Acute Suppurative Otitis Media (ASOM) 急性化脓性中耳炎

1. Acute Suppurative Otitis Media(ASOM)急性化脓性中耳炎 Guo Min The department of otorhinolaryngology

2. Key words • Acute急性 • Suppurative化脓性 • Otitis media中耳炎 • Acute Suppurative Otitis Media (ASOM) 急性化脓性中耳炎

3. Mucosa 粘膜 Middle ear中耳 Tympanic membrane(TM) 鼓膜 External acoustic canal外耳道 Eustachian tube咽鼓管 Malleus 锤骨

4. Hyperemia 充血 • Swell , swollen 肿胀 • Obstruction 阻塞 • Ear fullness耳闷 • Earache = ear pain = otalgia 耳痛 • Hearing loss耳聋 • Tinnitus 耳鸣

5. Otoscopy 耳镜检查 • Perforate 穿孔 Perforation • Pus 脓 • Retract 内陷 Retraction • Bulge 膨胀

6. Acute suppurative otitis media (ASOM) Case • A sick and crying boy • Earache • High fever • Caught a cold recently • Tympanic membrane was uniformly red and bulged outwards

8. Definition Acute suppurative otitis media ( ASOM) is an acute infection of the mucosa lining of the middle ear

9. WHY ? It occurs more easily in children and infants in winter and spring afterupper respiratory infection

10. Middle ear – conduct sound to inner ear • Tympanic cavity 鼓室 （ tympanic membrane 鼓膜） • Eustachiantube 咽鼓管 • Tympanicantrum 鼓窦 • Mastoidprocess 乳突

11. A small tube connecting the middle ear to the nasopharynx Eustachian tube

12. Function • Regulate and equalize pressure in middle ear • Prevent fluid from accumulating in middle ear • Protect from the nasopharyngeal infection

13. Regulate and equalize pressure in middle ear Air in the middle ear is absorbed on and on Eustachian tube is the main source of air AIR

14. Prevent fluid from accumulating in middle ear FLUID

15. Protect from the nasopharyngeal infection The mucosa and ciliary movement are helpful in protecting from the nasopharyngeal infection

16. In children and infants, it is shorter, narrower and more horizontal

17. Tympanic membrane It is a common wall between the external canal and the middle ear Function: loud-speaker

18. Tympanic membrane-- a pale grey, transparent membrane

19. Mastoiditis 乳突炎

20. The infectious way External acoustic canal Eustachian tube Blood-born Common organism: pneumococcus, haemolytic streptococcus, haemophilus influenzea, staphylococcus

21. Eustachian tube way • Most important • Because it is the only way that connected the middle ear to the nasopharynx • In some cases organisms staying in nasopharynx can go through this way into the middle ear • upper respiratory infection • acute infectious diseases ( scarlatina 猩红热, measles 麻疹and pertussis 百日咳) • blow nose improperly • swim or dive in dirty water • some improper therapy

22. Why are children and infants easier to infect ASOM? 1. Eustachian tubes are more horizontal , shorter – organism can go into the middle ear more easily narrower and less stiff – easier to blockage 2. The large adenoids (腺样体) can interfere with the opening of the eustachian tube. 3. Children’s immune systems are not fully developed

23. External acoustic meatus way ------ connected with the tympanic membrane perforation ( such as the tympanic membrane trauma, the insertion of tympanostomy tubes, tympanometry, myringotomy)

24. Blood-born rare

25. Pathophysiology&Manifestations

26. Mucosa: hyperemia and swollen Eustachian tube is occluded air fluid Intratympanic pressure Tympanic membrane retracts

27. TM retracts Signs and symptoms • Ear fullness • Tinnitus • Hearing loss • conductive hearing loss • may be unnoticed • Earache • not severe Handle of malleus: more horizontal Corn of light: disappear / broken

28. Tympanic membrane is hyperemia • The vessels become prominent, like the spokes of a wheel • Then the vessels become confluent and the membrane become uniformly red

29. Signs and symptoms • Earache increasing,pulsatile • Hearing loss can be detectable in adults and co-operative children may be overshadowed by earache • Tinnitus • General disturbance fever, loss of appetite for food, vomiting WBC increases

30. This stage is essential: it is the stage at which the disease is most often first seen by a doctor. • If the medical treatment is timely and properly, it can arrest and reverse the inflammation and can prevent suppuration.

