The classic signs and symptoms of acute otitis media include the following:

• Pain in one or both ears
• Hearing loss in one or both ears
• Discharge from the ear

These classic signs and symptoms may be accompanied by non-specific signs and symptoms such as fever, mild upper respiratory symptoms, malaise, vomiting and diarrhea.

In infants and neonates, the classic signs and symptoms can not be described. They may be asymptomatic or may present with only non-specific manifestations such as irritability, fever, diarrhea, vomiting; or they may pull at their ears.

Chronic otitis media has a pattern as compared to acute otitis media and presents with hearing impairment, perforation of the tympanic membrane and a foul smelling discharge from the ear canal; the latter persisting for longer than 6 weeks.

• Fever

  Chronic suppurative otitis media generally causes no fever and no pain. [ims.uniklinik-freiburg.de]

  They may be asymptomatic or may present with only non-specific manifestations such as irritability, fever, diarrhea, vomiting; or they may pull at their ears. [symptoma.com]

  In children without fever and vomiting, antibiotics are not given unless the child’s symptoms have not resolved within 2 days, or unless the child is less than 2 years of age. In children with fever and vomiting, antibiotics are generally given. [myvmc.com]

  The combination of these signs with ear pain or fever confirms the diagnosis of AOM. [medicalguidelines.msf.org]

  […] complications includes the following: Labyrinthitis - Fever, nystagmus, serous or suppurative otitis media Mastoiditis with subperiosteal abscess - Fever, fluctuance overlying the mastoid area, lateral displacement of pinna, otitis media Petrositis - [emedicine.com]

• Recurrent Otitis Media

  Recurrent otitis media:Patients with recurrent otitis media may be placed on daily doses of an antibiotic such as sulfisoxazole or amoxicillin prophylaxis for 3 to 6 months after acute infection has cleared. [symptoma.com]

  In addition, we examined human temporal bones from 2 deceased donors with clinical histories of otitis media (1 with acute onset otitis media, 1 with recurrent infection). [ncbi.nlm.nih.gov]

  When a single episode of infection occurs it’s called acute otitis media. If it happens more often it’s called recurrent otitis media. If fluid collects in the middle ear is known as acute otitis media with effusion. [nicklauschildrens.org]

  Sometimes, AOM infections can cause: recurrent ear infections enlarged adenoids enlarged tonsils a ruptured eardrum a cholesteatoma, which is a growth in the middle ear speech delays (in children who have recurrent otitis media infections) In rare cases [healthline.com]

• Asymptomatic

  He remains asymptomatic under outpatient surveillance till this report. [ncbi.nlm.nih.gov]

  Therefore a large proportion of cases can be managed by 'watchful waiting' (See RefHelp section "Adenoids") OME can be asymptomatic but can lead to conductive hearing loss (CHL) and/or recurrent acute otitis media (RAOM). [apps.nhslothian.scot]

  Otitis Media with Effusion (glue ear) Glue ear is an uncommon presenting complaint in an emergency department as it is usually asymptomatic, although it can cause balance issues It may be found as part of a routine assessment, although it is not readily [kidshealthwa.com]

  They may be asymptomatic or may present with only non-specific manifestations such as irritability, fever, diarrhea, vomiting; or they may pull at their ears. [symptoma.com]

• Fatigue

  This may also cause people to be irritable, as well as fatigued and have a decreased appetite. When the condition is particularly severe and often after inadequate treatment, it is possible for the tympanic membrane to rupture. [news-medical.net]

  The non-specific symptoms of otitis media include: fever (especially in infants), fatigue, intense malaise, nausea and vomiting. [ims.uniklinik-freiburg.de]

• Lymphadenopathy

  Examination should also include checking for any intracranial complications, cervical lymphadenopathy, and signs of infection in the throat and oral cavity. [teachmesurgery.com]

  […] seen in serous cystadenoma and other tumors frequently bilateral In the setting of suspected ovarian cystadenocarcinoma, features suggestive of extra-ovarian metastasis include: ascites - often of disproportionately large volume 3 peritoneal nodularity lymphadenopathy [radiopaedia.org]

• Rhinitis

  Chronic postnasal drip, chronic hypertrophic rhinitis, and nasal polyps were correlated with the presence of middle ear pathologies; allergic rhinitis was negatively correlated. [ncbi.nlm.nih.gov]

  The duration and severity of symptoms were not predictive for AOM, although rhinitis lasted longer and conjunctivitis was more severe in children with AOM. [doi.org]

