Acute Otitis Media

Acute otitis media is an infection in the middle ear characterized by mucosal inflammation and retention of fluid. The most common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The condition can present with fever, otalgia, and diminished hearing. Diagnosis is made by history and otoscopic exam showing a bulging tympanic membrane with reduced mobility. Observation or antibiotics are the usual management approaches, but surgery for tympanostomy tubes may be required if there are recurrent infections. Potential complications include hearing loss, tympanic membrane perforation, and mastoiditis.

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Overview

Definition

Acute otitis media is an infection characterized by the accumulation of fluid and inflammation within the middle ear.

Epidemiology

  • Age:
    • Occurs at all ages 
    • Most prevalent between 6 and 24 months of age
    • Children with a first episode before 6 months of age are at a higher risk for recurrence.
  • Sex: Incidence is slightly higher in boys.
  • Race and ethnicity: 
    • Higher incidence in Native American, Alaskan, and Canadian Inuit children 
    • Lower incidence in African American and white children

Etiology

Acute otitis media is an inflammatory condition of the middle ear with an infectious etiology that may be bacterial (most common) or viral. Causes include:

Bacterial:

  • Common:
    • Streptococcus pneumoniae
    • Haemophilus influenzae
    • Moraxella catarrhalis 
  • Uncommon:
    • Group A Streptococcus (uncommon, except with tympanostomy tubes)
    • Staphylococcus aureus (uncommon)
  • Rare:
    • Mycobacteria
    • Mycoplasma pneumoniae
    • Chlamydia trachomatis

Viral:

  • Respiratory syncytial virus
  • Influenza virus
  • Parainfluenza virus
  • Enteroviruses
  • Rhinovirus
  • Adenovirus
  • Coronavirus
  • Human metapneumovirus

Risk factors

  • Age < 2 years (eustachian tube is more horizontal and prone to infection)
  • Prematurity
  • Family history of repeated infection
  • Lack of breastfeeding
  • Crowded living situation or daycare
  • Pacifier use
  • Cleft palate
  • Down syndrome
  • Eustachian tube dysfunction
  • Eustachian tube obstruction:
    • Nasopharyngeal carcinoma
    • Lymphoma
  • Cigarette smoking
  • Seasonal allergies
  • Immunodeficiency syndromes

Pathophysiology and Clinical Presentation

Pathophysiology

The middle ear is lined with respiratory mucosa, and the cascade of events affecting adjacent areas is usually reflected in similar changes in the ear.

  • Triggering event (usually an upper respiratory infection) → inflammation and edema of the mucosa of the nasopharynx
  • Inflammation extends to the eustachian tube → subsequent obstruction → altered pressure within the middle ear
  • Bacteria colonize the middle ear space → inflammation and release of purulent exudates from the inflamed mucosa
  • Bulging of the tympanic membrane → otalgia

Clinical presentation

  • General signs and symptoms:
    • Ear pain (otalgia)
    • Fever
    • Decreased hearing
    • Loss of balance
  • In adults, symptoms will likely follow:
    • Upper respiratory tract infection
    • Seasonal allergic rhinitis
  • In young children, symptoms to be aware of include:
    • Irritability 
    • Trouble sleeping
    • Excessive crying
    • Tugging at the ears
    • Difficulty feeding
  • Signs and symptoms of tympanic membrane rupture:
    • Sudden relief of pain
    • Purulent discharge from the ear (otorrhea)

Otoscopic examination

  • Bulging tympanic membrane
  • Middle ear effusion
  • Tympanic membrane may appear cloudy or opaque.
  • Loss of the light reflex
  • Reduced mobility of tympanic membrane when pneumatic pressure is applied
  • Erythema (may also be from vascular engorgement)
  • Discharge in the ear may indicate perforation.

Diagnosis

The diagnosis of acute otitis media is primarily based on clinical presentation and otoscopic exam. No lab tests or imaging are needed unless there are special circumstances.

  • Cultures may be obtained with tympanocentesis:
    • Indications:
      • Critically ill patients with no response to treatment in 48–72 hours
      • Severely immunocompromised patients
      • Neonates < 6 weeks old
    • Procedure:
      • A small puncture is made in the tympanic membrane to drain fluid from the middle ear. 
      • The fluid is sent to the lab for culture and sensitivity.
      • Usually diagnostic, but may also be a therapeutic procedure
  • Imaging:
    • Not indicated unless complications are a concern as a result of extension beyond the middle ear
    • CT scan to evaluate for intracranial abscess or venous thrombosis if:
      • High-grade fever
      • Confusion
      • Focal neurological signs
  • Hearing testing by an audiologist, if indicated

Management and Complications

Management

Observation: 

  • Appropriate for 48–72 hours in non-severe illness
  • 80% of acute otitis media infections may resolve without antibiotics.

