Acute Otitis – Introduction
The word ‘Otitis’ means inflammation of the ear. Acute otitis is a common disease of the ear. It can be of any part of the ear as otitis externa, otitis media, and otitis interna each having its own pathology and should be managed accordingly. Here we will discuss otitis externa and otitis media only for an overview of each disease.
Acute otitis externa (AOE) is the inflammation of the external ear and is one of the most commonly encountered presentations in ENT departments. It is also called the swimmer’s ear because water retained in the ear during swimming increases the risk of it. Both infectious and non-infectious factors can lead to otitis externa.
Otitis externa can be defined as inflammation of the cutis and subcutis of the external auditory canal, sometimes involving the tympanic membrane and the pinna too. It is further classified as circumscribed otitis externa, diffused otitis externa, chronic otitis externa, and malignant (necrotizing) otitis externa. (1)
Almost 10% of people develop otitis externa at least once during their lifetime and most of them are acute. The incidence of otitis externa varies in different parts of the world. It is higher in tropical than temperate regions because humidity and high temperature increase the risk of infection. (2) It is also common in swimmers due to retained water in the ears after swimming.
Many pathogens are involved in the etiology of otitis externa and in many cases, almost one-third of them, it is polymicrobial. But the most important isolates are Pseudomonas aeruginosa and Staphylococcus aureus. Fungal species such as Aspergillus and Candida are also found as culprits in patients who were given antibiotics previously. Non-infectious causes of otitis externa include allergic and inflammatory conditions such as eczema and psoriasis. (3) Other risk factors include trauma to the ear canal, regularly getting water in the ear, humidity, radiotherapy, and chemotherapy.
The protective mechanisms of the external ear canal include cerumen-producing glands, which provide a surface barrier and also maintain acidic pH to prevent the growth of pathogens. Trauma to the ear, blockage, or obstruction of cerumen-producing glands can lead to a breach in protective mechanisms, higher pH, and bacterial and fungal growth leading to an inflammatory process in the ear canal. (8)
The diagnosis of otitis externa is made mostly on a clinical basis. So, the sign and symptoms of the disease are really important. These are as follows: (4)
|Pain in the ear (70%)
Sense of fullness (22%)
Hearing loss (32%)
Ear canal pain while chewing
Chondritis of pinna
To differentiate acute otitis externa from acute otitis media with effusion, tenderness of the tragus is checked. In AOE, tenderness is present when the tragus is pushed and when the pinna is pulled. (4)
Fig.1 a) Edematous external auditory canal introitus in AOM b) Bacterial acute otitis externa (1)
There are some other conditions that resemble AOE and should be considered while assessing the patient. These differential diagnoses include otitis media with perfusion, foreign body, otomycosis, herpes zoster oticus, Ramsay Hunt syndrome, cholesteatoma, otitis externa bullosa, and even carcinoma of the external auditory canal.
Diagnostic Criteria and Investigations:
The diagnosis of acute otitis externa is made mainly on the basis of clinical signs and symptoms. One of the accepted criteria for diagnosis is:
One of the following three symptoms should be present.
With at least two of the following signs:
- Edema (on otoscopy)
- Erythema (on otoscopy)
- Tenderness of tragus
- Wet debris (5)
Furthermore, laboratory investigations can be done for evaluation and confirmation of the disease. These include complete blood count (CBC), ESR, blood glucose (especially in patients with recurrent infections and diabetes) and culture sensitivity of ear canal.
The treatment of acute otitis externa includes:
The external auditory canal should be made clear of all the debris and exudate. It is usually done by suction clearance or irrigation with warm normal saline. It is one of the most important steps in management as it allows the healing process. (6)
After cleansing, medicated wicks, made by soaking gauze in antibiotic and steroid solution, can be used. They are placed in the ear canal and kept wet by instilling 2-3 drops of the solution. It helps to relieve itching and treat edema and erythema. (6)
Antibiotics are the mainstay of treatment of otitis externa. Both topical and systemic antibiotics can be used depending on the severity of the disease. In mild to moderate disease, topical antibiotics with or without steroids are used for 7-10 days, after which further assessment is done. Systemic antibiotics are preferred in severe conditions. (7) They are also important when there is associated cellulitis of pinna or lymphadenitis.
