ACUTE SUPPURATIVE OTITIS

MEDIA
Dr. M. Nyoka
Principal Specialist
ENT Department Wits University
Definition

• Acute suppurative otitis media is an

inflammation of the mucuos membrane
lining the middle ear cleft (consisting of
the Eustachian tube, tympanic cavity,
mastoid antrum, and mastoid air cells)
produced by pus- forming bacteria.
ANATOMY
ANATOMY OF THE MIDDLE EAR
ANATOMY OF THE MIDDLE EAR
ANATOMY
AETIOLOGY

• Infection occurs through spread of sepsis

via
1. The tympanic membrane
2. Haemotogenous spread
3. Via the eustachian tube
FREQUENCY

• In the USA 70% of children experience

one or more attacks before the age of two
years, with a peak around 3-18 months,
and the highest incidence among the
poor.
PATHOPHYSIOLOGY
1. Obstruction of the eustachian tube appears to be most
important event in the aetiology of AOM.
2. The vast majority of episodes are caused by an airway
infection.
3. The infection of the airway is usually viral.
4. The inflammation then spreads into the eustchian
tube.
5. Obstruction of the ET tube leads to stasis of middle
ear secretions.
6. Then pathogenic bacteria colonise the sterile
secretions.
High risk factors
1. Age: Acute suppurative otitis media is a common infection of childhood.
This is due to poorly developed immunity.
2. Adenoids
3. High incidence of upper airway infection and eustachian tube
dysfunction.
4. Prematurity.
5. Craniofacial anomalies espeacially those that lead to ET tube dysfunction.
6. Overcrowding.
7. Daycare
8. Not breast fed with prolonged bottle feeding.
9. Poor socio-economic conditions.
10. Cold weather conditions.
11. Preexisting middle ear effusion.
ADENOIDAL HYPERTROPHY
ADENOIDAL HYPERTROPHY
XRAYS OF THE POSTNASAL SPACE
CONGENITAL CAUSES

1. Cleft palate leads to middle infections

due to eustachian tube dysfunction.
2. Primary ciliary dyskinesia is rare can be
associated with middle ear effusions and
infections.
MICROBIOLOGY

• The bacteria involved are almost invariably

those normal found in the upper airway,
and in over 30% of cases more than one
organism is involved. Often, especially in
children, a history of upper airway
infection is present. This is commonly
viral, leading to a bacterial infection.
BACTERIA

1. Beta-hemolytic streptococci.
2. Staphylococcus aureus rarely recovered.
3. Streptococcus pneumococci is the most
common, found in 20-49% of cases.
4. Haemophillus influenza is found in about
20% of cases in the paediatric group.
5. Others e.g. pseudomonas.
SYMPTOMS

1. Otalgia: This can vary in severity from

mild to intense pain lasting several
hours.
2. Deafness in the affected ear.
3. Otorrhoea
4. Dizziness
5. Symptoms of the predisposing factor.
SIGNS
1. Tympanic membrane is inflammed,
hyperaemic, bulging and opaque’
2. Purulent ear discharge.
3. Perforation of the ear drum. This might
sometimes be seen only with difficulty
because of eodema.
4. Mastoid tenderness.
5. There may be signs of an upper airway
infection.
BULGING EAR DRUM
ACUTE OTITIS MEDIA (BULGING
EAR DRUM)
BULGING EAR DRUM
TRAUMATIC PERFORATION OF
THE EAR DRUM.
INVESTIGATIONS
1. Pus swab must be taken for culture and sensitivity.
2. Blood studies looking at the white cell count, and in
very sick patients a blood culture can be done.
3. Tympanometry may assist in detecting decreased
mobility of the eardrum, but for the skilled clinician is
often unnecessary.
4. Mastoid X-rays where mastoiditis is suspected.
5. CT scan only when complications are suspected.
LEFT MASTOIDITIS
LEFT MASTOIDITIS
RIGHT MASTOIDITIS
COMPLICATIONS
1. Mastoiditis
2. Facial Nerve paralysis.
3. Intracranial complications.
4. Labyrinthitis due to medial spread of the
infection.
5. Petrositis due spread of infection to the
Petrous apex of the Temporal bone.
6. Sigmoid sinus thrombosis.
ACUTE MASTOIDITIS
ACUTE MASTOIDITIS
CEREBELLAR ABSCESS
CEREBELLAR ABSCESS
LEFT FACIAL NERVE PARALYSIS
RIGHT FACIAL NERVE PARALYSIS
MEDICAL TREATMENT
1. Antibiotics: these are used by most otologists
even though some of the cases are due to a
virus. These are usually given orally except
for the very sick patients. The clinician must
be aware of increasing resistance to
Penicillin.
2. Decongestants.
3. Analgesics.
4. Topical: dry mopping of the ear.
ANTIBIOTIC TREATMENT

• There are some advocates of a wait and

see approach and withholding antibiotics
in these patients. Even though most of
them do get well, there is evidence of a
high incidence of complications when
antibiotics are withheld. Also the use of
antibiotics is associated with rapid
improvement of symptoms.
ANTIBIOTICS

• It is the Beta-lactam antibiotics that are useful

against the gram + bacteria. Amoxicillin remains
the most commonly used antibiotic, and the
Erythromycin/Sulphonamides for those with Pen-
sensitivity.
• Where there is drug-resistance, more broad
spectrum antibiotics may be used e.g.
combinations of amoxy+ clavulanate.
 SURGICAL TREATMENT
MYRINGOTOMY: while the vast
majority of patients respond to
medical treatment, in some cases
the effusion in the middle persists
requiring the perfomance of a
myringotomy.
MASTOIDITIS: Unresolving cases
of acute mastoiditis to medical
treatment will require
MASTOIDECTOMY.
GROMET IN-SITU
MASTOIDECTOMY
PERFORATION OF THE RIGHT EAR
DRUM.