tubercular otitis media

secondary inf usually in young people thr Etube/blood from focus in lungs/tonsils/lymph nodes.

pathology:

insidious pale tubercles in Mear cleft submucosa –>necrosis of TM,ossicles.

CF:

• foul discharge.
• multiple TM perforations.
• severe deafness.
• sudden facial paralysis.

diagnosis: culture sensitivity for discharge.

Rx:

• ATB
• aural toilet
• mastoid surgery for complications.

otitic hydrocephalus

raised ICP during Mear infs in children–>

• lateral sinus thrombosis–>obstr venous return.
• supsagittal thrombosis–>CSF not absorbed thr arach villi.

CF:

• severe headache, vomiting,nystagmus =CSF pressure>300mm.
• 6th CN -diplopia.
• pailledema,optic atrophy-blurring vision.

Rx: to prevent optic atrophy

• repeated lumbar puncture
• shunt operation CSF into a vein.
• Mear inf -antibiotics
• mastoidectomy -to expose lateral sinus & drain abscess.

lateral sinus thrombophlebitis / sigmoid sinus thrombosis.

inflm, thrombus in lateral venous sinus.

pyogens-proteus, Ecoli, pseudo, staph.

cause: CSOMcholesteat,mastoiditis –>bone erosion-thrombophlebitis.

pathology:

outer dura abscess[perisinus] –>endophlebitis + thrombus –>obliteratn + inf –>

• thrombus extension[ to supsagittal,cavernus,jugular vein,mastoid emissary vein],
• septicaemia,
• septic emboli.

CF:

• headache, irregular high fever + chills,rigor,sweating.
• anaemia,emaciation
• GRIESINGER’s sign- mastoid edema
• PAPILLEDEMA-blurred margins,dilated/haemrrhg.
• TOBEY AYER test- jugular compr causes no rise in CSF[thrombosis]
• CROWE BECK test- jugular compr dilates retinal,supraorb veins.
• tender lymphadenopahty, torticollis[tiltc neck].

diagnosis:

• blood- no malaria, culture-inf.
• ICP rised.
• xray mastoid- clouding,erosion.
• ear swab culture.
• CTscan.

complications:

• jugular thrombosis- CN 9,10,11.
• cav sinus thrombosis- chemosis,proptosis,fixed eye, papilledma.
• supsagittal thrombosis- ottitic hydrocephalus.
• septicaemia.
• meningitis, abscess-subdural,cerebellar,lung,joints,bone,subcutaneous.

Rx:

• surgical mastoidectomy[expose sinus & drain abscess] + 7days sys antibiotics.
• ligate int jugular vein to control thrombosis.
• raely- anticagulants for cav sinus thrombosis.
• blood transfuse for anaemia.

brain abscess – OM compl

cause: AOM – child, COM cholesteatoma – adult.

• aerobes: strep pyo, pneumo, proteus, Ecoli, pseudo
• anaerobes: pepto, bacteroids

thrombophleb, tegmen|trautmann’s triangle –>  cerebrum[twice common]|cerebellum + extradural|extradural,perisinus,sigmoid,labyrinthitis.

pathology: 4 stages.

• INVASION- headache, low fever, drowsy.
• ABSCESS LOCALIZATION- capsule from around pus.
• ENLARGEMENT- edema around pus–>ICP rises–>focal dysfunction.
• TERMINATION- rupture into CSF–> fatal.

CF:

• headache,vomiting,drowsy-stupor-coma, pulse & temp falls, late papilledema[early in cerebellar]
• cerebral[temporal]-aphasia[no names,know use], homonemous hemianopia[opp blind], contralat paralysis, epilepsy, smackng, hallucinatn, transtentorial hernia-oculomotor palsy.
• cerebellar- subocciput headache, neck rigidity, nystagmus, ipsilat ataxia, intension tremor, past pointing[finger-nose], dysdiadokokinesia-slow sup/pro froearm.

diagnosis:

• skull xray -midline shift, calcified penial, abscess gas.
• MRI,CTscan-site,size,complications.
• xray mastoid-ear disease.
• lumbar puncture-CSF-protein>,WBC>.

Rx:

• iv high dose antibiotics- pencillin,chloramphenicol,metronidazole-anaerobes,gentamycin-pseudo,proteus.
• dexamethasone,mannitol-ICP
• suction,ear drops- ear discharge.

NEUROSURG: repeated aspiration thr burr hole + instill pencillin, excise expanding abscess, evacuate pus thr open incision.

only then COM-rad mastoidectomy.

intracranial compl of OM – meningitis.

leptomeninges[arach+pia] inflmm.

labyrinth,petro sq suture,venous thromb,cholesteatoma bone erosion –>subarach[CSF] bacterial invasion.

cause: AOM in chlid, COM in adults.