For pain relief, analgesics such as Acetaminophen and NSAIDS can be used.
Patients should be advised to avoid inserting fingers and any other object, for example, cotton bud in the infected ear. Swimming should be avoided as it can exacerbate the disease due to humidity and water retention.
Otitis externa can lead to many complications if untreated. These include malignant (necrotizing) otitis externa, auricular cellulitis, mastoiditis, perichondritis, osteomyelitis, and systemic infection. The complications most commonly develop in immunocompromised and diabetic patients demanding extensive care. (8)
Otitis media is one of the most common pediatric diagnoses in the emergency department. It is the inflammation of the middle ear space, and it can also be associated with sore throat or respiratory tract infection. It usually affects children of age 6 months to 24 months as compared to adults, but it can occur at any age. According to a study, almost 80% of all children fall prey to this disease at least once in their lifetime. (9) Otitis media is further divided into acute suppurative otitis media, otitis media with effusion, acute necrotizing otitis media and aero-otitis media (otitic barotrauma). (6) We will discuss each of them separately here.
Fig. 2 Acute otitis media (a), otitis media with effusion (b), and otitis media with no effusion (c). (10)
Acute Suppurative Otitis Media:
Acute suppurative otitis media (also called simply ‘acute otitis media’ and abbreviated as AOM) is a common disease in childhood. Following respiratory tract diseases, it is considered the second most presented disease in pediatric emergency. (9) 11% of the total population of the whole world is affected by AOM (Monasta et al., 2012). (10)
Acute otitis media is defined as infection and inflammation of the middle ear space. (10, 11) It is characterized by bulging of the tympanic membrane and erythema with signs of effusion or recent spontaneous perforation (less than 2 weeks). (11)
The incidence of acute otitis media is highest (60.99%) during the first 1-4 years of life. It gets lower with increasing age as a recorded minimum (1.49%) at the age of 35-45 years. It then increases (to 2.3%) in old age, around 75 years of age.
As far as region and environmental conditions are concerned, it is more prevalent in sub-Saharan Africa due to risk factors like poverty, immunocompromised patients, poor healthcare facilities, and increased exposure to pathogens. (12)
Any disruption in eustachian tube functioning can lead to acute otitis media. This includes allergic, infectious, and environmental factors. The most important cause of them is bacteria. Streptococcus Pneumoniae (30%), Haemophilus Influenzae (20%), and Moraxella Catarrhalis (12%) are the main culprits of infectious acute otitis media. (6) Other risk factors include ciliary dysfunction, cochlear implants, viral infections, chronic rhinitis or sinusitis, passive smoking, adenoids and infections of tonsils, allergy, and family history of AOM in siblings or parents. (9, 6)
Pathophysiology and Clinical Features:
There are five different stages of the disease having signs and symptoms depending on the course of the disease. We will discuss them together here. These stages are as follows: (6)
1- Occlusion of Eustachian tube:
As a result of inflammation of the middle ear space, there is edema and hyperemia of the eustachian tube, and air within it is absorbed, leading to tympanic membrane retraction.
Symptoms: Otalgia (Ear pain) and deafness are present without fever but are not marked.
Signs: There is retraction of the tympanic membrane and loss of light reflex. Conductive deafness is shown on tuning fork tests.
Middle ear space is invaded by pyogenic pathogens causing hyperemia and congestion.
Symptoms: Throbbing pain in the ear with deafness and tinnitus are present. Fever is recorded in children mostly.
Signs: Cart-wheel appearance of the tympanic membrane (radiating blood vessels along the handle of malleus and pars tensa congestion) is present. Conductive deafness on tuning fork tests is persistent.
It is characterized by pus formation and tympanic membrane bulging to the point of rupture.
Symptoms: Deafness and fever intensity increase with severe otalgia.
