acute suppurative otitis media dr. vishal sharma
TRANSCRIPT
Acute Suppurative Otitis Media
Dr. Vishal Sharma
Definition
Pyogenic infection of middle ear cleft lasting for
< 3 weeks.
Routes for infection:
1. Via Eustachian tube
2. Via Tympanic membrane perforation
3. Haematogenous (rare)
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
Bacteriology
1. Haemophilus influenzae
2. Streptococcus pneumoniae
3. Staphylococcus aureus
4. Moraxella catarrhalis
5. - Hemolytic streptococci (causes acute
necrotizing otitis media)
Stages of A.S.O.M.
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
vessels from handle of malleus
Cart wheel appearance
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
Stage of Exudation
Stage of Exudation
Stage of Exudation
Stage of Exudation
Nipple sign (impending perforation)
Localized protrusion
of tympanic
membrane due to
destruction of
fibrous layer by
continuous pressure
of pus
3. Stage of Suppuration
Symptoms:
Ear discharge (blood-stained purulent)
Increased deafness
Decreased fever
Decreased earache
Blood stained otorrhoea
Signs & Investigations
Pinhole perforation + otorrhoea
Light house sign: intermittent reflection of light
Decreased mastoid tenderness
High (mass effect) + low frequency (stiffness
effect of thick periosteum) Conductive deafness
Clouding of air cells in mastoid X-ray
Light House sign
Pinhole perforation
Clouding of mastoid cells
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
peri-osteitis due to pus in adjacent mastoid antrum
Ironed out appearance of skin over mastoid due to
thickened periosteum
Mastoid cavity in X-ray & CT scan
PathogenesisAditus Blockage
Failure of drainage
Stasis of secretions
Hyperemic decalcification
Resorption of bony septa of air cells
Coalescence of small air cells to form cavity
Empyema of mastoid cavity
Pathogenesis
Mastoid reservoir sign
Sagging of posterior wall
Ironed out appearance
Mastoid cavity
Mastoid cavity
5. Stage of Resolution
Otorrhoea
stops
Normal
hearing
Healed
perforation
Stage of Resolution
Sterile exudate in middle ear
6. Stage of Complications
Sub-periosteal abscess
Vertigo
Headache + blurred vision + projectile vomiting
Fever + neck rigidity + irritability
Drowsiness
Gradenigo syndrome (apex petrositis)
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
6. Heat application for severe earache
7. Review after 48 hours
Amoxicillin-clavulanate duo: 625 mg B.D.
Ciprofloxacin: 500mg B.D.
Doxycycline: 100 mg B.D.
Cefadroxil: 500 mg B.D.
Cefaclor: 500 mg T.I.D.
Cefuroxime: 250 mg B.D.
Cefixime: 200 mg B.D.
Cefpodoxime: 200 mg B.D.
Azithromycin: 500 mg O.D.
Clarithromycin: 250 mg B.D.
Antihistamines
Systemic:
Cetirizine: 10 mg OD
Fexofenadine: 120 mg OD
Loratidine: 10 mg OD
Levocetrizine: 5 mg OD
Desloratidine: 5 mg OD
Topical: Azelastine spray (0.1%): 1-2 puff BD
Nasal Decongestants
Systemic decongestants
Phenylephrine
Pseudoephedrine
Topical decongestants
Xylometazoline
Oxymetazoline
Saline
Anti-cold preparationsName Chlorpheniramine Decongestant Paracetamol
COLDIN 4 mg PsE 60 mg 500 mg
SINAREST 4 mg PsE 60 mg 500 mg
DECOLD 4 mg PhE 7.5 mg 500 mg
SUPRIN 2 mg PhE 5 mg 500 mg
PsE = Pseudoephedrine; PhE = Phenylephrine
Topical Decongestants
Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)
Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P)
Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)
Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)
Saline 2 %: 3 drops TID
Saline 0.67 %: 2 drops BD (NASIVION-S)
On review after 48 hours
Earache + fever persists: change to higher
antibiotic. If T.M. is bulging perform myringotomy.
Send ear discharge for C/S.
