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Acute Suppurative Otitis Media (ASOM) - Complete Guide

Definition

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Etiology (Karan)

Predisposing Factors (Risk Factors)

Causative Organisms

• Streptococcus pneumoniae - Sabse common, zyada severe
• Haemophilus influenzae (non-typeable) - Especially persistent AOM and treatment failures mein
• Moraxella catarrhalis - Common, often beta-lactamase positive
• Streptococcus pyogenes (Group A Strep)
• Staphylococcus aureus - Less common
• Gram-negative rods (Pseudomonas) - Neonates mein

• Respiratory syncytial virus (RSV) - Sabse common
• Rhinovirus
• Coronavirus, Influenza A, Parainfluenzae, Adenovirus

Note: AOM commonly a co-infection hai - viral URTI bacterial superinfection ka door kholta hai.

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Etiopathogenesis (Disease Mechanism)

Upper Respiratory Infection (Viral/Bacterial)
           ↓
Nasopharyngeal Mucosal Inflammation
           ↓
Eustachian Tube Dysfunction / Obstruction
(mucosal edema → ET blocked)
           ↓
Middle Ear Negative Pressure
           ↓
Nasopharyngeal secretions + bacteria enter middle ear
via ET (ascending route)
           ↓
Middle Ear Effusion (MEE) forms
           ↓
Bacterial multiplication in middle ear
           ↓
ACUTE SUPPURATIVE OTITIS MEDIA

Eustachian Tube Role:

• ET normally: middle ear ventilate karta hai, drainage provide karta hai, nasopharyngeal secretions se protect karta hai
• Jab ET obstructed hoti hai: negative pressure develop hota hai → transudate forms → bacteria grow karte hain
• Children mein ET choti, horizontal aur zyada flexible hai - isliye infection zyada prone hai

Immune Response:

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Pathological Stages (4 Stages - Shambaugh Classification)

Stage 1 - Hyperemic Stage (Tubal Occlusion / Stage of Congestion)

• Onset: Antigen enter hone ke baad earliest response
• Mechanism: ET dysfunction + mucosal inflammation
• Pathology:
  • TM aur middle ear mucosa mein hyperemia aur edema
  • TM ke teeno layers involve hoti hain
  • Mucosal vessels dilate aur congested
• Clinical: Ear fullness, mild otalgia, mild hearing loss, TM erythematous

Stage 2 - Exudative Stage (Pre-Suppurative Stage)

• Mechanism: IL-2, PECAM-1 aur adhesion molecules release → vessels "leaky" ho jaate hain
• Pathology:
  • B aur T lymphocytes, macrophages, PMN cells middle ear mein rush karte hain
  • IgG-bearing B-cells pehle aate hain, phir IgM-bearing B-cells (24 hrs)
  • T-helper cells 24 hrs baad, 2-3 weeks mein peak
  • IgA-bearing B-cells ~3 weeks baad
  • Middle ear mein fluid accumulation (exudate)
• Clinical: Severe otalgia, high fever, conductive hearing loss, TM bulging/red, flat tympanogram

Stage 3 - Suppurative Stage (Stage of Suppuration)

• Only in bacterial infections
• Mechanism: Immunoglobulins bacteria ko coat karte hain → opsonization → complement cascade → bacterial destruction → pus formation
• Pathology:
  • Purulent fluid collection behind TM
  • TM severely bulging with pus
  • TM rupture ho sakta hai agar suppuration fulminant ho
• Clinical: Intense otalgia (bursting pain), very high fever, TM perforates → otorrhea ke baad pain relief (pathognomonic)

Stage 4 - Resolution Stage

• With/without antibiotics
• Pathology:
  • Immune system bacteria ko control kar leta hai
  • Fluid gradually absorb hota hai via ET
  • BUT - ET mucosal edema se blocked ho sakta hai → fluid persist karta hai
  • Agar sterile effusion persist kare → Otitis Media with Effusion (OME)
• Clinical: Fever subsides, pain reduces, hearing gradually recovers, TM heals (agar perforation hua)

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Clinical Features (Lakshan)

Symptoms (Subjective):

Signs (Objective / Otoscopic):

Otoscopic views: (A) Normal TM (B) Red, bulging TM in AOM (C) OME effusion (D) Tympanostomy tube

Bullous Myringitis:

