Acute inflammation of the muco-

periosteal lining of the middle ear

cleft commonly seen in children and
usually consequent to an upper
respiratory tract infection
 Eustachian tube dysfunction- MOST
COMMON
Viral rhinitis
Any form of rhinitis/ sinusitis
Other causes of ET dysfunction
Traumatic perforation of tympanic
membrane
Barotraumatic otitis media
Hematogenous
 Upper respiratory tract infections are
more common
Eustachian tube is more short, wide
and horizontal in children compared to
adults
Adenoid tends to hypertrophy and
obstruct the ET orifice in the
nasopharynx
Feeding habits in an infant-
nasopaharyngeal reflux more common
 Recurrent URTI
Tonsils and adenoid infection
Chr rhinitis and sinusitis
Nasal allergy
Cleft palate
Tumours of nasopharynx
 Peak incidence at the age of 3-18
months
60% of children below 1 year of age-
variable severity
80% of children below 3 years of age
Boys>girls
Native Americans> African
Americans
Rural>Urban: Reason?
 Usually starts as a viral infection. Ex:
RSV, Rhinovirus, CMV, measles, EBV.
Streptococcus pneumoniae ( 30-50%)
H. influenzae ( 20-30%)
Moraxiella catarrhalis ( 10-20%)
Streptococcus pyogenes
Pathology
 Tubal occlusion (hyperemia)
Pre-suppuration
Suppuration
Resolution or
Complications
 Pathology
URTI leads to ET
mucosal edema
ET gets occluded
Air in the middle
ear cleft gets
absorbed
Vacuum (negative
pressure in middle
ear)
Transudation
 Symptoms
Blocked feeling in
the ear following
URTI
Mild ache/
discomfort
Signs
Retracted drum
Hyperemia
 Pathology
Bacterial infection
Exudation of fluid
Increased mucus
secretion and
decreased drainage
Accumulation of
non-purulent fluid
in middle ear
Increased
congestion
 Symptoms
Irritable child
Increasing ear-ache and deafness
Autophony
Signs
Cart-wheel appearance of the TM
Bulging drum
Fluid level/ air bubbles seen through
TM
 Pathology
Suppuration
Accumulation of
pus in the middle
ear under tension
 Acute coalescent/ masked mastoiditis
Non resolved AOM- if no resolution by
one month
Recurrent ASOM
CSOM- tubotympanic disease (TM
perforation persists > 3 months)
 Symptoms
Unexplained cause of crying in a child
Fever, toxic symptoms
Severe otalgia
Deafness
Signs
Grossly congested and edematous TM
Bulging of TM- >posteriorly
Pus pointing +/-
 Pathology
Accumulation of
pus in the middle
ear under tension
Later- rupture of
the TM and release
of pus (discharge)
 Symptoms
At the peak of otalgiamucopurulent,
blood stained ear discharge
Otalgia subsides with onset of
discharge
Signs
RupturePulsatile ear discharge
Light house sign
Pin-hole perforation
 Pathology
With drainage of
the pus and
Host defense/
treatment
Inflammation
resolves
Pin-hole perforation
heals
 Symptoms
Acute symptoms subside
Ear becomes dry
Eventually hearing is restored
Signs
Pin-hole perforation without
discharge
Later healed perforation
 Pathology
Infection fails to resolve due to
Pneumatised mastoid with infection
extending
Organism- virulent
Resistance of host- poor
Treatment- inadequate
Or if the TM fails to perforate
Acute mastoiditis
 Symptoms
Ear symptoms persist or increase
Spiky temperature
Swelling post-auricular region
Signs
Persistent ear discharge and congestion
Mastoid tenderness and swelling
 Treatment usually started with clinical
diagnosis
Investigate if not resolving or if impending
complications suspected
Ear swab for C/S
X-ray mastoids
X-ray PNS/ nasopharynx
Audiological assessment
CT scan of temporal bone and
intracranium- with contrast
 Treat URTI
Broad spectrum antibiotics like amoxycillin/
ampicillin/ augmentin/ erythromycin etc.-
Orally as syrup/ tablets
High dose (meningitic dose) and parenteral
if complications suspected
Nasal decongestants
Analgesics
No role for topical antibiotics
Indications
TM fails to perforate
Severe otalgia
Non-resolving symptoms
If impending complications suspected
 Tympanocentesis- Needle aspiration of the
fluid
Myringotomy
Curvilinear incision on the TM at the site of
most prominent bulgeusually posteriorly
drainage of pus
Or widen the pin-hole perforation- better
drainage
Cortical mastoidectomy
To eradicate the diseased mucosa in the
mastoid antrum and the air cells
 Acute otitis media usually due to
streptococcus pneumoniae associated with
exanthematous fevers like measles,
chicken pox, etc.
