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    Acute Suppurative Otitis Media

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    Hermawan Surya Dharma
    This document provides an overview of acute suppurative otitis media (A.S.O.M.), including its definition, predisposing factors, bacteriology, stages, pathogenesis, treatment, complications, and surgical procedures. It defines A.S.O.M. as a pyogenic middle ear infection lasting less than 3 weeks. The document outlines the stages of A.S.O.M. from initial hyperaemia and exudation to potential complications like subperiosteal abscess or mastoiditis. Common bacteria that cause A.S.O.M. are discussed. Treatment involves antibiotics, nasal decongestants, and surgical drainage if needed. Complications like Gradenigo

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    Acute Suppurative Otitis Media

    Uploaded by

    Hermawan Surya Dharma
    894 views87 pages
    This document provides an overview of acute suppurative otitis media (A.S.O.M.), including its definition, predisposing factors, bacteriology, stages, pathogenesis, treatment, complications, and surgical procedures. It defines A.S.O.M. as a pyogenic middle ear infection lasting less than 3 weeks. The document outlines the stages of A.S.O.M. from initial hyperaemia and exudation to potential complications like subperiosteal abscess or mastoiditis. Common bacteria that cause A.S.O.M. are discussed. Treatment involves antibiotics, nasal decongestants, and surgical drainage if needed. Complications like Gradenigo

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    This document provides an overview of acute suppurative otitis media (A.S.O.M.), including its definition, predisposing factors, bacteriology, stages, pathogenesis, treatment, complications, and surgical procedures. It defines A.S.O.M. as a pyogenic middle ear infection lasting less than 3 weeks. The document outlines the stages of A.S.O.M. from initial hyperaemia and exudation to potential complications like subperiosteal abscess or mastoiditis. Common bacteria that cause A.S.O.M. are discussed. Treatment involves antibiotics, nasal decongestants, and surgical drainage if needed. Complications like Gradenigo

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    894 views87 pages

    Acute Suppurative Otitis Media

    Uploaded by

    Hermawan Surya Dharma
    This document provides an overview of acute suppurative otitis media (A.S.O.M.), including its definition, predisposing factors, bacteriology, stages, pathogenesis, treatment, complications, and surgical procedures. It defines A.S.O.M. as a pyogenic middle ear infection lasting less than 3 weeks. The document outlines the stages of A.S.O.M. from initial hyperaemia and exudation to potential complications like subperiosteal abscess or mastoiditis. Common bacteria that cause A.S.O.M. are discussed. Treatment involves antibiotics, nasal decongestants, and surgical drainage if needed. Complications like Gradenigo

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    Acute Suppurative Otitis Media

    Dr. Vishal Sharma

    Definition
    Pyogenic infection of middle ear cleft lasting for

    < 3 weeks.
    Routes for infection:
    1. 2. 3.

    Via Eustachian tube Via Tympanic membrane perforation 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

    Pathogenesis
    Aditus 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 preparations
    Name COLDIN SINAREST DECOLD SUPRIN Chlorpheniramine Decongestant Paracetamol 4 mg 4 mg 4 mg 2 mg PsE 60 mg PsE 60 mg PhE 7.5 mg PhE 5 mg 500 mg 500 mg 500 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 sternocleidomastoid muscle Citelli: neck swelling over posterior belly of digastric muscle

    Bezolds abscess

    Bezolds abscess

    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

    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 Dorellos canal under Grubers 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


    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

    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

    Wildes post-aural incision

    Incision deepened

    Musculoperiosteal flap elevated

    Bezolds 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

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