Transcript Acute Suppurative Otitis Media (A.S.O.M.)

Acute
Suppurative
Otitis Media
Dr. Vishal Sharma
Definition
Pyogenic infection of middle ear cleft lasting for
< 3 weeks.
Routes for infection:
1.
Via Eustachian tube
2.
Via Tympanic membrane perforation
3.
Haematogenous (rare)
Predisposing Factors
1. Breast feeding in supine position
2. Recurrent upper respiratory tract infection
3. Nasal allergy
4. Chronic rhinitis & sinusitis
5. Tumours of nose & nasopharynx
6. Exposure to cigarette smoke
7. Cleft palate
Bacteriology
1. Haemophilus influenzae
2. Streptococcus pneumoniae
3. Staphylococcus aureus
4. Moraxella catarrhalis
5.  - Hemolytic streptococci (causes acute
necrotizing otitis media)
Stages of A.S.O.M.
1. Stage of Hyperaemia

Synonym: Stage of tubal occlusion

Mild earache

T.M. retracted in early stage

T.M. congested later stage

Cartwheel appearance: radiating blood
vessels from handle of malleus
Cart wheel appearance
2. Stage of Exudation

High fever

Severe earache

Deafness

Marked congestion + bulging of T.M.

Mastoid tenderness

P.T.A.: high frequency conductive deafness
due to mass effect of pus
Stage of Exudation
Stage of Exudation
Stage of Exudation
Stage of Exudation
Nipple sign (impending perforation)
Localized protrusion
of tympanic
membrane due to
destruction of
fibrous layer by
continuous pressure
of pus
3. Stage of Suppuration
Symptoms:

Ear discharge (blood-stained  purulent)

Increased deafness

Decreased fever

Decreased earache
Blood stained otorrhoea
Signs & Investigations

Pinhole perforation + otorrhoea

Light house sign: intermittent reflection of light

Decreased mastoid tenderness

High (mass effect) + low frequency (stiffness
effect of thick periosteum) Conductive deafness

Clouding of air cells in mastoid X-ray
Light House sign
Pinhole perforation
Clouding of mastoid cells
4. Stage of Coalescent Mastoiditis

Otorrhoea > 2 weeks, otalgia & deafness

Mastoid reservoir sign: pus fills up on mopping

Sagging of postero-superior canal wall caused by
peri-osteitis due to pus in adjacent mastoid antrum

Ironed out appearance of skin over mastoid due to
thickened periosteum

Mastoid cavity in X-ray & CT scan
Pathogenesis
Aditus Blockage
 Failure of drainage
 Stasis of secretions
 Hyperemic decalcification
 Resorption of bony septa of air cells
 Coalescence of small air cells to form cavity
 Empyema of mastoid cavity
Pathogenesis
Mastoid reservoir sign
Sagging of posterior wall
Ironed out appearance
Mastoid cavity
Mastoid cavity
5. Stage of Resolution

Otorrhoea
stops

Normal
hearing

Healed
perforation
Stage of Resolution
Sterile exudate in middle ear
6. Stage of Complications

Sub-periosteal abscess

Vertigo

Headache + blurred vision + projectile vomiting

Fever + neck rigidity + irritability

Drowsiness

Gradenigo syndrome (apex petrositis)
Treatment of A.S.O.M.
1. Systemic Antibiotic
2. Nasal decongestants (systemic + topical)
3. H1 anti-histamines
4. Analgesic + anti-pyretic
5. Aural toilet for ear discharge
6. Heat application for severe earache
7. Review after 48 hours
Amoxicillin-clavulanate duo: 625 mg B.D.
Ciprofloxacin: 500mg B.D.
Doxycycline: 100 mg B.D.
Cefadroxil: 500 mg B.D.
Cefaclor: 500 mg T.I.D.
Cefuroxime: 250 mg B.D.
Cefixime: 200 mg B.D.
Cefpodoxime: 200 mg B.D.
Azithromycin: 500 mg O.D.
Clarithromycin: 250 mg B.D.
Antihistamines
Systemic:
Cetirizine: 10 mg OD
Fexofenadine: 120 mg OD
Loratidine: 10 mg OD
Levocetrizine: 5 mg OD
Desloratidine: 5 mg OD
Topical: Azelastine spray (0.1%): 1-2 puff BD
Nasal Decongestants
Systemic decongestants
 Phenylephrine
 Pseudoephedrine
Topical decongestants
 Xylometazoline
 Oxymetazoline
 Saline
Anti-cold preparations
Name
Chlorpheniramine Decongestant Paracetamol
COLDIN
4 mg
PsE 60 mg
500 mg
SINAREST
4 mg
PsE 60 mg
500 mg
DECOLD
4 mg
PhE 7.5 mg
500 mg
SUPRIN
2 mg
PhE 5 mg
500 mg
PsE = Pseudoephedrine;
PhE = Phenylephrine
Topical Decongestants

Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)

Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P)

Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)

Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)

Saline 2 %: 3 drops TID

Saline 0.67 %: 2 drops BD (NASIVION-S)
On review after 48 hours

Earache + fever persists: change to higher
antibiotic. If T.M. is bulging  perform myringotomy.
Send ear discharge for C/S.

