Acute suppurative otitis media - Clinicals, Diagnosis, and Management

Otorhinolaryngology

Clinicals - History

Fact Explanation
Otalgia( ear pain) first 3 weeks of a process which includes rapid onset of symptoms, middle ear effusion, and signs and symptoms of middle ear inflammation is the diagnostic criteria for acute otitis media. Acute suppurative otitis media is distinguished from secretory (serous) otitis media by the presence of purulent fluid in the middle ear.
acute otitis media is a common indication for medical attention specially the children younger than 5 years. Around 60% to 85% of children have AOM during the first year of life.
acute onset pain in the ear is the most common symptom. pain is a result of inflammatory reaction
Otalgia( ear pain)
first 3 weeks of a process which includes rapid onset of symptoms, middle ear effusion, and signs and symptoms of middle ear inflammation is the diagnostic criteria for acute otitis media. Acute suppurative otitis media is distinguished from secretory (serous) otitis media by the presence of purulent fluid in the middle ear.
acute otitis media is a common indication for medical attention specially the children younger than 5 years. Around 60% to 85% of children have AOM during the first year of life.
acute onset pain in the ear is the most common symptom. pain is a result of inflammatory reaction
Fever persistent or intermittent fever associated with ear pain is suggestive of acute otitis media Fever
persistent or intermittent fever associated with ear pain is suggestive of acute otitis media
symptoms of URTI allergy or upper respiratory tract infection causes congestion and swelling of the nasal mucosa, nasopharynx, and eustachian tube. Obstruction at the eustachian tube isthmus (i.e., the narrowest portion) results in accumulation of middle ear secretions; secondary bacterial or viral infection of the effusion causes suppuration and features of acute otitis media symptoms of URTI
allergy or upper respiratory tract infection causes congestion and swelling of the nasal mucosa, nasopharynx, and eustachian tube. Obstruction at the eustachian tube isthmus (i.e., the narrowest portion) results in accumulation of middle ear secretions; secondary bacterial or viral infection of the effusion causes suppuration and features of acute otitis media
loss of hearing Hearing loss is a constant feature of older children and adults. Conductive type of hearing loss is commonly seen in recurrent acute otitis media due to effusion of the middle ear. otitis media with effusion may occur spontaneously as a result of eustachian tube dysfunction or as an inflammatory response after acute infection loss of hearing
Hearing loss is a constant feature of older children and adults. Conductive type of hearing loss is commonly seen in recurrent acute otitis media due to effusion of the middle ear. otitis media with effusion may occur spontaneously as a result of eustachian tube dysfunction or as an inflammatory response after acute infection
Fullness of the ear adults and older children presents with ear fullness during suppurative otitis media . ear pressure or clogging sensation of the ear both are suggestive of aural fullness, otitis media due to effusion is the major diagnosis Fullness of the ear
adults and older children presents with ear fullness during suppurative otitis media . ear pressure or clogging sensation of the ear both are suggestive of aural fullness, otitis media due to effusion is the major diagnosis
Ear tugging ear tugging or rubbing in younger children is indicative of pain in the ear. Otalgia (i.e., ear pain) is the most prevalent and important symptom of AOM Ear tugging
ear tugging or rubbing in younger children is indicative of pain in the ear. Otalgia (i.e., ear pain) is the most prevalent and important symptom of AOM
Irritability In neonates , irritability , excessive crying , feeding difficulty may the only signs of acute infection leading to a difficult diagnosis Irritability
In neonates , irritability , excessive crying , feeding difficulty may the only signs of acute infection leading to a difficult diagnosis
Complications-Intracranial- symptoms of meningism(headache, neck stiffness, fever) , symptoms of raised intra cranial pressure , altered behaviour Intra cranial extension of acute infection results in complications such as Meningitis, encephalitis, brain abscess, otitis hydrocephalus etc Complications-Intracranial- symptoms of meningism(headache, neck stiffness, fever) , symptoms of raised intra cranial pressure , altered behaviour
Intra cranial extension of acute infection results in complications such as Meningitis, encephalitis, brain abscess, otitis hydrocephalus etc
Complications-intra temporal facial nerve palsy, Intra temporal extension of acute infection very well known for complications including facial nerve palsy, acute coalescent mastoiditis, acute labyrinthitis, acute necrotic otitis, petrositis, or development of chronic otitis media Complications-intra temporal facial nerve palsy,
Intra temporal extension of acute infection very well known for complications including facial nerve palsy, acute coalescent mastoiditis, acute labyrinthitis, acute necrotic otitis, petrositis, or development of chronic otitis media
Complications- systemic- symptoms of sepsis bacteremia and sepsis are rare but serious complication of acute otitis media, vague and inconclusive systemic signs such as fever, lethargy etc will mask the symptoms of acute middle ear infection. Complications- systemic- symptoms of sepsis
bacteremia and sepsis are rare but serious complication of acute otitis media, vague and inconclusive systemic signs such as fever, lethargy etc will mask the symptoms of acute middle ear infection.

