OTITIS MEDIA/

ADENOTONSILLITIS
 INTRODUCTION
• Otitis media refers to an inflammation of the
mucous membrane of the middle ear cleft.
• The middle ear extends from the tympanic
membrane to the oval window.
• The Middle ear cleft is made up of the middle
ear cavity( tympanic cavity), mastoid antrum,
mastoid air cells and the eustachian tube.
DIAGRAM OF EAR
 CLASSIFICATION
• Otitis media is classified into three viz;
1. Acute otitis media (AOM): This is suppurative
middle ear infection of relatively sudden
clinical onset.
2. Chronic suppurative otitis media (CSOM):
These are several forms of suppurative otitis
media of insidious onset that are not easily
differentiated by clinical or pathological
criteria. Examples include;
 CLASSIFICATION
i. Tubo-tympanic disease (permanent
perforation syndrome)
ii. Cholesteatoma (atticoantral disease or
shrapnell’s disease)
iii. End stage disease (e.g atelectatic ear or
tympanosclerosis
 CLASSIFICATION
3. Otitis media with effusion (OME): This is a
chronic non-suppurative condition
characterized by the persistent collection of
fluid in the middle ear. It can also be called
glue ear, secretory otitis media, serous otitis
and middle ear catarrh.
 EPIDEMIOLOGY
• The peak incidence and prevalence is during
the first 2 years of life.
• Incidence and severity is thought to be greater
in boys than girls.
• Otitis media tends to run in families.
• Occur more in people with low socioeconomic
status.
• Breastmilk is protective against otitis media,
thus breastfeeding is encouraged.
 EPIDEMIOLOGY
• Exposure to tobacco smoke is a risk factor.
• It is commoner in whites than blacks.
• It is commoner in the rainy or cold season.
• There is a strong positive relationship btw the
occurrence of otitis media and the extent of
repeated exposure to other children.
• More common with unrepaired cleft palate or
craniofacial anomalies and downs syndrome.
• Conjugated Pneumococcal vaccination is
protective.
 PATHOPHYSIOLOGY
• The pathophysiology of otitis media depends
on;
- Dysfunction of the eustachian tube
- Viral upper respiratory infection
- The Host’s immune system
A. Dysfunction of the eustachian tube: The three
main functions of the eustachian tube are
ventilation, protection and clearance. The
middle ear mucosa depends on a continuing
 PATHOPHYSIOLOGY
supply of air from the nasopharynx delivered by
way of the eustachian tube.
- If this ventilatory process is interrupted by tubal
obstrution, it initiates an inflammatory
response that includes;
i. secretory metaplasia,
ii. compromise of the mucociliary transport
system
iii. effusion of liquid into the tympanic cavity
 PATHOPHYSIOLOGY
B. Viral upper respiratory infection: These may
lead to development of otitis by the ff mech:
i. Inducing inflammation in the nasopharynx
and eustachian tube.
ii. Enhancing nasopharyngeal bacterial
colonisation.
iii. Impairing host immune system.
iv. Increasing susceptibility to secondary
bacterial infection.
 PATHOPHYSIOLOGY
C. Hosts immune system:
i. Maturation of the immune system during
early childhood is most likely the primary
event leading to the decrease in incidence of
Otitis media.
ii. Selective IgG subclass deficiencies (despite
normal total serum IgG) have been implicated
in children with recurrent otitis media.
 ACUTE OTITIS MEDIA(AOM)
AETIOLOGY.
 Bacterial causes include:
i. Streptococcus pneumonia
ii. Heamophilus influenza
iii. Moraxella catarrhalis
iv. Group A Streptococcus
v. Staphylococcus aureus
vi. Gram negative organismns
 ACUTE OTITIS MEDIA (AOM)
 Viral causes (seen alone or more commonly
with pathogenic bacteria) include:
i. Rhinovirus
ii. Respiratory syncytial virus
 ACUTE OTITIS MEDIA (AOM)
CLINICAL FEATURES (SYMPTOMS)
- Ear ache (otalgia)
- Pulling and rubbing of ears
- Ear discharge
- Fever
- Hearing loss
- Irritability or change in sleeping or eating habits.
