ACUTE SUPPURATIVE

OTITIS MEDIA

BY:
Vitaliy Leshak
CLASSIFICATION OF OTITIS MEDIA
Otitis media

suppurative Non-suppurative

acute Chronic Acute Chronic adhesive

Tubotympanic(safe Atticoantral
type) (unsafe type)
OTITIS MEDIA
 Inflammation of the middle ear.

 Middle ear implies middle ear cleft, which

includes:
Eustachian tube
Middle ear
Attic
Additus
Antrum
Mastoid air cells
Anatomy of ear
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MIDDLE EAR CLEFT

ETIOLOGY
• More common especially in infants and children
of lower socioeconomic group.
• The disease typically follows viral infection of
upper respiratory tract:
Rhinovirus
RSV
Influenza virus
enterovirus
BACTERIOLOGY
• Streptococcus pneumoniae 30%
• Haemophilus influenzae 20%
• Moraxella catarrhalis 12%
Also,
• Streptococcus pyogens
• Staphylococcus aureus
• Pseudomonas aeruginosa
• No growth in 18-20% cases
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Understanding position of
Ant.
Eustachian tube: Cranial
fossa

Middle cranial
fossa

nasopharynx
Posterior
cranial
fossa

Jugular
fossa

Sphenoid
sinus
Normal functions of Eustachian tube
• Normally Eustachian tube is closed.
• Functions:
 Ventilation and thus regulation of middle ear pressure

 Protection against

Nasopharyngeal reflux of nasopharyngeal

sound pressure secretions

 Clearance of middle ear secretions

 Via Eustachian tube
• Most common route.
• In infants and young children, tube
is:
Shorter
Wider
More horizontal

Via External ear

•Due to traumatic perforation of tympanic
membrane.
Blood-
borne
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•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.
PREDISPOSING FACTORS
Anything that interferes with the normal functioning
of Eustachian tube, predisposes to middle ear
infection, like:
1. Recurrent attacks of common cold
2. URI
3. Measles, diphtheria or whooping cough
4. Infection of tonsils and adenoids
5. Chronic rhinitis
6. Sinusitis
7. Nasal allergy
8. Tumors of nasopharynx, packing of nose or nasopharynx for
epistaxis
9. Cleft palate.
10. Down syndrome
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EXTERNAL ACCOUSTIC MEATUS WAY

• Associated with TM perforation
• Eg. TM trauma, insertion of
tympanostomy tubes, tympanometry,
myringotomy

BLOOD BOURNE
 This is an uncommon route
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PATHOPHYSIOLOGY
• The disease runs through the following
stages:
1. Stage of tubal occlusion
2. Stage of pre-suppuration
3. Stage of suppuration
4. Stage of resolution or
complication
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Mucosa: Hyperemia, Swelling

Eustachian tube is occluded

Intratympanic pressure ↓

Air ↓ fluid ↑

Tympanic membrane retracts

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C/F
TM RETRACTS

Ear
Tinnitus
fullness

Hearing
Earache
loss
STAGE OF TUBAL OCCLUSION
PATHOLOGY SYMPTOMS SIGNS

Tubal blockage due to Deafness T.M. retracted

edema and hyperemia of Earache Handle of malleus –
nasopharyngeal end of NOT marked horizontal
Eustachian tube Generally no fever Prominence of lateral
process of malleus
Loss of light reflex
Tuning fork test-
conductive deafness
Normal tympanic membrane
As the drum becomes increasingly retracted, it drapes over the ossicular chain,
and the incus and stapes head may be outlined.
STAGE OF PRESUPPURATION
PATHOLOGY SYMPTOMS SIGNS

Pyogenic organisms Marked throbbing Congestion of pars

invade tympanic cavity headache tensa
Adults – deafness and Cartwheel appearance
Hyperemia of lining of tinnitus of pars tensa
tympanic cavity Children – high degree Later- congestion of
of fever and restlesness whole tympanic
Inflammatory exudate membrane
in middle ear Tuning fork test-
conductive deafness
Tympanic membrane- found
congested
Normal Congested tympanic
membrane
STAGE OF SUPPURATION
PATHOLOGY SYMPTOMS SIGNS

