11.1 Acute Otitis Media, Tonsillitis & Epistaxis

Acute Otitis Media (AOM) & Chronic Suppurative Otitis Media (CSOM)

Otitis media represents inflammation of the middle ear cleft, which comprises the Eustachian tube, tympanic cavity, mastoid antrum, and mastoid air cells. It is one of the most common surgical conditions encountered in pediatric and adult otolaryngology.

Acute Otitis Media (AOM)

AOM occurs primarily in children under 5 years due to the shorter, wider, and more horizontal Eustachian tube. The most frequent causative organisms are Streptococcus pneumoniae (35-40%), non-typable Haemophilus influenzae (25-30%), and Moraxella catarrhalis (12-15%).

Classical Clinical Stages of AOM

1. Stage of Tubal Occlusion: Characterized by Eustachian tube congestion. The patient experiences mild earache, conductive hearing loss, and a feeling of ear fullness. Examination reveals an retracted tympanic membrane with prominent lateral process of malleus and handle of malleus appearing horizontal.
2. Stage of Hyperaemia: Bacterial invasion produces severe earache, high-grade fever, and hyperaemia of the tympanic membrane. The tympanic membrane displays a characteristic cartwheel appearance due to radial injection of blood vessels along the handle of malleus.
3. Stage of Suppuration: Pus accumulates in the middle ear under high pressure. Severe throbbing pain, toxic systemic signs, and conductive hearing loss occur. The tympanic membrane bulges outwards with a yellow nipple-like point (yellow spot) indicating impending rupture.
4. Stage of Perforation: The tympanic membrane ruptures under pressure at the pars tensa, discharging mucopurulent blood-stained otorrhea. Pulsatile discharge (light-reflex / lighthouse sign) is visible through the perforation. Pain rapidly subsides and fever defervesces after perforation.
5. Stage of Resolution or Complication: Without prompt antibiotic therapy (Amoxicillin/Clavulanate), infection may resolve or progress to acute coalescent mastoiditis, petrositis (Gradenigo's syndrome), facial nerve palsy, labyrinthitis, or intracranial complications (extradural abscess, sigmoid sinus thrombosis, otic hydrocephalus, meningitis).

Chronic Suppurative Otitis Media (CSOM)

CSOM is defined as chronic inflammation of the middle ear and mastoid cavity presenting with persistent or recurrent non-healing tympanic membrane perforation and discharge lasting >6 weeks. CSOM is divided into two distinct clinical types:

Classification & Comparative Features

Cholesteatoma Pathophysiology

Cholesteatoma is a non-neoplastic cystic mass lined by keratinizing stratified squamous epithelium containing desquamated keratin debris within the middle ear. The Wittmaack's retraction pocket theory posits that negative middle ear pressure (due to Eustachian tube dysfunction) pulls the pars flaccida inward, forming a pocket where desquamated debris accumulates. Cholesteatoma expands and produces osteolytic enzymes (collagenase, acid phosphatase), destroying surrounding bony walls, ossicular chain (incus long process first), tegmen tympani, and lateral semicircular canal.

Acute Tonsillitis, Peritonsillar Abscess (Quinsy) & Epistaxis

Acute Tonsillitis & Peritonsillar Abscess (Quinsy)

Acute Tonsillitis

Acute parenchymatous tonsillitis is an infection of the palatine tonsils, most commonly caused by Group A Beta-Hemolytic Streptococcus (GABHS / Streptococcus pyogenes). It presents with sudden high fever, odynophagia, referred otalgia (via glossopharyngeal nerve CN IX), tender jugulodigastric lymphadenopathy, and hyperemic enlarged tonsils with follicular exudates.

• Centor Criteria for GABHS assessment: Fever >38°C, Tonsillar exudates, Tender anterior cervical adenopathy, Absence of cough. Score ≥3 warrants rapid antigen detection or empiric penicillin/amoxicillin therapy to prevent Rheumatic Fever and Post-Streptococcal Glomerulonephritis.
• Indications for Tonsillectomy (Paradise Criteria): ≥7 episodes in 1 year, ≥5 episodes/year for 2 consecutive years, or ≥3 episodes/year for 3 consecutive years; obstructive sleep apnea; suspected malignancy; or recurrent peritonsillar abscess.

Peritonsillar Abscess (Quinsy)

Quinsy is a collection of pus in the potential space between the tonsillar capsule and the superior constrictor muscle of the pharynx. It usually follows acute follicular tonsillitis when infection ruptures through the capsule into Weber's glands.

• Clinical Features: Severe unilateral throat pain, marked trismus (due to spasm of internal pterygoid muscle), hot potato voice (muffled speech), drooling of saliva, and severe odynophagia.
• Physical Examination: Soft palate is bulged forward and downward on the affected side; the palatine tonsil is pushed medially and inferiorly; the uvula is edematous and pushed to the contralateral (unaffected) side.
• Management: Intravenous broad-spectrum antibiotics (Amoxicillin-clavulanate or Ceftriaxone + Metronidazole), analgesics, and definitive needle aspiration or incision and drainage (I&D) at the site of maximum bulge (usually a line drawn from base of uvula to upper molar tooth, intersected by anterior pillar margin). Emergency tonsillectomy ("abscess tonsillectomy") is reserved for refractory cases.

Epistaxis (Nasal Bleeding)

Epistaxis is defined as active bleeding from the nasal cavity. It is classified anatomically into anterior epistaxis (90%) and posterior epistaxis (10%).

Anatomical Comparison of Epistaxis

Clinical Management Protocol for Epistaxis

1. Resuscitation: Airway, Breathing, Circulation (ABC). Assess hemodynamic stability, measure blood pressure, establish large-bore IV access, and order blood cross-matching if severe.
2. First Aid (Trotter's position): Patient sits upright, leans forward (to prevent swallowing blood and aspiration), and pinches the soft cartilaginous part of the nose for 10 to 15 continuous minutes while breathing through the mouth.
3. Local Inspection: Clear clots with suction, apply topical vasoconstrictor (0.5% Oxymetazoline or 1:1000 Adrenaline) with 4% Lignocaine pack. Identify bleeding site using anterior rhinoscopy or nasal endoscope.
4. Cauterization: If a discrete anterior bleeding point is localized, apply silver nitrate stick for 5-10 seconds or perform bipolar electrocautery. Never cauterize both sides of the nasal septum simultaneously to avoid septal perforation.
5. Anterior Packing: Indicated if cautery fails or bleeding site is not visualized. Pack layered ribbon gauze lubricated with antibiotic ointment or Bismuth Iodoform Paraffin Paste (BIPP). Retain for 48 hours under oral antibiotic cover to prevent Toxic Shock Syndrome (Staphylococcus aureus).
6. Posterior Packing / ESPAL: Indicated for refractory posterior epistaxis. Insert a 12-14 Fr Foley catheter into the nasopharynx, inflate balloon with 10-15 mL sterile water, pull anteriorly until engaged against posterior choana, and secure with anterior nasal pack. If bleeding persists beyond 48 hours, proceed to ESPAL or transcatheter arterial embolization.