ACUTE SUPPURATUVE OTITIS MEDIA

1. .
ACUTE SUPPURATIVE OTITIS MEDIA(ASOM)
AND
ACUTE NECROTIZING OTITIS MEDIA

2. ACUTE SUPPURATIVE OTITIS MEDIA ( ASOM)
 It is an acute suppurative inflammation of the
mucoperiosteal layer of middle ear cleft by
suppurative organisms ;
 Middle ear cleft includes-Eustachian tube,
middle ear, attic ,aditus,antrum and mastoid air cells;
 Duration less than 3 weeks;
 Also known as acute otitis media or ASOM .

3.  ETIOLOGY AND PREDISPOSING FACTORS
 Age group - Infants and children;
 Infection through eustachian tube to the middle ear in following
conditions like –recurrent attacks of upper respiratory tract
infections
 Nose – acute or chronic rhinitis ;
 Sinuses – rhinosinusitis ;
 Nasopharynx –adenioditis , nasal packing for epistaxis , tumors;
 Oropharynx – tonsilitis , pharyngitis ;
 Vomitus or infected milk;
 Infected water in the swimmimg pools;
 Sniffing or forcible blowing of nose ;
 Common in winter;

5. ROUTES OF INFECTION
 Infection via eustachian tube is the most common
route of spread of infection which travel via lumen of
the tube or along subepithelial peritubal lymphatics.
 Higher incidence in infants and children due to
shorter, wider and more horizontal eustachian tube ;
 Abundance of lymphoid tissue in infants and
children producing obstruction to eustachian tube ;
 Breast or bottle feeding in young infant in horizontal
position force fluids through the tube into middle ear ;

6. 2) via external ear - traumatic perforation of tympanic
membrane due to any cause open a route to
middle ear infection;
3) Via blood borne - rare ;

7.  COMMON ORGANISMS
 Streptococcus pneumoniae ( 30%)
 Haemophilus influenzae (20%)
 Moraxella catarrhalis (12%)

8. PATHOLOGY AND CLINICAL FEATURES
 Described in stages
 Stage of tubal occlusion
 Stage of pre suppuration
 Stage of suppuration
 Stage of resolution
 Stage of complications

9.  Stage of Tubal occlusion
 oedema and hyperaemia of nasopharyngeal end of
eustachian tube ;blocks the tube leading to absorption of
gases at first oxygen is absorbed later other gases like CO2
,nitrogen also diffuse out into the blood ;
 resulting in negative intratympanic pressure and
 retraction of tympanic membrane ;

10.  Clinical features of stage of tubal occlusion
 Symptoms –
 earache – mild , pulsatile , worse at night
 Reduced feeding
 Fullness of the ear;
 Fever may or may not be present ;
 Hard of hearing- adults
 Associated symptoms of upper respiratory tract like –
running nose ( cold ),nasal obstruction
 cough

11.  Signs– Tympanic membrane is retracted
 Dull and lusterless tympanic membrane
 Cone of light - absent
 with handle of malleus assuming a more horizontal
position apparently foreshortened
 prominence of lateral process of malleus ;
 Anterior and posterior malleolar folds become more
prominent;
 Loss of light reflex;
 Mobility of tympanic membrane is reduced performed by
seigelization or valsalva

13. Tunning fork test – Rinne’s test BC > AC – Conductive
deafness;
Weber’s test –lateralized to diseased ear

14.  Examination of nasal cavity and nasopharynx –
 Deviated nasal septum
 Hypertrophied turbinates
 Mucoid discharge in middle meatus- sinusitis
 Nasal Polyps
 adeniod hypertrophy
 Examination of oropharynx - tonsillar hypertrophy ,
posterior pharyngeal congestion
 Cleft palate;

15.  STAGE OF PRESUPPURATION
 PATHOLOGY - If tubal occlusion is prolonged
pyogenic organisms invade tympanic cavity
causing hyperemia of its lining ;
 Inflammatory exudate appears in the middle ear
 Tympanic membrane becomes congested;

