Acute Suppurative Otits Media

Ans. C Subperiosteal abscess

As discussed earlier therelative incidence of various extracranial complications in a case of chronic, otitis media are:

So M/C complication is post auricular abscess

Now what is post auricular abscess

There are many abscesses in relation to mastoid –

So As is clear from above explanation – M/C. Extra cranial complication is – Post Aural sub periosteal abscess: If this option

is not given then the next best option would be Mastoiditis.

Streptococcus pneumoniae is the most common organism causing acute otitis media.

It accounts for roughly 30% of the cases. Other causative organisms includes Haemophilus influenzae (20%) Moraxella catarrhalis (12%), Streptococcus pyogenes and Staphylococcus aureus.

In acute suppurative otitis media, 85% of cases show a small perforation in antero-inferior quadrant of pars tensa.

Perforations in this location were associated with smooth margins, good drainage of pus, and a favorable clinical course.

Hence this area is termed as “perforation zone”.

Only 15% of perforations occurred in other locations, most typically the posterior-superior quadrant.

In the setting of middle ear infection, bacterial infection can invade through the round window causing acute suppurative labyrinthitis. 

From the labyrinth, bacteria gain access to the cochlear aqueduct, forming a conduit between the perilymph and the cerebrospinal fluid (CSF) resulting in meningeal infiltration.

Nasopharyngeal colonization with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis increases the risk of otitis media, whereas colonization with normal flora such as viridans streptococci may prevent otitis by inhibiting growth of these pathogens.

The most common cause of acute otitis media in children is Streptococcus pneumoniae with 35%, H.influenzae with 25% & Moraxella catarrhalis with 15%.

Ans. is ‘a’ i.e., Pneumococcus

Three most common organisms causing ASOM S. pneumoniae (40%), H. influenzae (25-30%), Moraxella, catarrhalis (10-15%)

Note – H.influenzae causing ASOM is nontypable. The incidence of H.influenzae type ‘b’ has decreased because of widespread use of Hib vaccine.

Ans. is ‘b’ i.e., Staphylococcal Scalded skin syndrome

o The extensive peeling of the skin after H/O drug intake makes it look like a case of Toxic epidermal necrolysis or Steven’s Jhonson syndrome on the first instance. But it is a case of staphylococcal scalded skin syndrome.

         Note that all the disease given in the question can cause extensive peeling of the skin.

o The points which favour the diagnosis of staphylococcal scalded skin syndrome are

         Mucosa is spared in staphylococcal scalded skin syndrome.

Absence of toxicity.

 S.S.S. usually have primary infection at sites other than skin eg – Nasopharynx, conjuctiva, throat middle ear (otitis media).

o Now, about the individual diseases

Staphylococcal scalded skin syndrome

• Usually begins as prodrome. The acute phase starts with the onset of erythematous rash in the periorbital and perioral area and is tender.

o These erythematous rashes are soon (within hrs or days) followed by wrinkling or sloughing of the skin. o The sloughing can be provoked by stroking of the skin (Nikolsky’s sign).

• In later stage, large flaccid bullae may develop. These bullae can cause loss of water and electrolyte. o Fever irritability and lethargy are common but systemic toxicity is not seen.

o The entire illness resolves within about 10 days.

Toxic epidermal necrolvsis ‑

• It is a severe form of drug reaction.
• Toxemia is characteristic
• It is characterized by bullae that arise on widespread areas of erythema and then they slough leaving behind raw ulcerated skin.
• Oral mucosa especially the lips, genital mucosa and conjunctiva are ofter involved. In some cases cornea is also involved leading to corneal opacities.

o Drugs commonly involved in TEN are —> Thioacetazone, INH, Sulphonamides, Phenolphthalein

Stevens Jhonson syndrome ‑

• It is also a severe form of drug eruption.

o Toxemia is characteristically present.

o It is less severe than toxic epidermal necrolysis. In Steven’s Jhonson’s syndrome bullaes and epidermal detachment is seen in > 10% of total surface area. Where as in TEN it is seen in > 30% of total surface area. o Mucous membrane is involved

o Common drugs causing this reaction —> Sulphonamides, Tetracycline, Oral antidiabetic drugs.

B i.e. Lepromin test

Lepromin test has no diagnostic value; it has only prognostic significanceQ as it tells about cell mediated immunity & classify the type of disease. Lepromin test is most positive in TT because cell mediated immunity is least suppressedQ

The most common cause of acute otitis media in children is Streptococcus pneumoniae with 35%, H.influenzae with 25% & Moraxella catarrhalis with 15%.

Most common cause of acute otitis media:

• Streptococcus pneumonia / pneumococcus (35-40% cases)
• H. influenza (25-30%)
• M. catarrhalis (10-20%)

Otoscopy Signs for ASOM:

• There is congestion of pars tensa
• Leash of blood vessels appear along the handle of malleus and at the periphery giving it a cartwheel like appearance.
• Transluscency is reduced
• Later tympanic membrane appears red and bulging with loss of landmarks.
• Tympanic membrane is immobile in pneumatic ostoscopy

Ans. C ASOM

ASOM -In stage of suppuration-pulsatile otorrhea is present .

Light house sign: Seen in ASOM when pulsatile otorrhea reflects light intermittently on-otoscopy

• Light house sign is seen in acute ASOM and in acute mastoiditis following ASOM.
• There is mucopurulent or purulent discharge, which is often pulsatile
• On otoscopy examination of ear, this pulsatile discharge reflects light which is called as light house effect

• Inadequate antibiotic treatment of acute suppurative otitis media may inactivate infection but fail to resolve it completely.
• Low grade infection lingers on which acts as a stimulus for the mucosa to secrete more mucus which leads to development of serous/secretory otitis media.

In SOM, myringotomy is done in antero-inferior quadrent because:

It is relatively avascular area. blood loss is less

No important structures are present here. No possibility of them being damaged.

To stimulate Eustachian tube (which also lies in antero inferior quadrant)

• Most common complication following ASOM is mastoiditis.
• Facial nerve palsy is an uncommon complication of ASOM
• Cholesteatoma is not associated with ASOM
• Deafness is the presenting feature of ASOM and not complication.

Indications of myringotomy in acute otitis media:

• Drum is bulging + acute pain.
• Incomplete resolution despite antibiotics when drum remains full with persistent conductive deafness.
• Persistent effusion beyond 12 weeks.

In the stage of supperation of ASOM, pus formation occurs, hence in this stage pulsatile otorrhea or light house sign in seen.