Acute suppurative otitis media

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1. Acute Suppurative Otitis Media Bijay shah kanu 4th year PAHS 09 sept 2019 2. ASOM ã Acute inflammation of middle ear by pyogenic organism ã Midle ear= ear cleft=…
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  • 1. Acute Suppurative Otitis Media Bijay shah kanu 4th year PAHS 09 sept 2019
  • 2. ASOM • Acute inflammation of middle ear by pyogenic organism • Midle ear= ear cleft= eustachian tube, middle ear, attic, aditus, antrum and mastoid air cells • More common in infants and children of lower socioeconomic class • Follows viral URTI
  • 3. Routes of infection • Via Eustachian tube • Via external ear in case of perforation • Blood borne: uncommon route
  • 4. Predisposing factors Any thing that interferes with normal functioning of Eustachian tube • Recurrent attacks of common cold, URTI, measles, diphtheria, whooping cough • Infection of tonsil and adenoids • Chronic rhinitis and sinusitis • Nasal allergy • Tumors of nasopharynx • Packing of nose and nasopharynx for epistaxis • Cleft palate
  • 5. Causative organism Most common organism in infants and young children are • Streptococcus pneumoniae -30% • Hemophilus influenzae -20% • Moraxella catarrhalis -12% • Strep. pyogens, Staph. aureus, P. aurugenosa are also involved • No growth in about 18-20% of cases
  • 6. Stages and clinical features 1. Tubal occlusion 2. Pre-suppuration 3. Suppuration 4. Resolution 5. Complication
  • 7. 1. Stage of Tubal occlusion • Edema and hyperemia of nasopharynx and eustachian tube blockage • Absorption of air and negative intratympanic pressure • Retraction of tympanic membrane with some degree of effusion
  • 8. Symptoms: • Deafness and earache (not so marked) • No fever Signs: • Retracted tympanic membrane • Horizontal handle of malleus • Predominance of lateral process of mallelus and loss of Light reflex • Conductive deafness
  • 9. 2. Stage of Pre-suppuration • Increased pyogenic activity in tympanic cavity • Hyperemia of its lining and inflammatory exudated • Congested tympanic membrane
  • 10. Contd… Symptoms: • Earache, throbbing type that disturbs the sleep • Deafness and tinnitus may be present • Child may have high fever and is restless Signs: • Congestion of pars tensa • Cart-wheel appearance • Blood vessels appears along the handle of malleus and at the periphery of TM • Uniformly red tympanic membranes in later stage • Conductive hearing loss
  • 11. 3. Stage of Suppuration • Formation of pus in middle ear and in mastoid air cells • Tympanic membrane starts bulging at point of rupture
  • 12. Symptoms: • Excruciating earache and increasing deafness • High fever, vomiting and convulsion (in children) Signs: • Red and bulges TM with loss of landmarks • Tenderness over mastoid antrum • X-ray of mastoid : clouding of air cells –exudate
  • 13. 4. Stage of resolution • Rupture of TM with release of pus and relief symptoms • Inflammatory process begins to resolve • If early treatment started or if infection is mild, resolution starts even without rupture of TM
  • 14. Symptoms: •Earache relieved and fever subsides Signs: • Blood tinged discharge in EAC which later becomes mucopurulent • Usually a small perforation in anteroinferior quadrant of pars tensa • Hyperemia of TM begins to subside with return to normal color and landmarks
  • 15. 5. Stage of Complication • Depends on • Virulence of organism is high or resistance of the patient ,resolution may not take place and disease spread beyond the confines of middle ear • May lead to mastoiditis, petrositis, extradural abscess, meningitis, brain abscess, lateral thrombophebitis
  • 16. Investigations • C/S of discharge • X-ray of ear/ mastoid • Audiometry
  • 17. Management Antibiotic therapy • Indicated in all cases with fever and severe earache • Ampicillin 50mg/kg/day in 4 divided dose • Amoxicillin 40mg/kg/day in 3 divided dose • Should be given till tympanic membrane regain normal appearance and hearing is normal (minimum 10 days)
  • 18. Antibiotics dose
  • 19. • Decongestant nasal drop : ephedrine 1% in adult and 0.5% in children )or oxymetazoline or xylometazoline – used to relieve Eustachian tube edema and promote ventilation • Oral nasal decongestant :pseudo ephedrine (Sudafed)30 mg twice daily or a combinations of decongestant and antihistaminic (triominic) – may achieve the same result without resort to nasal drops which are difficult to administer in children
  • 20. • Analgesics and antipyretics :to relieve pain and bring temperature down • Ear toilet : discharge in ear – dry mopped with sterile cotton buds and w wick moistened with antibiotics may be inserted • Dry local heat : to relieve pain
  • 21. Myringotomy • Incision of ear drum to evacuate the pus • Indications: • Bulged drum with acute pain • Incomplete resolution despite antibiotics when drum remains full with persistent conductive deafness • Persistent effusion beyond 12 weeks • All cases of ASOM should be followed till drum returns to its normal appearance and conductive deafness disappears
  • 22. References • PL Dhingra, et al. Diseases of ear, nose and throat & head and neck surgery, 6th edition
  • 23. Thank You
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