Medical: Differences Between Bacteremia and Septicemia

S.N.	Bacteremia	Septicemia
1.	Bacteremia is the simple presence of bacteria in the blood.	Septicemia is the presence and multiplication of bacteria in the blood.
2.	Bacteremia is not as dangerous as Septicemia.	Septicemia is a potentially life-threatening infection.
3.	Less amount of bacteria are present in blood.	Large amounts of bacteria are present in the blood.
4.	This may occur through a wound or infection, or through a surgical procedure or injection.	It can arise from infections throughout the body, including infections in the lungs, abdomen, and urinary tract.
5.	Toxins are not produced.	Toxins may be produced by bacteria.
6.	Bacteremia usually causes no symptoms or it may produce mild fever.	It shows symptoms like chills, fever, prostration, very fast respiration and/or heart rate.
7.	It can resolve without treatment.	Untreated septicemia can quickly progress to sepsis.
8.	Rapidly removed from the bloodstream by the immune system.	Antibiotics will be used to treat the bacterial infection that is causing septicemia.
9.	Caused by Staphylococcus, Streptococcus, Pseudomonas, Haemophilus, E. coli, dental procedures, herpes (including herpetic whitlow), urinary tract infections, peritonitis,Clostridium difficile colitis, intravenous drug use, and colorectal cancer.	Staphylococci, are thought to cause more than 50% of cases of sepsis. Other commonly implicated bacteria include Streptococcus pyogenes, Escherichia coli, Pseudomonas aeruginosa, Klebsiella species and evenCandida spp.

