ACUTE SUPPURATIVE OTITIS MEDIA

Acute suppurative otitis media is a common infection affecting the mucosa of middle ear cleft and it may cause severe pain which often wakes up the patient at night.

AETIOLOGY

Age: It occurs at all ages more common in children. Because the Eustachian Tube is shorter, wider, more horizontal and opens at a lower level.

Sex: It affects both sex equally.

Portals for entry of infection:

v Eustachian tube: In majority of cases infection reaches via Eustachian tube due to the following causes,

§ Anatomical obstruction caused by adenoids and nasopharyngeal tumors.

§ Infection like adenoids, tonsillitis, rhinitis, sinusitis, pharyngitis, influenza and infections secondary to cleft palate.

§ Hygiene: Often forcible blowing of the nose pushes the infection in to the ear through the Eustachian tube.

§ Swimming: Water entering the nose under pressure may spread the nasal infection to the middle ear.

§ Iatrogenic: After post nasal packing and badly performed adenoidectomy.

§ Feeding Bottle: The use of feeding bottle for an infant in the supine position may allow contaminated milk to enter the Eustachian tube.

v External Ear: Trauma to the ear drum while cleaning the external ear canal or a slap on the ear may rupture the ear drum.

v Head injury: May affect the middle ear if there is a fracture of the temporal bone involving the middle ear.

v Blood Borne infection: Rarely reaches the middle ear.

Predisposing factors:

v Reduced vitality: If the vitality of the patient reduced, infection in the middle ear may be easily caused.

v Atmospheric Pressure Changes: May occur during flying and diving. Infection reaches the middle ear via Eustachian tubule.

CAUSATIVE ORGANISMS

Usually streptococcus heamolyticus, staphylococcus aureus, heamophilus influenza, pneumococcus and other respiratory tract organisms are responsible.

PATHOLOGY

Infection passes through five stages:

1. Catarrhal Stage (Stage of congestion) : Is characterized by occlusion of Eustachian tube and congestion in the middle ear

2. Stage of Exudation : Exudates collects in the middle ear and the drum is pushed laterally. Initially the exudates is mucoid, later it becomes purulent.

3. Stage of Suppuration : Pus in the middle ear collects under tension, stretches the drum, and perforates it by pressure necrosis and the exudates starts escaping in to the external auditory canal.

4. Stage of Healing : The infection clears up completely without leaving any sequelae.

5. Stage of complications : Infection may spread to the mastoid antrum through the aditus. Initally it causes catarrhal mastoiditis characterized by congestion of the mastoid mucosa. In the next stage of coalescent mastoiditis, granulations and edema block the aditus to andrum pus collects in the mastoid under tension leading to the break down of septa between the air cells and the air cells in the mastoid coalesce. The mastoid is thus converted in to a bag full of pus and granulations. This is also called empyema of the mastoid.

CLINICAL FEATURES

Usually acute otitis media follows an attack of upper respiratory tract infection.

In young children, the classical features may not be present, they may be just unwell and have fever.

Catarrhal Stage (Stage of congestion)

Due to blocking of the Eustachian tube, the oxygen in the middle ear cavity is absorbed and a negative pressure is created. This retracts the tympanic membrane, irritates the mucosa and causes congestion.

Symptoms:

Fullness in the ear, sever pain at night in the recumbent position, deafness, tinnitus, autophony, constitutional symptoms like fever and malaise.

Signs:

v Retraction : Initially the drum gets retracted.

v Congestion : Drum becomes congested and may present a cart wheel appearance because of dilated blood vessels. Later the drum becomes completely red.

v Light reflex : The light reflex is lost due to edema of the drum

Stage of Exudation

All symptoms become more severe. The drum starts bulging and become convex. The exudates exerts pressure on one spot of the drum, which may be the point of perforation later and the point appears like a yellow nipple.

Stage of Suppuration

At this stage the drum perforates and the pus stars flowing out. Pain and constitutional symptoms lessen at this stage with the escape of ear discharge. The discharge may be initially blood stained. Discharge can range from mucoid to frankly purulent. Perforation in drum usually in the antro-inferior quadrant.

Stage of Healing

Healing may begin from any stage

Stage of Complication

In the second week, the infection may spread to the mastoid, and other neighboring structures.

Investigations

Tests of Hearing : Tuning fork tests reveal conductive deafness. Audiometry also shows conductive deafness, if the patient is in a condition to undergo audiometry in the early stages conductive deafness is mild, but it becomes severe as the disease progresses.

Radiography : In the first three stages the radiographs of the mastoid show no change. Changes begin when infection invades the mastoid.

Bacteriological Examination of the ear Discharge for detection of the causative organism and its antibiotic sensitivity should be carried out.

Differential Diagnosis

Ø Acute otitis externa

Ø Herpetic lesions of the external ear.

Ø All the causes of pain in ear.

Ø Crying child: The ear drum becomes red but not edematous, if the child cries due to any reason. Hence the light reflex is present.

Treatment

1) Antibacterial therapy: It is indicated in all cases with fever and sever earache. Most common organisms are streptococcus pneumonia and H influenza. Antibacterial therapy must be continued for a minimum of ten days, till tympanic membrane regains normal appearance and hearing returns to normal.

2) Decongestant Nasal Drops: It should be used to relieve Eustachian tube edema and promote ventilation of middle ear.

3) Oral Nasal Decongestant: It may achieve the same result as decongestant nasal drops. Which are difficult to administer in children.

4) Analgesics and anti pyretics: Helps to relieve pain and bring down temperature.

