Otitis media

Terminology
Otitis Media: inflammation of the middle ear cleft or mucosa. Acute Less than 6 weeks Chronic More than 6 weeks Recurrent acute otitis media 3 episodes/6 months or 4 or more episodes/1 year Otitis media with effusion: fluid in the middle ear without signs or symptoms of infection.

Middle ear cleft contains: 1. Middle ear cavity 2. Eustachian tube 3. Mastoid antrum 4. Mastoid air cells 5. Aditus 6. Atic

Acute Otitis Media

Its acute Short lived inflammation of the middle ear cavity It occurs most commonly in children Most commonly follows an acute URTI. Etiology: Viruses: Rhinovirus, Adenovirus, Influenza virus, Parainfluenza virus & RSV. Bacterial: Strep.pneumonia (35%), H.influenza (25%), Moraxilla (15%). Group.A.Strep& Staph. Aureusmay also be responsible.

Epidemiology: The most frequent diagnosis made by pediatricians Second only to the common cold. 2/3 of all American children have had at least 1 episode of AOM prior to 1 year of age 80% have had one by 3 years of age AOM is the most common indication for antimicrobial therapy in children in the United States. Clinicians often overdiagnose acute otitis media.

Predisposing factors
1. Age (chilidren) Low immunity More horizontal eustachian tube Feeding in supine position 2. Winter (URTIs) 3. White race 4. Eustachian tube malformations

Sx & Sx
Symptoms: Otalgia: may be slight in a mild case, but more usually throbbing and severe. Deafness: usually conductive and may be associated with tinnitus. Otorrhea: mucoid ear discharge which means a perforation. Signs: Pyrexia (temp may rise up to 40) Tenderness over the mastoid process Tympanic membrane changes (red, full, injected, bulged outward & with break up of its light reflex) Discharge

Stages
1. Microorg invades the mucous membrane leading to inflammation, edema, exudates & pus. 2. oedema closes & Obstuct of the Eustachian tube prevention of aeration & drainage -ve pressure in the middle ear tympanic membrane retraction. 3. Transudation pressure inc. tympanic membrane will bulge. 4. Necrosis of the tympanic membrane perforation. 5. The ear will continue to drain until the infection resolves.

DDx
Otitis Media With Effusion Otitis Externa Labyrinthitis URTIs Pharyngitis Sinusitis Foreign Bodies Herpes Zoster Oticus Dental pain Dysbarism

Diagnosis
1. Clinical 2. Laboratory Studies No definitive laboratory examination Sample of the effusion should be sent for culture and sensitivity by Tympanocentesis. 3. Imaging Studies Not valuable for diagnosis Radiography and/or CT scanning of the mastoid air cells may be helpful in select cases of suspected mastoiditis.

Treatment According to the stage

1. The early stage (pre-perforation): Antibiotics:Penicillin remains the drug of choice in most cases, and ideally should be given initially by injection followed by oral medication. -Amoxycillin more effective if H.influenza is suspected -Co-amoxiclav is useful in Moraxella infections Analgesic Myringotomy (if still bulgingdespite adequate antibiotic therapy), under general anesthesia to drain the pus & send a sample for sensitivity testing. Ear drops are of no value in AOM with intact membrane.

2. The discharge stage (perforation): Antibiotic treatment, send a sample for the sensitivity testing once the result come change according to the new microorganism. The majority of pts improve and the tympanic membrane heal with a scar within a week.

Some pts may develop sequels: Persistent perforation Otitis media with effusion Tympanosclerosis (fibrosis of tympanic membrane and osicles).

Otitis media with effusion (OME)

Accumulation of fluid in the middle ear Following an episode of Otitis media It is not necessary to have a prior episode of acute OM. Middle ear effusion short-lived & resolves completely no need for treatment. OME / glue ear fluid persists with an intact ear drum (no perforation) 3 months or more. Affects most children at one time or another in up to 1/3 Persist for 3 months or more Commoner in winter & small children Cause significant deafness if left untreated May result in permanent middle-ear changes.

Etiology
1. AOM (most imp) 2. Nasopharyngeal obstruction, e.g. large adenoids or tumour resulting in Eustachian tube dysfunction.The condition may be associated with recurrent attacks of acute otitis mediaAdenoid 3. Allergic rhinitis 4. Cleft palate 5. Passive smoker 6. Otitic barotraumamost commonly caused by descent in an aircraft,especially if the subject has a cold. Failure of middle-ear ventilation results in middle-ear effusion, sometimes blood-stained. Also occurs in scubadivers.