16.  CLINICAL FEATURES OF STAGE OF PRE SUPPURATION
 SYMPTOMS
 Marked earache which disturbs sleep; usually
throbbing in nature ;
 Fullness of ear;
 Hard of hearing /decreased hearing
 ringing sensation in the ear
 High grade of fever ;
 Cold /cough

17.  Signs of stage of presuppuration
 Congestion of pars tensa
 Leash of blood vessels appear along the handle of
malleus and at the periphery of tympanic membrane
imparting cart – wheel appearance ;
 Later entire tympanic membrane becomes uniformly
red
 Tuning fork tests – Rinne ‘s test – BC> AC conductive
deafness
 Weber’s test- lateralized to diseased ear;

19.  STAGE OF SUPPURATION
 PATHOLOGY – The collected exudate in the middle ear
will increase producing tension on the
tympanic membrane
Pressure necrosis in the pars tensa of tympanic
membrane leading to small central perforation
Ear starts draining
( serosanguinous later mucopurulent ) mucoperiosteum
of middle ear cleft will be thickened by neoformation
of capillaries in young fibrous tissue infiltrated with
lymphocytes , plasma cells and polymorphs;

20.  Clinical features of stage of suppuration
 Symptoms
 Earache is excruciating later once ear discharge starts
pain reduces ;
 Ear discharge – thin watery discharge
(serosanguinuous )later mucopurulent ;
 Hard of hearing
 Fever;

21.  SIGNS
 Tympanic membrane appears red and bulging with loss of
landmarks ;
 Handle of malleus may be engulfed by swollen and protruding
tympanic membrane ;
 Yellow spot may be seen on tympanic membrane where rupture
is imminent ;
 Ear discharge – in the ear canal is thin at first later mucopurulent
 after dry mopping -Tympanic membrane shows small central
perforation ;
 Pulsatile discharge may be present through the perforation
called – light house sign ;
 Mastoid tenderness may be present;

23. STAGE OF RESOLUTION
 PATHOLOGY- Inflammatory process begins to resolve
 as resistance of host overtakes the virulence of organisms and because
of proper antibiotic therapy , acute infection begins to subside ;if
proper treatment started early resolution may start even without
rupture of tympanic membrane ; pathological process resolves
 A large coalescent cavity fills first with vascular
connective tissue later becomes pale –
chicken fat granulation and finally replaced by osteoid tissues or
pneumatic cells may reform ;
 Symptoms are relieved –
 cessation ear discharge ,
 earache relieved ,
 fever subsides ; well being improved

24.  Signs of resolution
 Hyperemia of tympanic membrane subsides return to
normal colour and landmarks ;
 Small perforation seen in anteroinferior quadrant of
pars tensa ;

25.  Stage of complications
 If virulence of organisms is high or resistance of patient is
poor ,resolution may not take place , disease spreads
beyond the confines of middle ear ;
 Complications may occur either by erosion of bone or by
hyperemic decalcification or thromboembolic phenomena;
 Can be intracranial or extracranial complications
 Like – acute mastoditis , subperiosteal abscess ,
facial paralysis , labyrinthitis , petrositis, extradural abscess,
meningitis , brain abscess or lateral sinus thrombophlebitis

26. MANAGEMENT OF ASOM
 INVESTIGATIONS
 In the early stages no need of any investigations only if
symptoms are not subsiding then following can be done;
 PTA – Conductive deafness with hearing loss of ( 20-30 dB)
 Impedence audiometry shows B type curve;
 CBP – if fever is not subsided –Leukocytosis;
 CULTURE AND SENSITIVITY OF EAR DISCHARGE
 Xray PNS- To rule out sinusitis in recurrent cases
 XRAY MASTOID – cloudy ,haziness of mastoid air cells ;

