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    DR Akpalaba Otitis Media

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    shahid

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    DR Akpalaba Otitis Media

    Uploaded by

    shahid
    5 views35 pages

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    Dr Akpalaba Otitis Media

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    5 views35 pages

    DR Akpalaba Otitis Media

    Uploaded by

    shahid

    Copyright:

    © All Rights Reserved
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    of 35

    OTITIS MEDIA

    DR AKPALABA I.O.
    OTITIS MEDIA
    OUTLINE
    • Introduction and Classification
    • Brief Anatomy of the middle ear
    • Acute Suppurative Otitis Media (ASOM)
    • Chronic Suppurative Otitis Media (CSOM)
    • Nonsuppurative otitis media (NSOM)
    • Special forms of otitis media
    Introduction
    Inflammation of the middle ear
    In about 98% of cases are due to infection
    One of the 2 most common cause of ear pain
    Most common affliction necessitating medical
    therapy among U-5 in the US
    Accounts for one third of all a/biotic
    prescriptions in that age bracket
    70% of all U-7 has suffered it once
    Grossly under diagnosed and under reported
    in our setting.
    CLASSIFICATION
    Classified as
    Acute & Chronic
    Suppurative & Nonsuppurative

    AAP & AAFP defines acute otitis media with 3


    criteria
    Acute onset
    Middle Ear Effusion (MEE)
    Middle Ear inflammation
    • CLASSIFICATION contd
     WHO defines AOM as middle ear infection of
    acute onset less than a duration of 3wks
     COM when it persistent middle ear infection
    longer than 12wks with non intact ear drum
    (perforated TM) and discharge (otorrhea)

     Pathological classification is into


    Suppurative – highly exudative polymorphs
    Nonsuppurative – Poor in exudate

    Combining both
    ASOM CSOM ANSOM CNSOM
    • CLASSIFICATION contd
    Several factors determine the course of
    middle ear infection
    Px age and immunity
    Virulence of infective organism
    Degree of pneumatisation
    State of drainage of the middle ear
    A/b therapy
    ANATOMIC REVIEW OF THE MIDDLE EAR
    Consist of
    Middle ear cleft
    Pharyngotympanic (Eustachian) tube
    Mastoid air cell system
    Best understood as 6-sided cube
    Lateral boundary- TM
    Medial boundary – Promontory
    Posterior – Additus & facial ridge
    Anterior – tensor tympani & ET opening
    Roof – teggmen tympani
    Floor – jugular bulb/foramen
    ANATOMIC REVIEW OF THE MIDDLE EAR contd
    Lined by respiratory type epithelium
    Cleft contains ossicular chain
    Mastoid system
    • ACUTE SUPPURATIVE OTITS MEDIA
    Spreads rapidly
    Symptoms form ordered progression

    AETIOLOGY
    Usually follows URTI more commonly
    nasopharyngitis but also
    Rhinitis
    Sinusits
    Tonsilitis

    Commonest cause of URTI being RSV


    AETIOLOGIC AGENTS
    In the order of importance
    H. streptococcus
    S. pneumoniae
    S. albus & aureus
    H. influenzae
    Very rarely Pseudomonas
    PATHOLOGY
    Most times follows an organized order
    Tubal occlusion
    Cleft lining engorgement & oedema
    Exudation into the Tymp Cavity & mastoid air cells
    Initially serous later mucopurulent
    TM bulges
    Perforates/rupture
    Hyperaemic decalcification
    Osteitis
    Subperiosteal abscess
    CLINICAL FEATURES
    Basically Symptoms are best understood
    according to the stage of infection

    PHASE I Acute Eustachian Salpingitis


    Feeling of fullness in the ear
    Deafness – Conductive
    TM retraction
    CLINICAL FEATURES contd
     PHASE II Acute Infection of TC (Acute OM)
     Consist of 2 stages
    Stage 1 (b/4 perforation)
    ↑ Deafness
    Hearing of bubbling sound in the ear
    Stabbing or boring ear ache
    Constitutional sympt – High grade fever ≥39⁰C
    Malaise
    Meningism
    Convulsions
    vomitting
    Stage 2 (After perforation)
    Otorrhoea
    Relief of pain
    CLINICAL FEATURES contd
    PHASE III (Retention of pus in the Mastoid –
    Acute Mastoiditis)
    Pain/tenderness in the mastoid region
    Oedema
    Constitutional disturbances

    DIAGNOSIS
    Based on clinical hx and a thorough physical exam
    DIFFERENTIAL DIAGNOSIS
    Otitis Externa
    Furuncle of the external ear skin
    Post auricular adenitis
    Other causes of referred otalgia
    TREATMENT
    3 main modalities
    Symptomatic
    Rest & Sedation
    Anagesia
    Local heat (Hot water bottle)

