6. Suppurative otitis media (acute, chronic)

From greek.doctor
  • 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