Acute otitis media
Dr. Abdullah Alkhalil
MRCS-ENT(UK), DOHNS(London)
Higher specialty(JUST),
Jordanian Board.
Otitis Media
• Otitis media is an inflammation of part or all
of the mucosa of the middle-ear cleft, the
collective term for the eustachian tube,
tympanic cavity, and mastoid air cells.
Otitis Media
Classification of otitis media.
• Acute Otitis Media
Suppurative
Nonsuppurative
Recurrent
• Chronic Otitis Media
Suppurative
Tubotympanic
Cholesteatoma
Nonsuppurative
Otitis media with effusion
Otitis Media
• Acute OM - rapid onset of signs & symptoms,
< 3 wk course
• Subacute OM - 3 wks to 3 mos
• Chronic OM - 3 mos or longer
• Recurrent otitis media – 3 attacks in 6 months
or 4 attacks in one year
Otitis Media
• The eustachian tube appears to be central to the
pathogenesis of all forms of OM. The normal
physiologic functions of the eustachian tube are
to (1) maintain the gaseous pressure within the
middle ear cleft at a level that approximates
atmospheric pressure; (2) prevent reflux of the
contents of the nasopharynx into the middle ear;
and (3) clear secretions from the middle ear by
both mucociliary transport and a “pump action”
of the eustachian tube.
Middle ear is air filled, mucosa lined and sterile cavity
Nasopharynx has normal flora which should not reflux normally
Opening of eustachian tube (pump action) is mediated by tensor velli palatini &
levator velli palatini which contracts during chewing
Otitis Media
Shorter, more horizontal and wider in children
Acute suppurative otitis media
EPIDEMIOLOGY
• Peak incidence in the first two years of life (esp. 6-12
months)
• Boys more affected girls
• 50% of children 1 yr of age will have at least 1 episode.
• 1/3 of children will have 3 or more infections by age 3
• 90% of children will have at least one infection by age
6.
• Occurs more frequently in the winter months
Acute suppurative otitis media
Factors relevant to the epidemiology of otitis media.
• Environmental Factors
• Day-care attendance More transmission
• Not being breast-fed
• Exposure to tobacco smoke Damages cilia
• Seasonal variation in respiratory infections Winter → URTI
• Host Factors
• Genetics
• Immunodeficiency
• Birth defects
Cleft palate Bcz of weak insertion of tensor velli palatini on median raphe
Down syndrome of soft palate with subsequent dysfunction of eustachian tube
• Adeniods (nasal obstruction, eustachian obstruction, bacterial reservoir)
Acute suppurative otitis media
Pathogenesis
• In most cases of AOM, an antecedent viral upper
respiratory tract infection leads to disruption of
eustachian tube function. Inflammation of the
middle ear mucosa results in an effusion, which
cannot be cleared via the obstructed eustachian
tube. This effusion provides a favorable medium
for proliferation of bacterial pathogens, which
reach the middle ear via the eustachian tube,
resulting in suppuration.
Acute suppurative otitis media
Pathogenesis
• Although viral infection is important in the
pathogenesis of AOM, the majority of patients develop
subsequent bacterial colonization, and therefore AOM
should be considered a predominantly bacterial
infection. Many studies, using tympanocentesis, have
identified Streptococcus pneumoniae (up to 40%),
Haemophilus influenzae (25–30%), and Moraxella
catarrhalis (10–20%) as the organisms most commonly
responsible for AOM. Less frequently identified
pathogens include group A streptococci,
Staphylococcus aureus, and gram-negative organisms
such as Pseudomonas aeruginosa.
Acute suppurative otitis media
Pathogenesis
• There are two mechanisms by which the
adenoids may influence OM: (1) physical
obstruction of the eustachian tube when the
adenoids are enlarged and (2) a reservoir of
pathogenic bacteria harbored in the adenoid
tissue, which predisposes the patient to
repeated episodes of AOM.
Physiological hypertrophy between 3-9 years
Acute suppurative otitis media
SIGNS & SYMPTOMS
• Neonates/Infants: change in behavior,
irritability, tugging at ears, decreased appetite,
vomiting.
