Acute otitis media and mastoiditis

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Acute otitis media and mastoiditis

• Chunfu Dai M.D Ph.D
• Otolaryngology Department
• Fudan Univeristy

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Definition

• AOM is an infectious process of the middle ear
  cleft and to a variable extent, of the mastoid
  air cell system.

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Bacteriology

• Streptococcus pneumoniae (48)
• Haemophilus influenzae (31)
• Moraxella catarrhalis (20)
• P-hemolytic streptococcus (decreased following
  widespread immunization program)
• Pseudomonas aeruginosa (uncommon cause of AOM)

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50
Penicillin Resistance
40
33
???? (0.12 - 1.0 µg/ml) ?? (? 2.0 µg/ml)
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30
20
18
10
16
0
1979
1980
1981
1982
1983
1984
1985
1986
1987
1997
1998
1992-93
1988-89
1990-91
1994-95
(Doern. Am J Med. 199599(6B) 3S-7S Jacobs et
al., AAC 1999431901 Jacobs et al abstract
C-61, ICAAC 1999)
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Routine of infection

• Via eustachian tube
• upper respiratory infection (acute rhinonitis and
  nasal pharyngitis)
• Upper respiratory communicative disease (diaphea,
  mealse, et al)
• Swimming and dive in unclear water
• Anatomic contribution (Eustachian tube in infant
  is wide and short and the two orifice in the same
  level)

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Routine of infection

• Via external acoustic canal and TM
• Perforation
• Myringotomy or myrigotosis
• Via blood supply

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Pathology

• Mucosal inflammation
• Serous, hemorrhagic, or purulent exudate in
  middle cavity
• Rupture of tympanic membrane

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Symptoms

• Fever
• It may be masked by analgesics or antibiotic
• Otalgia
• 60 patients can spontaneous remission
• Fullness
• Hearing loss

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Physical findings

• Increased vascularization of the TM, initially
  located in pars of flaccida, frequently spreading
  beyond the annulus to the skin of the external
  canal.
• Bony landmarks are visible.

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Cholesteatoma Formation
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Physical findings

• Rapid middle ear exudation occurs,
• Blurring of the mallwall short process, followed
  by edema and bulging of the pars flaccida.

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Physical findings

• The progression of this disease may result in
  rupture of TM, releasing the middle ear contents
  (beating sign) leads to relief of otalgia and
  retraction of the pars flaccida

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Lab tests

• Blood counts usually shows leukocytosis with
  polymorphonuclear elevation.
• CT and MRI is necessary only for the rare
  patients with a serious complication (meningitis
  or brain abscess)

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Hearing tests

• Conductive hearing loss
• Degree of hearing loss will depend on the amount
  and viscosity of the middle ear exudate, TM edema
• It vary from 10-50 dB with predominant
  involvement of the low frequencies
• Hearing loss may mixed when there is labyrinthine
  extension.

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Managements

• Antibiotic therapy
• Experiences
• Antibiotic sensitivity and bacteriologic culture
• Traditional duration 10-14 d
• Currently duration 5-7 d

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Managements

• Nasal decongestants
• Best rest, light diet
• Avoidance of irritants (smoking)

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Managements

• Pre-perforation
• Pain relief drugs
• Surgery myringotomy
• Progression with a red, bulging TM, severe
  otalgia and fever
• Otitis media with impending complications
• perforation is not big enough to drain all pus

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Managements

• Post-proferation
• Clear-up pus with 3 hydro-oxygen
• Antibiotic ear drops
• With pus decreased and inflammation disappeared,
  alcohol can be used to facilitate dry ear.

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Follow-up

• Adequately treated AOM effusion may persist for
  2-6 weeks or even longer.
• Managements may require
• extended antibiotic treatment
• Otoscope and audiometric tests should be
  performed 3-4 weeks following apparent resolution
  of the acute infection
• Insertion of pressure equalization tubes due to
  fluid persists beyond 3 months

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Acute mastoiditis

• Definition an infection of the mastoid
  characterized by diffuse osteitis followed by
  rarefaction and breakdown of the bony septae.
• Acute coalescent mastoiditis
• Haemorrhagic mastoiditis
• Masked mastoiditis
• Predisposition to pneumatic mastoid
• Predilection to kid
• Mastoid is mature at age of 4 year old

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Acute mastoiditis

• Reduction of immune system
• Strong bacteria (type III pneumococus, haemolytic
  streptococcus)
• Obstruction- not effective drainage
• Imcompletely treatment

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Acute mastoiditis

• Symptoms
• Symptoms may follow AOM, with or without a
  symptom-free interval of a few days to several
  weeks or more.
• Otalgia
• Aural discharge
• Conductive hearing loss
• fever

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Acute mastoiditis

• Physical findings
• Fever, from a slight elevation to 39
• Otorrhea may be absent
• Pulsatile may be observed
• Tympanic perforation is present, but it may be
  obscured by intense edema
• Swelling of the superior TM and posterosuperior
  wall of EAC
• Postauricular area
• erythema and tenderness
• Pitting edema
• Obliteration of the postauricular crease

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Acute mastoiditis

• Radiographic evaluation
• Diffuse rarefaction of bone and breakdown of
  cellular sepae

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Acute mastoiditis

• interventions
• Medical management
• Antibiotic
• Intravenous antibiotic therapy should be
  maintained for at least 24-48 h after the
  resolution of symptoms
• Then followed with oral antibiotic for 2 weeks
• Surgical management
• Emergency surgery simple mastoidectomy
• Mastoidectomy ventilation tube placement

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