1. Acute Suppurative
Otitis Media
(ASOM)

2. Definition
Acute inflammation of the muco-periosteal lining of the middle ear cleft commonly seen in children and usually consequent to an upper respiratory tract infection

3. Etiology Eustachian tube dysfunction- MOST COMMON
Viral rhinitis
Any form of rhinitis/ sinusitis
Other causes of ET dysfunction
Traumatic perforation of tympanic membrane
Barotraumatic otitis media
Hematogenous

4. More common in children- Reasons
Upper respiratory tract infections are more common
Eustachian tube is more short, wide and horizontal in children compared to adults
Adenoid tends to hypertrophy and obstruct the ET orifice in the nasopharynx
Feeding habits in an infant- nasopaharyngeal reflux more common

5. Predisposing factors Recurrent URTI Tonsils and adenoid infection
Chr rhinitis and sinusitis
Nasal allergy
Cleft palate
Tumours of nasopharynx

7. Incidence Peak incidence at the age of 3-18 months
60% of children below 1 year of age- variable severity
80% of children below 3 years of age
Boys>girls
Native Americans> African Americans
Rural>Urban: Reason?

8. Microbiology
Usually starts as a viral infection. Ex: RSV, Rhinovirus, CMV, measles, EBV.
Streptococcus pneumoniae ( 30-50%)
H. influenzae ( 20-30%)
Moraxiella catarrhalis ( 10-20%)
Streptococcus pyogenes

9. Pathology

11. Clinico-pathologial stages of ASOM
Tubal occlusion (hyperemia)
Pre-suppuration
Suppuration
Resolution or
Complications

12. Stage of tubal occlusion (hyperemia)
Pathology
URTI leads to ET mucosal edema
ET gets occluded
Air in the middle ear cleft gets absorbed
Vacuum (negative pressure in middle ear)
Transudation

13. Symptoms
Blocked feeling in the ear following URTI
Mild ache/ discomfort
Signs
Retracted drum
Hyperemia

15. Stage of pre-suppuration
Pathology
Bacterial infection
Exudation of fluid
Increased mucus secretion and decreased drainage
Accumulation of non-purulent fluid in middle ear
Increased congestion

16. Symptoms
Irritable child
Increasing ear-ache and deafness
Autophony
Signs
Cart-wheel appearance of the TM
Bulging drum
Fluid level/ air bubbles seen through TM

19. Stage of suppuration -Before perforation
Pathology
Suppuration
Accumulation of pus in the middle ear under tension

20. Complications Acute coalescent/ masked mastoiditis
Non resolved AOM- if no resolution by one month
Recurrent ASOM
CSOM- tubotympanic disease (TM perforation persists > 3 months)

21. Symptoms
Unexplained cause of crying in a child
Fever, toxic symptoms
Severe otalgia
Deafness
Signs
Grossly congested and edematous TM
Bulging of TM- >posteriorly
Pus pointing +/-

24. Stage of suppuration -After perforation
Pathology
Accumulation of pus in the middle ear under tension
Later- rupture of the TM and release of pus (discharge)

25. Symptoms
At the peak of otalgia—mucopurulent, blood stained ear discharge
Otalgia subsides with onset of discharge
Signs
Rupture—Pulsatile ear discharge ‘Light house sign’
Pin-hole perforation

26. Stage of resolution Pathology With drainage of the pus and
Host defense/ treatment
Inflammation resolves
Pin-hole perforation heals

27. Symptoms
Acute symptoms subside
Ear becomes dry
Eventually hearing is restored
Signs
Pin-hole perforation without discharge
Later healed perforation

28. Infection fails to resolve due to
Pathology
Infection fails to resolve due to
Pneumatised mastoid with infection extending
Organism- virulent
Resistance of host- poor
Treatment- inadequate
Or if the TM fails to perforate
Acute mastoiditis

29. Stage of complications
Symptoms
Ear symptoms persist or increase
Spiky temperature
Swelling post-auricular region
Signs
Persistent ear discharge and congestion
Mastoid tenderness and swelling

31. Investigations Treatment usually started with clinical diagnosis
Investigate if not resolving or if impending complications suspected
Ear swab for C/S
X-ray mastoids
X-ray PNS/ nasopharynx
Audiological assessment
CT scan of temporal bone and intracranium- with contrast

32. Treatment- Medical Treat URTI
Broad spectrum antibiotics like amoxycillin/ ampicillin/ augmentin/ erythromycin etc.- Orally as syrup/ tablets
High dose (meningitic dose) and parenteral if complications suspected
Nasal decongestants
Analgesics
No role for topical antibiotics