Earache + fever subside: continue same
treatment for 10-14 days

Review after 3 months
On review after 3 months

No effusion: no further treatment

Effusion persists: treat as Otitis Media
with Effusion

Presence of abscess or coalescent
mastoiditis: do cortical mastoidectomy
Myringotomy in A.S.O.M.
Curvilinear incision made in
postero-inferior quadrant.
Incision is curvilinear & not
radial (as in OME), to cut
fibres of TM. This keeps
opening patent for long time.
Why make incision in PIQ?
 Least vascular area
 T.M. bulge is
maximum
 Ossicles not damaged
 Easily accessible
Sub-periosteal
abscess & fistula
Pathology
Production of pus under tension
 hyperaemic decalcification (halisteresis)
+ osteoclastic resorption of bone
 sub-periosteal abscess
 penetration of periosteum + skin
 fistula formation
Sub-periosteal abscess formation
Sub-periosteal fistula: dry
Sub-periosteal fistula: wet
Types of sub-periosteal abscess

Post-auricular

Bezold

Citelli

Zygomatic

Luc

Retro-mastoid

Parapharyngeal & Retropharyngeal
Types of sub-periosteal abscess
Post-auricular abscess
Commonest. Present behind the ear.
Pinna pushed forward & downward.
Bezold & Citelli abscesses
Bezold: neck swelling
over sternocleido-
mastoid muscle
Citelli: neck swelling
over posterior belly
of digastric muscle
Bezold’s abscess
Bezold’s abscess
Luc: swelling in external auditory canal
Zygomatic: swelling antero-superior to pinna +
upper eyelid oedema
Retro-mastoid: swelling over occipital bone
(? Citelli’s abscess)
Parapharyngeal & Retropharyngeal: due to spread
of pus along Eustachian tube
Retromastoid abscess
Gradenigo syndrome
Giuseppe Gradenigo (1859 – 1926)
Defining triad
 Persistent otorrhoea: despite adequate
cortical mastoidectomy
 Retro-orbital pain: Trigeminal nerve involvement
 Diplopia: convergent squint due to lateral rectus
palsy by injury to abducent nv in Dorello’s canal under
Gruber’s petro-sphenoid ligament, at petrous apex
Persistent otorrhoea + Retro-orbital pain +
Convergent squint
Right Convergent squint
Right gaze
Central gaze
Left gaze
Etiology: Coalescent mastoiditis involving
petrous apex along postero-superior & anteroinferior tracts in relation to bony labyrinth
Diagnosis: 1. C.T. scan temporal bone for bony
details. 2. M.R.I. to differ b/w bone marrow & pus
Treatment: Modified radical mastoidectomy &
clearance of petrous apex cells
C.T. scan & M.R.I.
Hearing preserving approaches to petrous apex

Eagleton’s middle cranial fossa approach

Frenckner’s subarcuate approach

Thornwaldt’s retro-labyrinthine approach

Dearmin & Farrior’s infra-labyrinthine approach

Farrior’s hypotympanic sub-cochlear approach

Lempert Ramadier’s peri-tubal approach

Kopetsky Almoor’s peri-tubal approach
Hearing sacrificing approaches to petrous apex

Trans-cochlear approach

Trans-labyrinthine approach
Spread of pus

Post-auricular: Lateral spread

Bezold: Inferior spread

Citelli: Inferior spread

Luc: Anterior spread

Zygomatic: Superior spread

Retro-mastoid: Posterior spread

Parapharyngeal: Medial spread

Retropharyngeal: Medial spread

Gradenigo syndrome: Medial spread
Cortical
Mastoidectomy
Antiseptic dressing
Draping
Infiltration
Marking of incision
Wilde’s post-aural incision
Incision deepened
Musculoperiosteal flap elevated
Bezold’s abscess
Aspiration of pus
Drainage of abscess
Drainage of abscess
Corical mastoidectomy begun
Exposure of mastoid antrum
Widening of aditus
Aditus widened
Final Cavity
Cortical Mastoidectomy
Drain put in mastoid cavity
Mastoid dressing
Healed post-aural scar
Thank you