Features

Definition

Acute Otitis Media (AOM) Otalgia Pyrexia Thickened, Bulging, Hyperemic Tympanic Membrane Hearing Loss Otorrhea Inflammatory process within the middle ear cleft, can be acute or chronic. Chronic persists for more than 3 months First 2 years Not being breastfed Day care attendance Exposure to tobacco smoke Seasonal variation in respiratory infections Genetics Immunodeficiency Birth defects (cleft palate, down syndrome) Begins with a viral upper respiratory tract infection which leads to disruption of eustachian tube function, inflammation of middle ear mucosa results in an effusion which cannot be cleared by Eustachian tube dysfunction. Effusion favors stasis of secretion which is a suitable environment for pathogens, reaches the middle ear and produces suppuration. Up to 72 hours with analgesia/antipyretics if nonsevere and patient is younger than 2 years old Antibiotics (amoxicillin) Myringotomy for refractory AOM

Otitis Media with Effusion (OME) Persistent Hearing Loss Dull, immobile tympanic membrane Flat tympanogram

Chronic Suppurative Otitis Media Chronic or recurrent otorrhea or both Hearing loss Tympanic membrane perfusion Mucopurulent discharge Persistent or intermittent infected discharge through a nonintact tympanic membrane Lower socioeconomic status and same factors associated with AOM

Risk Factors

Persistence of serous or mucoid middle ear effusion for 3 months or more A.K.A. chronic secretory otitis media, chronic serous otitis media 2 to 5 years of age Recurrent AOM

Pathogenesis

Overproduction of mucus, impaired clearance of mucus or both; bacterial exotoxins causes temporary paralysis of cilia; barotrauma can also contribute to OME as negative pressure in the canal results in the transudation of fluid into middle ear cleft

Occurs as a consequence of an episode of AOM with perforation with subsequent failure of the perforation to heal (P. aeruginosa, S. aureus, and the Proteus spp.)

Treatment Watchful waiting Medical therapy Surgical therapy

For three months from onset or diagnosis

Not indicated

Not indicated Ventilation tube insertion if unresolved after 3 months

Aural toilet and topical antibiotics (Quinolones) Tympanoplasty

Recurrent AOM: > 3 episodes of acute suppurative OM in a 6 month period or > 4 episodes in a 12 month period with complete resolution of symptoms and signs between episodes Complications of Otitis Media Sequelae: Tympanosclerosis Hyalinization and deposition of calcium in the tympanic membrane, middle ear or both Occurs as a result of inflammation or trauma and commonly seen after recurrent episodes of AOM and OME Clinical appearance: white plaques in the tympanic membrane If the middle ear is involved then the ossicular chain become immobilized, resulting in conductive hearing loss Atelectasis Presence of grossly retracted or collapsed tympanic membrane Occurs as a result of prolonged negative middle ear pressure secondary to chronic Eustachian tube dysfunction. If collapse is only partial, a retraction pocket is formed (if it forms in the pars flaccida or the posterosuperior pars tensa, high risk for accumulation of squamous debris and cholesteatoma formation) May not produce any symptoms but more commonly results in a mild conductive hearing loss Prolonged contact between tympanic membrane and ossicles can result in ossicular erosion (long process of incus) more significant hearing loss Intratemporal Complications Acute Mastoiditis Pain and tenderness over the mastoid process initially, and as it progresses, edema and erythema of postauricular soft tissues with loss of postauricular crease develop. Results in anteroinferior displacement of the pinna. Mastoid abscess extending to the neck (Bezolds abscess) [neknek mo Bezold], to the occipital bone (Citelli abscess) [see-telli, I can see with my occipital or occitelli (tnx pat)] CT scan provides information about the extent of opacification of mastoid air cells, formation of subperiosteal abscess and presence of intracranial complications Facial Nerve Paralysis Occurs as a result of either acute or chronic OM as a result of locally produced bacterial toxins or from direct pressure applied to the nerve by cholesteatoma or granulation tissue managed with aspiration of pus from the middle ear plus antibiotic therapy Suppurative labyrinthitis Direct bacterial invasion of the inner ear via the round window Erosion of the bony capsule of the inner ear by a cholesteatoma (most commonly in the lateral semicircunal canal) is an alternative route to the inner ear Presents with sudden sensorineural hearing loss, severe vertigo, nystagmus and nausea and vomiting The cochlear aqueduct provides direct communication between perilymph and cerebrospinal fluid and is therefore a significant risk of developing meningitis Intracranial Complications Early symptoms of intracranial extension: persistent headache and fever. Lethargy, irritability and neck stiffness Meningitis Occurs as a result of hematogenous spread, direct extension from the middle ear through a bony dehiscence, or through cochlear aqueduct via the inner ear (S. pneumoniae, H. influenza type B) Headaches, photophobia, neck stiffness, fluctuating levels of consciousness Intracranial abscess: Associated with chronic disease Brain abscess: Develop within the temporal lobe or cerebellum Subdural abscess: between the dura and arachnoid matter, symptoms progress more rapidly than those of brain abscess; Drainage is the mainstay of treatment Extradural abscess: formed in the middle fossa between dura mater and the thin bony plate of the tegmen; Can also occur in the posterior fossa and commonly associated with sinus thrombosis Lateral sinus thrombosis Because of close proximity to mastoid air cells, lateral or sigmoid sinus is prone to involvement in middle ear infections which lead to thrombosis;Intermittent episodes of high pyrexia associated with rigors