Otitis media/ Middle ear infection

What is otitis media or middle ear infection?

Otitis media (OM)/middle ear infection/ acute otitis media refers to the inflammation (mostly due to infection) of the middle ear.  

Otitis media (OM) sums up a spectrum of diseases including 

  • Acute otitis media (AOM)– sudden onset of OM
  • Recurrent acute otitis media (rAOM)– 4 or more episodes in 12 months
  • Otitis media with effusion (OME)– OM with fluid in middle ear space.
  • Chronic otitis media with effusion – OME persisting for a long time (3 months or more).
  • Chronic suppurative otitis media (CSOM)– chronic inflammation of middle ear & mastoid cavity with an intact tympanic membrane.
  • Chronic otitis media epitympanalis (cholesteatoma)– A cholesteatoma is defined as a benign collection of keratinized squamous epithelium in the middle ear space and mastoid process.

OM is caused due to various factors and is more common in children (6-24 months of age). OM is usually followed by an upper respiratory tract infection/cold. Let us learn more about otitis media, its causes, symptoms, pathogenesis, risk factors, diagnosis, complications and management in this article.

anatomy of the ear-external, inner and middle ear
Image source: Freepik
  • Tympanic membrane/ eardrum separates the external auditory canal and the middle ear.
  • Middle ear consists of middle ear space and the ossicles (malles, incus and stapes).
  • The eustachian tubes connect the nasopharynx and the middle ear.

Signs and symptoms

  • Ear pain
  • Anorexia/ Loss of appetite
  • Difficulty in sleeping
  • Ear block (trouble hearing)
  • Pressure in ear (causes pain)
  • Discharge from ear
  • Children often tug/rub their ears and become fussy
  • Crying in children
  • Fever
  • Headache
  • Snoring
  • Refuse feeding due to pain (children)
  • Mouth breathing (adenoid inflammation)
  • Vomiting
  • Diarrhoea

Causes of otitis media

Otitis media is caused due to multiple factors and there are many risk factors associated with it.

  • Bacteria is the most common causative agent of infection but viral infections can lead to OM too. 
causative agents of otitis media, bacteria and virus causing otitis media

 Risk factors of otitis media/ middle ear infection

  • Preceding Cold/ URTI
  • Age
  • Family history of OM
  • Children in daycare
  • Chronic illness (eg. asthma, immunodeficiency diseases)
  • Ethnicity
  • Poor air quality
  • Second hand smoke & environment smoke
  • GERD
  • Adenoid hypertrophy
  • Male gender
  • Pacifier use in children
  • Genetic predisposition
  • Poor immunity
  • Cleft palate
  • Low immunity (immunocompromised/ immunodeficiency)
  • Allergies
  • Lack of breastfeeding
  • Cochlear implant
  • Ciliary dysfunction
  • Poor hygiene

Epidemiology 

  • Otitis media is more common in children (6-24 months of age) but adults can get infected too. It is one of the common pediatric diagnoses.
  • Otitis media is more common in males..
  • More common in certain populations (eg. immunocompromised/ immunodeficient people)
  • Around 80% of children get affected with OM in their lifetime.
  • The risk of getting OM decreases after 5 years of age.

Why is otitis media more common in children?

  • Due to the developing immune system (difficulty in fighting infections)
  • The eustachian tubes of children is not developed like an adult (short, narrow, less rigid  and more horizontal)
  • Easily infected by other children.

Pathogenesis of acute otitis media

pathogenesis of acute otitis media/ middle ear infection
Pathogenesis of acute otitis media

CSOM is differentiated by a thick, amber coloured fluid in the middle ear and a retracted tympanic membrane.

Diagnosis of middle ear infection

The diagnosis is commonly done by

  • Signs and symptoms
  • Physical examination
  • Otoscopy 
  • Pneumatic otoscopy (decreased TM mobility)

Additionally by

  • Tympanometry 
  • Acoustic reflectometry
  • Tympanocentesis- to identify pathogen from middle ear fluid culture
  • Hearing tests
  • Imaging tests like CT/MRI.
  • Laboratory tests

Complications of middle ear infection

Though OM has less serious complication, repeated infections and not getting treated may lead to rare, serious complications like

  • Hearing loss (due to repeated damage to inner ear)
  • Delayed speech and language development in children
  • TM perforation (acute and chronic)
  • CSOM (with or without cholesteatoma)
  • Cholesteatoma
  • Tympanosclerosis
  • Brain abscess 
  • Mastoiditis
  • Meningitis 
  • Petrositis
  • Labyrinthitis
  • Facial paralysis
  • Cholesterol granuloma
  • Infectious eczematoid dermatitis
  • Lateral & cavernous sinus thrombosis

Management of acute otitis media

OM usually resolves on its own and antimicrobial therapy is not always necessary. Whether or not to use antibiotics for initial treatment of AOM is a matter of debate. Though some physicians recommend “watchful waiting”  (waiting for 24-48 hrs to see whether the body is fighting the infection) method before commencing antimicrobials, some physicians are unlikely to withhold prescribing initial antimicrobial therapy.Empirical treatment with antibiotics has become complex because of resistance.

Wait and watch method is also not preferable in high risk groups.

1. Pharmacological treatment of otitis media

  • Symptomatic treatment of pain and fever with analgesics and antipyretics.
  • Paracetamol
  • Ibuprofen 
  • Antimicrobial therapy

The treatment of OM with antimicrobials has become tedious due to the  increase in antimicrobial resistance (S.pneumoniae, H.influenzae, M.catarrhalis).

In some cases antibiotics are proven to be ineffective because the infection may be of viral origin.

1 st line antibiotics

  • Amoxicillin 

2nd line antibiotics

  • High dose of oral amoxicillin-clavulanate
  • Oral cefuroxime
  • IM ceftriaxone/ gatifloxacin

Penicillin/ beta lactam allergy

  • Cephalosporins (late-generation)
  • Trimethoprim-sulfamethoxazole
  • Macrolides
  • Levofloxacin

2.Surgical care for otitis media/ middle ear infection

This is done to prevent AOM in  cases of

  • Cleft palate
  • Down’s syndrome
  • Craniofacial abnormalities

3.Immunization for prevention of otitis media

Pneumococcal and influenza vaccines are available but their efficacy in protecting AOM requires further research.

Treatment of OME (otitis media with effusion)

  • Antimicrobials
  • Antihistamine
  • Decongestants
  • Intranasal & systemic steroids (prednisolone)
  • NSAIDs
  • Mucolytics 
  • Treating allergies

Written by Auxi Arobana.R

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