MANAGEMENT

OF DISEASES OF
EAR, NOSE AND
THROAT
 ACUTE OTITIS MEDIA
• Acute pyogenic inflammation of the middle ear cleft (ET, middle ear, attic, aditus,
antrum and mastoid air cells).
• usually seen in children as the ET is shorter, wider and more horizontal and
opens at the lower level in children.
Routes of Infection:
- Eustachian tube: anatomical obstruction like big adenoids.
- Infections: like adenoiditis, tonsillitis, rhinitis.
- Forceful blowing of nose can push the infection into middle ear through the ET.
- Swimming: If water is infected it can spread infection to nose, sinuses and the
middle ear.
- Iatrogenic: Postnasal packing and after adenoidectomy.
-Feeding bottle: In the supine position, bottle feeding may lead milk to enter
middle ear via ET
-Pre-existing tympanic membrane perforation: For eg : trauma while cleaning
the external auditory canal (EAC)
-Fracture of temporal bone

Predisposing Factors :
• Reduced immunity: Malnourishment, poor dietary habits, too much physical
and mental exertion, exposure to extremes of climate and temperatures.
• Barotrauma : Atmospheric pressure changes especially during flying and deep
water diving can affect ET.
• Exanthematous fevers: Measles, diphtheria, whooping cough.
• Nasal allergy: Inhalants and foods.
Causative Microorganisms

Most common organisms : Streptococcus pneumoniae, Haemophilus

influenzae, Branhamella catarrhalis (Morexella catarrhalis).
Other common organisms: Streptococcus pyogenes, Staphylococcus aureus
CLINICAL FEATURES :

I.Stage of tubal occlusion:

There is edema and hyperemia of nasopharynx, which leads to absorption of air
and creation of negative middle ear pressure.
Symptoms : Mild deafness,ear fullness and ear pain.No fever.
Signs : Retracted tympanic membrane , relative shortening and more horizontal
position of malleus handle, prominent lateral process of malleus and loss of light
reflex Conductive hearing loss.
II. Stage of presuppuration:
Prolonged tubal occlusion facilitates invasion of pyogenic organism into middle ear
and results in mucosal hyperemia. Inflammatory exudates appear in the middle ear
Symptoms : Marked throbbing ear pain, which can awake the child from sleep in
night. High degree of fever and restlessness. Bubbling sound in the ear.
Signs : Pars tensa congested and bulging out with cart-wheel appearance (leash
of blood vessels along the handle of malleus and at the periphery of TM) and loss
of light reflex. Tuning fork tests -conductive hearing loss.
III. Stage of suppuration
Formation of pus in the middle ear . Tympanic membrane starts bulging.
Symptoms : Excruciating ear pain,increasing deafness.Constitutional symptoms
due to absorption of toxins include rising fever, accompanied with vomiting,
diarrhea and even convulsions.
Signs : Tympanic membrane appears red and bulging . Handle of malleus
engulfed by the swollen and protruding TM. A yellow spot on the TM where
rupture is imminent . Tenderness over the mastoid antrum in the region of
suprameatal triangle . Clouding of air cells in X-ray of mastoid because of
exudates.
IV. Stage of resolution
The TM ruptures and results in otorrhea and subsidence of other symptoms.
Inflammatory process begins resolving.
Symptoms : otorrhea and ear pain.Fever subside.
Signs: External auditory canal filled with blood tinged or mucopurulent
discharge, which may be pulsatile (lighthouse sign: pus coming out under
pressure and synchronizing with each arterial dilatation of heartbeat).
Perforation of pars tensa usually in anteroinferior quadrant.
V. Stage of complication
In majority of the children AOM is self limiting and responds well to medical
treatment. If the virulence of organism is high and resistance of the child is poor,
infection may spread beyond the middle ear space. Complications include
include acute mastoiditis, subperiosteal abscess, facial paralysis , labyrinthitis,
meningitis, extradural abscess, brain abscess and lateral sinus thrombophlebitis.
DIAGNOSIS
Acute otitis media is a clinical diagnosis.
Hearing tests: They show conductive hearing loss.
CT temporal bone: indicated only in cases of refractory mastoiditis. The
clouding of air cells (because of exudates) and their pressure necrosis
(coalescent mastoiditis) may be seen. Demineralization of the air cell septa
is the key radiographic sign of mastoid osteitis.
Bacteriological examination: The ear discharge is submitted for the culture
and sensitivity to know the type of causative microorganism and the
antibiotic to which they are sensitive.
TREATMENT
Antibiotics :The first line of antibiotic is amoxicillin (40 mg/kg/day in three
divided doses). A single intramuscular dose of ceftriaxone.Other antibiotics
that can be given cefaclor, cotrimoxazole , erythromycin ,amoxicillin-
clavulanate, cefuroxime axetil or cefixime.
Decongestants: Topical ephedrine , oxymetazoline (nasivion) and
xylometazoline (otrivin) nasal drops and oral pseudoephedrine are said to
relieve ET edema and promote ventilation of middle ear.
Analgesics and antipyretics: Paracetamol for pain and fever.
Ear drop and aural toilet: Ear discharge must be cleaned. Water is
prevented from entering the ear. Quinolone/steroids ear wick/drops take
care of local infection and inflammation.
Dry local heat: It relieves pain.
Surgical Treatment:
Tympanocentesis: It is needle aspiration of fluid from middle ear for culture
and sensitivity of ear fluid for knowing the organism and selecting the
antibiotics
Myringotomy: An incision is put in the TM to evacuate middle ear fluid.
The indications are following: Bulging eardrum. Acute excruciating pain.
Unresponsive to antibiotics. Facial palsy. Intracranial complications.
Mastoidectomy: Diagnosis of osteitis warrants mastoidectomy to remove the
necrotic and infected bone.
Incision and drainage of Subperiosteal postauricular abscess.
Tympanoplasty : In cases of permanent tympanic perforation and ossicular
necrosis
 OTITIS MEDIA WITH EFFUSION

