1. Acute otitis media andAcute otitis media and
mastoiditismastoiditis
Chunfu Dai M.D & Ph.DChunfu Dai M.D & Ph.D
Otolaryngology DepartmentOtolaryngology Department
Fudan UniveristyFudan Univeristy

2. DefinitionDefinition
 AOM: is an infectious process ofAOM: is an infectious process of
the middle ear cleft and to athe middle ear cleft and to a
variable extent, of the mastoid airvariable extent, of the mastoid air
cell system.cell system.

3. BacteriologyBacteriology
 Streptococcus pneumoniaeStreptococcus pneumoniae
(48%)(48%)
 Haemophilus influenzae (31%)Haemophilus influenzae (31%)
 Moraxella catarrhalis (20%)Moraxella catarrhalis (20%)
 P-hemolytic streptococcusP-hemolytic streptococcus
(decreased following widespread(decreased following widespread
immunization program)immunization program)
 Pseudomonas aeruginosaPseudomonas aeruginosa
(uncommon cause of AOM)(uncommon cause of AOM)

4. 阻断细菌耐药性的“恶性循环”
感染
耐药性
增加
传播
选择
耐药菌
细菌
未消除
不合理
治疗
合 理
治 疗
临 床
治 愈
细 菌
消 除

5. (Doern. Am J Med. 1995;99(6B): 3S-7S; Jacobs et al., AAC 1999:43:1901; Jacobs et al
abstract C-61, ICAAC 1999)
0
10
20
30
40
50
%PenicillinResistance
中度敏感 (0.12 - 1.0 µg/ml)
耐药 (≥ 2.0 µg/ml)
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988-89
1990-91
1992-93
1994-95
1997
1998
16%
18%
29%
33%
青霉素耐药的肺炎链球菌
79 － 98 年在美国流行情况

6. Routine of infectionRoutine of infection
 Via eustachian tubeVia eustachian tube
 upper respiratory infectionupper respiratory infection
(acute rhinonitis and nasal(acute rhinonitis and nasal
pharyngitis)pharyngitis)
 Upper respiratoryUpper respiratory
communicative diseasecommunicative disease
(diaphea, mealse, et al)(diaphea, mealse, et al)
 Swimming and dive in unclearSwimming and dive in unclear
waterwater
 Anatomic contributionAnatomic contribution
(Eustachian tube in infant is(Eustachian tube in infant is
wide and short and the twowide and short and the two
orifice in the same level)orifice in the same level)

7. Routine of infectionRoutine of infection
 Via external acousticVia external acoustic
canal and TMcanal and TM
 PerforationPerforation
 Myringotomy or myrigotosisMyringotomy or myrigotosis
 Via blood supplyVia blood supply

8. PathologyPathology
 Mucosal inflammationMucosal inflammation
 Serous, hemorrhagic,Serous, hemorrhagic,
or purulent exudate inor purulent exudate in
middle cavitymiddle cavity
 Rupture of tympanicRupture of tympanic
membranemembrane

9. SymptomsSymptoms
 FeverFever
 It may be masked by analgesics orIt may be masked by analgesics or
antibioticantibiotic
 OtalgiaOtalgia
 60% patients can spontaneous remission60% patients can spontaneous remission
 FullnessFullness
 Hearing lossHearing loss

10. Physical findingsPhysical findings
 Increased vascularizationIncreased vascularization
of the TM, initially locatedof the TM, initially located
in pars of flaccida,in pars of flaccida,
frequently spreadingfrequently spreading
beyond the annulus tobeyond the annulus to
the skin of the externalthe skin of the external
canal.canal.
 Bony landmarks areBony landmarks are
visible.visible.

11. Cholesteatoma Formation

12. Physical findingsPhysical findings
 Rapid middle earRapid middle ear
exudation occurs,exudation occurs,
 Blurring of the mallwallBlurring of the mallwall
short process, followedshort process, followed
by edema and bulging ofby edema and bulging of
the pars flaccida.the pars flaccida.

13. Physical findingsPhysical findings
 The progression of thisThe progression of this
disease may result in rupturedisease may result in rupture
of TM, releasing the middleof TM, releasing the middle
ear contents (beating sign)ear contents (beating sign)
leads to relief of otalgia andleads to relief of otalgia and
retraction of the pars flaccidaretraction of the pars flaccida

14. Lab testsLab tests
 Blood counts usually shows leukocytosisBlood counts usually shows leukocytosis
with polymorphonuclear elevation.with polymorphonuclear elevation.
 CT and MRI is necessary only for the rareCT and MRI is necessary only for the rare
patients with a serious complicationpatients with a serious complication
(meningitis or brain abscess)(meningitis or brain abscess)

15. Hearing testsHearing tests
 Conductive hearing lossConductive hearing loss
 Degree of hearing lossDegree of hearing loss
will depend on thewill depend on the
amount and viscosity ofamount and viscosity of
the middle ear exudate,the middle ear exudate,
TM edemaTM edema
 It vary from 10-50 dB withIt vary from 10-50 dB with
predominant involvementpredominant involvement
of the low frequenciesof the low frequencies
 Hearing loss may mixedHearing loss may mixed
when there is labyrinthinewhen there is labyrinthine
extension.extension.

