ACUTE OTITIS MEDIA

DEFENTION:
Acute Inflammation of the mucoperiosteal lining of the middle ear cleft
(Eustachian tube, tympanic cavity, mastoid antrum and mastoid air cell )
• Incidence:
Acute otitis media is primarily a disease of children.
Its peak incidence is during the first 6 years of life.
• Several factors contribute to the prevalence of acute otitis media media in early
childhood. These include:
1 – Anatomical features of Eustachian tube :
The Eustachian tube is
– shorter,
– wider
– and more horizontal than in adults
&The orifices of the tube are surrounded by lymphoid tissues.
2 – Frequent exposure to upper respiratory infections
3 – Immature immune system

PREDISPOSING FACTORS :
-poor socioeconomic conditions
– Crowding
– Bottle feeding
– malnutrition
– immunodeficiency as: DM
– Passive Smoking
– Pollution
– Mucociliary disorders
_upper respiratory tract infection as: allergy, chronic sinusitis
_eustachian tube dysfunction
_ craniofacial abnormalities (such as cleft palate).
• Bacteriology
The common organisms include:
– Streptococcus pneumoniae,
– Moraxilla catarrhalis
– H. influenzae is more frequent during infancy and early childhood.
– Viral infection commonly precedes secondary bacterial invasion

ROUTES OF INFECTION :
a) Through the Eustachian tubes: This is the commonest route.
1-extention of infection from:

Nose:rhinitis

Sinuses:sinusitis

Nasopharynx:adenoid

2-passage of infected material as vomitus,infected milk or water,nasal packing

b) Through a drum perforation.

c) blood borne infection :rare

PREVENTION:
-Primary prevention:
prevent occurance of disease via

1-depend on breast feeding than formula especially in first year of life due to its benefits.
2-control and treat upper respiratory infections.

3-avoid passive smoking in children.

4-take all primary preventive measures for those having cleft palat.

5-antibiotics prophylasix

6- surgical correction of anatomical abnormalities are essential preventive strategie

adenoidectomy،

7-antimicrobial vaccines for bacteria caused it and for viruses.

Cessation of smoking, tight control of diabetes

Health education:

1-complete ttt of AOM especially in children as they more liable for complication due to
low immunity.

2-ttt upper respiratory tract infection.

3-take antimicrobial vaccines .

4-depend on breast feeding than formula especially in first year of life due to its benefits.

5-avoid flat position during breast or artificial feeding as it facilitates enterance of milk to
ET.

6-tell them about warning manifestations of complications as severe pain ,headache

,fever, vertigo, facial paralysis.

-secondary prevention :

Early detection and ttt Secondary (early diagnosis ,proper ttt)

Proper antibiotic selection and ensuring patient compliance through the whole course of
treatment are vital. For Streptococcal pneumoniae, Haemophilus influenza, and
Moraxella catarrhalis infection, high-dose amoxicillin or amoxicillin–clavulanate are
effective. Cephalosporins (such as cefuroxime or cefdinir), penicillin, beta-lactam, and
fluoroquinolones are other alternatives. Treatment duration should range from 10-14 days
at least.4-6 Treatment for shorter periods may lead to inadequate control of infection and
the evolution to otitis media with effusion or chronic suppurative otitis media

teriary prevention :

Ttt the complications and hearing aid .

TREATMENT:

Before the perforation :

• Antibiotic
• decongestant
• Antipyretic- analgesic preparations.
• Myringotomy
After the perforation of tympanic membrane
• Antibiotics ( Culture and sensitivity of the discharge may be needed)
• Antibiotic ear drops.
• Decongestant
• Frequent cleaning of the ear.

• Myringotomy
 Allergic Rhinitis

What is allergic rhinitis?

Allergic rhinitis (AR) is a chronic inflammatory immunoglobulin (Ig) E-mediated disease of
the nasal mucosa that can be triggered by the inhalation of seasonal or perennial allergens .
Pollen is the most common allergen in seasonal allergic rhinitis.

