acute inflammation of the muco- periosteal lining of the middle ear cleft commonly seen in children...
TRANSCRIPT
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
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
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
Recurrent URTI Tonsils and adenoid infection Chr rhinitis and sinusitis Nasal allergy Cleft palate Tumours of nasopharynx
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?
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
Pathology
Tubal occlusion (hyperemia) Pre-suppuration Suppuration Resolution or Complications
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
Symptoms Blocked feeling in
the ear following URTI
Mild ache/ discomfortSigns
Retracted drum Hyperemia
Pathology Bacterial infection Exudation of fluid Increased mucus
secretion and decreased drainage
Accumulation of non-purulent fluid in middle ear
Increased congestion
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
Pathology Suppuration Accumulation of
pus in the middle ear under tension
Acute coalescent/ masked mastoiditis Non resolved AOM- if no resolution by
one month Recurrent ASOM CSOM- tubotympanic disease (TM
perforation persists > 3 months)
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 +/-
Pathology Accumulation of
pus in the middle ear under tension
Later- rupture of the TM and release of pus (discharge)
Symptoms At the peak of otalgia—mucopurulent,
blood stained ear discharge Otalgia subsides with onset of
dischargeSigns
Rupture—Pulsatile ear discharge ‘Light house sign’
Pin-hole perforation
Pathology With drainage of
the pus and Host defense/
treatment Inflammation
resolves Pin-hole perforation
heals
Symptoms Acute symptoms subside Ear becomes dry Eventually hearing is restored
Signs Pin-hole perforation without
discharge Later healed perforation
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
Symptoms Ear symptoms persist or increase Spiky temperature Swelling post-auricular region
Signs Persistent ear discharge and congestion Mastoid tenderness and swelling
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
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
Indications TM fails to perforate Severe otalgia Non-resolving symptoms If impending complications suspected
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
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
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
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
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
EMPYEMA OF MASTOID Spread of infection to other
structures in/ out of mastoid--- intracranial/ extracranial complications
Extra-cranial
Mastoid abscess 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
Following ASOM Increasing pain and discharge in the
ear Post-aural painful swelling,fever,
malaise and lassitude Features of complications
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
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
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
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
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
Retraction of TM Transudation Exudation Micro-hemorrhage Traumatic perforation Ossicular discontinuity Round window rupture Inner ear damage
Otalgia Blocked sensation/ deafness Tinnitus Vertigo Ear discharge—blood stained initially
Congested retracted drum Fluid level/ air bubbles in middle ear Rupture TM Nystagmus +/- Conductive or mixed hearing loss
Pure tone audiogram Impedance audiometry Microscopic otological examination
Usually resolves within few weeks Analgesics/ and decongestants Labyrinthine sedatives/ steroids if
inner ear damage suspected Persistent fluid—myringotomy
grommet insertion Persistant perforation—myringoplasty