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

Key Features

Essentials of Diagnosis

  • Otalgia

  • Purulent fluid of the middle ear

  • Erythema and hypomobility of tympanic membrane

General Considerations

  • Bacterial infection of the mucosally lined, air-containing spaces of the middle ear

  • Purulent material forms may extend to pneumatized mastoid air cells and petrous apex of the lateral skull base

  • 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


  • Otitis externa 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

  • 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), debridement of the mastoid (mastoidectomy), or both 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



  • 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 ...

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