1. Acute Suppurative Otitis Media (ASOM)
Dr. Krishna Koirala

2. Defined as pyogenic infection of middle ear cleft lasting for < 3 weeks
Routes for infection
Via Eustachian tube
Via Tympanic membrane perforation
Hematogenous (rare)

3. Predisposing Factors 1. Breast feeding in supine position
2. Recurrent upper respiratory tract infection
3. Nasal allergy
4. Chronic rhinitis & sinusitis
5. Tumours of nose & nasopharynx
6. Cleft palate

4. Bacteriology Haemophilus influenzae Streptococcus pneumoniae
Staphylococcus aureus
Moraxella catarrhalis
Beta hemolytic Streptococci (causative agent in acute necrotizing otitis media)

5. Stages of ASOM 1. Stage of hyperemia (tubal occlusion) Mild earache
T.M. retracted initially and congested later
Blood vessels radiating out from handle of malleus (cartwheel appearance)
Cartwheel

6. 2. Stage of Exudation High fever, severe earache, deafness
Marked congestion and bulging of T.M.
Mastoid tenderness
P.T.A. : high frequency conductive deafness (due to mass effect of pus)

7. 3. Stage of Suppuration Increased deafness, ear discharge
Mastoid tenderness +
Fever and earache decrease
Otoscopy :
Bulged, congested tympanic membrane with a yellow spot (nipple sign)
Pulsatile discharge through small TM perforation (Lighthouse sign)

8. Clouding of mastoid air cells

9. 4. Stage of Coalescent Mastoiditis
Otorrhea > 2 weeks, otalgia and deafness
Mastoid reservoir sign : pus immediately fills the EAC after mopping
Sagging of Postero-superior bony canal wall due to peri-osteitis of mastoid floor
Ironed out appearance of skin over the mastoid due to thickened periosteum
Mastoid cavity in X-ray due to hyperemic decalcification

10. 5. Stage of Resolution Ear discharge stops Hearing improves
Perforation starts healing up

11. 6. Stage of Complications
Sub-periosteal abscess
Vertigo
Headache + blurred vision + projectile vomiting
Fever + neck rigidity + irritability
Drowsiness
Paralysis of cranial nerve(s)

12. Treatment of ASOM Antibiotic (Co-amoxyclav, Cefuroxime)
Nasal decongestants (systemic + topical)
H1 anti-histamines
Analgesic + anti-pyretic
Aural toilet for ear discharge
Heat application for severe earache

13. Review after 48 hours Earache + fever persists:
Change to higher antibiotic
If T.M. is bulging  perform myringotomy and send ear discharge for C/S
Earache + fever subside:
Continue same treatment for days

14. Review after 3 months No effusion No further treatment
Effusion persists
Treat as Otitis Media with Effusion (OME)
Presence of abscess or coalescent mastoiditis
Cortical mastoidectomy

15. Myringotomy in A.S.O.M.
Curvilinear incision made in postero-inferior quadrant
Incision is curvilinear & not radial (as in OME), to cut the fibres of TM (to keep the opening patent for longer duration)

16. Why incision in PIQ? Less vascular area T.M. bulge is maximum
Ossicles not damaged
Easily accessible

17. Sub-periosteal abscess & fistula

18. Pathology
Production of pus under tension  hyperemic decalcification (halisteresis) + osteoclastic resorption of bone  breakage of septa and formation of mastoid cavity  sub-periosteal abscess  penetration into periosteum + skin  mastoid fistula formation

19. Sub-periosteal abscess formation

20. Discharging mastoid fistula

21. Mastoid fistula: dry

22. Abscesses related to mastoid
Post-auricular
Bezold
Citelli
Zygomatic
Luc
Retro-mastoid
Parapharyngeal & Retropharyngeal

23. Abscesses related to mastoid

24. Post-auricular abscess
Commonest
Present behind the ear
Pinna pushed forwards & downwards

25. Bezold’s & Citelli’s abscesses
Bezold: neck swelling
over sternocleido-
mastoid muscle
Citelli: neck swelling
over posterior belly of
digastric muscle

26. Bezold’s abscess

27. Luc: swelling in external auditory canal
Zygomatic: swelling antero-superior to pinna + upper eyelid edema
Retro-mastoid: swelling over occipital bone
Parapharyngeal & Retropharyngeal: due to spread of pus along the Eustachian tube

28. Giuseppe Gradenigo (1859 – 1926)
Gradenigo’s Syndrome
Giuseppe Gradenigo (1859 – 1926)

29. Defining Triad
Persistent otorrhea despite adequate cortical mastoidectomy
Retro-orbital pain due to trigeminal nerve involvement
Diplopia: convergent squint due to lateral rectus palsy by injury to Abducent nerve in Dorello’s canal at the petrous apex

30. Etiology : Coalescent mastoiditis involving petrous apex along postero-superior & antero-inferior tracts in relation to bony labyrinth
Diagnosis:
C.T. scan temporal bone for bony details
MRI to differentiate b/w bone marrow & pus
Treatment: Modified radical mastoidectomy & clearance of petrous apex cells

31. Cortical Mastoidectomy

32. Antiseptic dressing

33. Draping

34. Infiltration

35. Marking of incision

36. Wilde’s post-aural incision

37. Incision deepened

38. Musculoperiosteal flap elevated

39. Cortical mastoidectomy begun

40. Exposure of mastoid antrum

41. Widening of aditus

42. Aditus widened

43. Final Cavity

44. Drain put in mastoid cavity

45. Mastoid dressing