Acute Suppurative Otitis Media

Dr. Vishal Sharma

Definition

Pyogenic infection of middle ear cleft lasting for

< 3 weeks.

Routes for infection:

1. Via Eustachian tube

2. Via Tympanic membrane perforation

3. Haematogenous (rare)

Predisposing Factors

1. Breast feeding in supine position

2. Recurrent upper respiratory tract infection

3. Nasal allergy

4. Chronic rhinitis & sinusitis

5. Tumours of nose & nasopharynx

6. Exposure to cigarette smoke

7. Cleft palate

Bacteriology

1. Haemophilus influenzae

2. Streptococcus pneumoniae

3. Staphylococcus aureus

4. Moraxella catarrhalis

5. - Hemolytic streptococci (causes acute

necrotizing otitis media)

Stages of A.S.O.M.

1. Stage of Hyperaemia

Synonym: Stage of tubal occlusion

Mild earache

T.M. retracted in early stage

T.M. congested later stage

Cartwheel appearance: radiating blood

vessels from handle of malleus

Cart wheel appearance

2. Stage of Exudation

High fever

Severe earache

Deafness

Marked congestion + bulging of T.M.

Mastoid tenderness

P.T.A.: high frequency conductive deafness

due to mass effect of pus

Stage of Exudation

Stage of Exudation

Stage of Exudation

Stage of Exudation

Nipple sign (impending perforation)

Localized protrusion

of tympanic

membrane due to

destruction of

fibrous layer by

continuous pressure

of pus

3. Stage of Suppuration

Symptoms:

Ear discharge (blood-stained purulent)

Increased deafness

Decreased fever

Decreased earache

Blood stained otorrhoea

Signs & Investigations

Pinhole perforation + otorrhoea

Light house sign: intermittent reflection of light

Decreased mastoid tenderness

High (mass effect) + low frequency (stiffness

effect of thick periosteum) Conductive deafness

Clouding of air cells in mastoid X-ray

Light House sign

Pinhole perforation

Clouding of mastoid cells

4. Stage of Coalescent Mastoiditis

Otorrhoea > 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

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

Pathogenesis

Mastoid reservoir sign

Sagging of posterior wall

Ironed out appearance

Mastoid cavity

Mastoid cavity

5. Stage of Resolution

Otorrhoea

stops

Normal

hearing

Healed

perforation

Stage of Resolution

Sterile exudate in middle ear

6. Stage of Complications

Sub-periosteal abscess

Vertigo

Headache + blurred vision + projectile vomiting

Fever + neck rigidity + irritability

Drowsiness

Gradenigo syndrome (apex petrositis)

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

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.

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

Nasal Decongestants

Systemic decongestants

Phenylephrine

Pseudoephedrine

Topical decongestants

Xylometazoline

Oxymetazoline

Saline

Anti-cold preparationsName 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

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)

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

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

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.

Why make incision in PIQ?

Least vascular area

T.M. bulge is maximum

Ossicles not damaged

Easily accessible

Sub-periosteal abscess & fistula

Pathology

Production of pus under tension

hyperaemic decalcification (halisteresis)

+ osteoclastic resorption of bone

sub-periosteal abscess

penetration of periosteum + skin

fistula formation

Sub-periosteal abscess formation

Sub-periosteal fistula: dry

Sub-periosteal fistula: wet

Types of sub-periosteal abscess

Post-auricular

Bezold

Citelli

Zygomatic

Luc

Retro-mastoid

Parapharyngeal & Retropharyngeal

Types of sub-periosteal abscess

Post-auricular abscess

Commonest. Present behind the ear.

Pinna pushed forward & downward.

Bezold & Citelli abscesses

Bezold: neck swelling

over sternocleido-

mastoid muscle

Citelli: neck swelling

over posterior belly

of digastric muscle

Bezold’s abscess

Bezold’s abscess

Luc: swelling in external auditory canal

Zygomatic: swelling antero-superior to pinna +

upper eyelid oedema

Retro-mastoid: swelling over occipital bone

(? Citelli’s abscess)

Parapharyngeal & Retropharyngeal: due to spread

of pus along Eustachian tube

Retromastoid abscess

Gradenigo syndrome

Giuseppe Gradenigo (1859 – 1926)

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 Dorello’s canal under

Gruber’s petro-sphenoid ligament, at petrous apex

Persistent otorrhoea + Retro-orbital pain +

Convergent squint

Right Convergent squint

Right gaze Central gaze Left gaze

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.

Hearing preserving approaches to petrous apex

Eagleton’s middle cranial fossa approach

Frenckner’s subarcuate approach

Thornwaldt’s retro-labyrinthine approach

Dearmin & Farrior’s infra-labyrinthine approach

Farrior’s hypotympanic sub-cochlear approach

Lempert Ramadier’s peri-tubal approach

Kopetsky Almoor’s peri-tubal approach

Hearing sacrificing approaches to petrous apex Trans-cochlear approach Trans-labyrinthine approach

Spread of pus

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

Cortical Mastoidectomy

Antiseptic dressing

Draping

Infiltration

Marking of incision

Wilde’s post-aural incision

Incision deepened

Musculoperiosteal flap elevated

Bezold’s abscess

Aspiration of pus

Drainage of abscess

Drainage of abscess

Corical mastoidectomy begun

Exposure of mastoid antrum

Widening of aditus

Aditus widened

Final Cavity

Cortical Mastoidectomy

Drain put in mastoid cavity

Mastoid dressing

Healed post-aural scar

Thank you