Otitis Media

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What Is Otitis Media?

Otitis media is the presence of an inflammation or infection of the middle ear, which is the section of the ear present behind the eardrum and in front of the oval window of the inner ear. It usually develops rapidly and is more often seen in children.

Alternate names

  • Middle ear infection

Is this condition a medical emergency?

It is not a medical emergency, but it is advisable to seek immediate medical attention if the symptoms are severe, last for more than a day or two, and especially for otitis media in infants.

Types of this condition

Otitis media may be of the following types:

  • Acute otitis media (AOM): It is of rapid onset and presents with pain.
  • Otitis media with effusion (OME): It may be asymptomatic, but there is the presence of non-infectious fluid within the middle ear for more than 3 months causing a feeling of fullness.
  • Chronic suppurative otitis media (CSOM): It is a middle ear infection that results in a discharge from the ear for more than 3 months.
  • Adhesive otitis media: When the eardrum becomes thin and is sucked into and gets stuck to the bones present within the middle ear.

Causes of otitis media

Otitis media is usually caused due to improper functioning of the eustachian tube that connects the middle ear with the nasopharynx. The improper functioning of the eustachian tube is secondary to the inflammation of the mucus membranes that line the nasopharynx following an upper respiratory tract infection.

The following are some of the causes of otitis media:

  • Eustachian tube dysfunction - Secondary to viral or bacterial upper respiratory tract infections
  • Clogging and improper draining of the Eustachian tube post-infection and inflammation - Especially in children as it is narrower and more horizontal
  • Swelling of the adenoids - Usually seen in upper respiratory tract infections. The swollen adenoids press on the eustachian tube and result in improper draining or accumulation of fluid in the middle ear.

Risk factors for otitis media

The risk factors for developing otitis media include:

  • Age: Babies and children below the age of 2 years are more at risk. This is because of the structure of the eustachian tube as well as the presence of an underdeveloped immune system that is not very effective at fighting off infections.
  • Cleft lip and palate: Babies and children with these structural abnormalities are at a greater risk of developing a middle ear infection.
  • Feeding methods: Breastfeeding protects from the development of otitis media; bottle feeding in a flat position increases the chance of developing a middle ear infection.
  • Exposure to cigarette smoke and air pollution.
  • Daycare centers: Babies and infants at daycare centers are at a greater risk of catching upper respiratory tract infections and subsequently a middle ear infection due to close contact with other babies and infants.
  • Seasonal factors: Increased chances of infections in cold weather and seasonal allergies are also risk factors for a middle ear infection.

Symptoms & signs of otitis media

The symptoms and signs of otitis media in children include the following:

  • Ear pain, which is usually more when lying down; usually at night or when taking a nap.
  • Tugging or pulling at the earlobes
  • Headache
  • Irritable, crying more and sleep disturbances
  • Hearing loss or not responding to sounds
  • Fever
  • Cough, nasal discharge and congestion
  • Loss of appetite, nausea, and vomiting
  • Diarrhea
  • Loss of balance

The symptoms and signs in adults may include:

  • Ear pain
  • Ear discharge
  • Trouble with hearing
  • Loss of balance, vertigo, and tinnitus

Investigations

The following investigations may be done to establish the diagnosis of otitis media

  • Pneumatic Otoscopy: This is the primary investigation that is used to evaluate the eardrum (tympanic membrane) for its color, position, movement, and perforation.

Additional investigations include:

  • Tympanometry or Impedance audiometry: To check for the movement of the eardrum and the pressure inside the middle ear.
  • Acoustic reflectometry: To measure the amount of sound that is reflected from the eardrum. A normal eardrum absorbs most sound, but with the presence of fluid in the middle ear, the sound is reflected, giving a measure of the amount of fluid that is present.
  • Tympanocentesis: To evaluate the fluid that is present inside the middle ear, a small amount is drawn for analysis.

In recurrent cases of the middle ear infection in addition to the above an assessment of the hearing, speech, language comprehension, and other developmental tests may also be required.

Diagnosis

The diagnosis of otitis media is established based on medical history, clinical evaluation, and results of the investigations done.