In addition to tree pollen, other common allergens include:

1. grass pollen
2. dust mites
3. animal dander, which is old skin
4. cat saliva
5. mold
During certain times of the year, pollen can be especially problematic. Tree and flower
pollens are more common in the spring. Grasses and weeds produce more pollen in the
summer and fall.

Risk factors for allergic rhinitis

Allergies can affect anyone, but more likely to develop allergic rhinitis if there is a history of
allergies in family. Having asthma or atopic eczema can also increase your risk of allergic
rhinitis.

Some external factors can trigger or worsen this condition, including:

1. cigarette smoke
2. chemicals
3. cold temperatures
4. humidity
5. wind
6. air pollution
7. hairspray
8. perfumes
9. colognes
10.wood smoke
11.fumes

What causes allergic rhinitis?

When your body comes into contact with an allergen, it releases histamine, which is a
natural chemical that defends your body from the allergen.
This chemical can cause allergic rhinitis and its symptoms
Symptoms of allergic rhinitis:
1. sneezing
2. a runny nose
3. a stuffy nose
4. an itchy nose
5. coughing
6. a sore or scratchy throat
7. itchy eyes
8. watery eyes
9. dark circles under the eyes
10.frequent headaches

Types of allergic rhinitis:

1-Seasonal: allergies usually occur during the spring and fall season and are typically in
response to outdoor allergens like pollen .

2-Perennial: allergies can occur year round, or at any time during the year in response to
indoor substances, like dust mites and pet dander.

Primary prevention
The best way to prevent allergy symptoms is to manage your allergies before your body has
a chance to respond to substances adversely .
Consider the following preventive measures for the particular allergens you’re sensitive to:
1. Stay indoors when pollen counts are high.
2. Avoid exercising outdoors early in the morning.
3. Take showers immediately after being outside.
4. Keep your windows and doors shut as frequently as possible during allergy season.
5. Keep your mouth and nose covered while performing yard work.
6. Try not to rake leaves or mow the lawn.
7. Bathe your dog at least twice per week to minimize dander.
8. Remove carpeting from your bedroom if you’re concerned about dust mites.

Immunotherapy

Types of Immunotherapy

1-Subcutaneous immunotherapy (SIT)

2-Local nasal immunotherapy (LNIT) and sublingual immunotherapy (SLIT).

Subcutaneous immunotherapy alters the natural course of allergic diseases.

Doses of 5–20 μg of the major allergen are optimal doses for most allergen vaccines.

Subcutaneous immunotherapy should be performed by trained personnel and patients

should be monitored for 20 min after injection.
In children, specific immunotherapy is effective. However, it is not recommended to
commence immunotherapy in children less than 5 years of age.

Mechanism of Action
1. Blunting of the usual seasonal rise in IgE antibodies,
2. Increase in serum IgE antibodies with change in subclasses (increased IgG 1 and
IgG2),
3. Down-regulation of the cellular and inflammatory mediators of allergic response,
4. Up-regulation of counter regulatory cytokines expressed by Th 1 response.

Secondary prevention:
Treatments for allergic rhinitis
1. Antihistamines: antihistamines to treat allergies.They work by stopping your body
from making histamine.
2. Decongestants: using decongestants over a short period, usually no longer than
three days, to relieve a stuffy nose and sinus pressure. Using them for a longer time
can cause a rebound effect, meaning once you stop your symptoms will actually get
worse.
3. Eye drops and nasal sprays: Eye drops and nasal sprays can help relieve itchiness and
other allergy-related symptoms for a short time.
4. Corticosteroids: can help with inflammation and immune responses. These do not
cause a rebound effect. Steroid nasal sprays are commonly recommended as a long-
term, useful way to manage allergy symptoms.
 Dysphagia
Definition:
 Difficult swallowing or sensation of the act of swallowing.
Types:
 Mechanical: Narrowing of the lumen of pharynx or esophagus More to solids.
 Functional: Inadequate function of the muscles of deglutition More to fluids.
Etiology:
Oral Causes:
 Cleft Palate
 Corrosives and Wounds
 Oral Ulcers
 Cancer Tongue
 Paralysis of Tongue
Pharyngeal Causes:
 Atresia
 Corrosives and Lacerations
 Tonsillitis, Pharyngitis
 Cancer Pharynx
 Pharyngeal Pouch
Esophageal Causes:
 Atresia, Tracheo-esophageal fistula
 Corrosives
 Esophagitis, Plummer-Vinson syndrome
 GERD
 Leiomyoma, Carcinoma
 Achlasia of Cardia
 Foreign Body
 Malignant Thyroid
 Hiatus Hernia
 Enlarged Left Lobe of Liver
Symptoms:
Dysphagia may be associated with:
 Choking on food or drinks
 Coughing during or after swallowing
 Pain during swallowing
 Aspiration
 Regurgitation
 Hoarseness
 Drooling of saliva
 Sense of lump in the throat
 Heartburn
Investigations:
 Barium Swallow
 Endoscopy
 Manometry (esophageal muscle test)
 Imaging: CT, MRI