Medical: Pediatric Procedure Listing

A. Introduction 
1. Pediatric blood collection may be by skin puncture or venipuncture. 
2. Skill in pediatric phlebotomy is gained by knowledge of special collection equipment, observation of skilled phlebotomists and practice. 
3. Very challenging patients due to size and emotional response to blood collection. 
4. Skills should be obtained by performing procedures on older children. 
5. Recognize limitations, always request help when necessary. B. Age Specific Care 1. Every person is unique, but each will go through various stages of development. a. Special consideration needs to be given to certain age groups, since not all of our patients are young or middle-aged. b. Children and older adults have different needs than young adults. c. By learning about how people in different stages of development respond to others and their surrounding environment, we can better formulate and implement their care. 2. The following are general guidelines to aid you in dealing with patients based on age: a. Infancy the period between birth and 1 year. They need to be provided with a protective environment, ensure warmth, cuddles and hugs, and protect them from skin abrasions. b. Pediatric - the period between 1 and 12 years. They need to have unfamiliar objects explained, should not be left unattended, and may need to be immobilized if necessary. Distraction techniques can also be used. c. Adolescent - the period between 12 and 18 year. They need to be included in explanations of procedures, provided privacy, and may need pregnancy addressed. d. Adult - the period between 18 and 65 years. They require explanations of procedures, want to ask questions, and be addressed with respect. e. Older Adult - 65 years and over. Things to consider include mobility, visual acuity, skin protection, and orientation. 3. Healthcare workers can use this information to help them provide the best care for each individual patient. 4. Study the chart in your textbook which illustrates age-specific care considerations which incorporate knowledge of child development, their fears and concerns, and possible parental involvement and tips for the phlebotomist.
9. Pediatric Procedures PLAB 1323/1023 C 75 C. Preparing Child and Parent 1. Important to develop good interpersonal skills and routine during pediatric blood collection. a. During the introduction be warm, friendly, calm and confident. b. Correctly identify the patient. c. Ask about previous blood drawing experiences the child has had. d. Develop a plan based your impression of the child’s and parent’s cooperation (or lack of cooperation), involve the child if possible. e. Explain and demonstrate the procedure. f. Establish guidelines. g. Be honest when asked about the amount of discomfort. h. Encourage parental involvement. 2. Children may have an extremely negative psychological response to the needle. 3. It is best for the child psychologically if the procedure can be performed in a treatment
room away from the child’s bed or play area, especially if the room is shared by another child. 4. Prepare equipment out of site of the child to reduce anxiety. 5. Restraining the Child a. Restraints may be necessary to help assure a successful procedure with no injury to the child. b. Important to restrain the arm during venipuncture to prevent injury to the child. 1) Have the parent hold the child on their lap with one arm around the child’s waist the other hand under and clasping the child’s elbow. 2) Have the child lay down, the parent leans over the child restraining the near arm with their body while holding the extended arm securely. 3) For small children do not allow full weight of adult to be put on child. b. Infants younger than 3 months usually do not need to be restrained. 7. Combative children a. At times the child may kick and thrash about even while restrained. b. Do not use excessive force to restrain the child, this may result in injury. c. Notify the nurse or physician. 8. Pain alleviation a. If many venipunctures are anticipated during a hospital stay a topical anesthetic
EMLA (eutectic mixture of local anesthetics) may be applied to intact skin. b. Combination of lidocaine and prilocaine which has minimal side effects. c. The anesthetic affect occurs after 60 minutes and lasts 2 to 3 hours. d. Disadvantages are cost, waiting 60 minutes, and advanced knowledge of vein to use. e. Visit the EMLA web site for additional information: http://www.emla-us.com/
9. Pediatric Procedures PLAB 1323/1023 C 76 9. Sucrose nipples or pacifiers given to infants during phlebotomy do not alleviate pain but may comfort the infant. D. Prevention of Disease Transmission 1. If isolation notice is posted wear the appropriate PPE. 2. Always follow Standard Precautions. 3. Be aware of the need to protect the child from infection. a. PPE may be required to protect extremely ill children. b. Always wash hands and change gown before going to the next infant or child. 4. Latex allergies are becoming more common, be aware and use non-latex supplies. E. Pediatric Phlebotomy Procedures 1. For pediatric and neonatal patients documentation of amounts drawn are critical. 2. Micro-capillary skin puncture is the procedure of choice when only a small amount of blood is needed. a. Collect hematology specimens first, then chemistry, then blood bank. b. Sites include the heel or finger. 3. Heelstick is the specimen of choice for infants. a. Avoid bruised areas and sites of previous punctures. b. The size of the lancet must not exceed 2.0 mm to avoid puncturing bones, nerves or tendons. c. Hold the heel gently as infant’s bruise easily. d. Avoid excessive milking or squeezing. e. Do not use adhesive bandages. f. Check site before leaving. 4. Warming the site is critical to increase blood flow to the area, commercial heel warmers or warm wash cloth may be used. 5. Complications of heelstick a. Cellulitis b. Osteomyelitis of the calcaneus bone c. Abscess formation d. Tissue loss e. Scarring of the heel F. Newborn Screening 1. Newborn screening for phenylketonuria (PKU) and hypothyroidism is mandatory by law. a. If these diseases are not caught early can result in mental retardation. b. Collected before the infant is 72 hours old, if infant is less than 24 hours old it must be repeated before the infant is 14 days old.
9. Pediatric Procedures PLAB 1323/1023 C 77 2. The heel is the most frequently used site, proper procedure is followed and the blood is collected onto circles on special filter paper. a. Each circle must be filled completely. b. The blood should be filled from one large drop, not layered on. c. Excessive squeezing may cause hemolysis. d. A heparinized capillary tube may be filled and used to fill the circles as long as the filter paper is not scratched or dented. e. Visit the Texas Department of Health Web Site for excellent illustrations of the procedure as well as pictures of improperly filled cards: http://www.tdh.state.tx.us/newborn/specimen.htm http://www.tdh.state.tx.us/newborn/spot_chk.htm G. Other Blood Collection Techniques 1. Venipuncture a. Routine b. Dorsal vein hand procedure c. Other sites may be used, equipment of choice is the butterfly. 2. Dorsal Hand Vein Procedure a. Infants, children and adults with small difficult veins. b. Use 21 -23 gauge needle, 3/4 to 1" in length, with a clear hub, butterfly is recommended. c. No tourniquet is necessary. d. Position middle and index finger to form a "V" over the vein and apply pressure. Bend babies wrist over middle finger but not to the extent veins collapse. e. Locate the vein, release pressure, cleanse the site. f. Insert the needle, when blood appears in the hub collect in appropriate microtainers. g. Steady flow of blood is sustained by applying gentle, periodic pressure. h. After collection, remove needle, apply pressure until bleeding stops. i. The technique reportedly resulted in decreased hemolysis, decrease sample dilution with
tissue fluid, fewer multiple punctures and decrease phlebotomist stress. It also appears to
be less painful. j. Only one site in Austin that performs routinely, and even there, not all nurses feel comfortable with it. 3. Scalp vein procedure a. This is usually performed by individuals who have acquired additional specialized training. b. The infants scalp is shaved if necessary. c. Palpate, make sure pulse is not present. If vein cannot be palpated a rubber band can be placed around the upper head. d. The site is disinfected with povidone iodine or alcohol. 4. Blood may be withdrawn from IV lines but also requires additional specialized training. 5. Careful monitoring of the number of times and amount of blood withdrawn is required. A volume of 10 mLs on a premature infant may be 10% of their total blood volume.
9. Pediatric Procedures PLAB 1323/1023 C 78 6. Heparin locks are special needles that are inserted and left in veins for several hours. a. The line must be flushed with saline prior to drawing the sample. b. The first blood withdrawn is discarded, and the specimen collected. c. The line is then flushed with a heparinized solution. d. In Texas, the flushing can only be performed by a nurse or specially trained personnel. 7. Central venous catheters can be used for blood collection but require special training

