| disease | Acute Suppurative Otitis Media |
Bacterial invasion of the tympanic cavity leading to purulent infection is called acute suppurative otitis media, often secondary to upper respiratory tract infections. Some cases may initially be caused by viral infections, followed by bacterial invasion. Common pathogens include hemolytic streptococcus, Staphylococcus aureus, type III pneumococcus, and Proteus. It is more prevalent in winter and spring, and is easily induced in individuals with blood disorders, malnutrition, allergies, cardiopulmonary diseases, nephritis, or diabetes. Statistics show that the incidence rate is as high as 3% in school-aged children between 5 and 16 years old, and 5–10% in those under 5 years old, with some cases experiencing recurrent episodes. The incidence rate is significantly higher among Eskimos and Native Americans compared to Caucasians, though it remains uncertain whether this is due to racial genetics or living conditions.
bubble_chart Etiology
(1) Eustachian tube infection After an upper respiratory tract infection, nasopharyngeal secretions can enter the tympanic cavity through actions such as nose blowing, swallowing, and vomiting, which is also the most common route of otitis media. The reasons for the high incidence in children are: ① They are prone to acute pestilence diseases such as measles, scarlet fever, whooping cough, and pneumonia, which mainly manifest as upper respiratory tract inflammation; ② The eustachian tube in children is relatively shorter, straighter, and more horizontal compared to adults, making it easier for secretions to enter the tympanic cavity through this passage; ③ Children often lie on their backs while nursing, especially during artificial feeding, making it easy for vomit and excess milk to flow into the tympanic cavity; ④ Children frequently suffer from adenoid hypertrophy and peritubal lymphadenitis, which can easily block the eustachian tube orifice, hinder drainage, and lead to inflammation; ⑤ During the teething period, children often experience poor appetite, local swelling, and weakened resistance, making them more susceptible to other infections; ⑥ Congenital chapped lips and cleft palate can lead to poor palatopharyngeal function, increasing the risk of eustachian tube infection, while the tympanic cavity contains more submucosal embryonic tissue with weak infection resistance. Surgeries such as adenoidectomy and nasal polyp removal, due to prolonged bleeding and packing, can also easily cause tympanic cavity infection.
(2) External auditory canal infection This is relatively rare, such as wartime firearm blast injuries, ear-picking injuries, boxing, or diving-induced tympanic membrane rupture followed by infection. Severe external otitis, if prolonged, can lead to tympanic membrane erosion and perforation, causing tympanic cavity infection.(3) Hematogenous infection This is the least common. In acute grade III pestilence diseases and septicemia, bacteria can directly enter the tympanic cavity through the stirred pulse or via infected venous thrombosis.
In the early stages of acute otitis media, viral antibody titers often rise, possibly due to adenovirus or influenza virus infection, followed by bacterial invasion. In children, the bacteria are mostly pneumococci, Hemophilus influenzae, and β-hemolytic streptococci, while in adults, they are mostly hemolytic streptococci, Staphylococcus aureus, and Proteus. Later, if the tympanic membrane perforates, mixed infections may occur.
bubble_chart Pathological Changes
Initially, the eustachian tube mucosa becomes inflamed and the pharyngeal orifice becomes blocked. The oxygen in the tympanic cavity is absorbed, creating negative pressure, leading to a large effusion in the tympanic cavity, which becomes a bacterial culture medium. Bacteria enter and multiply rapidly. In the early stage, the tympanic membrane is invaded inward, appearing dark gray, then becomes congested and bulges outward. The blood flow in the stirred pulse is obstructed by pressure, causing central necrosis of the tympanic membrane, which eventually ruptures and discharges pus. From infection to perforation and pus discharge of the tympanic membrane, it generally takes 5 to 7 days. In some cases where the bacteria are highly virulent, perforation and pus discharge may occur within 2 to 3 days.
bubble_chart Clinical Manifestations(1) Eustachian tube obstruction stage The tympanic membrane invades inward, presenting with low-pitched tinnitus, grade I conductive deafness. Children cannot describe it but feel ear discomfort, affecting normal play. The handle of the malleus is congested and prominent, positioned more horizontally, with the short process noticeably raised like a bone spur. Early effusion in the tympanic cavity may occasionally reveal air bubbles or fluid levels through the tympanic membrane. This stage is often mistaken by patients for a common cold.