• Children(2-4): otalgia, fever, noises in ears,
cannot hear properly, changes in personality
• Children (>4): complain of ear pain, changes
in personality
Acute suppurative otitis media
SIGNS & SYMPTOMS
• Preceding URTI
• Pain, which may increase rapidly in intensity to
become deep and throbbing.
• Blocked ear sensation.
• Fever.
• Deafness progresses as suppuration occurs and
both symptoms may rapidly improve if rupture of
the tympanic membrane produces a
mucopurulent otorrhoea.
Acute suppurative otitis media
• SIGNS & SYMPTOMS
• Dull tympanic membrane on examination.
Hyperaemia rapidly follows and leashes of vessels
may be seen running along or parallel to the
malleus handle. Soon radial vessels are visible on
the drumhead and a middle ear effusion occurs.
The drumhead takes on a full, red, angry
appearance. Pressure necrosis cause drumhead
to rupture allowing mucopus to drain into the
external ear canal.
Acute suppurative otitis media
Left side bcz cone of light on left
Right side bcz cone of light on right
Angry tympanic membrane, Perforation, 90-95% resolves
completely with antibiotic treatment.
Acute suppurative otitis media
Dx is clinical by Hx, Otoscope &
Pneumatoscope: push air and see no mobility of membrane
Acute suppurative otitis media
Treatment
Goals:
• Decreasing the duration of fever and pain
• Expediting the resumption of normal activity
• Limiting the small potential for suppurative
complications
Acute suppurative otitis media
Treatment
NONSURGICAL MEASURES
1. Watchful waiting— without antibiotic
therapy for healthy 2-year-olds or older children
with nonsevere illness (mild otalgia and fever <
39 °C) because AOM symptoms improve in most
within 1–3 days. Watchful waiting is not
recommended for children < 2 years old if AOM
is certain.
Acute suppurative otitis media
Treatment
NONSURGICAL MEASURES
2. Antibiotic therapy
• Augmentin (amoxicillin/clavulanate) 90
mg/kg/day divided bid for 10-14 days.
• Ceftin (cefuroxime axetil [a second generation
cephalosporin]) 30 mg/kg/day divided bid
• Rocephin (ceftriaxone) 50 mg/kg/dose IM/IV q
day for 3 days
Acute suppurative otitis media
Treatment
NONSURGICAL MEASURES
2. Antibiotic therapy
• For penicillin allergic children,
trimethoprim/sulfamethoxazole or
erythromycin/sulfisoxazole
sulfafurazole are the initial
choices
Acute suppurative otitis media
Treatment
NONSURGICAL MEASURES
• 3. Adjunctive therapy—The adjunctive
therapy for AOM should include analgesics
and antipyretics.
• 4. Conditions predisposing to ASOM should be
treated on their own merit after resolution.
Acute suppurative otitis media
Treatment
• SURGICAL MEASURES
• A minority of patients with AOM fail to
respond to medical therapy or develop a
complication. Myringotomy is then indicated
to allow the drainage of pus from the middle
ear space.
Surgical cut (myringotomy) has clear edges so healing is much more
(within 2 days) than spontaneous rupture with necrotic edges.
Acute suppurative otitis media
Acute suppurative otitis media
INDICATIONS FOR TYMPANOCENTESIS
• Toxic appearing child
• Failed treatment regimen with antibiotics
• Suppurative complications
• Immunosuppressed pt.
• Newborn infant in which the usual pathogens
may not be the case.
Acute suppurative otitis media
Sequel of ASOM
• Non-suppurative middle-ear effusion. These
persist for over 30 days in 40% of children and
for over 3 months in 10%.
• High-tone sensorineural hearing loss, perhaps
secondary to bacterial toxins migrating across
the round window.
• Tympanic membrane perforation.
Acute suppurative otitis media
• Sequelae of ASOM
• Adhesions between the tympanic membrane,
ossicles and the medial wall of the middle ear.
• Tympanosclerosis which may spread from the
tympanic membrane to the ossicular chain,
fixing the latter.
• Erosion of the ossicular chain, in particular the
long process of the incus, especially following
recurrent episodes of ASOM.
Acute suppurative otitis media
Typmanosclerosis, can lead to conductive hearing
loss if it goes to middle ear and ossicles involved
Complete adhesion
OTITIS MEDIA WITH EFFUSION
• Otitis media with effusion is defined as the
persistence of a serous or mucoid middle ear
effusion for 3 months or more. Various terms,
such as chronic secretory otitis media, chronic
serous otitis media, and “glue ear,” have been
used to describe the same condition.
