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Acute otitis media and mastoiditis
1. Acute otitis media andAcute otitis media and
mastoiditismastoiditis
Chunfu Dai M.D & Ph.DChunfu Dai M.D & Ph.D
Otolaryngology DepartmentOtolaryngology Department
Fudan UniveristyFudan Univeristy
2. DefinitionDefinition
AOM: is an infectious process ofAOM: is an infectious process of
the middle ear cleft and to athe middle ear cleft and to a
variable extent, of the mastoid airvariable extent, of the mastoid air
cell system.cell system.
3. BacteriologyBacteriology
Streptococcus pneumoniaeStreptococcus pneumoniae
(48%)(48%)
Haemophilus influenzae (31%)Haemophilus influenzae (31%)
Moraxella catarrhalis (20%)Moraxella catarrhalis (20%)
P-hemolytic streptococcusP-hemolytic streptococcus
(decreased following widespread(decreased following widespread
immunization program)immunization program)
Pseudomonas aeruginosaPseudomonas aeruginosa
(uncommon cause of AOM)(uncommon cause of AOM)
6. Routine of infectionRoutine of infection
Via eustachian tubeVia eustachian tube
upper respiratory infectionupper respiratory infection
(acute rhinonitis and nasal(acute rhinonitis and nasal
pharyngitis)pharyngitis)
Upper respiratoryUpper respiratory
communicative diseasecommunicative disease
(diaphea, mealse, et al)(diaphea, mealse, et al)
Swimming and dive in unclearSwimming and dive in unclear
waterwater
Anatomic contributionAnatomic contribution
(Eustachian tube in infant is(Eustachian tube in infant is
wide and short and the twowide and short and the two
orifice in the same level)orifice in the same level)
7. Routine of infectionRoutine of infection
Via external acousticVia external acoustic
canal and TMcanal and TM
PerforationPerforation
Myringotomy or myrigotosisMyringotomy or myrigotosis
Via blood supplyVia blood supply
8. PathologyPathology
Mucosal inflammationMucosal inflammation
Serous, hemorrhagic,Serous, hemorrhagic,
or purulent exudate inor purulent exudate in
middle cavitymiddle cavity
Rupture of tympanicRupture of tympanic
membranemembrane
9. SymptomsSymptoms
FeverFever
It may be masked by analgesics orIt may be masked by analgesics or
antibioticantibiotic
OtalgiaOtalgia
60% patients can spontaneous remission60% patients can spontaneous remission
FullnessFullness
Hearing lossHearing loss
10. Physical findingsPhysical findings
Increased vascularizationIncreased vascularization
of the TM, initially locatedof the TM, initially located
in pars of flaccida,in pars of flaccida,
frequently spreadingfrequently spreading
beyond the annulus tobeyond the annulus to
the skin of the externalthe skin of the external
canal.canal.
Bony landmarks areBony landmarks are
visible.visible.
12. Physical findingsPhysical findings
Rapid middle earRapid middle ear
exudation occurs,exudation occurs,
Blurring of the mallwallBlurring of the mallwall
short process, followedshort process, followed
by edema and bulging ofby edema and bulging of
the pars flaccida.the pars flaccida.
13. Physical findingsPhysical findings
The progression of thisThe progression of this
disease may result in rupturedisease may result in rupture
of TM, releasing the middleof TM, releasing the middle
ear contents (beating sign)ear contents (beating sign)
leads to relief of otalgia andleads to relief of otalgia and
retraction of the pars flaccidaretraction of the pars flaccida
14. Lab testsLab tests
Blood counts usually shows leukocytosisBlood counts usually shows leukocytosis
with polymorphonuclear elevation.with polymorphonuclear elevation.
CT and MRI is necessary only for the rareCT and MRI is necessary only for the rare
patients with a serious complicationpatients with a serious complication
(meningitis or brain abscess)(meningitis or brain abscess)
15. Hearing testsHearing tests
Conductive hearing lossConductive hearing loss
Degree of hearing lossDegree of hearing loss
will depend on thewill depend on the
amount and viscosity ofamount and viscosity of
the middle ear exudate,the middle ear exudate,
TM edemaTM edema
It vary from 10-50 dB withIt vary from 10-50 dB with
predominant involvementpredominant involvement
of the low frequenciesof the low frequencies
Hearing loss may mixedHearing loss may mixed
when there is labyrinthinewhen there is labyrinthine
extension.extension.