Signs: There is redness of the tympanic membrane and bulging with landmarks lost. Tenderness is present over the mastoid antrum, and exudate causes clouding of air cells on x-ray of the mastoid.
Fig.3: A, Normal TM. B, TM with mild bulging. C, TM with moderate bulging. D, TM with severe bulging. Courtesy of Alejandro Hoberman, MD. (13)
Symptoms are relieved by the evacuation of pus through tympanic membrane rupture. If antibiotics are given earlier, it may resolve without rupture of the membrane.
Symptoms: Ear pain diminishes with fever settling, and the condition of the patient improves.
Signs: Exudate and blood-tinged discharge are present in the external auditory canal.
If the disease does not resolve, it may lead to complications such as acute mastoiditis, labyrinthitis, facial nerve palsy, meningitis, petrositis, brain abscess, extradural abscess, and thrombophlebitis. (9, 6)
Diagnostic Criteria and Investigations:
History and clinical features are most important in the diagnosis of the disease. Each sign and symptom is important and different combinations of these are used for the clinical diagnosis. According to the American Academy of Pediatrics, the most important combination with the highest sensitivity and specificity is a cloudy and bulging tympanic membrane with defective mobility. (13) One of the criteria that can be used is:
- Tympanic membrane bulging (moderate to severe)
- Recent onset of otalgia (less than 2 days)
- Otorrhea (exclude discharge due to otitis externa) (13, 14)
Laboratory tests or imaging techniques are not commonly used in the diagnosis but can be helpful in excluding any complications. In that case, a CT scan and MRI of the temporal bone are good options. (9, 15) Culture and sensitivity can be done in case of resistance to treatment. (9)
Antibiotics are the mainstay of treatment in acute otitis media. They are indicated in almost all cases. (6) The first line of treatment for this disease is high-dose amoxicillin, as it is cost-effective and has fewer adverse effects. (16) While cefuroxime, azithromycin, and clarithromycin can also be given in case of hypersensitivity to penicillin. (9, 6, 14) Intramuscular ceftriaxone injections are also used sometimes, especially in severe infections that do not respond to oral therapy. One intramuscular injection is considered to have the same effect as 10 days of oral antibiotic therapy with ampicillin. (17) Furthermore, in non-responsive patients, 3 day IM ceftriaxone regimen is considered more effective. (18)
Oral and nasal decongestants:
These are helpful in relieving edema of the eustachian tube. Nasal decongestants include ephedrine, oxymetazoline, and xylometazoline and are used in the form of nasal drops. While oral forms of decongestants can also be used, especially when associated with respiratory tract infections. Antihistaminic drugs combined with a decongestant such as pseudoephedrine are most commonly used. (6)
Acetaminophen and NSAIDS can be used for pain relief in acute otitis media. It also helps to halt the inflammatory process. (9, 6) Hot compressions are also useful in relieving pain.
