Otitis Media

Otitis media is a group of inflammatory diseases of the middle ear, which is a common condition in childhood. It primarily presents in three forms: acute otitis media (AOM), otitis media with effusion (OME), and chronic suppurative otitis media (CSOM).

Signs and Symptoms

The primary symptom of acute otitis media (AOM) is ear pain. Other possible symptoms include fever, reduced hearing, tenderness above the ear, purulent discharge, irritability, ear blockage, and diarrhoea in infants. Often, AOM follows an upper respiratory tract infection (URTI), leading to accompanying symptoms like cough and nasal discharge.

A bulging tympanic membrane which is typical in a case of acute otitis media

Otitis media with effusion (OME), also known as serous or secretory otitis media, typically does not present with symptoms, though a feeling of fullness in the ear may be described. Chronic suppurative otitis media (CSOM) is characterised by a perforated tympanic membrane with discharge for more than six weeks, often following an episode of AOM. Pain is rarely present, but hearing loss is common across all three types of otitis media.

Diagram of otitis media showing the middle ear inflammation and fluid accumulation

Causes

The common cause of all forms of otitis media is dysfunction of the Eustachian tube. This dysfunction is usually due to inflammation of the mucous membranes in the nasopharynx, often caused by a viral URTI, strep throat, or possibly allergies. This can lead to fluid accumulation in the middle ear, which may become infected by bacteria or viruses.

Diagnosis

Diagnosis of otitis media requires visualisation of the tympanic membrane. Examiners may use a pneumatic otoscope to assess the mobility of the tympanic membrane. Tympanometry, reflectometry, and hearing tests can also aid in diagnosis.

Perforation of the right tympanic membrane resulting from previous severe acute otitis media

In severe cases, audiometry, tympanogram, temporal bone CT, and MRI can assess for complications like mastoid effusion, abscess formation, or meningitis. For accurate diagnosis, middle-ear effusion and inflammation of the eardrum must be identified.

Treatment

Pain management is very important in treating AOM, using oral agents like ibuprofen, paracetamol, or opiates, and effective topical agents like antipyrine and benzocaine ear drops. Decongestants and antihistamines are not recommended due to lack of benefit and potential side effects. Half of the cases resolve without treatment in three days, and 90% resolve in a week.

Antibiotics

Antibiotics can be beneficial but are not always necessary, as many episodes resolve without them. Narrow-spectrum antibiotics like amoxicillin are recommended initially. For recurrent infections, tympanostomy tubes may help reduce recurrence. For otitis media with effusion, antibiotics may increase symptom resolution but also increase risks of diarrhoea, vomiting, and rash.

Tympanostomy Tubes

Tympanostomy tubes are recommended for children with recurrent AOM, with evidence suggesting modest improvement in reducing episodes. However, they do not affect long-term hearing or language development.

Chronic Suppurative Otitis Media

Topical antibiotics may be useful for CSOM, especially quinolones, which are probably better at resolving ear discharge compared to antiseptics. Oral antibiotics are not recommended for uncomplicated tympanostomy tube otorrhea.

Outcomes

Complications of AOM include perforation of the tympanic membrane, mastoiditis, and rarely, intracranial complications like bacterial meningitis. Persistent middle ear fluid can lead to conductive hearing loss and impact speech development in children. Global prevalence of mild hearing loss due to otitis media is approximately 2.1%.

Disability-adjusted life year for otitis media per 100,000 inhabitants in 2004

Deaths from otitis media per million persons in 2012