SUPPURATIVE OTITIS MEDIA Notes
SUPPURATIVE OTITIS MEDIA
Objectives
To describe the etiology and management of acute and chronic suppurative otitis media.
Middle Ear Infection
Antibiotics are the primary treatment for uncomplicated acute otitis media (AOM) in adults.
Otitis media can be caused by bacteria or viruses.
If otitis media is not treated, it can lead to pain, pressure, fever, and potentially permanent hearing loss.
Classification of Otitis Media
Suppurative otitis media involves perforation of the tympanic membrane and discharge.
Acute Suppurative Otitis Media (ASOM): Main symptom is severe pain.
Chronic Suppurative Otitis Media (CSOM): Main symptom is discharge.
Tubo-tympanic CSOM: Common in children under 10 years, involves transudation of fluid in the middle ear due to eustachian tube dysfunction, leading to fluid → glue.
Attico-antral CSOM.
Non-suppurative otitis media: otitis media with effusion.
Acute Otitis Media (AOM): Bacteria or virus-induced acute inflammation in the middle ear, with rapid onset of otalgia and fever.
Acute Suppurative Otitis Media (ASOM): Subtype of AOM characterized by pus in the middle ear, with accompanying discharge if the eardrum perforates.
Acute Suppurative Otitis Media (ASOM)
Definition: Infection of the middle ear lasting up to 3 weeks.
Predisposing Factors for ASOM
Upper respiratory tract infection (Eustachian tube).
Tympanic membrane perforation.
Blood-borne (viral, bacterial).
Environmental and genetic factors.
Large adenoid.
Etiology of ASOM
Spread of infection:
Up the Eustachian tube: Ascending infection after upper respiratory tract infection (common).
Through pre-existing tympanic membrane perforation.
Blood-borne infection: Middle ear infection during viral illness predisposing to secondary bacterial infection.
Predisposing Factors (Detailed)
Environmental factors:
Use of pacifier.
Passive smoking.
Bottle feeding (less immunity than breastfeeding).
Low socioeconomic status (e.g., overcrowding).
Day-care attendance.
Genetic factors:
Maternal blood group A.
Specific abnormalities:
Immunosuppression, cleft palate, Down's syndrome, cystic fibrosis.
Large adenoid (adenoiditis):
Ascending infection through the Eustachian tube.
Bacteriology of ASOM
Common organisms:
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis (common in smokers)
Staphylococcus aureus
Streptococcus pyogenes
Viral illnesses facilitate bacterial infection.
Clinical Features of ASOM
Diagnosis is mainly clinical.
More common in children under 5 years.
History of viral URI a few days prior.
Severe ear pain (otalgia) is a main presentation.
Deafness (conductive).
Discharge (serous, purulent, mucopurulent, or blood-stained) when there is tympanic membrane perforation, leading to immediate pain relief.
Fever (low grade).
In children: irritability, poor feeding, vomiting, abdominal pain, and crying due to severe pain.
Tympanic membrane examination:
Red, bulging tympanic membrane or perforation with central discharge.
Weber test: Lateralized to the affected side (conductive deafness).
Rinne's test: Negative.
Tympanic Membrane observations
Red congested bulge indicates pre-suppuration stage.
Vascularization along the manubrium mallei indicates Eustachian tube dysfunction.
Congestion in periphery until perforation occurs.
Perforation in the supero-anterior part.
Investigations for ASOM
Ear swab for culture & sensitivity test when there is discharge.
Mastoid X-ray when there is spread of infection to mastoid antrum.
Treatment for ASOM
Analgesics: Paracetamol.
Antibiotics: For 10 days, such as Amoxicillin or Amoxiclav. If allergic to penicillin, use Cefixime, Erythromycin, or trimethoprim/sulfamethoxazole.
Aural toilet: Cleaning by suction or mopping, never syringing.
Treatment of upper respiratory tract infection: Nasal decongestant.
Protection of ear from water entry, especially with perforation.
Myringotomy: Incision in the tympanic membrane to allow drainage of pus and relieve pain.
Myringotomy is necessary to relieve pus in acute otitis media with complications like facial weakness.