  In case of any occlusion of the Eustachian tube due to any reason, (mechanical occlusives such as bottle feeding, finger imbibing/nipple usage, adenoid vegetation, mass or allergic cases such as rhinitis, sinusitis) air transfer to the middle ear is blocked [kuhead.org]

  Antibiotics should be given for bacterial rhinitis, sinusitis, and nasopharyngitis. Demonstrated allergens should be eliminated from the patient’s environment and immunotherapy should be considered. [msdmanuals.com]

• Sore Throat

  We describe the youngest case to date of a 2 year old child who developed central skull base osteomyelitis (SBO) initially presenting with a fever, vomiting and sore throat. [ncbi.nlm.nih.gov]

  Otitis media usually starts with a cold or a sore throat caused by bacteria or a virus. The infection spreads through the back of the throat to the middle ear, to which it is connected by the eustachian tube. [healthdirect.gov.au]

  This fluid may accumulate in the middle ear as a result of a cold, sore throat or upper respiratory infection. OME is usually self-limited, which means, the fluid usually resolves on its own within 4 to 6 weeks. [chop.edu]

  Common symptoms of a middle ear infection in adults are: Pain in 1 or both ears Drainage from the ear Muffled hearing Sore throat You may also have a fever. Rarely, your balance can be affected. [entcolumbia.org]

• Snoring

  Other symptoms include hearing loss, snoring, mouth breathing, fever, headache, vomiting, and diarrhea. Causes The Eustachian (pharyngotympanic) tube is a drain that connects the nose and throat to the middle ear. [nicklauschildrens.org]

  […] overweight and obesity may increase the risk for chronic otitis media with effusion (OME), or vice versa. [39] A study by Walker et al found that preschool children with chronic otitis media with effusion tended to be characterized by nasal obstruction, snoring [emedicine.com]

  Other indications for adenoidectomy included chronic rhinorrhea with associated rhinosinusitis or chronic mouth breathing with associated snoring. [jamanetwork.com]

  For the following symptoms, an AT is indicated: Nasal obstruction Recurrent infections of the upper airways with chronic adenoiditis Snoring High-risk patients The most important high-risk patients are children with a cleft palate, PCD, or Down’s syndrome [egms.de]

• Nasal Congestion

  Temporary hearing loss can result from middle ear infections, and he infection may occur in the presence of signs and symptoms of an upper respiratory infection, such as nasal congestion, runny nose, or cough. [medicinenet.com]

  […] allergies, but they may prolong middle ear effusion. 26 Oral decongestants may be used to relieve nasal congestion. [aafp.org]

• Vomiting

  They may be asymptomatic or may present with only non-specific manifestations such as irritability, fever, diarrhea, vomiting; or they may pull at their ears. [symptoma.com]

  In children without fever and vomiting, antibiotics are not given unless the child’s symptoms have not resolved within 2 days, or unless the child is less than 2 years of age. In children with fever and vomiting, antibiotics are generally given. [myvmc.com]

  Adverse effects likely to be related to the use of antibiotics such as vomiting, diarrhoea or rash. [doi.org]

  Symptoms Babies and toddlers often start with pulling or scratching at the ear, along with hearing problems, fever, drainage from the ear, irritability, and vomiting. [medtronic.com]

• Loss of Appetite

  Loss of appetite: This may be most noticeable in young children, especially during bottle feedings. Pressure in the middle ear changes as the child swallows, causing more pain and less desire to eat. [my.clevelandclinic.org]

  While there is fluid in the middle ear, there can be temporary hearing loss. Very rarely, an untreated acute otitis media can lead to permanent hearing loss. [nationwidechildrens.org]

  Symptoms of ear infections: Pain (earache) If you child cannot tell you he/she is in pain look for these symptoms: Drainage from the ear Pulling or rubbing the ears Loss of appetite Does not react to soft sounds Can’t sleep, wakes up at night Fever Cranky [chkd.org]

• Regurgitation

  Especially for the lying babies fed with bottles, when the regurgitated food reach the middle ear, and when the microorganisms accumulates in this media, it causes an infection in the ear and leads to Acute Otitis Media (AOM). [kuhead.org]

  The most common reason in both the zinc and placebo groups was a reaction to the taste of the syrup resulting in regurgitation; this was most common in the youngest participants. No trials reported any serious adverse events. [doi.org]

