9 Acute Suppurative Otitis Media

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AcuteSuppurative

Otitis Media

Dr. Vishal Sharma


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Definition

Pyogenic infection of middle ear cleft lasting for 2 weeks, otalgia & deafness

Mastoid reservoir sign: pus fills up on mopping

Sagging of postero-superior canal wall caused by

peri-osteitis due to pus in adjacent mastoid antrum

Ironed out appearance of skin over mastoid due to

thickened periosteum

Mastoid cavity in X-ray & CT scan


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PathogenesisAditus Blockage

Failure of drainage

Stasis of secretions

Hyperemic decalcification

Resorption of bony septa of air cells

Coalescence of small air cells to form cavity

Empyema of mastoid cavity


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Pathogenesis

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Fifth level


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Mastoid reservoir signClick to edit Master text styles

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Sagging of posterior wall

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Ironed out appearanceClick to edit Master text styles



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Mastoid cavityClick to edit Master text styles



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Mastoid cavityClick to edit Master text styles



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5. Stage of Resolution

Otorrhoeastops

Normalhearing

Healedperforation



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Stage of ResolutionClick to edit Master text styles



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Sterile exudate in middle ear



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6. Stage of Complications

Sub-periosteal abscess

Vertigo

Headache + blurred vision + projectile vomiting

Fever + neck rigidity + irritability

Drowsiness

Gradenigo syndrome (apex petrositis)


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Treatment of A.S.O.M.1. Systemic Antibiotic

2. Nasal decongestants (systemic + topical)

3. H1 anti-histamines

4. Analgesic + anti-pyretic

5. Aural toilet for ear discharge

6. Heat application for severe earache

7. Review after 48 hours


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Amoxicillin-clavulanate duo: 625 mg B.D.

Ciprofloxacin: 500mg B.D.

Doxycycline: 100 mg B.D.

Cefadroxil: 500 mg B.D.Cefaclor: 500 mg T.I.D.

Cefuroxime: 250 mg B.D.

Cefixime: 200 mg B.D.

Cefpodoxime: 200 mg B.D.

Azithromycin: 500 mg O.D.

Clarithromycin: 250 mg B.D.


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Antihistamines

Systemic:

Cetirizine: 10 mg OD

Fexofenadine: 120 mg OD

Loratidine: 10 mg OD

Levocetrizine: 5 mg OD

Desloratidine: 5 mg OD

Topical: Azelastine spray (0.1%): 1-2 puff BD


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Nasal Decongestants

Systemic decongestants

Phenylephrine

Pseudoephedrine

Topical decongestants

Xylometazoline

Oxymetazoline

Saline


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Anti-cold preparations

Name Chlorpheniramine Decongestant Paracetamol

COLDIN 4 mg PsE 60 mg 500 mg

SINAREST 4 mg PsE 60 mg 500 mg

DECOLD 4 mg PhE 7.5 mg 500 mg

SUPRIN 2 mg PhE 5 mg 500 mg

PsE = Pseudoephedrine; PhE = Phenylephrine


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Topical Decongestants

Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)

Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P)

Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)

Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)

Saline 2 %: 3 drops TID

Saline 0.67 %: 2 drops BD (NASIVION-S)

O f


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On review after 48 hours

Earache + fever persists: change to higher antibiotic.

If T.M. is bulging perform myringotomy. Send ear

discharge for C/S.

Earache + fever subside: continue same treatment

for 10-14 days

Review after 3 months

O i f 3 h


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On review after 3 months

No effusion: no further treatment

Effusion persists: treat as Otitis Media

with Effusion

Presence of abscess or coalescent mastoiditis:

do cortical mastoidectomy

M i t i A S O M


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Myringotomy in A.S.O.M.

Curvilinear incision made in

postero-inferior quadrant.

Incision is curvilinear & not radial

(as in OME), to cut fibres of TM.

This keeps opening patent for long

time.

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Fifth level


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Why make incision in PIQ?

Least vascular area

T.M. bulge is maximum

Ossicles not damaged

Easily accessible



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Sub-periosteal

abscess & fistula

P th l


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PathologyProduction of pus under tension

hyperaemic decalcification (halisteresis)

+ osteoclastic resorption of bone

sub-periosteal abscess

penetration of periosteum + skin

fistula formation

S b i t l b f ti


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Sub-periosteal abscess formation

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S b i t l fi t l d


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Sub-periosteal fistula: dryClick to edit Master text styles


S b i t l fi t l t


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Sub-periosteal fistula: wetClick to edit Master text styles


T f b i t l b


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Types of sub-periosteal abscess

Post-auricular

Bezold

Citelli

Zygomatic

Luc

Retro-mastoid

Parapharyngeal & Retropharyngeal

T f b i t l b


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Types of sub-periosteal abscess



P t i l b


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Post-auricular abscessClick to edit Master text styles


Commonest. Present behind the ear.

