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Otitis Media

last modified on: Tue, 04/09/2024 - 09:47

Return to: General Clerkship Objectives

see contemporary site: American Academy of Otolaryngology site addressing Otitis Media

Note: last updated before 2015

Otitis Media

  • Inflammation of the middle ear space
  • Two main types:
    • Acute Otitis Media (AOM)
    • Otitis Media with Effusion (OME)


By Michael Hake MD (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons

Acute Otitis Media (AOM)


  • Inflammatory response to virus or bacteria
  • Eustachian tube anatomy or dysfunction can predispose to infection
    •  Children have shorter, narrower, more horizontal Eustachian tubes
      • Bacteria from the nasopharynx can more easily travel to the middle ear
      • Even a small amount of inflammation can obstruct the lumen and trap bacteria
    • Individuals with abnormal Eustachian tube anatomy (Trisomy 21)
  •  Most common reason for children to seek medical care


  • Otalgia- ear tugging, irritability
  • Fever
  • Otorrhea
  • Tympanic membrane changes
    • Hyperemia
    • Bulging
    • Decreased mobility


  • Three main bacteria: 
    • Streptococcus pneumoniae
    • Haemophilus influenza
    • Moraxella catarrhalis
  • Infants can also have AOM due to gram negative enteric rods


  • Antibiotics
    • Should cover S. pneumo, H. influenza, and M. catarrhalis
    • Can depend on appropriate cultures
    • Considered drug of choice: Amoxicillin 80-90 mg/kg per day
      • Patients with penicillin allergy: Azithromycin
    • Second line: High dose amoxicillin-clavulanate 
  • Symptomatic treatment/anti-inflammatories
  • Myringotomy with tympanostomy tube insertion
    • Recurrent AOM
      • 3 episodes in 6 months
      • 4 episodes in 12 months
    • Poor response to antibiotics
    • Complications of AOM

Complications of Untreated AOM (not a benign disease!): 

  • Hearing loss- conductive or sensorineural
  • TM perforation
  • Mastoiditis
  • Meningitis
  • Cholesteatoma
  • Tympanosclerosis
  • Facial paralysis
  • Ossicular chain abnormalities

Otitis Media with Effusion


  • Fluid in the middle ear
  • No inflammatory response
  • Can occur:
    • After AOM episode
    • Chronic Eustachian tube dysfunction
    • Adenoid hypertrophy
    • Unilateral in adults- concern for nasopharyngeal malignancy 


  • Often asymptomatic
  • May have:
    • Mild otalgia
    • Conductive hearing loss
    • Aural fullness


  • Physical exam
  • Air-fluid level behind TM
  • No erythema or other inflammatory signs


  • Often watchful waiting initially
  • If OME is persistent:
    • Audiogram to assess hearing can be valuable
    • Medications:
      • Nasal steroids to decrease swelling
      • Possible short course of antibiotics
      • Antihistamines if allergic component
    • Surgery
      • Pressure Equalizing Tubes
        • If OME present for >3 months
        • If associated with hearing loss
      • Adenoidectomy
        • Controversial
        • If second set of tubes are needed
        • If adenoid hypertrophy is present


American Academy of Otolaryngology–Head and Neck Surgery Foundation. (2011). Primary Care Otolaryngology, Third Edition. Retrieved from: www.entnet.org

Facione N. Otitis media: an overview of acute and chronic disease. Nurse Pract. 1990;15(10):11-22.