- Anorexia and passage of loose stools
 ACUTE OTITIS MEDIA (AOM)
CLINICAL FEATURES
The following may be noted during otoscopic
examination of the ear depending on stage
i. General hyperaemia of the tympanic membrane
which is opaque.
ii. Bulging of the tympanic membrane with
disappearance of bony landmarks.
iii. Absent or poor light reflexes.
 ACUTE OTITIS MEDIA (AOM)
iv. Perforation with mucopurulent or frankly
purulent discharge.
v. Hypomotility of the tympanic membrane
which is an evidence of middle ear effusion. It
is assessed using pneumatic otoscope.
 ACUTE OTITIS MEDIA (AOM)
DIFFERENTIAL DIAGNOSIS
- Referred pain to the ear (otalgia) may be
associated with infections of the adenoids,
tonsils, pharynx or teeth.
- Pain from otitis externa (diseases of the external
ear) when manipulated.
 ACUTE OTITIS MEDIA (AOM)
INVESTIGATION
- Ear swab m/c/s
- FBC
 ACUTE OTITIS MEDIA (AOM)
TREATMENT
Medical:
1. Antibiotics: Ammoxicillin which is the drug
of first choice for uncomplicated AOM. Other
drugs include cefpodoxime, cefuroxime,
azithromycin, clarithromycin, ammoxicillin/
clavulanate combination, ceftriaxone.
2. Analgesics such as acetaminophen and
ibuprofen.
 ACUTE OTITIS MEDIA (AOM)
3. Ear toileting.
4. Note that antibiotic ear drops are of no significant
value in acute otitis media.
COMPLICATIONS OF AOM
- Mastoiditis or sub-periostal mastoid abscess.
- Facial nerve palsy
- Chronic suppurative otitis media
- Neck stiffness which can be an early sign of
complicating meningitis.
 CHRONIC SUPPURATIVE OTITIS
MEDIA
• Chronic suppurative otitis media (CSOM)
consists of persistent middle ear infection with
discharge through a perforated tympanic
membrane.
• The two common types are;
- Tubotympanic disease
- Attico-antral disease or cholesteatoma
 CHRONIC SUPPURATIVE OTITIS
MEDIA
• Tubtympanic disease: follows poorly treated or
untreated acute disease and is accompanied by
deafness.
- The most common aetiologic agents are P.
aeuriginosa and S. aureus.
- Treatment involves conservative, antibiotic
use, aural cleansing and in refractory cases
surgery(tympanomastoidectomy).
 CHRONIC SUPPURATIVE OTITIS
MEDIA
Cholesteatoma: Is a cyst like growth originating
in the middle ear, lined by keratinized, stratified
squamous epithelium and containing
desquamated epithelium and/or keratin.
Aetiology of cholesteatoma;
- Complication of long standing chronic OM.
- Traumatic perforation of the tympanic
membrane
- Insertion of a tympanostomy tube.
 CHRONIC SUPPURATIVE OTITIS
MEDIA
Clinical features of cholesteatoma: These are;
- Chronically draining ear in a patient with
history of previous ear disease.
- Conductive hearing loss.
- Progressive expansion causing bony resorption.
 CHRONIC SUPPURATIVE OTITIS
MEDIA
Complications of Cholesteatoma:
i. Permanent hearing loss
ii. Facial nerve injury
iii. Labyrinthine damage with loss of balance
function
iv. Intracranial extension
Treatment of Cholesteatoma: Tympanomastoid
surgery
 OTITIS MEDIA WITH
EFFUSION(OME)
• OME is defined as an effusion of the middle
ear without evidence of an acute or systemic
infection.
