Acute otitis media
FACULTY OF MEDICINE
Course: EAR, NOSE & THROAT
LECTURER: Prof/Dr. Abdullahi Hussein Abdi
Lecture Ass: Dr Hussein Omar Ahmed (Dr zuke)
INTRODUCTION
Acute otitis media (AOM) is primarily an infection of
childhood and is the most common pediatric infection for
which antibiotics are prescribed in the United States.
The vast majority of the lecturer focuses on the etiology,
symptoms, diagnosis, management, and complications of
AOM, associated with Chronic Otitis Media.
Acute Otitis Media (AOM )
It is an acute inflammation of the middle-ear cavity.
It occurs most commonly in infants and children of
lower socio-economic group and it is important to
manage with care to prevent subsequent
complications.
Most commonly follows an acute upper respiratory
tract infection and may be viral or bacterial.
It is impossible to decide , unless the ear discharges
pus from which an organism is cultured.
EPIDEMIOLOGY OF ACUTE OTITIS MEDIA
A global disease burden study
estimated the incidence of AOM as
follows:
children under age 5 years (45 to 60
percent);
children aged 5 to 14 years (19 to 22
percent);
children and adults aged 15 to 24
years (3.1 to 3.5 percent); and
adults aged 25 to 85 years (1.5 to 2.3
percent).
The incidence of AOM among adults in
developed countries is likely less than
1 percent based upon data from this
study.
ROUTES OF INFECTION
1. Via Eustachian tube.
It is the most common route. Infection travels via the
lumen of the tube or along subepithelial peritubal
lymphatics.
Eustachian tube in infants and young children is
shorter, wider and more horizontal and thus may
account for higher incidence of infections in this age
group.
Horizontal section through the eustachian tube showing
bony and cartilaginous parts, isthmus, tympanic and pharyngeal ends.
Cont…
Breast or bottle feeding in a young infant in horizontal
position may force fluids through the tube into the
middle ear and hence the need to keep the infant
propped up with head a little higher.
Swimming and diving can also force water through the
tube into the middle ear.
Cont….
2. Via external ear.
Traumatic perforations of tympanic membrane due to
any cause open a route to middle ear infection.
3. Blood-borne. This is an uncommon route.
PREDISPOSING FACTORS
Anything that interferes with normal functioning of
Eustachian tube predisposes to middle ear infection.
It could be:
1. Recurrent attacks of common cold, upper respiratory
tract infections and exanthematous fevers like measles,
diphtheria or whooping cough.
2. Infections of tonsils and adenoids.
Cont…
3. Chronic rhinitis and sinusitis.
4. Nasal allergy.
5. Tumours of nasopharynx, packing of nose or
nasopharynx for epistaxis.
6. Cleft palate.
7.Trauma to the tympanic membrane.
8.Temporal bone fracture
9.Barotrauma (air flight)
Bacteriology.
The infection occur on the mucous membrane of the
whole of the middle-ear.
The bacteria responsible for acute otitis media are:
Streptococcus pneumoniae 30%.
Haemophilus influenzae 20%.
Moraxella catarrhalis 12%..
Group A streptococci and Staphylococcus aureus
may also be responsible.
The sequence of events in acute otitis media is as
follows:
1. Organisms invade the mucous membrane causing
inflammation, oedema, exudate and later pus;
2. Oedema closes the Eustachian tube, preventing
aeration and drainage .
3. Pressure from the pus rises, causing the drum to
bulge.
4. Necrosis of the tympanic membrane results in
perforation;
5. The ear continues to drain until the infection
resolves.
Clinical presentation
The main clinical features of AOM are
otalgia (earache),
Pyrexia (fever),
Tenderness and
deafness followed by otorrhoea (discharge
from the ear,
Diagnosis
otoscopy — In adults with suspected AOM, the diagnosis is
confirmed by the presence of typical features on otoscopic
exam.
Key features include:
●Bulging tympanic membrane
●Reduced mobility of the tympanic membrane when pneumatic
pressure is applied (if pneumatoscopy is available)
Other features,
which may or may not be present in adults with AOM include:
●Partial or complete opacification of the tympanic membrane
●Erythema of tympanic membrane
TREATMENT
The treatment depends on the stage reached by the
infection.
The following stages may be considered:
Early, Bulging and Discharging.
