1. 1
Acute Otitis Media
Secretory Otitis Media
Prof. Dr. Ausaf Ahmed Khan
MBBS. DLO. FCPS. FRCS(Glasg)
Member IWGEES (International Working Group
of Endoscopic Ear Surgery)
Head of ENT / Head and Neck Surgery
Hamdard College of Medicine & Dentistry
Hamdard University. Karachi, Pakistan
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Acute Suppurative Otitis Media
Definition
Etiology
Pathogenesis
Clinical features
Differential diagnosis
Treatment
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Classification of Otitis Media
(according to the duration of illness)
Acute OM rapid onset of signs &
symptoms, < 3 wk course
Subacute OM Symptoms lasting for
3 wks to 3 months
Chronic OM Illness persisting for
3 months or longer
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Acute Suppurative Otitis Media
Definition
It is the acute suppurative inflammation of the
mucosal lining of the middle ear cleft
Duration of illness should be < 3 wks.
Normal TM A.O.Media
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Acute Suppurative Otitis Media
The infection affects infants and children more
commonly than the adults …..
The type of inflammatory reaction and its
progress depends on the ;
virulence of the organisms,
age and resistance of the patient,
therapy with the antibiotics
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Role of eustachian tube
in pathogenesis of ME infections
The ET does not opens regularly on swallowing
due to one of the following factors;
1. Obstruction of the tubal lumen by hypertrophied
adenoids in a child (or adult)
2. Swelling of the tubal mucosa due to chronic inflammation
of the neighboring structures such as the sinuses or
tonsils or allergy
3. An inadequate tensor palati muscle
4. Infiltration of the tube by a malignant tumor of the
nasopharynx
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Air in the ME
is resorbed
Negative
pressure
in ME
Acts an irritant to
the ME mucosa
ME is no longer aerated
ET dysfunction
Changes occur in the ME
Consequences
of
the
Eustachian
tube
blockage
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Etiology of the A.O.M.
Predisposing factors
1. General factors
2. Local factors ;
In the Nose.
In the Throat.
In the Tympanic membrane itself.
Exciting factors
Viruses and bacteria
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Predisposing factors
General
1. Age
Increase incidence in Infants and children.
Most common in 6 – 11 months age child.
2. Weather
Winter & spring
3. Racial factors
More in white races, native Americans, Eskimos
4. Socioeconomic condition
poor communities
5. Daycare vs. Homecare
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6. Poor hygiene
7. Breast feeding
Decrease risk of URTI & GI disturbances
Inverse relationship b/w incidence of OM & breast feeding
8. Swimming & diving in contaminated water
9. Systemic diseases
Typhoid, measles & mumps
10.Immunodeficiency states
AIDS, steroids, chemotherapy, IgG deficiency
Predisposing factors
General
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Predisposing factors
Local
In the nose
Rhinitis & Sinusitis
Excessive nasal
blowing
After anterior nasal
packing
NG tube insertion
In the pharynx
Adenoid hypertrophy
and infection
Pharyngitis
Nasopharyngeal
tumors
After post-nasal
packing
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In the throat
Acute tonsillitis
Cleft palate
Palatal paralysis
In the T. M.
After traumatic
perforation
After myringotomy
Predisposing factors
Local
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Exciting factors
A viral infection may
predispose secondary
bacterial infection.
RSV
Rhinovirus
Influenza virus
Parainfluenza virus
Organisms (in order of
decreasing frequency):
Hemophilus influenzae
Pneumococci (in infants)
Streptococci (in adults)
Moraxella catarrhalis
Stpahylococcus aureus
Others
In 90% of cases the infection is mono-microbial.
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Pathology
An acute infection can spread very rapidly to
involve the whole lining of the ME cleft
The successive stages in the pathogenesis are;
1. Stage of Tubo-tympanitis
2. Stage of catarrhal inflammation
3. Stage of suppuration
4. Stage of resolution or complication
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Pathology
1. Stage of tubo-tympanitis.
There is tubul occlusion &
engorgement and edema of
the lining of the Middle Ear
cleft
Normal TM
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication
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Pathology
2. Stage of catarrhal inflammation
There is exudation from the lining of the ME
mucosa and collection of fluid in the ME and
Mastoid air cells.
The exudate is serous in nature at this stage
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication
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Pathology
3. Stage of Suppuration
In this stage there is collection
of the purulent fluid in the ME
cleft due to secondary
bacterial infection.
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication
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Early stage of AOM.
Redness, edema and
bulging in Pars flaccida
Increased redness, edema
and marked outward bulge
of the pars flaccida
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication
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Pathology
4. Stage of resolution or complication
Resolution occur by appropriate antibiotic therapy/
surgical drainage
If treatment is not given adequately
the pus may find its way outside or
may causes mastoiditis and other complications.
Stage of Tubo-tympanitis
Stage of catarrhal inflammation
Stage of suppuration
Stage of resolution/
complication
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Clinical features
Symptoms
Clinical features may vary and depends on the
stage of the disease.
Fullness in the ear (in early stage)
Deep seated pain
Severe pain as the pus builds up pressure in the ME
Deafness (is present in all stages)
Discharge from the ear (once TM is perforated)
Discharge is profuse, purulent or muco-purulent in nature,
sometimes blood-stained and often pulsatile
Pain decreases after discharge occurs
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Other constitutional symptoms;
Features of a recent URTI in most of the cases
Fever
Headache
Malaise
Clinical features
Symptoms
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Clinical features
Signs
In the early stage there is retraction of the TM
with prominent blood vessels along HOM.
Then increased congestion of the periphery of
the pars tensa and pars flaccida.
Congestion of the whole TM.
Presence of pus in the ME and normal features
of the TM are lost leading to bulging of the TM.
After rupture of the TM, pus discharge in EAC.
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Diagnosis
of A.O.M.
History of URTI in recent
past.
Complains fever, otalgia,
deafness, discharge at
late stage
Findings TM is red, dull,
bulging, pus behind the
TM
if perf occurs it shows pus
in EAC & TM perforation.
Nose and throat shows
features of URTI
TFork tests shows CD.
Impedance test shows flat
line.
PTA shows CD.
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Differential diagnosis
Furuncle & Diffuse otitis externa
Pain is more superficially located
Discharge is serous
Tympanic membrane is not congested
Usually no / mild conductive deafness
Conditions causing referred otalgia
Ear examination is essentially normal
No hearing loss
Herpes zoster oticus
Vesicles are usually seen
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Management
Medical treatment
Bed rest, hot fomentation.
Analgesics/ antipyretics.
Antibiotics. (systemic/ topical)
Antihistamines & Decongestants
(have limited role).
Surgical treatment
Myringotomy if TM is bulging and about to
perforate or if complications occur.
Tympanoplasty at a later stage (if perf. persist)
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Antibiotics of choice
First line
Amoxicillin - 60-90 mg/kg divided tid
Co-Amoxical (Augmentin) - B lactam stable
Ceftin - B lactam stable
Bactrim, Pediazole
Second line
Augmentin
Ceftin
Rocephin
Macrolides - Zithromax, Biaxin
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Myringotomy
Is the surgery in which a hole
is made in the T.M. to evacuate
the pus.
Done by a Myringotome (myringotomy knife)
Incision is given in the postero-inferior quadrant of
the pars tensa (in case of ASOM).
Pus is evacuated and may be send for C/S.
Antibiotic ear drops are given.
