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Acute Suppurative otitis mediaAcute Suppurative otitis mediaDr. T. Balasubramanian M.S. D.L.O.Dr. T. Balasubramanian M.S. D.L.O.

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DefinitionDefinition

It is defined as suppurative infection It is defined as suppurative infection involving the mucosal lining of middle involving the mucosal lining of middle ear cleft. The term acute is used to ear cleft. The term acute is used to indicate infections of less than 3 indicate infections of less than 3 weeks durationweeks duration

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PathophysiologyPathophysiology

Obstructed Eustachean tubeObstructed Eustachean tubeRecurrent upper respiratory infections Recurrent upper respiratory infections can lead to microbial contamination can lead to microbial contamination of middle ear via the Eustachean tubeof middle ear via the Eustachean tubeNaso pharyngitisNaso pharyngitisNasal allergyNasal allergy

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MicrobiologyMicrobiology

Commonly viral (Viral infections help Commonly viral (Viral infections help bacteria to adhere to the middle ear bacteria to adhere to the middle ear mucosa)mucosa)Bacteria implicated include:Bacteria implicated include:

S. PneumoniaeS. Pneumoniae

H. InfluenzaH. InfluenzaM. CatarrhalisM. Catarrhalis

These infections commonly affects children because their These infections commonly affects children because their Eustachean tubes are shorter, wider and straighter Eustachean tubes are shorter, wider and straighter facilitating easy efflux of contaminants in to the middle ear facilitating easy efflux of contaminants in to the middle ear cavity from Nasopharynxcavity from Nasopharynx

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Role of Eustachean tubeRole of Eustachean tube

Patulous Patulous Eustachean tubeEustachean tubeHypotonic Hypotonic Eustachean tubeEustachean tubeCongenital Congenital abnormalities of 1abnormalities of 1stst

and 2and 2ndnd archarch

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Flask modelFlask model

ET, Middle ear, and mastoid air cell ET, Middle ear, and mastoid air cell system can be likened to be that of a system can be likened to be that of a flask with a narrow neckflask with a narrow neckThe mouth of the flask is the The mouth of the flask is the nasopharyngeal end of ETnasopharyngeal end of ETNarrow neck is the isthmus of the ETNarrow neck is the isthmus of the ETBulbous portion is the middle ear Bulbous portion is the middle ear chamber and mastoid systemchamber and mastoid system

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Flask modelFlask model

Fluid flow through the neck of the Fluid flow through the neck of the flask is dependent on:flask is dependent on:

1. Pressure at either end1. Pressure at either end2. Radius & length of the neck2. Radius & length of the neck3. Viscosity of the liquid3. Viscosity of the liquid

When a small amount of liquid is instilled into the mouth of tWhen a small amount of liquid is instilled into the mouth of the flask, liquid he flask, liquid flow stops somewhere in the narrow neck owing to capillarity witflow stops somewhere in the narrow neck owing to capillarity within the hin the neck and the relative positive air pressure that develops in theneck and the relative positive air pressure that develops in the chamber of chamber of the flask.the flask.

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Flask modelFlask model

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Protective function of ETProtective function of ET

ET protects middle ear from ET protects middle ear from nasopharyngeal contaminationnasopharyngeal contaminationThe basic geometry of the ET is The basic geometry of the ET is considered to be critical for this considered to be critical for this functionfunctionReflux of liquid into the body of the Reflux of liquid into the body of the flask occurs if the neck of the flask is flask occurs if the neck of the flask is wide / length of the neck of flask is wide / length of the neck of flask is short as is the case in childrenshort as is the case in children

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Differences between ET in adult / childDifferences between ET in adult / child

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Why ASOM is common in Why ASOM is common in children?children?

Because of ET geometryBecause of ET geometry

Because of recumbent position Because of recumbent position commonly occupied by the childcommonly occupied by the child

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Diagram showing Diagram showing pathophysiology of ASOMpathophysiology of ASOM

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ASOM (Stages)ASOM (Stages)

Stage of HyperemiaStage of HyperemiaStage of exudationStage of exudationStage of suppurationStage of suppurationStage of resolutionStage of resolution

The progression of these stages are dependent on:The progression of these stages are dependent on:

1. Virulence of infecting organism1. Virulence of infecting organism2. Host immunity2. Host immunity3. Adequacy of antibiotic therapy3. Adequacy of antibiotic therapy

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HyperemiaHyperemia

Hyperemia of Hyperemia of mucous membranemucous membraneOtalgia / fever / Otalgia / fever / fullness commonfullness commonAntibiotics during Antibiotics during this stage will help this stage will help in the resolution of in the resolution of diseasedisease

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ExudationExudation

Out pouring of fluid Out pouring of fluid from the blood vessels from the blood vessels of mucoperiosteum of of mucoperiosteum of middle earmiddle earFluid is initially serous Fluid is initially serous in naturein natureThe whole middle ear The whole middle ear cavity is tensecavity is tenseSuppuration eventually Suppuration eventually followsfollowsEar drum starts to Ear drum starts to bulgebulgeThese patients have These patients have mastoid tendernessmastoid tenderness

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SuppurationSuppuration

Exudate present in Exudate present in the middle ear the middle ear suppurates due to suppurates due to superadded superadded infectioninfectionThis stage needs to This stage needs to be treated with be treated with antibioticsantibiotics

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ResolutionResolution

This stage is preceded by rupture of This stage is preceded by rupture of ear drumear drumDischarge from the middle ear starts Discharge from the middle ear starts to flow out (Light House sign)to flow out (Light House sign)These patients have reduced OtalgiaThese patients have reduced OtalgiaFever if present subsidesFever if present subsidesPatients show excellent clinical Patients show excellent clinical improvementimprovement

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ComplicationsComplications

Presence of middle ear infections for more Presence of middle ear infections for more than 2 weeks cause complicationsthan 2 weeks cause complicationsThis is due to obstruction of normal This is due to obstruction of normal drainage of middle ear due to thickening of drainage of middle ear due to thickening of mucoperiosteummucoperiosteumComplications commonly include coalescent Complications commonly include coalescent mastoiditis, subperiosteal abscessmastoiditis, subperiosteal abscessThese patients have low grade fever and These patients have low grade fever and OtalgiaOtalgia

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ManagementManagement

Antibiotics (Amoxicillin / Antibiotics (Amoxicillin / Cephalosporins)Cephalosporins)In resistant cases MyringotomyIn resistant cases MyringotomySubperiosteal abscess if present Subperiosteal abscess if present should be treated surgicallyshould be treated surgicallyTreatment of focal sepsis (sinusitis / Treatment of focal sepsis (sinusitis / adenotonsillitis)adenotonsillitis)

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