Clinicals - Examination

Fact Explanation
Pneumataic otoscopy- signs of middle ear effusion -colour change in the tympanic membrane It clearly demonstrate the signs of inflammation. it might be in red, grey or yelow Pneumataic otoscopy- signs of middle ear effusion -colour change in the tympanic membrane
It clearly demonstrate the signs of inflammation. it might be in red, grey or yelow
Pneumatic otoscopy- bulging of the ear drum this is a sign of middle ear effusion, commonly seen in suppurative otitis media, the bulge may be in the posterior quadrants, with the epithelial layer exhibiting a scalded appearance Pneumatic otoscopy- bulging of the ear drum
this is a sign of middle ear effusion, commonly seen in suppurative otitis media, the bulge may be in the posterior quadrants, with the epithelial layer exhibiting a scalded appearance
Pneumatic otoscopy-Perforation of tympanic membrane spontaneous perforation of the ear drum in acute otitis media is commonly seen among children Acute suppurative otitis media or otitis media with effusion are common with persistent tympanic membrane perforation Pneumatic otoscopy-Perforation of tympanic membrane
spontaneous perforation of the ear drum in acute otitis media is commonly seen among children Acute suppurative otitis media or otitis media with effusion are common with persistent tympanic membrane perforation
Pneumatic otoscopy- signs of middle ear effusion(presence of purulent fluid in the middle ear)-reduction of TM mobility this is either due to effusion or inflammation . studies have there is a TM mobility difference between the AOM and OME ears which is mainly caused by the middle ear ossicular structure changes during the bacterial infection in AOM.TM mobility in AOM ears was lower than OME ears at low frequencies Pneumatic otoscopy- signs of middle ear effusion(presence of purulent fluid in the middle ear)-reduction of TM mobility
this is either due to effusion or inflammation . studies have there is a TM mobility difference between the AOM and OME ears which is mainly caused by the middle ear ossicular structure changes during the bacterial infection in AOM.TM mobility in AOM ears was lower than OME ears at low frequencies
Pneumatic otoscopy- signs of middle ear effusion-Loss of the bony landmarks behind the tympanic membrane this is a feature of middle ear effusion (presence of purulent fluid in the middle ear) Pneumatic otoscopy- signs of middle ear effusion-Loss of the bony landmarks behind the tympanic membrane
this is a feature of middle ear effusion (presence of purulent fluid in the middle ear)
Pneumatic otoscopy- signs of middle ear effusion- A visible air fluid level behind the tympanic membrane this is a feature of middle ear effusion(presence of purulent fluid in the middle ear) Pneumatic otoscopy- signs of middle ear effusion- A visible air fluid level behind the tympanic membrane
this is a feature of middle ear effusion(presence of purulent fluid in the middle ear)

