bacterial infection of middle ear

OTITIS MEDIA
Marmara University School Of Medicine
Department of Otorhinolaryngology,
Head and Neck Surgery
Istanbul, Turkiye
 OTITIS MEDIA

§ Acute suppurative otitis media mostly bacterial infection

§ Acute viral otitis media and bullous myringitis
§ Acute necrotizing otitis media
§ Tuberculous chronic otitis media bacteria reach middle ear by way
of nasopharynx
§ Otitis media with effusion not a bacterial inf
§ Chronic otitis media happens after acute otitis media
 ACUTE SUPPURATIVE OTITIS
MEDIA
• most common in young children
ear ache bc of pus inside
• severe earache, hearing loss, fever (up to
40.5° C), nausea, vomiting, and diarrhea
• The tympanic membrane is erythematous
and may bulge if too much fluid
• Diagnosis is usually made clinically
• TX: Streptococcus pneumoniae,
Haemophilus influenzae, Moraxella
(Branhamella) catarrhalis
infection of sinus, pass through
eustachian tube to middle ear.
 ACUTE SUPPURATIVE OTITIS
MEDIA
§ 1. Stage, hyperemia:
– fever and pain
so tx includes antibiotics and decongestants to open the eustachian tube
– fullness in the ear
– normal hearing
– congestion of the
vessels entire
membrane
 ACUTE SUPPURATIVE OTITIS
MEDIA
§ 2. Stage, Exudation
– ­ pain and fever bc of the exudate
– outpouring from the
capillaries of serum,
fibrin, red cells, PMN
leukocytes, fill the
entire middle ear
space
– thickened and bulging
membrane
– myringotomy to releive
the pain
A myringotomy is a procedure to create a hole in the ear drum to allow fluid that is trapped in the middle ear to drain out. The fluid may
be blood, pus and/or water. In many cases, a small tube is inserted into the hole in the ear drum to help maintain drainage.
 ACUTE SUPPURATIVE OTITIS
MEDIA
§ 3. Stage, suppuration:
– small spontaneous
rupture of the
membrane in the pars
tensa
– ¯ pain and fever bc the abscess
is drained
– mucopurulent
drainage
– conductive hearing
loss bc of massive fluid in middle
ear ,ear canal thickened
tympanic membrane
 ACUTE SUPPURATIVE OTITIS
MEDIA if no tx, the pus will go to mastoid
region and accumulates there

§ 4. Stage, coalescent mastoiditis:

u need to drain
the abscess!
simple
mastoidectomy to
drain (open way
from middle ear to
mastoid)
 ACUTE SUPPURATIVE OTITIS
MEDIA
§ 5. Stage, complications:
§ 6. Stage, resolution: if u tx well

– perforation closes spontanously

– hearing loss recovers
– residual accumulation of fluid frequent
– 90-95% resolves within 3 months. if tx well.

tx: antibiotics, decongestants through eustachian tube by steroid ear drops which resolve
the edema to allow for drainage through it, analgesics, antipyretics
 ACUTE VIRAL OTITIS MEDIA
§ Associated with viral URI:
– eustachian tube blockage
– effusion in the middle ear
§ Bullous myringitis: too painful!
– epidemics
– younger children
– severe pain without fever and hearing
loss
– multiple blebs on the membrane like HS
– resolves in 2-3 days
– Tx: puncture of blebs, antibiotics if
secondary bacterial infection
 OTITIS MEDIA WITH EFFUSION
google: Otitis media with effusion (OME) and acute otitis media (AOM) are two main types of otitis
media (OM). OME describes the symptoms of middle ear effusion (MEE) without infection, and AOM
is an acute infection of the middle ear and caused by bacteria in about 70% of cases
§ Epidemiology
– age: disease of infants and young children
65% by 2 years disease of young children (2 yrs) bc in these, the
eustachian tube is completely blocked

– sex: male prediliction?

– socioeconomic conditions: crowding, poor
hygiene, inadequate nutrition, delayed
medical attention this is a complication of urti, in which eustachian tube is blocked by
some reason, or adenoid vegetation which blocks the eustachian tube:
adenoid enlarges bc of repeated urti
– genetic factors: siblings and parents with
the same history
– season: winter and spring, viral URI
– breast-feeding fluid collection in middle ear
by lying on bed, milk could pass through eustachian tube
OTITIS MEDIA WITH EFFUSION

mucoid
air fluid levels, bubbles
OTITIS MEDIA WITH EFFUSION

§ Etiology and pathogenesis

§ Mucosal changes
middle ear doesn't normally secrete anything but in otitis media with effusion we have mucosal changes
and these make an effusion in middle ear- goblet cell hyperplasia- blockage of tube
– Microrganisms: S.pneumonia, H. influenza
– Eustachian tube key anatomical structure iin development of this diseasse
 OTITIS MEDIA WITH EFFUSION

§ Etiology and pathogenesis

– Related clinical conditions
üAdenoid hypertophy
üCleft palatetissue,
more prone, too much contamination in adenoid
more infections in nasopharynx, muscular
incompetence of eustachian tube, may not work