33. Treatment- Surgical Indications TM fails to perforate Severe otalgia
Non-resolving symptoms
If impending complications suspected

34. Treatment- Surgical Tympanocentesis- Needle aspiration of the fluid
Myringotomy
Curvilinear incision on the TM at the site of most prominent bulge—usually posteriorly—drainage of pus
Or widen the pin-hole perforation- better drainage
Cortical mastoidectomy
To eradicate the diseased mucosa in the mastoid antrum and the air cells

36. Acute necrotising otitis media
Acute otitis media usually due to streptococcus pneumoniae associated with exanthematous fevers like measles, chicken pox, etc.
Extensive destruction of the middle ear structures
Total perforation
Ossicular discontinuity
Higher incidence of mixed hearing loss
Treatment is same as AOM

37. Acute coalescent mastoiditis
Acute inflammation of the muco-periosteum of mastoid antrum and mastoid air cells, usually a result of ASOM, characterized by coalescence of the mastoid air cells and collection of pus under tension (empyema) within the mastoids

38. Etiopathology
Following ASOM, infection in the middle ear spreads into the mastoid antrum and cells
Mucosal odema blocks the aditus- no drainage of mastiod antrum
Mucopus in mastoids collect under tension
HYPERAEMIC DE-CALCIFICATION gives rise to soft bone
COALESCENCE DUE TO INTERCELLULAR BONE DESTRUCTION---EMPYEMA

39. Predisposing factors Pneumatized mastoid—more cells--more mucosa
Organism—virulent
Resistance of the host—poor
Treatment—inadequate or inappropriate
Failure of tympanic membrane to perforate in ASOM or perforation is too small for complete drainage

40. EMPYEMA OF MASTOID
Spread of infection to other structures in/ out of mastoid--- intracranial/ extracranial complications

41. Complications Extra-cranial Intra-cranial Mastoid abscess Meningitis
Facial paralysis
Labyrinthitis
Petrositis
Septicemia
Osteomyelitis of temporal bone
Intra-cranial
Meningitis
Extradural abscess
Subdural abscess
Brain abscess
Lateral sinus thrombophlebitis
Otitic hydrochephalus
Cortical venous thrombophlebitis

42. Clinical features- Symptoms
Following ASOM
Increasing pain and discharge in the ear
Post-aural painful swelling,fever, malaise and lassitude
Features of complications

43. Clinical features- Signs
Post-auricular swelling due to cellulitis/ abscess
Mastoid tenderness positive
Pinna is pushed forwards and downwards
Sagging of the canal skin
Congested bulging drum with no perforation or with small perforation
Pulsatile ear discharge

44. Investigations Ear swab for culture and sensitivity
Pure tone audiogram if possible
X-ray mastoids—Schuller’s view---shows clouding of the mastoid air cells and coalescence
CT scan of the temporal bone and intracranium with contrast--if complications are suspected

45. Treatment intravenous antibiotics
Penicillin group with metronidazole preferred
Early stage—myringotomy/ widening of perforation may be tried
I&D if mastoid abscess is present followed by
Emergency exploration of mastoid and cortical mastoidectomy
Treatment of complications

46. Otitic baro-trauma
Injury to the middle and/or inner ear due to sudden negative middle ear pressure caused by sudden descent during flight or sudden deep diving
Predisposed by pre-existing ET dysfunction

47. Etiopathology Higher the altitude—lower the atmospheric pressure
Ascent- passive movement of air out of ET
Sudden descent—middle ear pressure is negative compared to atmospheric pressure
Locking of the tube occurs if pressure difference
Early locking in case of ET dysfunction

48. Pathology Retraction of TM Transudation Exudation Micro-hemorrhage
Traumatic perforation
Ossicular discontinuity
Round window rupture
Inner ear damage

49. Clinical features Otalgia Blocked sensation/ deafness Tinnitus Vertigo
Ear discharge—blood stained initially

50. Signs Congested retracted drum Fluid level/ air bubbles in middle ear
Rupture TM
Nystagmus +/-
Conductive or mixed hearing loss

51. Investigations Pure tone audiogram Impedance audiometry
Microscopic otological examination

52. Treatment Usually resolves within few weeks
Analgesics/ and decongestants
Labyrinthine sedatives/ steroids if inner ear damage suspected
Persistent fluid—myringotomy grommet insertion
Persistant perforation—myringoplasty