1. Acute otitis media and mastoiditis
Chunfu Dai M.D & Ph.D
Otolaryngology Department
Fudan Univeristy

2. Definition
AOM: is an infectious process of the middle ear cleft and to a variable extent, of the mastoid air cell system.

3. Bacteriology Streptococcus pneumoniae (48%)
Haemophilus influenzae (31%)
Moraxella catarrhalis (20%)
P-hemolytic streptococcus (decreased following widespread immunization program)
Pseudomonas aeruginosa (uncommon cause of AOM)

4. 阻断细菌耐药性的“恶性循环” 感染 合 理 治 疗 临 床 治 愈 细 菌 消 除 不合理 治疗 耐药性 增加 传播 细菌 未消除 选择
细 菌
消 除
不合理 治疗
耐药性 增加 传播 细菌
未消除 选择
耐药菌

5. 青霉素耐药的肺炎链球菌 79－98年在美国流行情况 中度敏感 (0.12 - 1.0 µg/ml) 耐药 ( 2.0 µg/ml) 50
% Penicillin Resistance 40
中度敏感 ( µg/ml)
耐药 ( 2.0 µg/ml)
33%
29% 30 20
18% 10
16%
1979
1980
1981
1982
1983
1984
1985
1986
1987
1997
1998
(Doern. Am J Med. 1995;99(6B): 3S-7S; Jacobs et al., AAC 1999:43:1901; Jacobs et al abstract C-61, ICAAC 1999)

6. Routine of infection Via eustachian tube
upper respiratory infection (acute rhinonitis and nasal pharyngitis)
Upper respiratory communicative disease (diaphea, mealse, et al)
Swimming and dive in unclear water
Anatomic contribution (Eustachian tube in infant is wide and short and the two orifice in the same level)

7. Routine of infection Via external acoustic canal and TM
Perforation
Myringotomy or myrigotosis
Via blood supply

8. Pathology Mucosal inflammation
Serous, hemorrhagic, or purulent exudate in middle cavity
Rupture of tympanic membrane

9. Symptoms Fever Otalgia Fullness Hearing loss
It may be masked by analgesics or antibiotic
Otalgia
60% patients can spontaneous remission
Fullness
Hearing loss

10. Physical findings
Increased vascularization of the TM, initially located in pars of flaccida, frequently spreading beyond the annulus to the skin of the external canal.
Bony landmarks are visible.

11. Cholesteatoma Formation

12. Physical findings Rapid middle ear exudation occurs,
Blurring of the mallwall short process, followed by edema and bulging of the pars flaccida.

13. Physical findings
The progression of this disease may result in rupture of TM, releasing the middle ear contents (beating sign) leads to relief of otalgia and retraction of the pars flaccida

14. Lab tests
Blood counts usually shows leukocytosis with polymorphonuclear elevation.
CT and MRI is necessary only for the rare patients with a serious complication (meningitis or brain abscess)

15. Hearing tests Conductive hearing loss
Degree of hearing loss will depend on the amount and viscosity of the middle ear exudate, TM edema
It vary from dB with predominant involvement of the low frequencies
Hearing loss may mixed when there is labyrinthine extension.

16. Managements Antibiotic therapy Experiences
Antibiotic sensitivity and bacteriologic culture
Traditional duration d
Currently duration 5-7 d

17. Managements Nasal decongestants Best rest, light diet
Avoidance of irritants (smoking)

18. Managements Pre-perforation Pain relief drugs Surgery: myringotomy
Progression with a red, bulging TM, severe otalgia and fever
Otitis media with impending complications
perforation is not big enough to drain all pus

19. Managements Post-proferation: Clear-up pus with 3% hydro-oxygen
Antibiotic ear drops
With pus decreased and inflammation disappeared, alcohol can be used to facilitate dry ear.

20. Follow-up
Adequately treated AOM effusion may persist for 2-6 weeks or even longer.
Managements may require
extended antibiotic treatment
Otoscope and audiometric tests should be performed 3-4 weeks following apparent resolution of the acute infection
Insertion of pressure equalization tubes due to fluid persists beyond 3 months

21. Acute mastoiditis
Definition: an infection of the mastoid characterized by diffuse osteitis followed by rarefaction and breakdown of the bony septae.
Acute coalescent mastoiditis
Haemorrhagic mastoiditis
Masked mastoiditis
Predisposition to pneumatic mastoid
Predilection to kid
Mastoid is mature at age of 4 year old

22. Acute mastoiditis Reduction of immune system
Strong bacteria (type III pneumococus, haemolytic streptococcus)
Obstruction- not effective drainage
Imcompletely treatment

23. Acute mastoiditis Symptoms
Symptoms may follow AOM, with or without a symptom-free interval of a few days to several weeks or more.
Otalgia
Aural discharge
Conductive hearing loss
fever

24. Acute mastoiditis Physical findings
Fever, from a slight elevation to 39
Otorrhea may be absent
Pulsatile may be observed
Tympanic perforation is present, but it may be obscured by intense edema
Swelling of the superior TM and posterosuperior wall of EAC
Postauricular area
erythema and tenderness
Pitting edema
Obliteration of the postauricular crease

25. Acute mastoiditis Radiographic evaluation
Diffuse rarefaction of bone and breakdown of cellular sepae

26. Acute mastoiditis interventions Medical management Surgical management
Antibiotic
Intravenous antibiotic therapy should be maintained for at least h after the resolution of symptoms
Then followed with oral antibiotic for 2 weeks
Surgical management
Emergency surgery: simple mastoidectomy
Mastoidectomy + ventilation tube placement