Acute Otitis Media (AOM) - Presentation PDF

ACUTE OTITIS MEDIA Dr.Abdallah ORL  Outline Introduction Epidemiology Etiology Risk factors Clinical features Investigations Management Complications Prevention October 23, 2024 2  Case 1 A 3-year-old girl is brought to your...

ACUTE OTITIS MEDIA Dr.Abdallah ORL  Outline Introduction Epidemiology Etiology Risk factors Clinical features Investigations Management Complications Prevention October 23, 2024 2  Case 1 A 3-year-old girl is brought to your The only abnormalities on office by her mother because she has otoscopic examination were a fever, and complains that her ear hyperemic bulging tympanic hurts. The child is not pleased to be membranes. in the physician's office and has been What is the most likely diagnosis? crying. Her mother explains that she developed a “cold” about 3 days ago with sniffles. Her temperature is 37.8°C (100°F), and the rest of the physical examination is completed with some difficulty.  Case 2 A 7-year-old girl is brought to your The only abnormalities on otoscopic office by her mother because she has examination were air bubbles behind aural fullness and reduced hearing the translucent tympanic membrane from both ears. She denies history of What is the most likely diagnosis? ear pain and fever and complains that her ear hurts. Her mother explains that she developed a “cold” about 10 days ago. Her temperature is 37.1°C , and the rest of the general examination is normal. Introduction Acute Otitis Media (AOM ) represents the rapid onset of an inflammatory process of the middle ear space ie. inflammation of the mucous membrane lining the middle ear cleft without reference to cause or pathogenesis. It is the second most common illness in childhood after URTI. By convention it is termed as acute if the infection is less than three weeks in duration October 23, 2024 5  ANATOMY OT THE MIDDLE EAR The middle ear cleft consists of: Tympanic cavity Eustachian tube Mastoid air cell system EUSTACHIAN TUBE EPIDEMIOLOGY Acute otitis media (AOM) occurs much more commonly in children than in adults, second after URTI Boys are more affected than girls Peak incidence of AOM occur in the first 6 to 12months. Approximately 80% of all children will experience at least one episode of AOM in their lifetime. The incidence of AOM decline significantly after age of 7yrs. RISK FACTORS The main risk factors are: Host factors Environmental factors Anatomical/Physiological RISK FACTORS Age- common in children Allergy Gender-slightly common in males. Immunocompromised Race-less in European descent Cleft palate and craniofacial abnormalities Prematurity Genetic predisposition RISK FACTOR… Seasonality-during rainy Tobacco smoke exposure Day care-overcrowded Poor socioeconomic status Siblings Pacifier use Lack proper breastfeeding  AETIOLOGY Bacterial Streptococcus pneumoniae - 30-35% Haemophilus influenzae -20-25% Moraxella catarrhalis- 10-15% Streptococcus pyogens-3% Staphylococcus aureus-1% Gram negative bacilli (higher incidence in Infants) October 23, 2024 13 ROUTES OF INFECTION The three main routes of infections to the middle ear are via: Eustachian tube External auditory canal Blood borne 1. The Eustachian tube… In children and infants the ET is the common route of infection because; A) It is shorter, wider, more horizontal and less stiff B) Large adenoids that interfere with the opening of the tube C) Immune system not fully developed  ROUTES… 2. External Acoustic Meatus This is associated with tympanic membrane perforation secondary to; Infections, TM trauma, Tympanostomy tubes & myringotomy. 3. Blood; Uncommon route PATHOGENESIS STAGES; 1.Stage of tubal occlusion 2.Stage of pre suppuration 3.stage of suppuration 4.Stage resolution & complications Normal TM Vascularised TM October 23, 2024 18  Stage of tubal occlusion The edema and hyperemia of nasopharynx and Eustachian tube can occludes ET, which leads to absorption of air and creation of negative middle ear pressure. Symptoms; TM retraction cause ear fullness, tinnitus, hearing loss, earache. Signs; short handle of malleus, loss of cone reflex, prominent lateral process of malleus, conductive deafness in tuning fork test.  Stage of pre suppuration Prolonged tubal occlusion facilitates invasion of pyogenic organisms into middle ear and results in mucosal hyperemia. Inflammatory exudates appear in the middle ear Symptoms ;throbbing ear pain, bubbling sound in the ear, tinnitus, Signs; high fever, cartwheel appearance of the TM, Tuning fork tests show conductive hearing loss  Stage of suppuration This is marked by formation of pus in the middle ear and to some extent in mastoid air cells. Tympanic membrane starts bulging Symptoms; high grade fever, excruciating ear pain, deafness, X-ray of mastoid show clouding of air cells due to exudate.  