Acute Otitis Media

D.Balakrishnan
BSc, MS, DLO

Professor of ENT Diseases

ENT Surgeon, Kanchi Kamakoti Childs Trust Hospital
Secretary, Assn. of Paed. Otolaryngologists of India
Understanding Acute Otitis Media

A Paediatric Emergency
Easy to learn
Easy to practice
Very rewarding

Balakrishnan D
 Baby crying - Midnight
Feeding bottle does not help

? Did she fall down

? Insect bite
? Abdominal colic

No, there could be another reason …

The cry could be due to ear pain

How to find out …

 How to find out ?

• Ask for a preceding cold

• Look for nasal discharge
• And look inside the ear

The above might indicate Acute Otitis Media

Here is another clue …

Many times, you may see

babies tugging at the ear
 Baby crying – Midnight
Feeding bottle does not help

Think of Acute Otitis Media

Look inside the ear with an otoscope.

Every third baby crying in

the night has AOM
 Baby crying - Do an Otoscopy

Red TM

Bulging TM

Discharge

If you see one of these pictures, it is AOM

 Otoscopy is easy to learn
Additional skill – Pneumatic otoscopy

If fluid is present, the drum will not move freely.

Adhesions will be seen better. Perforation seen distinctly.
 Otoscopy is easy to learn
Never fail to do it

If you miss an AOM, you miss the correct

diagnosis in every third baby coming to you
Additional corroboration will come from
examination of Throat and Nose

Note the tonsils.They

may be enlarged, red
and purulent. This
child may have fever.
Look for neck nodes.
Adenoidal infection and enlargement
often accompanies Tonsillitis

Extreme encroachment
of the airway. No
wonder the child
resorts to mouth
breathing and snoring
 Understanding Acute Otitis Media

The Natural History of AOM

Balakrishnan D
 Understanding Acute Otitis Media
The Natural History of AOM

• Aetiology
• Progression and stages of AOM
• In a few cases, sequelae might occur
• Secretory Otitis Media
• Persistent perforation syndrome – CSOM
Understanding Acute Otitis Media

First, let us see how we hear ?

 Understanding Acute Otitis Media
The role of Auditory tube in hearing

The Eustachian tube connects the middle ear with the

throat. With each swallow, it opens and equalizes the
pressure on either side of the drum. Hence the drum
moves well and we hear well.
 Then, the infection strikes
Obviously it is from their peers.
Play school children get it more often.

Bacterial Viral
Streptococcus pneumoniae RSV
Haemophilus influenzae Influenza
Moraxella catarrhalis
Streptococcus sp
 Understanding Acute Otitis Media

Blockage of Auditory tube leads to AOM

During a cold, the auditory tube gets blocked. And, a

vacuum is produced in the middle ear. Hence, the drum
gets stretched … Pain…. Also, signs of inflammation
manifest. Fluid collects in the middle ear …The TM
bulges.
 An infection of the ear can be
identified by the presence of
the cardinal signs of
inflammation : Heat, Redness,
Pain, Swelling, Hearing loss
Understanding Acute Otitis Media

The Stages of AOM

Balakrishnan D
AOM : Initial stage

red, congested drum

 Next stages of AOM

Bulging
Bubbles
 Next stages of AOM

Bulging TM

About to perforate
 AOM - The bulging drum may perforate

Discharge + blood

This stage is Acute Suppurative Otits Media (ASOM)

 The Glue Ear - Secretory Otitis Media

Many times, the drum may

not perforate. Instead, the
fluid resolves and in the
process gets thickened like
a glue.

The Americans call this Otitis Media with Effusion (OME)

 The last stage of AOM

Glue adhesion White deposits

The glue may stick the drum to the inside - Adhesive OM

Sometimes, calcareous deposits may also occur -
Tympanosclerosis.
Understanding Acute Otitis Media

The Diagnosis of AOM

Balakrishnan D
 Understanding Acute Otitis Media
The Diagnosis of AOM is a clinical one

• Awareness of AOM
• A high index of suspicion
• History - Acute onset *
• Otoscopy must show fluid in the middle ear *
• Otoscopy must show signs of inflammation *

* Based on AAP sub committee on Management of AOM, 2004

 Understanding Acute Otitis Media
The treatment of AOM

• Pain relievers *
• Suitable antibiotics
• Observation the next day
• No role for ear drops or oil
• No role for steroids
• No role for antihistamines

* Based on AAP sub committee on Management of AOM, 2004

 Understanding Acute Otitis Media
The controversy of antibiotics

Not necessary. Observe for 24 – 72 hours. Dutch College

of General Practitioners 1990

May or may not give. AAP sub committee on Treatment

of AOM 2004. When withheld, review at 24 hours is
necessary
However, survey shows that 90% of doctors in UK, USA,
Canada & Australia do give antibiotic at first visit.
 Understanding Acute Otitis Media
The treatment outcome

Recovery is the usual outcome. The pain

will be gone the next day. Sometimes, the
fluid will remain and impair the drum
mobility, leading to hearing loss. If the pain
is not relieved or if the drum is still bulged,
refer to an ENT surgeon.
 The ENT consult

The ENT surgeon will confirm the diagnosis.

He will assess the efficacy of the antibiotic.
If necessary, change it. He must consider a
Myringotomy.
 Understanding Acute Otitis Media
Myringotomy

Day care procedure. Done preferably under GA. May

be done with good restraint and LA. This myringotomy
is an emergency procedure. This is an elegant way of
draining the pus. The incision heals excellently. A
permanent perforation syndrome is prevented. Hearing
is preserved.
Understanding Acute Otitis Media
Treatment for Glue Ears

A ventilation tube may be fixed.

 Understanding Acute Otitis Media
Ventilation tube - Grommet

This is a day care surgery. After a

myringotomy incision, a grommet is
inserted. This takes the place of
auditory tube and allows the drum to
move freely and improves the hearing.
 Understanding Acute Otitis Media
Surgical Option

Recurrent adenoiditis may need Adenoidectomy &

ventilation tube insertion.
Adenoidectomy & Tonsillectomy

Operated specimens
 Understanding Acute Otitis Media
Preventive measures
It is impossible to protect the child from infections

Children with cold can be given leave easily.

Tobacco smoke - Remember passive smoking also.

Teach mothers the correct posture while feeding

Sit the baby up during feedings
 Sylvan E. Stool MD

Pioneer Pediatric ENT surgeon in United States

Prof. of Paediatrics & ORL, U. of Denver, Colorado
Founder - ASPO and SENTAC
Started AOM courses for Pediatricians, General Practitioners
and Nurses, for the first time
 Sylvan E. Stool MD

Visited India in 2000 - Manipur & Chennai - on my

invitation. He presided over the First Indian AOM
course in Chennai on 20 October 2000
 Understanding Acute Otitis Media
The guidelines of the following societies are
closely followed in this presentation.

• The American Academy of Pediatrics

• American Academy of Family Physicians
• Agency for Healthcare Research and Quality
• Society for ENT Advances in Children
Guidelines for AOM in India
None formulated so far….

A road too far

…
 APOI
IAP

These two great institutions must work together

to create a national consensus
 Understanding Acute Otitis Media

Thank you for your patient listening

D. Balakrishnan
Professor of ENT Diseases
ENT Surgeon, Kanchi Kamakoti Childs Trust Hospital
Secretary, Assn. of Paed. Otolaryngologists of India