Acute Suppurative Otitis Media ENT

Definition: Acute inflammation of the Middle Ear Cleft (Eustachian tube, Middle ear, Attic, Aditus, Antrum, and Mastoid air cells) by pyogenic organisms.

Etiology & Bacteriology

Demographics: More common in infants and children (lower socioeconomic groups).

Bacteriology:

• Streptococcus pneumoniae (30%).
• Haemophilus influenzae (20%).
• Moraxella catarrhalis (12%).
• Strep. pyogenes / Staph. aureus.

Routes of Infection

1. Via Eustachian Tube (Most Common):
   • Anatomy in Infants: Tube is Shorter, Wider, and Horizontal.
   • Mechanism: Horizontal bottle feeding forces fluid into tube; Swimming/Diving.
2. Via External Ear: Traumatic perforation of TM.
3. Blood-Borne: Uncommon.

Pathology & Clinical Stages

The disease progresses through 5 distinct stages:

1. Stage of Tubal Occlusion

• Pathology: Oedema of ET → Absorption of air → Negative pressure.
• Symptoms: Deafness and mild earache. No fever.
• Signs: Retracted TM, Handle of malleus horizontal, Loss of light reflex.

2. Stage of Presuppuration

• Pathology: Pyogenic invasion → Hyperaemia.
• Symptoms: Throbbing earache (disturbs sleep), Tinnitus, High fever/Restlessness (in children).
• Signs:
  • Congestion of Pars Tensa.
  • Leash of vessels along handle of malleus.
  • Cart-wheel appearance of TM.

3. Stage of Suppuration

• Pathology: Pus formation in middle ear/mastoid. TM bulges.
• Symptoms: Excruciating pain, Deafness increases, Vomiting/Convulsions.
• Signs:
  • Red and Bulging TM with loss of landmarks.
  • Yellow Spot (where rupture is imminent).
  • "Nipple-like protrusion" (pre-antibiotic era sign).
  • Mastoid tenderness present.

4. Stage of Resolution

• Pathology: TM ruptures → Pus release → Symptoms subside.
• Signs:
  • Blood-tinged discharge becoming mucopurulent.
  • Small perforation in Antero-Inferior Quadrant.

5. Stage of Complication

• Occurs if virulence is high or resistance is poor.
• Spread: Mastoiditis, Petrositis, Facial paralysis, Meningitis, Brain Abscess.

Treatment

1. Medical Management

• Antibiotics: Indicated for fever/severe pain.
  • Amoxicillin (Drug of choice).
  • Alternatives: Co-trimoxazole, Erythromycin, Cefaclor.
  • Duration: Minimum 10 days.
• Decongestants:
  • Nasal Drops: Oxymetazoline/Xylometazoline (promote ventilation).
  • Oral: Pseudoephedrine.
• Analgesics: Paracetamol (for pain/fever).
• Ear Toilet: Dry mopping of discharge.

2. Surgical: Myringotomy

Incision of the drum to evacuate pus. Indications:

• Bulging drum with acute pain.
• Incomplete resolution despite antibiotics (persistent conductive loss).
• Persistent effusion (>12 weeks).