Otitis Media – At A Glance

Inflammation of the middle ear cleft is called as otitis media
In this article, I have discussed about….

  1. Acute suppurative otitis media (ASOM)
  2. Chronic suppurative otitis media (CSOM)
  3. Otitis media with effusion

Acute Suppurative Otitis Media (ASOM)

It is the acute inflammation of the mucoperiosteal lining membrane of the whole middle ear cleft.
More common in infants and children as they have a short, narrow and more horizontal Eustachian tube
Causative Organisms
  1. Streptococcus haemolyticus
  2. Staphylococcus aureus
  3. Streptococcus pneumoniae
  4. Haemophilus influenzae
Stages Of ASOM
  1. Stage of tubal occlusion
    • Eustachian tube becomes obstructed
    • There is engorgement and oedema of the middle ear cleft lining
  2. Stage of pre-suppuration
    • Acute inflammation of the middle ear cleft lining
    • Hyperaemia of the tympanic membrane
    • Bulging of the tympanic membrane due to collection of serous exudate
  3. Stage of suppuration
    • Exudate becomes purulent
    • Bulging of the tympanic membrane increases
    • Perforation may occur due to ischemic necrosis
  4. Stage of resolution
    • With effective treatment, infection resolves
    • Middle ear returns to the normal appearance and function
    • In case of small perforation, it may heal up and gradually the hearing will recover
    • Myringotomy will help to quickly heal and to recover hearing
  5. Stage of complication
    • Due to inadequate treatment or ill drainage, infection may persists and the disease may extend beyond the muco-periosteal lining of the middle ear involving the mastoid air cells and intracranial structures
    • This is rare
Management Of Acute Suppurative Otitis Media (ASOM)
Clinical features and examination

  • Stage of tubal occlusion
    • Clinical features
      1. Fullness of the ear
      2. Mild earache
      3. Mild deafness
    •  Examination
      1. Tympanic membrane is retracted
      2. Conductive deafness
  • Stage of pre-suppuration
    • Clinical features
      1. Severe earache (Sharp, stabbing)
      2. Increasing deafness
      3. Bubbling sound may be heard
      4. Fever
    • Examination
      1. Tympanic membrane shows bulging and congested blood vessels
      2. Cart wheel appearance (Due to congested blood vessels)
      3. Conductive deafness increases
  • Stage of suppuration
    • Clinical features
      1. Severe pain (Throbbing)
      2. Deafness is more marked
      3. High fever (101 – 103 oF)
    • Examination
      1. Tympanic membrane shows bulging, congestion and pus point may be seen
      2. Pulsating discharge of pus – called as light house sign
  1. Control of infection by giving broad spectrum antibiotics
    • Co-amoxiclav, amoxicillin, cefuroxime
  2. Symptomatic relief : Paracetamol / Ibuprofen (For pain and fever)
  3. Maintenance of patency of the Eustachian tube – Along with antibiotics, a nasal decongestant should be used
  4. In case of perforation – Pus should be cleaned till the ear is dry
  5. Drainage of pus and help resolution – It can be done by a myringotomy or cortical mastoidectomy
Chronic Suppurative Otitis Media (CSOM)
It is a long standing chronic inflammation of the muco-periosteal lining of the middle ear cleft resulting in discharging ear and deafness
Organisms responsible : Both aerobes and anaerobes are responsible

