Welcome to this video tutorial about otitis media, or middle ear infection. Otitis media refers to inflammation of the mucous membranes of the middle ear or eustachian tube. This area is continuous with the respiratory tract, thus allowing infection to easily ascend to the ear. Otitis media is usually caused by various types of bacteria such as E. coli and Staphylococcus aureus, but can also be caused by a virus, and is often associated with upper respiratory infections. Otitis media can occur at any age, but is most common between the ages of 3 months and 3 years old, due to the eustachian tube being more horizontal at this age.
There are three types of otitis media: acute, chronic, and with effusion. Acute otitis media (AOM) develops suddenly and doesn’t last very long. Chronic otitis media results from recurrent or untreated infection and usually involves drainage and perforation of the tympanic membrane. Otitis media with effusion (OME) is a collection of noninfectious fluid in the middle ear, resulting from an acute infection that didn’t completely go away, an allergic reaction, or an obstruction of the eustachian tube.
Even though otitis media is most commonly seen in children, it is also seen in adults, but the symptoms are usually less dramatic than in a child. However, adults are vulnerable to developing chronic otitis media, especially if they experienced multiple acute episodes as a child. Patients exposed to passive smoke have a significantly increased risk for acute otitis media. Other risk factors include a positive family history for ear infections, bottle feeding instead of breastfeeding, use of pacifiers, attending a daycare center, and those with chronic allergies and sinusitis.
The initial symptom of otitis media is usually an earache. Since the middle ear transmits sound from the tympanic membrane to the inner ear, middle ear infection frequently causes a conductive hearing loss due to the pressure behind the tympanic membrane. Usually once the infection is resolved, the hearing loss is corrected. Additional symptoms that are commonly seen include throbbing pain in the infected ear, fever, inflammation, drainage, and bulging of the eardrum with possible perforation. When perforation occurs, pus, blood, or other material may be seen. A common finding with chronic otitis media is a thick, yellow, purulent discharge. In infants and young children you often see crankiness, pulling on the ear, difficulty sleeping, fever, N/V, or diarrhea.
Complications are uncommon, but the primary complication is perforation of the eardrum and conductive hearing loss. The hearing loss usually resolves with treatment, but may be permanent if chronic disease is present. Acute perforations usually heal spontaneously without problems, but complex situations may require surgical closure of the perforation. In rare cases, bacterial middle ear infection can spread locally, resulting in mastoiditis, which involves the cells of the skull behind the ear. Intracranial spread is extremely rare and usually causes meningitis, but brain abscess may also occur, due to the anatomy of the temporal bone. Severe headache, confusion, or neurologic signs may occur with intracranial spread of infection. Infection can also spread to the labyrinth (inner ear), causing vertigo or facial paralysis. Repeated infections can cause tympanosclerosis, a deposit of collagen and calcium in the middle ear. This deposit can harden around the ossicles and cause further conductive hearing loss.
Treatment of otitis media starts with analgesics, such as acetaminophen or ibuprofen. These oral analgesics are usually effective. There are also topical agents that may provide a short amount of relief, but they should not be used if the tympanic membrane is perforated.
Antibiotics are often given for otitis media, and seem to relieve symptoms quicker and reduce the chance of complications. However, due to many resistant organisms, pediatric organizations strongly recommend antibiotics primarily for the very young child, the more severely ill, or those with more than 4 episodes in 6 months. It should be noted that 80% of cases resolve on their own, and most can safely be observed for 48 to 72 hours, and only given antibiotics if no improvement is seen at that point.
Amoxicillin is the preferred antibiotic of choice. If allergic to penicillins, a 2nd or 3rd generation cephalosporin can be given. If there is no improvement after 48-72 hours of treatment, or previous resistance to amoxicillin; Augmentin, Rocephin, or Clindamycin can be used.
Antihistamines and decongestants are not recommended for children. Decongestants may help adults, but antihistamines should only be taken by adults with a truly allergic cause.
If a patient has acute otitis media 3 or more times in 6 months, or 4 or more times in a year, tympanostomy tubes are recommended. A tympanostomy tube, also known as a myringotomy tube, or grommet, is a small tube inserted into the eardrum to drain fluid and keep the middle ear ventilated. By equalizing air pressure in the middle ear space, the ear stops making fluid. Fluid in the ears impairs hearing and serves as a culture medium for bacteria, so it is important to avoid a buildup of fluid in the middle ear space.
Insertion of the tubes is a surgical procedure under local or general anesthesia. Local can be used for adults, but general is usually always required for children, since it is necessary to be very still during the procedure. The tube is either shaped like a grommet, which generally remains in the eardrum for 6 months to 2 yrs, or a “T”-shaped tube can stay in place for 2-4 years. Ear tubes fall out of the tympanic membrane spontaneously as the child grows and the eardrum slowly migrates out towards the ear canal wall over time. The eardrum usually closes without leaving a hole.
Patient / family teaching for otitis media includes educating the patient to take antibiotics as prescribed for the full course, even if symptoms have gone away. Avoid getting water in the ear during treatment – avoid swimming and use ear plugs when showering or shampooing. Report any decrease in hearing, ear drainage, or return of pain.
Patient education for post-op placement of ear tubes includes educating the parent that the child may experience brief nausea or vomiting after anesthesia, and may sleep longer that day or be irritable for several hours. The child may bathe, shampoo or swim with tubes in place, but if an older child is swimming deeper than 3 feet underwater, ear plugs should be worn. Ear tubes are smaller than a match head and are not visible on the outside of the ear, but can be seen with an otoscope. After tubes are inserted, it is possible that the ear may drain for awhile, especially during upper respiratory infections. Ear drops may be prescribed, but only use what is prescribed, nothing over the counter. It takes approximately 3 months for the lining of the middle ear to return to normal after the insertion of tubes. When the tube comes out of the eardrum, it will fall into the ear canal, get lodged in earwax, and fall out of the ear, or be removed with the earwax at a checkup. It is very rare for it to fall into the middle ear space, but if it does, it can be removed with a brief procedure without causing harm.
Here’s a study question to get you thinking…
Which of the following is the primary complication of a middle ear infection?
3. Perforation of the eardrum
If you chose #3, perforation of the eardrum, you’re right! Sensorineural hearing loss results from interference with conduction in the inner ear. Vertigo results from an infection that has spread to the inner ear. Tympanosclerosis is caused by repeated ear infections. Thus, perforation of the eardrum and conductive hearing loss are the primary complication of a middle ear infection.
Thank you for watching this video tutorial on otitis media – be sure to check out our other videos!