Earache + fever subside: continue same
treatment for 10-14 days
Review after 3 months
On review after 3 months No effusion: no further treatment
Effusion persists: treat as Otitis Media
with Effusion
Presence of abscess or coalescent
mastoiditis: do cortical mastoidectomy
Myringotomy in A.S.O.M.
Curvilinear incision made in
postero-inferior quadrant.
Incision is curvilinear & not
radial (as in OME), to cut
fibres of TM. This keeps
opening patent for long time.
Why make incision in PIQ?
Least vascular area
T.M. bulge is maximum
Ossicles not damaged
Easily accessible
Sub-periosteal abscess & fistula
Pathology
Production of pus under tension
hyperaemic decalcification (halisteresis)
+ osteoclastic resorption of bone
sub-periosteal abscess
penetration of periosteum + skin
fistula formation
Sub-periosteal abscess formation
Sub-periosteal fistula: dry
Sub-periosteal fistula: wet
Types of sub-periosteal abscess
Post-auricular
Bezold
Citelli
Zygomatic
Luc
Retro-mastoid
Parapharyngeal & Retropharyngeal
Types of sub-periosteal abscess
Post-auricular abscess
Commonest. Present behind the ear.
Pinna pushed forward & downward.
Bezold & Citelli abscesses
Bezold: neck swelling
over sternocleido-
mastoid muscle
Citelli: neck swelling
over posterior belly
of digastric muscle
Bezold’s abscess
Bezold’s abscess
Luc: swelling in external auditory canal
Zygomatic: swelling antero-superior to pinna +
upper eyelid oedema
Retro-mastoid: swelling over occipital bone
(? Citelli’s abscess)
Parapharyngeal & Retropharyngeal: due to spread
of pus along Eustachian tube
Retromastoid abscess
Gradenigo syndrome
Giuseppe Gradenigo (1859 – 1926)
Defining triad
Persistent otorrhoea: despite adequate
cortical mastoidectomy
Retro-orbital pain: Trigeminal nerve involvement
Diplopia: convergent squint due to lateral rectus
palsy by injury to abducent nv in Dorello’s canal under
Gruber’s petro-sphenoid ligament, at petrous apex
Persistent otorrhoea + Retro-orbital pain +
Convergent squint
Right Convergent squint
Right gaze Central gaze Left gaze
Etiology: Coalescent mastoiditis involving
petrous apex along postero-superior & antero-
inferior tracts in relation to bony labyrinth
Diagnosis: 1. C.T. scan temporal bone for bony
details. 2. M.R.I. to differ b/w bone marrow & pus
Treatment: Modified radical mastoidectomy &
clearance of petrous apex cells
C.T. scan & M.R.I.
Hearing preserving approaches to petrous apex
Eagleton’s middle cranial fossa approach
Frenckner’s subarcuate approach
Thornwaldt’s retro-labyrinthine approach
Dearmin & Farrior’s infra-labyrinthine approach
Farrior’s hypotympanic sub-cochlear approach
Lempert Ramadier’s peri-tubal approach
Kopetsky Almoor’s peri-tubal approach
Hearing sacrificing approaches to petrous apex Trans-cochlear approach Trans-labyrinthine approach
Spread of pus
Post-auricular: Lateral spread
Bezold: Inferior spread
Citelli: Inferior spread
Luc: Anterior spread
Zygomatic: Superior spread
Retro-mastoid: Posterior spread
Parapharyngeal: Medial spread
Retropharyngeal: Medial spread
Gradenigo syndrome: Medial spread
Cortical Mastoidectomy
Antiseptic dressing
Draping
Infiltration
Marking of incision
Wilde’s post-aural incision
Incision deepened
Musculoperiosteal flap elevated
Bezold’s abscess
Aspiration of pus
Drainage of abscess
Drainage of abscess
Corical mastoidectomy begun
Exposure of mastoid antrum
Widening of aditus
Aditus widened
Final Cavity
Cortical Mastoidectomy
Drain put in mastoid cavity
Mastoid dressing
Healed post-aural scar
Thank you