• Mouth Breathing

  Other symptoms include hearing loss, snoring, mouth breathing, fever, headache, vomiting, and diarrhea. Causes The Eustachian (pharyngotympanic) tube is a drain that connects the nose and throat to the middle ear. [nicklauschildrens.org]

  Other indications for adenoidectomy included chronic rhinorrhea with associated rhinosinusitis or chronic mouth breathing with associated snoring. [jamanetwork.com]

• Visual Impairment

  Identification of neonatal hearing impairment: hearing status at 8 to 12 months corrected age using a visual reinforcement audiometry protocol. Ear Hear. 2000 ;21: 471 - 487. Google Scholar | Medline | ISI 158. Casby, MW. [doi.org]

• Otalgia

  Severe illness is defined as moderate to severe otalgia or temperature greater than 39°C, whereas nonsevere illness is defined as mild otalgia and temperature less than 39°C. [emedicine.com]

  Acute suppurative otitis media (ASOM) - A history of gradually increasing otalgia followed by the appearance of a discharge with some reduction in otalgia. Patients sometimes hear/feel a 'pop' just before the discharge appears. [entsho.com]

  Otalgia (i.e., ear pain) is the most prevalent and important symptom of AOM Ear tugging ear tugging or rubbing in younger children is indicative of pain in the ear. [medicaljoyworks.com]

  Severe illness is defined as moderate-to-severe otalgia or temperature greater than 39°C, whereas nonsevere illness is defined as mild otalgia and temperature less than 39°C. [emedicine.medscape.com]

• Hearing Impairment

  Children can be impacted mainly with hearing impairment and/or co-occurring recurrent acute otitis media (AOM) thus requiring treatment. [ncbi.nlm.nih.gov]

  Grades of Hearing Impairment*:9 Grade of Impairment Corresponding Audiometric Value from ‘Australian Hearing’ 0 No Hearing Loss 20dB or better (better ear) 1 Mild Hearing Loss 21-45dB (better ear) 2 Moderate Hearing Loss 46-65dB (better ear) 3 Severe [www1.health.gov.au]

  OM-related hearing impairment has a prevalence of 30.82 per ten-thousand. Each year 21thousand people die due to complications of OM. [doi.org]

• Tinnitus

  Here too the patient notices progressive hearing loss up to deafness, either with or without tinnitus. [ims.uniklinik-freiburg.de]

  Learn More About Topic Tinnitus Over 50 million Americans have experienced tinnitus, or ringing in ears, which is the perception of sound without an external source being present. [entnet.org]

• Normal Hearing

  METHODS: Forty-one children with normal hearing and normal middle ear status and 84 children with OME with or without hearing loss participated in this study. [ncbi.nlm.nih.gov]

  However, normal hearing usually returns within months without surgery 4 and there is no long-term difference in the hearing of patients who have had grommet operations compared with those who have not. 12 Perhaps we should be more cautious in the use [nps.org.au]

  THE EARDRUM WILL NOT VIBRATE NORMALLY WHEN A CHILD HAS FLUID IN THE MIDDLE EAR. *Your GP may diagnose glue ear but then it may not be present at the time of the hearing testing. [hearourheart.org]

• Ear Fullness

  Fullness of the ear adults and older children presents with ear fullness during suppurative otitis media. ear pressure or clogging sensation of the ear both are suggestive of aural fullness, otitis media due to effusion is the major diagnosis Ear tugging [medicaljoyworks.com]

  However, sometimes there is enough fluid in the middle ear space that you will notice one or more of the following symptoms: Pain Hearing loss Ear fullness Child pulling at their ear Child has a change in behavior If you notice a prolonged behavior change [verywellhealth.com]

  Symptoms of acute otitis media (AOM) The following are symptoms of acute otitis media: fever ear pulling complaints of ear pain, ear fullness, or hearing loss by older children fussiness, irritability, or difficulties in hearing, feeding, or sleeping [healthofchildren.com]

• Distractibility

  […] problems Your child may be struggling to hear if they often: speak more loudly or quietly than usual are difficult to understand ask people to repeat what they say ask for the TV or music to be turned up loud struggle to hear people far away become easily distracted [nhs.uk]

  A child with “glue ear” may not respond to soft sounds, like to turn up the television or radio, may talk loud, and appear to be distracted or inattentive. [hear-the-world.com]

  Other obstacles identified in this pilot survey were supervision, liability, school regulation, compliance issues, potential distractions to classes and risk of choking. [doi.org]

