
of Pittsburgh : 90% incidence of otitis
media in urban children within the first 2
years of life.
(Clinical Otology,2007)
 Children who live in crowded
households,low socioeconomic
conditions, poor medical care increasing
incidence of acute otitis media
(Bailey,2006)

8. OVERVIEW
 ANATOMY

9. Innervation
 The nerves that innervate tympanic cavity is
tympanic plexus.
 Derives from the tympanic branch of the
glossopharyngeal nerve and the caroticotympanic
nerves.

10. Eustachian Tube Paediatric Vs Adult
 In infants eustachian tube is
 Shorter
 Wider
 Horizontal

12. Middle Ear Pressure Difference

13. Acute Otitis Media
 Acute otitis media (AOM) represents the rapid
onset of an inflammatory process of the middle
ear space associated with one or more symptoms
or local or systemic signs
(Healy and Rosbe,2002)
 Acute otitis media (AOM) is an infection that
involves the middle ear. The tympanic membrane
becomes inflamed and opaque. Blood vessels to
the area dilate. Fluid accumulates in the middle
ear space. AOM is usually associated with
infection by viruses or bacteria.
- (http://www.utmb.edu/pedi_ed/AOM-Otitis/default.htm)

14. OVERVIEW
ETIOLOGY
 Most common bacterial pathogens:
- Streptococcus pneumonia (35%)
- Haemophilis influenza (23%)
 Less Frequent
- Moraxella catarrhalis
- Group A Streptococcus
- Branhamella catarrhalis
- Staphylococcus aureu
- gram-negative enteric bacteria

15. PATHOPHYSIOLOGY
Infection
Tubal dysfuction air resorbtion
negative pressure
Obstructed tubal
influx bacteria
AOM

17. Clinical Features
 Occlusion tube stage
- Performing tympanic membrane retraction due to
negative pressure inside the middle ear due to
air.
- Sometimes the color of tympanic membrane
normal or pale.

18. Clinical Features
 Hyperemia stage or
presupuration stage
- Dilated vessels in the
tympanic membrane
- The tympanic membrane is
hyperemia and edema.
- The performing discharge
may be serous so that
difficult to assess.

19. Suppuration Stage
- All symptoms become
more severe.
- The drum now starts
bulging and convex.
- The exudates exerts
pressure on one spot of
the ear drum, may be
the point of perforation
later and the point
appears like yellow
nipple.

20. Perforation stage
- The drum perforates , pus
starts flowing out.
- Pain and constitutional
symptoms lessen with the
escape of ear discharge.
Otorrhoea ,may be initially
blood-stained,discharge
can range from mucoid to
frankly purulent.
Examination: ear drum
reveals a small
perforation, usually in the
anteroinferior quadrant
with pulsatile discharge.

21. Resolution stage
- If the tympanic membrane is still intact
gradually back to normal condition.
- If perforation happens, the discharge will
decrease and finally become dry.
In good immunity system , resulotion will be
performed even though without any medical
treatment

22. Risk Factors For AOM
Risk Factors:
- Exposure to group day care with subsequent
increase in respiratory infections.
- Exposure to environmental smoke or other
respiratory irritants and allergens that interfere
with
- Eustachian tube function.
- Lack of breast feeding & Supine feeding position

23. SIGN and SYMPTOM
Common signs and symptoms
 Fever
 Otalgia
 Otorhea
 Fullness in the ear
 Irritability
 Crying/shouting (child)
 Eardrum : light reflect (-),hyperemia, bulging, perforation
Less common signs and symptoms
 Tinnitus
 Vertigo
 Facial paralysis
 Swelling behind the ear

24. Treatment
- Watchful waiting without antibiotic therapy
healthy 2-year-olds or older children with non
severe illness
- Antibiotic therapy
First line therapy: Amoxicillin 80mg-90mg/kg/24
hours in three divided doses , for 10 days
- The adjunctive therapy
include analgesics and antipyretics.
- Myringotomy

25. Diagnosis
 Careful history (fulfilled/fullness ear,otalgia, fever)
and physical examination will lead to the accurate
diagnosis of acute otitis media
 The ultimate diagnostic test to confirm the
presence of AOM involves aspiration of middle
ear contents

26. Use of Antibiotics?
According to Guidelines & Protocols Advisory
Commitee :
If older than 24 months, most cases of AOM
resolve with systemic analgesics alone and do
not require antibiotics.
If signs and symptoms of AOM persist in spite of
systemic analgesics after 48 to 72 hours, treat
with antibiotics

27. Risk Factors For AOM
 High Risk Factors
Craniofacial abnormalities.
Immune deficiency.
Gastro-esophageal reflux.

28. Bluestone CD, Klein JO Otitis Media in Infants and
Children 1995
S. pneumoniae H. influenzae
Amoxicillin +++ +++
Amoxicillin
(80-100
mg/kg/d)
++++ +++
Amoxicillin/
Clavulanate
+++ ++++

29. Bluestone CD, Klein JO Otitis Media in Infants and
Children 1995
S.pnuemoniae H. influenzae
Cefaclor ++ +++
Cefixime ++ ++++
Cefuroxime ++++ ++++
Cefprozil ++++ +++
Ceftibuten ++ ++++
Ceftriaxone ++++ ++++
Cefpodoxime ++++ ++++
Loracarbef +++ ++++

30. Treatment
 Analgesia
 Antibiotics
 Decongestant/
 Anti histamine
 No role of ear drops

31. Otis Media With Effusion

32. Otitis Media with Effusion
(Chronic non-suppurative Otitis Media)
Diagnosis :
 History.
 Clinical Examination.
 Tuning fork tests.
 Audiological assessment.

33. History
 Decrease hearing
 Ear pain
 Inactive/ dull
 Decreasing school grades
 Mouth breathing
 Snoring
 Nasal obstruction

34. Clinical Examination

35. Clinical Examination

36. Clinical Examination
Diagnostic nasoendoscopy is not possible in
children

37. Otitis Media with Effusion
(Chronic non-suppurative Otitis Media)
 Tuning fork test ( Weber and Renine test)
 Audiological assessment:
1. Tympanometry

38. Otitis Media with Effusion
(Chronic non-suppurative Otitis Media)
Audiological assessment:
2. B-Pure tone audiogram

39. X Ray Neck Lateral View Soft Tissue
Shadow

40. Otitis Media with Effusion
(Chronic non-suppurative Otitis Media)
 Medical Treatment of OME :
 Observation – many European countries wait 6-
9 months prior to placement of ear tubes.
 Antibiotics????
 Meta-analysis shows beneficial short-term resolution
of OME
 Audiogram at 3 months with persistent effusion
to determine impact on hearing

41. Otitis Media with Effusion
(Chronic non-suppurative Otitis Media)
Surgical treatment (Tympanostomy Tubes ) :
 +/- adenoidectomy
 Indication : chronic OME >3mos with hearing loss
and/or speech delay is an indication for
tympanostomy tube placement.

42. Case
 Sixty years old male with complain of right ear
decrease hearing for 2 months. Denied any
episode of URTI or air travel.
 Tuning fork
 rinnie’s

43. Questions ?