Asom

Acute Otitis Media
Dr H P Singh
Additional Professor
Disclaimer
This presentation is for educational

purposes only not for commercial activity.
Acute OTITIS MEDIA
the presence of fluid in the middle ear with the

acute onset of signs and symptoms of middle ear
inflammation.
Microbiology/Virology
►S. pneumoniae - 30-35%
►H. influenzae - 20-25%
►M. catarrhalis - 10-15%
►Group A strep - 2-4%
►Others
Infants with higher incidence of gram negative bacilli

RSV - 74% of middle ear isolates
Rhinovirus
Parainfluenza virus
Influenza virus
Routes of Infection
1. Via eustachian tube. It is the most common route. Infection travels via the
lumen of the tube or along subepithelial peritubal lymphatics. Eustachian
tube in infants and young children is shorter, wider and more horizontal and
thus may account for higher incidence of infections in this age group. Breast
or bottle feeding in a young infant in horizontal position may force fluids
through the tube into the middle ear and hence the need to keep the infant
propped up with head a little higher.
Swimming and diving can also force water through the tube into the
middle ear.
2. Via external ear. Traumatic perforations of tympanic membrane due to any
cause open a route to middle ear infection.
3. Blood-borne. This is an uncommon route.
Stages of ASOM
➢Stage of tubal occlusion
➢Stage of presuppuration
➢Stage of suppuration
➢Stage of resolution/ complication

➢Stage of tubal occlusion
Negative intratympanic pressure
A small effusion ( sub-clinical)
deafness/ earache
➢Stage of presuppuration
if occlusion prolonged
inflammatory exudate /
suppuration
high grade fever/restless
cart wheel appearance
Stage of suppuration
pus formation
point of rupture: nipple like pron
TM bulges
fever / convulsion
mastoid tenderness
➢Stage of resolution/ complication
Resolve by / without medication
Partial resolution
Complete resolution
ACUTE NECROTISING OTITIS
MEDIA
• It is a variety of acute suppurative otitis media, often seen in children
suffering from measles, scarlet fever or influenza.
• Causative organism is Beta-haemolytic streptococcus.
• There is rapid destruction of whole of tympanic membrane with its

annulus, mucosa of promontory, ossicular chain and even mastoid air
cells. There is profuse otorrhoea.
• In these cases, healing is followed by fibrosis or ingrowth of squamous

epithelium from the meatus (secondary acquired cholesteatoma).
ACUTE NECROTISING OTITIS
MEDIA
• Treatment is early institution of antibacterial
therapy. It is continued for at least 7-10 days,
even if response is seen early.
• Cortical mastoidectomy may be indicated if
medical treatment fails to control or the
condition gets complicated by acute
mastoiditis.
• the presence of fluid in the middle ear
without acute signs or symptoms
►Eustachian tube dysfunction
►Post-AOM
►Most episodes resolve spontaneously within 3
months
►30%-40% Recurrent OME
►5%-10% Persistent OME > 1 year
►Clinicians should use pneumatic otoscopy as the primary
diagnostic method for OME. OME should be
distinguished from AOM.
►Strong recommendation
– Pneumatic otoscopy is gold standard
►Color
►Position
►Mobility
►Tympanic membrane appearance
– Sensitivity of 94% and specificity of 80% versus myringotomy
– Readily available, cost effective and accurate in experienced
hands
►Tympanometry can be used to confirm
diagnosis.
– When diagnosis is uncertain, consider
tympanometry
►Cost associated with equipment
►Painless
►Reliable for ages 4 months or older
► Population-based screening programs for OME are not
recommended in healthy, asymptomatic children.
► Highly prevalent in young children. 15%-40% point prevalence in
healthy children under 5 yr
– No influence on short-term language outcomes
– No benefit from treatment that exceeds the favorable natural
history of the disease
– Risk of inaccurate diagnoses, overtreatment, parental
anxiety, and increased cost
►Clinicians should document the laterality,
duration of effusion, and presence and
severity of associated symptoms at each
assessment of the child with OME.
Recommendation
– Medical decision making depends on these
features
– 40%-50% of OME cases no symptoms
– Preponderance of benefit over harm
► Clinicians should distinguish the child with OME who is at risk for speech,
language, or learning problems from other children with OME, and should
more promptly evaluate hearing, speech, language, and need for
intervention.
– Permanent hearing loss
– Speech and language delay or disorder
– Autism-spectrum disorder/PDD
– Syndromes with cognitive, speech, and language delays
– Blindness
– Cleft Palate
– Developmental delay
►Clinicians should manage the child with OME who is
not at risk with watchful waiting for 3 months from the
date effusion onset (if known) or from the date of
diagnosis (if onset is unknown).
– OME is usually self-limited
– 75%-90% of OME after AOM resolves spontaneously
by 3 months
– Waiting results in little harm to child
– Optimize listening and learning environment until
effusion resolves
►Antihistamines and decongestants are
ineffective for OME and are not recommended
for treatment.
►Antimicrobials and corticosteroids do no have
long-term efficacy and are not recommended
for routine management.
– Short-term, small magnitude benefits
– Significant adverse effects
►Hearing testing is recommended when OME
persists for 3 months or longer, or at any time
that language delay, learning problems, or a
significant hearing loss is suspected in a child
with OME. Language testing should be
conducted for children with hearing loss.
►HL may impair early language acquisition
►Extended periods of CHL may result in
developmental and academic sequelae
►Early language delays are associated with
later delays in reading and writing.
► Children with persistent OME who are not at risk should be
reexamined at 3- to 6-month intervals until the effusion is no
longer present, significant hearing loss is identified, or
structural abnormalities of the TM or middle ear are
suspected.
– Resolution rates decrease the longer the effusion has been present
– Risk factors for non-resolution:
►Summer or fall onset
►HL>30dB
►H/O prior tympanostomy tubes
►Not having had an adenoidectomy
►When a child becomes a surgical candidate,
tympanostomy tube insertion is the preferred
initial procedure; adenoidectomy should not
be performed unless a distinct indication
exists (nasal obstruction, chronic adenoiditis).
Repeat surgery consists of adenoidectomy
plus myringotomy, with or without tube
insertion. Tonsillectomy alone or myringotomy
alone should not be used to treat OME.
►OME > 4 months with persistent hearing loss
►Recurrent or persistent OME in at risk child
►OME with structural damage to TM or ME
Consequences
►Inappropriate antibiotic treatment of OM
– Multidrug-resistant strains
– Drug side effects
– Parental/caregiver confusion
Recurrent Acute Otitis Media
• Infants and children between the age of 6 months