Medical: Global Database on Child Growth and Malnutrition

Cut-off points and summary statistics

For population-based assessment, there are two ways of expressing child growth survey results using Z-scores. One is the commonly used cut-off-based prevalence; the other includes the summary statistics of the Z-scores: mean, standard deviation, standard error, and frequency distribution.

Prevalence-based reporting:

For consistency with clinical screening, prevalence-based data are commonly reported using a cut-off value, often <-2 and >+2 Z-scores. The rationale for this is the statistical definition of the central 95% of a distribution as the "normal" range, which is not necessarily based on the optimal point for predicting functional outcomes.

The WHO Global Database on Child Growth and Malnutrition uses a Z-score cut-off point of <-2 SD to classify low weight-for-age, low height-for-age and low weight-for-height as moderate and severe undernutrition, and <-3 SD to define severe undernutrition. The cut-off point of >+2 SD classifies high weight-for-height as overweight in children.

The use of -2 Z-scores as a cut-off implies that 2.3% of the reference population will be classified as malnourished even if they are truly "healthy" individuals with no growth impairment. Hence, 2.3% can be regarded as the baseline or expected prevalence. To be precise the reported values in the surveys would need to subtract this baseline value in order to calculate the prevalence above normal. It is important to note, however, that the 2.3% figure is customarily not subtracted from the observed value. In reporting underweight and stunting rates this is not a serious problem because prevalences in deprived populations are usually much higher than 2.3%. However, for wasting, with much lower prevalence levels, not subtracting this baseline level undoubtedly affects the interpretation of findings.

Summary statistics of the Z-scores:

A major advantage of the Z-score system is that a group of Z-scores can be subjected to summary statistics such as the mean and standard deviation. The mean Z-score, though less commonly used, has the advantage of describing the nutritional status of the entire population directly without resorting to a subset of individuals below a set cut-off. A mean Z-score significantly lower than zero—the expected value for the reference distribution—usually means that the entire distribution has shifted downward, suggesting that most, if not all, individuals have been affected. Using the mean Z-score as an index of severity for health and nutrition problems results in increased awareness that, if a condition is severe, an intervention is required for the entire community, not just those who are classified as "malnourished" by the cut-off criteria (15).

The observed SD value of the Z-score distribution is very useful for assessing data quality. With accurate age assessment and anthropometric measurements, the SDs of the observed height-for-age, weight-for-age, and weight-for-height Z-score distributions should be relatively constant and close to the expected value of 1.0 for the reference distribution. An SD that is significantly lower than 0.9 describes a distribution that is more homogenous, or one that has a narrower spread, compared to the distribution of the reference population. If the surveyed standard deviation of the Z-score ranges between 1.1 and 1.2, the distribution of the sample has a wider spread than the reference. Any standard deviation of the Z-scores above 1.3 suggests inaccurate data due to measurement error or incorrect age reporting. The expected ranges of standard deviations of the Z-score distributions for the three anthropometric indicators are as follows (5):

• height-for-age Z-score: 1.10 to 1.30
• weight-for-age Z-score: 1.00 to 1.20
• weight-for-height Z-score: 0.85 to 1.10

Available means and SDs of Z-scores of survey data are being included in the Global Database. However, as these summary statistics have been available only for a number of surveys, they do not appear on the website. Given the importance of the mean and SD of Z-scores, it is hoped that an increasing number of survey reports will include them in the future.

