Acute otitis media and mastoAcute otitis media and mastoiditisiditis

Chunfu Dai M.D & Ph.DChunfu Dai M.D & Ph.DOtolaryngology DepartmentOtolaryngology Department

Fudan UniveristyFudan Univeristy

Definition Definition

AOM: is an infectious process AOM: is an infectious process of the middle ear cleft and to a of the middle ear cleft and to a variable extent, of the mastoid variable extent, of the mastoid air cell system.air cell system.

Bacteriology Bacteriology

Streptococcus pneumoniae (48Streptococcus pneumoniae (48%)%)

Haemophilus influenzae (31%)Haemophilus influenzae (31%) Moraxella catarrhalis (20%)Moraxella catarrhalis (20%) P-hemolytic streptococcus (deP-hemolytic streptococcus (de

creased following widespread icreased following widespread immunization program)mmunization program)

Pseudomonas aeruginosa (uncPseudomonas aeruginosa (uncommon cause of AOM)ommon cause of AOM)

阻断细菌耐药性的“恶性循环”

感染

耐药性增加

传播

选择 耐药菌

细菌未消除

不合理治疗

合 理 治 疗 临 床

治 愈细 菌 消 除

(Doern. Am J Med. 1995;99(6B): 3S-7S; Jacobs et al., AAC 1999:43:1901; Jacobs et al abstract C-61, ICAAC 1999)

0

10

20

30

40

50

% P

enic

illin

Resi

stance

中度敏感 (0.12 - 1.0 µg/ml)耐药 ( 2.0 µg/ml)

1979

1980

1981

1982

1983

1984

1985

198 6

1987

1988

-89

1990

-91

1992

-93

1994

-95

1997

1998

16%

18%

29%

33%

青霉素耐药的肺炎链球菌79 － 98 年在美国流行情况

Routine of infectionRoutine of infection

Via eustachian tubeVia eustachian tube upper respiratory infection upper respiratory infection

(acute rhinonitis and nasal p(acute rhinonitis and nasal pharyngitis)haryngitis)

Upper respiratory communicUpper respiratory communicative disease (diaphea, mealative disease (diaphea, mealse, et al)se, et al)

Swimming and dive in uncleSwimming and dive in unclear waterar water

Anatomic contribution (EustAnatomic contribution (Eustachian tube in infant is wide achian tube in infant is wide and short and the two orifice and short and the two orifice in the same level)in the same level)

Routine of infectionRoutine of infection

Via external acoustic canVia external acoustic canal and TMal and TM Perforation Perforation Myringotomy or myrigotoMyringotomy or myrigoto

sissis Via blood supplyVia blood supply

Pathology Pathology

Mucosal inflammatioMucosal inflammationn

Serous, hemorrhagic,Serous, hemorrhagic, or purulent exudate or purulent exudate in middle cavityin middle cavity

Rupture of tympanic Rupture of tympanic membranemembrane

Symptoms Symptoms

Fever Fever It may be masked by analgesics or antiIt may be masked by analgesics or anti

bioticbiotic Otalgia Otalgia

60% patients can spontaneous remissi60% patients can spontaneous remissionon

FullnessFullness Hearing lossHearing loss

Physical findingsPhysical findings

Increased vascularizatioIncreased vascularization of the TM, initially locan of the TM, initially located in pars of flaccida, frted in pars of flaccida, frequently spreading beyoequently spreading beyond the annulus to the skind the annulus to the skin of the external canal.n of the external canal.

Bony landmarks are visiBony landmarks are visible.ble.

Cholesteatoma Formation

Physical findingsPhysical findings

Rapid middle ear exudatRapid middle ear exudation occurs, ion occurs,

Blurring of the mallwall Blurring of the mallwall short process, followed short process, followed by edema and bulging of by edema and bulging of the pars flaccida.the pars flaccida.

Physical findingsPhysical findings

The progression of this diseThe progression of this disease may result in rupture of ase may result in rupture of TM, releasing the middle eaTM, releasing the middle ear contents (beating sign) lear contents (beating sign) leads to relief of otalgia and reds to relief of otalgia and retraction of the pars flaccidatraction of the pars flaccida

Lab testsLab tests

Blood counts usually shows leukocytosiBlood counts usually shows leukocytosis with polymorphonuclear elevation.s with polymorphonuclear elevation.

CT and MRI is necessary only for the rare CT and MRI is necessary only for the rare patients with a serious complication (mpatients with a serious complication (meningitis or brain abscess)eningitis or brain abscess)

Hearing testsHearing tests Conductive hearing lossConductive hearing loss

Degree of hearing loss will Degree of hearing loss will depend on the amount andepend on the amount and viscosity of the middle ed viscosity of the middle ear exudate, TM edemaar exudate, TM edema

It vary from 10-50 dB with It vary from 10-50 dB with predominant involvemenpredominant involvement of the low frequenciest of the low frequencies

Hearing loss may mixed wHearing loss may mixed when there is labyrinthine ehen there is labyrinthine extension.xtension.

