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For further information, see CMDT Part 8-05: Diseases of the Middle Ear

Key Features

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


  • External otitis and acute otitis media are the most common causes of earache

  • Although it may occur at any age, acute otitis media is most common in infants and children

Clinical Findings

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



  • Oral antibiotic therapy

    • Amoxicillin

      • First-choice antibiotic

      • Dose: 1 g orally every 8 hours for 5–7 days

    • Alternatives (useful in resistant cases) are

      • Amoxicillin-clavulanate, 875/125 mg or 2 g/125 mg ER every 12 hours for 5–10 days

      • Cefuroxime, 500 mg orally every 12 hours for 5–7 days

      • Cefpodoxime, 200 mg orally every 12 hours for 5–7 days

  • 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


  • 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


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