• There are two types;
i. Persistent otitis media with effusion: This is
effusion that is present for over 1 month.
ii. Chronic otitis media is effusion that is present
for over 3 months.
 OTITIS MEDIA WITH
EFFUSION(OME)
• Clinical features;
- May be an incidental finding as it may be
asymptomatic.
- Mild disturbance in balance especially in
young children.
- A change in the behaviour of the child.
- Hearing loss is usually conductive.
 OTITIS MEDIA WITH
EFFUSION(OME)
INVESTIGATION/DIAGNOSIS
1. Pneumatic otoscopy: This is the mainstay of
diagnosis. It shows a retracted tympanic
membrane with decreased motility with or
without fluid.
2. Tympanometry
3. Acoustic reflectometry
4. Audiometry
 OTITIS MEDIA WITH
EFFUSION(OME)
COMPLICATIONS
- Persistent and fluctuant hearing impairment.
- Delayed language and speech development.
- Tympanic membrane retraction.
- Ossicular erosion due to adherence of the
tympanic membrane to the ossicles.
- Adhesive otitis media due to adherence of the
tympanic membrane to the medial wall of the
middle ear.
- Cholesteatoma
 OTITIS MEDIA WITH
EFFUSION(OME)
TREATMENT
- OME resolves completely within two months
of diagnosis in 80% of cases.
- Antibiotics can be given for a duration of 10-
28 days.
- Systemic antihistamines, systemic or topical
decongestants and topical steroids may be used
in combination with antibiotics.
 ADENOTONSILITIS
Adenotonsillitis refers to inflammation of the
adenoid and tonsils caused by infections.
ANATOMY
• The Waldeyers ring refers to the lymphoid
tissue that surrounds the opening of the oral
and nasal cavties into the pharynx. It is
composed of the following:
i. The palatine tonsils
ii. The Pharyngeal tonsils or adenoids
 ADENOTONSILITIS
iii. The lymphoid tissue surrounding the
eustachian tube orifice in the lateral walls of the
nasopharynx.
iv. The lingual tonsil at the base of the tongue.
v. Scattered lymphoid tissue throughout the
remainder of the pharynx, particularly behind
the posterior pharyngeal pillars and along the
posterior pharyngeal wall.
 ADENOTONSILITIS
The adenoid is a single aggregation of lymphoid
tissue that occupies the space between the nasal
septum and the posterior pharyngeal wall.
PHYSIOLOGY
• Approximately 65% of the lymphocytes that
make up the lymphoid tissue of Waldeyer ring
are B lymphocytes, the remainder are either T
lymphocytes or plasma cells.
 ADENOTONSILITIS
PHYSIOLOGY CONTD.
• The immunologic role of the tonsils and adenoid is
to induce secretory immunity and to regulate the
production of the secretory immunoglobulins.
• The tonsils and adenoid are in a position to
provide primary defense against foreign matter.
• Lymphoid tissue of Waldeyer ring is most
immunologically active between 4 and 10 yr of
age, with a decrease after puberty.
 ADENOTONSILLITIS
• No major immunologic deficiency has been
demonstrated after removal of either or both of the
tonsils and adenoid.
• Deep crevices within tonsillar tissue form tonsillar
crypts that are lined with squamous epithelium but
have a concentration of lymphocytes at their bases.
• The adenoid does not contain the complex crypts
that are found in the palatine tonsils but rather
more simple crypts.
 ADENOTONSILITIS
AETIOLOGY
• Acute infection:
-Most commonly caused by viruses .
-Group A β-hemolytic streptococcus (GABHS) is
the most common cause of bacterial infection
in the pharynx.