(2) Pre-suppurative stage The tympanic membrane shows radial centripetal congestion, and the handle of the malleus turns into a red rod-like structure. Subsequently, the flaccid part becomes swollen and protrudes outward, soon followed by the entire tympanic membrane turning red and bulging. In this stage, children develop high fever, convulsions, head-shaking, ear-grabbing, and restless crying, often accompanied by diarrhea and vomiting, which may be misdiagnosed as gastrointestinal disorders. Adults experience significant tinnitus, deafness, and severe ear pain, with fever reaching 38–40°C. If effective antibiotic treatment is administered promptly during this stage, recovery may gradually occur; otherwise, it progresses to the suppurative phase.
(3) Suppurative stage The tympanic cavity accumulates a large amount of pus, and the tympanic membrane bulges outward extremely, with the shape of the malleus disappearing. Symptoms include pulsatile tinnitus, severe deafness, and intense ear pain that may radiate to the maxillary teeth and temporoparietal region. The posterior wall of the external auditory canal (Macewen’s triangle) and the mastoid antrum area show obvious tenderness. Children exhibit high fever, refusal to eat, restlessness, and signs of intoxication such as pale complexion.
(4) Resolution stage After 4–5 days of infection, the center of the tympanic membrane turns yellow and necrotic, eventually rupturing to discharge pus—initially serous, then mucopurulent, and finally pure pus. The perforation starts as a small central hole and enlarges into a kidney-shaped defect. Once pus drains, all symptoms except tinnitus and deafness disappear abruptly, body temperature returns to normal, children can feed and sleep, and adults can resume normal work.Based on medical history and signs, diagnosis is relatively easy in adults but more challenging in children. One reason is the lack of ear-related symptoms, with severe gastrointestinal reactions being the main manifestation. Another is the narrow ear canal in children, making the eardrum difficult to examine. If a child has a high fever following an upper respiratory infection and frequently shakes their head or scratches their ears, this condition should be considered. First, check for pharyngeal infections or teething, as well as tenderness or swollen lymph nodes in the ear area. In children, the eardrum is often thickened, making the light reflex and congestion hard to observe. Even grade I congestion may result from prolonged crying or teething. If necessary, tympanocentesis should be performed for differentiation.
bubble_chart Treatment Measures
In the early stage of eustachian tube obstruction, use chloramphenicol and ephedrine nasal drops to constrict the pharyngeal opening, and instruct the patient to perform swallowing and yawning movements to open the pharyngeal opening for ventilation. Avoid performing the Valsalva maneuver or eustachian tube catheterization. For ear pain, analgesics can be administered, and compound formula Sinomin can be given orally to prevent bacterial infection. If bacterial infection progresses to the pre-suppurative stage, presenting with ear pain and fever, promptly administer penicillin 800,000 units intramuscularly twice daily, or 4–8 million units intravenously via drip. After one week of treatment, 80% of patients can be cured. Erythromycin and josamycin are also effective when taken orally. Treatment failure is often due to infection with drug-resistant cocci or bacilli, and the medication should be promptly changed. If excessive pus accumulates in the tympanic cavity, causing significant bulging of the tympanic membrane, high fever, and severe pain, the pus may not drain through the eustachian tube into the pharynx. In children, the eustachian tube is short and wide, and early drainage may occasionally be possible by instilling 1–2% phenol glycerin to reduce inflammation and relieve pain. In addition to continuing broad-spectrum antibiotic therapy, consider measures to expel pus:
(1) **Tympanocentesis for pus aspiration**: First, disinfect the external auditory canal with alcohol. Apply a cotton ball soaked in Bonain’s solution (a mixture of equal parts cocaine, menthol, and phenol) to the surface of the tympanic membrane for 3–5 minutes; this solution has strong surface anesthetic effects. Then, insert a thick, long 12-gauge needle into the anteroinferior quadrant of the tympanic membrane and slowly aspirate the pus. The cavity can be rinsed with 3% hydrogen peroxide or saline, followed by irrigation with penicillin or gentamicin solution, which is then left in the cavity. Perform this once daily; most cases are cured after 1–2 treatments. During the procedure, the patient should lie on their side and may occasionally experience pain or vertigo. This method can replace the traditional tympanotomy and is particularly suitable for children with narrow external auditory canals. If repeated aspirations fail to resolve the condition, proceed with tympanotomy.
