ACUTE SUPPURATIVE OTITIS MEDIA

It is an acute inflammation of middle ear by pyogenic
organisms. Here, middle ear implies middle ear cleft, i.e.
eustachian tube, middle ear, attic, aditus, antrum and
mastoid air cells.
Aetiology
It is more common especially in infants and children of
lower socio-economic group. Typically, the disease follows
viral infection of upper respiratory tract but soon the
pyogenic organisms invade the middle ear.
Routes of Infection
1. Via eustachian tube. It is the most common route.
Infection travels via the lumen of the tube or along subepith
elial peritubal lymphatics. Eustachian tube in infants
and young children is shorter, wider and more horizontal
and thus may account for higher incidence of infections
n this age group. 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
nd diving can also force water through the tube into the
middle ear.
2. Via external ear. Traumatic perforations of tymp
anic membrane due to any cause open a route to middle
ill infection.
3. Blood-borne. This is an uncommon route.
Predisposing Factors
Anything that interferes with normal functioning of eusta-
chian 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, 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.
Bacteriology. Most common organisms in infants and
young children are Streptococcus pneumoniae (30%),
Haemophilus influenzae (20%) and Moraxella catarrhalis
U 2%). Other organisms include Streptococcus pyogenes,
Staphylococcus aureus and sometimes Pseudomonas aerugnosa.
In about 18-20%, no growth is seen. Many of
[he strains of H. inJluenzae and MoraxelLa cawrrhalis are
b -lactamase producing.
Pathology and Clinical Features
The disease runs through the follOWing stages:
1. Stage of tubal occlusion
2. Stage: of pre-suppuration
3. Stage of suppuration
4. Stage of resolution or complication
1. Stage of tubal occlusion. Oedema and hyperaemia
of nasopharyngeal end of eustachian tube blocks the tube,
leading to absorption of air and negative intratympanic
pressure. There is retraction of tympanic membrane with
some degree of effusion in the middle ear but fluid may not
be clinically apprC'ciable.
Symptoms. Deafness and earache are the two symptoms
but they are not marked. There is generally no fever.
Signs. Tympanic membrane is relracted with handle of
malleus assuming a more horizontal position, prominence
of lateral process of malleus and loss of light reflex.
Tuning fork tests show conductive deClfness.
2. Stage of pre-suppuration. If tubal occlusion is prolonged,
py0genic organisms invade tympanic cavity causing
hyperaemia of its lining. Inflammatory exudate appearS in
the middle ear. Tympanic membrane becomes congested.
Symptoms. Th re is marked earache which my disturb
sleep and is of throbbing n ature. Deafness and tinnitus
are a L~ o present, but complained only by adults.
Usually, ch ild runs high degree of fever and is restl ess.
Signs. To begin with, there is congestion of pars tensa.
Leash of blood vessels appear along the handle of malleus
and at the periphery of tympanic membrane imparting It
a cart-wheel appearance. Later, whole of tympanic membrane
incl uding pars flaccida becomes uniformly red.
Tuning fork tests will again show conductive type of
hearing loss.
3. Stage of suppuratio n. This is marked by formation
of p us in the middle ear and to some extent in mastoid
air cells. Tympanic membrane starts bulging to the
point of ruptu re.
Symptoms. Earache becomes excruciating. Deafne".increases,
child may run fever of 102-103°F. This may be
accompanied by vomiting and even convulsions.
Signs. Tympanic membrane appears red and bulging
with loss of landmarks. Handle of malleus may be engulfed
by the swollen and protruding tympanic memhrane and
may not he discernible. A yellow spot may be seen on the
tympanic membrane where rupture is imminent. In preantibiotic
era, one could see a nipple-like protrusion of
tympanic membrane with a yellow spot on its summit.
Tenderness may he eli cited over the mastoid antrum.
X-rays of mastoid will show clouding of air cells
because of exudate.
4. Stage of resolution. The tympanic membrane
rupture, with release of pus and subsidence of symptoms.
Inflammatory process begins to resol ve. If proper treatment
is started early or if the infection was mild, reso lution
may start even without rupture of tympanic membrane.
Symptoms. With evacuation of pus, earache is
relieved, fever comes down and ch ild feels better.
Signs . External auditory canal may contain blood tinged
discharge which later becomes mucopurulent. Usually, a
small perforation is seen in antero-inferior quadrant of
pars tensa. Hyperaemia of tympanic membrane begins to
subside with return to normal colour and landmarks.
5. Stage of complication. If virulence of organism is
high or resistance of patient poor, resolution may not take
place and disease spreads beyond the confines of middle ear.
It may lead to acute mastoiditis, subperiosteal abscess, facial
paralysis, labyrinth itis, petrositis, extradural abscess, meningitis,
brain absces or lateral sinus thromboph lebitis.
Treatment
1. Antibacterial therapy : It is indicated
in all cases with fever and severe earache. As the most common
organisms are Strert. pneumoniae and H. inj7uenzae,
the drugs which are effective in acute otitis media are
ampic illin (50 mg/kg/day in 4 divided doses), amoxicillin(40 mg/kg/day in 3 divided duses). Those allergic to these
penicillins can be given cefaclor, co-trimoxazole or
erythromycin. In cases where b-lactamase-producing H.
inj7uenzae or Moraxella cararrhalis are isolated, antibiotics
like amoxicillin-clavulanate, augmentin, cefuroxime axetil
or cefixime may be used. Antibacteria l therapy must
be continued for a minimum of 10 days, till tympanic
membrane regains normal appearance and hearing returns
to normaL Early discontinuance of therapy with relief of
earache and fever, or therapy given in inadequate doses
may lead to secretory otitis media and residual hearing loss.
2. Decongestant nasal drops. Ephedrine nose drops
(1 % in adults and 0.5% in children) or oxymetazoline
(Nasivion) or xylometazoline (Otrivin) should be used to
relieve eustachian tube oedema and promo te ventilation
of middle ear.
3. Oral nasal decongestants. Pseudoephedrine
(Sudafed) 30 mg twice daily or a combination of decongestant
and antihistaminic (Triominic) may achieve the
same result without resort to nasal drops which are difficult
to administer in children.
4. Analgesics and antipyretics. Paracetamol helps to
relieve pain and bring down temperature.
5. Ear toilet. If there is discharge in the ear, it is drymopped
with sterile cotton buds and a wick moistened
with antibiotic may be inserted.
6. Dry local heat. It helps to relieve pain.
7. Myringotomy. It is incising the drum to evacuate
pus and is indicated when (a) drum is bulging and there is
acute pain, (b) there is an incomplete resolution despite
antibiotics when drum remains full with persistent conductive
deafness, (C) there is persistent effusion beyond
12 weeks.
All cases of acute suppurative otitis media shou ld be
carefully followed till drum membrane returns to its normal
appearance and conductive deafness disappears