• TM pe bullae (fluid-filled blisters) - AOM ke 5% cases mein
• Previously Mycoplasma pneumoniae se associated maana jaata tha
• Ab jaana jaata hai ki typical AOM pathogens hi cause karte hain
• Treatment same as regular AOM - alag nahi

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Management

1. Pain Management (PEHLE):

• Analgesics: Paracetamol (Acetaminophen) / Ibuprofen
• Antibiotics pehle 24 hrs mein pain mein improvement nahi dete - isliye analgesic zaroori hai

2. Antibiotic Therapy:

Immediate Antibiotics Dene ki Indications:

• Infants < 6 months: Hamesha antibiotics
• 6 months - 2 years: Bilateral AOM ya otorrhea → antibiotics; unilateral mild AOM → observe kar sakte hain

• 2 years: Severe AOM → antibiotics; mild unilateral → 48-72 hrs observe (watchful waiting)

• Adults: Observation validated nahi hai - antibiotics de sakte hain

First-Line Treatment:

Treatment Failure (48-72 hrs mein improvement nahi):

• Amoxicillin-Clavulanate (beta-lactamase resistant organisms ke liye - M. catarrhalis, H. influenzae)
• IM Ceftriaxone (single dose ya 3 doses) - oral treatment fail hone par

3. Myringotomy (Tympanocentesis):

• Indications:
  • Severe pain with bulging TM
  • High fever not responding to antibiotics
  • Complications develop hone par
  • Immunocompromised patients
  • Neonates (culture ke liye bhi)
• Procedure: Antero-inferior quadrant mein incision
• Immediate relief of pain and pressure

4. Tympanostomy Tubes (Grommets):

• Indication for recurrent AOM: ≥3 episodes in 6 months ya ≥4 episodes in 12 months
• Ventilation provide karta hai, fluid drain karta hai
• Grommet type: Typically 6-14 months mein spontaneously extrude hote hain

5. Adjunctive Measures:

• Nasal decongestants (limited evidence)
• Antihistamines (allergic component mein)
• Adenoidectomy: > 4 years ke children mein recurrent OM ke liye (tympanostomy tubes ke saath)

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Complications

Intratemporal (Local):

• Mastoiditis - Sabse common complication (acute coalescent mastoiditis)
• Facial nerve palsy
• Labyrinthitis (suppurative)
• Petrositis
• Hearing loss (conductive or sensorineural)
• TM perforation → Chronic OM / Cholesteatoma

Intracranial (Rare, < 1%):

• Meningitis
• Brain abscess
• Subdural empyema
• Lateral sinus thrombosis
• Otitic hydrocephalus

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Summary Flowchart

ASOM
├── ETIOLOGY: S. pneumoniae > H. influenzae > M. catarrhalis + Viruses
├── ROUTE: ET dysfunction → Ascending infection
├── STAGES:
│   Stage 1 Hyperemic → Stage 2 Exudative → Stage 3 Suppurative → Stage 4 Resolution
│   (Congestion)      (PMN infiltration)   (Pus + perforation)   (Healing/OME)
├── CLINICAL: Otalgia + Fever + TM bulging/perforation + Conductive HL
└── MANAGEMENT:
    Analgesics + Amoxicillin (DOC)
    ├── Failure → Amoxicillin-Clavulanate
    ├── Recurrent → Tympanostomy tubes
    └── Complications → Myringotomy + IV antibiotics + Surgery

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• Shambaugh Surgery of the Ear, Ch. 25 - Pathology & Clinical Course of Inflammatory Diseases of the Middle Ear
• Cummings Otolaryngology Head & Neck Surgery, Ch. 199 - Otitis Media
• Rosen's Emergency Medicine - Otitis Media, Ch. 58
• Scott-Brown's Otorhinolaryngology - Otitis Media sections

ASOM - Simple & Easy Version 🦻

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🔑 Pehle Samjho - Ye Hota Kya Hai?

ASOM = Middle ear mein bacterial infection = Kaan ke andar pus bhar jaana

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😈 Bacteria Kaun Kaun Se?

• S - Streptococcus pneumoniae (Sabse dangerous)
• H - H. influenzae (non-typeable)
• M - Moraxella catarrhalis

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🔄 Etiopathogenesis (Simple Version)

Sardi/Khansi (URTI)
        ↓
Eustachian Tube mein Swelling/Block
        ↓
Kaan ke andar negative pressure bana
        ↓
Nasopharynx se bacteria andar khich gaye
        ↓
Middle ear mein bacteria multiply hue
        ↓
Pus bana → ASOM!