Marked pus formation Excruciating earache Redness and bulging in

in middle ear tympanic membrane
Deafness increases
May extend upto Ручка молоточка не
mastoid air cells Children- fever 102- візуалізується
103 degree F Жовта пляма на БП,
де в майбутньому
Vomiting відбудеться прорив
На рентгенограмі -
Convulsions затемнення
соскоподібного
відростка
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STAGE OF RESOLUTION
• Follows TM
perforation
• Earache relieved at
once
• General
condition(temp,
wbc count)
improves
STAGE OF RESOLUTION
PATHOLOGY SYMPTOMS SIGNS

T.M. – ruptures with Earache relieved EAC- blood tinged

release of pus discharge may be
Fever – down present
Hence subsidence of
symptoms Small perforation in
anteroinferior quadrants
of pars tensa

Hyperemia of T.M.
subsides- normal colour
and landmarks
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STAGE OF COMPLICATION
• Intratemporal(within the • Intracranial:
confines of temporal 1. Extradural abscess
bone) 2. Subdural abscess
1. Acute mastoiditis 3. Meningitis
2. Facial paralysis 4. Brain abscess
3. Labyrinthitis 5. Lateral sinus
4. Petrositis thrombophlebitis
6. Otic hydrocephalous
STAGE OF COMPLICATIONS
 Acute Mastoiditis
 Petrositis GRADENIGO’S SYNDROME
 Sub-periosteal abscess
 Facial paralysis
 Labyrinthitis
 Extradural abscess
 Meningitis
 Brain abscess or lateral sinus thrombophlebitis
• Gradenigo's syndrome, also called Gradenigo-Lannois
syndrome and petrous apicitis
is a complication of otitis
media and mastoiditis involving the apex of the
petrous temporal bone.

SYMPTOMS:
triad of symptoms consisting of
 periorbital unilateral pain related to trigeminal nerve
involvement,
 diplopia due to sixth nerve palsy (Dorello’s canal)
 persistent otorrhea, associated with bacterial
otitis media with apex involvement of the petrous part
of the temporal bone (petrositis).
 retroorbital pain due to pain in the area supplied by the
ophthalmic branch of the trigeminal nerve (fifth cranial
nerve),
 Bell's palsycaused by invo lvement of the facial nerve
(seventh cranial nerve), and
 otitis media.
 Other symptoms can include photophobia, excessive
lacrimation, fever, and reduced corneal sensitivity.
The syndrome is usually caused by the spread of an
infection into the petrous apex of the temporal bone.

TREATMENT:
 Mastoid exploration.
 Exeneration of the cell tracts leading to petrous apex
 TREATMENT
Acute otitis
media

Review after 48-

72hours
Antibacterial
therapy

Earache and
Good response
fever
Another antibacterial
therapy therapy for 10 days
or myringotomy and culture
and specific antimicrobial
Persistent fluid
Complete Complete
for 10 days but earache and
resolution resolution
fever abate
Periodic checks for 12
weeks

Complete
Persistent
resolution (no
effusion
effusion)

Treat as otitis
media with
effusion
DRUGS
 Antimicrobial agents:
 Amoxicillin
 Ampicillin
 co-amoxiclav
 Erythromycin
 Cephalosporins

 Decongestant nasal drops:

 Ephedrine
Oral nasal decongestants:
Pseudoephedrine

Analgesics:
Paracetamaol

Ear toilet:

