Otitis Media
Definition: "otitis media' means
inflammation of the middle ear ,Eustachian tube and mastoid air cell.
Most common among children of low
socio economic status following a URTI
Classification:
1 . Acute otitis media
·
Non
suppurative (including barotrauma)
·
Suppurative
2. Chronic otitis media
·
non
suppurative
a. otitis media with effusion
b. adhesive otitis media
c. tympanosclerosis
·
suppurative
3. Specific type of otitis media
(tuberculosis, syphilis, diptheria)
Otitis media with effusion (OME)
Synonyms: secretory otitis media, serous
otitis media, glue ear, seromucinous otitis media
·
insidious
onset of accumulation of non purulent effusion in the middle ear without any
pyogenic organisms involvement.
·
effusion
is thick and viscid or thin or serous
·
fluid
is nearly sterile
·
commonly
seen among 5-8 years of age
Etiology
the
exact etiology is not known.
tubal occlusion: in children
enlargements of the adenoids and any infection in the nose or throat
allergy: can cause mucosal edema of the
eustachian tube orifice
hypogammaglobulinemia: predisposes to
inflammatory response because of low immune
status.
Pathogenesis
·
increased
secretory activity of middle ear mucosa
·
malfunctioning
of Eustachian tube
·
if
the Eustachian tube does not open and allow equalization of pressure, negative
pressure within the middle ear causes fluid to seep from the tissue.
clinical manifestation:
·
feeling
of fullness in ear
·
hearing
loss
·
delayed
or defective speech
·
mild
ear aches
·
client
does not experience pain. Fever, or discharge from ear.
Diagnosis:
·
TM
appears as yellow, gray, or bluish in colour
·
fluid
level and bubbles may seen when TM is transparent
·
Tuning
fork tests:
a. Rinne test- negative on the affected
side
b. Weber test- lateralization to the
affected side
·
Absolute
bone conduction- normal
·
plain
x-ray — paranasal sinuses, hypertrophied adenoids
 |
| hypertrophied adenoids |
·
audiometry:
conductive hearing loss
Treatment:
Non surgical
·
decongestants
·
anti-allergy
treatment antihistamines
·
antibiotics
·
middle
ear aeration: by valsalva maneuver and chewing gum to encourage frequent
swallowing
Surgical
·
Myringotomy
and aspiration of fluids
·
Grommet
insertion (tympanostomy or ventilation tubes)
·
surgical
management of the causative factors: (adenoidectomy, tonsillectomy etc.)
Otitic barotrauma
Damage that results from failure of
the Eustachian tube to equalize air pressure on either side of the tympanic
membrane, occurs most commonly during descent from high altitude in an aircraft
or descent in under water diving.
Causes:
·
air
travel while there is a functional problem with ET tube e.g., URTI
·
sleep
during descent of an aircraft from high altitude
·
in-
flight, alcohol leading to sleep thus causing et muscle relaxation
·
patient
undergoing hyperbaric O2 therapy in decompression chamber
Signs and symptoms
·
pain
·
swishing
sensation in ear on movement
·
hearing
loss
·
tinnitus
·
erythema
of tympanic membrane
·
sensation
of wooliness in ear
·
haemorrhages
on tympanic membrane
·
in
severe cases- rupture of tympanic membrane
Treatment
Prevention
is by:
·
the
effusion of barotrauma tends to resolve spontaneously in 6 weeks usually
·
avoiding
air travel during URTI
·
topical
nasal decongestants
·
avoidance
of alcohol on the journey
·
topical
and systemic decongestants
·
myringotomy
and ventilation tube insertion
Acute suppurative otitis media (ASOM)
·
acute
onset of symptoms, evidence of a middle ear effusion, and signs or symptoms of
middle ear inflammation by pyogenic organism.
·
it
is an acute suppurative inflammation of the periosteal layer of the middle ear
clef by suppurative organisms.
·
commonly
seen in children
Etiological factors:
·
Streptococcus
pneumoniae
·
Staph
aureus
·
Haemophilus
influenza
·
Pseudomonas
aeruginosa
·
Streptococcus
pyogens
·
Moraxella
catarrhalis
risk factors:
·
upper
respiratory infections
·
craniofacial
abnormalities (cleft palate)
·
allergies
·
recurrent
common cold
·
infections
of tonsils and adenoids
·
blood
borne infections- rare
·
traumatic
perforation
Causes (young children)
·
Eustachian
tube is narrow, stiff, shorter and
somewhat flat
·
exposure
to cigarette smoke
·
bottle
feeding (bottle at night, nap time)
·
direct
route for bacteria and viruses
·
easier
to get blocked
·
day
care (kid-to-kid)
·
immune
system not fully developed
Pathophysiology & clinical manifestation
Stage I- stage of hyperaemia
The mucosa in the middle ear and the ET
will get congested because of invasion by microorganisms
The hyperaemia may extend to the
antrum and mastoid region
CM:
·
otalgia-
mild to moderate
·
fever
·
obstruction
or fullness of the ear
·
deafness
·
associated
symptoms- running nose, nasal obstruction
·
tympanic
membrane- congested
Stage II- stage of exudation
In addition to hyperemia, there will
be collection of the exudate in the middle ear cavity
CM
·
pain
will increase
·
blocking
sensation of the ear will increase
·
Deafness
increases
·
Tympanic
membrane- thick, congested, bulging
Stage III- stage of suppuration
The collected exudate in the middle
ear will increase producing tension on the tympanic membrane
Produces pressure necrosis in the
pars tensa of the TM leading to a small central perforation ear starts draining
CM:
·
pain
is less, because of discharge
·
discharge
— blood stained , serosanguinous, mucopurulent
·
TM-
small central perforation
·
Lighthouse sign- pulsatile discharge present through
the perforation
·
x-
ray mastóid- cloudy
Stage IV -coalescent mastoiditis/ surgical mastoiditis
There will be reinfection in the
middle ear seen usually after a period 2 weeks after the previous stage series
of pathological changes in the middle ear cleft leading to colescent of mastoid
air cells mastoid will be a bag of pus
CM:
·
Fever,
high ESR
·
Ear
ache increases
·
Mucopurulent
discharge
·
Deafness
will increase
·
Mastoid
tenderness
·
Reservoir sign- copious and continuous discharge
which reappears immediately after wiping
·
Cardinal sign- sagging of the posterior superior
meatal wall
Stage V- stage of complications
·
If
virulence of organism is higher
·
Resolution
may not takes place
·
Disease
spread beyond middle ear by erosion of bone or by hyperemic decalcification or
thromboembolic phenomena
Complication:
Extra cranial
Intracranial
Stage VI- Stage of resolution
·
As
resistance of the host overtakes the virulence of the organism or because of
proper antibiotic therapy, the acute infection begins to subside
·
The
first evidence of resolution will be cessation of ear discharge
Diagnosis:
·
Otoscopic
examination: the tympanic membrane looks erythematic, opaque, bulging with loss
of anatomic landmarks
·
Pneumatic
otoscopy: decreased tympanic membrane mobility
·
impedance
tympanometry: measures the resonance of the ear canal for a fixed sound as the
air pressure is varied.
