Acute Suppurative Otitis
Media
& Serous Otitis Media
Roll numbers:
174,175,176,177
Acute Suppurative Otitis
Media
- Acute inflammation of the middle ear by pyogenic organisms.
- Here Middle ear implies:
“Middle ear cleft"
1.Eustachian Tube
2.Middle Ear
3.Attic
4.Aditus
5.Antrum
6.Mastoid Air Cells
Etiology of ASOM
- More common in: infants, children, low SES
- Typically starts as a URT Viral infection -> later pyogenic organisms invade
middle ear
- Routes of Infection:
1. Via Eustachian Tube: most common, via lumen / peritubal lymphatics,
accounts for infections in infant age group (ET is short, wide & horizontal)
2. Via External Ear: Trauma -> Perforation of Tympanic membrane -> open
entry
3. Blood Borne: Uncommon
Predisposing factors
1. Recurrent attacks : common cold, URT, and exanthematous fevers
like measles, diphtheria, whooping cough.
2. Infections of tonsils and adenoids
3. Chronic rhinitis and sinusitis
4. Nasal allergy
5. Tumours of nasopharynx, packing of nose or nasopharynx
for epistaxis
6. Cleft palate
PATHOLOGY AND CLINICAL FEATURES
Tubal occlusion
Pre-Suppuration
Suppuration
Resolution Complications
PATHOLOGY AND CLINICAL FEATURES
1 Stage of tubal occlusion
- Symptoms - pain in the ear and
2 Stage of pre-suppuration -
Symptoms - throbbing pain , hearing
. no fever.
- Signs - tuning fork test shows
. loss , tinnitus , fever .
Signs – Redness and congestion of pars
conductive deafness tensa and pars flaccida . Also, the tympanic
membrane shows fibers running radially
called CARTWHEEL appearance
PATHOLOGY AND CLINICAL FEATURES
Stage of suppuration Stage of resolution –
3 Symptoms- pain becomes 4 Symptoms – pus exudate , pain
. .
excruciating, fever , vomiting , relieved, fever comes down , child
convulsions . feels better .
Signs - red, bulging and loss of landmarks. Signs – blood-tinged discharge
Pulsation ottorhea or lighthouse sign is which later turns to be mucopurulent.
prominent. Hyperaemia subsides. Small
X ray shows clouding of air cells because perforation seen in pars tensa in
of exudate. Myringotomy is indicated in anteroinferior quadrant.
this case
High virulence organism Low patient immunity
Stage of Complications –
5.
- Disease spreads beyond the middle ear.
- May cause: acute mastoiditis, subperiosteal
abscess, facial paralysis, labyrinthitis, petrositis, extradural
abscess, meningitis, brain abscess or lateral sinus
thrombophlebitis.
Treatment
Treatment
1. Antibacterial Therapy-
- Indicated in fever and severe earache.
- Must be continued for 10 days (minimum)
till tympanic membrane regains normal appearance and hearing returns to
normal.
- Early discontinuation or inadequate doses -> secretory otitis media and
residual hearing loss.
Treatment
2.Decongestant Nasal Drops Ephedrine (1% in adults and 0.5% in
children), Oxymetazoline, Xylometazoline.
3.Oral Nasal Decongestants Pseudoephedrine- 30 mg twice daily or a combination of
decongestant and antihistaminic
4.Analgesics and Antipyretics - Paracetamol or Ibuprofen syrup 5. Ear Toilet If there is
discharge in the ear, it is dry-mopped with sterile cotton buds and a wick moistened with
antibiotic solution may be inserted.
5. Ear Toilet. discharge in the ear -> drymopped with sterile cotton buds and a wick
moistened with antibiotic may be inserted.
6. Dry Local Heat- to relieve pain
Treatment
7. Myringotomy - incising the drum -> evacuate pus
indicated when:
(i) The drum is bulging and there is acute pain,
(ii) Incomplete resolution despite antibiotics/ when
drum remains full/ with persistent conductive hearing
loss and
(iii) There is persistent effusion beyond 12 weeks
Acute Necrotizing Otitis Media
- Variety of ASOM
- Often seen in children suffering from measles, scarlet fever or
influenza.
- Causative organism is β-haemolytic streptococcus.
- Rapid destruction of whole of tympanic membrane, mucosa of
promontory, ossicular chain and mastoid air cells with profuse otorrhoea.
- Healing is followed by fibrosis or ingrowth of squamous epithelium
from the meatus (secondary acquired cholesteatoma).
- Treatment -> early institution of antibacterial therapy.
Continued for at least 7–10 days
Cortical mastoidectomy may be indicated if medical treatment fails or
complicated by acute mastoiditis.