'Trigger-levels' as a basis of public health decisions

Experience with surveillance has contributed to emphasizing the usefulness of identifying prevalence ranges to assess the severity of a situation as the basis for making public health decisions. For example, when 10% of a population is below the -2SD cut-off for weight-for-height, is that too much, too little, or average? The intention of the so-called 'trigger-levels' is to assist in answering this question by giving some kind of guideline for the purpose of establishing levels of public health importance of a situation. Such classifications are very helpful for summarizing prevalence data and can be used for targeting purposes when establishing intervention priorities.

The prevalence ranges shown in Table 1 are those currently used by WHO to classify levels of stunting, underweight, and wasting. It should be borne in mind, however, that this classification is largely arbitrary and simply reflects a convenient statistical grouping of prevalence levels worldwide. Moreover, the designations of a prevalence as "low" or "medium" should be interpreted cautiously and not be taken as grounds for complacency. Since only 2.3% of the children in a well-nourished population would be expected to fall below the cut-off, the "low" weight-for-age group, for example, includes communities with up to four times that expected prevalence, and the "medium" group communities with up to an eightfold excess.

Table 1. Classification for assessing severity of malnutrition by prevalence ranges among children under 5 years of age

Indicator	Severity of malnutrition by prevalence ranges (%)
	Low	Medium	High	Very high
Stunting	<20	20-29	30-39	>=40
Underweight	<10	10-19	20-29	>=30
Wasting	< 5	5-9	10-14	>=15

Medical: Management of Malnutrition in Children Under Five Years

Feeding formulas: What are F-75 and F-100?

F-75 is the "starter" formula used during initial management of malnutrition, beginning as soon as possible and continuing for 2-7 days until the child is stabilized. Severely malnourished children cannot tolerate normal amounts of protein and sodium or high amounts of fat. They may die if given too much protein or sodium. They also need glucose, so they must be given a diet that is low in protein and sodium and high in carbohydrate. F-75 has is specially mixed to meet the child's needs without overwhelming the body's systems in the initial stage of treatment. Use of F-75 prevents deaths. F-75 contains 75 kcal and 0.9 g protein per 100 ml.

As soon as the child is stabilized on F-75, F-100 is used as a "catch-up" formula to rebuild wasted tissues. F-100 contains more calories and protein: 100 kcal and 2.9g protein per 100 ml.

The table below shows a number of recipes. The choice of recipe may depend on the availability of ingredients, particularly the type of milk, and the availability of cooking facilities.

The principle behind the recipes is to provide the energy and protein needed for stabilization and catch-up. For stabilization (F-75), it is important to provide a formula with the energy and protein as shown (no less and no more). For catch-up (F-100), the recipes show the minimum energy and protein contents needed.

The first three recipes given for F-75 include cereal flour and require cooking. The second part of the table shows recipes for F-75 that can be used if there is no cereal flour or no cooking facilities. However, the recipes with no cereal flour have a high osmolarity (415 mOsmol/l) and may not be tolerated well by some children with diarrhoea.

The F-100 recipes do not require cooking as they do not contain cereal flour.

It is hoped that one or more of the recipes can be made in your hospital. If your hospital cannot use any of the recipes due to lack of ingredients, seek expert help to modify a recipe using available ingredients.