    Systemic
    A/biotic therapy

    Local
    Myringotomy done before rupture
    No ear drops except soothing ear drops like glycerine
    TREATMENT contd
    Local contd
    After rupture
     Aural toileting
     Systemic a/b in right dosing & duration
     Vasoconstrictor NASAL sprays/drops every 4-6hours

    In severe infections with fulminating mastoiditis,


    mastoidectomy is the tx of choice.
    PROGNOSIS/SEQUELAE
    Resolution without sequelae
    Healing with scar – hearing impairment
    Open perforation
    Progression to CSOM
    Petrositis
    Meningitis
    Encephalitis
    CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM)
    Defined by the ffg criteria
    Duration of at least 12weeks
    Disrupted (ruptured) TM
    Purulent exudate
    Otorrhoea

    Basically 2 clinical types


    Tubotympanic (‘safe’) type
    Atticoantral (‘dangerous’) type
    TUBOTYMPANIC DX
    Usually arise from ASOM in childhood or early
    infancy
    Xterized by
    Centrally located perforation i.e non marginal
    Intact ossicular chain
    Pink & velvety TC mucosa which may be
    oedematous
    Metaplastic mucosa epithelial cells
    CLINICAL FEATURES
    Discharge usually mucoid, scanty &
    intermittent
    Deafness
    Usually no fever except during exercerbation

    TREATMENT
    Systemic & local a/b during active infections
    Aural toileting
    Tx of adjacent foci of infections
    Myringoplasty & ossiculoplasty
    ATTICOANTRAL DX
     Xterised by
    Marginal rupture
    Associated with cholesteatoma the hallmark
    Disrupted ossicular chain

     CHOLESTEATOMA
    A destructive and expanding cystic growth of
    keratinizing squamous cell epith in the ME &/or
    mastoid process and contains cholesterol crystals and
    foreign body giant cells
    2 types
    Congenital Acquired
    ATTICOANTRAL DX contd
    Congenital or Primary
    Arise from embryonic epith tissues
    Involves otic capsule causing
    facial nerve palsy
    Sensorineural deafness
    Diagnosis is usually confirmed at surgey

    Acquired or Secondary type


    Occur in infancy or early childhood
    Arise from blockage of ET due to infection of URT
    & adenoids
    PATHOPHYSIOLOGY
    Retraction pocket formation in the postero
    superior margin of the attic
    Collection & impregnation with keratin
    Perforation of the weakened retraction pocket
    Invasion of attic
    Expansion of sac

    Once formed a cholesteatoma can suffer any


    of the ffg fate
    PATHOPHYSIOLOGY contd
    Extrusion into the EAM
    Invasion of the tympanic cavity
    Disruption of the ossicular chain with sclerosis
    Encroachment of the mastoid
    Interference with ventilation
    Active infection of the keratotic mass

    Clinical fx
    Deafness
    Malodorous otorrhoea
    DIAGNOSIS
     Usually from the hx of insiduous onset and
    physical exam and at surgery
     There may be no hx of AOM
     Finding of marginal TM perforation should always
    necessitate a more careful exam
     Findings of acellular mastoid on radiograph

     Tx
     Conservative
    removal using fine crocodile forceps
    Dry mopping
    Lifetime follow up
    Tx contd
     Surgical
    In failed conservative mgmt orcomplications
    Includes any of the ffg
    Atticotomy
    Antrotomy
    Mastoidectomy

     COMPLICATIONS
    Extracranial
    Subperiosteal abscess
     Zygomatic
     Postauricular
    Temporal bone osteomyelitis
    septicemia
    COMPLICATIONS contd
    Intracranial
    Menigitis
    Encephalitis
    Sigmoid sinus thrombosis
    NSOM
    Synonyms – glue ear, serous OM, OME
    Simply a collection of fluid in the ME
    No purulent exudate
    Usually caused by negative press in the cleft as a
    result of
    ETD
    Unresolved AOM
    Viral Infection
    Allergy
    Cleft palate
    Clinical Fx
    Deafness
    Tinitus
    Vertigo
    Pain

    Examination reveals
    Dull & retracted TM
    Prominent malleus handle
    Meniscus – air-fluid level & air bubbles
    Diagnosis
     Suspect in all children suffering from all forms of
    ‘tonsils & adenoid’ syndromes
     Findings of a meniscus, bubble or air-fluid level or
    culture of fluid found on myringotomy confirms
    it.

     Tx
    Myringotomy
    Insertion of a grommet tube
    Very rarely mastoidectomy

    Recurrence occur in about 20% of cases.


    SPECIAL FORMS OF OTITIS MEDIA
     Tuberculous
    Xterised by tubercle formation, caseation & multiple
    perforations
    Mgmt include aural toilet, mastoidectomy & anti-TB.

     Syphititic
    Manifests as meningoneurolabyrinthitis & xterised by
    gumma formation
    Diagnosis is by serological test & a finding of
    sensorineural deafness.

     Tx is by use of antisyphilitic a/b & occasionally


    mastoidectomy.

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