Furunculosis of the nasal vestibule: causes, diagnosis, complications, treatment

Definition: ASOM is an acute inflammation of the mucosal lining of the middle ear cleft (middle ear, Eustachian tube and mastoid air cells).

Route of infection:

1.Via the Eustachian tube from:

• The nose: (Sinusitis, acute rhinitis).
• The nasopharynx (Adenoiditis, nasal pack, vomitus, milk regurge).
• The Oropharynx (Tonsillitis, Pharyngitis).

2. Through a drum perforation (swimming and bathing).

3. Blood-borne infection (rare).

Causative organisms:

1. Bacterial:

• Beta haemolytic streptococcus.
• Staphylococcus aureus.
• Streptococcus pneumoniae.
• Haemophilus influenzae.

2. Viral: 

Viruses play a role paving the way for pyococcal invasion e.g influenza and exanthema.

Stages of ASOM (Pathology)

1. Stage of Eustachian tube obstruction (Tubal catarrh): Oedema and congestion obstructing the Eustachian tube. Air gets absorbed from the middle ear with failure of Eustachian tube opening to equalize the negative pressure.
2. Stage of acute catarrhal otitis media: congestion and oedema of the middle ear mucosa with serous exudation.
3. Stage of suppuration: The exudate becomes mucopurulent and pus accumulates under tension.
4. Stage of perforation: Necrosis of the drum causes perforation.

Incidence: more in infant & children.

Clinical picture of Acute Suppurative Otitis media:

1- Stage of eustachian tube obstruction (tubal catarrh)

Pathology: Tubal obstruction due to congestion, then air is absorbed.

Symptoms: 1- Fullness in the ear. 2-Deafness. 3-Tinnitus

Signs:

• Retracted Tympanic membrane (T.M).
• Prominent lat. process of malleus.
• Exaggerated malleolar folds.
• Shortened handle of malleus.
• Distorted cone of light.
• Limited mobility by siegle.
• Conductive deafness

2- Stage of hyperaemia & congestion : (catarrhal O.M)

Pathology: Oedema & congestion of ME & serous exudate.

Symptoms:

• Starting general symptoms.
• Deafness, tinnitus, pain.

Signs:

• T.M is congested with prominent vascularity, lost cone of light.
• Conductive deafness.

3. Stage of suppuration:

Pathology: Pus accumulates under tension.

Symptoms:

• More severe general symptoms.
• Deafness increase.
• Tinnitus increase.
• Pain: severe, throbbing.

Signs:

• T.M is congested markedly & bulging with lost cone of light.
• Conductive deafness.

4- Stage of perforation

Pathology: Necrosis of part of T.M.

Symptoms:

• General symptoms start to subside.
• Aural discharge.
• Deafness.
• Pain starts to subside.

Signs: 

• Mucopurulent, bloody, pulsating discharge.
• Perforated T.M: usually anteroinferior, if large ME mucosa appears congested.
• Conductive deafness.

Investigations:

• Culture and sensitivity.
• Hearing tests: Conductive deafness.

Treatment of Acute Suppurative Otitis media

I- Before perforation treatment:

a- Medical:

• Rest, light diet, fluids.
• Systemic antibiotics, for 10 days.
• Analgesics.
• Nasal decongestants.
• local antibiotic drops or warm glycerin phenol to decrease edema &pain.

b- Surgical: myringotomy

Indications of myringotomy:

• Failed medical ttt for 48 hours.
• Bulging T.M (pus under tension).
• Complications. -Immunosuppressed patients,for fear of complications.
• Infants and children (don’t wait for bulging to occur).

After myringotomy, Doctor should give: 

• Antibiotics according to Culture and sensitivity.
• Local ear drops.
• Avoid water entry.
• Aural toilet.

II- After perforation treatment:

a- Medical:

As done "after myringotomy".

b- Surgical: 

Myringotomy if perforation is small or high.

Prognosis of ASOM:

1. Cure: middle ear mucosa & hearing return normal.
2. Chronicity: suppurative or non suppurative.
3. Complications.

References