Otitis Media is also called Middle Ear infection and occurs as an inflammation of the middle ear; This covers the different types of Otitis Media (Acute and Chronic type (Otitis media with Effusion). The Symptoms, Signs and Treatment including the causes of Otitis Media and the complications will also be discussed.

Otitis Media Definition (What is Otitis Media?)

Otitis Media is an infection of the middle ear that is mostly caused by bacteria but can be caused by other organisms such as Viruses and Fungi. The middle ear cleft is inflamed and this inflammation may also affect other parts of the ear such as inflammation of the mastoid, petrous apex and peri-labyrinthine air cells.

Otitis Media Epidemiology

Otitis media mostly affects children between the age of 6 months to 3 years and it occurs commonly in Eskimos, Cherokee Indians, Australians and African aborigines. Middle ear infection is also associated with poor Socioeconomic factors such as poor hygiene, overcrowding and poverty.

Otitis Media Pathogenesis

Pathophysiology of otitis media begins with inflammation of the mucosa lining of the middle ear leading to formation of edema of the mucosa, capillary engorgement and goblet cell hyperplasia with secretion of mucus. This inflammation of the mucosa of the middle ear causes Metaplasia of middle ear mucosa and changes it to type similar to the respiratory mucosa. Coupled with mucociliary malfunction, stasis occurs with development of Otitis media with effusion (glue ear). As bacteria superimpose due to stasis, pus production occurs that then accumulates in the middle ear and causes pain in the acute stage of Otitis media. As pus accumulates, perforation of the Tympanic membrane (TM) occurs and this reliefs the pressure and the ear pain subsides. The persistence of this disease for more than 3 months makes it chronic otitis media.

Otitis Media Classification

There are different types of Otitis media that have been classified base on presence or absent of discharge, clinical types and also based on duration of infection.

Otitis Media Classification based on Duration

1. Acute Otitis Media: this occurs suddenly and has rapid onset of symptoms and signs that resolves within 3 weeks.
2. Sub-acute Otitis Media: this takes a period of about 3 weeks to 3 months
3. Chronic Otitis Media (Otitis Media with Serous effusion): this last for a long time, lasting for more than 3 months

Types of Otitis Media based on discharge

1. Suppurative Otitis media this could further be classified as Acute Suppurative Otitis Media and Chronic Suppurative Otitis Media
2. Non-suppurative Otitis media

Clinical types of Otitis media

1. Tubotympanic (safe disease)
2. Atticoantral (unsafe disease)

Other types include Otitis media coexisting with Otitis externa.

Tubotympanic disease

Tubotympanic disease is a type of otitis media that occurs through the spread of infection from the Eustachian tube following Upper Respiratory Tract Infections (URTI), or due to perforation of the tympanic membrane from External auditory canal (EAC) as a result of swimming or deep sea diving. Tubotympanic disease may also occur due to poorly treated or untreated URTI and could also occur due to Blood borne infections (of which is rare).

Atticoantral disease

Atticoantral disease is associated with cholesteatoma and it is regarded as dangerous or unsafe disease.

Otitis Media Causes (Etiology of Middle ear infection)

1. Streptococcus pneumoniae (the commonest cause of otitis media in children)
2. Haemophilus influenza
3. Streptococcus pyogenes
4. Staphylococcus aureus
5. Moraxella catarrhalis this causes otitis media in children in most cases
6. Respiratory viruses such as Respiratory Syncytial Virus (RSV)these are implicated in 25% of cases

Theses causative agents of otitis media have been listed from the commonest cause (number 1 to the least common (Number 6)

Otitis Media Risk factors

1. Passive smoking
2. Male gender
3. Eustachian tube dysfunction and obstruction
4. Having a Family history of otitis media
5. Children in day care
6. Use of formula feed for babies

Middle ear infection symptoms: Otitis media with bulging tympanic membrane

Otitis Media Symptoms and Signs (Middle Ear Infection Symptoms)

1. Earache that is often pulsating in nature – Severe pains in the ears (Otalgia). Mastoid pain is pathognomonic of otitis media; Mastoid pain is aggravated by blowing the nose
2. Conductive hearing loss
3. Otorrhea (discharge from the ear)
4. There may be Vertigo (feeling dizzy as if the world is turning)
5. Fever
6. Excessive crying in babies
7. Tinnitus ringing sound in the ear
8. Examination of the ear will show immobility of the Tympanic membrane (TM) with air insufflation
9. Other physical findings include: air-fluid levels or bubbles behind the Tympanic membrane
10. Retraction or bulging of the Tympanic membrane
11. Blurring of osseous middle ear landmarks and TM color change