Pain control:

  • Topical ear drops with benzocaine or lidocaine
  • Systemic therapy:
    • Acetaminophen
    • Ibuprofen
    • No aspirin in children (due to the concern for Reye syndrome)

Antibiotics:

  • Benefits:
    • Reduce contralateral acute otitis media
    • Improve resolution of infection
    • Reduce the risk of perforation
    • Reduce pain
  • Empiric treatment:
    • Amoxicillin (1st-line) or amoxicillin-clavulanate 
    • Second or 3rd-generation cephalosporins (for penicillin allergy)
    • Macrolides (e.g., azithromycin, clarithromycin) 
    • Doxycycline

Prevention

  • Vaccinations:
    • Decrease the incidence of acute otitis media
    • Pneumococcal and H. influenzae type B (Hib)
  • Breastfeeding for at least 6 months 
  • Avoid secondhand smoke exposure.
  • Tympanostomy tubes may be needed for recurrent infections.

Complications

Two types of complications can occur.

Intratemporal complications:

  • Permanent hearing loss
  • Tympanic membrane perforation
  • Tympanosclerosis 
  • Mastoiditis
  • Facial palsy
  • Cholesteatoma 

Intracranial complications:

  • Meningitis
  • Subdural empyema
  • Brain abscess
  • Lateral sinus thrombosis

Differential Diagnosis

  • Cholesteatoma: a non-neoplastic collection of keratinized, desquamated epithelial cells in the middle ear caused by chronic ear infections, sinus infections, and allergies. Patients may be asymptomatic or present with vertigo, otorrhea, and hearing loss. Diagnosis is by otoscopic examination and imaging. Treatment includes surgical removal of the mass.
  • Temporomandibular joint disorders: presents with pain in the jaw joint and muscles surrounding it, difficulty or pain while chewing, and ear pain. Diagnosis is based on the history and physical examination. Treatment includes medication, physiotherapy, and, rarely, surgical management.
  • Dental pain: inflammation around a tooth due to decay or an infection can also present with ear pain and other symptoms, including headache, local pain, halitosis, fever, and bleeding or discharge from gums. The diagnosis is made with examination and imaging. Management is based on the cause and extent of the damage.
  • Otitis externa: inflammation of the external ear canal caused by an infection. Patients present with ear pain, discharge, and pruritus of the ear canal. The diagnosis is clinical, and the condition is treated with topical antibiotics.
  • Acute pharyngitis: inflammation in the pharynx or tonsils, which may be viral or bacterial (including group A Streptococcus). Patients present with throat pain, fever, and lymphadenopathy. Ear pain can be present. The diagnosis can be made with clinical exam, Streptococcus rapid antigen testing, or culture. Management includes symptomatic treatment and antibiotics for Streptococcus infection.

References

  1.  Limb, C.J., et al.  (2020). Acute otitis media in adults. UpToDate. Retrieved April 29, 2021, from https://www.uptodate.com/contents/acute-otitis-media-in-adults
  2. Pelton, S., Tähtinen, P. (2020). Acute otitis media in children: Epidemiology, microbiology, and complications. UpToDate. Retrieved April 29, 2021, from https://www.uptodate.com/contents/acute-otitis-media-in-children-epidemiology-microbiology-and-complications
  3. Pelton, S. (2019). Acute otitis media in children: Treatment. UpToDate. Retrieved April 29, 2021, from https://www.uptodate.com/contents/acute-otitis-media-in-children-treatment
  4. Danishyar, A., Ashurst, J.V.,  (2021). Acute otitis media. StatPearls. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK470332/
  5. Miyamoto, R.T. (2020). Otitis media (acute). [online] MSD Manual Professional Version. Retrieved May 5, 2021, from https://www.msdmanuals.com/professional/ear,-nose,-and-throat-disorders/middle-ear-and-tympanic-membrane-disorders/otitis-media-acute
  6. Maranhão, A.S., et al. (2013). Intratemporal complications of otitis media. Brazilian Journal of Otorhinolaryngology, 79(2), 141-9. DOI: 10.5935/1808-8694.20130026
  7. Donadlson, J.D. (2019). Acute otitis media. In Meyers, A.D. (Ed.), Medscape. Retrieved May 5, 2021, from https://emedicine.medscape.com/article/859316-overview

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