6. Suppurative otitis media (acute, chronic)

Acute (suppurative) otitis media
- Epidemiology
  - Infants
  - Small children
  - 80% by 3 years of age
- Etiology
  - Bacterial superinfection (on viral URTI) which ascends through eustachian tube
  - S. pneumoniae
  - H. influenzae
- Risk factors
  - Previous AOM
  - Chronic otitis media
  - Parental smoking
- Protective factors
  - Prolonged breastfeeding
  - Pneumococcal vaccine
- Clinical features
  - Ear pain
    - Infants repeatedly touch the ear
  - Fever
  - Discharge from ear
    - Only if there is spontaneous tympanic perforation
  - Conductive hearing loss
- Diagnosis
  - Early: Retracted, hypomobile tympanic membrane
  - Then: Bulging tympanic membrane
    - Due to accumulation of pus
  - Loss of light reflex
- Treatment
  - NSAIDs
  - Not decongestants! – prolong course
  - Antibiotics
    - Only in < 2 years, or > 2 years if bilateral, no resolution in 2 days
    - Amoxicillin
    - Clavulanic acid added if treatment failure
- Complications
  - Intratemporal complications
    - Mastoiditis
      - Children
      - Infection spread to mastoid -> collection of pus -> destruction of air cells -> empyema
      - Antibiotics
        Always!
        
        Vancomycin
      - Mastoidectomy in severe cases
    - Peripheral facial nerve palsy
    - Labyrinthitis
      - Inflammation of inner ear
      - Vertigo
      - Nystagmus
      - Sensorineural hearing loss
  - Intracranial complications
    - Meningitis
    - Otogenic abscess
      - Epidural, subdural or cerebral
      - Headache
    - Sinus thrombosis
  - Extracranial complications
    - Bezold abscess
      - Deep to sternocleidomastoid, pus from mastoiditis erodes through the mastoid part of the temporal bone

Chronic suppurative otitis media
- Persistent drainage from middle ear through perforated tympanic membrane lasting > 6 weeks
  - Perforated tympanic membrane usually heals within weeks
  - No healing -> sign of chronic inflammation
- Older children
- Bacteria enter through perforated TM
- Clinical features
  - 3 yes 1 no
  - Yes: Perforation of TM
  - Yes: Ear discharge
  - Yes: Conductive hearing loss
  - No: No pain
- Two types
  - Mesotympanic
    - Central perforation
    - Treatment: tympanoplasty
  - With cholesteatoma
    - Cholesteatoma: keratinizing squamous epithelium found in bony spaces, and the bone is destroyed by inflammatory osteoclastic process
      - In TM, auditory canal or mastoid
    - Can become infected
    - Marginal perforation
    - Brown irregular mass
    - Imaging to assess bone destruction
    - Treatment: surgery