27. Pure tone audiogram and Impedance
audiogram –
acute suppurative otitis media

28. TREATMENT
 Antibiotics of choice – Amoxiclav
 40 mg / kg in 2-3 divided doses;
 Those allergic to penicillins can be given with cefaclor, cotrimoxazole or erythromycin ;
 Decongestant nasal drops – oxymetazoline or xylometazoline nasal drops to reduce
eustachian tube edema and promote ventilation of middle ear;
 Oral nasal decongestants – pseudoephedrine 30mg twice daily or combination with anti
histaminics ;
 Anti histaminics – levo cetrizine or fexofenadine ;
 Analgesics and antipyretics – paracetamol;
 Dry mopping in suppurative stage and topical antibiotics added follow up must be done;
 Avoid exposure to cold
 Keep ear dry by placing cotton while taking bath;
 Avoid swimming
 Proper positioning of baby while breast feeding must be instructed;
 If any pharyngitis or tonsillitis salt water gargling must be instructed
 Steam inhalation in case of sinusitis

29. surgical
 Myringotomy
 Indications – bulging tympanic membrane with acute
pain;
 Incomplete resolution despite antibiotics when
tympanic membrane remains full with persistent
conductive deafness;
 Persistent effusion beyond 12 weeks ;

30.  Incising the tympanic membrane to evacuate pus
 Circumferential incision is given in case of ASOM
 In the antero-inferior quadrant grommet is placed for
weeks till it is spontaneously extruded;

31. MYRINGOTOMY

32.  To treat underlying cause –
 adenoidectomy
 Tonsillectomy
 Cleft palate repair
 in recurrent cases –
 Submucosal resection of nasal septum
 Submucosal diathermy ;

33. ACUTE NECROTIZING OTITIS
MEDIA(ANOM)
 It’s a form of acute suppurative otitis media
 Seen in children;
 Suffering from measles , scarlet fever or influenza
 Cause: upper respiratory tract infection or
exanthematous fever caused by
beta – hemolytic streptococcus;

34.  Pathogenesis:
 There is rapid destruction of whole tympsanic
membrane with its annulus , mucosa of promontry ,
ossicular chain and even mastoid air cells;
 Healing is by fibrosis or ingrowth of squamous
epithelium leading to secondary acquired
cholesteatoma;

35.  SYMPTOMS
 Ear discharge – profuse , foul smelling, purulent
 ear pain
 Decreased hearing;
 Symptoms of upper respiratory tract infection like –
fever , cold , skin rashes may be present;

36.  Signs
purulent ear discharge in the external auditory meatus
– foul smelling;
After dry mopping- tympanic membrane shows
total perforation;
Mastoid tenderness;
Tunning fork test – rinne’s test BC > AC – Conductive
deafness;
Weber’s test –lateralized to diseased ear

37. Total perforation of Tympanic membrane

38. MANAGEMENT OF ANOM
 INVESTIGATIONS
 PTA – Conductive deafness with hearing loss of ( 20-30
dB)
 CBP – if fever is not subsided –Leukocytosis;
 CULTURE AND SENSITIVITY OF EAR DISCHARGE
 Xray PNS- To rule out sinusitis in recurrent cases
 XRAY MASTOID – cloudy ,haziness of mastoid air cells ;

39. TREATMENT
 Antibiotics of choice – Amoxiclav
 40 mg / kg in 2-3 divided doses;
 Those allergic to penicillins can be given with cefaclor, cotrimoxazole
or erythromycin ;
 Decongestant nasal drops – oxymetazoline or xylometazoline nasal
drops to reduce eustachian tube edema and promote ventilation of
middle ear;
 Oral nasal decongestants – pseudoephedrine 30mg twice daily or
combination with anti histaminics ;
 Anti histaminics – levo cetrizine or fexofenadine ;
 Analgesics and antipyretics – paracetamol;
 Dry mopping in suppurative stage and topical antibiotics added follow
up must be done;
 Avoid exposure to cold
 Keep ear dry by placing cotton while taking bath;

40.  If antibacterial therapy fails even after 10 days;
 Cortical mastoidectomy is done ;