Otitis Media Diagnosis

1. Ear swab for Microscopy, Culture and Sensitivity of bacteria of middle ear
2. Otoscopy
3. Pure Tone Audiometry (PTA)
4. Tympanometry (impedance audimetry)
5. Radiological imaging which helps to show plain mastoid x-rays and CT scan of temporal bone

Otitis Media Differential Diagnosis

1. Otitis externa
2. Mastoiditis
3. Myringitis Bullosa Haemorrhagica
4. Labyrinthitis
5. Menieres disease
6. Cholesteatoma

Serous Otitis Media (Glue ear)

Otitis Media Treatment

Otitis media treatment could be Medical or Surgical. Because Otitis media is often caused by viruses especially in children, it usually resolves within 72 hours (within 3 days) even without antibacterial treatment; if patients there is no relief of symptoms after 3 days, consider using systemic antibiotics.

1. Myringotomy surgical incision into the eardrum for drainage of accumulated pus to relief pain and pressure in the ear.
2. Medical treatment involves the use of appropriate antibiotics based on culture results for bacteria causes and use of antifungal drugs for fungi; it also entails frequent gentle aural toileting, use of topical antibiotics, Use of wick drain into affected External auditory canal, treatment of URTI and keeping of ear dry such as avoiding of swimming and deep sea diving.
3. Surgical treatment of Otitis media is done mostly for atticoantral disease (unsafe disease) and may be done for some cases of tubotympanic disease. Surgical procedures done are listed below
4. Supportive treatment like use of Analgesics to relief pain

Otitis Media Antibiotics (Drugs for treatment of Otitis Media)

1. Amoxicillin (80 mg/kg/d) is the recommended agent for most patients with Otitis Media and is given for 10 days
2. Other alternative drugs include Macrolides
3. Amoxicillin and Clavulanate
4. Cephalosporins
5. Trimethoprim and sulfamethoxazole
6. Erythromycin and Sulfisoxazole
7. Clindamycin.

Types of Surgical procedures for Otitis media

1. Atticotomy: in which the disease is limited to the attic
2. Antrotomy: if cholesteatoma extends into aditus then mastoid antrum needs exposing
3. Intact canal wall mastoidectomy: in this, the recurrence is very common
4. Posterior tympanotomy– if there is residual disease, middle ear exposed via mastoid, disease remnant removed but leave stapes alone
5. Modified radical mastoidectomy– remove facial Nerve if it is involved
6. Radical mastoidectomy– removal of remnant of Tympanic membrane
7. Tympanoplasty: which is the reconstruction of Tympanic Membrane.

Otitis media Treatment principles and aims

1. To eradicate disease and have a dry ear
2. To prevent recurrence of infection
3. To prevent development of complications
4. To restore function

Otitis Media Complications

1. Unilateral facial nerve palsy
2. Meningitis
3. Developmental abnormalities such as abnormal speech development in a child with recurrent otitis media
4. Hearing loss
5. Hemiplegia
6. Subperiosteal abscesses
7. Postauricular abscess
8. Zygomatic abscess
9. Von-Bezolds abscess
10. Citellis abscess
11. Pharyngeal abscess
12. Osteomyelitis of temporal bone
13. Labyrinthitis
14. Mastoiditis
15. Tympanosclerosis
16. Extradural abscess
17. Cerebral abscess
18. Subdural empyema
19. Lateral sinus thrombosis
20. Apical petrositis
21. Otitic hydrocephalus- benign intracranial hypertension

Otitis Media Prevention

1. Encourage continuous exclusive breastfeeding as long as possible
2. Avoid bottle feeding of infants
3. Smoke-free environment
4. Children at high-risk for recurrent acute Otitis Media should be placed on prolonged courses of antimicrobial prophylaxis that will reduce recurrences significantly such as the use of Amoxicillin (20 to 30 mg/kg/day) or Sulfisoxazole (50 mg/kg/day) given once daily at bedtime for 3 to 6 months or longer as prophylaxis for Otitis media
5. The conjugate Streptococcus pneumoniae Vaccine reduces pneumococcal Otitis media caused by vaccine-serotypes by 50%, all pneumococcal otitis media by 33%, and all Otitis media by 6%.
6. Annual immunization against influenza virus may be helpful in high-risk children