OTITIS MEDIA and its complications prof. O.I.Yashan It is estimated that 70% of children will have had one or more episodes of otitis media (OM) by their third birthday. This disease process knows no age boundaries but occurs mainly in children from the newborn period through approximately age 7 years, when the incidence begins to decrease. It occurs equally in males and females.

Middle ear effusion is the liquid resulting from OM. Ways of spreading of infection to the middle ear : 1. Toubo genes - through an auditory tube (more frequent), in such cases acute rhinitis took place before otitis. 2. Haematoma genes – with the flow of blood (at a flu, scarlet, misle and others like that). 3. Through the perforation due to a trauma of ear-drum. Mainly, inflammation is limited by a mucus lining. Middle ear effusion is the liquid resulting from OM. An effusion may be either serous (thin, watery), mucoid (viscid, thick), or purulent (pus). The process may be acute (0 to 3 weeks in duration), subacute (3 to 12 weeks in duration), or chronic (greater than 12 weeks in duration).

Acute otitis media –represents the rapid onset of an inflammatory process of the middle ear space associated with one or more symptoms or local or systemic signs. AOM - acute inflammation of mucus lining of middle ear cleft. AOM often appears as a complication of viral disease (flu, AVI) is with subsequent stratification of bacterial infection (streptococcus, staphylococcus, pneumococcus, Pseudomonas aerogenosa and others like that). Classification According to clinico-morphologic proceed of acute middle otitis, catarrhal and purulent his forms are distinguished

ACUTE CATARRHAL OTITIS MEDIA Acute catarrhal otitis media– easy form of acute otitis media, that develops mainly as a result of auditory tube disfunction. Influential factors: Pathological processes: in nasopharynx (adenoids, tumours); nose (acute and chronic rhinitis) and in paranasal cavities (acute and chronic sinusitis). They cause the violation of functions of auditory tube – ventilation, drainage and protective. As the tube’s mucus lining is covered by a cilliar epithelium in continuation of mucus lining of nasopharynx, through the tube infection gets in a tympanic cavity, causing its inflammation.

Clinic Feeling of otologic fullness. Moderate hearing loss. Tinnitus. Insignificant excretions from an ear (possible). Temperature reaction and general state are normal (mainly).

Otoscopy The ear-drum is slightly bulged, gray-pink color. Air bubbles and prominent vascularity. The perforation is absent in most cases, if it arises up, brief excretion from the ear appears. Recovery takes place already in a few days. It is needed to remember that complications can also develop in patients without the perforation. Therefore the they must be under the medical observation until complete convalescence.

Additional inspection methods Diagnostics Otoscopy Veber’s test – lateralizatsiya sound in a sick ear, Rine’s test – negative, Shvabah’s test – is prolonged (pathology of conductive mechanism). Impossibility to blow the auditory tube during the Valsalva maneuver. Negative or poorly positive Polittcer’s test. Additional inspection methods General blood test : leukocytosis, change to the left, speed-up SHOE; Bacteriological research of pus to find a sensitiveness to the antibiotics (with the purpose of choice of adequate antibiotic therapy – better locally). X-ray of mastoid process – fogging of middle ear cavities.

Audiogramm – presence of air-bone gap (pathology of conductive or mixed type).

Complications Sensoneural hearing loss. Transition in purulent form with development of the proper complications.

Medical Treatment decongescent drops to the nose (treatment of inflammatory processes in nose and pharynx) smearing of pharynx, gargling, physiotherapy on the nose, paranasal cavities and pharynx. In addition, warmly on the area of ear,– anodynes, alcoholic drops to the ear (3% alcoholic solution of salicylic acid, 2% r-n of novoimanin, Chlorofilipt and others like that). At the presence of excretions the careful clearing of external auditory canal and subsequent ear drops. Valsalva and Polittser maneuver for the improvement of auditory tube’s function. catheterization of auditory tube, and at suspicion of complications – tympanostomya (introduction a little tube in the ear-drum), at development of complications – antro mastoidotomia

Prophylaxis adenotomiya, septoplasty, Treatment of sinusitis

ACUTE SUPERATIVE OTITIS MEDIA Purulent inflammation of middle ear mucus lining: auditory tube, tympanic cavity and mastoid process. Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis. Reasons upper respiratory infection precedes the ear involvement and spreads up the eustachian tube. In most cases acute cold traumas

