Otitis Media in a Developing World

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Otitis Media in a Developing World

• Dr Wakisa Mulwafu, MBBS, FCORL( SA) , FCS(ECSA)

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Otitis Media

• Literally means inflammation of the middle ear
• Most often, synonymous with infections of the
  middle ear
• Consider other causes allergy, anatomical
  defects

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• In Africa and other developing nations the
  disease prevalence could be as high as 11

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• The middle ear cleft
• middle ear cavity, ossicles, additus ad
  antrum-recess
• mastoid cavity,
• Eustachian tube narrow air pressure

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Middle ear cleft anatomy
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Normal TM
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• The functions of the middle ear structures
• transformation
• transmission
• amplification of sound in hearing
• This function is impaired in otitis media

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Classification of Otitis Media

• Otitis media is a broad subject which could be
  classified according to
• Duration - acute otitis media and chronic otitis
  media
• Nature of fluid/discharge - suppurative and
  non-suppurative otitis media.
• Otitis media with effusion and Aero-otitis media
• Causative organism- bacterial otitis media
  (common) and specific otitis media
• e.g. Tubercular and syphilitic otitis media(less
  common).

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• Browning et al
• de-emphasizes the words suppurative and
  nonsuppurativeotitis media
• active, inactive, healed,
• The standard classification remains acute otitis
  media, chronic otitis media, otitis media with
  effusion and specific otitis media.

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Two conditions Leading to COM

• AOM
• OME

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Acute Otitis Media (AOM)

• This is an acute infection/inflammation of the
  middle ear mucosa which also involves the mastoid
  air cells most often.
• predominantly a childhood infection
• without sex preponderance
• 75 of the few adults that have this condition
  are young adults below 44 years of age

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Microbiology

• Global reports show that
• Hemophilus influenza
• Streptococcus pneumonia are the most prevalent
  organisms.

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• However, most studies (past and present) from
  different parts of Africa suggest a different
  bacteriology spectrum.
• Staphyloccocus aureus and Streptococcus pyogenes
• sensitive to penicillin based antibiotics,
  Cephalosporins, and Quinolones.

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• Ruohola et al demonstrated that
• most cases of AOM consist of mixed infection of
  bacteria and virus

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Clinical features

• systemic and local.
• high grade fever (40-41C),
• refusal of feeds, incessant cries and
  irritability.
• Otalgia
• tinnitus
• conductive hearing loss.
• Ear discharge is seen in well above 90 of cases
• Hyperemic tympanic membrane

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• sometimes bulging (if there are exudates within
  the middle ear).

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Sequelae

• may resolve following appropriate measures such
  as suitable antibiotics
• may progress to complications in the presence of
  poorly treated or untreated virulent organisms.
• extracranial or intracranial complications.
• Acute mastoiditis
• facial nerve paralysis
• labyrinthitis
• petrositis
• extradural and subdural abscesses
• meningitis
• otitic brain abscesses
• otitic hydrocephalus
• and lateral sinus thrombosis.

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Traetment

• Guided by the knowledge and behavior of
  predominant causative agents
• One school of thought precludes antibiotics
  therapy
• associated with viral infections 32-34, however
• Within the developing world
• most of the cases are either mixed (bacterial
  viral) or bacterial infections18,35.

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Treatment

• Daily aural toileting is mandatory for the
  discharging ear.
• Myringotomy in bulging TM is encouraged prior to
  antibiotics management.
• Adequate analgesia to reduce otalgia

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OME

• Accumulation of fluid (non-purulent) within the
  middle ear cleft with an intact TM

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• also been referred to as
• Glue ear
• Mucoid otitis media
• Secretory Otitis media
• Serous otitis media

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Pathogenesis

• Firstly
• Eustachian tube disorder which results in poor
  aeration of the middle ear and poordrainage of
  secreted fluids.
• Secondly,
• results from hyperactivity of the middle ear
  glands which leads to excessive accumulation of
  mucus secretions

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Clinical features

• present with conductive hearing loss.
• 40dB).
• otalgia
• speech difficulties since the child requires
  proper hearing for speech acquisition
• intact but dull tympanic membrane
• lacking in the light reflex
• obvious restrictions in mobility
• brown to yellow

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OME
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Medical treatment

• Topical vasoconstrictors/nasal decongestants
  encourage
• aeration of the middle ear and
• Use of appropriate antibiotics
• anti- allergic drugs
• Relevant physical exercises e.g. jaw exercises
  (through gum chewing)
• Valsalva maneuvers

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Surgical treatment

• Evidence has shown
• better outcome
• lesser complications with tympanostomy tube as
  compared to those managed conservatively.

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Chronic Otitis Media

• permanent abnormality on the TM
• follows a long standing middle ear infection
  emanating from previous AOM or OME

Monolayer mimicking perforation
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• No generally accepted time divide between acute
  and chronic OM.
• Some authorities time ranges from 2 weeks to 3
  months.

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• COM is commoner in
• the developing countries
• people of lower socioeconomic class 2, 69
• patients suffering from gastroesophageal diseases
  (GERD). 71
• patients with craniofacial
• abnormalities e.g. cleft lips/palates,
  velopalatine muscle incompetence
• affects all age groups with preponderance in
  adults, but no sex discrimination.

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Bacteriology

• The bacteriological causative agents most
  commonly associated with COM include
• Pseudomonas aeruginosa, proteusspp, E. coli and
  Staphylococcus areus. 15, 16
• Common anerobes include Peptostreptococcusspp,
  Prevotella melaninogenica and B.fragilis. 74

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• Pathologically, sub-divided into
• mucosal and squamous COM
• tubotympanic -safe and atticoantral - unsafe

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Principles of management

• Eradication of disease
• Restoration of function

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Medical treatment

• Aural toileting
• Appropriate antibiotics
• Topical or systemic
• Nasal decongestants