ACUTE OTITIS MEDIADr. Ajay ManickamJUNIOR RESIDENTRG KAR MEDICAL COLLEGE HOSPITAL

Acute otitis media• Acute inflammation of the muco periosteal layer of the middle ear cleft

• Inflammation typically occur in <6 weeks

• 60%-70% of children have >1 episode before 1st birthday

• Early onset <6 months is associated with recurrent AOM and chronic OME

Routes of infection • 1. Via Eustachian Tube - most common -inf. travels via

lumen of tube peritubal lymphatic's • 2. Via External Ear traumatic perforation of tympanic

membrane• 3. Blood Borne -uncommon

Predisposing factors• Recurrent common cold, URTI, exanthematous fevers

(like measles, diphtheria, whooping cough) • Infection of tonsils & adenoids • Chronic rhinitis & sinusitis • Nasal allergy • Tumours of nasopharynx • Cleft palate 

Eustachian tube & AOM• In children ET is at an angle of 10° while in adults it is at an angle of 45°.

• ISTHMUS is a narrowing in the ET, at the junction of the cartilaginous and bony part.

• It is only present in adults.

Infectious organisms• Streptococcus pneumonia (30%)• Haemophilus influenzae (20%)• Moraxella catarrhalis (12%)• Others: Streptococcus pyogenes,

Staphylococcus aureus and Pseudomonas • Fungal less common – aspergillus & candida• Bacterial otitis media from super infection of viral also

possible

Pathophysiology

Stage of tubal occlusion/ hyperemic

Stage of presuppuration

/ exudative

Stage of suppuration

Stage of resolution /

complication

Stage of tubal occlusion

• SYMPTOMS : Deafness Ear ache • SIGNS : Retraction of the TM. Loss of cone of light. Tuning Fork Test - conductive

deafness

Mucosa: Hyperemia, Swelling

Eustachian tube is occluded

Intratympanic pressure ↓

Air ↓ fluid ↑

Tympanic membrane retracts

Otoscopy – Stage 1

•TM retracted•Foreshortened handle of malleus

•No cone of light•Prominent lateral process of malleus

Stage of pre suppuration

• SYMPTOMS : Marked ear-ache(throbbing nature) Deafness & tinnitus High degree fever & restlessness

• SIGNS : Congested pars tensa Cart Wheel appearance of T.M Tuning fork test conductive loss 

Bacteria invade tympanic cavity

Hyperemia

Inflammatory exudate

Congested TM

Otoscopy - Stage 2

•Cart wheel appearance of the TM

•No cone of light

Stage of suppuration

• Symptoms - EXCRUCIATING PAIN, Deafness, Fever 102-103°F, Vomiting, Convulsions

•  Signs - T.M appears red & bulging Yellow spot on T.M, Tenderness over mastoid antrum, X-ray mastoid - clouding of air cells

Pus increases

TM is compressed, ischemic

TM is tense and bulges

TM necrosis

Signs – Stage 3• Bulging out tympanic membrane • Loss of anatomical land marks

Clouding of mastoid aircells

Stage of resolution •  Pathology - T.M ruptures,

releases pus, symptoms subside & resolution starts, Mild infection/Early antibiotics resolution no rupture of TM

• Symptoms - Ear-ache relieved, Fever comes down

• Signs - EAC contain blood-tinged discharge or mucopurulent, Small perforation of T.M

Complication • Highly virulent organisms/ low immunity disease spreads

beyond middle ear resulting in • Acute mastoiditis • Sub periosteal abscess • Facial paralysis • Labyrinthitis • Petrostitis • Meningitis • Brain abscess

Medical Management

1. Systemic Antibiotic

2. Nasal decongestants (systemic + topical)

3. H1 anti-histamines

4. Analgesic + anti-pyretic

5. Aural toilet for ear discharge

6. Hot fomentation for severe earache

7. Review after 48 hours

48 hours review• Earache + fever persists: change to higher antibiotic.• If T.M. is bulging perform myringotomy. Send ear

discharge for C/S.• Earache + fever subside: continue same treatment for

10-14 days• Review after 3 months• No effusion: no further treatment• Effusion persists: treat as Otitis Media with Effusion• Presence of abscess or coalescent mastoiditis: do cortical

mastoidectomy

Myringotomy • INDICATIONS :• Symptoms are not relieved by antibiotics• TM bulges significantly• TM perforation is too small• Incomplete resolution• Persistent effusion beyond 12 weeks

Myringotomy • Myringotomy is a surgical procedure in which a tiny incision is created in the eardrum to relieve pressure caused by fluid or to drain pus from the middle ear.

Underlying predisposing factor• Chronic rhinitis• Chronic sinusitis• Chronic tonsillitis• Chronic adenoiditis