Secretory otitis media is treated by myringotomy and insertion of ventilation tubes (grommet) when medical treatment fails.
Chronic Suppurative Otitis Media (CSOM)
Definition: Infection of the middle ear lasting more than 3 weeks.
Main feature: Discharge (usually painless).
Types of CSOM
Tubo-tympanic Disease (Safe):
Involves the Eustachian tube, tympanic membrane, and nasopharynx.
Granulations are mild.
Otorrhea is profuse, mucoid, and odorless.
Perforation is central.
Cholesteatoma is absent.
Complications are uncommon.
Treatment involves myringoplasty/tympanoplasty.
Attico-antral Disease (Dangerous):
Involves the attic, mastoid antrum, and air cells.
Granulations are red and fleshy with possible perforation.
Otorrhea is scanty, purulent, and foul-smelling.
Perforation is attic or marginal.
Cholesteatoma is present.
Complications are common.
Treatment involves mastoid exploration.
Tubo-Tympanic CSOM (Detailed)
Less dangerous type.
Residue of ASOM when there is persistence of the perforation either through the eustachian tube or tympanic membrane.
The edges of the perforation are covered by squamous epithelium, preventing healing.
Perforation is central, surrounded by the tympanic membrane, usually antero-inferior, but may be anterior, posterior, or kidney-shaped.
Usually not associated with cholesteatoma.
Often linked with eustachian tube dysfunction and upper respiratory tract infections.
Clinical Features of Tubo-Tympanic CSOM
Deafness (conductive), sometimes sensori-neural deafness due to passage of mucopurulent discharge through oval or round windows to the inner ear.
Discharge: Usually mucoid or mucopurulent, profuse & odorless.
Otoscopy: Central, pars tensa perforation.
Audiological Assessment of Tubo-Tympanic CSOM
Tuning Fork tests: Show conductive deafness.
Rinne's test is negative.
Weber's test is lateralized to the affected side.
Pure Tone Audiogram (PTA): Shows conductive deafness (mainly), sometimes mixed deafness (conductive & sensori-neural).
Investigations for Tubo-Tympanic CSOM
Mastoid X-ray: Usually shows cellular mastoid, and sometimes sclerotic mastoid, but there is no bone erosion.
Sinus X-ray: To exclude sinusitis.
CT scan (sometimes done): To exclude intracranial complications.
Ear swab for culture & sensitivity: To determine the causative organism and its antibiotic sensitivity. Stop antibiotics three days before taking the swab.
Bacteriology of Tubo-Tympanic CSOM
Causative organisms of tubo-tympanic CSOM & attico-antral CSOM are the same:
Gram-negative bacteria (Pseudomonas aeruginosa, Proteus).
Anaerobic bacteria (Bacteroides fragilis).
Gram-positive bacteria (Staphylococcus aureus, Streptococcus pyogenes).
Treatment for Tubo-Tympanic CSOM
Usually responds to conservative treatment:
Aural toilet: By mopping or suction under a microscope.
Antibiotics:
Topical: Gentamicin or neomycin/hydrocortisone drops or ciprofloxacin ear drops. However, topical antibiotics are not of great use as fibrosis limits circulation; systemic antibiotics are better.
Systemic: Ciprofloxacin (anti-pseudomonal), metronidazole for anaerobic bacteria.
Treatment of foci of infection: Sinusitis, adenoiditis, or tonsillitis.
Ear protection from water entry: Ear molds or cotton soaked in ointment.
Polypectomy: Removal of the polyp when present by cap forceps.
If the disease is not responding to the above treatments:
Cortical mastoidectomy: To eradicate infection from mastoid air cells.
Myringoplasty: To close the persistent perforation.
Attico-antral CSOM
Regarded as an unsafe type.
Involves the attic & antrum.
Perforation is either in pars flaccida (attic perforation) or postero-superior marginal perforation in pars tensa.
Perforation extends to annulus of tympanic membrane.
Could be associated with retraction pocket, cholesteatoma, or granulation tissue.
