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Otitis Media

ACUTE
Acute Viral Om
Acute Suppurative OM Acute Necrotizing OM Acute Allergic OM

CHRONIC
Specific

Non-specific

Tuberculous OM Syphilitic OM

Non-suppurative
Tubo-tympanic Attico-antral

Suppurative
OM with Effusion Chronic Adhesive OM

Chronic Suppurative Otitis Media (CSOM)


Tubo-tympanic OM Attico-antral OM

Tubo-tympanic OM
The aim is to control infection. Eliminate ear discharge. Later, correct the hearing loss by surgery.

1. Aural toilet.
To remove all discharge and debris from the ear. It can be done by : - dry mopping with absorbent cotton buds - suction clearance under microscope - irrigation Ear must be dried after irrigation.

2. Ear drops
Antibiotic ear drops (neomycin, polymyxin, chloromycetin or gentamicin)

Combined with steroids.


Patient lies down with the diseased ear up, antibiotic drops are instilled and then intermittent pressure applied on the tragus for antibiotic solution to reach the middle ear. 3-4 times/day

3. Systemic antibiotics
Useful in acute exacerbation of chronically infected ear. Otherwise, role of systemic antibiotics in the treatment of CSOM is limited.

4. Precautions
Keep water out of the ear during bathing, swimming and hair wash. Hard nose-blowing can also push the infection from nasopharynx to middle ear and should be avoided.

5. Treatment of contributory causes


Infected tonsils, adenoids, maxillary antra, and nasal allergy.

6. Surgical treatment
Aural polyp or granulations, if present, should be removed before local treatment with antibiotics. It will facilitate ear toilet and permit ear drops to be used effectively. An aural polyp should never be avulsed as it may be arising from the stapes, facial nerve or horizontal canal and thus lead to facial paralysis or labyrinthitis.

7. Reconstructive surgery
Myringoplasty with or without ossicular reconstruction - to restore hearing. Closure of perforation - prevent repeated infection from the external canal.

Attico-antral OM
1. Surgical
Mainstay of treatment. Remove the disease and render the ear safe. Preserve or reconstruct the hearing. Two types of surgical procedures are done to deal with cholesteatoma:
(a)Canal wall down procedures. (b)Canal wall up procedures.

(a) Canal wall down procedures.


Leave the mastoid cavity open into the external auditory canal so that the diseased area is fully exteriorised. Commonly performed operations are : i) atticotomy ii) modified radical mastoidectomy iii) radical mastoidectomy

(b) Canal wall up procedures.


Combined approach through the meatus and mastoid but retaining the posterior bony meatal wall intact, thereby avoiding an open mastoid cavity. It gives dry ear and permits easy reconstruction of hearing mechanism.

Incidence of residual or recurrent cholesteatoma in these cases is very high and therefore longterm follow-up is essential.
In combined-approach or intact canal wall mastoidectomy, disease is removed both permeatally, and through cortical mastoidectomy and posterior tympanotomy approach.
(in which a window is created between the mastoid and middle ear, through the facial recess, to reach sinus tympani)

Difference between canal wall up and canal wall down

2. Reconstructive surgery
Hearing can be restored by myringoplasty or tympanoplasty.
It can be done at the time of primary surgery or as a second stage procedure.

3. Conservative treatment
Limited role. Repeated suction clearance and periodic check ups are essential. It can also be tried out in elderly patients above 65 and those who are unfit for general anaesthesia or those refusing surgery. Polyps and granulations can be cauterised by chemical agents like silver nitrate or trichloroacetic acid.

Otitis Media
ACUTE
Acute Viral Om
Acute Suppurative OM Acute Necrotizing OM Acute Allergic OM

CHRONIC
Specific

Non-specific

Tuberculous OM Syphilitic OM

Non-suppurative
Tubo-tympanic Attico-antral

Suppurative
OM with Effusion Chronic Adhesive OM

Chronic OM - Specific
Tuberculous OM Syphilitic OM

Tuberculous OM
1. Systemic antitubercular therapy as being carried for primary disease. (EHRZ) 2. Local treatment in the form of aural toilet, and control of secondary pyogenic infection. 3. Mastoid surgery indicated for complications. Healing is delayed in tuberculous cases. Wound break-down and fistula formation are common. Reconstructive surgery of middle ear is delayed till antitubercular therapy has been completed.

Syphilitic OM
Treatment consists of antisyphilitic therapy* with attention to aural toilet and control of secondary infection. Surgery may be required for removal of sequestra.

* Benzathine penicillin G 2.4 million units (IM) in a single dose.