and 6 years may get recurrent episodes of acute
otitis media.
• Such episodes may occur 4-5 times in a year. Usually,

they occur after acute upper respiratory infection,
the child being free of symptoms between the
episodes.
Recurrent Acute Otitis Media
• Recurrent middle ear infections may sometimes be
superimposed upon an existing middle ear effusion.
Sometimes, the underlying cause is recurrent
sinusitis, velopharyngeal insufficiency, hypertrophy
of adenoids, infected tonsils, allergy and immune
deficiency.
• Feeding the babies in supine position without
propping up the head may also use the milk to enter
the middle ear directly that can lead to middle ear
infection.
Management of Recurrent Acute Otitis
Media
• Finding the cause and eliminating it, if possible.
• Antimicrobial prophylaxis for those having recurrent otitis
media associated with upper respiratory infections. In such
cases, low dose, long term antibiotic or sulphonamide can be
instituted.
• Myringotomy and insertion of a ventilating tube in cases
where acute episodes supervene on chronic middle ear
effusion.
• Adenoidectomy with or without tonsillectomy.
• Management of inhalant or food allergy
AERO-OTITIS MEDIA (OTITIC
BAROTRAUMA)
• It is a non-suppurative condition resulting
from failure of eustachian tube to maintain
middle ear pressure at ambient atmospheric
level.
• The usual cause is rapid descent during air
flight, underwater diving or compression in
pressure chamber.
Mechanism
• Eustachian tube allows easy and passive egress of air
from middle ear to the pharynx if middle ear
pressure is high.
• In the reverse situation, where nasopharyngeal air
pressure is high, air cannot enter the middle ear
unless tube is actively opened by the contraction of
muscles as in swallowing, yawning or Valsalva
maneuver.
• When atmospheric pressure is higher than that of middle car
by critical level of 90 mm of Hg, eustachian tube gets
"locked", i.e. soft tissues of pharyngeal end of the tube are
forced into its lumen.
• In the presence of eustachian tube oedema, even smaller
pressure differentials cause "locking“ of the tube. Sudden
negative pressure in the middle ear causes retraction of
tympanic membrane, hyperaemia and engorgement of
vessels, transudation and haemorrhages.
• Sometimes, rupture of labyrinthine membranes with vertigo
and sensorineural hearing loss.
Clinical Features
• Severe earache, deafness and tinnitus are common
complaints.
• Vertigo is uncommon.
• Tympanic membrane appears retracted and
congested. It may get ruptured.
• Middle ear may show air bubbles or haemorrhagic
effusion.
• Hearing loss is usually conductive but sensorineural
type of loss may also be seen.
Treatment
• The aim is to restore middle ear aeration.
• This is done by catheterization or politzerization.
• In mild cases, decongestant nasal drops or oral nasal
decongestant with antihistaminic are helpful.
• In the presence of fluid or failure of the above
methods, myringotomy may be performed to
"unlock" the tube and aspirate the fluid.
Prevention
1. Avoid air travel in the presence of upper respiratory infection
or allergy.
2. Swallow repeatedly during descenT. Sucking sweets or
chewing gum is useful.
3. Do not permit sleep during descent as number of swallows
normally decrease during sleep.
4. Autoinflation of the tube by Valsalva should be performed
intermittently during descent.
5. Use vasoconstrictor nasal spray and a tablet of antihistaminic
and systemic decongestant, half an hour before descent in
persons with previous history of this episode.
6. In recurrent barotrauma, attention should be paid to nasal
polyps, septal deviation, nasal allergy and chronic sinus
infections.

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Acute Otitis Media

This presentation is for educational

the presence of fluid in the middle ear with the

Infants with higher incidence of gram negative bacilli

➢Stage of resolution/ complication

Negative intratympanic pressure

A small effusion ( sub-clinical)

Resolve by / without medication

• Causative organism is Beta-haemolytic streptococcus.

• There is rapid destruction of whole of tympanic membrane with its

• In these cases, healing is followed by fibrosis or ingrowth of squamous

• Infants and children between the age of 6 months

• Such episodes may occur 4-5 times in a year. Usually,

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