Dry local heat

Myringotomy: incising the drum to evacuate

pus.
• Indications of myringotomy:
 Bulging drum and acute pain
 Incomplete resolution
 drum remains full with persistent conductive
deafness
 Persistent effusion beyond 12 weeks
 Onset of complications like facial nerve
paralysis or labyrinthitis
 Serous otitis media
 Non suppurative otitis media
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LOCAL THERAPY
• AFTER PERFORATION
1. Clear external acoustic canal-Ear toilet
2. Control infection
3. Repair TM
INTRATEMPORAL COMPLICATIONS
OF OTITIS MEDIA
●
Otitis media is an inflammation of part or
all of the mucoperiosteal lining of the
tympanomastoid compartment comprising
of eustachian tube, tympanic cavity,
mastoid antrum and all the pneumatized
spaces of the temporal bone.
●
Complications of otitis media have been
defined as spread of infection beyond the
confines of lining mucosa of the middle
ear cleft
●
Both acute and chronic otitis media can
cause complications
●
In preantibiotic era, 52% of complications
were associated with virulent AOM
●
Today, majority of complications result
from COM
●
Complications of otitis media can be
classified into two main categories:
●
Intratemporal (those within the temporal
bone)
●
Intracranial (those within the cranial cavity)
Intratemporal complications
●
MASTOIDITIS, PETROSITIS, FACIAL
NERVE PALSY, LABYRINTHITIS
Intracranial complications
●
EXTRADURAL ABSCESS
●
SUBDURAL ABSCESS
●
MENINGITIS
●
BRAIN ABSCESS
●
LATERAL SINUS THROMBOPHLEBITIS
●
OTITIC HYDROCEPHALUS
Pathways of spread of infections
●
Direct bone erosion
●
Acute infections – hyperaemic decalcification
●
Chronic infections – bone resorption by
cholesteatoma / granulation tissue / osteitis
●
Venous thrombophlebitis
●
Infected clot within small veins – bone and dura –
venous sinuses
●
Intact bone may be transgressed by
thrombophlebitis within haversian canal system –
dural veins – dural venous sinuses – superficial
veins of brain
●
Preformed pathways
●
Anatomic pathways
– Oval window / round window
– Cochlear & vestibular ducts
– Dehiscence of thin bony covering of jugular bulb
– Dehiscence of tegmen tympani
– Dehiscent suture lines
 ●
Non anatomical defects
– Trauma:
●
Accidental – through fracture lines
●
Surgical - stapedectomy, fenestra
– Neoplastic erosions

●
Into brain tissue along periarteriolar spaces
of Virchow-Robin
Factors influencing development of
complications
●
Age
●
Poor socioeconomic group
●
Virulence of organisms
●
Immunocompromised hosts
Acute Mastoiditis
●
It is the extension of middle ear
inflammation of AOM into antrum and
mastoid air cells
●
This spread is because mastoid antrum
and epitympanum communicate freely
through aditus and antrum
●
Common in children
●
Pathogenesis:
●
Following otitis media – tympanomastoiditis
●
Blockade of aditus – loculation of
mucopurulent material within antrum and air
cells
●
Persistent blockade of aditus – retrograde
thrombophlebitis – oedema and cellulitis of
tissues overlying mastoid
●
If pus not drained – necrosis and
demineralization of bony trabeculae –
'Coalescent mastoiditis'
●
Further disease depends on direction of erosive
process
●
Mastoid cortex is eroded – Subperiosteal abscess
●
Medial progression – petrous pyramid
●
Anterior – fallopian canal / labyrinth
●
Mastoid tip – Bezold's abscess
●
Towards tegmen / trautmann's triangle – epidural
abscess
●
Invasion of perilymph / CSF - meningitis
●
Clinical features
●
Symptoms
●
Pain behind the ear
●
Fever
●
Ear discharge
●
Signs
●
Mastoid tenderness
●
Ear discharge – 'light house sign'
●
Sagging of posterosuperior meatal wall
●
Perforation of pars tensa
●
Swelling over mastoid
●
Hearing loss
●
Masked Mastoiditis -
●
Complication of COM with granulation
tissue formation and bone erosion which
can occur without ottorhoea
●
Usually occurs in patients who have
received numerous courses of antibiotics
●
Epitympanum and aditus is blocked so that
middle ear responds to antibiotics but
mastoid does not
●
Symptoms & Signs
– Often occurs in children
– Mild pain behind the ear
– Persistent hearing loss
– TM – appears thick, loss of translucency
– Slight tenderness over mastoid
– PTA – conductive hearing loss
– X-ray mastoids – clouding of air cells
●
Differential diagnosis
●
Furunculosis of meatus
●
Suppuration of mastoid lymph node
●
Infected sebaceous cyst
●
Managment
●
Treatment
●
Antibiotics
●
Myringotomy
●
Cortical mastoidectomy
●
Complications
●
Subperiosteal abscess
●
Labyrinthitis
●
Facial paralysis
●
Petrositis
●
Extradural abscess
●
Subdural abscess
●
Meningitis
●
Brain abscess
●
Lateral sinus thrombophlebitis
●
Otitic hydrocephalus
●
Abscesses in relation to mastoiditis
●
Postauricular abscess
– Commonest abscess – forms over mastoid
– Pinna displaced – outward & forward
– Infection may spread from mastoid to
subperiosteal space
– Treatment includes incision and drainage along
with mastoidectomy
●
Bezold's abscess -
– Occur following acute coalescent mastoiditis
– Pus breaks through thin medial side of tip of mastoid
– Swelling in upper neck
– Abcess may
●
Deep to SCM pushing the muscle outwards
●
Along posterior belly of digastric – swelling between tip of
mastoid and angle of jaw
●
Upper part of psterior triangle
●
Parapharyngeal space
●
Along the carotid vessels
●
Clinical features – insidous onset, h/o of
ottorhoea, sweeling in neck associated with
pain, torticollis
●
CT temporal bone & neck
●
Treatment
– Drainage of abscess
– Cortical mastoidectomy
●
Luc's abscess -
– Meatal abscess
– Pus breaks through bony wall between
antrum and bony external auditory
meatus
– It may burst into meatus