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📊 4 Stages (Bahut Important!)

Ek Story ki tarah Yaad Karo:

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• Bacteria andar gaye → kaan laal hua
• TM red, swollen
• Hafif dard, hafif bukhaar
• Light reflex dull hona shuru

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• White blood cells bhaagte hue aaye
• Middle ear mein fluid/exudate bhar gaya
• TM bulge karne laga
• Dard badh gaya, fever tez hua
• Sunna kam hua (conductive hearing loss)

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• Bacteria maar diye → pus ban gaya
• TM bahut phul gaya
• Intense pain - "kaan phatne wala dard"
• Agar pressure zyada hua → TM phat jaata hai → pus bahar aata hai
• Pus bahar = Pain khatam! ← Ye classic sign hai ✅

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• Bacteria control ho gaye
• Fluid absorb hone laga
• Fever jaata raha, dard khatam
• TM heal hone laga
• Agar fluid ruk gaya → OME (Otitis Media with Effusion)

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😷 Clinical Features (Yaad Karne ka Trick)

"FHOP"

• F - Fever (bukhaar, high grade)
• H - Hearing loss (conductive)
• O - Otalgia (kaan dard - sabse important!)
• P - Perforation ke baad Pus (otorrhea)

Otoscope mein kya dikhega?

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💊 Management (Treatment)

Step 1 - Dard pehle khatam karo

Paracetamol / Ibuprofen deo pehle - antibiotics 24 hrs mein dard nahi hatate!

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Step 2 - Antibiotic do ya wait karo?

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Step 3 - Antibiotic Choice

1st Line → AMOXICILLIN (DOC)
              ↓ agar 48-72 hrs mein theek nahi hua
2nd Line → AMOXICILLIN + CLAVULANATE
              ↓ agar phir bhi fail
3rd Line → IM CEFTRIAXONE

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Step 4 - Myringotomy (Kaan chhedna)

• Bahut tez dard, bulging TM
• Fever antibiotics se nahi ja raha
• Complications ho rahi hain
• Neonates mein (culture ke liye bhi)

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Step 5 - Baar baar ho toh? (Recurrent AOM)

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⚠️ Complications (2 Types)

• Mastoiditis ← Sabse common
• Hearing loss
• Facial nerve palsy

• Meningitis
• Brain abscess

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🧠 Quick Revision Table

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🦻 ASOM - Deep but Easy Explanation

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🏠 Pehle Anatomy Samjho (Foundation)

1. Outer ear - Jo dikhta hai + ear canal
2. Middle ear - TM (tympanic membrane/eardrum) ke peeche wali cavity
3. Inner ear - Cochlea (sunne ke liye)

1. Middle ear mein fresh air daalna (pressure balance)
2. Middle ear ka paani bahar nikalna (drainage)
3. Naak ke bacteria ko andar aane se rokna (protection)

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❓ ASOM Hota Kyun Hai? (Etiology + Etiopathogenesis)

Whole Story Step by Step:

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Children mein Zyada Kyun?

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Risk Factors

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🦠 Bacteria Kaun Se Hain? (Organisms)

Bacteria (The Main Villains):

• Sabse common, sabse dangerous
• Gram +ve, lancet shaped diplococci
• Zyada severe disease karta hai
• Antibiotic resistance bhi ho sakti hai

• 2nd most common
• Gram -ve rod
• Bilkul interesting - "non-typeable" matlab ye wala H. influenzae type b nahi hai (vaccine se wo cover ho gayi)
• Treatment failure aur persistent cases mein zyada
• TM perforation wale cases mein bhi common

• Gram -ve diplococcus
• 3rd most common
• Important: Almost always beta-lactamase positive - matlab plain amoxicillin se resist kar sakta hai
• Lekin theek bhi khud hi ho jaata hai often (high spontaneous resolution rate)

Viruses:

• 70% cases mein viruses bhi middle ear mein milte hain
• Akele viral AOM hoti hai, ya phir viral ke baad bacterial superinfection
• RSV, Rhinovirus, Influenza A, Adenovirus, Coronavirus, Parainfluenzae

Special Situations:

• Neonates mein: Group B Streptococcus, S. aureus, Gram-negative rods bhi possible
• Immunocompromised mein: Aspergillus, Candida (fungal) bhi soch lena

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🔬 Etiopathogenesis - Immune Response Deep Mein

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📊 4 Pathological Stages - Story Format Mein

🔴 STAGE 1 - HYPEREMIC (Congestion / Lali ki Stage)

• Antigen pehunchne ke baad, blood vessels dilate hoti hain
• Kaan ki TM aur middle ear ki inner lining (mucosa) laal aur swollen ho jaati hai
• TM ke teeno layers (outer, middle, inner) mein swelling aati hai
• Ek "emergency broadcast" jaisi hoti hai - "intruder aa gaya!"