  • Acute Otitis media: The eardrum is bulging, poorly mobile, and usually yellow and opacified on pneumatic otoscopy.
  • Otitis Media with Effusion: The eardrum is either neutral or retracted, with very limited movement on positive and negative pressure on pneumatic otoscopy.
  • The absence of eardrum movement indicates the perforation of the eardrum.

Treatment options for otitis media

The treatment of otitis media depends on the type and the severity of the condition as well as the age of the individual at the time of diagnosis. Treatment can include medical and surgical management. Await and watch approach may be adopted under certain circumstances, as some otitis media resolve spontaneously on their own. The wait and watch policy may be adopted if

  • The child is 6: 23 months of age, has mild middle ear pain in one ear for less than 48 hours, and fever less than 102.2F.
  • The child is older than 24 months, has mild middle ear pain in one or both ears for less than 48 hours, and fever less than 102.2F.

A. Medical management

Medical management of otitis media may include:

  • Antibiotics: To fight infections. They may be prescribed under the following circumstances.
  • The child is 6 months or older, moderate to severe ear pain in one or both ears for at least 48 hours, fever of 102.2 F or higher.
  • The child is 6 to 23 months, mild middle ear pain in one or both ears for less than 48 hours, fever less than 102.2 F.
  • The child is 24 months or older, mild middle ear pain in one or both ears for less than 48 hours, fever less than 102.2 F.
  • Analgesics: To provide relief from pain.
  • Anaesthetic drops: To provide relief from pain.

B. Interventional including surgery and indications for surgery

Otitis media that persists for more than 3 months could potentially require surgical intervention, which may include:

  • Tympanocentesis: It is done using a small gauge needle to puncture the eardrum and drain the fluid. It is indicated under the following circumstances.
  • Otitis media with severe pain, in children who are extremely ill.
  • Unsatisfactory response to antibiotic therapy.
  • A middle ear infection is associated with confirmed or potential pus formation.
  • Middle ear infection in the newborn, unwell neonate, or immunodeficient individuals.
  • Myringotomy & Tympanostomy tubes: a small cut is made in the eardrum and the fluid drained out, and a small tube called a tympanostomy tube is placed in the eardrum opening, to help future draining of fluids from the middle ear and prevent their build-up.

The procedure is done under the following circumstances:

  • Children with impaired hearing and both sided OME for more than 3 months.
  • Children with one-sided or both side OME lasting for 3 months or more with symptoms of imbalance, dizziness, behavioral or educational problems, and reduced quality of life.
  • Children with recurrent otitis media with middle ear effusion.
  • Children with OME lasting less than three months but with other conditions such as cleft palate, downs syndrome, speech or language disorders, autism spectrum disorders, etc.

C. Role of diet/exercise/lifestyle changes/preventive measures

Some measures that can be taken to prevent the occurrence of otitis media include:

  • Inculcating good hygiene and habits in children about washing hands before eating.
  • Avoiding smoking, passive smoking, and exposure to air pollution.
  • Breastfeeding: Reduces the risk of middle ear infection.
  • Holding the baby in an upright position if bottle feeding.
  • Limiting the time spent in a daycare center.
  • Vaccinations where available.

Complications

The complications of otitis media may include:

  • Damage to the eardrum and or middle ear structures leading to permanent hearing loss.
  • Speech and developmental delays
  • Eardrum tear or rupture
  • Spread of infection to the surrounding bones causing mastoiditis.
  • Facial paralysis
  • Spread of infection to the brain causing meningitis, epidural abscess, brain abscess.

Prognosis

The prognosis for otitis media is generally excellent when managed well. However, if intracranial complications develop the prognosis may not be good.

When to contact the doctor or hospital/How to identify the emergency or complications?

It is advisable to seek immediate medical attention if the following symptoms or signs are present especially in an infant less than 6 months.

  • The ear pain is severe and lasts for more than 1 - 2 days.
  • Extreme irritability and sleep disturbances
  • Discharge of fluid that is bloody or pus-like

Indications for hospitalization if required

Hospitalization is usually not required for otitis media but it may be needed if complications develop or if surgical interventions need to be done.

Suggested clinical specialist/Departments to consult for this condition

Otitis Media will be attended by specialists from the Department of Otorhinolaryngology (ENT).

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