Nonsterile non suppurative fluid (there is bacteria
but no pus, no fever no pain) → decreased hearing
OTITIS MEDIA WITH EFFUSION
• It is the most common cause of hearing loss in
children in the developed world and has peaks
in incidence at 2 and 5 years of age.
• The risk factors for OME are closely
interrelated with those associated with AOM.
• In fact, the formation of a middle ear effusion
frequently occurs after an episode of AOM,
and children with OME are far more likely to
suffer from recurrent AOM.
OTITIS MEDIA WITH EFFUSION
Pathogenesis
• Under normal conditions, the middle ear
mucosa constantly secretes mucus, which is
removed by mucociliary transport into the
nasopharynx via the eustachian tube.
• As a consequence, factors resulting in an
overproduction of mucus, an impaired
clearance of mucus, or both can result in the
formation of a middle ear effusion.
OTITIS MEDIA WITH EFFUSION
Pathogenesis
• Both viral and bacterial infection can lead to
the increased production and viscosity of
secretions from the middle ear mucosa.
• Eustachian tube dysfunction
• Barotrauma(scuba diving)
• Exposure to smoking
OTITIS MEDIA WITH EFFUSION
SYMPTOMS AND SIGNS
• Asymptomatic
• Decreased hearing.
• School !! Decreased performance
• Delayed speech in younger children
• Blocked ear
• Rarely earache, tinnitus, or balance disorder
may be present.
OTITIS MEDIA WITH EFFUSION
SYMPTOMS AND SIGNS
• Otoscopy classically reveals a dull gray- or
yellow colored tympanic membrane that has
reduced mobility on pneumatic otoscopy. If
the tympanic membrane is translucent, an air-
fluid level or small air bubbles within the
middle ear effusion may be seen.
OTITIS MEDIA WITH EFFUSION
OTITIS MEDIA WITH EFFUSION
SPECIAL TESTS Type A, normal pressure
& mobility → normal
• tympanometery
Type B: flat graph → OME
Type C: there is mobility but
to the ⊖ side → ⊖ middle
ear pressure → beginning
of middle ear problems
OTITIS MEDIA WITH EFFUSION
SPECIAL TESTS
• Audiometery
Conductive hearing loss
https://youtu.be/acYMy9b0F2A
OTITIS MEDIA WITH EFFUSION
Treatment
OBSERVATION
• A large number of patients with OME require no
treatment, particularly if the hearing impairment
is mild. Spontaneous resolution occurs in a
significant proportion of patients. A period of
watchful waiting of 3 months from the onset (if
known) or from the diagnosis (if onset unknown)
before considering intervention is therefore
advisable.
OTITIS MEDIA WITH EFFUSION
Treatment
NONSURGICAL MEASURES
fl
• Medical treatments include antibiotics,
steroids, decongestants, and antihistamines.
↓• inAntibiotics
ammation around
eustachian tube to
• Steroids
enhance drainage
OTITIS MEDIA WITH EFFUSION
Treatment
• The surgical options for OME are
tympanostomy tubes and adenoidectomy.
Myringotomy and aspiration of middle ear
effusion without ventilation tube insertion has
a short-lived benefit and is not recommended.
OTITIS MEDIA WITH EFFUSION
Treatment Replace function of eustachian tube
1. Insertion of tympanostomy tubes—The aim of
tympanostomy tube insertion is to allow ventilation
of the middle ear space—hence to improve hearing
thresholds. The prolonged ventilation of the middle
ear may also allow resolution of chronic
inflammation of the middle ear mucosa.
Complications include myringosclerosis, purulent
otorrhea, and residual perforation after extrusion.
Ventilation tubes
Short term tubes are extruded within 6-12 months with 3% risk of persistent perforation.
Long duration ventilation tube (T tube), used after extrusion of the first one but get OME again.
They are more effective, stays 2-4 years but much more risk of persistence of perforation
OTITIS MEDIA WITH EFFUSION
Treatment
2. Adenoidectomy— The rationale for
adenoidectomy is that it relieves nasal
obstruction, improves eustachian tube function,
and eliminates a potential reservoir of bacteria.