Acute Suppurative Otitis Media

(ASOM)

Dr. Krishna Koirala

Definition Pyogenic infection of middle ear

cleft lasting for < 3 weeks Routes for infection

Via Eustachian tubeVia Eustachian tube Via Tympanic membrane perforationVia Tympanic membrane perforation Hematogenous (rare)Hematogenous (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. Cleft palate

Bacteriology

1. Haemophilus influenzae

2. Streptococcus pneumoniae

3. Staphylococcus aureus

4. Moraxella catarrhalis

5. Beta hemolytic Streptococci (causative

agent in acute necrotizing otitis media)

Stages of ASOM

1) Stage of Hyperemia/Tubal occlusion Mild earacheMild earache

T.M. retracted initially and congested T.M. retracted initially and congested

later later

Cartwheel appearance: Cartwheel appearance: blood vessels blood vessels

radiating out from handle of malleusradiating out from handle of malleus

Cart wheel appearance

2) Stage of Exudation High fever High fever Severe earache Severe earache DeafnessDeafness Marked congestion and bulging of T.M.Marked congestion and bulging of T.M. Mastoid tenderness Mastoid tenderness P.T.A. : high frequency conductive P.T.A. : high frequency conductive

deafness deafness

due to due to mass effectmass effect of pus of pus

Stage of Exudation

3) Stage of Suppuration

Ear discharge Ear discharge

Increased deafnessIncreased deafness

Decreased fever Decreased fever

Decreased earacheDecreased earache

Otoscopy

Pinhole perforation of pars tensa + otorrhea Pinhole perforation of pars tensa + otorrhea

Light house sign: Light house sign: intermittent reflection of intermittent reflection of

light light

Decreased mastoid tenderness

High (mass effect) + low frequency (stiffness

effect ) Conductive deafness

Clouding of air cells in mastoid X-ray

Light House sign

Clouding of mastoid air cells

4) Stage of Coalescent Mastoiditis Otorrhea > 2 weeks, otalgia & deafness Mastoid reservoir sign : pus fills up on

mopping Sagging of postero-superior canal wall

due to peri-osteitis Ironed out appearance of skin over the

mastoid due to thickened periosteum Mastoid cavity in X-ray

5) Stage of Resolution

Ear discharge stopsEar discharge stops

Hearing improvesHearing improves

perforation starts healing upperforation starts healing up

6) Stage of Complications Sub-periosteal abscess Vertigo Headache + blurred vision +

projectile vomiting Fever + neck rigidity + irritability Drowsiness Paralysis of Cranial nerve(s)

Treatment of ASOM1. Antibiotic (Co-amoxyclav, Cefuroxime)

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

Review after 48 hours Earache + fever persists:

Change to higher antibioticChange to higher antibiotic

If T.M. is bulging If T.M. is bulging perform myringotomy perform myringotomy

and send ear discharge for C/Sand send ear discharge for C/S

Earache + fever subside:

Continue same treatment for 10-14 daysContinue same treatment for 10-14 days

Review after 3 months No effusion

No further treatmentNo further treatment Effusion persists

Treat as Otitis Media with Effusion (OME)Treat as Otitis Media with Effusion (OME) Presence of abscess or coalescent

mastoiditis Cortical mastoidectomyCortical mastoidectomy

Myringotomy in A.S.O.M. Curvilinear incision made

in postero-inferior

quadrant

Incision is curvilinear &

not radial (as in OME), to

cut the fibres of TM (to

keep the opening patent

for longer duration)

Why incision in PIQ? Less vascular area

T.M. bulge is

maximum

Ossicles not

damaged

Easily accessible

Sub-periosteal abscess & fistula

Pathology

Production of pus under tension

hyperemic decalcification (halisteresis)

+ osteoclastic resorption of bone sub-

periosteal abscess penetration into

periosteum + skin fistula formation

Sub-periosteal abscess formation

Sub-periosteal fistula: discharging

Sub-periosteal fistula: dry

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 forwards & downwards

Bezold’s & Citelli’s abscesses

Bezold: neck swelling

over sternocleido-

mastoid muscle

Citelli: neck swelling

over posterior belly of

digastric muscle

Bezold’s abscess

Luc: swelling in external auditory canal Zygomatic: swelling antero-superior to

pinna + upper eyelid edema Retro-mastoid: swelling over occipital

bone Parapharyngeal & Retropharyngeal: due

to spread of pus along the Eustachian tube

Gradenigo’s Syndrome

Giuseppe Gradenigo (1859 – 1926)

Defining Triad Persistent otorrhea despite adequate

cortical mastoidectomy

Retro-orbital pain due to trigeminal

nerve involvement

Diplopia: convergent squint due to lateral

rectus palsy by injury to Abducent nerve

in Dorello’s canal at the petrous apex

Etiology :Coalescent mastoiditis involving petrous apex along postero-superior & antero-inferior tracts in relation to bony labyrinth

Diagnosis: C.T. scan temporal bone for bony detailsC.T. scan temporal bone for bony details MRI to differentiate b/w bone marrow & MRI to differentiate b/w bone marrow &

puspus Treatment: Modified radical mastoidectomy

& clearance of petrous apex cells

Cortical Mastoidectomy

Antiseptic dressing

Draping

Infiltration

Marking of incision

Wilde’s post-aural incision

Incision deepened

Musculoperiosteal flap elevated

Cortical mastoidectomy begun

Exposure of mastoid antrum

Widening of aditus

Aditus widened

Final Cavity

Drain put in mastoid cavity

Mastoid dressing