Symptoms: 1. Conductive deafness 2. Discomfort but not pain 3. Sometimes tinnitus. Signs: 1. Otoscope: Dull yellow fluid behind the ear drum 2. Audiogram: flat curve

Management
Improve spontaneously(Many cases will resolve

spontaneously, and the child should usually be observed for 3 months before embarking on surgery)
Treat predisposing condition (allergic rhinitis or cleft palate) Myringostomy & grommet tube Puncture of the drum Aspiration of the fluid Insertion of a small tube (grommet) in the eardrum done under general anesthesia.

The function of the grommet is to ventilate the middle ear and not to drain the fluid

OME in adults
My follow URTI Otitic barotraumaSudden change in pressure (deep sea diving or a rapid descent from an aircraft). Improvement is spontaneous & gradual my take up to 6wks. Rarely a presentation of nasopharyngeal malignancy.

Chronic otitis media

Inflammation of the middle ear Lasts for more than 6 weeks. Usually preceded by Acute otitis media Viral URTI Age 3-6 y.

Causes & predisposing factors

Late treatment of acute otitis media. Inadequate or inappropriate antibiotic treatment of AOM URTI Lowered Resistance (malnutrition & anemia ,immunological impairment.) Eustachian tube deformity Cleft palate

Symptoms Conductive deafness Vertigo Tinnitus Ear discharge Etiologies P. aerugenosa Proteus E.coli H. influenza

There are two major types of CSOM.

1-Mucosal disease with tympanic membrane perforation (tubo-tympanic disease, relatively safe). 2 Bony dangerous (attico-antral disease).

Serous OME
Enlarged adenoid is most common cause in children Stages: 1. URTI or acute otitis media Fluid collection in middle ear & obstruction of eutachian tube tympanic membrane retraction. 2. Fluid become pus and glue like conductive hearing impairment & pain necrosis tympanic membrane perforation. 3. Could end up with mastoiditis (if untreated) Management 1. Systemic decongestants 2. Nasal drops 3. Myringotomy (if the above 2 failed), tiny incision done in the ear drum to relief pressure and drain pus.

Tubo-tympanic otitis media (Safe type)

Acute otitis media permanent perforation muco-purulent discharge. Infection is limited to the mucosa (ant. Inf.) Not have any risk of bone erosion Central perforation Management 1. Clean the ear by syringing or hydrogen peroxide. 2. Local antibiotic (when the ear is totally clean and dry) 3. Surgery (if medical treatment failed) Myringoplasty: repair of tympanic membrane perforation & ossicles are intact (most used graft is autologous temporalis fascia) Tympanoplasty: repair of tympanic membrane & ossicles.

Perforation

Atico-antral chronic otitis media (unsafe type)

Life threatening (intra & extra cranial complications) spreads by bone erosion (mastoid, tympanic ring, ossicles ) Perforation is posterio-superior Discharge is usually persistent and often foul smelling. There is granulation due to osteitis. Aural polyps formed by granulation tissues Associated with chlesteatoma: Management: Regular aural toilet in early cases of annular osteitis may be adequate to prevent progression. Surgical removal of cholestetoma Mastoidectomy for mastoiditis

Cholesteatoma
Skin in wrong place Epithelial cells collection in the middle ear cleft Produces mass effect on the structures their Managed by surgical removal Theories of bone erosions: 1. Pressure theory 2. Enzymatic theory (acid phosphatase, collagenase &other proteolytic enzymes) 3. Pyogenic osteitis (Pyogneic bacteria may release enzymes)

Complications of OM

 Rare High morbidity & mortality Depend on: Causative MO Antimicrobial therapy Host resistance Anatomic barriers Available drainage Most occur in subacute or chronic OM In young children & meningitis occur in AOM Classified: Extracranial (intratemporal) Intracranial both in 50%

Extracranial Mastoiditis Petrositis Labyrinthitis Facial paralysis Adhesive OM Tympanosclerosis Ossicular dyscontinuity and fixation

Intracranial Meningitis Extradural abscess Subdural abscess Brain abscess Lateral sinus thrombosis Otitic hydrocephalus Focal encephalitis