• TM laal dikhti hai (erythematous)
• Light reflex dull hone lagta hai
• Hafif kaan dard (otalgia) - tolerable
• Hafif sunna kam hona
• Low-grade fever

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🟡 STAGE 2 - EXUDATIVE (Fluid aane ki Stage)

• IL-2 aur PECAM-1 (Platelet Endothelial Cell Adhesion Molecule) release hote hain
• Blood vessels ki walls par adhesion molecules express hoti hain
• Vessels "leaky" ho jaati hain - bilkul jaise flood mein deewar mein chhek ho jata hai

• IL-1, IL-6, IL-8 (pro-inflammatory signals)
• TNF-alpha (tumor necrosis factor - bacteria ko maar ke)
• Leukotriene B4 (aur zyada neutrophils bulane ke liye)

• TM bulging (tympanic membrane bahar ki taraf phool jaati hai) - MOST IMPORTANT SIGN
• Severe otalgia - throbbing, bursting pain
• High fever (38-39°C)
• Significant conductive hearing loss (fluid ki wajah se TM theek vibrate nahi karti)
• Flat tympanogram (tympanometry par)
• Absent acoustic reflexes

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🟠 STAGE 3 - SUPPURATIVE (Pus ki Stage)

1. Opsonization: B-cells antibodies (IgG) release karte hain jo bacteria ki surface par coat ho jaati hain → bacteria "labeled" ho jaate hain "mujhe khao" ka tag lagake
2. Phagocytosis: Macrophages in labeled bacteria ko khaa lete hain
3. Complement Cascade activate: C3, C5 activate → bacteria ki cell wall tod di jaati hai
4. Neutrophils apni enzymes chhodte hain, bacteria ko destroy karte hain
5. Dead bacteria + dead WBCs + fluid = PUS

Classic Sign: Jaise hi pus bahar aata hai, DARD KHATAM! 🎯 Kyun? Kyunki pressure release ho jaata hai. Patient achanak better feel karta hai. Ye ek pathognomonic feature hai ASOM ka.

• Intense, excruciating otalgia (kaan mein bahut tez dard - "kaanphat" jaisa)
• Very high fever (39°C+)
• TM - bright red, severely bulging, ya perforation with otorrhea (pus discharge)
• Hearing almost gone (conductive HL)
• Child bahut irritable, rota hai, kaan pakad ke rota hai
• Perforation ke baad: Pain suddenly khatam, pus discharge shuru

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🟢 STAGE 4 - RESOLUTION (Theek Hone ki Stage)

• Inflammation slowly kam hoti hai
• Fluid ET se drain hona shuru hota hai
• TM ki perforation (agar hoi thi) spontaneously heal ho jaati hai (usually 2-4 weeks)
• Hearing wapas aati hai
• Fever jaata hai

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👁️ Clinical Features - Detailed

Symptoms (Patient Kya Batata Hai):

• Stage 1-2 mein: Dull, throbbing
• Stage 3 mein: Very severe, "kaan phat raha hai" jaisa
• Stage 3 ke baad perforation: SUDDEN RELIEF - dard khatam

• TM rupture ke baad aata hai
• Purulent (pus jaisa) - yellow/green
• Kabhi kabhi blood-tinged
• Parents notice karte hain - "taaki pe pus aa gaya"

• Conductive type (TM aur ossicles proper vibrate nahi kar paate)
• 25-40 dB loss roughly
• Bachche mein: TV zyada loud karna, baat baar baar poochna

• Children mein high grade (39°C+)
• Infants mein severe - hypothermia bhi possible (paradoxical)

• Irritability (bachche mein)
• Kaan pakad ke rona
• Poor feeding / appetite loss
• Vomiting, nausea
• Disturbed sleep
• Khangsi (cough) - URTI ki wajah se

Signs (Doctor Kya Dekhta Hai):

