otorhinolaryngology

1. Dr. P. Hemalatha. MS. ENT
Acute Suppurative
Otitis Media

2. Viral Otitis Media
 Ciliated columnar epithelium sloughs leaving basal germinal layer of non
ciliated cuboidal cells
 In ET, swelling and hyperemia with increased production of mucus cause
temroary closure of tubal orfice
 With oxygen absorption,negative intratympanic pressure cause
accumulation of transudate causing non inflammatory sterile otitis media.
 Subclinical mucoperiosteal hyperemia accounts for conductive hearing loss
during colds
 Bacterial otitis media differentiated from viral otitis media by fever, hearing
impairment, positive culture.

3. Acute Suppurative Otitis Media
 Acute Suppurative inflammation of mucoperiosteal lining of
middle ear cleft lasting for 3 weeks and end result is normal with
no loss of tympanic mucosal.
 2peaks-one at 3 years and 2nd at 6 years when child starts going
to school
 Infantile Otitis media – bacteria can easily access middle ear due
to short patent Eustachian tube.

4. Predisposing Factors
1. Breast feeding in supine position
2. Recurrent upper respiratory tract infection
3. Nasal allergy
4. Chronic rhinitis & sinusitis
5. Tumours of nose & nasopharynx
6. Exposure to cigarette smoke
7. Cleft palate

5. Bacteriology
1. Haemophilus influenzae
2. Streptococcus pneumoniae type 3
3. Staphylococcus aureus
4. Moraxella catarrhalis
5.  - Hemolytic streptococci (causes acute necr
otizing otitis media)

6. Pathogenesis
 1st response to invading microorganism is Hyperemia
 Hyperemia followed by outpouring from dilated permeable capillaries-fibrin
rbc wbc.
 Due to accumulation of exudate intratympanic pressure increases, ear
perforated causing mucopurulent discharge and relief of pain, the epithelium
becomes progressively thickened and secretory.
 Thickened mucosal obstruct drainage of secretions in epitympanum causing
venous stasis, local acidosis, dissolution of bony walls (halisteresis) and
formation of mucoperiosteal vascular granulation tissue.
 As host resistance overtakes the microbial invasion, resolution occur with
decrease in aural discharge. Small central perforation closes immediately.
Granular mucoperiosteum thickening recede slowly.
 Conductive hearing loss recover with decrease in fluid of middle ear and
reduction of thickened mucoperiosteum.

7. 1. Stage of Hyperaemia
 Synonym: Stage of tubal occlusion
 Mild earache
 T.M. retracted in early stage
 T.M. congested later stage
 Cartwheel appearance: radiating blood vesse
ls from handle of malleus

8. Cart wheel appearance

9. 2. Stage of Exudation
 High fever
 Severe earache
 Deafness
 Marked congestion + bulging of T.M.
 Mastoid tenderness
 P.T.A.: high frequency conductive deafness
due to mass effect of pus

10. Stage of Exudation

11. Stage of Exudation

12. Stage of Exudation

13. Stage of Exudation

14. Nipple sign (impending perforation)
Localized protrusion
of tympanic
membrane due to
destruction of
fibrous layer by
continuous pressure
of pus

15. 3. Stage of Suppuration
Symptoms:
 Ear discharge (blood-stained  purulent)
 Increased deafness
 Decreased fever
 Decreased earache

16. Blood stained otorrhoea

17. Signs & Investigations
 Pinhole perforation + otorrhoea
 Light house sign: intermittent reflection of light
 Decreased mastoid tenderness
 High (mass effect) + low frequency (stiffness eff
ect of thick periosteum) Conductive deafness
 Clouding of air cells in mastoid X-ray

18. Light House sign

19. Pinhole perforation

20. Clouding of mastoid cells

21. 4. Stage of Coalescent Mastoiditis
 Otorrhoea > 2 weeks, otalgia & deafness
 Mastoid reservoir sign: pus fills up on mopping
 Sagging of postero-superior canal wall caused by p
eri-osteitis due to pus in adjacent mastoid antrum
 Ironed out appearance of skin over mastoid due to th
ickened periosteum
 Mastoid cavity in X-ray & CT scan

22. Pathogenesis

23. Mastoid reservoir sign

24. Sagging of posterior wall

25. Ironed out appearance

26. Mastoid cavity

27. Mastoid cavity

28. 5. Stage of Resolution
 Otorrhoea
stops
 Normal
hearing
 Healed perfo
ration

29. Stage of Resolution

30. Sterile exudate in middle
ear

31. 6. Stage of Complications
 Sub-periosteal abscess
 Vertigo
 Headache + blurred vision + projectile vomiting
 Fever + neck rigidity + irritability
 Drowsiness
 Gradenigo syndrome (apex petrositis)

32. Treatment of A.S.O.M.
1. Systemic Antibiotic
2. Nasal decongestants (systemic + topical)
3. H1 anti-histamines
4. Analgesic + anti-pyretic
5. Aural toilet for ear discharge

33. Nasal Decongestants
Systemic decongestants
 Phenylephrine
 Pseudoephedrine
Topical decongestants
 Xylometazoline
 Oxymetazoline
 Saline

34. Topical Decongestants
 Oxymetazoline 0.05 %: 2-3 drops BD
 Oxymetazoline 0.025 %: 2 drops BD
 Xylometazoline 0.1 %: 3 drops TID
 Xylometazoline 0.05 %: 2 DROP BD
 Saline 2 %: 3 drops TID
 Saline 0.67 %: 2 drops BD

35. On review after 48 hours
 Earache + fever persists: change to higher antibioti
c. If T.M. is bulging  perform myringotomy. Send e
ar discharge for C/S.
 Earache + fever subside: continue same treatmen
t for 10-14 days
 Review after 3 months

36. On review after 3 months
 No effusion: no further treatment
 Effusion persists: treat as Otitis Media
with Effusion
 Presence of abscess or coalescent mastoiditi
s: do cortical mastoidectomy

37. Myringotomy in A.S.O.M.
Curvilinear incision made in pos
tero-inferior quadrant.
Incision is curvilinear & not radi
al (as in OME), to cut fibres of T
M. This keeps opening patent f
or long time.

38. Why make incision in PIQ?
 Least vascular area
 T.M. bulge is maximum
 Ossicles not damaged
 Easily accessible

39. Thank you