Pathology of Attico-antral CSOM
Three basic pathological findings:
Cholesteatoma: Benign squamous cell cyst containing keratin, surrounded by granulation tissue, showing independent growth, replacing middle ear mucosa, and causing bone resorption due to the production of lysozymes.
Granulation tissue: Due to bony involvement (osteitis of mastoid bone). It can cause destruction of surrounding structures.
Cholesterol granuloma: Dark brown gelatinous material, gives the ear drum a dark blue or black appearance.
Classification of Cholesteatoma
Congenital cholesteatoma: Unrelated to CSOM. Arises from embryonic epithelial tissue.
Acquired cholesteatoma: Theories:
Metaplasia of middle ear mucosa: From columnar or pulmonary to cuboidal epithelium to squamous epithelium.
Ingrowth (implantation) of squamous epithelium: Squamous epithelium of the outer surface of the membrane may migrate around the rim of the perforation to the medial surface.
Retraction pocket: Obstruction of Eustachian tube leads to -ve middle ear pressure causing retraction of tympanic membrane in the pars flaccida.
Clinical Features of Attico-antral CSOM
Deafness: Conductive (mainly), sometimes sensori-neural deafness (mixed deafness).
Discharge: Scanty purulent (creamy) & foul-smelling. Blood-stained discharge may occur due to granulation tissue.
Otoscopic examination: Attic or postero-superior marginal perforation, associated attic retraction pocket, or cholesteatoma (pearly white mass).
Weber's & Rinne's tests: Show conductive deafness.
Investigations for Attico-antral CSOM
PTA: Shows conductive deafness, & sometimes mixed deafness.
Ear swab: For culture & sensitivity.
Mastoid X-ray: Usually shows sclerotic mastoid, sometimes cellular, & there may be bone erosion or radiolucency due to cholesteatoma.
CT scan & MRI: Sometimes done to check for intracranial complications.
Treatment for Attico-antral CSOM
When there is no cholesteatoma, conservative treatment as in tubo-tympanic CSOM can be tried:
Ear protection from water entry.
Aural toilet.
Antibiotics:
Topical AB: Gentamicin, neomycin ear drops, or ciprofloxacin ear drops.
Systemic AB: Ciprofloxacin (anti-pseudomonal), & metronidazole for anaerobic bacteria.
Polypectomy: Removal of polyp.
Cauterization: Of granulation tissue by silver nitrate.
Surgery (some form of mastoidectomy) is the treatment of choice when there is cholesteatoma or failure of conservative treatment.
CSOM: Tubo-Tympanic vs. Attico-Antral
Tubo-Tympanic CSOM
Less dangerous type.
Persistent infection through perforated TM or Eustachian tube.
Perforation in Pars tensa antero-inferior or kidney shape and is Central (surrounded by tympanic membrane).
No cholesteatoma, granulation tissue, and retraction pocket.
Discharge is copious mucoid or mucopurulent and odorless.
On X-Ray, the mastoid is cellular or sclerotic with No Bone erosion.
Less severe deafness.
Usually responds to conservative treatment.
Attico-Antral CSOM
Unsafe type (more dangerous).
Persistent infection in the attic or mastoid antrum.
Perforation in Pars Flaccida (attic) or postero-superior (marginal) (Not completely surrounded by TM).
Cholesteatoma, granulation tissue, and retraction Pocket.
Discharge is scanty Purulant (creamy) and foul-smelling - some times associated with Blood from Granulation tissue.
Cellular or sclerotic with Bone erosion.
More severe deafness because cholesteatoma contains lysozymes that erode the ossicles.
Cholesteatoma requires surgery.
Similarities Between attico antras and tubo-tympanic Csom.
Both Cause Conductive or mixed deafness
Both can be associated with Polyp
Both have the same line of conservative management
Both are caused by same micro-organism
CSOM Topical +AB systemic +AB
ASOM → systemic AB only why?
Ans Topical AB Can Cause Sensori- neural deafness if reach the inner ear
in Chom, the car is fibrosed,so systemic AB won't reach the ear properly. Treatment of CSOM
-Medical Tubo tympanic non-cholesteatoma attico-antral
-surgical Faillure of Medical Cholesteatoma attico-antral