Prevention:
Primary
1- Change lifestyle (eating slowly and chewing well).
2- Avoiding alcohol, tobacco and caffeine. These can make heartburn worse.
3- Avoiding talking while eating.
4- Avoiding eating while lying down.
Secondary:
1- Early detection and management of leading causes such as GERD, plummer vinson
syndrome.
2- TTT of oropharyngeal causes by exercises for cheek muscles, swallowing
techniques.
3- TTT of esophageal causes by esophageal dilatation, surgery, medications (PPI,
steroids, muscle relaxant).
4- TTT of neoplastic diseases present in the pathway of food passage to the stomach
such as cancer tongue or pharyngeal carcinoma or esophageal carcinoma.
5- TTT of Congenital malformation of oral cavity, esophagus, as cleft palate or
esophageal atresia.
 Epistaxis

• Definition:

It is bleeding from the nose

• Incidance

Epistaxis occurs commonly in the general population, with most people

experiencing at least 1 episode in a lifetime. The age of patients most affected
by epistaxis follows a bimodal distribution, with the highest rates in those less
than 10 years of age as well as those 70 years and older.

Epistaxis is also commonly observed in clinical practice among patients taking

antithrombotic therapies. As numerous cases are self-limiting and do not
require patients to seek medical attention, the true incidence is likely not
known. In an American study over a 10-year period, epistaxis was responsible
for 1 in 200 emergency room (ER) visits, 6% of which required hospitalization.

• Risk factors:
 • Causes

1- local -Idiopathic -Trauma -Inflammation –Tumors

2- systemic -Hypertension -Bleeding tendency -Drug

• Diagnosis

1- coagulation profile

2- CBC

3- CT of nose and paranasal sinuses

4- biopsy from tumor if present

• Prevention

Primary prevention:

- staying well hydrated,

- avoid hot dry weather

- avoid hot & spicy food

- Avoid forceful nose blowing,

- do not try to clear your nose with an object like a Q-tip

- If you must take a medication that can cause bleeding, ask your doctor whether
a lower dose or different drug might be used.

Secondry prevention:

- keep allergic rhinitis under control

if epistaxis is related to other conditions treat / control the condition use nasal
sprays to keep your nose moist - stop smoking as it causes dryness and irritation

Tertiary prevention

nasal packing

cautery ( chemical & electro-cautery & endoscopy guided cautery )

artery ligation according to site of bleed ( maxillary & ethmoidal )

embolization of bleeding vessel

 Facial nerve
facial nerve paralysis:

 is a loss of facial movement due to nerve damage.

Symptoms and signs:

 drooling
 difficulty eating and drinking
 an inability to make facial expressions, such as smiling or frowning
 facial weakness
 muscle twitches in the face
 dry eye and mouth
 hyperacusis
 irritation of the eye on the involved side

Causes:

Diagnosis:

 Radological: CT, MRI for fractures and tumors

 Audiological: associated ear lesion by PTA
 Detection of level for paralysis by Schrimmer test, taste sensation, stapedial reflex,
submandibular flow test
 Electrophysiological tests to detect degree of paralysis (Nerve excitability test,
electromyography)
Primary prevention:

 Health education: About the possible causes of facial paralysis and how to protect
from them
 Early treatment of causes that may lead to fascial paralysis eg: otitis media ,
Cholesteatoma, parotid tumor.

