ACUTE OTITIS MEDIA

Dr. Ajay Manickam

JUNIOR RESIDENT
RG KAR MEDICAL COLLEGE HOSPITAL
Acute otitis media
• Acute inflammation of the
muco periosteal layer of the
middle ear cleft
• Inflammation typically occur
in <6 weeks
• 60%-70% of children have >1
episode before 1st birthday
• Early onset <6 months is
associated with recurrent
AOM and chronic OME
Routes of infection
• 1. Via Eustachian Tube - most common -inf. travels via
lumen of tube peritubal lymphatic's
• 2. Via External Ear traumatic perforation of tympanic
membrane
• 3. Blood Borne -uncommon
Predisposing factors
• Recurrent common cold, URTI, exanthematous fevers
(like measles, diphtheria, whooping cough)
• Infection of tonsils & adenoids
• Chronic rhinitis & sinusitis
• Nasal allergy
• Tumours of nasopharynx
• Cleft palate
Eustachian tube & AOM
• In children ET is at an
angle of 10° while in
adults it is at an angle of
45°.
• ISTHMUS is a
narrowing in the ET, at
the junction of the
cartilaginous and bony
part.
• It is only present in
adults.
Infectious organisms
• Streptococcus pneumonia (30%)
• Haemophilus influenzae (20%)
• Moraxella catarrhalis (12%)
• Others: Streptococcus pyogenes,
Staphylococcus aureus and Pseudomonas
• Fungal less common – aspergillus & candida
• Bacterial otitis media from super infection of viral also
possible
Pathophysiology

Stage of tubal Stage of Stage of

Stage of
occlusion/ presuppuration/ resolution /
suppuration
hyperemic exudative complication
Stage of tubal occlusion

Mucosa: Hyperemia, Swelling

Eustachian tube is occluded
Intratympanic pressure ↓

Air ↓ fluid ↑
Tympanic membrane retracts
• SYMPTOMS : Deafness Ear ache
• SIGNS : Retraction of the TM. Loss of cone of light. Tuning Fork Test -
conductive deafness
Otoscopy – Stage 1
• TM retracted
• Foreshortened
handle of
malleus
• No cone of light
• Prominent
lateral process
of malleus
 Stage of pre suppuration
Bacteria invade tympanic cavity
Hyperemia

Inflammatory exudate

Congested TM
• SYMPTOMS : Marked ear-ache(throbbing nature)
Deafness & tinnitus High degree fever & restlessness
• SIGNS : Congested pars tensa Cart Wheel
appearance of T.M Tuning fork test conductive loss
Otoscopy - Stage 2

•Cart wheel
appearance of
the TM
•No cone of light
Stage of suppuration

Pus increases

TM is compressed, ischemic

TM is tense and bulges

TM necrosis

• Symptoms - EXCRUCIATING PAIN, Deafness, Fever 102-

103°F, Vomiting, Convulsions
• Signs - T.M appears red & bulging Yellow spot on T.M,
Tenderness over mastoid antrum, X-ray mastoid - clouding of
air cells
Signs – Stage 3
• Bulging out tympanic Clouding of mastoid aircells
membrane
• Loss of anatomical land marks
Stage of resolution
• Pathology - T.M ruptures,
releases pus, symptoms
subside & resolution starts,
Mild infection/Early antibiotics
resolution no rupture of TM
• Symptoms - Ear-ache
relieved, Fever comes down
• Signs - EAC contain blood-
tinged discharge or
mucopurulent, Small
perforation of T.M
Complication
• Highly virulent organisms/ low immunity disease spreads
beyond middle ear resulting in
• Acute mastoiditis
• Sub periosteal abscess
• Facial paralysis
• Labyrinthitis
• Petrostitis
• Meningitis
• Brain abscess
Medical Management
1. Systemic Antibiotic

2. Nasal decongestants (systemic + topical)

3. H1 anti-histamines

4. Analgesic + anti-pyretic

5. Aural toilet for ear discharge

6. Hot fomentation for severe earache

7. Review after 48 hours

48 hours review
• 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
• No effusion: no further treatment
• Effusion persists: treat as Otitis Media with Effusion
• Presence of abscess or coalescent mastoiditis: do cortical
mastoidectomy
Myringotomy
• INDICATIONS :
• Symptoms are not relieved by antibiotics
• TM bulges significantly
• TM perforation is too small
• Incomplete resolution
• Persistent effusion beyond 12 weeks
Myringotomy
• Myringotomy is
a surgical procedure in
which a tiny incision is
created in
the eardrum to relieve
pressure caused by
fluid or to drain pus from
the middle ear.
Underlying predisposing factor
• Chronic rhinitis
• Chronic sinusitis
• Chronic tonsillitis
• Chronic adenoiditis