otitis media

1. OTITIS MEDIA Dr. Suchit Roy B.R Assistant Professor of ENT Medical College, Thiruvananthapuram

3. Acute Otitis Media Acute infection of middle ear cleft with presence of middle ear effusion and signs of middle ear inflammation: AAP Recurrent otitis media is defined as 3 or more episodes in 6 months or 4 or more in a year

4. Predisposing causes Mainly in children -40% of children <10 years, (peak 3 yrs) Males sex Adenoids Rhinitis/sinusitis Nasal allergy Cleft palate Winter months

5. Predisposing causes (contd.) Organisms in children Viruses Haemophilus influenzae Moraxella catarrhalis Streptococcus pneumoniae Streptococcus pyogenses Staphlococcus aureus Organisms in neonates Eschericia coli

6. Predisposing causes (contd.) Organisms in adults Streptococcus pneumoniae Streptococcus pyogenses Organisms in Immunosuppressed Usual organisms Pseudomonas, P.carinil, M.tuberculosis, Nocardia asteroides, Candida

7. Clinical features Stage of hyperaemia Symptoms Earache fullness Fever Hearing loss (mild) Incessant cry & rubbing of ears in infants Signs Loss of luster Injection of blood vessels (cartwheel)

8. Clinical features Stage of exudation Symptoms High degree pain High fever Vomiting /convulsions/meningism in infants Marked hearing impairment Signs -Red thick bulging drum -Post-aural hyperaemial & oedema in infants -X-ray: clouding of air cells

9. Clinical features Stage of suppuration Symptoms Decreased pain Decreased fever Increased hearing loss Signs Perforation with discharge-mucopus Mastoid signs disappear X-ray: Fluid levels in cells/walls intact

10. Clinical features Stage of coalescence Symptoms Pain recurs (more at night) Fever (low grade) Discharge (mucoid to purulent) Signs Mastoid tenderness (mild) X-Ray: Clouding with destruction of cell walls

11. Clinical features Stage of complications Mastoid abscess Facial nerve palsy Labyrinthitis Extra/sub dural abscess Meningitis Brain abscess Lateral sinus thrombophlebitis Petrositis

12. Clinical features Stage of resolution Discharge subsides Perforation heals soon Hearing loss recovers last

13. Differential Diagnosis Furuncle or diffuse otitis externa Post auricular adenitis Referred otalgia (e.g,from teeth) Herpetic lesion of ear Bullous myringitis

14. Treatment 80% will resolve within 3 days without treatment, 95% in 5 days Antibiotics may improve short term symptoms, although evidence for evidence for any gain in medium to long term outcome is lacking Countries with lower rates of antibiotic prescribing for acute otitis media do not have an increase in the number of complications

15. Treatment No antibiotic if no fever; analgesic and reassurance Amoxycillin 30-40mg/kg/d 3DDx10d Amoxycillin clavulanate Cefacior 30 mg/kg/d 2DDx10d Cefuroxime 30mg/kg/d 2DDx10d Clarithromycin 15mg/kg/d 2DDx10d Azithromycin 10mg/kg OD x 5d,5mg/kg ODx5d Cotrimoxazole 10mg/kg/d 2DDx10d (Trimetho)

16. Treatment Simple analgesia Paracetamol Ibuprofen(some evidence superior) Antihistamine & decongestant?? Aural toilet Culture & sensitivity Myringotomy Bulging drum Facial palsy Incomplete resolution

17. Recurrent otitis Eliminate cause Long term low dose antibiotics Amoxycillin/cotrimoxazole Myringotomy +grommet Adenoldectomy Treat allergy Pneumococcal vaccine

18. When to refer? Persistence/reappearance of pain Persistence/reappearance of discharge Persistent fever Symptoms 7 signs of complications Vertigo/Nystagmus/Ataxia Facial palsy/diplopia Headache, vomiting, drowsiness Abscess behind ear/in neck

19. Preventive measures Breast feeding Eliminate cigarette smoking in the household Blowing up balloons is effective in some small children

20. Acute Necrotising Otitis Media Infants & young children Follows measles, influenza, pneumonia ?-haemolytic streptococci Otorrhoea without pain Foul smelling discharge Sensorineural deafness Large perforation?CSOM

21. Otitis media with effusion Causes ET obstruction Adenoids Chronic rhinitis/sinusitis Tumours of nasopharynx Palatal defects Allergy Unresolved otitis

22. OME Clinical features Symptoms Hearing loss Delayed speech & development Backwardness in school Signs Retracted TM Fluid/air bubbles Conductive hearing loss B type tympanogram

23. OME Treatment Treat cause Anti allergic Mucolytics Antibiotics Ventilation tubes

24. Tuberculous otitis Rare In tuberculosis patients Through infected milk Immunosupressed Painless, thin, scanty, odourless discharge Multiple perforations Pale granulations Hearing loss out of proportion to symptoms Facial palsy

25. Chronic Suppurative Otitis Media (CSOM) Long standing infection of middle ear cleft with ear discharge and permanent perforation Two types Tubo-tympanic Attico antral

26. CSOM Types

27. CSOM Investigations Culture & sensitivity Pseudomonas, Proteus, E.coil, Staph aureus Bacteroids, Streptococci Pure-tone audiometry X-Ray mastoids CT Scan is suspected complications Examination under microscope

28. CSOM-TTD Treatment Aural toilet Ear drops plain or with steroids Ciprofloxacin Ofloxacin Gentamicin Systemic antibiotics Precautions Treat contributing factors Surgery-tympanoplasty+mastoidectomy

29. CSOM-AAD Treatment Surgery Modified radical mastoidectomy+ tympanoplasty Conservative only in select cases

30. When to refer? Persistence of discharge in TTDs All AADs real or suspected Symptoms & sign of complications Vertigo/Nystagmus/Ataxia Facial palsy/Diplopia Fever, headache, vomiting, drowsiness Abscess behind ear/in neck

31. LABYRINTHITIS Common condition caused by biochemical toxins or bacteria or virus damaging the vestibular labyrinth TREATMENT: Treatment of inner ear complications Treatment of primary disease antibiotics

32. VESTIBULOTOXIC DRUGS Certain drugs damaged outer hair cells Amino glycosides Antihypertensive Oestrogen preparations Diuretics Antimalarials etc

33. HEAD TRAUMA Head injury cause concussion of labyrinth, disrupt bony labyrinth or 8th nerve Severe acoustic trauma like explosion also cause vertigo

34. ACOCUSTIC NEUROMA Tumor from vestibular nerve Vertigo comes late due to adaptation Other neurological findings may be there

35. CENTRAL VERTIGO Vertebrobasilar insufficiency Posterior inferior Cerebellar Artery Syndrome Basilar Migraine Cerebellar disease Multiple sclerosis Tumours of brainstem and IV the ventricle Epilepsy

36. Treatment Specific-Treatment of cause Symptomatic-Suppress vertigo, antiemetics, Betahistine Rehabilitative-Specific exercise