ACUTE SUPPURATIVE

OTITIS MEDIA (ASOM)

DEFINITION
The acute inflammation of the mucoperiosteal lining of the middle ear cleft by pyogenic organisms.

AETIOLOGY
• More common in infants and children
• Follows viral infection of upper respiratory tract

Bacteriology: Most common organisms involved are:

• Streptococcus pneumoniae (30%)
• Haemophilus influenzae (20%)
• Moraxella catarrhalis (12%)
• Other organisms: Streptococcus pyogenes, Staphylococcus aureus and Pseudomonas aeruginosa.
ROUTES OF INFECTION

• Via eustachian tube

• most common route
• via the lumen of the tube or along subepithelial
peritubal lymphatics
• eustachian tube in infants & children is shorter,
wider and more horizontal  higher incidence
• swimming and diving can also force water through
the tube into the middle ear.

• Via external ear: through traumatic perforations of

TM

• Blood-borne: uncommon route

PREDISPOSING FACTORS

Anything that interferes with normal functioning of eustachian tube predisposes to middle ear
infection. It could be:

• Recurrent attacks of common cold, URTI

• Infections of tonsils and adenoids
• Chronic rhinitis and sinusitis
• Nasal allergy
• Tumors of nasopharynx
• Cleft palate
PATHOLOGY AND CLINICAL FEATURES

The disease runs through the following stages:

I. Stage of hyperemia
II. Stage of exudation
III. Stage of suppuration
IV. Stage of coalescent mastoiditis
V. Stage of complications
VI. Stage of resolution
STAGE I: STAGE OF HYPEREMIA

• Oedema and hyperemia of the mucosa of the middle ear and Signs
eustachian tube because of microorganism invasion
• Tympanic membrane-congested.
• blocks the tube leading to absorption of air  negative
intratympanic pressure  retraction of tympanic membrane • Landmarks of the tympanic membrane may be
distorted associated with dilated radial blood vessels
(cartwheel appearance).
• Nasal mucosa congestion or mucopurulent discharge
on rhinoscopy.
Symptoms
• Earache- mild to moderate.
• Obstruction or fullness of the ear. Treatment
• Fever • Antibiotics
• Deafness-mild conductive type. • Analgesics and antipyretics
• Associated symptoms like running nose, nasal obstruction. • Decongestants
• Nasal drops
• Menthol or tincture benzoin steam inhalation.
STAGE II: STAGE OF EXUDATION
In addition to hyperemia, there will be collection of the exudate in the middle ear cavity.

Symptoms
• Increased pain
• Blocking sensation of the ear will increase.
• Deafness increases

Signs
• Tympanic membrane-thick, congested, loss of landmarks; bulging
• X-ray mastoid-haziness, cloudy.

Treatment
• Antibiotics
• Myringotomy
STAGE III: STAGE OF SUPPURATION

• Collected exudate in the middle ear increases in volume

• Produces tension on the TM  pressure necrosis 
perforation of the TM
• The ear starts draining; may be blood stained initially, then Signs
serosanguineous and later the discharge may be • Small CP in the tympanic membrane
mucopurulent.
• Pulsatile discharge presents through the perforation
• The mucoperiosteum of the middle ear cleft will be (Light house sign)
thickened by new capillary formation in the fibrous tissue
infiltrated with lymphocytes, plasma cells and polymorphs.
• X-ray mastoid is cloudy, but the walls of the mastoid
air cells are intact.

Symptoms
Treatment
• Following discharge, there is pain relief
• Aural toilet-dry mopping or suction cleaning.
• Discharge- blood stained, serosanguineous, mucopurulent.
• Broad spectrum antibiotic ear drops
STAGE IV: STAGE OF COALESCENT MASTOIDITIS / SURGICAL MASTOIDITIS

Re-infection in the middle ear is seen usually after a period

of two weeks after the previous stage.

Hyperemia and mucosal edema of middle ear

Symptoms
Obstruction of the aditus  Failure of drainage • Earache increases after a period of two weeks
• Fever
Venous congestion  Local acidosis • Ear discharge (most often mucopurulent)
• Increased deafness
Destruction of septa (bony walls of the air cells) by
hyperemic decalcification

Coalescence of mastoid air cells  Mastoid filled with pus

Signs
• Thickening of mastoid periosteum (ironed out mastoid)
• Mastoid tenderness is present
• Discharge is copious and continuous. It reappears immediately after wiping (Mastoid reservoir sign)
• TM with central perforation and polypoidal middle ear mucosa
• Sagging of the posterior superior meatal wall
• X-ray mastoid: clouding of the mastoid air cells with loss of septa

Treatment
• Surgical management: Cortical mastoidectomy + Drainage of pus
STAGE V: STAGE OF COMPLICATIONS

EXTRACRANIAL COMPLICATIONS
• Mastoiditis
Untreated cases can lead to many complications which can be
divided into two groups:
• Petrositis

• Intracranial
• Facial nerve paralysis

• Extracranial
• Labyrinthitis

INTRACRANIAL COMPLICATIONS

Complications may occur either by:

• Meningitis

• Direct erosion of bone by hyperemic decalcification

• Extradural abscess

• Venous thrombophlebitis of venous sinuses

• Subdural abscess

• Preformed pathways (E.g., Congenital dehiscences, patent suture lines,

• Brain abscess
previous skull fractures, surgical defects, through oval or round • Lateral sinus thrombophlebitis
window) • Otitic hydrocephalus
STAGE VI: STAGE OF RESOLUTION

• The resolution of the disease occurs when:

• resistance of the host overtakes the virulence of the organism
• Following proper antibiotic therapy, the acute infection begins to subside

• First evidence of resolution: cessation of ear discharge.

TREATMENT OF ACUTE SUPPURATIVE OTITIS MEDIA

• Antibacterial therapy: indicated in all cases with fever and severe earache.
• Drugs used: ampicillin and amoxicillin (if allergic  cefaclor, co-trimoxazole or erythromycin)
• For β-lactamase-producing bacteria  amoxicillin clavulanate, cefuroxime or cefixime
• Antibacterial therapy must be continued for a minimum of 10 days, till tympanic membrane regains normal
appearance and hearing returns to normal.
• Early discontinuance of therapy  secretory otitis media and residual hearing loss.

• Decongestant nasal drops: Ephedrine, oxymetazoline or xylometazoline should be used to relieve eustachian tube
oedema and promote ventilation of middle ear.

• Oral nasal decongestants

• Analgesics and antipyretics: to relieve pain and fever

• Aural toilet: to clear discharge

• Dry local heat

• Myringotomy: to evacuate pus; is indicated when:

• drum is bulging and there is acute pain
• there is an incomplete resolution despite antibiotics
• there is persistent effusion beyond 12 weeks

Incision given for ASOM: circumferential incision in PI quadrant

All cases of ASOM should be followed-up till TM returns to its normal appearance and conductive deafness disappears
ACUTE NECROTIZING OTITIS MEDIA (ANOM)

It is a special form of ASOM that occurs mostly in infants and young children, suffering from scarlet fever,
measles, pneumonia or influenza
Causative organism: Beta-hemolytic streptococcus

Pathology
• Early necrosis and destruction of most of the tympanic membrane, with its annulus, mucosa of the promontory,
ossicular chain and even mastoid air cells.
• TM usually shows a total perforation with foul smelling purulent discharge
• Necrosis of the ear ossicles
• Healing is followed by fibrosis and ingrowth of squamous epithelium (secondary acquired cholesteatoma)

Treatment
• Early institution of intravenous antibiotics therapy
• Cortical mastoidectomy if the condition gets complicated by acute mastoiditis
THANK YOU!!