• Inattentive Behavior

  […] to age 13 years and with hyperactive and inattentive behavior until age 15 years. 76 The largest effects were observed for defects in reading ability between 11 and 18 years. [doi.org]

• Irritability

  Irritants such as tobacco smoke in the air also increase the chance of otitis media. Children with cleft palate or Down syndrome are predisposed to ear infections. [medicinenet.com]

  Irritability: Any kind of continuing pain may cause irritability in children and adults. Poor sleep: Pain may be worse when the child is lying down, as fluid is shifting. Fever: Ear infections can cause temperatures up to 104° F. [my.clevelandclinic.org]

  […] sleeplessness pulling on the ears ear pain a headache neck pain a feeling of fullness in the ear fluid drainage from the ear a fever vomiting diarrhea irritability a lack of balance hearing loss The eustachian tube is the tube that runs from the middle [healthline.com]

• Vertigo

  Benign Paroxysmal Positional Vertigo (BPPV) Benign paroxysmal positional vertigo, or BPPV, is the most common inner ear problem and cause of vertigo, or false sense of spinning. [entnet.org]

  Presenting symptoms of the latter condition may include hearing loss, tinnitus, dizziness, vertigo and facial palsy. Otitis media with effusion secondary to eustachian tube dysfunction has also been reported. [ncbi.nlm.nih.gov]

• Agitation

  A popular agitation set in, which,' starting as a purely local movement, led to and merged itself in a national struggle of All India character against the British, which never ceased till India won her independence. [shabdkosh.com]

In addition to the clinical features, the following investigations are needed to establish the diagnosis of otitis media.

Otoscopy and tympanometry: Otoscopy and tympanometry will reveal several abnormal features characteristic of otitis media including the following.

• There is an abnormal contour of tympanic membrane (which consists of fullness, bulging and/or extreme retraction).
• Erythema of tympanic membrane is often present. Presence of liquid in the middle ear cavity may impart a pale yellow color in the tympanic membrane.
• There may be opacification in the tympanic membrane.
• Structural changes in the tympanic membrane such as scars or perforation may also be seen.
• The mobility of the tympanic membrane is also impaired. Mobility is the most sensitive and specific indicator to detect the presence or absence of effusion in the middle ear.

Culture of the ear discharge: Culture of the ear discharge may be done to determine the presence and type of the causative agent.

Needle aspiration with culture (or PCR) of middle ear contents: Aspiration and culture of the contents of the middle ear contents may be done in cases when there is no discharge from the ear. It is the most reliable method for confirming the presence of infection and identifying the causative agent. In place of culture, polymerase chain reaction (PCR) may also be used to detect the bacteria with high sensitivity and specificity [5] [6].

The treatment of various types of otitis media is as below.

Acute otitis media:

• Dry mopping of the ear should be done.
• Analgesics are given to relieve pain.
• Antipyretics are given to reduce fever.
• The initial treatment is directed against the most common organisms (Streptococcus pneumonia and Hemophilus influenza). Amoxicillin is the drug of choice while alternative drugs include erythromycin, cefaclor, cefuroxime and trimethoprim-sulfamethoxazole. Later on, if needed, antibiotics can be changed according to the culture and sensitivity report.
• The patients who are not cured after a second course of antibiotics, or those who become severely ill may be considered for tympanocentesis to identify the causal pathogen so that the appropriate antibiotic can be used.

Recurrent otitis media:
Patients with recurrent otitis media may be placed on daily doses of an antibiotic such as sulfisoxazole or amoxicillin prophylaxis for 3 to 6 months after acute infection has cleared.

Chronic suppurative otitis media:
The pathogens are usually mixed in this case and commonly include S. aureus and P. aeuroginosa, or both [7]. Initial therapy with oral antibiotic that is effective against Staphylococcus is tried but optimal therapy is based on middle ear cultures and may require intravenous antibiotics against Psuedomonas.

Chronic otitis media with effusion:
In this case, a 2 to 4 weeks course of oral antbiotics is usually effective. In resistant cases, the placement of tympanostomy tubes is recommended for more than 2 months.

With proper treatment, the majority of the cases of otitis media recover completely. Untreated and complicated otitis media can lead to the development of a number of serious complications including meningitis, mastoiditis and permanent hearing loss.

