ACUTE SUPPURATI VE OTITIS MEDIA

Acute suppurative otitis media is an inflammation of the muco-periosteal lining of the middle ear cleft produced by pus forming organisms lasting up to 3wks. Middle ear cleft consists of:
a) b) c) d) Eustachian tube. Tympanic cavity. Mastoid antrum. Mastoid air cells.

MIDDLE EAR CLEFT


i.

AETIOLOGY:
Route of infection:
Via the eustachian tube. Via the tympanic membrane. Blood-borne infection. Age . Socio-economic factors. Climate. Racial factors. Nasopharyngeal tissue masses. Other nasopharyngeal masses:
Polyps. Teratoma. Angiofibroma. Lymphoma. Carcinoma.

ii.

Predisposing factors:

Respiratory disease. Allergy. Pre-existing middle ear effusion. Immunodeficiency syndromes. Chronic systemic disorders. Cleft palate. Primary ciliary dyskinesia.

 PATHOLOGY:
Microbiology:
Haemolytic streptococcus. Staphylococcus aureus. Streptococcus pneumoniae. Haemophilus influenzae. Viruses , paving way for pyococcal invasion. Stage of tubo-tympanitis. Stage of acute serous inflammation. Stage of acute suppurative inflammation. Stage of resolution.

Middle ear inflammatory process:

 Spread of infection:
Retrograde thrombophlebitis. Bone necrosis. Congenital dehiscences. Fracture lines. 1.Mastoiditis . 2.Intracranially causing extradural or subdural abscess, meningitis ,brain abscess, lateral sinus thrombosis & otitic hydrocephalus. 3.To labyrinth causing suppurative labyrinthitis. 4.To facial nerve canal causing facial paralysis. 5.To the neck producing Bezolds or Citellis abscess. 6.To the petrous apex causing petrositis & Gradenigos Synd.

 SIGNS & SYMPTOMS:

SYMPTOMS: 1. GENERAL:
1. 2. 3. 4. Fever. Headache. Malaise.
ACUTE OTITIS MEDIA

2. LOCAL:
Deep seated throbbing pain in ear. Deafness. Aural discharge. H/O previous upper respiratory tract infection. 5. Complain of giddiness.

TM IS HAEMORRHAGIC ALONG HANDLE OF MALLEUS & PARS FLACCIDA

EARLY STAGE OF AC.OM WITH MODERATE INFLAMMATION & LATERAL BULGING OF TM

HYPERAEMIC BULGING TM & INJECTION OF THE VASCULATURE ALONG THE MALLEUS HANDLE

 1. 2.

I.

SIGNS: GENERAL:
Temperature: 103 - 104F. Pulse rate proportionately increased.

LOCAL:
Stage of tubotympanitis:
a. b. c. d. e. Leash of blood vessels along the handle of malleus. Injection of pars flaccida. Retracted ear drum. Immobility of the ear drum. Ipsilateral conductive deafness.

PARS TENSA INTENSELY INJECTED & HAEMORRHAGIC

II.
a. b. c. d. e. f.

Stage of acute serous inflammation:

In addition to a , b & e of stage 1 , theres leash of blood vessles at the periphery of pars tensa. Loss of landmarks. Loss of light reflex. Bulging of ear drum. Presence of fluid in the middle ear. Mastoid tenderness elicited by pressure over the McEwens triangle. AC.OM WITH HERNIATION OF TM

III.

Stage of acute suppurative inflammation:

Before perforation:
a. b. c. d. Intense injection of the TM. Loss of landmarks & light reflex. Bulging of TM . Ipsilateral conductive deafness ( Rinnes & Webers tuning fork tests ) .

a. b. c. d.

After perforation:
Pus in EAC. Perforation in the TM ( small central perforation in the posterior segment of pars tensa ) . Injection of the residual ear drum. Ipsilateral conductive deafness.

III.
a. b.

Stage of resolution:
Dry perforation in the ear drum. Ipsilateral conductive deafness.

GROSSLY INFLAMMED PARS TENSA,THICKENED & BULGED LATERALLY

III.
1. 2. 3.

Examination of Nose & throat. Variation in clinical picture in any infection is due to:
Differing virulence of invading microorganisms. Varying host defence. Effectiveness of & compliance in Rx. CHRONIC MYRINGITIS

 SIGNS OF COMPLICATIONS:
Tenderness & oedema over the mastoid process. Protuberance of pinna. Sagging of posterosuperior canal wall. Granulation tissue pouting through the perforation. Aural discharge persisting for 3-4wks. Neck stiffness. Examination of CNS to rule out impending I/C complications. Nystagmus in patients with vertigo should be sought. Fistula test carried out.

INVESTIGATIONS
Microbiology:
Ear swab for C/S.

Blood studies:
FBC.

Audiometry:
PTA. Tympanometry.

Examination under microscope. Mastoid X-Rays.

 DIAGNOSIS:
H/O earache. Deafness. Otorrhoea. Preceding H/O URTI. Inflammatory changes found on clinical examination. Otitis externa. Tympanic membrane hyperaemia. Otitis media with effusion ( OME ) . Herpes zoster oticus. Myringitis haemorrhagica bullosa. Other conditions.

DIFFERENTIAL DIAGNOSIS:
AC.OM BULLOUS MYRINGITIS

SEQUELAE:

Persistence of a sterile middle ear effusion. High tone sensorineural deafness. Persistent perforation. Extensive scarring of TM, middle ear adhesions & resorption of ossicles ( Adhesive otitis media ).

BULLOUS MYRINGITIS TYPE

TREATMENT: 1. Curative:
Medical :
1. 2. 3. 4. 5. General. Analgesics. Topical. Antibiotics. Decongestants.

Surgical :
1. Myringotomy.

2. 3. 4.

Prophylactic. Treatment of associated conditions. Treatment of complications.

STEPS OF MYRINGOTOMY STAGE 1: BEFORE MYRINGOTOMY 1 STAGE 2: MYRINGOTOME MAKING INCISION STAGE 3: FOLLOWING MYRINGOTOMY PURULENT EXUDATE&BLOOD FLOW INTO EAC 3 4 STAGE 4: ONE MONTH FOLLOWING MYRINGOTOMY 2

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