Recipes for F-75 and F-100

If you have cereal flour and cooking facilities, use one of the top three recipes for F-75:
Alternatives	Ingredient	Amount for F-75
If you have dried skimmed milk	Dried skimmed milk	25 g
	Sugar	70 g
	Cereal flour	35 g
	Vegetable oil	30 g
	Mineral mix*	20ml
	Water to make 1000 ml	1000 ml**
If you have dried whole milk	Dried whole milk	35 g
	Sugar	70 g
	Cereal flour	35 g
	Vegetable oil	20 g
	Mineral mix*	20 ml
	Water to make 1000 ml	1000 m/**
If you have fresh cow's milk, or full- cream (whole) long life milk	Fresh cow's milk, or full-cream (whole) long life milk	300ml
	Sugar	70 g
	Cereal flour	35 g
	Vegetable oil	20 g
	Mineral mix*	20 ml
	Water to make 1000 ml	1000 ml**
If you do not have cereal flour, or there are no cooking facilities, use one of the following recipes for F-75:			No cooking is required for F-100:
Alternatives	Ingredient	Amount for F-75	Amount for F-100
If you have dried skimmed milk	Dried skimmed milk	25 g	80 g
	Sugar	100 g	50 g
	Vegetable oil	30 g	60 g
	Mineral mix*	20 ml	20 ml
	Water to make 1000 ml	1000 ml**	1000 ml**
If you have dried whole milk	Dried whole milk	35 g	110 g
	Sugar	100 g	50 g
	Vegetable oil	20 g	30 g
	Mineral mix*	20 ml	20 ml
	Water to make 1000 ml	1000 ml**	1000 ml**
If you have fresh cow's milk, or full- cream (whole) long life milk	Fresh cow's milk, or full-cream (whole) long life milk	300 ml	880 ml
	Sugar	100 g	75 g
	Vegetable oil	20 g	20 g
	Mineral mix*	20ml	20ml
	Water to make 1000 ml	1000 ml**	1000 ml**

*Check contents of mineral mix or alternatively use ready-made Combined Mineral Vitamin Mix (CMV).

** Important note about adding water: Add just the amount of water needed to make 1000 ml of formula. (This amount will vary from recipe to recipe, depending on the other ingredients). Do not simply add 1000 ml of water as this will make the formula too dilute. A mark for 1000 ml should be made on the mixing container for the formula so that water can be added to the other ingredients up to this measure.

Add water just up to 1000 ml mark

Mineral mix

The mix contains potassium, magnesium and other essential minerals. It must be included in F-75 and F-100 to correct electrolyte imbalance. The mineral mix may be made in the pharmacy of the hospital or a commercial product called Combined Mineral Vitamin Mix (CMV) may be used to provide the necessary minerals.

Vitamins

Vitamins are also needed in or with the feed. Children are usually given multivitamin drops as well. The multivitamin preparation should not include iron.

If available, CMV may be used to provide the necessary vitamins. If CMV is used separate multivitamin drops are not needed.

Correct position to feed a severely malnourished child with F75 and F100

(Source: Protocol for the management of Severe Acute Malnutrition, Ethiopian Federal MOH, February 2007)

Tips for correct preparation of F75 and F100 using other ingredients

• Apply hygiene at all levels
   
• Mix oil well so that it does not separate. If oil floats to the top of the mixture, there is a risk that some children will get too much and others too little. Use a long hand whisk to thoroughly mix the oil.
   
• Be careful to add the correct amount of water to make up 1000 ml of formula. If 1000 ml of water is mistakenly added, the resulting formula will be about 15% too dilute.
   
• Required equipment include: hand whisk (rotary whisk or balloon whisk), a 1-litre measuring jug, a cooking pot, and a stove or hot plate.
   
• Amounts of ingredients are listed in the table above. Cereal flour may be maize meal, rice flour or millet.
   
• It is important to use cooled, boiled water even for recipes that involve cooking. The water should be cooled because adding boiling water to the powdered ingredients may create lumps.
   
• The cooking time will depend on the type of cereal flour to be used and the nature of the heat source.
   

For cooking:

1. Mix the flour, milk or milk powder, sugar, oil, and mineral mix in a 1-litre measuring jug (If using milk powder, this will be a paste).
    
2. Slowly add cooled, boiled water up to 1000 ml.
    
3. Transfer to cooking pot and whisk the mixture vigorously.
    
4. Boil gently for 4 minutes, stirring continuously. Maize-flour based recipe should be boiled for longer periods.
    
5. Some water will evaporate while cooking, so transfer the mixture back to the measuring jug after cooking and add enough boiled water to make 1000 ml. Whisk again.

Pre-packed F75 and F100

These are commercially available and include already all required nutrients.

Preparation:

• Add one large packet of F75 or F100 to 2 litres of water.
   
• Where very few children are being treated, smaller volumes can be mixed using the red scoop (20 ml water per red scoop or F75/F100 powder)
   
• Close the F75 / F100 sachet appropriately by rolling down the top.

