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314                                          THE EAR

Where the causal condition is in the nose, nasal sinuses or nasopharynx
appropriate treatment should be applied early, adenoidectomy being done
when myringotomy is performed.


{Acute Purulent Otitis Media)

Acute inflammation of the middle ear cleft with pus formation is the result
of invasion of the mucoperiosteal lining by pyogenic organisms.

AETIOLOGY. It is a common disease of childhood and it occurs frequently
as a result of acute upper respiratory infections of^yiral origin^ in which
there is secondaoJuofection .with -pyogenicjicganisms. Certain other diseases
with respiratory involvement such asjnea§leSj^scarlet feyer,jraumiis^who£>p-
ingjcoughjind dij3hthej:iajn                             by acute otitis media. The

inhalation of" infected water from ^immmglind diving during which "Infec-
tion reaches the Eustachian tube is sometimes the cause of otitis media.
Inhalation or aspiration of food and other fluids may occur during vomiting
and introduce infection. A nasopharyngeal pack inserted to control bleeding
in a case of epistaxis, if left there too long, may initiate infection spreading
along the tube to the middle ear.

The middle ear may also be infected via the external meatus when the
drumhead is perforated. Invasion of the middle ear through the oval or
round window may rarely follow suppuration in the inner ear and meninges,
but blood-borne infection is uncommon.

BACTERIOLOGY. Staph. aureus* Strep, haemolytfcus^and Strep, pneumoniae
are the most common organisms responsible for acute otitis me3Ta.~nCess
commonly, H.Jnffuenzae^JEsch. coli, B. proteusjmdJPs. pyocyanea are found
and in many cases cultures are sterile~as a result of antibiotic therapy.

SYMPTOMS. In the early stage of the infection pain is a variable symptom,
the patient complaining more often of fullness in the ear, dullness of hearing
with excessive loudness of their own voice in the affected ear and sometimes
a high-pitched tinnitus. As the inflammatory reaction spreads from the
Eustachian tube to involve the tympanic cavity resulting hi increasing
vascular dilatation and tension, pain becomes the most prominent symptom
and deafness more pronounced, Earache is variously described as sharp,
throbbing or lancinating. It is initially confined to the depths of the ear but
later radiates over the affected side of the head and is intensified by any
activity which increases intratympanic pressure. Sleep may be lost on account
of the severity of the pain. 'Early' mastoid tenderness in the first few days
of the illness is not of serious import, since it usually disappears after tension
is relieved in the middle ear. Symptoms of a general nature may occur,
especially in children, such as restlessness, fever, thirst and vomiting, before
there is clear evidence of suppuration.

In the early stage of frank suppuration with production of pus tension
within the middle ear reaches a peak at which the symptoms are most severe.
Children may show a sharp rise in temperature to around 39 °C. There may
also be symptoms suggestive of meningitis, e.g. vomiting and convulsions
with positive Kernig and Babinski signs. In infants significant signs are
persistent restlessness, rubbing the affected ear, boring into the pillow on
the affected side and suddenly waking, screaming with pain. In adults the