31. Pus forms and increases Tympanic membrane is compressed and ischemia • Tympanic membrane: tense and bulges • appears “full”: convex • handle of malleus: vertical or invisible Thrombophlebitis (血栓性静脉炎） Tympanic membrane necroses Small yellow point in the tympanic membrane

32. Signs and symptoms • Earache more severe, preventing sleep. children and infants: cry pounding, pulsatile • General disturbance: worse temperature: over 39℃ obviously ill • Hearing loss and tinnitus

33. TM perforation Signs and symptoms • Pus discharge • Earache: relieved at once • General condition: better Temperature falls WBC decreases • Otoscopy: perforation -- hearing loss disappearance of hyperemia restoration of normal colourand landmarks

34. In some cases, resolution of inflammation without spontaneous perforation in the natural course of a mild infection or under the influence of antibiotics.

35. stage clinic

36. Supplementary investigations • Audiometric testing: • mild – middle level conductive hearing loss • if the cochlea is infected: sensorineural / mixed hearing loss • Blood analysis: WBC increases then decreases

37. History Signs and symptoms DIAGNOSIS Otoscopy Supplementary investigation

38. Differential diagnosis At the stage of eustachian tube occlusion: distinguished from occlusion due to other causes, such as by adenoids, allergic swelling of the lining membrane. history and physical examination are important.

39. Meatal furuncle 外耳道湿疹 Earache no hearing loss Tympanic membrane is normal / slightly red Acute myringitis 急性鼓膜炎 Severe earache Hearing loss is slight Tympanic membrane is hyperemia and bulla forms After influenza or zoster At the stage of suppuration

40. Acute myringitis

41. Treatment • Control infection • Local therapy • Treat related disease

42. Control infection ---- Antibiotics • Arrest and reverse the inflammation • Prevent suppuration and perforation • Relieve symptoms • hasten resolution of the infection • Reduce the chance of complications • Most important

43. If the pus is cultured and for sensitivity studies: the result can direct the therapy If not: (Common organism: pneumococcus, haemolytic streptococcus, haemophilus influenzea, staphylococcus) Recommended drug: penicillin ( 青霉素） and cephalosporin (先锋霉素） Recommended using time: 10days

44. Local therapy Therapies before perforation and after perforation are different! Pay attention !!!

45. Before perforation • Relief earache and control local inflammation 1. phenol glycerine（酚甘油）: drop into ear to relief earache and control inflammation 2. ephedrine and furacilline solution :（麻黄素呋喃西林溶液） drop into nose to improve the function of eustachian tube • Myringotomy （鼓膜切开术）

46. Myringotomy -- a technique of opening the tympanic membrane Indications: • the manifestations are not relieved by antibiotics • tympanic membrane bulges significantly • tympanic membrane perforation is too small to discharge the pus

47. After perforation • Clear pus and external acoustic canal • Control infection 1. antibiotic solution : chloromycetin solution (氯霉素滴耳液） drop into ear to control infection 2. ephedrine and furacilline solution :（麻黄素呋喃西林溶液） drop into nose to improve the function of eustachian tube • Repair the tympanic membrane: is not at once

48. Treat related disease Treat the chronic disease in nose, sinus, pharynx, and nasopharynx: chronic rhinitis( 慢性鼻炎）, chronic sinusitis（慢性鼻窦炎）, chronic tonsillitis （慢性扁桃体炎）and adenoid vegetation（腺样体肥大）.

49. Prevention • Treat the upper respiratory infection • Avoid dirty water flowing into the middle ear • For children and infants: proper breastfeed

50. SUMMARY • Definition • Pathophysiology • Manifestations • Otoscopy • Diagnosis • Principles of treatment