Early stage
Antibiotics
Penicillin remains the drug of choice in most cases,
and ideally should be given initially by injection
followed by oral medication.
In children under 5-years, when Haemophilus
influenzae is likely to be present.
Cont..
Ampicillin (50 mg/kg/day in four divided doses) and
amoxicillin (40 mg/kg/day in three divided doses).
In cases where β-lactamase-producing H.influenza or
M. catarrhalis are isolated, antibiotics like
amoxicillin clavulanate, augmentin, cefuroxime or
cefixime may be used.
Antibacterial therapy must be continued for a
minimum of 10 days, till tympanic membrane regains
normal appearance and hearing returns to normal.
Analgesics
Analgesics and antipyretics. Paracetamol helps to
relieve pain and bring down temperature.
Avoid the use of aspirin in children because of the
risk of Reye’s syndrome.
Decongestant nasal drops.
Ephedrine nose drops (1% in adults and 0.5% in
children)
Oxymetazoline(Nasivion)
Xylometazoline (Otrivin) should be used to relieve
eustachian tube oedema and promote ventilation of
middle ear.
Ear toilet.
If there is discharge in the ear, it is dry-mopped with
sterile cotton buds and a wick moistened with
antibiotic may be inserted.
Ear drops are in acute otitis media with an intact
drum.
Especially illogical is the use of drops containing
local anesthetics, which can have no effect on the
middle-ear mucosa yet may cause a sensitivity
reaction in the meatal skin.
Bulging :
Myringotomy is necessary when bulging of the
tympanic membrane persists, despite adequate
antibiotic therapy.
If the attacks persist, grommet insertion may prevent
further attacks but may result in purulent discharge.
It should be carried out under general anaesthesia in
theatre and a large incision in the membrane should be
made to allow the ear to drain.
Indications of Myringotomy
The common indications of this procedure are
the following:
1. Acute suppurative otitis media, particularly
during exudative stage when the drum is
bulging or the patient has severe pain.
2. In cases where deafness persists even after
apparent control of acute suppurative otitis
media.
3. In secretory otitis media, for aeration of the
middle ear (grommet insertion) and removal of
secretions.
4. In adhesive otitis media—for aeration.
5. Aero-otitis media.
6. In Ménière’s disease, myringotomy
sometimes gives dramatic relief though the
exact mechanism is not known.
Pus should be sent for bacteriological assessment.
Following myringotomy, the ear will discharge and
the outer meatus should be dry-mopped regularly.
RECURRENT ACUTE OTITIS MEDIA (AOM)
Some children are susceptible to repeated attacks of
(AOM) for Anatomical structure .
There may be an underlying immunological deficit
such as IgA deficiency or hypogammaglobulinaemia
that will need to be investigated.
Complication Acute Otitis Media
Chronic OM
Mastotitis
Bacterial Meningitis
Brain Abscess
tympanic membrane perforation
Hearing loss
Case scenario
A 4-year-old child complains of otalgia,
He has a temperature of 102.1°F (38.9°C) and
has had a cold for several days, on
Examination findings include a red, bulging
tympanic membrane that does not move well
with pneumatic otoscopy but he has been
eating well and his activity has been
essentially normal.
➤ What is the most likely diagnosis?
➤ What is the best therapy?
➤ Most likely diagnosis: Acute otitis
media (AOM)
➤ Best therapy: Oral antibiotics
Short note
➤ The most common bacterial pathogens
causing otitis media (OM) are
S pneumoniae, nontypeable H influenzae, and M
catarrhalis.
➤ Examination findings of otitis media include a
red, bulging tympanic membrane that does not
move well with pneumatic otoscopy, an opaque
tympanic membrane with pus behind it,
obscured middle-ear landmarks, and, if the
tympanic membrane has ruptured, pus in the
ear canal.
➤ Initial treatment of otitis media often
includes amoxicillin (depending on local rate
of resistant S pneumonia). If a clinical failure
is seen on day 3, a change to amoxicillin-
clavulanate, cefuroxime axetil, ceftriaxone, or
a tympanocentesis is indicated.
➤ Complications are rare but include
mastoiditis, temporal bone osteomyelitis,
facial nerve palsy, epidural and subdural
abscess formation, meningitis, lateral sinus
thrombosis, and otitic hydrocephalus.
END
