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Acute Otitis media

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Sami m09

on 15 September 2013

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Transcript of Acute Otitis media

Done by :
Sami Al-Loqmani
Intern -QU- ENT department
Acute Otitis media
Contents of presentation
Basic concept (anatomy )
AOM :
Definition
Etiology
Routes of Infection
Predisposing Factors
Clinico-pathological stages
Differential diagnosis
treatment


Definition
Inflammation of muco-periosteal lining of middle ear and mastoid air cells .

Aetiology
It is more common especially in infants and children of lower socio-economic group.

Routes of Infection:

1-Via eustachian tube.
2- Via external ear.
3- Blood-borne.

Predisposing Factors

Recurrent attacks of common cold.
upper respiratory tract infections.
Exanthematous fevers like measles, diphtheria, whooping cough.
Infections of tonsils and adenoids.
Chronic rhinitis and sinusitis.
Nasal allergy.
packing of nose .
Cleft palate.

Bacteriology

Common organisms:
Streptococcus pneumonia 30%.
Haemophilus influenzae 20%
Moraxella catarrhalis 12%.
Others: Strept. pyogenes, Staph. aureus, Pseudomonas aerugnosa.
No growth 18-20%.

Clinico-pathological stages

Stage of Eustachian tube occlusion
Stage of pre-suppuration
Stage of suppuration
Stage of resolution
Stage of complications

Stage of tubal occlusion
Pathology
: Edema and hyperemia of ET opening leads to absorption of air and negative intra- tympanic pressure

Clinical :
- Symptoms : ear fullness and earache
- Signs : retraction of the tympanic ,handle of malleus in more horizontal position and it is fore-shortened; lateral process of malleus is prominent. Loss of light reflex .

Normal tympanic membrane
Stage of pre-suppuration
Pathology:
Viruses and pyogenic organisms invade middle ear cavity resulting in hyperemia of its lining. Inflammatory exudate appears in middle ear. Tympanic membrane becomes congested.

Clinical:
-
Symptoms
: increasing ear ache, disturbed sleep, restlessness, fever, conductive HL .
-
Signs
: TM congested. Leash of blood vessels appear along handle of malleus and at periphery of TM (cart-wheel like shape) .

Stage of hyperemia
Stage of suppuration
Pathology
: pus forms in middle ear and in mastoid air cells.

Clinical:

-
Symptoms:
severe ear pain, deafness, fever (102-103 Fo ); vomiting, convulsions.
-
Signs:
TM is red and bulging, loss of land marks, a yellow spot or a nipple like protrusion where rupture is imminent. Mild tenderness on mastoid.
-
X ray mastoid
: show clouding of air cells

Stage of suppuration
Stage of resolution

Pathology
: TM perforates with discharge . Inflammatory process begin to resolve. If proper treatment is given resolution takes place without perforation.

Clinical :
-
Symptoms
: less earache and fever. Child feels better.
-
Signs
: EAC full of mucopurulent discharge. Pinpoint TM perforation (or pulsating discharge) in the antero- inferior quadrant

Stage of complications
Resolution may not take place:
- High virulence of bacteria
- Low resistance of patient

Disease spreads beyond confines of middle ear causing complications:
-
Cranial
: acute mastoiditis, facial palsy,
labyrinthitis, petrositis,
-
Intracranial
: extradural abscess, meningitis,
brain abscess, lateral sinus
thrombophlebitis

DIFFERENTIAL DIAGNOSIS 
The main consideration in the differential diagnosis of AOM is otitis media with effusion .

-
In AOM-->
the tympanic membrane is usually bulging
-
In OME-->
it is usually retracted or in the neutral position.

-
In AOM-->
TM is typically red or pale yellow.
-
In OME-->
it is typically amber or blue.


- In AOM-->
pus may be visualized behind the tympanic membrane, the tympanic membrane may be perforated with acute purulent otorrhea.

-In OME-->
a fluid level or bubbles may be seen.

Treatment of AOM
Antibiotics

- Given for a period of two weeks till TM regains normal appearance and hearing returns to normal
- H. influenzae or Moraxella catarrhalis are beta lactamase producers .
- Choices: Amoxicillin –clavulanate, 2nd or 3rd generation cephalosporins, macrolides and sulpha.

Treat of AOM (cont.)

Decongestants
: to relieve Eustachian tube obstruction & edema and prompt middle ear ventilation


Topical
: ephedrine nasal drops 1% in adults and 0.5% in children, oxymetazoline, xylometazoline

Oral
: pseudoephedrine

Analgesics & Dry local heat
Ear cleaning

Treatment of AOM (cont.)

Myringotomy
: Incision of TM to drain pus.

Indications:
- Bulging TM with severe pain and high fever
- Imminent complications: acute mastoid, facial
weakness .
- Incomplete resolution despite antibiotic cover
- Immune-deficiency syndromes

Under GA
; in the postero-inferior quadrant using a circumferential incision.Send a sample for C&S .

Follow up
All patients of acute suppurative otitis media should followed till :
TM becomes normal
Tympanometry becomes normal

Middle ear effusion may persist after AOM for up to 3 months.
There is a group of children who are otitis prone.
Look for risk factors.
Consider pneumococcal vaccines and antibiotic prophylaxis.

References

Diseases of Ear, Nose and throat ( PL Dhingra) 4th ed
online websites


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