5) Ear toilet: If there is discharge in the ear it is dry-mopped with sterile cotton buds.

6) Dry Local Heat: It helps to relieve pain.

7) Myringotomy: It is incising the drum to evacuate pus and is indicated when

i. Drum bulging and there is acute pain

ii. There is an incomplete resolution

iii. There is persistent effusion beyond twelve weeks

Therapeutics

Rubric: EAR – Inflammation,media

3 Mark : Calc C, Calc Sulph, Cham, Hep, Kali Bich, Lyco, Merc, Merc D, Puls, Sil, Sulph

2 Mark : Apis, Arn, Bar C, Bell, Bor, Caps, Cab V, Caust, Dulc, Ferr P, Kali C, Kali Chl, Kali I, Nat C, Nat M, Psor, Tell, Thuj

1 Mark : Cur, Gels, Hydr, Rhus T, Zinc

Calcarea carbonica

Otitis externa suppurative in scrofulous persons; dermoid layer of membrana tympani destroyed by ulceration and covered with exuberant granulations which may fill the meatus; polypus of ear; humming, roaring, buzzing in ears from abnormal pressure on the bones of the ear; pain in internal ears, first right then left, aggr. extreme heat or cold, blowing nose or coughing; muco-purulent otorrhoea, sometimes offensive; deafness from Eustachian catarrh; painful inflammatory swelling of parotids; corrosive nasal discharge, glandular swellings; fistulous ulcers. (Sil. follows well.)

Chamomilla

Lancinations, or tensive and drawing pains extending to lobe of ears; dry ears as if stopped up; great sensitiveness to noise, especially to music; excessive sensitiveness to pain; suspicious, ill-humored and easily angered; stitches in ear, especially when stooping; earache with toothache, the latter amel. by holding cold water in mouth, paroxysmal pains in ears, causing sudden screams; child sleeps with eyes only partly closed.

Hepar Sulph

Extreme sensitiveness to contact; dread of contact, cut of proportion to the actual pain; canal filled with white, cheesy, bloody pus, and surrounding skin scurfy and irritated; little pustules in the meatus and auricle, wherever the pus touched; haemorrhage from the slightest touch; relief from hot applications, cannot bear anything cold; cracking in ears when blowing nose; obstinate purulent and offensive discharge.

Kalium bichromicum

Otitis media; ulceration of membrana tympani; discharge of thick, yellow, foetid pus; itching deep in ear, with stinging pains; sharp stitching pains dart from the ear to throat; ulcers upon tympanum, which are dry but not painful, excepting the sharp stitches; naso-pharyngeal catarrh; ulceration of anterior nares, with a discharge of tough, ropy mucus; indolent ulcers; glands swollen, neck painful to touch, after scarlatina.

Lycopodium

Eczema of ears, with thick crusts and fissures in the skin; purulent ichorous otorrhoea, with impaired hearing; polypus of ears; sensation as if hot blood rushed into the ears: over sensitiveness of hearing, music and sounds affect hearing painfully; after scarlatina.

Mercurius solubilis

Otitis secondary to exanthemata, and in scrofulous and syphilitic patients; pains in ear, extending to face and teeth, worse by the heat of bed; excoriation and ulceration of meatus; sensitive to cold; abundant secretion or cerumen of flow of pus and blood; sweating, without relief, occurring from cold, when there are hypertrophied tonsils or diseased parotids; pulsative roaring in the affected part; ulceration of the membrana tympani, which bleeds from the slightest touch; constant cold sensation in the ears; ulceration of concha; fungous growth in meatus; swelling of parotid; deafness relieved by blowing the nose.

Mercurius dulcis

Otitis secondary to exanthemata, and in scrofulous and syphilitic patients; pains in ear, extending to face and teeth, worse by the heat of bed; excoriation and ulceration of meatus; sensitive to cold; abundant secretion or cerumen of flow of pus and blood; sweating, without relief, occurring from cold, when there are hypertrophied tonsils or diseased parotids; pulsative roaring in the affected part; ulceration of the membrana tympani, which bleeds from the slightest touch; constant cold sensation in the ears; ulceration of concha; fungous growth in meatus; swelling of parotid; deafness relieved by blowing the nose.

Pulsatilla pratensis

Otitis externa; heat, redness, lancinating pains and sensation as if something were crawling out of the ear; remissions followed by exacerbations of intense pain, noises and buzzing in ears; sensation of a plug in ear and defective hearing; otorrhoea, with redness and pain, pressure through ear, with free formation of crusts in meatus; otalgia, with darting tearing pains and pulsating at night, with bland, nearly inoffensive, greenish discharge of mucus and pus; better out-doors and during day; scabs on tragus; otorrhoea alternating with difficult hearing; after measles.

Silicea

Caries of mastoid cells; offensive, watery, curdy otorrhoea, with soreness of inner nose and crusts on upper lip; itching in Eustachian tube and in ears; the child bores into its ears when asleep, causing a discharge of blood and pus; sudden stopped feeling in ears, passing off when yawning or swallowing; ulceration of the tympanum, with itching and sharp stinging pains; the child seems to enjoy having the ears cleansed with the cotton probe; sounds in ears like the ringing of bells; otalgia from within outward; slow painless swelling and suppuration of parotid.

Sulphur

Much itching in ears, changing to pain when attempting to scratch them; dirty, offensive, sometimes sour-smelling pus flowing from ears; children averse to having them washed; wabbling as if water were in the ears; acrid, burning, offensive discharge, with excessive burning after syringing ears, aggr. left ear.