Secondary prevention:
1 conservative:

a-Care of the eye:

 Aim: to avoid exposure keratitis , dryness

 Method: eye drops ,oinment ,glasses
 In sever cases: gold weight or lateral tarssoraphy

b-Care of the paralyzed muscle:

 Aim: to avoid disuse atrophy

 Method: massage of the facial muscles. active muscular exercise when recovery
begins

2 Therapeutic:

1. pulse steroid therapy

2. surgical exploration

Tertiary prevention (Rehabilitation):

1-Dynamic

 Aim: to regain motor activity of face when facial muscles are still liable
 Method:
1. hypoglosso-facial anastomosis.
2. facio-facial anastomosis

2-Static

 Aim:to improve appearance of the face during rest when facial muscles are fibrosed
 Method:
1. fascia lata sling to elevate angle of mouth.
2. implantation of temporalis muscle in the cheek
Definition:
Inflammation of the mucosa of sinuses, it’s usually associated with rhinitis
(inflammation of the nose), so it is called rhino sinusitis.

Classification:
infectious
1. viral
2. Bacterial
3. fungal

Non infectious
1. Chemical irritation
2. Structural problems as: nasal and sinus tumor, FB
3. Allergies
4. Air pollution

Causative organisms:
1- Virus
rhinovirus
influenza
para influenza

2- Bacteria
Sterpt. Pneumonia
Hemophilus influenza
Moraxella catarrahalis

3- Fungi
Aspergillus

Epidemiology:
• acute rhino sinusitis is affecting an estimates 6-10% of patients seen in daily
outpatient practice.
• Prevalence of chronic rhino sinusitis is 5-12%, might be overestimated
because of overlap with other diseases as allergic rhinitis.
 • Bacterial sinusitis develops in 90% of patients with viral upper respiratory
tract infection.
• More often seen with:
 25-30% of allergic patients
 43% of asthmatic patients
 54-68% of AIDS patients

Routes of infection:
1- Nasal:

* extension of infection: rhinitis then secondary infection

* Passage of infected material
- FB in nose - nasal pack
- nasogastric tube - infected water
2-Dental: dental caries or oro-antral fistula lead to maxillary sinusitis

Risk factors:
1- A previous cold

2- Seasonal allergies
3- Smoking and exposure to secondhand smoke
4- Air pollution
5- Nasal obstruction due to polyps, foreign bodies and tumors.
6- A weak immune system or taking drugs that weaken the immune system
7- Dental diseases

Symptoms:
1- General: Fever, Malaise

2- Nasal obstruction
3- Nasal discharge
4- Reduction or loss of smell
5- Facial pain or pressure
6- Headache
7- Cough
8- Bad breath

Diagnosis:
Clinical picture:
1- fever, headache, malaise
2- nasal obstruction, discharge, facial pain
Investigation:
3- Culture and sensitivity of discharge.
4- X-ray: it shows opacity or fluid level.
5- CT: it shows opacity of the infected sinus.

Prevention
Primary prevention:

1- Health education:
* Keep your distance: Limit your contact with people who are sick
* Open the windows: Ventilate your house.
* Avoid harsh fumes and Exposure to cigarette and cigar smoke.
* Bathe your nasal passages daily
* Avoid antihistamines unless prescribed
2- Control of diseases that predispose to sinusitis:
Recurrent upper respiratory tract infection, allergic rhinitis, deviated septum
Secondary Prevention:

1- Early detection for people at risk: as recurrent upper respiratory tract infection,
allergic rhinitis.
2-Treatment for cases of sinusitis:
* Complete bed rest with plenty of warm fluids in acute cases
* Systemic antibiotics according to culture and sensitivity
* Analgesics, antipyretics for pain and headache
* Decongestant nasal drops
* Steam inhalation
* Warm fomentation over the affected sinus
Tertiary prevention:
Aims to minimize the impact of the ongoing illness through treatment of
complications as:
• Orbital complications by:
- Hospitalization
- Systemic antibiotics
- Steroids if there is diminution of vision
- Decompression and drainage of pus by endoscopic sinus surgery (ESS)