Medical: F-100 and F-75 (foods)

F-100 and F-75 (also known as Formula 100 and Formula 75) are therapeutic milk products designed to treat severe malnutrition. In 1994,Action Against Hunger / Action Contre la Faim (ACF) pioneered the use of milk formula F-100 for the treatment of severe acute malnutrition. In 1997, a French medical researcher together with the French company Nutriset succeeded in making a nutrient-dense spread for the treatment of severe acute malnutrition. The formula is used in therapeutic feeding centers where children are hospitalized for treatment.^[1]Action Against Hunger’s Scientific Committee pioneered the therapeutic milk formula (F-100), now used by all major humanitarian aid organizations to treat acute malnutrition. As a result, the global mortality rate of severely malnourished children under the age of five has been reduced from 25% to 5%.^[2] F-100 and other therapeutic nutritional products are widely used by a number of humanitarian aidorganizations, such as Unicef, Action Against Hunger, Concern Worldwide, Valid International, and Médecins Sans Frontières, when treating severe malnutrition among vulnerable populations.

F-75 is considered the "starter" formula, and F-100 the "catch-up" formula. The designations mean that the product contains respectively 75 and 100 kcals per 100 ml. Both are very high in energy, fat, and protein, and provide a large amount of nutrients. Ingredients include concentrated milk powder, food oil (sometimes grease), and dextrin vitamin complexes. The formulas may be prepared by mixing with the local water supply.^{[citation needed]} Sometimes Plumpy'nut is substituted for F-100. F-75 may be cereal-based in place of milk.^{[citation needed]}

There are other variants like Low Lactose F-75 and Lactose Free F-75 which are used in case of persistent diarrhoea in severe acute malnutrition.

Medical: SUPPURATIVE OTITIS MEDIA

DEFINITION: Inflammatory condition of the mucoperiosteum

                     of the middle ear cleft.

TYPE: (1) Acute suppurative otitis media

             (2) Chronic suppurative otitis media

(a)  Tubo-tympanic SOM

(b)  Attico Antiro SOM

ACUTE SUPPURATIVE OTITIS MEDIA AETIOLOGY

          BACTERIAL

(1)  Streptococcus pneumonia

(2)  Haemophylus influeuza

(3)  Moxirella catarrhalis

(4)  Streptococcus pyogenes

VIRUSES

(1)  Rhinovirusses etc.

ROUTE OF ENTRY

(1)  ascending from the  nasopharynx

(2)  From External auditory meatus

(3)  Haematogenous (rare)

PATHOLOGY

(1)    Stage of hyperaemia-Generalized  vascular dilatation and  permeability

(2)    Stage of exudation

(3)    Stage of suppuration

(4)    Stage of coalescence

(5)    Stage of complications.

ACUTE NECROTISING OTITIS MEDIA

Occur in malnourished children.

Usual pathogen is B-haemolytic streptococcus.

It is characterized  by necrotizing inflammation that leads to large drum perforations and ossicular chair necrosis.

CLINICAL PRESENTATION OF ASOM

(1)  Fever

(2)  Pain

(3)  Hearing loss

(4)  Discharge

(5)  Tinnitus

(6)  Vertigo

(7)  Facial asymmetry

Differencial Diagnosis

          Diffuse otitis Externa

MANAGEMENT

(1)  Bedrest

(2)  Analgesics

(3)  Decongestants

(4)  Antibiotics

(5)  Myringotomy

COMPLICATIONS OF ASOM

Factors that influence complications.

(1)  Virulence of the organism

(2)  Host resistance

(3)  Adequacy of treatment

(4)  Susceptibility to chemotherapy

CHRONIC OTITIS MEDIA (COM)

This is one of the complications of acute suppurative otitis media.

Types (as above)

Tubo tympanic O.M.

Charactarized by chronic inflammation of mucoperiosteum and anterior tympanic mambrane perforation.

Route of Entry

(1)  Ascending through the Eustachian tube

(2)  Through Drum perforation.

Predisponsing factors:

See above

Pathology

(a)  Thickened, oedematous occasionally polypoid mucosa.

(b)  Granulation tissue

(c)  Drum perforation

(d)  Osteitis and Ossicular necrosis

(e)  Mucopurulent discharge.

Bacteriology

(1)  Pseugomonas

(2)  Proteus

(3)  Klebsiella

(4)  Staphylococcus

(5)  Anaerotic bactetia

(a)  Bacterioides melonogenicus etc.

Investigations

(1)  Culture and sensitivity of the pus

(2)  X-ray of mastoids

(3)  FBP

(4)  Audiometry.