·
Diagnostic
tympanocentesis: involves puncturing the tympanic membrane and aspirating middle ear fluid to relieve pressure.
TREATMENT
Nonsurgical
·
antibacterial
therapy- broad spectrum
·
decongestant
nasal spray: ephedrine, otrivin
·
nasal
drops
·
analgesics
and antipyretics
·
dry
local heat
·
menthol/
tincture benzoin steam inhalation
·
aural
toilet- dry mopping or suction cleaning
Surgical
·
Myringotomy
·
Cortical
mastoidectomy and drainage of pus
·
tympanostomy
tube: pressure equalization tubes (PE tubes)
v slit in eardrum
v drain fluid in ear
v place tube in ear (usually
bilaterally)
v tube ventilates and equalizes
pressure in middle ear, and subsequently will normalize hearing
Complications
·
hearing
loss: conductive, sensoneural, mixed
·
acute
mastoiditis
·
chronic
perforation of the TM
·
tympanosclerosis
·
chronic
suppurative OM
·
facial
nerve paralysis (bell's palsy)
·
Cholesteatoma
·
intracranial
complications- bacterial meningitis, epidural abscess, brain abscess, otitic
hydrocephalus, lateral sinus thrombosis
Acute necrotizing otitis media
·
is
a special form of ASOM
·
occurs
mostly in infants and young children suffering from scarlet fever, measles,
pneumonia, influenza, or systemic illness
·
there
is an early necrosis and destruction of most of the tympanic membrane
·
TM
usually shows a total perforation with foul smelling purulent discharge
·
necrotic
ossicles may be seen
Chronic suppurative otitis media(CSOM)
·
it
is a long standing infection of a part or whole of the middle ear characterized
by ear discharge and a permanent perforation
·
Incidence
will be more in developing country
·
low
socio economic status
·
poor
nutrition
Pathology:
• it
is the sequela of acute otitis media leaving behind a large perforation
• the
perforation becomes permanent and permits repeated infection from external ear
Types
·
tubotympanic
type or safe type
·
attico
— antral or dangerous type
tubotympanic type —
etiology:
1 . Predisposing factors:
·
inadequate/
improper treatment of ASOM
·
infection
from surrounding areas like nose, nasopharynx & oropharynx
·
diseases
like tuberculosis
·
pneumatization
of mastoid- sclerotic mastoid are more prone
2. Exciting factors:
·
gram
negative oreamsms like pseudomonas, proteus, E Coli.
·
streptococcus
·
staphylococcus
Symptoms:
Discharge:
profuse, intermittent, predominantly mucoid, non foul smelling, whitish/
yellowish and tenacious.
·
It
increases with attacks of cold
·
Depending
on the discharge it is divided into four stages:
·
Active
-actively discharging at the time of clinical examination
·
quiescent-
no ear discharge for less than 3 to 6 months period
·
inactive
— no ear discharge for more than 6 months
·
healed-
central perforation has healed
2. Deafness- mild conductive
3. Ear ache- if associated with otitis externa
Diagnosis
* culture
& sensitivity of the discharge
* examination
under microscopy
* pure
tone audiogram
* x-
ray mastoids, paranasal sinuses, soft tissue neck
* diagnostic nasal endoscopy
Patch test-
·
examination
under microscopy
·
base
line audiogram
·
perforation
closed with cigarette foil
·
repeat
audiogram
* improved
hearing (intact ossicular chain)
* decreased hearing (discontinuity)
* no
improvement (technical fault)
Treatment
Medical management
·
Aural
toilet
·
dry
mopping/ wet mopping
·
suction
and cleaning
·
antibiotics
(based on c/s report)
·
topical
antibiotics
·
Systemic
antibiotics
Surgical treatment
aural polypectomy
meringoplasty- if hearing loss is
below 40 db
tympanoplasty- if hearing loss is
above 40 db
mastoidectomy:
precipitating disease: adenoid/
tonsil/ DNS/ nasal polyps/ sinus wash
Attico- antral or dangerous type
It is usually associated with
cholesteatoma formation
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