CIPLADOC - Infection Update - Disease Update - OTITIS MEDIA SOUND DIAGNOSIS

OTITIS MEDIA: "SOUND DIAGNOSIS"

	CLASSIFICATION
	DIAGNOSIS
	MANAGEMENT

Inflammation of the middle ear is the most common illness among children. The disease is benign but its complications can be severe and permanent. Since the disease presents as variable clinical manifestations, some simple otoscopic clues can ease diagnosis. Management modalities include medical therapy and surgery.

A restless, irritable child pulling frequently at his ear presents at the clinic. He has a raised temperature and general malaise. These clues are sufficient for the doctor to suspect otitis media.

Otitis media, one of the commonest conditions among children continues to be the leading cause of hearing loss in them. Statistics show that it affects 84 percent of children by the age of three.

The diagnosis of otitis media is often elusive. In majority of the children, the initial episodes occur during the first years of life, when the patient is too young to describe the symptoms and physical examination can be less than revealing. Symptoms can vary from none to severe otalgia and otorrhoea.

Among older children, the condition is suspected when they perform poorly in school or have behavioural problems both of which are due to hearing loss. Some may report a blocked feeling in their ears as is felt in high altitudes. Otitis media with effusion (OME) is silent and because children seldom complain about this problem, diagnosis is often delayed for months or years resulting impairment of speech and language development.

CLASSIFICATION

Otitis media actually represents a continuum of pathologic processes, indicated by varied clinical manifestations.

Acute otitis media (AOM) generally causes ear pain and predominantly purulent middle ear effusion, but infection may also be present with mucoid effusion. Otitis media with effusion (OME), commonly follows recurrent episodes of AOM and is characterised by mucous and serious effusion. The effusion results from incomplete resolution of acute otitis media or from chronic obstruction or dysfunction of eustachian tube. Chronic otitis media (COM) includes additional pathology, such as suppurative discharge through a ruptured tympanic membrane, growth of granulation tissue in the middle ear, damage to the ossicles, hearing loss, cholesteatoma, and mastoiditis.

In many cases the pathophysiologic conditions may be asymptomatic or if acute symptoms are present initially, it may become silent. Because of this silent feature, careful examinations are essential.

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DIAGNOSIS

The clinical appearance of the ear drum gives a definitive diagnosis of otitis media. For example, a decrease in the amount of wax is indicative of infection. Otoscopy is the key to physical examination. Otoscopic examination of the tympanic membrane reveals changes in colour, translucency and contour, which are significant diagnostic clues.

The ear drum normally has a pearly translucent appearance. On infection this is replaced by opacity and discolouration. The membrane may bulge especially if active infection is present. Increased vascularisation along the malleus handle is also a key finding, typical of infection.

Otoscopic Findings To Confirm Diagnosis

Condition	Observations
1.Acute otitis media (early stag)	A blush of erythema. The light reflex shortened.
2.. Acute otitis media	The manubrium of the malleus prominent. Retraction of the entire drum begins
3.Acute suppurative otitis media	Moderate bulging in the posterior quadrant; progresses to the entire drum.
4.Acute otitis media (final stage)	The entire tympanic membrane presents a diffuse redness and is markedly retracted. The cone of light is absent.
5.. Otitis media with effusion (serous)	The fluid level seen at the top of the umbo. Tilting the head forward causes shift in the fluid level.
6.Chronic otitis media	The entire tympanic membrane is markedly retracted. Dull grey colour.

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MANAGEMENT

The modalities used for management of otitis media consists of medical therapy and surgery.

Medical treatment of acute otitis media with effusion must be aimed at the causative organism(s). Commonly used antibacterials are amoxycillin, amoxycillin-clavulanate, ampicillin, co-trimoxazole, erythromycin, and first or second generation cephalosporins such as cephalexin, cefadroxil and cefaclor. The criteria for antibiotic selection are efficacy, penetration into middle ear fluid, ease of dosing and side effects. Prophylaxis is recommended for children with recurrent attacks of otitis media. However, the use of long-term, low dose antibiotics as prophylaxis merely masks symptoms of infection and are not truly prophylactic against the basic condition. Polyvalent pneumococcal vaccine has been shown to lead to reduction in the incidence of acute otitis media in children.

The length of treatment can vary from 10 to 14 days. Careful follow-up examinations are essential. If otitis media persists, extended treatment for another two to four weeks with the same or changed antibiotic or a trial with steroids can be considered. Prolonged or frequent use of steroids however, should preferably be avoided. Topical ear drops may also be effective. Decongestants and antihistamines may help by reducing oedema in the Eustachian tubes and nasopharynx.

Surgical intervention is reserved for patients who do not respond to conventional medical treatment. It consists of myringotomy (incision in the tympanic membrane for obtaining a culture or draining middle ear fluid), myringotomy with insertion of tympanostomy tube, mastoidectomy (removal of mastoid air cells to treat disease) and tympanoplasty (repair of tympanic membrane).

Even though otitis media is typically benign and self-limited, its complications can be severe and permanent. The diagnosis of this disease in young children requires all the skills of a doctor for accurate and timely detection and appropriate management.

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