When the tympanic membrane is bulging with pus and the patient is in severe pain, myringotomy can be done by giving an incision in the tympanic membrane to evacuate pus. It relieves pain and is also important in cases not responding to medical treatment. (6)
In the case of recurrent otitis media with deafness, myringotomy with placement of a tympanostomy tube (TT) is a good option, as mentioned by the American Academy of Pediatrics. It helps in allowing air passage (which was otherwise blocked by tubal occlusion), and normal hearing is restored. (19)
Positioning of the baby during breastfeeding should be accurate as it predisposes to ear infections. Passive smoking (through the mother or any other family member) should be avoided. Reduction of air pollution is also important. Vaccination of the child for Hemophilus Influenza and Streptococcus Pneomoniae is also considered a preventive factor. (12) There are some studies showing low levels of zinc in children affected with recurrent otitis media and zinc supplementation should be considered for prevention. But the evidence of the zinc-induced reduction in recurrence is mixed. (21)
With the use of effective antibacterial therapy, resolution is achieved without any complications in most cases. But once complications develop, it is difficult to handle the situation. Mortality is rare. (20)
Otitis media with effusion:
This is the second type of otitis media and is the most common cause of hearing loss in children. (22) It is characterized by non-purulent fluid in the middle ear. The fluid is usually thick and mucoid but can also be serous and thin. (6, 23) It is also known as secretory otitis media, mucoid otitis media, and serous otitis media. (6′)
It is defined as the presence of fluid in the middle ear space without any signs of infection. (Mawson, 1976) Epithelial metaplasia may also be present as a result of inflammation leading to collection of liquid. (23) This collection puts pressure on the tympanic membrane pushing it outside and diminishing its vibrating movements. As a result, hearing is impaired. (24)
Otitis media with effusion (OME) has a high prevalence in children (90%) as compared to adults (0.6%). (22) It usually affects between the age of 1 to 6 years, with a bimodal peak at 2 and 5 years of age. The incidence rate also depends upon the environmental conditions, as it is higher during winter. (22, 24)
The most important risk factor is the age of the patient; as mentioned earlier, OME is more prevalent in children. This is due to the position of the eustachian tube, as it is more horizontal in children as compared to adults. (25) Other risk factors include atopic conditions, passive smoking, and feeding the baby with a bottle. (22, 24) Other conditions, such as cleft palate and Down syndrome, which involve defects in palate anatomy, may also predispose to otitis media with effusion. (26)
The mechanism of OME is not clear. Some assumptions are made, such as increased secretion of fluid by mucus or serous secretory cells of middle ear mucosa or defect in the functioning of the eustachian tube in clearing fluid from the cavity, which leads to OME. (6)
It is also considered to happen as a result of an inflammatory process leading to increased permeability and exudate formation. Previously, the fluid was considered to be sterile, but DNA and RNA of infectious organisms are found in the exudate in OME following an infection of acute otitis media which is the cause of inflammation. (23)
Symptoms: OME should be considered in any case of hearing loss in children as it is the most common presentation of the disease. (6, 22, 23, 24) Other symptoms include difficulty in communication, delayed speech and language development, withdrawal, and sleep disorders. Intermittent otalgia can also be present. (24)
Signs: On otoscopy, there is dullness of the tympanic membrane with absent light reflex. The color of the tympanic membrane may be bluish, yellowish, or grey, with bubbles seen sometimes. (6, 23) The tympanic membrane may be bulging or retracted. If there is severe retraction of the tympanic membrane, it can lead to the formation of a retraction pocket. For its prevention, surgical intervention such as modified cartilage augmentation tympanoplasty may be needed. (27)
Audiometry and hearing loss assessment should also be done as it is a good indicator of the severity of the disease. In infants and children with age of 5 years or less, hearing tests are performed using auditory brainstem responses (ABR). It detects the electrical activity of the brain when an acoustic signal is generated and determines frequency and sound intensity. (28) Hearing loss in OME ranges from 20 dB to 50 dB. If it is more than 50 dB then inner ear disease should be considered. (24)
Diagnostic criteria and Investigations:
The diagnosis is made purely on clinical features and hearing loss assessment. Tuning fork tests, otoscopic examination, and hearing assessment is a must. (6) X-ray mastoid can be done to check the clouding of cells. According to the NICE guidelines, bilateral OME and hearing loss should be assessed for 3 months before starting any interventions. Eosinophilia is considered if present as it may be indicative of any associated atopic disease. (22) Routine assessment for associated GERD or allergies is not supported but should be considered in eosinophilia, family history, and related symptoms. (29)
OME in children is mostly due to the positioning of the eustachian tube, which predisposes to the edematous type of mucosal response leading to the disease. Currently, no treatment, either medical or surgical, can solve this condition until the child grows and an effective eustachian tube position is reached. Thus, the aim of the treatment strategies is to limit the inflammatory process as much as possible. (23) The medical and surgical options used for it are as follows:
- Antibiotics: The use of antibiotics is controversial in OME. Current guidelines do not recommend this approach. (23) But some studies have shown the use of antibiotics as a good predictor of treatment success. (30) While a study has shown that macrolides such as clarithromycin and azithromycin can be used if OME is associated with rhinosinusitis. (23, 30) However, it is not recommended by current guidelines.