TREATMENT

(1)  Aural Toilet

(2)  Local antibiotic therapy

(3)  Systemic antibiotics

(4)  Tympanoplasty

(5)  Mastoidectomy

(6)  Adenotonsillectomy.

ATTICO ANTRO CHRONIC SOM

DEFINITION

This is the presence of chronic otitis media with  cholesteatoma in the middle ear.

CHOLESTEATOMA:

This is the presence of Keratinizing squamous epithelium in an ectopic site ( e.g. middle or brain).

SITE

Attico antro COM occurs in the epitympanum (attic) and mastoid antrum.

AETIOLOGY

            The aetiology is not well known ,however some theories have been raised.

1.       Congenital theory

Embryonic  cell rests of Epithelial origin; later become cholesteatoma in middle ear.

2.       Metaplasia Theory

Middle ear columna epithelium changes to squamous epithelium due to chronic irritation.

3.       Migration theory

Movement of squamous epithelium from the external ouditory canal into the middle ear through a drum perforation.

4.       Retraction Pocket Theory

Eustachian tube dysfunction leads to negative middle ear pressure. This leads to a tympanic emberane retraction pocket that draws squamous epithelium into the middle ear.

Clinical feature

1.       Otorrhoea: Thick foul discharge blotting paper like material may be seen in the middle ear.

2.       Drum perforation

Most commonly occur in the pars flaccida and posterior upper quadrant.

3.       Hearing loss: may be mild or severe

4.       Ear ache: occur if there is associated otitis externa

5.       Bleeding: may occur if associated granulation tissue is traumatized.

6.       Vertigo: Occurs if the horizontal semicircular canal is envolved.

7.       Headache: This symtom suggests pending intracranial complications.

INVESTIGATIONS:

As for tubo tympanic SOM.

TREATMENT

This disease is more often associated with complications than tubotympanic COM.

Treatment is surgical unless there are contra indications to surgery.

Aim of surgery

(1)  To create a safe ear.

(2)  Hearing improvement procedure can follow control of the infection.

Types of Surgery

(1) Mastoidectomy: This is done to eradicate the choesteatoma

(2)tympanoplasty:This is a procedure done to improve the 

   hearing.

COMPLICATIONS OF SUPPURATIVE OTITIS MEDIA

Complications occur when the infection spread beyond the mucoperiosteum of the middle ear cavity.

Predisposing factors:

As for ASOM.

Types of complications

(1)  OTOLOGIC

(2)  INTRACRANIAL

OTOLOGIC COMPLICATIONS

A.      MASTOIDITIS

Destruction of mastoid air cells by inflammatory exudates under pressure occurs.

(i)       A subperiosteal abscess may occur->Post auricular abscess.

(ii)      Pus from the mastoid may extend along the sternomastoid muscle forming abscesses in the neck. (Bezold’s abscess)

B.      PETROSITIS

This is inflammation of the petrous pyramid. Such inflammation may involve adjacent structures i.e. the trigeminal nerve ganglion, and the abducent nerve causing the gradenigo’s syndrome.

C.      FACIAL NERVE PARALYSIS

Facial nerve paralysis occurs when infection extends into the falopain canal, through bone erosion or dehiscence.

D.      LABYRINTHITIS

Serous type: Hyperaemia of the labyrinth.

Supprative type: Infection has directly entered the labyrinth fluid.

Clinical features

(a)  Hearing loss

(b)  Tinnitus

(c)  Vertigo

(d)  Spontaneous horizontal nystagmus

INTRA-CRANIAL COMPLICATIONS

1.  Extradural abscess

2.  Subdural abscess

3.  Brain abscess

The above will present with

a)  Otorrhea

b)  Fever

c)  Headached

d)  Papilloedema

e)  Convulsions and other neurologic signs.

4.       Otic meningitis

          Most common intracranial complication

5.       Lateral sinus thrombophlebitis

This usually follows chronic mastoiditis

6.       Ottic hydrocephalus

May follow reduced CSF reabsoption.

Management of the complications

a)    This depends on the type of complication. However mastoidectomy is indicated to control the aural infection.

b)    A neurosurgeon is involved to handle the intra cranial complication.

c)       Chemotherapy must take into account gram negative bacillus and anaerobic bacteria