Otitis Media

By Dr. Rajal Sukhiyaji

Structure of Ear

Acute Suppurative Otitis Media

Definition :-• It is an acute pyogenic infection of the mucosa of the middle ear cleft.

Aetiology :-• Age :- any, but more common in children• Sex :- Male = Female• Geographic variation :- None• Reduced vitality• Atmospheric pressure changes, as during flying and diving• Upper respiratory tract infection• Swimming

Pathophysiology1) Eustachian tube :-

Anatomical obstruction Forcible blowing of nose Source of infection :

i. Adenoiditisii. Tonsillitisiii. Rhinitisiv. Pharyngitisv. Influenzavi. Infections secondary to cleft palate.

Feeding an infant with a bottle in supine position may permit contaminated milk to enter the tube.

Iatrogenic

2) External ear :- following traumatic rupture of the tympanic membrane.3) Head injury :- fracture of temporal bone.4) Haematogenous spread

The causative organisms are as follows :-• Streptococcus haemolyticus• Staphylococcus aureus• Haemophilus influenza• Penumococcus• Non-haemolytic Streptococcus.

Pathology :-Stage Features Symptoms Signs

Catarrhal Occlusion of the Eustachian tube.Congestion in the middle ear.

• Fullness and heaviness in the ear.

• Pain: severe, worse at night in recumbent position

• Deafness: progressive

• Tinitus: bubbling• Autophony: own

spoken words echo in the ear.

• Constitutional symptoms: fever, malaise.

• Retraction of tympanic membrane: early

• Congestion of tympanic membrane

Exudation • Collection of exudate in the middle ear, mucoid in the beginning, purulent later on

• Lateral bulging of the tympanic membrane.

All symptoms as Catarrhal, but more severe.

• A point is seen on the tympanic membrane as a yellow nipple, the site of future perforation.

• Tenderness of mastoidism.

Suppuration • Pus collects in the middle ear under tension

• Tympanic membrane bulges laterally and finally gets perforated, discharging pus into the external ear.

• Perforation of the drum and escape of pus into the auditory canal: otorrhoea is initially, blood stained and later mucoid to frankly purulent.

• Lessening of pain and constitutional symptoms.

• A small perforation is seen

• Pulsatile discharge from the perforation, due to synchronization with arterial pulsations

( lighthouse sign ).

Healing • Resolution may begin at any of the stages, depending upon patient’s resistance and antibiotic therapy.

May begin at any stage.

Coalescent mastoiditis

• Coalescent mastoiditis:-Block of the aditus to antrum by granulations and oedema, collection of pus under tension within the mastoid, and coalescence of mastoid air cells due to break down of septa between them.

• Catarrhal mastoiditis

• Empyema of mastoid.

Investigation

• Test of hearing1. Tuning fork tests2. Audiometry• Microbiologic tests :on the ear discharge• Radiography

Treatment 1) Systemic :-• Broad spectrum antibiotics : Penicillin, Ampicillin, Amoxycillin

• Nasal decongestants• Systemic decongestants• NSAID• Rest2) Local :-• Ear drops• Aural toilet3) Surgical : Myringotomy

Chronic Otitis Media

• It is the chronic infection of the middle ear cleft mucosa.

• It may be divided into 3 groups :1. Chronic suppurative otitis media (otorrhoea,

continuous/intermittent)2. Chronic non-suppurative otits media (no

otorrhoea)3. Chronic specific otitis media (TB/syphilitic otitis

media)

1) Chronic Suppurative Otitis Media• Definition :- CSOM is a chronic inflammatory process involving the middle ear cleft producing irreversible pathological changes.

• Classification :1)Benign or Tubotympanic type : • Central perforation of the tympanic membrane. • Limited to the tympanum and the Eustachian tube.• No complication2) Dangerous or atticoantral type :• Marginal perforation• Destructive cholesteatoma in the attic and the antrum• Life threatening complications

Aetiology :• Age : any• Sex : Male = Female• Low socioeconomic status• Malnutrition• Poor hygiene• Persistence of acute suppurative media

Pathophysiology :1) Microbiology : organisms are as follows.

Benign tubotympanic perforationi. Streptococciii. Staphylococciiii. Pneumococci

Atticoantral or dangerous perforationi. Bacillus pyocyneuii. Bacillus proteusiii. Bacillus coli

Acute nacrotic otitis mediai. Haemolytic streptococci

2) Sequelae of acute suppurative otitis media3) Clinical stages :

Benign perforation i. Active : active flow of dischargeii. Quiscent : ear is dry for up to 6 monthsiii. Inactive : ear is dry for more than 6 months.iv. Healing

Dangerous perforation :it is always in the active stage.

Pathology :

Reduced blood supply of ear drumNecrosis start

Affects ossiclesSclerosis of mastoid

Polyps may comeTympanosclerosis due to hyaline degeneration of middle layer of

mucosa with calcificationOssicular chain discontinuityAdhesions of tympanic cavity

Cholesteatoma :- • It occurs in dangerous type otitis media. It is a sac lined by keratinising stratified squamous epithelium in the middle ear cleft and contains desquamated epithelium arranged like onion – skin layer.