Pinna pushed forward & downward.



B ld & Cit lli b


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Bezold & Citelli abscesses

Bezold: neck swelling

over sternocleido-

mastoid muscle

Citelli: neck swelling

over posterior belly

of digastric muscle

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B ld b


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Bezolds abscessClick to edit Master text styles


Be olds abscess


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Bezolds abscessClick to edit Master text styles


L lli i t l dit l


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Luc: swelling in external auditory canal

Zygomatic: swelling antero-superior to pinna +

upper eyelid oedema

Retro-mastoid: swelling over occipital bone

(? Citellis abscess)

Parapharyngeal & Retropharyngeal: due to spread

of pus along Eustachian tube

Retromastoid abscess


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Retromastoid abscess


G d i d


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Gradenigo syndromeClick to edit Master text styles


Giuseppe Gradenigo (1859 1926)

Defining triad


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Defining triad Persistent otorrhoea:despite adequate

cortical mastoidectomy

Retro-orbital pain: Trigeminal nerve involvement

Diplopia:convergent squint due to lateral rectus

palsy by injury to abducent nv in Dorellos canal under Grubers

petro-sphenoid ligament, at petrous apex



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Persistent otorrhoea + Retro-orbital pain +

Convergent squint


Right Convergent squint


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Right Convergent squint

Right gaze Central gaze Left gaze

Etiology: Coalescent mastoiditis involving


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Etiology: Coalescent mastoiditis involving

petrous apex along postero-superior & antero-

inferior tracts in relation to bony labyrinth

Diagnosis: 1. C.T. scan temporal bone for bony

details. 2. M.R.I. to differ b/w bone marrow & pus

Treatment: Modified radical mastoidectomy &

clearance of petrous apex cells

C T scan & M R I


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C.T. scan & M.R.I.Click to edit Master text styles


Hearing preserving approaches to petrous apex


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Hearing preserving approaches to petrous apex

Eagletons middle cranial fossa approach

Frenckners subarcuate approach

Thornwaldts retro-labyrinthine approach

Dearmin & Farriors infra-labyrinthine approach

Farriors hypotympanic sub-cochlear approach

Lempert Ramadiers peri-tubal approach

Kopetsky Almoors peri-tubal approach



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Fifth level

H i ifi i h t t


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Hearing sacrificing approaches to petrous apex

Trans-cochlear approach

Trans-labyrinthine approach


Spread of pus


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Spread of pusClick to edit Master text stylesSecond level Third level Fourth level Fifth level

Post-auricular: Lateral spread


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Post auricular: Lateral spread

Bezold: Inferior spread

Citelli: Inferior spread

Luc: Anterior spread

Zygomatic: Superior spread

Retro-mastoid: Posterior spread

Parapharyngeal: Medial spread

Retropharyngeal: Medial spread

Gradenigo syndrome: Medial spread


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Cortical

Mastoidectomy

Antiseptic dressing


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Antiseptic dressingClick to edit Master text styles


Draping


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DrapingClick to edit Master text styles


Infiltration


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InfiltrationClick to edit Master text stylesSecond level Third level Fourth level Fifth level

Marking of incision


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Marking of incisionClick to edit Master text styles


Wildes post-aural incision


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Wilde s post-aural incisionClick to edit Master text styles


Incision deepened


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Incision deepenedClick to edit Master text styles


Musculoperiosteal flap elevated


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Musculoperiosteal flap elevated



Bezolds abscess


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Bezold s abscessClick to edit Master text stylesSecond level Third level Fourth level Fifth level

Aspiration of pus


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Aspiration of pusClick to edit Master text styles


Drainage of abscess


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Drainage of abscess



Drainage of abscess


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Drainage of abscess



Corical mastoidectomy begun


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Corical mastoidectomy begunClick to edit Master text styles


Exposure of mastoid antrum


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Exposure of mastoid antrumClick to edit Master text styles


Widening of aditus


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Widening of aditusClick to edit Master text styles


Aditus widened


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Aditus widenedClick to edit Master text stylesSecond level Third level Fourth level Fifth level

Final Cavity


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Final CavityClick to edit Master text styles


Cortical Mastoidectomy


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Cortical MastoidectomyClick to edit Master text styles


Drain put in mastoid cavity


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Drain put in mastoid cavityClick to edit Master text styles


Mastoid dressing


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Mastoid dressingClick to edit Master text styles


Healed post-aural scar


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Healed post aural scarClick to edit Master text styles


Thank you


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yClick to edit Master text stylesSecond level

Third level Fourth level Fifth level

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9 Acute Suppurative Otitis Media