Otitis Media, Acute

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

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

• Clinical

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

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