more you read more you known

1. Frantz Fanon University
Faculty of Medicine & Surgery
Acute otitis media
Dr. Jamal A. Dirir
MBBS

2. Otitis Media
The term otitis media (OM) refers to an
inflammatory process within the middle ear
cleft. Otitis media can be either acute or
chronic. There is no absolute time period,
but, in general, disease that persists for more
than 3 months should be considered as
chronic. The Eustachian tube appears to be
central to the pathogenesis of all forms of
OM.

3. The normal physiological functions
of the Eustachian tube are to;
(1) maintain the gaseous pressure within the
middle ear cleft at a level that approximates
atmospheric pressure;
(2) prevent reflux of the contents of the
nasopharynx into the middle ear and
(3) clear secretions from the middle ear by both
mucociliary transport and a “pump action” of the
eustachian tube.

4. Cont..
The failure of any or all of these normal functions of
the eustachian tube can result in OM. Both anatomic and
functional obstruction of the eustachian tube results in
the failure of normal regulation of the middle ear pressure.
Anatomic obstruction is most commonly caused by
inflammation of the eustachian tube mucosa or extrinsic
compression by tumor or large adenoids.

5. Cont..
Functional obstruction usually occurs as a
result of the failure of the normal muscular
mechanism of eustachian tube opening, as
seen in cleft palate, or insufficient stiffness of
the cartilaginous portion of the eustachian
tube, often seen in infants and young children.

6. ACUTE OTITIS MEDIA
ESSENTIALS OF DIAGNOSIS
o Otalgia.
o Pyrexia.
o Thickened, bulging, hyperemic tympanic membrane.
o Hearing loss.
o otorrhea

7. General Considerations
Acute otitis media (AOM) is one of the most
common infectious diseases seen in children,
with its peak incidence in the first 2 years of
life. Most of the population will suffer at least
one episode of AOM at some point in their
childhood. It can occur in suppurative,
nonsuppurative ,and recurrent forms.

8. Cont..
Recurrent AOM is defined as ≥ 3 episodes of
acute suppurative OM in a 6-month period, or
≥ 4 episodes in a 12-month period, with
complete resolution of symptoms and signs
between the episodes.

9. Classification of otitis media
.
Acute Otitis Media
Suppurative
Nonsuppurative
Recurrent
Chronic Otitis Media
Suppurative
Tubotympanic
Cholesteatoma
Nonsuppurative
Otitis media with effusion

10. Factors relevant to the epidemiology
of otitis media
Environmental Factors
Day-care attendance
Not being breast-fed
Exposure to tobacco smoke
Seasonal variation in respiratory infections
Host Factors
Genetics
Immunodeficiency
Birth defects
Cleft palate
Down syndrome

11. Pathogenesis
In most cases of AOM, an antecedent viral
upper respiratory tract infection leads to
disruption of eustachian tube function.
Inflammation of the middle ear mucosa
results in an effusion, which cannot be cleared
via the obstructed eustachian tube. This
effusion provides a favorable medium for
proliferation of bacterial pathogens, which
reach the middle ear via the eustachian tube,
resulting in suppuration.

12. Cont..
Although viral infection is important in the
pathogenesis of AOM, the majority of patients
develop subsequent bacterial colonization, and
therefore AOM should be considered a
predominantly bacterial infection. Many studies,
using tympanocentesis, have identified
Streptococcus pneumoniae (up to 40%),
Haemophilus influenzae (25–30%), and Moraxella
catarrhalis (10–20%) as the organisms most
commonly responsible for AOM.

13. Cont..
Less frequently identified pathogens include
group A streptococci, Staphylococcus aureus,
and gram-negative organisms such as
Pseudomonas aeruginosa.

14. Clinical Findings
A. SYMPTOMS AND SIGNS
Before the onset of symptoms of AOM, the patient frequently
has symptoms of an upper respiratory tract infection. Older
children usually complain of earache, whereas infants become
irritable and pull at the affected ear. A high fever is often
present and may be associated with systemic symptoms of
infection, such as anorexia, vomiting, and diarrhea. Otoscopy
classically shows a thickened hyperemic tympanic membrane,

15. Cont..
Further progression of the infective process
may lead to the spontaneous rupture of the
tympanic membrane, resulting in otorrhea. If
this occurs, the Otalgia and fever often
subside. At this stage, it is often not possible
to visualize the tympanic membrane because
of the discharge in the ear canal.