Pathomorphology Mucus lining acutely, is thickened in 10-20 times, the mucoid edema, smallcells infiltration, arterial hyperemia. Excretion, which can be serous, hemorrhagic, purulent or mixed, accumulates in the tympanic cavity. As the auditory tube function is deteriorate and excretion can not be eliminated through the tube in the nasopharynx, pressure rises in tympanic cavity, that bulges the ear-drum outside. The micro thromboses appear in drum vessels, that lead to necrosis of the thinnest areas of ear-drum. In this place the perforation forms, through it the excretion is selected in external auditory canal. Exudation diminishes gradually, excretions become not so abundant and acquire purulent, and then mucus character. The auditory tube function gradually improves, excretions find the natural way to outflow - in nasopharynx, the perforation closes, the auditory function recovers.

Clinic: three stages of APOM I stage – before perforative (1-3 days duration) – is characterized by a diffuse inflammatory process in a middle ear without restriction. Beginning of disease is acute, from appearance of the expressed shooting, pulsating pain in the ear, which hides other otologic symptoms: hearing loss, tinnitus, feeling of liquid in the ear (ear fullness). There are expressed symptoms of general intoxication: high body temperature, chill and common indisposition. There can be the vestibular signs: dizziness, nausea, nystagmus, considerable hearing loss. A mastoid process is slightly painful. The infection can be spread to the labyrinth and in the skull, causing early complications with especially heavy motion.

Otoscopy of first APOM stage The ear-drum is red (at the beginning on the maleus handle, and then fully), bulged, especially in back quadrants (due to accumulation of excretion in the tympanic cavity), thickened, infiltrative; the cognitive ear-drum points disappear; the line between ear-drum and auditory canal disappear

Influenza AOM Hemorrhagic discharges Bullous myringitis with hemorrhagic blebs on tympanic membrane and skin of EAC Sensorineural hearing loss.

The ІІ stage – perforative (4-7 days duration) Spontaneous perforation in ear-drum appears. Excretion outflows from a middle ear cleft; pain calms down quickly, the body temperature of goes down; general intoxication decreases. Otoscopy The external auditory canal is filled with excretions: at the beginning of illnesses with heamorhagic or serous, and then - mucus or purulent. Appearance of excretions with an unpleasant smell suspects necrosis of bone (necrotic inflammation of the ear), which more frequent arises up at scarlet fever, measles, agranulocitosis and others like that.

Otoscopiya of the second APOM stage Ear Drum is red, thickened, infiltrated. Positive symptom of „pulsating drop” - through the small perforate opening, located mainly in the back-lower quadrant of ear-drum, in time by cardiac abbreviation the exudates get out.

The third stage – convalescence (reverse development or reparative, lasts to the end of third week). The quantity of excretions diminishes, they become thicker, flow out without periodic shoves. The hearing gets better, a tinnitus disappears. Otoscopy The ear-drum was insignificantly swollen and pink during a maleus handle, the small perforation is closed by a thin scar.

Diagnostics Veber’s Test– sound lateralization in a sick ear, Rine’s test– negative, Shvabah’s test – is prolonged (defeat of conductive mechanism). Audiogramm – presence of air-bone gap (worsening of hearing by conductive or mixed type). Impossibility to do the Valsalva maneuver. Negative or poorly positive Polittser’s test. Additional inspection methods General blood test: leycotsitosis, change to the left; Bacteriological research of pus on a sensitiveness to the antibiotics (with the purpose of choice of adequate antibiotic therapy - it is better locally). X-ray of mastoid process – the fogging of middle ear cavities.

Consequences 1. The most frequent is complete convalescence, the criteria of which is normalization of the common state, normal otoscopy picture of ear-drum and complete hear recovering. 2. Firm hearing loss as a result of scar formation in a tympanic cavity (without the perforation). 3. Permanent perforation of the ear-drum (transition in a chronic otitis media). If convalescence does not come to the end of 3th week, there is the danger of appearance of complications, the signs of which are: worsening of the common state, the repeated rise of body temperature, strengthening of pain in the ear which already began to calm down, increase of quantity of excretions, absence of improvement of hearing loss, appearance of pain in the mastoid process.

Complications Mastoiditis, Labyrinthitis, Sensoneural hearing loss (cochleitis), Facial nerve palsy, Otogenic sepsis, Intracranial complications.

Chronic mesotympanitis Central drum perforation; Permanent or periodical discharges without bad smell.

Chronic epitympanitis with cholesteatoma

Audiogram Air-bone gap (conductive hearing loss)

CT or MRI scan Coronary projection