Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 8-05: Diseases of the Middle Ear + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Otalgia, often with an upper respiratory tract infection Erythema and hypomobility of tympanic membrane +++ General Considerations ++ Bacterial infection of the mucosally lined air-containing spaces of the temporal bone Purulent material forms within the middle ear cleft but also within the pneumatized mastoid air cells and petrous apex Usually precipitated by a viral upper respiratory tract infection that causes eustachian tube obstruction, resulting in accumulation of fluid and mucus, which become secondarily infected by bacteria Nasotracheal intubation can cause otitis media Most common pathogens Streptococcus pneumoniae Haemophilus influenzae Streptococcus pyogenes Chronic otitis media is usually not painful except during acute exacerbations +++ Demographics ++ Most common in infants and children, although it may occur at any age External otitis and acute otitis media are the most common causes of earache + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Otalgia, aural pressure, decreased hearing, and often fever Typically, erythema and decreased mobility of the tympanic membrane Occasionally, bullae will appear on the tympanic membrane When middle ear empyema is severe, the tympanic membrane can bulge outward In external otitis the ear canal skin is erythematous, whereas in acute otitis media this generally occurs only if the tympanic membrane has ruptured, spilling purulent material into the ear canal Persistent otorrhea despite topical and systemic antibiotic therapy Frank swelling over the mastoid bone or the association of cranial neuropathies or central findings indicates severe disease requiring urgent care +++ Differential Diagnosis ++ Otitis externa Eustachian tube dysfunction Mastoiditis Tympanosclerosis (scarred tympanic membrane) Referred pain: pharyngitis, sinusitis, toothache Glossopharyngeal neuralgia Temporomandibular joint syndrome Foreign body Cholesteatoma Bullous myringitis Herpes zoster oticus, especially when vesicles appear in the ear canal or concha + Diagnosis Download Section PDF Listen +++ ++ Clinical + Treatment Download Section PDF Listen +++ +++ Medications ++ Oral antibiotic therapy Amoxicillin (80–90 mg/kg/day divided twice daily) or erythromycin (50 mg/kg/day) plus sulfonamide (150 mg/kg/day) for 10 days Alternatives useful in resistant cases are cefaclor (20–40 mg/kg/day) or amoxicillin-clavulanate (20–40 mg/kg/day) Nasal decongestants, particularly if symptomatic Recurrent acute otitis media Use long-term antibiotic prophylaxis: single oral daily doses of sulfamethoxazole (500 mg) or amoxicillin (250 or 500 mg) for 1–3 months +++ Surgery ++ Surgical drainage of the middle ear (myringotomy) is reserved for patients with severe otalgia or when complications of otitis (eg, mastoiditis, meningitis) have occurred Failure of long-term antibiotic prophylaxis to manage recurrent infection is an indication for insertion of ventilating tubes +++ Therapeutic Procedures ++ Tympanocentesis is useful for otitis media in immunocompromised patients and when infection persists or recurs despite multiple courses of antibiotics + Outcome Download Section PDF Listen +++ +++ Complications ++ Tympanic membrane rupture Chronic otitis media Medical treatment includes regular removal of infected debris, use of earplugs to protect against water exposure, and topical antibiotic drops for exacerbations Ciprofloxacin may help to dry a chronically discharging ear when given in a dosage of 500 mg twice daily orally for 1–6 weeks Definitive management is surgical in most cases Mastoiditis Meningitis The most common intracranial complication of ear infection In acute otitis media, it arises from hematogenous spread of bacteria, most commonly H influenzae and S pneumoniae In chronic otitis media, it results either from passage of infections along preformed pathways or from direct extension Epidural or brain abscess (temporal lobe or cerebellum) Facial palsy Sigmoid sinus thrombosis + References Download Section PDF Listen +++ + +Hutz MJ et al. Neurological complications of acute and chronic otitis media. Curr Neurol Neurosci Rep. 2018 Feb 14;18(3):11. [PubMed: 29445883] + +Szmuilowicz J et al. Infections of the ear. Emerg Med Clin North Am. 2019 Feb;37(1):1–9. [PubMed: 30454772]