- β-hemolytic streptococcal species (group C)
- Staphylococcus aureus
 ADENOTONSILLITIS
-gram-negative organisms
- Mycoplasma pneumoniae
- rarely Neisseria gonorrhoeae
- Corynebacterium diphtheriae
- Candida
• Chronic infection:
- β-lactamase–producing organisms
 ADENOTONSILLITIS
-streptococci
-Haemophilus influenzae
-Anaerobic species, such as Peptostreptococcus,
Prevotella, and Fusobacterium.
 ADENOTONSILLITIS
CLINICAL FEATURES FOR ACUTE
INFECTION
• Symptoms include;
- odynophagia, dry throat, malaise, fever and
chills, dysphagia, referred otalgia, headache,
muscular aches, and enlarged cervical nodes.
• Signs include;
- dry tongue, erythematous enlarged tonsils,
tonsillar or pharyngeal exudate, palatine pete-
 ADENOTONSILLITIS
chiae, and enlargement and tenderness of the
jugulodigastric lymph nodes.
CLINICAL FEATURES FOR CHRONIC
INFECTION
• Symptoms; halitosis, chronic sore throats,
foreign body sensation, or a history of
expelling foul-tasting and smelling cheesy
lumps.
• Signs; tonsils of almost any size, frequently
containing copious debris within the crypts.
 ADENOTONSILLITIS
CLINICAL FEATURES CONTD.
• Airway obstruction can occur with both acute
and chronic tonsillitis.
• It is usually due to adenotonsillar hypertrophy
• Daytime symptoms of airway obstruction,
secondary to adenotonsillar hypertrophy,
include chronic mouth breathing, nasal
obstruction, hyponasal speech, hyposmia
 ADENOTONSILITIS
decreased appetite, poor school performance,
and, rarely, symptoms of right-sided heart
failure.
• Nighttime symptoms of adenotonsillar
hypertrophy consist of loud snoring, choking,
gasping, frank apneas, restless sleep, abnormal
sleep positions, somnambulism, night terrors,
diaphoresis, enuresis, and sleep talking.
 ADENOTONSILLITIS
• INVESTIGATIONS
- Throat swab m/c/s
- FBC
- lateral neck radiograph: detects size of the
adenoid
- flexible endoscopy: detects size of the
adenoids
 ADENOTONSILITIS
TREATMENT
MEDICAL
- Antibiotics
SURGICAL
i. Tonsillectomy alone is usually performed for
recurrent or chronic pharyngotonsillitis.
ii. Adenoidectomy alone may be indicated for the
treatment of chronic nasal infection(chro-
 ADENOTONSILITIS
nic adenoiditis), chronic sinus infections that
have failed medical management, and recurrent
bouts of acute otitis media.
iii. Adenotonsillectomy is indicated for upper
airway obstruction secondary to adenotonsillar
hypertrophy that results in sleep-disordered
breathing, failure to thrive, craniofacial or
occlusive developmental abnormalities, speech
abnormalities.
 ADENOTONSILITIS
COMPLICATIONS
- Acute pharyngotonsillitis
- Peritonsilar abscess
- Recurrent or chronic pharyngotonsillitis
- Retropharyngeal space infection
- Parapharyngeal space infection
- Chronic airway obstruction
 .

• THANKS FOR YOUR

ATTENTION
 SUGGESTED READING
1)Paul IN, Ibekwe MU. Common Ear, Nose and
Throat disorders in children. In Azubuike JC,
Nkanginieme KEO. Paediatrics and Child
Health in a Tropical region.3rd ed. Owerri:
African Educational services; 2007.
(2) Wetmore RF. Tonsils and Adenoids.In :
Kleigman MR, Berham ER, Jenson BH,
Stanton FB, editors. Nelson’s Textbook of
Paediatrics.18th ed. Elsevier; 2011.
 SUGGESTED READING
(3)Webb JKG. Diseases of the respiratory system.
In: Stanfield P, Brueton M, Chan M, Parkin M,
Waterston T, editors. Diseases of Children in
the Subtropics and Tropics. 4th ed. Educational
Low priced books.
(4) Internet.