ACUTE OTITIS MEDIA

Facilitator: Dr. Zephania Saitabau

University of Dodoma-College of
Health Sciences
Semester 5
 Definition
• Acute otitis media (AOM): Represents an inflammatory
condition of the mucoperiosteum of the middle ear without
reference to cause or pathogenesis.
• AOM: Defined by convention as the first 3 weeks of a
process in which the middle ear shows the signs and
symptoms of acute inflammation.
Contn….
• Acute otitis media is an infection of the mucous membrane
of the whole of the middle-ear cleft—Eustachian tube,
tympanic cavity, attic, aditus, mastoid antrum and air
cells
• AOM is a common condition and is frequently bilateral.
• It occurs most commonly in children and it is important that it
is managed with care to prevent subsequent complications.
• It most commonly follows an acute upper respiratory tract
infection and may be viral or bacterial.
 EPIDEMIOLOGY
• AOM occurs more in children and infants especially
during winter and spring periods and after upper
respiratory tract infections. Eg; measles, diphtheria,
tonsillitis etc.
• The highest prevalence occurs in the first 2 years of
life and decreases there-after.
 RISK FACTORS FOR ACUTE OTITIS MEDIA
 Prematurity and low birth weight
 Young age
 Early onset
 Family history
 Race - Native American, Inuit, Australian aborigine
 Altered immunity
 Craniofacial abnormalities
 Genetics
 Contn……Risk factors
• Sex-Male gender,
• Bottle feeding, Breast feeding reduce risk of URI)
• A sibling with OM,
• Smoking by the mother,
• Parental history of OM,
• Viral infections at home place
 Contn…..Risk factors
• Allergy
 Day care
 Crowded living conditions
 Low socioeconomic status
 Tobacco and pollutant exposure
 Use of pacifier
 Fall or winter season
 AETIOLOGY OF ACUTE OTITIS MEDIA
BACTERIA
• Streptococcus pneumoniae - 30-35%
• Haemophilus influenzae - 20-25%
• Moraxella catarrhalis, 10-15%
• Streptococcus pyogens-3%
• Staphylococcus aureus-1%
• Group A strep - 2-4%
• Gram negative bacilli (higher incidence in Infants)
 VIRUSES
• RSV - 74% of middle ear isolates
• Influenzae A & B
• Parainfluenzae 1,2, & 3
• Rhinovirus
• Adenovirus
• Enterovirus
• Coronavirus
 ROUTES OF INFECTION
• There are two major routes of infection to the middle
ear;
I. Via the Eustachian tube
II. Blood born (Hematogenous)
 THE EUSTACHIAN TUBE
This is a small tube connecting the middle ear to the
nasopharynx;
It functions to regulate and equalize pressure of the middle
ear, prevent fluid from accumulating in the middle ear, and
protect the ear from nasopharyngeal infection.
In children and infants the ET is the common route of infection
because;
• It is shorter
• Wider
• More horizontal
• Less stiff
• Large adenoids that interfere with the opening of the tube
• Immune system not fully developed
 HEMATOGENOUS ROUTE
• Micro-organisms may get access into the middle ear
space via hematogenous route and consequently
paving way to the pathogenesis of acute otitis media
 STAGES OF ACUTE OTITIS MEDIA
1.Stage of tubal occlusion
2.Stage of pre-suppuration
3.stage of suppuration
4.Stage resolution & complications
 STAGE OF TUBAL OCCLUSION
• This is characterized by; mucosal hyperemia and swelling-
>Eustachian tube occlusion->decrease in intratympanic pressure-
>Air decreases->fluid increases->tympanic membrane retracts
• Symptoms; TM retraction cause ear fullness, tinnitus, hearing loss,
earache.
• Signs; short handle of malleus, loss of cone reflex, prominent lateral
process of malleus, conductive hearing loss
 STAGE OF PRE-SUPPURATION
• Bacteria invade the tympanic cavity->hyperemia-
>inflammatory exudate->congested tympanic membrane.
• Symptoms ;Ear ache, tinnitus,
• Signs; high fever, cartwheel appearance of the TM.
 STAGE OF SUPPURATION
• Pus increases ->TM is compressed and ischemic ->tm
tense and bulge->TM necrosis----TM perforation
• Clinical features: Excruciating pain, hearing loss,
fever, convulsions, Xray of mastoid show clouding of
air cells due to exudates.
 STAGE OF RESOLUTION
• Pain is relieved,
• temperature decreases,
• WBC count improves
 STAGE OF COMPLICATIONS
Factors that influence complications;
• Virulence of the organism
• Host resistance
• Adequacy of treatment
• Susceptibility to chemotherapy
Complications can be;
I. Intratemporal-Facial nerve paralysis, labyrinthitis, petrositis,
Mastoiditis
II. Intracranial-Meningitis, brain abscess, subdural abscess,
epidural abscess
CLINICAL FEATURES OF ACUTE OTITIS MEDIA
• Ear ache/otalgia-Earache may be slight in a mild case, but
more usually it is throbbing and severe. The child may cry
and scream inconsolably until the ear perforates, the pain is
relieved and peace is restored.
• Hearing loss-It is conductive in nature and may be
accompanied by tinnitus. In an adult, the deafness or
tinnitus may be the first complaint.
• Tinnitus
• Fever-The child is flushed and ill. The temperature
may be as high as 40°C.
• Tenderness on the mastoid antrum-There is usually
some tenderness to pressure on the mastoid antrum.
• Other features: Vertigo, facial asymmetry (facial
nerve paralysis)
 Tympanic membrane changes
The tympanic membrane varies in appearance according to
the stage of the infection;
1. Loss of lustre and break-up of the light reflex.
2. Injection of the small vessels around the periphery and
along the handle
of the malleus.
3. Redness and fullness of the drum; the malleus handle
becomes more vertical.
4. Bulging, with loss of landmarks. Outer layer may
desquamate, causing blood-stained serous discharge. Early
necrosis may be recognized, heralding imminent perforation.
5. Perforation with otorrhoea, which will often be blood-
stained. Profuse and mucoid at first, later becoming thick and
yellow.
 TREATMENT OF ACUTE OTITIS MEDIA
The treatment depends on the stage reached by the infection
ANTIBIOTICS
 Penicillin remains the drug of choice in most cases, and ideally
should be given initially by injection followed by oral medication.
• In children under 5 years, when Haemophilus influenzae is likely
to be present, amoxicillin will be more effective, and should always
be considered if there is not a rapid response to penicillin. Co-
amoxiclav is useful in Moraxella infections.
• Other antibiotics: Cefixime, Cefuroxime
Analgesics;
• Simple analgesics, such as aspirin or paracetamol,
should suffice. Avoid the use of aspirin in children
because of the risk of Reye’s syndrome.
Nasal decongestants
• The role of 0.5% ephedrine nasal drops is traditional
but its value is uncertain in the presence of acute
inflammation of the middle ear though of help in
children with URTI
 Myringotomy
• Myringotomy is necessary when bulging of the tympanic
membrane persists, despite adequate antibiotic therapy.
• A large incision in the membrane should be made to allow
the ear to drain. Pus should be sent for bacteriological
assessment.
• Following myringotomy, the ear will discharge and the outer
meatus should be dry-mopped regularly.
 Further Management
Do not consider acute otitis media to be cured until the
hearing and the appearance of the membrane have
returned to normal
If resolution does not occur, suspect:
1 The nose, sinuses or nasopharynx? Infection may be
present;
2 The choice or dose of antibiotic;
3 Low-grade infection in the mastoid cells.
THE END