16. ManagementsManagements
Antibiotic therapyAntibiotic therapy
ExperiencesExperiences
Antibiotic sensitivity and bacteriologic cultureAntibiotic sensitivity and bacteriologic culture
Traditional duration 10-14 dTraditional duration 10-14 d
Currently duration 5-7 dCurrently duration 5-7 d
18. ManagementsManagements
Pre-perforationPre-perforation
Pain relief drugsPain relief drugs
Surgery: myringotomySurgery: myringotomy
Progression with a red,Progression with a red,
bulging TM, severe otalgiabulging TM, severe otalgia
and feverand fever
Otitis media with impendingOtitis media with impending
complicationscomplications
perforation is not big enoughperforation is not big enough
to drain all pusto drain all pus
19. ManagementsManagements
Post-proferation:Post-proferation:
Clear-up pus with 3% hydro-oxygenClear-up pus with 3% hydro-oxygen
Antibiotic ear dropsAntibiotic ear drops
With pus decreased and inflammationWith pus decreased and inflammation
disappeared, alcohol can be used to facilitatedisappeared, alcohol can be used to facilitate
dry ear.dry ear.
20. Follow-upFollow-up
Adequately treated AOM effusion mayAdequately treated AOM effusion may
persist for 2-6 weeks or even longer.persist for 2-6 weeks or even longer.
Managements may requireManagements may require
extended antibiotic treatmentextended antibiotic treatment
Otoscope and audiometric tests should beOtoscope and audiometric tests should be
performed 3-4 weeks following apparentperformed 3-4 weeks following apparent
resolution of the acute infectionresolution of the acute infection
Insertion of pressure equalization tubes dueInsertion of pressure equalization tubes due
to fluid persists beyond 3 monthsto fluid persists beyond 3 months
21. Acute mastoiditisAcute mastoiditis
Definition: an infection of the mastoidDefinition: an infection of the mastoid
characterized by diffuse osteitis followed bycharacterized by diffuse osteitis followed by
rarefaction and breakdown of the bony septae.rarefaction and breakdown of the bony septae.
Acute coalescent mastoiditisAcute coalescent mastoiditis
Haemorrhagic mastoiditisHaemorrhagic mastoiditis
Masked mastoiditisMasked mastoiditis
Predisposition to pneumatic mastoidPredisposition to pneumatic mastoid
Predilection to kidPredilection to kid
Mastoid is mature at age of 4 year oldMastoid is mature at age of 4 year old
22. Acute mastoiditisAcute mastoiditis
Reduction of immune systemReduction of immune system
Strong bacteria (type III pneumococus,Strong bacteria (type III pneumococus,
haemolytic streptococcus)haemolytic streptococcus)
Obstruction- not effective drainageObstruction- not effective drainage
Imcompletely treatmentImcompletely treatment
23. Acute mastoiditisAcute mastoiditis
SymptomsSymptoms
Symptoms may follow AOM, with or without aSymptoms may follow AOM, with or without a
symptom-free interval of a few days to severalsymptom-free interval of a few days to several
weeks or more.weeks or more.
OtalgiaOtalgia
Aural dischargeAural discharge
Conductive hearing lossConductive hearing loss
feverfever
24. Acute mastoiditisAcute mastoiditis
Physical findingsPhysical findings
Fever, from a slight elevation to 39Fever, from a slight elevation to 39
Otorrhea may be absentOtorrhea may be absent
Pulsatile may be observedPulsatile may be observed
Tympanic perforation is present, but it may be obscured byTympanic perforation is present, but it may be obscured by
intense edemaintense edema
Swelling of the superior TM and posterosuperior wall of EACSwelling of the superior TM and posterosuperior wall of EAC
Postauricular areaPostauricular area
erythema and tendernesserythema and tenderness
Pitting edemaPitting edema
Obliteration of the postauricular creaseObliteration of the postauricular crease
25. Acute mastoiditisAcute mastoiditis
RadiographicRadiographic
evaluationevaluation
DiffuseDiffuse
rarefaction ofrarefaction of
bone andbone and
breakdown ofbreakdown of
cellular sepaecellular sepae
26. Acute mastoiditisAcute mastoiditis
interventionsinterventions
Medical managementMedical management
AntibioticAntibiotic
Intravenous antibiotic therapy should be maintained for at leastIntravenous antibiotic therapy should be maintained for at least
24-48 h after the resolution of symptoms24-48 h after the resolution of symptoms
Then followed with oral antibiotic for 2 weeksThen followed with oral antibiotic for 2 weeks
Surgical managementSurgical management
Emergency surgery: simple mastoidectomyEmergency surgery: simple mastoidectomy
Mastoidectomy + ventilation tube placementMastoidectomy + ventilation tube placement