Sirf laal TM = AOM nahi. Rona ya fever se bhi TM laal ho sakti hai. Bulging + redness = TRUE AOM

• Normally TM hawa se hilti hai
• AOM mein: TM ki movement reduced ya absent (fluid ki wajah se)

• Normal: Type A (peak with positive pressure)
• AOM mein: Type B (flat) - no peak - fluid hai andar

• Conductive hearing loss - 25-40 dB

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💊 Management - Step by Step

Step 1: Dard Control (PEHLA KAAM)

• Paracetamol - 15 mg/kg/dose, 4-6 hourly
• Ibuprofen - 10 mg/kg/dose, 6-8 hourly

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Step 2: Antibiotic - Do Ya Wait Karo?

• Otalgia > 48 hours duration
• Temperature > 39°C

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Step 3: Antibiotic Selection

• S. pneumoniae ke against highly effective (most dangerous pathogen)
• Cost-effective
• Safe side effect profile
• Palatable (taste theek hai bacchon ke liye)
• Ye HIGH dose isliye hai kyunki intermediate resistance wale pneumococcus ko bhi cover karta hai

• < 2 years: 10 days
• > 2 years, first episode, mild: 7 days (shorter course bhi equally effective)

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Step 4: Agar 48-72 Hours Mein Theek Na Ho (Treatment Failure)

• Beta-lactamase producing organisms (M. catarrhalis, H. influenzae)
• Antibiotic resistant pneumococcus
• Galat diagnosis thi

• Clavulanate beta-lactamase ko block karta hai
• Ab M. catarrhalis aur H. influenzae bhi cover hote hain

• Jab oral bhi fail ho

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Step 5: Kaan Chhedna - Myringotomy

• Bahut tez dard, bulging TM aur antibiotics kaam nahi kar rahi
• Fever 48 hours ke baad bhi high grade
• Complications develop ho rahi hain (mastoiditis, facial palsy)
• Immunocompromised patient
• Neonates (culture bhi lete hain yahan se - exact organism jaanne ke liye)
• Resistant organisms ki suspicion

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Step 6: Tympanostomy Tube (Grommet) - Recurrent Cases

• ≥ 3 episodes in 6 months
• ≥ 4 episodes in 12 months

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Step 7: Adenoidectomy

• Children > 4 years mein, recurrent OM mein
• Adenoids ET opening ke paas hote hain - bacteria ka reservoir bante hain + ET block karte hain
• Adenoidectomy se tube reinsertion ki need 10% kam hoti hai

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What NOT to Do:

• Antihistamines - koi benefit nahi AOM mein
• Decongestants - koi benefit nahi
• Steroids - AOM mein recommended nahi
• Aminoglycoside ear drops (Gentamicin) - ototoxic hain - perforated TM mein kabhi mat daalo!
• Fluoroquinolone drops - perforated TM ke saath safe hain

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⚠️ Complications

1. Intratemporal (Temporal bone ke andar)

• Middle ear mastoid air cells se connected hai - infection spread hoti hai
• Initially hamesha "physiological mastoiditis" hoti hai (normal hi)
• Coalescent mastoiditis serious hai: bony septae breakdown ho jaati hain, abscess banta hai
• Sign: Kaan peeche ke baad swelling + ear bahaar ki taraf push hona (auricular displacement) ← AOM se distinguish karta hai
• Treatment: IV antibiotics + mastoidectomy surgery

• Inner ear mein infection spread
• Severe vertigo + sensorineural hearing loss
• Emergency hai

• Facial nerve ka canal middle ear ke paas se guzarta hai
• Infection spread hone se nerve compress ya inflame ho sakti hai
• Unilateral facial weakness

• Petrous bone mein infection extend hoti hai
• Gradenigo's Syndrome: Petrositis + Trigeminal pain + Lateral rectus palsy (diplopia)

• Chronic inflammation se TM ya ossicles mein calcium deposit ho jaata hai
• Conductive hearing loss

• Chronic perforation se squamous epithelium middle ear mein grow karne lagti hai
• Bone destroy karta hai

2. Intracranial (Rare - < 1% cases in antibiotic era)

• Fever, neck stiffness, photophobia
• Emergency

• Headache, fever, "picket fence fever" (spike hoti hai)

• CSF absorption disturb hone se ICP badh jaata hai

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🧠 Exam Ke Liye Final Revision Points

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