• It has got consistency of a tooth paste with high destructive power.

• Hence, it is defined as a “ non malignant bone destroying disease of ear “.

Symptoms :1) Otorrhoea 2) Deafness ( mild to moderate degree )3) Earache 4) Tinitus5) Giddiness (due to labyrinthitis)6) Bleeding or blood-stained discharge (due to

granulations or polyps)7) Swelling in the mastoid region due to

mastoid abscess.

Signs :

1) Perforation • Central in benign type• Marginal in dangerous type2) Tenderness over the mastoid : due to

mastoiditis

Investigation :1) Examination of nose/pharynx2) Hearing tests3) Microbiologic studies : on the ear discharge4) Radiology of mastoid5) Tests for patency of Eustachian tube :

If the ear drops reaches the throat, the tube is patent.

6) Otomicroscopy 7) Fistula test8) Examination of the CNS for intracranial

complications.

Treatment :1. Conservative treatment:

Removal of septic foci like adenoids, tonsils, sinusitis. Aural toilet :

Prevention of entry of water into the ear. Cleaning of the ear with a dry swab stick or suction.

Ear drops : otorrhoea : antiseptic or antibiotic ear drops, as in acute suppurative otitis media. The drops are changed if there is no response in 6 or 7 days.

Chemical cautery Good nutrition Improvement of general condition

2) Surgical treatment : Adenoidectomy, septoplasty Aural polypectomy : Removal of polyps and granulation followed by chemical cauterization or by tympanoplasty

Myringoplasty Tympanoplasty : reconstructive surgery of the damaged ossicles and the membrane.

Depending upon extent of disease and degree of deafness, various surgical procedures are undertaken like, oAtticotomyoModified radical mastoidectomyoRadical mastoidectomyoMastoidectomy with tympanoplastyoCombined approach tympanoplasty (CAT)

Comparison of Benign and Dangerous Types of CSOM

Variable Benign type Dangerous type

Site Tubotympanic Atticoantral Perforation Central Attic or marginal Discharge • Intermittent

• Mucopurulent / purulent• Without foul smell• White/yellowish• Copious• Bleeding uncommon• More with upper

respiratory tract infection.

• Continuous • Purulent • Foul smelling• Yellowish/brownish/

greenis• Often scanty• Bleeding possible• No effect of upper

respiratory tract infection.

Deafness • Conductive, mild to moderate

• Conductive/mixed, mild to severe

Polyp Occasional Common

Cholesteatoma Very rare Almost always present

Complications Very rare Common

Radiography of mastoid

Cellular/sclerotic Sclerotic with erosion

2)Chronic non-suppurative otitis media

• Characterized by accumulation of a non-purulent effusion in the middle ear cleft.

• The following diseases occur as a result.

1) Eustachian catarrh :- Due to the obstruction of the Eustachian tube, the air in the middle ear gets absorbed and the eardrum becomes retracted.

Patient experiences conductive deafness

2) Serous Otitis Media (otitis media with effusion) :

Fluid having a consistency of glue in the middle ear, producing conductive deafness.

Features : Deafness Impairment of speech and language development in children Sensation of fluid in the ear Tinnitus Earache Tympanic membrane : normal or retracted with or without a fluid level behind it.

3) Atelectasis of the tympanum : It is the collapse and medial retraction of the tympanic membrane following long standing non-supurrative otitis media.

Stages :i. Effusion stageii. Retraction stageiii. Atelectatic eardrumiv. Adhesive otitis media

4) Tympanosclerosis : It is a condition characterized by white plaques (chalk patches) occurring in the tympanic membrane and surrounding ossicles.

It results from healed chronic otitis media. There is hyaline degeneration of middle ear mucosa which undergoes calcification and appears like the flakes of white snow.

Treatment :-1) Treat the causative factors like diseases of nose, sinuses or pharynx 2) Eustachian catheterization 3) Myringopuncture :- Injection of air into the middle ear may give

relief. 4) Myringotomy : Surgical incision into the eardrum, to relieve pressure

or drain fluid.5) Grommet : In recurrent cases a temporary Teflon tube is inserted for

ventilation through the eardrum6) Adenoidectomy : In obstructive cases7) Tympanoplasty / ossiculoplasty8) Hearing aid9) Antibiotics, decongestants, steroid, mucolytics are used.

3) Tuberculous otitis media• Not uncommon disease.• Secondary to pulmonary TB Clinical features :• Slow onset of disease • Painless condition • Discharge is thin, scanty and odourless• Tympanic membrane is pale yellow to rosy pink in colour.• Perforations in the membrane are usually multiple and may be associated with pale granulations.

• Hearing loss is disproportionate to other symptoms.

Treatment :-

• Antitubercular therapy

• Advanced cases may require surgical intervention.

Thank you