 Extension of acute otitis media into the mastoid air cells with suppuration and bone necrosis. Symptoms: 1. Pain, persistent and throbbing. 2. Otorrhea, creamy and profuse. 3. Increasing deafness. Sings: 1. Pyrexia 2. Tenderness is marked over the mastoid antrum 3. Postauricular region swelling pinna is pushed downward & forward 4. The tympanic membrane is either Perforated and discharging Red and bulging Normal tympanic membrane no mastoiditis 5. Sagging of the meatal roof or posterior wall (weaker)

Investigation: 1. WBC count (raised neutrophil count) 2. CT scanning (opacity and air cells coalescence)

Treatment: 1. Admit the pt. 2. Start antibiotics with amoxicillin & metronidazole, then according to the sensitivity test 3. Cortical mastoidectomy only 1. Subperiosteal abscess (Bezolds abscess) 2. No response to antibiotics

mastoiditis

Bezolds abscess

Abscess in the sternocleidomastoid muscle Pus from a mastoiditis escapes into the sternocleidomastoid Rare complication of acute otitis media

 Very rarely The infection may spread to the petrous apex and involve the 6th CN. Clinical features: Mastoiditis + retroorpital pain + abducent nerve paralysis 1. Evidence of middle ear infection (discharge). 2. Diplopia (affection of lateral rectus muscle) 3. Trigeminal neuralgia (affection of 5th CN) Treatment: 1. Antibitics 2. Mastoidectomy with drainage of apical cells

Gradenigo s.

 Cholestetoma erosion fistula labyrinth infection Clinical features: 1. Vertigo 2. Nausea and vomiting 3. Nystagmus towards the opposite side 4. Profound sensorineural deafness in purulent labyrinthitis 5. Positive fistula sign (press on the tragus vertigo) Treatment: 1. Antibiotic 2. Mastoidectomy for chronic ear disease 3. Occasionally labyrinth drainage

 Can result from both acute & chronic otitis media In early stages the patient may complain of dribbling from the corners of the mouth Treatment: Antibiotics for acute otitis media full recovery should be expected by. Mastoidectomy for CSOM is mandatory with clearance of disease from around the facial nerve.

Clinical features: 1. The patient is unwell 2. Pyrexia 3. Neck rigidity 4. Positive kernig sign 5. Photophobia 6. CSF is essential unless there is increase ICP: a. Often cloudy b. Pressure raised c. WBCs raised d. Proteins raised e. Glucose lowered f. Chloride lowered g. Organisms present on culture and gram stain Treatment: Do not start antibiotic until CSF results has been obtained for culture & diagnosis Then start penicillin parenterally & intrathecally.

Features of mastoiditis are present and often accentuated. Sever pain is common. Treatment: Antibiotics Mastoid surgery is essential to treat the ear disease and drain the abscess.

May occur in the cerebellum or temporal lobe. The infection may spread directly to the brain via the bone & meninges or via blood vessels. Effects of abscess: 1. Systemic effects (malaise, pyrexia.) 2. Raised ICP (headache, drowsiness ,confusion , papilloedema) 3. Localizing signs Treatment: Burr hole or craniotomy to drain abscess. Antibiotic is essential after pus culture Prognosis: Carries high mortality.

Temporal lobe abscess: 1. Dysphasia. 2. Contralateral upper quadrant hemianopia. 3. Paralysis-contralateral face and arm. 4. Hallucination of taste and smell. Cerebellar abscess: 1. Ataxia 2. Intention tremor 3. Neck stiffness 4. Weakness and loss of tone on same side. 5. Dysdiadokokinesis 6. Nystagmus

Follow: Frontal sinusitis (more commonly) Ear disease Focal epilepsy may result from cortical damage Poor prognosis

 Caused by perisinus abscess from mastoiditis. Clinical features: 1. Swinging pyrexia (up to 40) 2. Rigors 3. Meningeal signs sometimes 4. Papilloedema sometimes 5. Positive blood culture especially if taken during rigors 6. Cortical signs (facial weakness, hemiparesis) Treatment: 1. Antibiotics 2. Mastoidectomy with wide exposure of lateral sinus even removal of infected thrombus

subduraL

Brain abscess

Epidural abscess

Burr holes