16. ManagementsManagements
 Antibiotic therapyAntibiotic therapy
 ExperiencesExperiences
 Antibiotic sensitivity and bacteriologic cultureAntibiotic sensitivity and bacteriologic culture
 Traditional duration 10-14 dTraditional duration 10-14 d
 Currently duration 5-7 dCurrently duration 5-7 d

17. ManagementsManagements
 Nasal decongestantsNasal decongestants
 Best rest, light dietBest rest, light diet
 Avoidance of irritants (smoking)Avoidance of irritants (smoking)

18. ManagementsManagements
 Pre-perforationPre-perforation
 Pain relief drugsPain relief drugs
 Surgery: myringotomySurgery: myringotomy
 Progression with a red,Progression with a red,
bulging TM, severe otalgiabulging TM, severe otalgia
and feverand fever
 Otitis media with impendingOtitis media with impending
complicationscomplications
 perforation is not big enoughperforation is not big enough
to drain all pusto drain all pus

19. ManagementsManagements
 Post-proferation:Post-proferation:
 Clear-up pus with 3% hydro-oxygenClear-up pus with 3% hydro-oxygen
 Antibiotic ear dropsAntibiotic ear drops
 With pus decreased and inflammationWith pus decreased and inflammation
disappeared, alcohol can be used to facilitatedisappeared, alcohol can be used to facilitate
dry ear.dry ear.

20. Follow-upFollow-up
 Adequately treated AOM effusion mayAdequately treated AOM effusion may
persist for 2-6 weeks or even longer.persist for 2-6 weeks or even longer.
 Managements may requireManagements may require
 extended antibiotic treatmentextended antibiotic treatment
 Otoscope and audiometric tests should beOtoscope and audiometric tests should be
performed 3-4 weeks following apparentperformed 3-4 weeks following apparent
resolution of the acute infectionresolution of the acute infection
 Insertion of pressure equalization tubes dueInsertion of pressure equalization tubes due
to fluid persists beyond 3 monthsto fluid persists beyond 3 months

21. Acute mastoiditisAcute mastoiditis
 Definition: an infection of the mastoidDefinition: an infection of the mastoid
characterized by diffuse osteitis followed bycharacterized by diffuse osteitis followed by
rarefaction and breakdown of the bony septae.rarefaction and breakdown of the bony septae.
 Acute coalescent mastoiditisAcute coalescent mastoiditis
 Haemorrhagic mastoiditisHaemorrhagic mastoiditis
 Masked mastoiditisMasked mastoiditis
 Predisposition to pneumatic mastoidPredisposition to pneumatic mastoid
 Predilection to kidPredilection to kid
 Mastoid is mature at age of 4 year oldMastoid is mature at age of 4 year old

22. Acute mastoiditisAcute mastoiditis
 Reduction of immune systemReduction of immune system
 Strong bacteria (type III pneumococus,Strong bacteria (type III pneumococus,
haemolytic streptococcus)haemolytic streptococcus)
 Obstruction- not effective drainageObstruction- not effective drainage
 Imcompletely treatmentImcompletely treatment

23. Acute mastoiditisAcute mastoiditis
 SymptomsSymptoms
 Symptoms may follow AOM, with or without aSymptoms may follow AOM, with or without a
symptom-free interval of a few days to severalsymptom-free interval of a few days to several
weeks or more.weeks or more.
 OtalgiaOtalgia
 Aural dischargeAural discharge
 Conductive hearing lossConductive hearing loss
 feverfever

24. Acute mastoiditisAcute mastoiditis
 Physical findingsPhysical findings
 Fever, from a slight elevation to 39Fever, from a slight elevation to 39
 Otorrhea may be absentOtorrhea may be absent
 Pulsatile may be observedPulsatile may be observed
 Tympanic perforation is present, but it may be obscured byTympanic perforation is present, but it may be obscured by
intense edemaintense edema
 Swelling of the superior TM and posterosuperior wall of EACSwelling of the superior TM and posterosuperior wall of EAC
 Postauricular areaPostauricular area
 erythema and tendernesserythema and tenderness
 Pitting edemaPitting edema
 Obliteration of the postauricular creaseObliteration of the postauricular crease

25. Acute mastoiditisAcute mastoiditis
 RadiographicRadiographic
evaluationevaluation
 DiffuseDiffuse
rarefaction ofrarefaction of
bone andbone and
breakdown ofbreakdown of
cellular sepaecellular sepae

26. Acute mastoiditisAcute mastoiditis
 interventionsinterventions
 Medical managementMedical management
 AntibioticAntibiotic
 Intravenous antibiotic therapy should be maintained for at leastIntravenous antibiotic therapy should be maintained for at least
24-48 h after the resolution of symptoms24-48 h after the resolution of symptoms
 Then followed with oral antibiotic for 2 weeksThen followed with oral antibiotic for 2 weeks
 Surgical managementSurgical management
 Emergency surgery: simple mastoidectomyEmergency surgery: simple mastoidectomy
 Mastoidectomy + ventilation tube placementMastoidectomy + ventilation tube placement