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Otitis media(OM)
Acute suppurative otitis media(ASOM)
Def : it is an acute inflammatory reaction of mucosal
lining of middle ear cleft the type of this reaction
and its progress to become suppurative depend on :
Ø
Virulence of M.O invading the cleft.
Ø
Resistance of patients, age of patients.
Ø
Drainage mechanism of cleft, pneumatization .
Ø
AB therapy.
Aetiology
1.rhinosinusitis .
2.nasophyrngitis.
3.tonsillitis.
4.influenza and acute infectious diseases.
5.nasopharyngeal tumor.
6.traumatic perforation of TM.
7.operation on nose & throat.
Bacteriology
1.haemolytic streptococcus.
2.stre. pneumoniea.
3.staph. aureous.
4.H. influenzae.
Histopathology
The accepted sequel of events in ASOM is the
deposit of causal MO at the nasopharyngeal end of
Eustachian tube followed by spread of inflammation
throughout the cleft , the progress sometime vary
rapid so need only one night from the onset till
perforation of TM and pus discharge.
The 1
st
effect of tubal infection is the inflammation
and occlusion of the tube, air in the middle ear
absorbed and not replaced so exudation lead to
collection of fluid(effusion) and that is good culture
for growth of M.O =lead to suppuration then
resolution with or without perforation of TM.
There are 4 stages: according to otoscopic finding:
1.tubal occlusion : retraction of tymp. Mem. Due to
air absorption and –ve pressure , effusion may be
present but undetectable .
2.hyperaemic stage (presuppuration stage):
Hyperemia of tympanic vessels or diffuse hyperemic
membrane ,at this stage serous exudates is present.
3.suppuration :
Gross engorgement of TM, bulging of TM
deterioration in patient general condition
appearance of yellow area on the TM which is the
site of perforation as follow .
4.resolution : return to normal if there is no
perforation .
If there is perforation the discharge
decrease till it is cease.
Clinical picture:
1. stage of tubal occlusion =
1) Deafness conductive type so the patient hear
own voice sound loud in the affected ear .
Otoscopy show retracted TM lead to horizontal
displacement of handle of malleus ,loss of cone
of light , prominence of lateral process of
maleus ,sometime fluid level with air bubbles.
2)slight pain or discomfort.
2.Stage of hyperemia (presuppuration):
1)increasing ear ache , deafness & tinnitus.
2)Increase temp. , PR, loss of appetite & vomiting
so its stage of visit to Dr. & there is indication of
medical treatment to prevent suppuration.
3. Stage of suppuration :
previous symptoms become worse & the patient
will obviously ill.
4.Stage of resolution :
1)without perforation the symptoms relief .
2)with perforation the pus discharge decrease
with the time & symp. Relief.
Differential diagnosis
i. Allergy
ii. Viral infection
iii. Adenoid hypertrophy
iv. Barotraumas
v. Glomus tumor
vi. Otitis externa haemrrohgica
vii. H. zoster infection
viii. Furunclosis of external ear.
Treatment of (ASOM):
The treatment depend on the stage reached by the
infection.
1)stage of tubal occlusion treated by
a. Local decongestants combined by swallowing
& yawing or(valsalva maneuver) ,the nasal
drop as 1% ephedrine hydrochloride.
b. Analgesia as paracetamol , no need for AB in
this stage.
2)stage of hyperemia or(presuppuration):
i. Nasal drop
ii. Analgesia
iii. Antibiotic as amoxicillin started with IM
injection followed by oral administration of
250 mg/8 hr’s for 5 days ,if patient sensitive to
penicillin erythromycin used.
If there is no response to the previous AB we
can use cephalosporin (claforan)
3.stage of suppuration : over using of previous
treatment there is place of surgery as myringotomy
to drainage of middle ear cavity pus.
i. When there is no response to previous medical
treatment.
ii. Bulging of TM.
iii. Delayed in resolution.
4.stage of resolution : treated when there is:
i. Continual drainage of pus.
ii. Retention of effusion .
iii. Persistent mucosal engorgement with
earache & deafness.
All these criteria of non resolution so in case of
continual otorrhaea more than 10 days treated by :
a) Second course of AB after culture and
sensetivity test.
b) When there is inadequate drainage (pin hole)
perforation myringotomy is indicated .
c) When there is x-ray finding of mastoid reservoir
(cortical mastoidectomy indicated).
In case of retention of effusion : treated by 2
nd
&
3
rd
course of AB & medical support then
myringotomy if need.
Same treatment use in case of persistent mucosal
engorgement.