Acute otitis media and mastoiditis

1. Acute otitis media and mastoiditis Chunfu Dai M.D & Ph.D Otolaryngology Department Fudan Univeristy

2. Definition • AOM: is an infectious process of the middle ear cleft and to a variable extent, of the mastoid air cell system.

3. Bacteriology • Streptococcus pneumoniae (48%) • Haemophilus influenzae (31%) • Moraxella catarrhalis (20%) • P-hemolytic streptococcus (decreased following widespread immunization program) • Pseudomonas aeruginosa (uncommon cause of AOM)

4. 阻断细菌耐药性的“恶性循环” 感染 合 理 治 疗 临 床 治 愈 细 菌 消 除 不合理治疗 耐药性增加 传播 细菌 未消除 选择 耐药菌

5. 青霉素耐药的肺炎链球菌 79－98年在美国流行情况 50 % Penicillin Resistance 40 33% 中度敏感 (0.12 - 1.0 µg/ml) 耐药 ( 2.0 µg/ml) 29% 30 20 18% 10 16% 0 1984 1979 1980 1981 1982 1983 1985 1986 1987 1997 1998 1992-93 1990-91 1988-89 1994-95 (Doern. Am J Med. 1995;99(6B): 3S-7S; Jacobs et al., AAC 1999:43:1901; Jacobs et al abstract C-61, ICAAC 1999)

6. Routine of infection • Via eustachian tube • upper respiratory infection (acute rhinonitis and nasal pharyngitis) • Upper respiratory communicative disease (diaphea, mealse, et al) • Swimming and dive in unclear water • Anatomic contribution (Eustachian tube in infant is wide and short and the two orifice in the same level)

7. Routine of infection • Via external acoustic canal and TM • Perforation • Myringotomy or myrigotosis • Via blood supply

8. Pathology • Mucosal inflammation • Serous, hemorrhagic, or purulent exudate in middle cavity • Rupture of tympanic membrane

9. Symptoms • Fever • It may be masked by analgesics or antibiotic • Otalgia • 60% patients can spontaneous remission • Fullness • Hearing loss

10. Physical findings • Increased vascularization of the TM, initially located in pars of flaccida, frequently spreading beyond the annulus to the skin of the external canal. • Bony landmarks are visible.

11. Cholesteatoma Formation

12. Physical findings • Rapid middle ear exudation occurs, • Blurring of the mallwall short process, followed by edema and bulging of the pars flaccida.

13. Physical findings • The progression of this disease may result in rupture of TM, releasing the middle ear contents (beating sign) leads to relief of otalgia and retraction of the pars flaccida

14. Lab tests • Blood counts usually shows leukocytosis with polymorphonuclear elevation. • CT and MRI is necessary only for the rare patients with a serious complication (meningitis or brain abscess)

15. Hearing tests • Conductive hearing loss • Degree of hearing loss will depend on the amount and viscosity of the middle ear exudate, TM edema • It vary from 10-50 dB with predominant involvement of the low frequencies • Hearing loss may mixed when there is labyrinthine extension.

16. Managements • Antibiotic therapy • Experiences • Antibiotic sensitivity and bacteriologic culture • Traditional duration 10-14 d • Currently duration 5-7 d

17. Managements • Nasal decongestants • Best rest, light diet • Avoidance of irritants (smoking)

18. Managements • Pre-perforation • Pain relief drugs • Surgery: myringotomy • Progression with a red, bulging TM, severe otalgia and fever • Otitis media with impending complications • perforation is not big enough to drain all pus

19. Managements • Post-proferation: • Clear-up pus with 3% hydro-oxygen • Antibiotic ear drops • With pus decreased and inflammation disappeared, alcohol can be used to facilitate dry ear.

20. Follow-up • Adequately treated AOM effusion may persist for 2-6 weeks or even longer. • Managements may require • extended antibiotic treatment • Otoscope and audiometric tests should be performed 3-4 weeks following apparent resolution of the acute infection • Insertion of pressure equalization tubes due to fluid persists beyond 3 months

21. Acute mastoiditis • Definition: an infection of the mastoid characterized by diffuse osteitis followed by rarefaction and breakdown of the bony septae. • Acute coalescent mastoiditis • Haemorrhagic mastoiditis • Masked mastoiditis • Predisposition to pneumatic mastoid • Predilection to kid • Mastoid is mature at age of 4 year old

22. Acute mastoiditis • Reduction of immune system • Strong bacteria (type III pneumococus, haemolytic streptococcus) • Obstruction- not effective drainage • Imcompletely treatment

23. Acute mastoiditis • Symptoms • Symptoms may follow AOM, with or without a symptom-free interval of a few days to several weeks or more. • Otalgia • Aural discharge • Conductive hearing loss • fever

24. Acute mastoiditis • Physical findings • Fever, from a slight elevation to 39 • Otorrhea may be absent • Pulsatile may be observed • Tympanic perforation is present, but it may be obscured by intense edema • Swelling of the superior TM and posterosuperior wall of EAC • Postauricular area • erythema and tenderness • Pitting edema • Obliteration of the postauricular crease

25. Acute mastoiditis • Radiographic evaluation • Diffuse rarefaction of bone and breakdown of cellular sepae

26. Acute mastoiditis • interventions • Medical management • Antibiotic • Intravenous antibiotic therapy should be maintained for at least 24-48 h after the resolution of symptoms • Then followed with oral antibiotic for 2 weeks • Surgical management • Emergency surgery: simple mastoidectomy • Mastoidectomy + ventilation tube placement