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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)

Etiology:

• 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

Signs/Symptoms:

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

Microbiology: 

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

Treatment:

• 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

Etiology:

• 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 

Symptoms:

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

Diagnosis:

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

Treatment:

• 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

References

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.