middle ear disorder-ENT

1. ACUTE
SUPPURATIVE
OTITIS MEDIA
BY:
NEHIL NIGAM

2. CLASSIFICATION OF OTITIS MEDIA
Otitis media
suppurative
acute Chronic
Tubotympanic(safe
type)
Atticoantral
(unsafe type)
Non-suppurative
Acute Chronic adhesive

3. OTITIS MEDIA
 Inflammation of the middle ear.
 Middle ear implies middle ear cleft, which
includes:
Eustachian tube
Middle ear
Attic
Additus
Antrum
Mastoid air cells

4. Anatomy of ear

6. AETIOLOGY
• More common especially in infants and children
of lower socioeconomic group.
• The disease typically follows viral infection of
upper respiratory tract:
Rhinovirus
RSV
Influenza virus
enterovirus

7. BACTERIOLOGY
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
Also,
• Streptococcus pyogens
• Staphylococcus aureus
• Pseudomonas aeruginosa

8. ROUTES OF INFECTION
1. Via Eustachian tube.
2. Via external ear.
3. Blood-borne.

9. Understanding position of
Eustachian tube:
Ant.
Cranial
fossa
Middle cranial
fossa
Posterior
cranial
fossa
Jugular
fossa
Sphenoid
sinus
nasopharynx

11. Normal functions of Eustachian tube
• Normally Eustachian tube is closed.
• Functions:
Ventilation and thus regulation of middle ear pressure
Protection against
Nasopharyngeal reflux of nasopharyngeal
sound pressure secretions
Clearance of middle ear secretions

12. Via Eustachian tube
• Most common route.
• In infants and young children, tube
is:
Shorter
Wider
More horizontal
Via External ear
•Due to traumatic perforation of tympanic
membrane.
Blood-borne

13. PREDISPOSING FACTORS
Anything that interferes with the normal functioning
of Eustachian tube, predisposes to middle ear
infection, like:
1. Recurrent attacks of common cold
2. URI
3. Measles, diphtheria or whooping cough
4. Infection of tonsils and adenoids
5. Chronic rhinitis
6. Sinusitis
7. Nasal allergy
8. Tumors of nasopharynx, packing of nose or
nasopharynx for epistaxis
9. Cleft palate.
10. Down syndrome

14. PREDISP
OSING
FACTORS
Acute tubal blockage
Absorption of middle
ear gases
Negative pressure in
middle ear
Transudate in middle
ear/ haemorrhage
Prolonged tubal
blockage
OME (thin watery or
mucoid discharge)
Atelactatic
ear/perforation
Retraction pocket/
cholesteatoma
Erosion of
incudostapedial joint

15. (A) incomplete unilateral cleft of the lip, (B) unilateral cleft of the lip, alveolus, and palate, (C) bilateral cleft of
the lip, alveolus, and palate, (D) isolated (median) cleft palate.

16. Torus
tubarius
Tensor
veli
palatini
muscle

17. PATHOLOGY AND CLINICAL FEATURES
STAGE OF
TUBAL
OCCLUSION
STAGE OF
PRESUPPURATION
STAGE OF
SUPPURATION
STAGE OF
RESOLUTION
STAGE OF
COMPLICATIONS

18. STAGE OF TUBAL OCCLUSION
PATHOLOGY SYMPTOMS SIGNS
Tubal blockage due to
edema and hyperemia of
nasopharyngeal end of
Eustachian tube
Deafness
Earache
NOT marked
Generally no fever
T.M. retracted
Handle of malleus –
horizontal
Prominence of lateral
process of malleus
Loss of light reflex
Tuning fork test-conductive
deafness

19. Normal tympanic membrane

20. As the drum becomes increasingly retracted, it drapes over the ossicular chain,
and the incus and stapes head may be outlined.