Clinico-Pathological Varieties Of CSOM

  1. Tubo-tympanic variety / Safe variety
  2. Attico-antral variety / Unsafe variety

Difference Between Safe And Unsafe Variety
Safe Variety
Unsafe Variety
1. Otorrhoea
Mucoid / muco-purulent
Non feotid
2. Blood stained discharge
Usually absent
3. Deafness
Conductive type of deafness
Slight – moderate
Conductive type of deafness
Moderate to severe
4. Symptoms of complications
(Headache and vertigo)
Not present
Maybe present
5. Perforation
Attic / Marginal
6. Granulation / aural polyp
7. Fistula test
Maybe positive
8. Pathology
Tubo-tympanic disase
Attico-antral disease
9. Cholesteatoma
Does not occur
May occur
10. Radiology
No bone erosion
Bone erosion
11. Complications
Usually absent
Management Of Chronic Suppurative Otitis Media (CSOM)
Safe Variety
Unsafe Variety
Clinical features
1. Otorrhoea
Mucoid / muco-purulent, profuse and non foetid
2. Deafness
1. Otorrhoea
Purulent, scanty, foetid
2. Deafness
3. Symptoms of complications
Earache, headache, vertigo, tinnitus, fever
Examination – Otoscopy
Perforation is central
Dry in between infections
Perforation is either marginal or in pars flaccida
Discharge is purulent, scanty and foetid
Granulation / aural polyp can be seen in the attic
Fistula test is positive
Investigations – Radiology
Mastoid is usually cellular ; maybe hypocellular
No evidence of bone erosion
Mastoid is sclerotic
Shows evidence of bone erosion
1. Aural toilet
Dry mopping, suction clearance
2. Ear drops containing steroids and neomycin
3. If infection still persists, systemic antibiotics
are given according to CS report
4. Advice to the patient….
Avoid water entry to the ear during bathing
Avoid swimming and diving
Maintain aural hygiene
Tetanus immunization
5. Surgery
a. Cortical mastoidectomy
b. Myringoplasty
1. Aural toilet
Dry mopping, suction clearance
2. Ear drops containing steroids and neomycin
3. Removal of small polyp or granulation
4. If potentially dangerous type, surgery is done
and efforts are made to preserve the ossicles for
reconstruction surgery
a. Atticotomy
b. Modified radical mastoidectomy
c. Radical mastoidectomy
d. Tympanoplasty without mastoidectomy
e. Tympamoplasty with mastoidectomy
5. If dangerous type, with symptoms of
complications, surgery is done. But no efforts
are made to preserve the ossicles
a. Radical mastoidectomy
Complications Of Chronic Suppurative Otitis Media (CSOM)
  •  Extracranial complications
    1. Acute mastoiditis
    2. Labyrinthitis
    3. Petrositis
    4. Osteomyelitis of temporal bone
    5. Subperiosteal abscess
    6. Facial nerve palsy
    7. Septicaemia and pyremia
    8. Otogenic tetanus
  • Intracranial complications
    1. Extra-dural abscess
    2. Sub-dural abscess
    3. Peri-sinus abscess
    4. Brain abscess
    5. Meningitis
    6. Encephalitis
    7. Otitic hydrocephalus
    8. Sigmoid sinus thrombosis

It is a surgical procedure that removes diseased mastoid air cells

Type of mastoidectomy
  1. Cortical mastoidectomy
  2. Radial mastoidectomy
  3. Modified mastoidectomy
  4. Canal up / down mastoidectomy
Cortical Mastoidectomy
It is the operation for the removal of only the diseased mastoid air cells for drainage purpose without disturbing the contents of the middle ear
1. Acute mastoiditis
2. Masked mastoiditis
3. Unresolved ASOM
4. Recurrent OME
Radical Mastoidectomy
It is the operation for the radical clearance of the disease pathology from the middle ear cleft including epitympanium and mastoid-temporal bone, making it a single cavity communicating with the external canal
1. Unsafe CSOM with
2. CSOM with complicat-n
3. Glomus tumor invading
mastoid bone
4. Malignancy of middle
1. Facial palsy
2. Labyrinthitis
3. Severe sensori-neural
4. Persistent discharge
from mastoid cavity
5. Injury to sigmoid sinus,
dura matter leading to
intracranial complication
Modified Radical Mastoidectomy
It is the operation for the eradication of the mastoid disease pathology and partly downing the facial bridge, but preserving the hearing mechanism as far as possible for subsequent tympanoplasty
1. Unsafe CSOM with
attico-antral disease
2. Limited mastoid

Secretory Otitis Media / Otitis Media With Effusion (OME)
It is a clinical condition, characterized by the presence of fluid in the middle ear resulting in conductive deafness
Causes Of Otitis Media With Effusion (OME)
  1. Tubal dysfunction & sniffing habits of children
  2. Obstruction of Eustachian tube due to….
    • Enlarged adenoids
    • Adhesion following adenoidectomy
    • Nasopharyngeal tumors
  3. Viral infection
  4. Allergy of middle ear cleft / Eustachian tube
  5. Disturbance in the mucociliary function of the middle ear
  6. Immunological diseases of the middle ear mucosa
  7. Unresolved acute otitis media
  8. Cleft lip / cleft palate
  9. Barotrauma


Management Of Otitis Media With Effusion
Clinical features
  1. Age : Common in 2 – 5 years
  2. Usually bilateral
  3. Children are less attentive & non responsive
  4. Defects in speech
  5. Sometimes painful


  1. Otoscopy
    • Tympanic membrane is intact
    • Fluid level or air bubbles may be seen
  2. Otogram
    • Conductive deafness


  1. Nasal decongestant to clear the eustachian tube
  2. Anti-histamin – Helps in allergic conditions
  3. Inflation of the middle ear by Valsalva’s maneuver
  4. Surgery – Myringotomy and suction
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