●
Citelli's abscess -
– Abscess formed behind the mastoid
towards the occipital bone
Petrositis
●
It is the inflammation of pneumatized
spaces of petrous portion of temporal
bone
●
Is pneumatised only in 30% of individuals
●
Air cells of petrous pyramid are classified
into two groups
●
Anterior group – extends from
mesotympanum, hypotympanum and
protympanum and passes around cochlea
to petrous apex
●
Posterior group – continous with mastoid
antrum and epitympanum that cluster
around semicircular canals at base of
pyramid and extend medially to petrous
apex
●
Acute Petrosistis -
●
Middle ear inflammation – antrum and mastoid air
cells – medial progression involving petrous pyramid
●
If inflammatory products are retained – osteitis of
petrous apex – retro orbital pain, іпсилатеральний
латеральний прямий параліч.
●
Gradenigo's syndrome – lateral rectus palsy
(Abducens N), deep seated ear / retroorbital pain
(Trigeminal N), Ear discharge
●
Chronic Petrositis -
●
In addition to inflammatory changes – new bone
formation and resorption
●
●
Management
●
Investigations
●
CT temporal bone
●
Treatment
●
Systemic Antibiotics
●
Radical Mastoidectomy with skeletinization of
semicircular canals to remove disease from
middle ear and petrous apex
●
Approaches to Petrous apex
●
Eagleton's approach -
– This is the superior approach to the petrous
apex involving removal of tegmen to base of
zygoma together with removal of part of
squamous temporal bone. Dura of MCF is
now elevated to expose the petrous apex
●
Thornwaldt's operation -
– This approach is along the supralabyrithine
tracts. It merges with Eagleton's approach
●
Almoor's approach -
– It is an inferior approach to petrous apex through a
space bounded by cochlea, carotid artery and
tegmen tympani

●
Ramadier's operation -
– This approach is slightly anterior to that of Almmor's
approach that pursues the peritubal cells to petrous
apex between cochlea and carotid artery

