Endoscopic Tympanocentesis and bacteriological study in acute suppurative oitis media in Imphal

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1 Int J Res Med. 2017; 5(4); 1-5 e ISSN:2320-2742 p ISSN: 2320-2734

Endoscopic Tympanocentesis and bacteriological study in acute

suppurative oitis media in Imphal

Dhakeswar Singh Potsangbam1*,Akoijam Babie Anand2

1

MS, DLO, 2MS, Department of Otorhinolaryngology, J. N. Institute of Medical Sciences, Imphal

INTRODUCTION

Acute suppurative otitis media is one of the most common illness in children below 2 years1. More than 40% of all children have three or more episodes of acute suppurative otitis media during first three years of life2. The incidence rate decreases as age advances but ASOM is also encountered in all age groups3. It is important to administer proper and prompt treatment in the early stages of the illness to prevent complications and sequelae4.

Over the years Otomicroscopic

Myringotomy and Aspiration of pus was the mainstay of surgical management in uncomplicated Acute Suppurative Otitis Media. Our study uses Endoscopic Tympanocentesis as a measure to remove the excessive middle ear pressure and

*Corresponding Author:

Dhakeswar Singh Potsangbam Singjamei Chingamakha, Heirangoithong Bazar Imphal, Manipur-795001 Contact No: 9862027652 Email: [email protected]

earache and compares the two methods.

Streptococcus pneumoniae and

Haemophilus influenza are the most

common bacteria causing acute

suppurative otitis media5,6. Our study was taken to establish the common bacteria causing this condition and find out the sensitive antibiotics to help us establish a treatment protocol for Imphal, Manipur. MATERIAL AND METHODS

The study was taken in the

Otorhinolaryngoly Department, J N.

Institute of Medical Sciences, Imphal, Manipur. Patients of all age groups suffering from early stage of acute suppurative otits media before rupture of the tympanic membrane, recorded in a span of two years were taken into the study. Examinations were done in cases suffering from 1acute earache, 2fever, 3

rhinorrhoea and 4irritability. Diagnostic criteria include1 hyperaemic, lustreless tympanic membrane, loss of light reflex and bulging of the drum in Otoscopy or

Oto-endoscopy and2 Tympanometry

findings of As, C and B type

tympanogram. Patients having

ORIGINAL ARTICLE

ABSTRACT

BACKGROUND AND OBJECTIVES: Acute middle ear infection is a serious inflammatory condition and can affect all age groups. It is more common in the preschool age groups in children and more so below the age of 2 years. The treatment consists primarily of prompt administration of antibiotics aimed at subsiding the infection and surgical release of the tension of the middle ear pressure exerted by the inflammatory fluid to bring about the immediate normalization of the middle ear and Eustachian tube mucociliary functions. The study was taken up to find out common aerobic bacterial pathogens in Imphal, the sensitive antibiotics and effectiveness of Endoscopic Tympanocentesis in the treatment. METHODS: A prospective study of acute otitis media cases in all age groups in a span of 24 months, comprising of 385 cases was done. Tympanometry followed by Mocroscopic Myringotomy or Endoscopic Tympanocentesis and collection of pus for culture and sensitivity tests were done.

RESULTS: Staphylococcus aureus emerged as a significant pathogen and Endoscopic Tympanocentesis proved to be better treatment option than Microscopic Myringotomy. CONCLUSION: Endoscopic Tympanocentesis under short infusion anaesthesia in children and under local anaesthesia in adults was a very effective, short duration-day-care procedure. The difference of the result of the study from the published literature regarding bacterial culture could be due to1_{rampant self-medication ,}2_{availability of over-the-counter antibiotics and}3_{taking of}

antibiotics before coming to the hospital for treatment.

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tympanogram A types were excluded from the study. Cases only with severe earache of duration of more than 48 hours with bulged drum and B type tympanograms underwent Tympanocentesis. The rest of the cases were given antibiotics and other supportive medications like analgesics, anti-inflammatory preparations, systemic and local nasal decongestants. Children above 12 years and adults underwent Tympanocentesis under local injection anaesthesia. Children below 12 years were

given infusion anaesthesia with

intravenous ketamine with appropriate pre-medications. Operating microscope was used in some of the cases and Oto-Endoscope was used in the remaining ones.

