ACUTE SUPPURATIVE OTITIS MEDIA

 It is an acute inflammation of middle ear by pyogenic

organisms.
 Here, middle ear implies middle ear cleft, i.e. eustachian tube,
middle ear, attic, aditus, antrum and mastoid air cells.

Aetiology
 It is more common especially in infants and children of lower
socioeconomic group.
 Typically, the disease follows viral infection of upper respiratory
tract but soon the pyogenic organisms invade the middle ear.

Routes of infection
1. Via Eustachian Tube.
 It is the most common route.
 Infection travels via the lumen of the tube or along subepithelial
peritubal lymphatics.
 Eustachian tube in infants and young children is shorter, wider
and more horizontal and thus may account for higher incidence of
infections in this age group.
 Breast or bottle feeding in a young infant in horizontal position
may force fluids through the tube into the middle ear and hence
the need to keep the infant propped up with head a little higher.
 Swimming and diving can also force water through the tube
into the middle ear.

2. Via External Ear.

 Traumatic perforations of tympanic membrane due to any cause
open a route to middle ear infection.

3. Blood-Borne.
 This is an uncommon route.

Predisposing factors
 Anything that interferes with normal functioning of Eustachian
tube predisposes to middle ear infection.
 It could be:
1. Recurrent attacks of common cold, upper respiratory tract
infections and exanthematous fevers like measles, diphtheria or
whooping cough.
2. Infections of tonsils and adenoids.
3. Chronic rhinitis and sinusitis.
 4. Nasal allergy.
5. Tumours of nasopharynx, packing of nose or nasopharynx for
epistaxis.
6. Cleft palate.

Bacteriology
 Most common organisms in infants and young children are:
 Streptococcus pneumoniae (30%),
 Haemophilus influenzae (20%) and
 Moraxella catarrhalis (12%).
 Other organisms include:
 Streptococcus pyogenes,
 Staphylococcus aureus and sometimes
 Pseudomonas aeruginosa.
 In about 18–20%, no growth is seen.

Pathology and clinical features

 The disease runs through the following stages:
1. Stage of Tubal Occlusion.
 Oedema and hyperaemia of nasopharyngeal end of eustachian
tube blocks the tube leading to absorption of air and negative
intratympanic pressure.
 There is retraction of tympanic membrane with some degree of
effusion in the middle ear but fluid may not be clinically
appreciable.
 Symptoms.
 Deafness and earache are the two symptoms but they are not
marked.
 There is generally no fever.
 Signs.
 Tympanic membrane is retracted with handle of malleus
assuming a more horizontal position
 Prominence of lateral process of malleus
 Loss of light reflex.
 Tuning fork tests show conductive deafness.

2. Stage of Presuppuration.
 If tubal occlusion is prolonged, pyogenic organisms invade
tympanic cavity causing hyperaemia of its lining.
 Inflammatory exudate appears in the middle ear.
 Tympanic membrane becomes congested.
 Symptoms.
 There is marked earache which may disturb sleep and is of
throbbing nature.
  Deafness and tinnitus are also present, but complained only by
adults.
 Usually, child runs high degree of fever and is restless.
 Signs.
 Congestion of pars tensa.
 Leash of blood vessels appear along the handle of malleus and
at the periphery of tympanic membrane imparting it a cart-wheel
appearance.
 Later, whole of tympanic membrane including pars flaccida
becomes uniformly red.
 Tuning fork tests will again show conductive type of hearing
loss.

3. Stage of Suppuration.
 This is marked by formation of pus in the middle ear and to some
extent in mastoid air cells.
 Tympanic membrane starts bulging to the point of rupture.
 Symptoms.
 Earache becomes excruciating.
 Deafness increases
 Child may run fever of 102–103 °F.
 This may be accompanied by vomiting and even convulsions.
 Signs.
 Tympanic membrane appears red and bulging with loss of
landmarks.
 Handle of malleus may be engulfed by the swollen and
protruding tympanic membrane and may not be discernible.
 A yellow spot may be seen on the tympanic membrane where
rupture is imminent.
 Tenderness may be elicited over the mastoid antrum.
 X-rays of mastoid will show clouding of air cells because of
exudate.

4. Stage of Resolution.
 The tympanic membrane ruptures with release of pus and
subsidence of symptoms.
 Inflammatory process begins to resolve.
 If proper treatment is started early or if the infection was mild,
resolution may start even without rupture of tympanic
membrane.
 Symptoms.
 With evacuation of pus, earache is relieved
 Fever comes down and child feels better.
 Signs.
  External auditory canal may contain blood-tinged discharge
which later becomes mucopurulent.
 Usually, a small perforation is seen in anteroinferior quadrant
of pars tensa.
 Hyperaemia of tympanic membrane begins to subside with
return to normal colour and landmarks.

5. Stage of Complication.
 If virulence of organism is high or resistance of patient poor,
resolution may not take place and disease spreads beyond the
confines of middle ear.
 It may lead to:
1. acute mastoiditis
2. subperiosteal abscess
3. facial paralysis
4. labyrinthitis
5. petrositis
6. extradural abscess
7. meningitis
8. brain abscess
9. lateral sinus thrombophlebitis.

Treatment
1. Antibacterial Therapy
 It is indicated in all cases with fever and severe earache.
 As the most common organisms are S. pneumoniae and H.
influenzae, the drugs which are effective in acute otitis media are:
 ampicillin (50 mg/kg/day in four divided doses)
 amoxicillin (40 mg/kg/day in three divided doses).
 Those allergic to these penicillins can be given:
 cefaclor,
 co-trimoxazole or
 erythromycin.
 In cases where β-lactamase producing H. influenzae or M.
catarrhalis are isolated, antibiotics like:
 amoxicillin clavulanate
 cefuroxime axetil or
 cefixime may be used.
 Antibacterial therapy must be continued for a minimum of 10
days, till tympanic membrane regains normal appearance and
hearing returns to normal.
 Early discontinuance of therapy with relief of earache and
fever, or therapy given in inadequate doses may lead to:
 secretory otitis media
 residual hearing loss.
2. Decongestant Nasal Drops.
 Ephedrine nose drops (1% in adults and 0.5% in children)
 Oxymetazoline (Nasivion)
 Oxylometazoline (Otrivin)
 should be used to relieve eustachian tube oedema and promote
ventilation of middle ear.

3. Oral Nasal Decongestants.

 Pseudoephedrine (Sudafed) 30 mg twice daily
 Combination of decongestant and antihistaminic (Triominic)
 may achieve the same result without resort to nasal drops which are
difficult to administer in children.

4. Analgesics and Antipyretics.

 Paracetamol helps to relieve pain and bring down temperature.

5. Ear Toilet.
 If there is discharge in the ear, it is drymopped with sterile cotton
buds and a wick moistened with antibiotic may be inserted.

6. Dry Local Heat.

 Helps to relieve pain.

7. Myringotomy.
 It is incising the drum to evacuate pus and is indicated when:
1. drum is bulging and there is acute pain,
2. there is an incomplete resolution despite antibiotics when
drum remains full with persistent conductive hearing loss and
3. there is persistent effusion beyond 12 weeks.
 All cases of acute suppurative otitis media should be carefully
followed till:
 tympanic membrane returns to its normal appearance and
 conductive hearing loss disappears