Transcript Acute otitis media and mastoiditis

Acute otitis media and
mastoiditis
Chunfu Dai M.D & Ph.D
Otolaryngology Department
Fudan Univeristy
Definition
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AOM: is an infectious process of the
middle ear cleft and to a variable
extent, of the mastoid air cell
system.
Bacteriology
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Streptococcus pneumoniae (48%)
Haemophilus influenzae (31%)
Moraxella catarrhalis (20%)
P-hemolytic streptococcus
(decreased following widespread
immunization program)
Pseudomonas aeruginosa
(uncommon cause of AOM)
阻断细菌耐药性的“恶性循环”
感染
合理
治疗
不合理
治疗
耐药性
增加
传播
细菌
未消除
选择
耐药菌
临床
治愈
细 菌
消 除
青霉素耐药的肺炎链球菌
79－98年在美国流行情况
40
33%
中度敏感 (0.12 - 1.0 µg/ml)
耐药 ( 2.0 µg/ml)
30
29%
20
18%
10
(Doern. Am J Med. 1995;99(6B): 3S-7S; Jacobs et al., AAC 1999:43:1901; Jacobs et al
abstract C-61, ICAAC 1999)
1998
1997
1994-95
1992-93
1990-91
1988-89
1987
1986
1985
1984
1983
1982
1981
1980
0
16%
1979
% Penicillin Resistance
50
Routine of infection
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Via eustachian tube
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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)
Routine of infection
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Via external acoustic canal
and TM
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Perforation
Myringotomy or myrigotosis
Via blood supply
Pathology
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Mucosal inflammation
Serous, hemorrhagic,
or purulent exudate in
middle cavity
Rupture of tympanic
membrane
Symptoms
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Fever
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Otalgia
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It may be masked by analgesics or
antibiotic
60% patients can spontaneous remission
Fullness
Hearing loss
Physical findings
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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.
Cholesteatoma Formation
Physical findings
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Rapid middle ear
exudation occurs,
Blurring of the mallwall
short process, followed
by edema and bulging of
the pars flaccida.
Physical findings
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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
Lab tests
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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)
Hearing tests
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Conductive hearing loss
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Degree of hearing loss
will depend on the
amount and viscosity of
the middle ear exudate,
TM edema
It vary from 10-50 dB
with predominant
involvement of the low
frequencies
Hearing loss may mixed
when there is labyrinthine
extension.
Managements
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Antibiotic therapy
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Experiences
Antibiotic sensitivity and bacteriologic culture
Traditional duration 10-14 d
Currently duration 5-7 d
Managements
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Nasal decongestants
Best rest, light diet
Avoidance of irritants (smoking)
Managements
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Pre-perforation
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Pain relief drugs
Surgery: myringotomy
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Progression with a red,
bulging TM, severe otalgia
and fever
Otitis media with impending
complications
perforation is not big enough
to drain all pus
Managements
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Post-proferation:
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Clear-up pus with 3% hydro-oxygen
Antibiotic ear drops
With pus decreased and inflammation
disappeared, alcohol can be used to facilitate
dry ear.
Follow-up
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Adequately treated AOM effusion may
persist for 2-6 weeks or even longer.
Managements may require
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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
Acute mastoiditis
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Definition: an infection of the mastoid
characterized by diffuse osteitis followed by
rarefaction and breakdown of the bony septae.
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Acute coalescent mastoiditis
Haemorrhagic mastoiditis
Masked mastoiditis
Predisposition to pneumatic mastoid
Predilection to kid
Mastoid is mature at age of 4 year old
Acute mastoiditis
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Reduction of immune system
Strong bacteria (type III pneumococus,
haemolytic streptococcus)
Obstruction- not effective drainage
Imcompletely treatment
Acute mastoiditis
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Symptoms
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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
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Acute mastoiditis
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Physical findings
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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
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erythema and tenderness
Pitting edema
Obliteration of the postauricular crease
Acute mastoiditis
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Radiographic
evaluation
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Diffuse
rarefaction of
bone and
breakdown of
cellular sepae
Acute mastoiditis
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interventions
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Medical management
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Antibiotic
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Intravenous antibiotic therapy should be maintained for at least
24-48 h after the resolution of symptoms
Then followed with oral antibiotic for 2 weeks
Surgical management
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Emergency surgery: simple mastoidectomy
Mastoidectomy + ventilation tube placement