21. STAGE OF PRESUPPURATION
PATHOLOGY SYMPTOMS SIGNS
Pyogenic organisms
invade tympanic cavity
Hyperemia of lining of
tympanic cavity
Inflammatory exudate
in middle ear
Tympanic membrane-congested
Marked throbbing
headache
Adults – deafness and
tinnitus
Children – high degree
of fever and restlesness
Congestion of pars
tensa
Cartwheel appearance
of pars tensa
Later- congestion of
whole tympanic
membrane
Tuning fork test-conductive
deafness
found

22. Normal Congested tympanic
membrane

23. STAGE OF SUPPURATION
PATHOLOGY SYMPTOMS SIGNS
Marked pus formation
in middle ear
May extend upto
mastoid air cells
Excruciating earache
Deafness increases
Children- fever 102-
103 degree F
Vomiting
Convulsions
Redness and bulging in
tympanic membrane
handle of malleus-engulfed
Yellow spot on T.M.
where rupture imminent
X-ray of mastoid-clouding
of air cells

26. STAGE OF RESOLUTION
PATHOLOGY SYMPTOMS SIGNS
T.M. – ruptures with
release of pus
Hence subsidence of
symptoms
Earache relieved
Fever – down
EAC- blood tinged
discharge may be
present
Small perforation in
anteroinferior
quadrants of pars tensa
Hyperemia of T.M.
subsides- normal colour
and landmarks

28. STAGE OF COMPLICATIONS
Acute Mastoiditis
Petrositis GRADENIGO’S SYNDROME
Sub-periosteal abscess
Facial paralysis
Labyrinthitis
Extradural abscess
Meningitis
Brain abscess or lateral sinus thrombophlebitis

29. • Gradenigo's syndrome, also called Gradenigo-Lannois
syndrome and petrous apicitis
is a complication of otitis
media and mastoiditis involving the apex of the
petrous temporal bone.
SYMPTOMS:
triad of symptoms consisting of
 periorbital unilateral pain related to trigeminal nerve
involvement,
 diplopia due to sixth nerve palsy (Dorello’s canal)
 persistent otorrhea, associated with bacterial
otitis media with apex involvement of the petrous part
of the temporal bone (petrositis).

30. retroorbital pain due to pain in the area supplied by the
ophthalmic branch of the trigeminal nerve (fifth cranial
nerve),
Bell's palsy caused by invo lvement of the facial
nerve (seventh cranial nerve), and
otitis media.
Other symptoms can include photophobia,
excessive lacrimation, fever, and
reduced corneal sensitivity.
The syndrome is usually caused by the spread of
an infection into the petrous apex of the temporal bone.
TREATMENT:
Mastoid exploration.
Exeneration of the cell tracts leading to petrous apex

31. TREATMENT
Acute otitis
media
Antibacterial
therapy
Earache and
fever
Complete
resolution
Review after 48-
72hours
Good response
Persistent fluid
but earache and
fever abate
Complete
resolution (no
effusion)
Persistent
effusion
Treat as otitis
media with
effusion
Complete
resolution
Another antibacterial
therapy therapy for 10 days
or myringotomy and culture
and specific antimicrobial
for 10 days
Periodic checks for 12
weeks

32. DRUGS
 Antimicrobial agents:
 Amoxicillin
 Ampicillin
 co-amoxiclav
 Erythromycin
 Cephalosporins
 Decongestant nasal drops:
 Ephedrine

33. Oral nasal decongestants:
Pseudoephedrine
Analgesics:
Paracetamaol
Ear toilet:
Dry local heat
Myringotomy: incising the drum to evacuate
pus.

34. • Indications of myringotomy:
 Bulging drum and acute pain
 Incomplete resolution
 drum remains full with persistent conductive
deafness
 Persistent effusion beyond 12 weeks
 Onset of complications like facial nerve
paralysis or labyrinthitis
 Serous otitis media
 Non suppurative otitis media

35. PREVENTION
Routine childhood vaccination against:
pneumococci (with pneumococcal conjugate
vaccine),
 H. influenzae type B, and
influenza
decreases the incidence of AOM.
Infants should not sleep with a bottle, and
elimination of household smoking may decrease
incidence.