üTumors
well.
also nasopharyngeal tumors

– Iatrogenic causes
üInadequate antibiotic therapy
üRadiation therapy pts with nasopharyngeal tumors- edema - ome

inadequate therapy of acute otitis media -

excess fluid in middle ear- resolves in
coouple of weeks , so u can see otitis
media with effusion during the tx of acute
otitis media
OTITIS MEDIA WITH EFFUSION fluid in middle ear, beats pressure in nasopharynx, so
some fluid goes into nasopharynx, so less complaints, not
veryyy annoying earache, no perforation. but in acute
no ear drum perforation suppurative media the accumualtion of fluid is more, so

§ History: Conductive HL, earache, recurrent

ear drum can perforate
but not very annoying earache- bc
colds
– tympanic membrane: opaque amber, retraction
of the membrane, fluid levels or bubbles, blue
membrane there could be venous bleeding in middle ear bc of the pressure- leading to
blue membrane.
– audiologic exam: type B, absent stapedial reflex,
conductive HL 10-40 dB type B: ur ear drum with this pressure is not
moving- type B - there is fluid behind the ear drum,
if u give pressure it wont move
 TREATMENT
§ Medical management
– Antibiotics incase of urti by bacteria - also use intranasal steroids
– Antihistamines and decongestants to open eustachian tube
– Steroids, vaccines, mucolytics
§ Surgical management if no response:
– Intranasal or sinus procedures +
adenoidectomy ± tonsillectomy
– Tympanostomy tubes

inflating the balloon, eustachian tube is opened by force

 SEQUELAE
§ Developmental and behavioral sequelae
§ Atrophic drumhead
§ Ossicular erosion
§ Tympanosclerosis
-ve pressure- sucks the tympanic membrane: cholesteatoma
§ Chronic otitis media and cholesteatoma
bc of goblet cell hyperplasia
§ Cholesterol granuloma and glandular formation
§ Sensorineural hearing loss (SNHL) too much pressure in middle ear
makes too much pressure on
oval and round windows -
destruction of round window -
labyrinthitis may occur
 CHRONIC OTITIS MEDIA
long standing perforation viral urti

§ Tympanic membrane
perforation ­ 3
months, conductive
HL, intermittent
discharge of pus

pt had suppurative
otitis media, and ear
drum got perforated..
once
it has been more than
3months then its
chronic 5als
CHRONIC OTITIS MEDIA

ear canal skin can go through into middle ear-

cholestatoma
 CHOLESTEATOMA
§ Invagination theory
§ Epithelial invasion theory
§ Basal cell hyperplasia
theory
§ Squamous metaplasia
theory
as a result of
labyrnthitis

bc facial n passes through temporal bone

 COMPLICATIONS
§ Intratemporal :
– Middle ear:
ü Facial nerve paralysis
ü Ossicular lesions
ü Perforation of TM
– Mastoid:
ü Petrositis
ü ¯ pneumatization
ü Coalescent mastoiditis
– İnner ear:
ü Labyrinthitis
ü SNHL
 COMPLICATIONS
§ Extratemporal-Intracranial
– Extradural abscess
– Subdural abscess
– Brain abscess
– Meningitis
– Lateral sinus thrombophlebitis
– Otitic hydrocephalus
 COMPLICATIONS
§ Extratemporal-Extracranial
– Bezold’s abscess
– Zygomatic abscess
– Postauricular abscess
§ Others
– Developmental
– Behavioral
SUBPERIOSTAL ABSCESS
FACIAL NERVE PARALYSIS acute otitis media or senositis media

§ more common in children

§ 50% dehiscent in the tympanic segment
in adults 7%

§ Venous congestion, acute neuritis,

tissue edema and compression within
its bony canal leads neuropraxia
§ Tx: Acute OM ®
myringotomy+antibiotics give steroids to prevent edema

but if it is:
FACIAL NERVE PARALYSIS
 LABYRINTHITIS
1. serous- toxic byproducts temporary loss of vestibular function- not very severe
2. suppurative- bacteria / some material invasion - total loss of hearing

§ Suppurative labyrinthitis:
§ Total loss of hearing and vestibular
function
§ Tx: hospitalization, hydration, antimicrobial
therapy, antivertiginous medications,
mastoidectomy
 PETROSITIS happens in pts who have air sacs in
petrous bone.

§ Guiseppe Gradenigo, 1904(7)

§ Gradenigo’s syndrome triad:
– retro-orbital pain V. Nerve
– diplopia VI. Nerve
– otorrhea
§ mastoidectomy+petrous apipectomy
PETROSITIS
 LATERAL SINUS
THROMBOPHLEBITIS
§ Fever: spiking, picket-fence pattern!
§ Neck tenderness
§ Otalgia
§ Papilledema
§ ­ CSF pressure
§ Anemia, leukocytosis, ­ ESR
§ MRI is very useful
§ Mastoidectomy + internal jugular vein
ligation, for and against ?
 MENINGITIS
§ Most common intracranial complication of COM
§ headache, fever, nausea-vomiting, neck
stiffness, Kernig’s and Brudzinski’s signs
§ LP® ­ protein, ¯ glucose
§ Mastoidectomy+AB
 INTRACRANIAL ABSCESS
§ Type
– extradural (most common)
– subdural (btwn dura mater and arachnoid)
– intracerebral or cerebellar
§ headache, fever, otalgia
§ temporal lobe abs / cerebellar abs = 2/1
§ but cerebellar abs more frequently fatal