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Otitis Media

Middle Ear Infection

Inflammation of the middle ear frequently presenting with ear pain, discharge and hearing loss is known as otitis media.


Presentation

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
  • If your child is younger than three months of age and has a fever, it’s important to always call your healthcare provider right away.[web.archive.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]
  • Abstract A previously healthy 77-year-old Japanese man presented with a 2-week history of daily fevers peaking at 38 C, chills, hearing loss, and almost 10 kg of unintentional weight loss over 2 months.[ncbi.nlm.nih.gov]
  • Symptoms of otitis media include fever , earache, and sometimes suppuration (discharge of pus).[britannica.com]
  • We presented the first case report of Pseudoclavibacter otitis media in a boy with pulmonary and spinal tuberculosis.A 3-year-old boy was referred to our hospital due to prolonged fever and progressive paraplegia for 3 months.[ncbi.nlm.nih.gov]
Weight Loss
  • Abstract A previously healthy 77-year-old Japanese man presented with a 2-week history of daily fevers peaking at 38 C, chills, hearing loss, and almost 10 kg of unintentional weight loss over 2 months.[ncbi.nlm.nih.gov]
  • Other effective non-invasive physical treatments or patient education Exercise therapy, advice about weight loss, appropriate footwear, pulsed electromagnetic field therapy, acupuncture, and TENS [ 112 , 127 – 131 ] Ankle and foot conditions Definition[doi.org]
Intravenous Administration
  • No signs of improvement were observed after the intravenous administration of several antibiotics. Magnetic resonance imaging (MRI) revealed right thrombophlebitis extending from the sigmoid sinus to the jugular vein.[ncbi.nlm.nih.gov]
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]
  • Fever, otalgia, headache, irritability, cough, rhinitis, listlessness, anorexia, vomiting, diarrhea, and pulling at the ears are common, but nonspecific symptoms.[aafp.org]
  • The following is a brief list of evidence for and against the etiologic role of allergy in OM: Many patients with OM have concomitant allergic respiratory disease (eg, allergic rhinitis, asthma) Many patients with OM have positive results to skin testing[emedicine.com]
Snoring
  • […] 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]
  • 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[doi.org]
Vomiting
  • Although evidence indicates that oral antibiotics are associated with an increased chance of complete resolution of OME at various time points, we also found evidence that these children are more likely to experience diarrhoea, vomiting or skin rash.[ncbi.nlm.nih.gov]
  • Abstract 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]
  • Adverse events (vomiting, diarrhoea or rash) The occurrence of vomiting, diarrhoea or rash was reported in seven trials.[doi.org]
  • Adverse effects likely to be related to the use of antibiotics such as vomiting, diarrhoea or rash.[doi.org]
  • Adverse events One trial reported no difference between zinc and placebo in the proportion of doses given where vomiting followed within 15 minutes (0.6% in each group, 246 participants) ( Penny 2004 ), while another reported more days of vomiting with[doi.org]
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]
  • […] of appetite (refusing to eat) Infants will not suck because it causes pain Vomiting Diarrhea Signs and symptoms of chronic otitis media with effusion If your child is old enough to tell you, he may complain of: A feeling of fullness in the ears A popping[nationwidechildrens.org]
  • The typical signs to watch for include: Tugging or pulling at the ear(s) Loss of appetite Unsettledness and crying Trouble sleeping High fever Discharge from the ears Problems with balance Trouble hearing, especially soft sounds or when being spoken to[hear-the-world.com]
  • […] of appetite Adults Common signs and symptoms in adults include: Ear pain Drainage of fluid from the ear Diminished hearing When to see a doctor Signs and symptoms of an ear infection can indicate a number of conditions.[mayoclinic.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]
  • Here,we present a 9-year-old boy who had left facial swelling after a period of otalgia, diagnosed as Luc abscess without mastoiditis.[ncbi.nlm.nih.gov]
  • ., moderate or severe otalgia or otalgia for at least 48 hours or temperature 39 C [102.2 F] or higher). Antibiotic therapy should be prescribed for bilateral AOM in children 6 months through 23 months of age without severe signs or symptoms.[aafp.org]
Tinnitus
  • 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]
  • Here too the patient notices progressive hearing loss up to deafness, either with or without tinnitus.[ims.uniklinik-freiburg.de]
  • Associated features - Some hearing loss, tinnitus and fever. Small children may appear unwell, crying and be pulling at the affected ear. Remember - Document facial nerve exam, neurological status and ear examination including mastoid area.[entsho.com]
  • In more severe cases the symptoms include hearing loss, earache or pain, dizziness, high fever, ear discharge, nausea and tinnitus. In some cases the eardrum cannot withstand the increasing pressure from the buildup of fluid and tears.[hear-the-world.com]
  • Other symptoms may include: earache or ear pain hearing sounds like ringing or buzzing (tinnitus) Glue ear is much more common in children, but adults with glue ear have the same symptoms.[nhs.uk]
Cesarean Section
  • RESULTS: Short time with breastfeeding, early introduction to daycare, cesarean section, and low compliance to the national vaccination program were all associated with an increased risk of 3 episodes of otitis media at 18 months of age and at 7 years[ncbi.nlm.nih.gov]
Irritability
  • OME is more common than AOM, and may be caused by viral upper respiratory infections, allergies, or exposure to irritants (such as cigarette smoke).[web.archive.org]
  • 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]
  • Irritability and ear rubbing in babies don’t necessarily mean there’s an infection or a serious ear problem.[medtronic.com]
  • […] of an ear infection usually start quickly and include: pain inside the ear a high temperature of 38C or above being sick a lack of energy difficulty hearing discharge running out of the ear feeling of pressure or fullness inside the ear itching and irritation[nhs.uk]
Vertigo
  • 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]
  • Complications specific to mastoidectomy include hearing loss, vertigo, tinnitus, facial nerve injury, altered taste sensation, and the possible need for further surgery.[emedicine.com]
  • Hearing loss and vertigo have been avoided. This case strongly suggests that eosinophilic otitis media can be a manifestation of CSS.[doi.org]
  • […] policy Combination antibiotic and steroid ear drops Good analgesia IV fluids if the patient is vomiting or dehydrated Artificial tears and eye lubrication if there is facial palsy Short term vestibular sedative eg prochlorperazine if there is dizziness/vertigo[entsho.com]
  • Serous otitis media may be associated with both hearing loss and vertigo. Chronic otitis media may be associated with a chronically draining ear, mastoiditis, and cholesteatoma.[dizziness-and-balance.com]
Encephalopathy
  • A case of tubercular otitis media with atypical clinical manifestations in the form of encephalopathy is presented.[ncbi.nlm.nih.gov]

Workup

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].

Liver Biopsy
  • A thorough examination and a definitive proactive decision to perform a liver biopsy resulted in early diagnosis of a rare disease. BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.[ncbi.nlm.nih.gov]

Treatment

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.

Prognosis

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.

Etiology

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.

Epidemiology

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.

Sex distribution
Age distribution

Pathophysiology

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].

Prevention

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].

Summary

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.

Patient Information

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. 

References

Article

  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.

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Last updated: 2017-08-09 17:32