This document provides an overview of otitis media, including its different types and stages, associated clinical features, investigations, and treatment approaches. It discusses acute suppurative otitis media and its typical stages of tubal occlusion, presuppuration, suppuration, resolution, and potential complications. It also covers otitis media with effusion, chronic suppurative otitis media including its tubotympanic and atticoantral types, complications of suppurative otitis media involving the temporal bone and intracranial regions, and adhesive 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.
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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.
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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.
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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.
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
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.
20. +
TUBOTYMPANIC TYPE
After recurrent or untreated acute OM
Pseudomonas aeruginosa, Proteus, Escherichia coli and
Staphylococcus aureus, while anaerobes include Bacteroides
fragilis and anaerobic Streptococci
21. +
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
22. +
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
23. +
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 ( ينفخبخشمهبقوه )can also push the infection from
nasopharynx to middle ear and should b e avoided.
24. +
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
25. +
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.
26. +
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
28. +
ATTICOANTRAL TYPE
TREATMENT: surgery is main TTT
Mastiodectomy
Canal wall down procedures
Canal wall up procedures
Hearing can be restored by myringoplasty or tympanoplasty
29. +
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
31. +
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
35. +
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
36. +
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
37. +
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
38. +
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
39. +
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)
40. +
ANY ABSCESS you should TTT by:
Antibiotic
Craniotomy Drainage
OM TTT (Mastoidectomy)