Investigations - Diagnosis

Fact Explanation
Tympanometry provides useful information about the presence of fluid in the middle ear, mobility of the middle ear system, and ear canal volume, pneumatic otoscopy with tympanometry is very useful in diagnosis of acute suppurative otitis media. Acute otitis media (AOM) is defined as the presence of middle ear effusion in conjunction with the recent, abrupt onset of one or more signs or symptoms of inflammation of the middle ear Tympanometry
provides useful information about the presence of fluid in the middle ear, mobility of the middle ear system, and ear canal volume, pneumatic otoscopy with tympanometry is very useful in diagnosis of acute suppurative otitis media. Acute otitis media (AOM) is defined as the presence of middle ear effusion in conjunction with the recent, abrupt onset of one or more signs or symptoms of inflammation of the middle ear
Tympanocentesis and culture Involves aspiration the middle ear cleft contents by piercing the membrane with a needle and collecting them for diagnostic examination. either from tympanocentesis or specimen from fresh perforation is cultured for organisms like typical aerobic bacteria, such as Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis or Streptococcus pyogenes, may be helpful. Tympanocentesis and culture
Involves aspiration the middle ear cleft contents by piercing the membrane with a needle and collecting them for diagnostic examination. either from tympanocentesis or specimen from fresh perforation is cultured for organisms like typical aerobic bacteria, such as Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis or Streptococcus pyogenes, may be helpful.
Acoustic reflectometry this investigation detects middle ear fluid by analyzing the spectral gradient of sound reflected off the tympanic membrane.this is generally easy test to perform and has a high success rate even among crying and struggling children. Acoustic reflectometry
this investigation detects middle ear fluid by analyzing the spectral gradient of sound reflected off the tympanic membrane.this is generally easy test to perform and has a high success rate even among crying and struggling children.
Inflammatory markers inflammatory markers such as ESR , CRP will be elevated in the situation, much higher values can be identified when the AOM is complicated with sepsis Inflammatory markers
inflammatory markers such as ESR , CRP will be elevated in the situation, much higher values can be identified when the AOM is complicated with sepsis
maging studies: CT scan or MRI Usually for the detection of complications but some situations it can be used for exclusion of trauma maging studies: CT scan or MRI
Usually for the detection of complications but some situations it can be used for exclusion of trauma

Investigations - Management

Fact Explanation
Imaging studies: CT scan or MRI this investigations are usually not recommended, only in suspected cases of complications like intra-cranial extension of an infection or mastoid abscess. Imaging studies: CT scan or MRI
this investigations are usually not recommended, only in suspected cases of complications like intra-cranial extension of an infection or mastoid abscess.

Management - Supportive

Fact Explanation
Antihistamines this may help with nasal congestion, but may prolongs the duration of middle ear efusion Antihistamines
this may help with nasal congestion, but may prolongs the duration of middle ear efusion
Nasal decongestant this is used to relieve nasal congestion. but does not improve healing or minimize complications of acute otitis media, Nasal decongestant
this is used to relieve nasal congestion. but does not improve healing or minimize complications of acute otitis media,
Analgesics : NAIDS studies have found that are more effective in relieving pain than paracetamol Analgesics : NAIDS
studies have found that are more effective in relieving pain than paracetamol
Antipyretics effective in patients presents with fever Antipyretics
effective in patients presents with fever
Patient education Is very crucial in management AOM is self curing disease and Either a bacterial infection or a viral infection of the ear can cause AOM.
the tendency of recurrence, risk factors , possible complications and importance of treatment and follow up
Patient education
Is very crucial in management AOM is self curing disease and Either a bacterial infection or a viral infection of the ear can cause AOM.
the tendency of recurrence, risk factors , possible complications and importance of treatment and follow up
Preventive measures 1. Day care, smoke, pacifier use- Exposure to day care, pacifier use, and tobacco smoke significantly increase the risk of AOM, OME and symptoms of upper respiratory infection. 2. Hand washing can be helpful in limiting spread.
3. Immunizations. The conjugated pneumococcal vaccine, reduces the risk of ear infections slightly. Children with recurrent ear
infections should probably get an annual influenza vaccine.
3. Xylitol. -containing chewing gum significantly decreases the risk of
recurrent ear infections. However, the use of such gum should be balanced by the risk of choking, especially in younger children, and
children should not be allowed to chew gum when physically active.
4. Ear infections are not generally contagious, and children with isolated AOM can return to school whether or not they are receiving antibiotics.
Preventive measures
1. Day care, smoke, pacifier use- Exposure to day care, pacifier use, and tobacco smoke significantly increase the risk of AOM, OME and symptoms of upper respiratory infection. 2. Hand washing can be helpful in limiting spread.
3. Immunizations. The conjugated pneumococcal vaccine, reduces the risk of ear infections slightly. Children with recurrent ear
infections should probably get an annual influenza vaccine.
3. Xylitol. -containing chewing gum significantly decreases the risk of
recurrent ear infections. However, the use of such gum should be balanced by the risk of choking, especially in younger children, and
children should not be allowed to chew gum when physically active.
4. Ear infections are not generally contagious, and children with isolated AOM can return to school whether or not they are receiving antibiotics.

