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Acute Suppurative Otitis Media

Acute Suppurative Otitis Media. Dr. Vishal Sharma. Definition. Pyogenic infection of middle ear cleft lasting for < 3 weeks. Routes for infection: Via Eustachian tube Via Tympanic membrane perforation Haematogenous (rare). Predisposing Factors. 1. Breast feeding in supine position

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Acute Suppurative Otitis Media

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  1. Acute Suppurative Otitis Media Dr. Vishal Sharma

  2. Definition Pyogenic infection of middle ear cleft lasting for < 3 weeks. Routes for infection: • Via Eustachian tube • Via Tympanic membrane perforation • Haematogenous (rare)

  3. Predisposing Factors 1. Breast feeding in supine position 2. Recurrent upper respiratory tract infection 3. Nasal allergy 4. Chronic rhinitis & sinusitis 5. Tumours of nose & nasopharynx 6. Exposure to cigarette smoke 7. Cleft palate

  4. Bacteriology • Haemophilus influenzae • Streptococcus pneumoniae • Staphylococcus aureus • Moraxella catarrhalis •  - Hemolytic streptococci (causes acute necrotizing otitis media)

  5. Stages of A.S.O.M.

  6. 1. Stage of Hyperaemia • Synonym: Stage of tubal occlusion • Mild earache • T.M. retracted in early stage • T.M. congested later stage • Cartwheel appearance: radiating blood vessels from handle of malleus

  7. Cart wheel appearance

  8. 2. Stage of Exudation • High fever • Severe earache • Deafness • Marked congestion + bulging of T.M. • Mastoid tenderness • P.T.A.: high frequency conductive deafness due to mass effect of pus

  9. Stage of Exudation

  10. Stage of Exudation

  11. Stage of Exudation

  12. Stage of Exudation

  13. Nipple sign (impending perforation) Localized protrusion of tympanic membrane due to destruction of fibrous layer by continuous pressure of pus

  14. 3. Stage of Suppuration Symptoms: • Ear discharge (blood-stained  purulent) • Increased deafness • Decreased fever • Decreased earache

  15. Blood stained otorrhoea

  16. Signs & Investigations • Pinhole perforation + otorrhoea • Light house sign: intermittent reflection of light • Decreased mastoid tenderness • High (mass effect) + low frequency (stiffness effect of thick periosteum) Conductive deafness • Clouding of air cells in mastoid X-ray

  17. Light House sign

  18. Pinhole perforation

  19. Clouding of mastoid cells

  20. 4. Stage of Coalescent Mastoiditis • Otorrhoea > 2 weeks, otalgia & deafness • Mastoid reservoir sign: pus fills up on mopping • Sagging of postero-superior canal wallcaused by peri-osteitis due to pus in adjacent mastoid antrum • Ironed out appearanceof skin over mastoid due to thickened periosteum • Mastoid cavity in X-ray & CT scan

  21. Pathogenesis Aditus Blockage  Failure of drainage  Stasis of secretions  Hyperemic decalcification  Resorption of bony septa of air cells  Coalescence of small air cells to form cavity  Empyema of mastoid cavity

  22. Pathogenesis

  23. Mastoid reservoir sign

  24. Sagging of posterior wall

  25. Ironed out appearance

  26. Mastoid cavity

  27. Mastoid cavity

  28. 5. Stage of Resolution • Otorrhoea stops • Normal hearing • Healed perforation

  29. Stage of Resolution

  30. Sterile exudate in middle ear

  31. 6. Stage of Complications • Sub-periosteal abscess • Vertigo • Headache + blurred vision + projectile vomiting • Fever + neck rigidity + irritability • Drowsiness • Gradenigo syndrome (apex petrositis)

  32. Treatment of A.S.O.M. • Systemic Antibiotic • Nasal decongestants (systemic + topical) • H1 anti-histamines • Analgesic + anti-pyretic • Aural toilet for ear discharge • Heat application for severe earache • Review after 48 hours

  33. Amoxicillin-clavulanate duo: 625 mg B.D. Ciprofloxacin: 500mg B.D. Doxycycline: 100 mg B.D. Cefadroxil: 500 mg B.D. Cefaclor: 500 mg T.I.D. Cefuroxime: 250 mg B.D. Cefixime: 200 mg B.D. Cefpodoxime: 200 mg B.D. Azithromycin: 500 mg O.D. Clarithromycin: 250 mg B.D.

  34. Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD Loratidine: 10 mg OD Levocetrizine: 5 mg OD Desloratidine: 5 mg OD Topical:Azelastine spray (0.1%): 1-2 puff BD

  35. Nasal Decongestants Systemic decongestants  Phenylephrine  Pseudoephedrine Topical decongestants  Xylometazoline  Oxymetazoline  Saline

  36. Anti-cold preparations PsE = Pseudoephedrine; PhE = Phenylephrine

  37. Topical Decongestants • Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION) • Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P) • Xylometazoline 0.1 %: 3 drops TID (OTRIVIN) • Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P) • Saline 2 %: 3 drops TID • Saline 0.67 %: 2 drops BD (NASIVION-S)

  38. On review after 48 hours • 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

  39. On 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

  40. Myringotomy in A.S.O.M. Curvilinear incision made in postero-inferior quadrant. Incision is curvilinear & not radial (as in OME), to cut fibres of TM. This keeps opening patent for long time.

  41. Why make incision in PIQ?  Least vascular area  T.M. bulge is maximum  Ossicles not damaged  Easily accessible

  42. Sub-periosteal abscess & fistula

  43. Pathology Production of pus under tension  hyperaemic decalcification (halisteresis) + osteoclastic resorption of bone  sub-periosteal abscess  penetration of periosteum + skin  fistula formation

  44. Sub-periosteal abscess formation

  45. Sub-periosteal fistula: dry

  46. Sub-periosteal fistula: wet

  47. Types of sub-periosteal abscess • Post-auricular • Bezold • Citelli • Zygomatic • Luc • Retro-mastoid • Parapharyngeal & Retropharyngeal

  48. Types of sub-periosteal abscess

  49. Post-auricular abscess Commonest. Present behind the ear. Pinna pushed forward & downward.

  50. Bezold & Citelli abscesses Bezold: neck swelling over sternocleido- mastoid muscle Citelli:neck swelling over posterior belly of digastric muscle

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