acute suppurative otitis media dr. vishal sharma
TRANSCRIPT
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Acute Suppurative Otitis Media
Dr. Vishal Sharma
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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)
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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
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Bacteriology
1. Haemophilus influenzae
2. Streptococcus pneumoniae
3. Staphylococcus aureus
4. Moraxella catarrhalis
5. - Hemolytic streptococci (causes acute
necrotizing otitis media)
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Stages of A.S.O.M.
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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
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Cart wheel appearance
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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
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Stage of Exudation
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Stage of Exudation
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Stage of Exudation
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Stage of Exudation
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Nipple sign (impending perforation)
Localized protrusion
of tympanic
membrane due to
destruction of
fibrous layer by
continuous pressure
of pus
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3. Stage of Suppuration
Symptoms:
Ear discharge (blood-stained purulent)
Increased deafness
Decreased fever
Decreased earache
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Blood stained otorrhoea
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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
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Light House sign
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Pinhole perforation
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Clouding of mastoid cells
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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
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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
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Pathogenesis
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Mastoid reservoir sign
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Sagging of posterior wall
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Ironed out appearance
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Mastoid cavity
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Mastoid cavity
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5. Stage of Resolution
Otorrhoea
stops
Normal
hearing
Healed
perforation
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Stage of Resolution
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Sterile exudate in middle ear
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6. Stage of Complications
Sub-periosteal abscess
Vertigo
Headache + blurred vision + projectile vomiting
Fever + neck rigidity + irritability
Drowsiness
Gradenigo syndrome (apex petrositis)
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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
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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.
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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
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Nasal Decongestants
Systemic decongestants
Phenylephrine
Pseudoephedrine
Topical decongestants
Xylometazoline
Oxymetazoline
Saline
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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
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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)
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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
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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
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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.
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Why make incision in PIQ?
Least vascular area
T.M. bulge is maximum
Ossicles not damaged
Easily accessible
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Sub-periosteal abscess & fistula
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Pathology
Production of pus under tension
hyperaemic decalcification (halisteresis)
+ osteoclastic resorption of bone
sub-periosteal abscess
penetration of periosteum + skin
fistula formation
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Sub-periosteal abscess formation
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Sub-periosteal fistula: dry
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Sub-periosteal fistula: wet
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Types of sub-periosteal abscess
Post-auricular
Bezold
Citelli
Zygomatic
Luc
Retro-mastoid
Parapharyngeal & Retropharyngeal
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Types of sub-periosteal abscess
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Post-auricular abscess
Commonest. Present behind the ear.
Pinna pushed forward & downward.
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Bezold & Citelli abscesses
Bezold: neck swelling
over sternocleido-
mastoid muscle
Citelli: neck swelling
over posterior belly
of digastric muscle
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Bezold’s abscess
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Bezold’s abscess
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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
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Retromastoid abscess
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Gradenigo syndrome
Giuseppe Gradenigo (1859 – 1926)
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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
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Persistent otorrhoea + Retro-orbital pain +
Convergent squint
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Right Convergent squint
Right gaze Central gaze Left gaze
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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
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C.T. scan & M.R.I.
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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
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Hearing sacrificing approaches to petrous apex Trans-cochlear approach Trans-labyrinthine approach
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Spread of pus
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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
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Cortical Mastoidectomy
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Antiseptic dressing
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Draping
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Infiltration
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Marking of incision
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Wilde’s post-aural incision
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Incision deepened
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Musculoperiosteal flap elevated
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Bezold’s abscess
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Aspiration of pus
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Drainage of abscess
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Drainage of abscess
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Corical mastoidectomy begun
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Exposure of mastoid antrum
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Widening of aditus
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Aditus widened
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Final Cavity
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Cortical Mastoidectomy
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Drain put in mastoid cavity
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Mastoid dressing
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Healed post-aural scar
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Thank you