Collection of non-purulent nearly sterile effusion in the middle ear cleft.

The effusion is usually thick and viscid but may be thin and serous.
ETIOLOGY
-malfunctioning of Eustachian tube - It fails to ventilate and drain the
middle ear. For eg - mucosal edema,viscous secretions,chronic rhinitis,
sinusitis, tonsillitis.
-Allergy
-Viral infections
-Unresolved acute otitis media
CLINICAL FEATURES
-May be completely asymptomatic.
-The child turns up the volume of television and is not attentive during normal
conversation.
-Insidious conductive hearing loss (rarely exceeds 40 dB), which may be unnoticed
by the parents and is accidentally discovered during audiometry.
-Delayed and defective speech in children due to the hearing loss.
DIAGNOSIS
Tympanometry: When the middle ear is filled or impacted with effusion,
compliance is low and the tympanogram is flat.
Audiometry: Mild to moderate conductive hearing loss is the most common
finding.
Pneumatic otoscopy: It is the gold standard for the diagnosis of otitis media with
effusion
TREATMENT
-Antibiotics : Combination of erythromycin ethylsuccinate and sulfisoxazole.
Trimethoprim-sulfisoxazole. Amoxicillin-clavulanate.
-Antihistamines and decongestant.
-Inflation of middle ear(Valsalva’s maneuver, Politzerization or Eustachian
catheterization
-Corticosteroids
-Surgical treatment is considered when effusion persists and is associated with
hearing loss. The insertion of tympanostomy tube (grommet) with or without
adenoidectomy is preferred over myringotomy alone.
Myringotomy: Aspiration of “glue” or middle ear effusion
Tympanostomy tube (Grommet): Most widely used treatment option for OME
when present for more than 3 months with associated hearing loss of more than
30 dB in better ear
COMPLICATIONS
Atrophic TM
Atelectasis of the middle ear
Tympanic membrane perforation
Ossicular necrosis
Tympanosclerosis
Adhesive OM
Retraction pockets
Chronic suppurative OM and cholesteatoma
Cholesterol granuloma
Sensorineural hearing loss
Otitis media with effusion Grommet insertion