Serous Otitis Media
Synonyms: Otitis media with effusion, Secretory otitis media,
Glue Ear, Non Suppurative Otitis Media, Middle Ear Effusion, and
Mucoid Otitis Media
• Insidious condition: characterized by accumulation of non-purulent effusion in
the middle ear cleft.
• Often the effusion is thick and viscid but sometimes it may be thin and serous.
• The fluid is nearly sterile.
• The condition is commonly seen in school-going children.
Aetiology
1. Eustachian Tube Dysfunction
→ Due to:
• Adenoid hyperplasia
• Chronic rhinitis/sinusitis
• Chronic tonsillitis (obstructs soft palate movement)
• Nasopharyngeal tumours (esp. in unilateral adult cases)
• Palatal defects (e.g., cleft palate, paralysis)
2. Allergy
→ Seasonal/perennial (inhalants or food)
→ Causes:
• Eustachian tube oedema
• Hyperactive middle ear mucosa → ↑ secretions
Aetiology
3. Unresolved Otitis Media
→ Inadequate treatment of acute otitis media
→ Leads to:
• Persistent low-grade infection
• Mucosal stimulation → ↑ goblet cells & secretions
• 4. Viral Infections
→ Adenoviruses, rhinoviruses
→ Direct stimulation of middle ear mucosa → ↑ fluid production
Pathogenes
Two main mechanisms
is
1. Malfunctioning of Eustachian Tube:
tube fails to aerate the middle ear; also unable to
drain the fluid.
2. Increased Secretory Activity of Middle Ear Mucosa.
Biopsies of middle ear mucosa in such cases confirm increase in
number of mucus or serous secreting cells.
Clinical Features
1. Symptoms (typically in children aged 5–8 years)
•Hearing loss: Most common; insidious onset, ≤40 dB; often unnoticed
•Speech delay/defect: Due to hearing impairment
•Mild earaches: May follow URTIs
2. Otoscopic Findings
•Dull, opaque tympanic membrane (yellow/grey/bluish)
•Loss of light reflex
•Thin blood vessels along malleus or periphery
•Retraction or mild bulging (esp. posteriorly)
•Fluid level and air bubbles may be seen when fluid is
thin and tympanic membrane (on Valsalva manoeuvre)
•Decreased TM mobility
Hearing Tests
1.Tuning Fork Tests:
→ Conductive hearing loss
2.Audiometry:
→ Conductive loss (20–40 dB)
→ May show reversible sensorineural loss (due to round
window pressure)
3.Impedance Audiometry (objective, good for children):
→ Flat curve, reduced compliance
→ Negative pressure shift = middle ear fluid
4.X-ray Mastoids:
→ Clouding of mastoid air cells (indicates fluid presence)
Treatment
Aim: removal of fluid and prevent its recurrence.
1) Medical
(a) Decongestants like nasal drops to relieve oedema of eustachian tube.
(b) Anti-allergic measures: Antihistaminics or steroids may be used in cases of
allergy.
(c) Antibiotics: useful in upper respiratory tract infections or unresolved acute
suppurative
otitis media.
(d) Middle Ear Aeration: by Valsalva manoeuvre.
Sometimes, politzerization or ET catheterization to ventilate middle ear and
promote drainage of fluid.
2) Surgical- When fluid is thick and medical treatment alone does not
help, fluid must be surgically removed.
Surgical treatment
a. Myringotomy & Aspiration
→ Incision in tympanic membrane (Anteroinferior quadrant)
→ Suction of fluid (may need saline/mucolytic agents)
→ Dual incisions sometimes used for thick mucus (“beer-can”
method)
b. Grommet Insertion
→ Ventilation tube placed if fluid recurs
→ Ensures middle ear aeration
→ Left for weeks/months until spontaneous extrusion
c. Tympanotomy / Cortical Mastoidectomy
→ For thick loculated fluid or associated pathologies (e.g.,
cholesterol granuloma)
d. Surgical Treatment of Causes
→ Adenoidectomy, tonsillectomy, or maxillary sinus washout
→ Often combined with myringotomy
Sequelae of Chronic Secretory Otitis Media
1.Atrophic Tympanic Membrane & Atelectasis
→ TM becomes thin, loses fibrous layer, retracts into middle ear
2.Ossicular Necrosis
→ Commonly affects incus/stapes → conductive hearing loss > 50 dB
3.Tympanosclerosis
→ Chalky hyalinized deposits → ossicle/joint fixation
4.Retraction Pockets & Cholesteatoma
→ Invagination of atrophic TM or attic region → pocket formation
5.Cholesterol Granuloma
→ Due to secretion stasis in middle ear/mastoid
References
- Diseases of Ear, Nose & Throat 8th Edition
- Google Scholar
- Google Images
Thank You!
