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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.

Via Eustachian tube Via Tympanic membrane perforation Haematogenous (rare)

2.

3.

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


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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
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Stage of Exudation
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Stage of Exudation
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Stage of Exudation
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Nipple sign (impending perforation)


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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


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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


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Pinhole perforation
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Clouding of mastoid cells


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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
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Mastoid reservoir sign


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Sagging of posterior wall


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Ironed out appearance


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Mastoid cavity
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Mastoid cavity
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5. Stage of Resolution
Otorrhoea stops Normal hearing Healed perforation
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Stage of Resolution
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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)

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 Click to edit Master text styles postero-inferior quadrant. Second level Third level Fourth level Incision is curvilinear & not radial Fifth level (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
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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


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Sub-periosteal fistula: dry


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Sub-periosteal fistula: wet


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Types of sub-periosteal abscess


Post-auricular Bezold Citelli Zygomatic Luc Retro-mastoid Parapharyngeal & Retropharyngeal

Types of sub-periosteal abscess


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Post-auricular abscess
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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
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Bezolds abscess
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Bezolds abscess
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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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Gradenigo syndrome
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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

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


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Spread of pus
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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

Cortical Mastoidectomy

Antiseptic dressing
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Draping
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Infiltration
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Marking of incision
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Wildes post-aural incision


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Incision deepened
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Musculoperiosteal flap elevated


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Bezolds abscess
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Aspiration of pus
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Drainage of abscess
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Drainage of abscess
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Corical mastoidectomy begun


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Exposure of mastoid antrum


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Widening of aditus
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Aditus widened
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Final Cavity
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Cortical Mastoidectomy
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Drain put in mastoid cavity


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Mastoid dressing
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Healed post-aural scar


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Thank you
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