Method of Tympanocentesis: Before the start of the procedure and anaesthesia, proper antiseptic dressing of the external canals of the ears were done by painting with povidone iodine solution 10% w/v and followed by cleaning with rectified spirit in all the cases.

Anaesthesia methods:

 Local anaesthesia: This procedure is done in children above 12 years and adults. 0.4 ml each of 2% xylocaine with 1:30000 adrenaline solution was injected in the external canal at the

bony-cartilaginous junction with 2cc

disposable syringe, at four

circumferential anatomical points: 12, 3, 6 and 9 O’clock positions. A cotton ball soaked in 4% xylocaine with 1:10000 adrenaline solution was kept in contact with the tympanic membrane. After this a waiting time of 5-7 minutes was taken before the commencement of surgical procedure as illustrated below.

 Short general infusion anaesthesia: This procedure is done in infants and children below 12 years of age. A fasting of minimum 9 hours before the

procedure is recommended. After

establishing an intravenous line,

injections of 0.008 mg/Kg bodyweight of

glycopyrolate and 0.16 mg/Kg

bodyweight of ondasetron injections were given by intravenous route as premedication. After a wait of 15 minutes, 1 mg/Kg bodyweight of

injection ketamine was given by

intravenous quick shot. Proper pulse-oximeter monitoring was done during the procedure.

Surgical methods: Time duration of the procedures by the same surgeon was taken and the structures seen with the two different methods were recorded and compared.

Microscopic Myringotomy and

Aspiration: Permeatal microscopic

myringotomy and aspiration was done with the help of myringotome knife and aural speculum. Pus from the middle ear was collected with the help of sterile 2 cc syringe and sent for culture and sensitivity. Suction clearance of the middle ear cavity was done with the help of 18G suction cannula.

Endoscopic Tympanocentesis: 4 mm

nasoendoscope of zero-degree angle was used. 24G 25 mm length bevelled needle on 2cc disposable syringe was used to cut the antero-inferior quadrant of the tympanic membrane in a radial direction

from the umbo to the annulus

tympanicum. Usually the cut measures 2-3 mm. Pus is collected in this sterile 2 cc disposable syringe and sent for culture and sensitivity. Final suction clearance of the tympanic cavity was done with the 18G suction cannula.

Bacteriological culture: Collected

samples in sterile 2 cc disposable syringes were sealed by dipping the tip of the needle in hot paraffin wax and the syringes were again sealed in sterile plastic envelopes and sent immediately to the

microbiological laboratory. Classic

bacterial culture was done in blood agar and MacConkey agar media. Incubation at 37 degrees Celsius were done for 48 hours. Any growth during this period of bacterial culture were isolated and used for antibiotic sensitivity tests. Only common antibiotics were taken up for study though many other higher generation antibiotics were also used during the culture and sensitivity procedures.

RESULTS

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patients underwent surgical drainage of middle ear fluid under tension by tympanocentesis. 71 patients underwent Endoscopic Tympanocentesis in 131 ears.

30 patients underwent Microscopic

Myringotomy and Aspiration in 50 ears. Females [198 cases] were marginally more affected than the males [187 cases]. The highest incidence of cases occurred in below 5 years of age. Average time taken [excluding the time taken for anaesthetic procedure] by Microscopic Myringtomy and aspiration was 5 minutes and that of Endoscopic Tympanocentesis was 2.5 minutes. Visibility of parts of tympanic membrane in a single visual field was 100 % in Endoscopic procedure and about 48% in Microscopic procedure. Endoscopic Tympanocentesis was more convenient because it was a lesser time consuming technique with a clear panoramic view and the tympanic membrane along with middle ear structures could be assessed more

accurately. Microscopic Myringotomy

cannot be done in narrow canals. Follow up of the cases were done from 5 to 17 months. Patients treated with surgical drainage of pus before actual rupture of the tympanic membrane showed excellent healing leaving no scar and incidences of recurrent episodes of acute suppurative otitis media, during follow up was less than 2%.

