Acute suppurative otitis media

1. Acute Suppurative Otitis Media
Bijay shah kanu
4th year
PAHS
09 sept 2019

2. ASOM
• Acute inflammation of middle ear by pyogenic organism
• Midle ear= ear cleft= eustachian tube, middle ear, attic, aditus,
antrum and mastoid air cells
• More common in infants and children of lower socioeconomic class
• Follows viral URTI

3. Routes of infection
• Via Eustachian tube
• Via external ear in case of perforation
• Blood borne: uncommon route

4. Predisposing factors
Any thing that interferes with normal functioning of Eustachian
tube
• Recurrent attacks of common cold, URTI, measles, diphtheria, whooping
cough
• Infection of tonsil and adenoids
• Chronic rhinitis and sinusitis
• Nasal allergy
• Tumors of nasopharynx
• Packing of nose and nasopharynx for epistaxis
• Cleft palate

5. Causative organism
Most common organism in infants and young children are
• Streptococcus pneumoniae -30%
• Hemophilus influenzae -20%
• Moraxella catarrhalis -12%
• Strep. pyogens, Staph. aureus, P. aurugenosa are also involved
• No growth in about 18-20% of cases

6. Stages and clinical features
1. Tubal occlusion
2. Pre-suppuration
3. Suppuration
4. Resolution
5. Complication

7. 1. Stage of Tubal occlusion
• Edema and hyperemia of nasopharynx and eustachian tube blockage
• Absorption of air and negative intratympanic pressure
• Retraction of tympanic membrane with some degree of effusion

8. Symptoms:
• Deafness and earache (not so marked)
• No fever
Signs:
• Retracted tympanic membrane
• Horizontal handle of malleus
• Predominance of lateral process of mallelus and loss of Light reflex
• Conductive deafness

9. 2. Stage of Pre-suppuration
• Increased pyogenic activity in tympanic cavity
• Hyperemia of its lining and inflammatory exudated
• Congested tympanic membrane

10. Contd…
Symptoms:
• Earache, throbbing type that disturbs the sleep
• Deafness and tinnitus may be present
• Child may have high fever and is restless
Signs:
• Congestion of pars tensa
• Cart-wheel appearance
• Blood vessels appears along the handle of malleus and at the periphery of TM
• Uniformly red tympanic membranes in later stage
• Conductive hearing loss

11. 3. Stage of Suppuration
• Formation of pus in middle ear and in mastoid air cells
• Tympanic membrane starts bulging at point of rupture

12. Symptoms:
• Excruciating earache and increasing deafness
• High fever, vomiting and convulsion (in children)
Signs:
• Red and bulges TM with loss of landmarks
• Tenderness over mastoid antrum
• X-ray of mastoid : clouding of air cells –exudate

13. 4. Stage of resolution
• Rupture of TM with release of pus and relief symptoms
• Inflammatory process begins to resolve
• If early treatment started or if infection is mild, resolution starts even
without rupture of TM

14. Symptoms:
•Earache relieved and fever subsides
Signs:
• Blood tinged discharge in EAC which later becomes mucopurulent
• Usually a small perforation in anteroinferior quadrant of pars tensa
• Hyperemia of TM begins to subside with return to normal color and landmarks

15. 5. Stage of Complication
• Depends on
• Virulence of organism is high or resistance of the patient ,resolution may not
take place and disease spread beyond the confines of middle ear
• May lead to mastoiditis, petrositis, extradural abscess, meningitis,
brain abscess, lateral thrombophebitis

16. Investigations
• C/S of discharge
• X-ray of ear/ mastoid
• Audiometry

17. Management
Antibiotic therapy
• Indicated in all cases with fever and severe earache
• Ampicillin 50mg/kg/day in 4 divided dose
• Amoxicillin 40mg/kg/day in 3 divided dose
• Should be given till tympanic membrane regain normal appearance
and hearing is normal (minimum 10 days)

18. Antibiotics dose

19. • Decongestant nasal drop : ephedrine 1% in adult and 0.5% in children
)or oxymetazoline or xylometazoline – used to relieve Eustachian tube
edema and promote ventilation
• Oral nasal decongestant :pseudo ephedrine (Sudafed)30 mg twice
daily or a combinations of decongestant and antihistaminic (triominic)
– may achieve the same result without resort to nasal drops which
are difficult to administer in children

20. • Analgesics and antipyretics :to relieve pain and bring temperature
down
• Ear toilet : discharge in ear – dry mopped with sterile cotton buds and
w wick moistened with antibiotics may be inserted
• Dry local heat : to relieve pain

21. Myringotomy
• Incision of ear drum to evacuate the pus
• Indications:
• Bulged drum with acute pain
• Incomplete resolution despite antibiotics when drum remains full with persistent
conductive deafness
• Persistent effusion beyond 12 weeks
• All cases of ASOM should be followed till drum returns to its normal appearance
and conductive deafness disappears

23. References
• PL Dhingra, et al. Diseases of ear, nose and throat & head and neck
surgery, 6th edition

24. Thank You