Bacteria are the most common agents causing otitis media [1] [2]. In around 25 to 40% of the cases, the underlying agent is Streptococcus pneumonia. Hemophilus influenza causes otitis media in around 15 to 25% of causes. Otitis media caused by Hemophilus influenza is often recurrent. 12 to 20% of the cases are caused by Moraxella catarrhalis. Other agents include group A streptococci, staphylococcus aureus and Pseudomonas aeruginosa; the latter being a cause of chronic otitis media.

Viruses are not important direct causes of otitis media; however, viral upper respiratory tract infections commonly result in the obstruction of the Eustachian tube which allow bacteria to multiply in the middle ear space.

The following factors are associated with an increased incidence of otitis media in childhood:

• Age less than 1 year
• Immunodeficiency
• Down’s syndrome
• Structural defects that impair Eustachian tube function (such as cleft palate)
• Siblings with recurrent otitis media
• Passive smoking
• Low socioeconomic status and poor living conditions

Breast feeding reduces the incidence of acute respiratory tract infections and prevents colonization with otitis pathogens through selective IgA antibodies.

Otitis media is one of the most common infections of childhood. It is particularly common between the ages of 6 months and 3 years. It is also relatively common in adults.

Bacteria gain access to the middle ear usually from the nasopharynx. When the normal patency of the Eustachian tube is blocked by local infection, pharyngitis or hypertrophied adenoids [3], obstruction to the flow of secretions from the middle ear to the pharynx results in the development of an effusion in the middle ear. This effusion then becomes infected by bacteria leading to otitis media [4].

Proper care of the patients suffering from upper respiratory infections, structural defects of the Eustachian tube or immunodeficiency can prevent otitis media from occurring. Vaccines against Streptococcus pneumonia may prevent otitis media [8] [9]. The use of Xylitol syrup may also prevent otitis media [10].

Otitis media is defined as the inflammation of the middle ear which is the second part of the ear. It is the cavity in the temporal bone comprising the cavitas tympani, auditory ossicles and tube auditiva. On the basis of the pattern of the disease, otitis media may be classified as acute, chronic or recurrent.

• Acute otitis media presents with rapid onset of symptoms such as pain and hearing loss in one or both of the ears.
• Recurrent otitis media can be defined as three or more new episodes of acute otitis media within a 6 months period. It may also be defined as four or more episodes of acute otitis media during a period of one year. 
• Chronic otitis media is defined as persistent discharge from the ear for a duration longer than 6 weeks.

Otitis media refers to the the infection and swelling of the middle part of the ear. If treated properly and early, it has a good prognosis. Untreated cases may develop serious complications such as hearing loss and life threatening infection of the membranes around the brain. Common symptoms include ear pain, hearing loss and discharge from the ear. 

1. St. Clair CT, Jr. The etiology of otitis media. The West Virginia medical journal. Mar 1956;52(3):67-68.
2. Feingold M. Acute otitis media in children. Comments on etiology and treatment. Clinical pediatrics. May 1967;6(5):255-257.
3. Bluestone CD. Pathogenesis of otitis media: role of eustachian tube. The Pediatric infectious disease journal. Apr 1996;15(4):281-291.
4. Paparella MM, Kim CS, Goycoolea MV, Giebink S. Pathogenesis of otitis media. The Annals of otology, rhinology, and laryngology. Jul-Aug 1977;86(4 Pt 1):481-492.
5. Virolainen A, Salo P, Jero J, Karma P, Eskola J, Leinonen M. Comparison of PCR assay with bacterial culture for detecting Streptococcus pneumoniae in middle ear fluid of children with acute otitis media. Journal of clinical microbiology. Nov 1994;32(11):2667-2670.
6. Liederman EM, Post JC, Aul JJ, et al. Analysis of adult otitis media: polymerase chain reaction versus culture for bacteria and viruses. The Annals of otology, rhinology, and laryngology. Jan 1998;107(1):10-16.
7. Wilson TG. The etiology of chronic suppurative otitis media. Acta oto-laryngologica. Supplementum. 1963;183:142-144.
8. Felix F, Gomes GA, Cabral GA, Cordeiro JR, Tomita S. The role of new vaccines in the prevention of otitis media. Brazilian journal of otorhinolaryngology. Jul-Aug 2008;74(4):613-616.
9. Principi N, Baggi E, Esposito S. Prevention of acute otitis media using currently available vaccines. Future microbiology. Apr 2012;7(4):457-465.
10. Vernacchio L, Corwin MJ, Vezina RM, et al. Xylitol syrup for the prevention of acute otitis media. Pediatrics. Feb 2014;133(2):289-295.