(2) **Tympanotomy**: For children, general anesthesia is used, while adults may receive surface anesthesia with Bonain’s solution or nerve block anesthesia around the external auditory canal with 1–2% lidocaine. The patient is positioned laterally or supine with the head turned to the side. After disinfecting the external auditory canal and tympanic membrane, insert a large ear speculum. Under direct vision or microscopy, insert a tympanotomy knife into the ear canal and make a 2–3 mm incision in the anteroinferior quadrant of the tympanic membrane. Avoid inserting too deeply to prevent injury to the promontory mucosa or ossicles. Then, aspirate the pus with a suction device and rinse with the aforementioned solutions. The tympanotomy knife may sometimes be insufficiently sharp, making it difficult to complete the incision smoothly in one attempt, and there is a risk of injuring the ossicular chain or even the facial nerve, especially in 1–2-year-old children, for whom the procedure is challenging. Currently, aspiration is often preferred as an alternative.
**Post-tympanic membrane perforation treatment**: After perforation, in addition to continuing broad-spectrum antibiotic therapy, local medication is crucial. Improper treatment or poor drainage, leading to persistent pus discharge for over a month, may result in chronic otitis media. Principles of local medication:
1. **Ear drops**: Typically, solutions are prepared with water, alcohol, or glycerin, containing broad-spectrum antibiotics such as penicillin, chloramphenicol, erythromycin, or polymyxin. Avoid ototoxic drugs like neomycin, gentamicin, or streptomycin. The solution may also contain boric acid, borax, phenol, or sulfonamides, as well as Chinese herbal medicines such as coptis rhizome extract or rehmannia. When applying, the affected ear should face upward while lying on the side. First, clean with 3% hydrogen peroxide, dry thoroughly, and then instill the drops. Adhere strictly to cleaning and instilling drops 2–3 times daily. After instillation, press the tragus toward the ear canal or cover the ear with the palm to help guide the medication into the tympanic cavity. Frequent swallowing can also aid in this process. In the early stage with abundant pus, use glycerin or aqueous solutions; in advanced stages, opt for alcohol or aqueous drops to promote drying and anti-inflammatory effects. Avoid colored solutions such as gentian violet, mercurochrome, or iodine preparations, as they may obscure observation of the lesion.
2. **Ear powders**: For minimal pus, powders such as chloramphenicol, boric acid powder, sulfonamides, or prednisone can be sprayed to promote drying. Avoid excessive use, as this may cause the powder to clump with pus and obstruct drainage, potentially leading to intracranial complications.
3. Systemic treatment should be based on pus culture and drug sensitivity tests, using effective antibiotics in large doses to maintain high blood concentrations for at least one week or more. Chinese medicinals can also be taken. It is crucial to avoid small doses, short durations, or frequent changes of medication to prevent bacteria from developing resistance, which could prolong the course of the disease or lead to latent otitis media—temporary improvement followed by rapid deterioration. With proper treatment, 85–90% of patients can expect recovery within two weeks, with small perforations possibly healing and hearing returning to normal. Large perforations may require surgical repair.
Improper treatment of acute suppurative otitis media or weakened systemic resistance can lead to inflammation spreading directly from the tympanic sinus to the mastoid, forming acute mastoiditis. It may also penetrate the cortical bone to create a subperiosteal abscess or enter the intracranial space through congenital cranial sutures, causing intracranial complications and affecting the facial nerve, resulting in deviation of the mouth. In the past, acute otitis media in children often led to suppurative meningitis, but with the widespread use of broad-spectrum antibiotics, such complications have become rare.
(1) External Otitis and Furuncle There is diffuse swelling at the external auditory canal opening and within the canal, with exudation of serous secretions. In the advanced stage, localized furuncles form with pus, and the secretions are non-mucoid. Mild deafness is characteristic. Pressure on the tragus causes severe pain, and the postauricular lymph nodes are often enlarged.
(2) Acute Tympanic Membrane Inflammation Often complicating epidemic common cold and herpes zoster oticus, the tympanic membrane becomes congested and forms bullae, accompanied by severe ear pain. However, there is no perforation or purulent discharge, hearing loss is mild, and the white blood cell count does not increase.
