Acute suppurative otitis

media
6th semester mbbs
Nischal shrestha
• It is an acute inflammation of middle ear cleft by pyogenic
organisms.
• Middle ear cleft includes Eustachian tube, middle ear, attic,
aditus, antrum and mastoid air cells
• Aetiology :
More common in infants and children of lower socioeconomic
group.
Typically disease follows viral infection of URT
 Routes of infection
1. Via Eustachian tube: most common route.
Via lumen of tube Along sub-epithelial
peritubal lymphatics

Also ET in infants and young children is shorter, wider and more horizontal

So breast or bottle feeding in horizontal position may force fluid through tube
into middle ear

Also swimming and diving can force water through tube into middle ear

2. Via External Ear: traumatic perforations of TM d/t any cause

3. Blood borne: uncommon route
 Predisposing Factors
• Anything that interferes with normal functioning of ET, it could be:
1. Recurrent attacks of common cold, URTI and exanthematous fevers
like measles, diphtheria or whooping cough
2. Infections of tonsils and adenoids
3. Chronic rhinitis and sinusitis
4. Nasal allergy
5. Tumors of nasopharynx, packing of nose or nasopharynx for
epistaxis
6. Cleft palate: caused by anatomic problems in the muscles that open
the tube.
Bacteriology
- In infants and young children
1. Streptococcus pneumoniae 30%
2. Hemophilus influenzae 20%
3. Moraxella catarrhalis 12%
- Many strains of H. influenzae and M. catarrhalis are beta
lactamase producing
 Clinical features and pathophysiology
• The disease runs through following stages:

Stage of tubal occlusion

Stage of presuppuration

Stage of suppuration

Stage of resolution

Stage of complication
 1. Stage of Tubal Occlusion

Mucosa: edema and hyperemia of Blocks the tube Lining of middle ear
nasopharyngeal end of ET absorbs the remaining air

Negative intratympanic pressure

Retraction of tympanic membrane

• Symptoms:
- Deafness and earache , but are not marked
- There is generally no fever
 Signs
> Otoscopy :
1. TM is retracted with handle of malleus assuming a more
horizontal position
2. Prominence of lateral process of malleus
3. Loss of cone of light
> Tuning fork tests show conductive deafness
 2. Stage of presuppuration (exudation)
• Prolonged tubal occlusion Pyogenic organism invasion Signs of inflammation (hyperemia
of its lining)

Inflammatory exudation
and congestion of TM

• Symptoms :
Marked earache (throbbing type) which may disturb sleep
Child runs high degree of fever and is restlessness
Deafness and tinnitus , complained by adults, d/t fluid in middle ear
Signs
• From beginning, there is congestion of pars tensa and loss of
landmarks
• Cartwheel appearance of TM as blood vessels appear along
the handle of malleus and at periphery of TM
• Later, whole of TM including pars flaccida becomes
uniformly red. This appearance is also termed angry looking
TM.
• Tuning fork tests show conductive type of hearing loss
3.
• Symptoms :
- Excruciating ear pain
- Deafness increases
- Child may run fever of 102-103 °F. This may be accompanied by
vomiting and even convulsion
Signs
• TM appears red and bulging with loss of landmarks
• Handle of malleus may not be perceptible d/t swollen TM
• A nipple like protrusion of TM with a yellow spot where
rupture is imminent, on its summit may be seen ( in pre-
antibiotic era when course of disease was allowed to
progress
• Tenderness over mastoid area may be present
• X –rays of mastoid will show clouding of air cells because of
exudate
Nipple like protrusion
Clouding of mastoid cells
 4. Stage of Resolution
•
> Symptoms :
With evacuation of pus, earache is relieved, fever comes down and
child feels better
Signs :
- external auditory canal may contain blood tinged discharge which
later becomes mucopurulent
- Usually small perforation is seen in anteroinferior quadrant of
pars tensa.
- +ve light house sign: pus oozing out from perforated site in a
pulsatile fashion
- Hyperemia of TM begins to subside with return to normal color
and landmarks
Pinhole appearance
Light house sign
5. Stage of complication
• If virulence of organism is high or resistant of pt. poor,
resolution may not take place and disease spreads beyond
the middle ear
Treatment
1. Control infection
2. Local therapy
3. Treat related disease
 Control infection: antibiotics
• To arrest and reverse inflammation
• Prevent suppuration and perforation
• Relieve symptoms and hasten resolution
• Reduce risk of complication
Ampicillin 50mg/kg/day in 4 divided doses

Amoxicillin 40mg/kg/day in 3 divided doses

 Antibiotics
• Indicated in all cases with fever and severe earache
• m/c organism : S. pneumoniae and H. influenza. So effective
drugs are ampicillin and amoxicillin
• Those allergic to penicillins, give  cefaclor, cotrimoxazole or
erythromycin
• For beta lactamase producing H. influenza or M. catarrhalis ,
give  amoxicillin clavulanate, cefixime
• Therapy must be continued for a min of 10 days, till TM regains
normal appearance and hearing returns to normal
• Early discontinuance with relief of earache & fever, or therapy
in inadequate doses may lead to secretory otitis media and
residual hearing loss
 Local Therapy
• Before perforation
• Relieve earache and control inflammation
• Dry local heat to relieve severe earache
1. Decongestant nasal drops (ephedrine, oxymetazoline,
xylometazoline)
2. Oral nasal decongestant (pseudoephedrine)
3. Analgesic and antipyretic (paracetamol)
 Myringotomy
• Curvilinear incision made in postero-inferior quadrant.
• Done to relieve pressure caused by
excessive build up of fluid, or to drain pus
from Middle ear
• Incision is curvilinear & not radial
(as in OME), to cut fibres of TM.
This keeps opening patent for long time
 Why to make incision in PIQ?
• Least vascular area
• T.M. bulge is maximum
• Ossicles not damaged
• Easily accessible
• A tympanostomy tube is inserted into the eardrum to keep middle
ear aerated for prolonged time and to prevent reaccumulation of
fluid
 Indications of myringotomy
1. Symptoms are not relieved by antibiotics
2. TM bulges significantly
3. TM perforation is too small
4. Incomplete resolution( persistent conductive hearing loss)
5. Persistent effusion beyond 12 weeks
Local Therapy after perforation
• Clear external acoustic canal – ear toilet
• Control infection
• Repair TM
Treat related diseases
• Chronic rhinitis
• Chronic sinusitis
• Chronic tonsillitis
• Adenoid vegetation
• Acute otitis media

Antibacterial
therapy
Review after 48-72 hours

Earache and fever persist

Good response
or increase
Another antibacterial therapy for 10 days or
if TM is bulging  myringotomy and culture Continue same for 10 days
and specific antimicrobial for 10 days

Complete Complete resolution

Persistent fluid but earache and fever subside
resolution
Periodic checks for 12 weeks

Abscess or coalescent
Complete resolution Persistent
mastoiditis
(no effusion) effusion
Do cortical
t/t as OME mastoidectomy