CF:

• fever,chills,rigor,vomiting.
• ICP rise- headache, neck rigidity, irritability, photophobia,CN palsy, hemiplagia, drowsy->delirium->coma.
• KERNIG’s sign   o–’ [hip+knee joint flexion -->pain.]
• BRUDZINSKI’s sign  [neck flexion--> hip,knee flexion.]
• TENDON REFLEXES – first incr, later decr.
• pappilledema.

diagnosis:

• CSF= turbid, cells[Nphills]>1000/ml, protein>, sugar<, [Cl]-<
• culture sensitivity

Rx:

• 7-10 days iv cryst pencillin, ampicillin, chloromycetin, cephalosporin[3rd]
• AOM-myringotomy,cortical mastoid
• COM-mod rad mastoid.

acute mastoiditis

spread of acute otitis media to bony walls of mastoid air cells from mucoperiosteum when host is immunedef [systemic disease/children], virulent[beta hemolytic strp,anaerobes].

pathology:

mastoid air cells inf [large area]–>increased pus–>inadequate drainage causes pus to accummulate under tension–>hypaeremic decalcification of bony walls of air cells–>single cavity of pus [mastoid empyema]–>adv stage subperiosteal abscess[commonest-postauricular]–>fistula.

CF:

• unresolving pain & fever after treatment.
• tender mastoid,zygoma root.
• TM-opaque/central perforation.
• >3wks discharge -purulent .
• mastoid-smooth,ironed out obliterated retroauricular sulcus. adv stage edema pinna–>fluctuant abscess.
• sagging postsup meatus.
• conductive deafness.

diagnosis:

• elevated ESR,Nphils.
• xray mastoid-clouding/cavity.
• culture-sensitivity of discharge.

differetial diagnosis [no preceeding otitis media]:

• scalp inf–>mastoid lymph node suppuration.
• meatal furunculosis–>serous discharge from nonmucous meatal glands, N TM, xray mastoid-clear.

Rx:

• amoxicillin,ampicilli+chloramphenicol,metronidazole.
• wide myringotomy to relieve pus.
• abscess, sagging,unresolved with >48hrs treatment,reservoir sign[pus fills soon after drainage] –>cortical mastoidectomy+5days antibiotics.

MASKED/LATENT MASTOIDITIS-caused from inadequate treatment, no acute CF–>slow destruction of air cells,gelatinous dark material.

complications of SOM

spread beyond mucoperiosteal layer of Mear cleft.

• virulent org/ inadequate antibiotic for otitis media.
• host immuno def/ systemic disease-DM,TB,AIDS,nephritis,leukaemia.
• poor socioeco, lack helth edu, lack health facilities.

pathways of spread:

• bone erosion- acute hyperaemic decalcification, chronic osteitis/cholestatoma/choleterol granuloma.
• venous thrombophlebitis of haversian canals in mastoid –>dural veins–>DVsinuses–>brain cortical vein thrombosis.
• preformed-
  • congenital dehiscences-bony facial canal,Mear floor over jugular bulb.
  • patent petro squamous suture.
  • healed fibrous scar at fracture.
  • exposed dura at surgical defects[stapidectomy,mastoidectomy].
  • oval/round windows/labyrinth–> cochlea–>meninges.

classif:

• intratemporal: mastoiditis,petrositis,facial paralysis,labyrinthitis.
• intracranial:extradural,subdural,brain abscess,meningitis,lateral thrmbphlbtis,otitic hydrocephalus.

petrositis

otitis media complication associated w/ CSOM,mastoiditis.

CF:

headache,fever,vomiting,gardenigo’s syndrome-

• 6 CN palsy -ext rectus -diplopia.
• 5 CN involve -deep orbital pain.
• persistant ear discharge.

diagnosis: xrays,ct scan.

Rx:

• 5 days high dose antibiotics.
• mastoidectomy to enlarge fistula for drainage.

nonsuppurative /otitic barotrauma /aero otitis media

etiology:

>90mm negative intratympanic pressure during rapid decompression[ descent-airplane,underwater diving,compression chamber]

Etube locked w/ phryngeal tissues–> no entry of air into Mear –>TM retraction.

CF:

• earache,deafness,tinnitus.
• TM-congested,retracted/rupture.
• air buubles, haemorrage.

Rx:

• decongestants, politzerization, myringotomy to unlock & aspirate.
• precautions during travel: for inf/allergy–> 30min before- vasocnstr/antiH/decongetsants, valsalva/chew to autoinflate.

SEROUS/secretory otiti media w/ nonpupulent effusion/ GLUE EAR

etiology= increased secretory cells + abn functioning[blocked] Etube.

CF:

• 5-8 yrs children.
• <40db conductive deafness + delayed speech.
• h/o URTinf-mild earaches.
• TM-opaque, no light reflex, bv leash differ from ASOM, mobility restricted, [retraction,fluid,air bubbles].

diagnosis:

• tunning fork, audiometry, impedance audiometry in infants.
• xray mastid-clouding=fluid.

Rx: to remove fluid.

• decongestants to remove edema of Etube.
• anti-H+steroids.
• antibiotics for unresolved ASOM.
• ventilate Mear- valsalva,politzerization[blow air up the nose during swallow],chew-swallow.
• thick glue like mucus –> myringotomy/beer can principle -2 insisions in antinf,antsup.+mucolytic[chymotrypsin] + aspiration.
• grommet insersion for spontaneous extrusion for months.
• cause–>  mastoidectomy,adenectomy,tonsillectomy.

COMPLICATIONS:

• atrophic TM from chronic effusion.
• ossicular necrosis >40 deafness.
• tympanosclerosis.
• retraction pockets + cholesteatoma.
• cholestrol granuloma.