Management - Specific

Fact Explanation
Antibiotics Antibiotics improving patient outcomes in early and late phases of AOM has been demonstrated in studies. current guidelines suggest that antibiotics should be used in children aged over 6 months when unilateral or bilateral when the condition is severe. Uncomplicated AOM in patients older than 2 years treated with a 5-7 day course of antimicrobials
High-dosage amoxicillin which has excellent middle ear penetration is recommended as first-line antibiotic therapy in children with AOM. (80-90 mg per kg per day, for 10 days in divided doses)
Cephalosporin or macrolides can be used as secondary drugs if there is allergy.
early use of antimicrobials have proven to reduce serious complications of AOM, such as mastoiditis, meningitis and intracranial abscesses
Symptoms should improve within one to two days and resolve within two to three days of starting antimicrobials if not change of the antimicrobial agent should be considered,
Combination therapy may help in preventing the emergence of resistance by means of mutation, provided that the pathogen is initially sensitive to both of the components in combination therapy
Antibiotics
Antibiotics improving patient outcomes in early and late phases of AOM has been demonstrated in studies. current guidelines suggest that antibiotics should be used in children aged over 6 months when unilateral or bilateral when the condition is severe. Uncomplicated AOM in patients older than 2 years treated with a 5-7 day course of antimicrobials
High-dosage amoxicillin which has excellent middle ear penetration is recommended as first-line antibiotic therapy in children with AOM. (80-90 mg per kg per day, for 10 days in divided doses)
Cephalosporin or macrolides can be used as secondary drugs if there is allergy.
early use of antimicrobials have proven to reduce serious complications of AOM, such as mastoiditis, meningitis and intracranial abscesses
Symptoms should improve within one to two days and resolve within two to three days of starting antimicrobials if not change of the antimicrobial agent should be considered,
Combination therapy may help in preventing the emergence of resistance by means of mutation, provided that the pathogen is initially sensitive to both of the components in combination therapy
Surgical management-Tympanocentesis Tympanocentesis, , is primarily a diagnostic procedure and can also be a therapeutic one. tympanocentesis and associated antimicrobial therapy has provrn to reduce the recurrence as well as the need for tympanostomy tube surgery
Specially considered in suppressed or those who failed to respond for an appropriate antibiotic treatment.
Surgical management-Tympanocentesis
Tympanocentesis, , is primarily a diagnostic procedure and can also be a therapeutic one. tympanocentesis and associated antimicrobial therapy has provrn to reduce the recurrence as well as the need for tympanostomy tube surgery
Specially considered in suppressed or those who failed to respond for an appropriate antibiotic treatment.
Surgical management-tympanostomy tubes Ventilation/drainage of the ear cleft for an extended period is beneficial in some patients especially those with complications and recurrent acute attacks. Surgical intervention is more considered with
increasing antimicrobial resistance.
otorrhea is a frequent sequela.complication of surgical interventions are as followed
Injury to the skin of the ear canal and ossicular chain are the immediate complications where
Persistent otorrhea, implantation cholesteatoma, external otitis from persistent drainage consist of intermediate ones
Long-term complications include Persistent perforation of the membrane with or without otorrhea and ear canal stenosis
Surgical management-tympanostomy tubes
Ventilation/drainage of the ear cleft for an extended period is beneficial in some patients especially those with complications and recurrent acute attacks. Surgical intervention is more considered with
increasing antimicrobial resistance.
otorrhea is a frequent sequela.complication of surgical interventions are as followed
Injury to the skin of the ear canal and ossicular chain are the immediate complications where
Persistent otorrhea, implantation cholesteatoma, external otitis from persistent drainage consist of intermediate ones
Long-term complications include Persistent perforation of the membrane with or without otorrhea and ear canal stenosis

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