- Decongestants, steroids, and antihistamine drugs: These can be used in OME associated with atopic conditions and rhinosinusitis. (6) But there are not enough studies to show their effect in OME. It does not affect the severity of OME or delay its onset. (31)
- Middle ear aeration: Valsalva maneuver is an important technique and is recommended to be used by children, especially as it helps in middle ear aeration and draining the fluid from the cavity. Chewing gums can also be used as it produces continuous aeration of the middle ear by opening the eustachian tube during swallowing. (6)
- Myringotomy with aspiration of fluid and grommet insertion: Incision and drainage of fluid from the middle ear by myringotomy can be done to relieve symptoms and ear pain. If recurrent, a grommet can also be placed for continuous aeration of the middle ear and to prevent fluid accumulation. (6)
Fig. 4. Most common types of ventilation tubes (or grommets). a) Shepard’s grommets are short-term tubes which extrude within six months b) Armstrong’s grommets are intermediate tube which extrude between 9 and 14 months on average; c) T-tubes are long-term tubes and have to be manually removed and are generally kept up to two years. (29)
- Tympanostomy tube (TT) insertion: This is the benchmark treatment for recurrent cases with hearing improvement. Hearing loss of 25 dB to 40 dB is the indication for TT placement. (23) It allows middle-air ventilation and prevents fluid accumulation. Many patients are usually satisfied with this technique and do not need any other intervention mostly. (32)
- Surgical removal of causative factor: Tonsillectomy, adenoidectomy, or removal of carcinoma causing obstruction may also be done and may prove to be helpful in the management of OME. (6)
Long-term complications may develop in recurrent cases of OME, and tympanostomy tubes (TT) are used to prevent them. However, even the treatment does not assure safety from complications such as tympanosclerosis, perforation, structural modification, and ossicular discontinuity. (33)
Most cases of OME may resolve after some time spontaneously without any complications. But if persistent, it might progress to hearing problems leading to defective speech and language development in children.
Causative factors should be addressed appropriately, and effective management should be done. Patient education and awareness are also important in this aspect.
Acute necrotizing otitis media:
Another type of otitis media is acute necrotizing type, in which there is severe inflammation leading to rapid involvement of the tympanic membrane, including the annulus, ear bones, and mastoid air cells. Ear pain and discharge are the main symptoms that are severe in intensity. Even after healing, there is squamous metaplasia of the meatus and fibrosis. Antibiotics are the main pillar of management and should be started as early as possible. Surgical treatment such as cortical mastoidectomy is also an option. The duration of the disease is 7-10 days. Children with scarlet fever or measles are mostly affected. (6)
Aero-otitis media (Otitic barotrauma):
It is a type of otitis media caused by an increase in atmospheric pressure as compared to middle ear pressure by a critical level of 90 dB. It usually happens in underwater diving and rapid descent in flight. Due to high pressure, the eustachian tube is blocked, and aeration of the middle ear air is not done. Symptoms include sudden otalgia, tinnitus, and impaired hearing. Signs are sensorineural hearing loss and hyperemia of the tympanic membrane with hemorrhagic effusion. Catheterization may be done to aerate the cavity. Nasal sprays and decongestants may also help. It can be prevented by swallowing or chewing during flight descent, the Valsalva maneuver, and not sleeping during flight descent. Air travel during respiratory infection should be avoided. (6)
The author does not report any conflict of interest.
This information is for educational purposes and is not intended to treat disease or supplant professional medical judgment. Physicians should follow local policy regarding the diagnosis and management of medical conditions.
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Dr. Muhammad Daniyal Haider is a general physician who continuously seeks for platforms to serve the community and utilize his knowledge and abilities to improve the health
system. Dedication to the cure of diseases and, more importantly, prevention and
awareness of people about these diseases is the goal. He is a general physician, author
and a calligrapher. He is passionate about research projects, latest guidelines and
techniques which can lead to a better approach to the patient’s condition.