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Acute suppurative otitis media and mastoiditis

Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal, for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology. <br>A clear and concise explanation of the basic concepts in the subject matter concerned. <br>He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students

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Acute suppurative otitis media and mastoiditis

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  1. Acute Suppurative Otitis Media (ASOM) Dr. Krishna Koirala

  2. Defined as pyogenic infection of middle ear cleft lasting for < 3 weeks • Routes for infection • Via Eustachian tube • Via Tympanic membrane perforation • Hematogenous (rare)

  3. 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

  4. Bacteriology • Haemophilus influenzae • Streptococcus pneumoniae • Staphylococcus aureus • Moraxella catarrhalis • Beta hemolytic Streptococci (causative agent in acute necrotizing otitis media)

  5. Stages of ASOM 1. Stage of hyperemia (tubal occlusion) • Mild earache • T.M. retracted initially and congested later • Blood vessels radiating out from handle of malleus (cartwheel appearance) Cartwheel

  6. 2. Stage of Exudation • High fever, severe earache, deafness • Marked congestion and bulging of T.M. • Mastoid tenderness • P.T.A. : high frequency conductive deafness (due to mass effect of pus)

  7. 3. Stage of Suppuration • Increased deafness, ear discharge • Mastoid tenderness + • Fever and earache decrease • Otoscopy : • Bulged, congested tympanic membrane with a yellow spot (nipple sign) • Pulsatile discharge through small TM perforation (Lighthouse sign)

  8. Clouding of mastoid air cells

  9. 4. Stage of Coalescent Mastoiditis • Otorrhea > 2 weeks, otalgia and deafness • Mastoid reservoir sign : pus immediately fills the EAC after mopping • Sagging of Postero-superior bony canal wall due to peri-osteitis of mastoid floor • Ironed out appearance of skin over the mastoid due to thickened periosteum • Mastoid cavity in X-ray due to hyperemic decalcification

  10. 5. Stage of Resolution • Ear discharge stops • Hearing improves • Perforation starts healing up

  11. 6. Stage of Complications • Sub-periosteal abscess • Vertigo • Headache + blurred vision + projectile vomiting • Fever + neck rigidity + irritability • Drowsiness • Paralysis of cranial nerve(s)

  12. Treatment of ASOM • Antibiotic (Co-amoxyclav, Cefuroxime) • Nasal decongestants (systemic + topical) • H1 anti-histamines • Analgesic + anti-pyretic • Aural toilet for ear discharge • Heat application for severe earache

  13. Review after 48 hours • Earache + fever persists: • Change to higher antibiotic • If T.M. is bulging  perform myringotomy and send ear discharge for C/S • Earache + fever subside: • Continue same treatment for 10-14 days

  14. Review after 3 months • No effusion • No further treatment • Effusion persists • Treat as Otitis Media with Effusion (OME) • Presence of abscess or coalescent mastoiditis • Cortical mastoidectomy

  15. 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)

  16. Why incision in PIQ? • Less vascular area • T.M. bulge is maximum • Ossicles not damaged • Easily accessible

  17. Sub-periosteal abscess & fistula

  18. Pathology Production of pus under tension  hyperemic decalcification (halisteresis) + osteoclastic resorption of bone  breakage of septa and formation of mastoid cavity  sub-periosteal abscess  penetration into periosteum + skin  mastoid fistula formation

  19. Sub-periosteal abscess formation

  20. Discharging mastoid fistula

  21. Mastoid fistula: dry

  22. Abscesses related to mastoid • Post-auricular • Bezold • Citelli • Zygomatic • Luc • Retro-mastoid • Parapharyngeal & Retropharyngeal

  23. Abscesses related to mastoid

  24. Post-auricular abscess • Commonest • Present behind the ear • Pinna pushed forwards & downwards

  25. Bezold’s & Citelli’s abscesses Bezold:neck swelling over sternocleido- mastoid muscle Citelli:neck swelling over posterior belly of digastric muscle

  26. Bezold’s abscess

  27. 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

  28. Gradenigo’s Syndrome Giuseppe Gradenigo (1859 – 1926)

  29. 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

  30. 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 details • MRI to differentiate b/w bone marrow & pus • Treatment:Modified radical mastoidectomy & clearance of petrous apex cells

  31. Cortical Mastoidectomy

  32. Antiseptic dressing

  33. Draping

  34. Infiltration

  35. Marking of incision

  36. Wilde’s post-aural incision

  37. Incision deepened

  38. Musculoperiosteal flap elevated

  39. Cortical mastoidectomy begun

  40. Exposure of mastoid antrum

  41. Widening of aditus

  42. Aditus widened

  43. Final Cavity

  44. Drain put in mastoid cavity

  45. Mastoid dressing

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