Managements Managements

Antibiotic therapyAntibiotic therapy ExperiencesExperiences Antibiotic sensitivity and bacteriologic Antibiotic sensitivity and bacteriologic

cultureculture Traditional duration 10-14 dTraditional duration 10-14 d Currently duration 5-7 dCurrently duration 5-7 d

ManagementsManagements

Nasal decongestantsNasal decongestants Best rest, light diet Best rest, light diet Avoidance of irritants (smoking)Avoidance of irritants (smoking)

ManagementsManagements

Pre-perforation Pre-perforation Pain relief drugs Pain relief drugs Surgery: myringotomySurgery: myringotomy

Progression with a red, bulProgression with a red, bulging TM, severe otalgia and ging TM, severe otalgia and feverfever

Otitis media with impendinOtitis media with impending complicationsg complications

perforation is not big enougperforation is not big enough to drain all push to drain all pus

Managements Managements

Post-proferation:Post-proferation: Clear-up pus with 3% hydro-oxygenClear-up pus with 3% hydro-oxygen Antibiotic ear dropsAntibiotic ear drops With pus decreased and inflammation disapWith pus decreased and inflammation disap

peared, alcohol can be used to facilitate dry peared, alcohol can be used to facilitate dry ear.ear.

Follow-upFollow-up

Adequately treated AOM effusion may pAdequately treated AOM effusion may persist for 2-6 weeks or even longer.ersist for 2-6 weeks or even longer.

Managements may require Managements may require extended antibiotic treatmentextended antibiotic treatment Otoscope and audiometric tests should be pOtoscope and audiometric tests should be p

erformed 3-4 weeks following apparent resoerformed 3-4 weeks following apparent resolution of the acute infectionlution of the acute infection

Insertion of pressure equalization tubes due Insertion of pressure equalization tubes due to fluid persists beyond 3 monthsto fluid persists beyond 3 months

Acute mastoiditisAcute mastoiditis Definition: an infection of the mastoid charactDefinition: an infection of the mastoid charact

erized by diffuse osteitis followed by rarefactioerized by diffuse osteitis followed by rarefaction and breakdown of the bony septae. n and breakdown of the bony septae. Acute coalescent mastoiditisAcute coalescent mastoiditis Haemorrhagic mastoiditisHaemorrhagic mastoiditis Masked mastoiditisMasked mastoiditis

Predisposition to pneumatic mastoidPredisposition to pneumatic mastoid Predilection to kidPredilection to kid Mastoid is mature at age of 4 year oldMastoid is mature at age of 4 year old

Acute mastoiditisAcute mastoiditis

Reduction of immune systemReduction of immune system Strong bacteria (type III pneumococus, hStrong bacteria (type III pneumococus, h

aemolytic streptococcus)aemolytic streptococcus) Obstruction- not effective drainageObstruction- not effective drainage Imcompletely treatmentImcompletely treatment

Acute mastoiditisAcute mastoiditis

SymptomsSymptoms Symptoms may follow AOM, with or without Symptoms may follow AOM, with or without

a symptom-free interval of a few days to seva symptom-free interval of a few days to several weeks or more.eral weeks or more.

OtalgiaOtalgia Aural dischargeAural discharge Conductive hearing lossConductive hearing loss feverfever

Acute mastoiditisAcute mastoiditis Physical findingsPhysical findings

Fever, from a slight elevation to 39Fever, from a slight elevation to 39 Otorrhea may be absentOtorrhea may be absent Pulsatile may be observedPulsatile may be observed Tympanic perforation is present, but it may be obscured by inTympanic perforation is present, but it may be obscured by in

tense edema tense edema Swelling of the superior TM and posterosuperior wall of EACSwelling of the superior TM and posterosuperior wall of EAC Postauricular area Postauricular area

erythema and tendernesserythema and tenderness Pitting edemaPitting edema Obliteration of the postauricular creaseObliteration of the postauricular crease

Acute mastoiditisAcute mastoiditis Radiographic evRadiographic ev

aluationaluation Diffuse rarefactiDiffuse rarefacti

on of bone and on of bone and breakdown of cbreakdown of cellular sepaeellular sepae

Acute mastoiditisAcute mastoiditis interventionsinterventions

Medical managementMedical management Antibiotic Antibiotic

Intravenous antibiotic therapy should be maintained for at leIntravenous antibiotic therapy should be maintained for at least 24-48 h after the resolution of symptomsast 24-48 h after the resolution of symptoms

Then followed with oral antibiotic for 2 weeks Then followed with oral antibiotic for 2 weeks Surgical managementSurgical management

Emergency surgery: simple mastoidectomyEmergency surgery: simple mastoidectomy Mastoidectomy + ventilation tube placementMastoidectomy + ventilation tube placement