Extensive destruction of the middle ear
structures
Total perforation
Ossicular discontinuity
Higher incidence of mixed hearing loss
Treatment is same as AOM
 Acute inflammation of the muco-
periosteum of mastoid antrum and
mastoid air cells, usually a result of
ASOM, characterized by coalescence
of the mastoid air cells and collection
of pus under tension (empyema)
within the mastoids
 Following ASOM, infection in the middle
ear spreads into the mastoid antrum and
cells
Mucosal odema blocks the aditus- no
drainage of mastiod antrum
Mucopus in mastoids collect under tension
HYPERAEMIC DE-CALCIFICATION gives rise
to soft bone
COALESCENCE DUE TO INTERCELLULAR
BONE DESTRUCTION---EMPYEMA
 Pneumatized mastoidmore cells--
more mucosa
Organismvirulent
Resistance of the hostpoor
Treatmentinadequate or
inappropriate
Failure of tympanic membrane to perforate in
ASOM or perforation is too small for complete
drainage
 EMPYEMA OF MASTOID
Spread of infection to other
structures in/ out of mastoid---
intracranial/ extracranial
complications
 Extra-cranial Intra-cranial
Mastoid abscess Meningitis
Facial paralysis Extradural
Labyrinthitis abscess
Petrositis Subdural abscess
Septicemia Brain abscess
Osteomyelitis of Lateral sinus
temporal bone thrombophlebitis
Otitic
hydrochephalus
Cortical venous
thrombophlebitis
 Following ASOM
Increasing pain and discharge in the
ear
Post-aural painful swelling,fever,
malaise and lassitude
Features of complications
 Post-auricular swelling due to
cellulitis/ abscess
Mastoid tenderness positive
Pinna is pushed forwards and
downwards
Sagging of the canal skin
Congested bulging drum with no
perforation or with small perforation
Pulsatile ear discharge
 Ear swab for culture and sensitivity
Pure tone audiogram if possible
X-ray mastoidsSchullers view---shows
clouding of the mastoid air cells and
coalescence
CT scan of the temporal bone and
intracranium with contrast--if
complications are suspected
 intravenous antibiotics
Penicillin group with metronidazole
preferred
Early stagemyringotomy/ widening of
perforation may be tried
I&D if mastoid abscess is present followed
by
Emergency exploration of mastoid and
cortical mastoidectomy
Treatment of complications
 Injury to the middle and/or inner ear
due to sudden negative middle ear
pressure caused by sudden descent
during flight or sudden deep diving
Predisposed by pre-existing ET
dysfunction
 Higher the altitudelower the atmospheric
pressure
Ascent- passive movement of air out of ET
Sudden descentmiddle ear pressure is
negative compared to atmospheric
pressure
Locking of the tube occurs if pressure
difference
Early locking in case of ET dysfunction
 Retraction of TM
Transudation
Exudation
Micro-hemorrhage
Traumatic perforation
Ossicular discontinuity
Round window rupture
Inner ear damage
 Otalgia
Blocked sensation/ deafness
Tinnitus
Vertigo
Ear dischargeblood stained initially
 Congested retracted drum
Fluid level/ air bubbles in middle ear
Rupture TM
Nystagmus +/-
Conductive or mixed hearing loss
 Pure tone audiogram
Impedance audiometry
Microscopic otological examination
 Usually resolves within few weeks
Analgesics/ and decongestants
Labyrinthine sedatives/ steroids if
inner ear damage suspected
Persistent fluidmyringotomy
grommet insertion
Persistant perforationmyringoplasty