2.otitis medianew

7/30/2019 2.Otitis Medianew

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Otitis media


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Terminology

Otitis Media: inflammation of the middle ear cleft or mucosa.

Acute Less than 6 weeks

ChronicMore than 6 weeks

Recurrent acute otitis media 3 episodes/6 months or 4 ormore episodes/1 year

Otitis media with effusion: fluid in the middle ear without

signs or symptoms of infection.


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Middle ear cleft contains:

1. Middle ear cavity2. Eustachian tube

3. Mastoid antrum

4. Mastoid air cells5. Aditus

6. Atic


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Acute Otitis Media

Its acute Short lived inflammation of the middle earcavity

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.


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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 episodeof 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.


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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


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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 aperforation.

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


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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 eartympanic membrane retraction.

3. Transudation pressure inc. tympanic membrane will

bulge.

4. Necrosis of the tympanic membraneperforation.

5. The ear will continue to drain until the infection resolves.


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DDx

Otitis Media With Effusion

Otitis Externa

Labyrinthitis

URTIs

Pharyngitis

Sinusitis

Foreign Bodies

Herpes Zoster Oticus Dental pain

Dysbarism


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Diagnosis

1. Clinical

2. Laboratory Studies

No definitive laboratory examination

Sample of the effusion should be sent forculture andsensitivityby Tympanocentesis.

3. Imaging Studies

Not valuable for diagnosis

Radiography and/or CT scanning of the mastoid air cellsmay be helpful in select cases of suspected mastoiditis.


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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 ifH.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.


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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).


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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 for3 months or more

Commoner in winter & small children Cause significant deafness if left untreated

May result in permanent middle-ear changes.


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Etiology

1. AOM (most imp)

2. Nasopharyngeal obstruction, e.g. large adenoids ortumour resulting in Eustachian tube dysfunction.Thecondition may be associated with recurrent attacks of

acute otitis mediaAdenoid3. Allergic rhinitis

4. Cleft palate

5. Passive smoker

6. Otitic barotraumamost commonly caused by descentin an aircraft,especially if the subject has a cold. Failureof middle-ear ventilation results in middle-ear effusion,sometimes blood-stained. Also occurs in scubadivers.


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Symptoms:

1. Conductive deafness

2. Discomfort but not pain3. Sometimes tinnitus.

Signs:

1. Otoscope: Dull yellow fluidbehind the ear drum

2. Audiogram: flat curve


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Management

Improve spontaneously(Many cases will resolvespontaneously, and the child should usually

be observed for 3 months before embarkingon surgery)

Treatpredisposing condition (allergic rhinitis or

cleft palate) Myringostomy & grommet tube

Puncture of the drum

Aspiration of the fluid

Insertion of a small tube (grommet) in theeardrum done under general anesthesia.

The function of the grommet is toventilate the middle ear and notto drain the fluid


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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.


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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.


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Causes & predisposing factors

Late treatment of acute otitis media.

Inadequate or inappropriate antibiotic treatment ofAOM

URTI

Lowered Resistance (malnutrition & anemia ,immunological impairment.)

Eustachian tube deformity

Cleft palate


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Symptoms

Conductive deafness

Vertigo

Tinnitus

Eardischarge

Etiologies P. aerugenosa

Proteus

E.coli

H. influenza


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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).


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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 membraneperforation.

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.


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Tubo-tympanic otitis media

(Safe type) Acute otitis mediapermanent 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 & ossiclesare intact (most used graft is autologous temporalis fascia)

Tympanoplasty: repair of tympanic membrane & ossicles.


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Perforation


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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:

Regularaural toilet in early cases of annular osteitis may be adequate toprevent progression.

Surgical removal of cholestetoma

Mastoidectomy for mastoiditis


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Cholesteatoma

Skin in wrong place

Epithelial cells collection in the middle ear cleft

Produces mass effect on the structures their

Managed by surgical removalTheories of bone erosions:

1. Pressure theory

2. Enzymatic theory (acid phosphatase, collagenase &other

proteolytic enzymes)3. Pyogenic osteitis (Pyogneic bacteria may release enzymes)


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Complications of OM


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Rare

High morbidity & mortality

Depend on: Causative MO

Antimicrobial therapy

Host resistance

Anatomic barriers

Available drainage

Most occur in subacute orchronic OM

In young children & meningitis occur in AOM

Classified:

Extracranial (intratemporal)

Intracranial

both in 50%


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Extracranial

Mastoiditis

Petrositis

Labyrinthitis

Facial paralysis

Adhesive OM

Tympanosclerosis

Ossicular dyscontinuity andfixation

Intracranial

Meningitis

Extradural abscess

Subdural abscess

Brain abscess

Lateral sinus thrombosis

Otitic hydrocephalus

Focal encephalitis


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Extension of acute otitis media into the mastoid air cells with suppuration

andbone 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)


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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, thenaccording to the sensitivity test

3. Cortical mastoidectomy only

1. Subperiosteal abscess (Bezolds abscess)

2. No response to antibiotics


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mastoiditis


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Bezolds abscess

Abscess in the

sternocleidomastoid muscle

Pus from a mastoiditis

escapes into the

sternocleidomastoid

Rare complication of acute

otitis media


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Very rarely

The infection may spread to the petrous apex and involve the6th CN.

Clinical features:

Mastoiditis + retroorpital pain + abducent nerve paralysis1. Evidence ofmiddle 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


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Gradenigo s.


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Cholestetoma erosion fistula labyrinth infection

Clinical features:

1. Vertigo

2. Nausea and vomiting3. 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


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Can result from both acute & chronic otitis media

In early stages the patient may complain ofdribbling 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:


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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 loweredg. Organisms present on culture and gram stain

Treatment:

Do not start antibiotic until CSF results has been obtained for culture

& diagnosis

Then startpenicillin parenterally & intrathecally.


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Features ofmastoiditis are present and often

accentuated.

Sever pain is common.

Treatment: Antibiotics

Mastoid surgery is essential to treat the ear disease

and drain the abscess.


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May occur in the cerebellum ortemporal lobe.

The infection may spread directly to the brain via thebone & meninges

or viablood vessels.

Effects of abscess:

1. Systemiceffects (malaise, pyrexia.)2. Raised ICP (headache, drowsiness ,confusion , papilloedema)

3. Localizing signs

Treatment:

Burr hole orcraniotomy to drain abscess.

Antibiotic is essential after pus culture

Prognosis:

Carries high mortality.


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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


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Follow:

Frontal sinusitis (more commonly)

Ear disease

Focal epilepsy may result from cortical damage Poor prognosis


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Caused by perisinus abscess from mastoiditis.Clinical features:

1. Swingingpyrexia (up to 40)

2. Rigors

3. Meningeal signs sometimes4. 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 evenremoval of infected thrombus


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subduraL


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Brain abscess


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Epidural abscess


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Burr holes


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