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.

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Otitis media
Abdullatif Sami Al Rashed
College of Medicine, King Faisal University
Al Ahsa, KSA

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ACUTE SUPPURATIVE
OTITIS MEDIA

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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

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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.

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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

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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.

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OTITIS MEDIA WITH
EFFUSION

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ETIOLOGY
 Adenoid hyperplasia
 Chronic rhinitis and sinusitis
 Chronic tonsillitis
 Benign and malignant tumours of nasopharynx
 Unresolved acute otitis media
 Viral

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CLINICAL FEATURES
 Hearing loss
 Delayed and defective speech
 Discomfort in the ear or very mild pain

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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

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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.

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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

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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

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CHRONIC SUPPURATIVE
OTITIS MEDIA

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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.

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TUBOTYMPANIC TYPE
 After recurrent or untreated acute OM
 Pseudomonas aeruginosa, Proteus, Escherichia coli and
Staphylococcus aureus, while anaerobes include Bacteroides
fragilis and anaerobic Streptococci

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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

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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

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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.

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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

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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.

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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

27. Only study the yellow color

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ATTICOANTRAL TYPE
 TREATMENT: surgery is main TTT
 Mastiodectomy
 Canal wall down procedures
 Canal wall up procedures
 Hearing can be restored by myringoplasty or tympanoplasty

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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

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Complications of Suppurative
Otitis Media

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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

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INTRATEMPORAL
COMPLICATIONS
 (I) ACUTE MASTOIDITIS
 CBC, ESR, X Ray Mastoid, Ear swab
 Hospitalization of the patient, Antibiotics, Myringotomy.

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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

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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

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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

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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

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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)

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 ANY ABSCESS you should TTT by:
 Antibiotic
 Craniotomy Drainage
 OM TTT (Mastoidectomy)

41. THANK YOU