●
Frenckner's operation -
– This approach is through arch of superior
semicicular canal. Blood supply to the labyrinth
arises from this arch and some labyrinthine loss in
inevitable in this approach.
– This has to be combined with an inferior approach
Facial nerve palsy
●
It can occur in acute and chronic otitis
media
●
Pathophysiology – routes of spread
●
natural dehiscences – fallopian canal
●
natural pathways – canal for stapedius,
neurovascular bundle, mastoid air cells
●
direct infection - osteitis
●
Symptoms and Signs -
Insidious onset , gradually progressive
Unable to close the eyes
Facial asymmetry
Epiphora
Noise intolerance due to stapedial palsy
Loss of taste sensation
Bell's phenomenon
●
In AOM – pus/osteitis around dehiscent facial N –
inflammation / swelling around the nerve
●
Management
●
Treat AOM with antibiotics
●
Myringotomy with/without tympanostomy tube
insertion
●
Intact canal wall mastoidectomy – coalescent
mastoiditis
●
Facial N decompression is not indicated as 95% of
casesnrecover completely secondary to AOM
●
In COM – cholesteatoma – bony erosion –
direect infection of nerve
●
Management -
●
Antibiotics
●
Steroids
●
Definitive treatment – Canal wall down
mastoidectomy and decompression of
fallopian canal
Labyrinthitis
●
Inflammation of inner ear / labyrinth
●
Pathogenesis -
●
AOM:
– Spread through round window
– Round window : thinner , increased permeability
– Inflammatory products pass into perilymph of scala
tympani by diapedesis from adjacent labyrinthine
vessels
– Fibrilliary precipitate accumalates in perilymphatic
and endolymphatic spaces – endolymphatic hydrops
– destruction of membranous labyrinth
 – Preformed fistula into labyrinth from middle ear
after stapedectomy offer another route for
infective spread

●
If inflammatory changes induced in labyrinth by
transgression are irreversible – Serous labyrinthitis
●
If intralabyrinthine suppuration destroy cochlear
and vestibular function in affected ear –
Suppurative labyrinthitis
●
COM :
– Erode bony labyrinth by cholesteatoma or osteitis
leading to inner ear destruction
– Fully developed intralabyrinthine inflammation is
preceded by thining of labyrinthine wall and
development of fistula of labyrinth
– Labyrinthine damage from slowly eroding
cholesteatoma is followed by new bone deposition –
destruction of part of labyrinth with partitioning and
preservation of rest
– Bony fistula are often closed by new bone deposition
after eroding disease has been eliminated
●
Suppurative labyrinthitis is a rare complication
of OM – prompt use of antibiotics
●
Development of labyrinthine fistula has
remained common in COM – about 10%
●
Rarely infection maay spread from meningitis
to labyrinth through internal auditory meatus
or through cochlear / vestibular aqueducts
●
Most rarely infection may be blood borne
●
Symptoms and signs -
●
Vertigo
●
Loss of balance
●
Tinnitus
●
Nausea / vomiting
●
Hearing loss – SNHL
●
Treatment
●
Complete bed rest – with restriction of head movt
●
Vertigo/vomiting – parenteral chlorperazine /
cinnarizine
●
Dehydration – IV fluids
●
IV antibiotics
●
Acute infection – Myringotomy
●
Chronic infection – Mastoid exploration
– Premature surgical trauma – dissemination of
infection
●
After recovery of acute symptoms
– Vestibular head exercises – Cawthrone-Cooksey
●
Labyrinthine fistula
●
Complication of COM
●
Results from erosion of endochondral bone of
bony labyrinth – movement of perilymph and
structures of endolymphatic compartments when
pressure in EAC changes
●
Most commonly – dome of lateral SCC
●
Cholesteatoma is found in all cases
●
Incidence of fistula in cholesteatoma is 7-10%
●
Symptoms / Signs -
●
Short periods of imbalance
●
Vertigo
●
Tullio's phenomenon – feeling of imbalance on
sudden exposure to loud noise
●
Fistula sign – positive
●
Investigations:
– CT – erosion of lateral SCC, cholesteatoma
●
Treatment -
●
Canal wall down mastoidectomy
– All cholesteatoma is removed except for small area
around fistula site. After careful removal of
cholesteatoma debri without disturbing matrix.
Matrix is elevated. A small piece of tissue / thin cap
of bone placed over site and secured with fibrin
glue / packing after the cholesteatoma is removed
– Risk of removing cholesteatoma from fistula is total
/ partial loss of hearing
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