DNB Pediatrics FAQ 5 - ASOM

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About Shailesh Gophane
DCH from J.J. Hospital, Mumbai and DNB from Port Trust Hospital Mumbai.
 This is a series of Notes for dnb pediatrics theory exams. Definitely they are not the alternative to reading Nelson's thoroughly, but these notes will prove helpful during final days of revision and may be helpful to overcome any loopholes if you are not having enough time to cover whole system. " December 2015 had 6 repeat questions from these notes.
FAQ: 5
Outline the etiopathogenesis of acute suppurative otitis media. Discuss in brief the treatment and complications of acute suppurative otitis media (asom) in children.

Etiology:

1.Pre pneumococcal vaccine era

Streptococcus pneumoniae,
Nontypable Haemophilus influenza
Moraxella catarrhalis.

2.Post conjugate pneumococcal vaccine era

Nontypable H. influenzae (40-50% of cases )

3.Other pathogens

Group A streptococcus, Staphylococcus aureus, and gram-negative organisms.


4.Viruses

RSV, Rhino virus

They impair local immune function and increases bacterial adherence

Pathogenesis:

1.Anatomical factors

Interruption of ventilation to middle ear mucosa by tubal obstruction initiates an inflammatory response that compromises the mucociliary transport system, and causes effusion of liquid into the tympanic cavity.

2.Eustachian tube obstruction

Extraluminal blockage by hypertrophied nasopharyngeal adenoid tissue or tumor.

Intraluminal obstruction via inflammatory edema of the tubal mucosa.

Excessively patulous or compliant eustachian tube may fail to protect the middle ear from reflux of infective nasopharyngeal secretions.

Impairment of the mucociliary clearance leads to establishment and persistence of infection.   

The shorter and more horizontal orientation of the tube in infants and young children increases the risk of reflux from the nasopharynx.

3.Host factors:

Ig A deficiency and IgG sub class deficiency.

Treatment:

1.Medical
a.First line

Amoxycillin 40-90mg/kg/day for 3-5 days in milder cases to 10 days in severe cases.
For those with Penicillin allergy
Type 1 [itching, urticaria] Cefdinir can be given.
Type 2 - Azithromycin can be given.

b.Second line

Amoxy Clav , Cefdinir, Cefuroxime axetil, IM Ceftriaxone.

2.Surgical

Myringotomies & Tympanocentesis.

Indications are

Severe, refractory pain, Hyperpyrexia.
Complications of AOM such as facial paralysis, mastoiditis, labyrinthitis, or central nervous system infection.
Tympanostomy tube insertion in recurrent AOM despite adequate medical therapy.

Complications :

1.Tympanosclerosis

2.Atelectasis of the TM - as a consequence of long-standing retraction or severe or chronic inflammation.

3.retraction pocket is a localized area of atelectasis. A deep retraction pocket may lead to erosion of the ossicles and adhesive otitis, and may serve as the nidus of a cholesteatoma.

4.Chronic perforation more commonly results as a sequelae of CSOM, generally accompanied by conductive hearing loss.

5.Cholesteatoma formation.

6.Permanent conductive hearing loss.

7.Permanent sensorineural hearing loss with acute or chronic OM, secondary to spread of infection or products of inflammation through the round window membrane, or as a consequence of suppurative labyrinthitis.

8.Permanent hearing loss can cause delay in speech and language development.

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