Stage of resolution The TM ruptures (due to pressure necrosis) and results in otorrhea and subsidence of other symptoms. Inflammatory process begins resolving with ear pain and fever subsidence Stage Of complications; I. Intratemporal II. intracranial PATHOGENESIS  CLINICAL PRESENTATION Signs and symptoms ❖ Neonates: Irritability or feeding difficulties may be the only indication of a septic focus ❖ Older children: Fever and otalgia or ear tugging ❖ Reduced hearing ❖ Signs of conjunctivitis : tearing, itchiness of eyes October 23, 2024 24 ❖ Older children and adults: Hearing loss becomes a constant feature of AOM and otitis media with effusion (OME); ear stuffiness is noted before the detection of middle ear fluid ❖ Otalgia without hearing loss or fever is observed in adults with acute otitis media, dental abscess, or pain referred from the temporomandibular joint. Orthodontic appliances often elicit referred pain as the dental occlusion is altered.  Diagnosis TM examination is key. Pneumatic otoscopy is the standard of care in the diagnosis of acute and chronic otitis media. The following findings may be found on examination in patients with AOM: Signs of inflammation in the tympanic membrane Four key features based on TM; I. Colour– red TM II. Position---displaced TM and bulging III. Transluency---opaque IV. Mobility --- immobile TM. October 23, 2024 26 Pneumatic otoscopy  INVESTIGATIONS: Testing in the acute phase is generally unhelpful, because all children with AOM have conductive hearing loss associated with the middle ear effusion. In addition, although tympanometry may assist in the diagnosis of middle ear effusion, this test is seldom necessary for the skilled pneumatic otoscopist. Tympanocentesis for M/C/S: Culture and sensitivity of a specimen from a fresh perforation or a tympanocentesis may be helpful.  Imaging Radiological procedures may be unnecessary in uncomplicated AOM. But Ct scan can help to rule out any complications. MRI is useful when intracranial complications are suspected X-ray temporal bone- shows clouding of air cells with destruction of the intercellular partitions CT scan temporal bone-spaces in bone that in general contain air) in the mastoid process are full of fluid  Differential diagnosis Otitis media with effusion Presence of middle ear fluid without acute signs of bacterial infections Symptoms temporary conductive hearing loss and a sense of aural fullness Otoscopy; visible fluid or viscous bubbles behind an intact tympanic membrane. Normal or retracted tympanic membrane Differential diagnosis…… Chronic suppurative otitis media chronic purulent drainage through the perforated tympanic membrane. TREATMENTS OF AOM There are two modalities; medical and surgical therapies MEDICAL Antibiotics Decongestants/ Antihistamines Steroids  PHARMACOTHERAPY Antibiotics used for AOM : Penicillins (amoxillin and augumentin) Penicillins (amoxillin and augumentin) Cephalosporin eg cefuroxime Macrolides eg azithromycin October 23, 2024 33  SURGICAL THERAPIES Surgical management of AOM can be: Tympanocentesis Myringotomy +/- grommet Adenoidectomy with and without Tonsillectomy October 23, 2024 34 Myringotomy with ventilation tube  Adenoidectomy The rationale for removal of the adenoids in children with otitis media is that the enlargement of the adenoids may cause obstruction of the nasopharynx and blockage of the eustachian tube, preventing ventilation of the middle ear–mastoid system. Also, the adenoid tissue in children with otitis media has been found to have increased bacterial colonization, which may predispose to recurrent infections. Adenoids are covered with biofilm, which may act as a reservoir for bacteria causing middle ear disease.  COMPLICATIONS OF AOM Intratemporal /extracranial Intracranial Hearing loss, Meningitis(most common intracranial Vestibular and balance problems complication from acute otitis media Acute perforation of the TM Sigmoid sinus thrombophlebitis Mastoiditis Epidural abscess Petrositis , Subdural empyema Labyrinthitis Focal otitic encephalitis Facial paralysis Brain abscess Lateral sinus thrombosis Otic hydrocephalus.  PREVENTION Prevention and modification of risk factors and vaccine development are two recommended strategies for the prevention of disease. 1. Vaccine use Based on the same premise as the successful H. influenzae type b vaccine, in which the capsular polysaccharide is conjugated with a protein, a heptavalent pneumococcal conjugate vaccine, PCV7 (Prevanar) has become available. PCV7 and other pneumococcal vaccines may prove to be an important step in the prevention of AOM. This vaccine is recommended for universal use in children 23 months and younger. Prevention 2.Management of Environmental Factors Promotion of breastfeeding in the first 6 months of life, Avoidance of supine bottle feeding and pacifier use, Elimination of passive tobacco smoke Alteration of child care arrangements such that the child is exposed to fewer children may also be of benefit.  Prevention… Control of nasal inflammation in children, whether caused by an allergy or by recurrent infection, appears to decrease the recurrence of AOM In children with recurrent AOM, adenoidectomy has demonstrated efficacy October 23, 2024 40 REFERENCES Cummings otolaryngology- head and neck surgery 4th edition by Paul W. Flint et al Prevalence of otitis media with effusion among pre school children in kinondoni district in dar Es salaam tanzania’ by E. R Massawe Otitis media with effusion medscape article by T s higgins,jr updated on 6th april 2020. Scott-browns otorhinolaryngology, head and neck chapters 13 and 82 Ballenger’s otorhinolaryngology, head and neck surgery 16th edition chapter 9 by James B. Snow et al