Table 1: Sex and age incidence

Table 2: Comparison of surgical procedures

Table 3: Microbiology of middle ear aspirates

Table 4: Culture sensitivity report of common antibiotics showing number of positive cultures resistant or sensitive to the given antibiotic

Table 5: The number of patients already taken antibiotics in improper dosing by

self-medication or family or

acquaintances before coming to the hospital.

Of the 181 ears aspirated, 59 samples showed positive culture growth and 122 samples did not show any growth on 48 hours of aerobic incubation. Streptococcus

pneumoniae, Staphylococcus aureus,

Haemophilus influenza and Klebsiella pneumoniae were found in this order of

incidence in the positive cultures.

Staphylococcus aureus growth was found in increased incidence than in earlier

reported studies worldwide. Most

organisms were resistant to penicillin, ampicillin and amoxicillin. Amikacin,

azithromycin, ciprofloxacin,

cotrimoxazole, erythromycin, gentamicin, levofloxacin and tetracycline are sensitive in most cases. Almost everyone had been administered antibiotics by parents or self, prior to coming to the hospital for

treatment. Ampicillin, amoxicillin

clavulinate and azithromycin were the 0

50 100

0-5 years 6-15 years 16-50 years >50 years

Sex and Age Incidence

Male Female

0 100 200

Average duration/ear without anaesthetic

procedure (min)

Percentage of visibility of

Tympanic membrane/field

Total no. of ears

Comparison of Procedures

Endoscopic Tympanocentesis Microscopic Myringotomy

0 20

Positive culture

Bacterial Culture

Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Klebsiella pneumoniae

0 50

100 Culture Sensitivity Report

Resistant Sensitive

0 500

Incidence History

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common self-administered antibiotics, as per history of antibiotic intake at home. DISCUSSION

Acute suppurative otitis media is one of the most common diagnosis in infants and children seeking physicians’ appointment because of illness. Acute Suppurative Otitis Media can be classified into 5 stages: Stages of Hyperaemia, Exudation,

Suppuration, Coalescence and

Complication7. In our study we have taken into account only those with non-perforated tympanic membrane. This was done to exclude contamination by the bacteria of the external canal and also to study the effectiveness of the surgical intervention techniques. The organisms identified were not identical to the findings reported in other centres8,9. The reason for the unusual findings can be attributed to the rampant self-medication by taking over-the-counter antibiotics which is the usual practice by common people in Imphal, Manipur. The number of negative cultures were quite high. This could be ascribed to antibiotic treatment before tympanocentesis or presence of pathogens that do not grow in classic culture conditions like anaerobic organisms or mycobacterium or presence of non-bacterial organisms like viruses, chlamydia

or mycoplasma10,11,12. Some basic

antibiotics like the cotrimoxazole,

tetracyclines are found to be sensitive for treatment of this condition. Drainage of the middle ear fluid in this condition leads to more rapid healing of the condition and avoidance of complications. Further study may be needed to establish this as there are conflicting evidences13. Endoscopic ear procedures are well accepted to be more

advantageous due to less time

consumption and possibilities of having

panoramic view of the tympanic

membrane showing all quadrants of the tympanic membrane in a single visual field, of getting more accurate control of

the instruments, of visualization of middle ear structures and of working in a narrow external canal14.

CONCLUSION

The incidence of Acute Suppurative Otitis Media is very high in pre-school children below 5 years. Treatment should be prompt and antibiotics should be started immediately to avoid complications. It is extremely important to have a data on

local bacteriology specific to the

geographical area and the antibiotics sensitive to these organisms so that an effective empirical treatment can be started initially. Endoscopic Tympanocentesis is an effective, day-care surgical procedure to control the disease and prevent complications in high tension fluid collection in middle ear. A long-term longitudinal study will be beneficial to find out resistant strains and serve as treatment guidelines tailor-made for local conditions.

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