Otitis media (OM)

- is any inflammation of the middle ear (see the images below), without
reference to etiology or pathogenesis. It is very common in children.

- An ear infection, or otitis media, is the most common cause of earaches.

Although this condition is a frequent cause of infant distress and is often
associated with children, it can also affect adults.

Acute otitis media with purulent effusion behind a bulging tympanic membrane.
Chronic otitis media with a retraction pocket of the pars flaccida.

There are several subtypes of OM, as follows:

Acute OM (AOM)

OM with effusion (OME)

Chronic suppurative OM - Chronic suppurative otitis media is a persistent ear infection

that results in tearing or perforation of the eardrum.

Adhesive OM - Adhesive otitis media occurs when a thin retracted ear drum becomes
sucked into the middle ear space and stuck.

Causes
The eustachian tube runs from the middle part of each ear to the back of the throat. This tube
drains fluid that is made in the middle ear. If the eustachian tube becomes blocked, fluid can
build up. This may lead to pressure behind the eardrum or an ear infection.

Ear pain in adults is less likely to be from an ear infection. Pain that you feel in the ear may be
coming from another place, such as your teeth, the joint in your jaw (temporomandibular joint),
or your throat. This is called "referred" pain.

Causes of ear pain may include:

 Arthritis of the jaw

Short-term ear infection

Long-term ear infection

Ear injury from pressure changes (from high altitudes and other causes)

Object stuck in the ear or buildup of ear wax

Hole in the eardrum

Sinus infection

Sore throat

Temporomandibular joint syndrome (TMJ)

Tooth infection

Ear pain in a child or infant may be due to infection. Other causes may include:

Ear canal irritation from cotton-tipped swabs

Soap or shampoo staying in the ear

RISK FACTORS

Males

Individuals with a family history of ear infections

Babies who are bottle-fed (breastfed babies get fewer ear infections)

Children in day care centers

People living in households with tobacco smokers

People with abnormalities of the palate, such as a cleft palate

People with poor immune systems or chronic respiratory diseases, such as cystic fibrosis
and asthma
Signs and symptoms

Acute OM (AOM) implies rapid onset of disease associated with one or more of the following
symptoms:

Otalgia - EARACHE

Fever

Otorrhea EAR DRAINAGE

Recent onset of anorexia/ Loss of appetite

Irritability

Vomiting

Diarrhea

These symptoms are accompanied by abnormal otoscopic findings of the tympanic membrane
(TM), which may include the following:

Opacity

Bulging

Erythema

Middle ear effusion (MEE)

Decreased mobility with pneumatic otoscopy

OME often follows an episode of AOM. Symptoms that may be indicative of OME include the
following:

Hearing loss

Tinnitus

Vertigo
 Otalgia

Diagnosis

OME does not benefit from antibiotic treatment. Therefore, it is critical for clinicians to be able
to distinguish normal middle ear status from OME or AOM. Doing so will avoid unnecessary use
of antibiotics, which leads to increased adverse effects of medication and facilitates the
development of antimicrobial resistance.

Examination

Pneumatic otoscopy remains the standard examination technique for patients with suspected OM.
In addition to a carefully documented examination of the external ear and tympanic membrane
(TM), examining the entire head and neck region of patients with suspected OM is important.

Every examination should include an evaluation and description of the following four TM
characteristics:

Color A normal TM is a translucent pale gray; an opaque yellow or blue TM is

consistent with middle ear effusion (MEE)

Position In AOM, the TM is usually bulging; in OME, the TM is typically retracted or

in the neutral position

Mobility Impaired mobility is the most consistent finding in patients with OME

Perforation Single perforations are most common

Adjunctive screening techniques for OM include tympanometry, which measures changes in

acoustic impedance of the TM/middle ear system with air pressure changes in the external
auditory canal, and acoustic reflectometry, which measures reflected sound from the TM; the
louder the reflected sound, the greater the likelihood of an MEE.

Management

Most cases of AOM improve spontaneously. Cases that require treatment may be managed with
antibiotics and analgesics or with observation alone.

Guidelines from American Academy of Pediatrics

In February 2013, the American Academy of Pediatrics (AAP) and the American Academy of
Family Physicians (AAFP) released updated guidelines for the diagnosis and management of
AOM, including recurrent AOM, in children aged 6 months through 12 years. The
recommendations offer more rigorous diagnostic criteria to reduce unnecessary antibiotic use.

According to the guidelines, management of AOM should include an assessment of pain.

Analgesics, particularly acetaminophen and ibuprofen, should be used to treat pain
whether antibiotic therapy is or is not prescribed.

Recommendations for prescribing antibiotics include the following:

Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at least
6 months with severe signs or symptoms (moderate or severe otalgia, otalgia for 48 hours
or longer, or temperature 39C or higher) and for nonsevere, bilateral AOM in children
aged 6 to 23 months

On the basis of joint decision-making with the parents, unilateral, nonsevere AOM in
children aged 6-23 months or nonsevere AOM in older children may be managed either
with antibiotics or with close follow-up and withholding antibiotics unless the child
worsens or does not improve within 48-72 hours of symptom onset

Amoxicillin is the antibiotic of choice unless the child received it within 30 days, has
concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases, clinicians
should prescribe an antibiotic with additional beta-lactamase coverage

Pathophysiology
The most important factor in middle ear disease is eustachian tube (ET) dysfunction (ETD), in
which the mucosa at the pharyngeal end of the ET is part of the mucociliary system of the middle
ear. Interference with this mucosa by edema, tumor, or negative intratympanic pressure facilitates
direct extension of infectious processes from the nasopharynx to the middle ear, causing OM.
Esophageal contents regurgitated into the nasopharynx and middle ear through the ET can create
a direct mechanical disturbance of the middle ear mucosa and cause middle ear inflammation.

The infection in the middle ear (the space behind the eardrum where tiny bones pick up
vibrations and pass them along to the inner ear) very often accompanies a common cold, the flu,
or other types of respiratory infections. This is because the middle ear is connected to the upper
respiratory tract by a tiny channel known as the Eustachian tube. Germs that are growing in the
nose or sinus cavities can climb up the Eustachian tube and enter the middle ear to start growing.
Patient Education
Patient education topics should include the following:

Avoiding risk factors - infectious, allergic, and environmental factors

Appropriate use of antibiotics

Understanding the implications of antibiotic-resistant bacteria in OM

Education for health care providers should focus on the following topics:

Antibiotic-resistant bacteria and the need to avoid overprescribing antibiotics

Importance of pneumatic otoscope examination to distinguish AOM from OME

Treatment differences between AOM and OME