16. In most cases of AOM, no further
investigations are necessary since the
diagnosis is clinical. If symptoms are severe, a
blood count often reveals a leukocytosis, and
blood cultures may detect bacteremia during
episodes of high fever. A culture of the ear
discharge is helpful in guiding antibiotic
therapy in patients in whom the first-line
treatment is unsuccessful.

17. Cont..

18. Treatment
A. NONSURGICAL MEASURES
1. Watchful waiting—The current practice guidelines
advise on an initial watchful waiting without
antibiotic therapy for healthy 2-year-olds or older
children with Non severe illness (mild Otalgia and
fever < 39 °C) because AOM symptoms improve in
most within 1–3 days. However, guidelines should
not replace clinical judgment. Watchful waiting is not
recommended for children < 2 years old if AOM is
certain

19. 2. Antibiotic therapy
AOM does not settle after the watchful waiting period, then
antibiotic therapy should begin. The use of antibiotics is
probably beneficial, but there is a trade-off between benefits
and side effects. There is no difference demonstrated in
recurrence rates or the development of complications among
different antibiotics. Amoxicillin (80 mg/kg/d given in three
divided doses for 10 days) remains the first-line therapy for
AOM, although with increasing numbers of resistant strains of
bacteria, it may be necessary to use more broad-spectrum
antibiotics in the future. In resistant cases, amoxicillin should
be given in combination with clavulanate.

20. 3. Adjunctive therapy
adjunctive therapy for the AOM should include analgesics and
antipyretics. There is no role for oral decongestants or
antihistamines in the treatment of AOM

21. B. SURGICAL MEASURES
A minority of patients with AOM fail to
respond to medical therapy or develop a
complication. Myringotomy is then indicated
to allow the drainage of pus.
Myringotomy is a surgical procedure in which
a tiny incision is created in the eardrum
(tympanic membrane) to relieve pressure
caused by excessive buildup of fluid, or to
drain pus from the middle ear.

22. OTITIS MEDIA WITH EFFUSION
ESSENTIALS OF DIAGNOSIS
• Persistent hearing loss.
• Dull, immobile tympanic membrane.
• “Flat” tympanogram.

23. General Considerations
Otitis media with effusion is defined as the
persistence of a serous or mucoid middle ear
effusion for 3 months or more. Various terms,
such as chronic secretory otitis media, chronic
serous otitis media, and “glue ear,” have been
used to describe the same condition. It is the
most common cause of hearing loss in
children in the developed world and has peaks
in incidence at 2 and 5 years of age.

24. Cont..
The risk factors for OME are closely
interrelated with those associated with AOM
and have already been described in the
previous section. In fact, the formation of a
middle ear effusion frequently occurs after an
episode of AOM, and children with OME are
far more likely to suffer from recurrent AOM.

25. Clinical Findings
A. SYMPTOMS AND SIGNS
Otitis media with effusion may be completely
asymptomatic and detected only on routine
audiologic screening. The most common
symptom of OME is hearing loss. Although
older children may complain of reduced
hearing.

26. B. SPECIAL TESTS
1. Tympanometry:-
it is typically used to detect or rule out several
things: the presence of fluid in the middle ear, a
middle ear infection, a hole in the eardrum
(perforation), or Eustachian tube dysfunction.
2. Audiometry:-
Patients who have OME usually have a moderate
conductive hearing loss.

27. Treatment
A. OBSERVATION
A large number of patients with OME require
no treatment, particularly if the hearing
impairment is mild. Spontaneous resolution
occurs in a significant proportion of patients.
A period of watchful waiting of 3 months from
the onset (if known) or from the diagnosis (if
onset unknown) before considering
intervention is therefore advisable.

28. B. NONSURGICAL MEASURES
The medical treatment of OME is controversial
and there is a wide geographic variability in
practice. Autoinflation with purpose-built
nasal balloon has been shown to be beneficial,
although compliance is generally poor.
Medical treatments include antibiotics,
steroids, decongestants, and antihistamines.

29. C. SURGICAL MEASURES
The surgical options for OME is tympanostomy
tubes. It is surgical procedure during which
a surgical opening is made in the eardrum,
or tympanic membrane, in order to
promote drainage of infected fluid from the
middle ear and ear tubes are surgically
implanted into the eardrum to promote
ongoing drainage.

30. THANK YOU FOR YOUR ATTENTION