Definition

It is an acute inflammation of middle ear by pyogenic organisms. Here, middle ear

implies middle ear cleft, i.e. eustachian tube, middle ear, attic, aditus, antrum and
mastoid air cells.

Pathophysiology

Obstructed Eustachean tube

Recurrent upper respiratory infections can lead to microbial contamination of
middle ear via the Eustachean tube
Naso pharyngitis
Nasal allergy

Microbiology

Commonly viral (Viral infections help bacteria to adhere to the middle ear
mucosa)
Bacteria implicated include:
S. Pneumoniae
H. Influenza
M. Catarrhalis
These infections commonly affects children because their Eustachian tubes
are shorter, wider and straighter facilitating easy efflux of contaminants in to
the middle ear cavity from Nasopharynx

Why ASOM is common in children?

Because of ET geometry
Because of recumbent position commonly occupied by the child

Pathology and Clinical features

The disease runs through the following stages:
1. Stage of tubal occlusion
2. Stage of pre-suppuration
3. Stage of suppuration
4. Stage of resolution or complication
1. Stage of tubal occlusion. Oedema and hyperaemia of nasopharyngeal end of
Eustachian tube blocks the tube, leading to absorption of air and negative
intratympanic pressure. There is retraction of tympanic membrane with some
degree of effusion in the middle ear but fluid may not be clinically appreciable.
Symptoms. Deafness and earache are the two symptoms but they are not marked.
There is generally no fever.
Signs. Tympanic membrane is retracted with handle of malleus assuming a more

horizontal position, prominence of lateral process of malleus and loss of light reflex.
Tuning fork tests show conductive deafness.
2. Stage of pre-suppuration. If tubal occlusion is prolonged, py0genic organisms
invade tympanic cavity causing hyperaemia of its lining. Inflammatory exudate
appears in the middle ear. Tympanic membrane becomes congested.
Symptoms. There is marked earache which my disturb sleep and is of throbbing
nature. Deafness and tinnitus are a present, but complained only by adults. Usually,
child runs high degree of fever and is restless.
Signs. To begin with, there is 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. Later, whole of tympanic membrane including
pars flaccida becomes uniformly red. Tuning fork tests will again show conductive
type of hearing loss.
3. Stage of suppuration. This is marked by formation of pus in the middle ear and
to some extent in mastoid air cells. Tympanic membrane starts bulging to the point
of rupture.
Symptoms. Earache becomes excruciating. Deafness increases, child may run
fever of 102-103F. This may be accompanied by vomiting and even convulsions.
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 he discernible. A yellow spot may be seen on the tympanic
membrane where rupture is imminent. In pre-antibiotic era, one could see a nipplelike protrusion of tympanic membrane with a yellow spot on its summit. Tenderness
may be elicited over the mastoid antrum. X-rays of mastoid will show clouding of air
cells because of exudate.
4. Stage of resolution. The tympanic membrane rupture, with release of pus and
subsidence of symptoms. Inflammatory process begins to resolve. If proper
treatment is started early or if the infection was mild, resolution may start even
without rupture of tympanic membrane.
Symptoms. With evacuation of pus, earache is relieved, fever comes down and
child feels better.
Signs. External auditory canal may contain blood tinged discharge which later
becomes mucopurulent. Usually, a small perforation is seen in antero-inferior
quadrant of pars tensa. Hyperaemia of tympanic membrane begins to subside with
return to normal colour and landmarks.

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, subperiosteal abscess, facial paralysis,
labyrinth itis, petrositis, extradural abscess, meningitis, brain abscess or lateral
sinus thrombophlebitis.

Investigations

In an acute infection, no investigations are generally warranted.

If the infection ruptures the eardrum, a culture and sensitivity of the discharge can
be taken.

Treatment
Mainly conservative.
1. Antibiotics control of infection, arrest & reverse inflammation, prevent

2.
3.
4.
5.
6.

suppuration and
perforation, relieve symptoms and reduce risk of complications.
Amoxicillin 40mg/kg/day TDS
Decongestant nasal drops - used to relieve Eustachian tube oedema and
promote ventilation
of middle ear.
Oral nasal decongestants
Analgesics and antipyretics PCM to relieve pain and bring down temperature
Ear toilet - If there is discharge in the ear, it is dry mopped with sterile cotton
buds and a wick
moistened with antibiotic may be inserted.
Myringotomy - It is incising the drum to evacuate pus and is indicated when:
(a) Drum is bulging and there is acute pain,
(b) There is an incomplete resolution despite antibiotics when drum
remains full with
persistent conductive deafness,
(c) There is persistent effusion beyond 12 weeks.

All cases of acute suppurative otitis media should be carefully followed till drum
membrane returns to its normal appearance and conductive deafness disappears