Acute otitis media (AOM) is a painful type of ear infection. It occurs when the area behind the eardrum called the middle ear becomes inflamed and infected.

The following behaviors in children often mean they have AOM:

·         fits of fussiness and intense crying (in infants)

·         clutching the ear while wincing in pain (in toddlers)

·         complaining about a pain in the ear (in older children)

What Are the Symptoms of Acute Otitis Media

Infants and children may have one or more of the following symptoms:

·         crying

·         irritability

·         sleeplessness

·         pulling on the ears

·         ear pain

·         a headache

·         neck pain

·         a feeling of fullness in the ear

·         fluid drainage from the ear

·         a fever

·         vomiting

·         diarrhea

·         irritability

·         a lack of balance

·         hearing loss

What Causes Acute Otitis Media?

The eustachian tube is the tube that runs from the middle of the ear to the back of the throat. An AOM occurs when your child’s eustachian tube becomes swollen or blocked and traps fluid in the middle ear. The trapped fluid can become infected. In young children, the eustachian tube is shorter and more horizontal than it is in older children and adults. This makes it more likely to become infected.

The eustachian tube can become swollen or blocked for several reasons:

·         allergies

·         a cold

·         the flu

·         a sinus infection

·         infected or enlarged adenoids

·         cigarette smoke

·         drinking while laying down (in infants)

Who Is at Risk for Acute Otitis Media?

The risk factors for AOM include:

·         being between 6 and 36 months old

·         using a pacifier

·         attending daycare

·         being bottle fed instead of breastfed (in infants)

·         drinking while laying down (in infants)

·         being exposed to cigarette smoke

·         being exposed to high levels of air pollution

·         experiencing changes in altitude

·         experiencing changes in climate

·         being in a cold climate

·         having had a recent cold, flu, sinus, or ear infection

Genetics also plays a role in increasing your child’s risk of AOM.

How Is Acute Otitis Media Diagnosed?

Your child’s doctor may use one or more of the following methods to diagnose AOM:

Otoscope

Your child’s doctor uses an instrument called an otoscope to look into your child’s ear and detect:

·         redness

·         swelling

·         blood

·         pus

·         air bubbles

·         fluid in the middle ear

·         perforation of the eardrum

Tympanometry

During a tympanometry test, your child’s doctor uses a small instrument to measure the air pressure in your child’s ear and determine if the eardrum is ruptured.

Reflectometry

During a reflectometry test, your child’s doctor uses a small instrument that makes a sound near your child’s ear. Your child’s doctor can determine if there’s fluid in the ear by listening to the sound reflected back from their ear.

Hearing Test

Your doctor may perform a hearing test to determine if your child is experiencing hearing loss. Otitis media is a group of inflammatory diseases of the middle ear. The two main types areacute otitis media (AOM) and otitis media with effusion (OME).AOM is an infection of abrupt onset that usually presents with ear pain. In young children this may result in pulling at the ear, increased crying, and poor sleep. Decreased eating and a fever may also be present. OME is typically not associated with symptoms. Occasionally a feeling of fullness is described. It is defined as the presence of non-infectious fluid in the middle ear for more than three months. Chronic suppurative otitis media (CSOM) is middle ear inflammation of greater than two weeks that results in episodes of discharge from the ear. It may be a complication of acute otitis media. Pain is rarely present.^[4] All three may be associated withhearing loss.The hearing loss in OME, due to its chronic nature, may affect a child's ability to learn.

The cause of AOM is related to childhood anatomy and immune function. Either bacteria or viruses may be involved. Risk factors include exposure to smoke, use of pacifiers, and attending daycare. It occurs more commonly in those who are Native American or who haveDown syndrome. OME frequently occurs following AOM and may be related to viral upper respiratory infections, irritants such as smoke, or allergies. Looking at the eardrum is important for making the correct diagnosis.Signs of AOM include bulging or a lack of movement of the tympanic membrane from a puff of air. New discharge not related to otitis externa also indicates the diagnosis.

A number of measures decrease the risk of otitis media including pneumococcal and influenza vaccination, exclusive breastfeeding for the first six months of life, and avoiding tobacco smoke In those with otitis media with effusion antibiotics do not generally speed recovery.The use of pain medications for AOM is important.This may includeparacetamol (acetaminophen), ibuprofen, benzocaine ear drops, or opioids.^[3] In AOM, antibiotics may speed recovery but may result in side effects.^[8] Antibiotics are often recommended in those with severe disease or under two years old. In those with less severe disease they may only be recommended in those who do not improve after two or three days.^[6]The initial antibiotic of choice is typically amoxicillin. In those with frequent infectionstympanostomy tubes may decrease recurrence.^[3]

Otitis media.

An integral symptom of acute otitis media is ear pain; other possible symptoms include fever, and irritability (in infants). Since an episode of otitis media is usually precipitated by an upper respiratory tract infection (URTI), there often are accompanying symptoms like cough and nasal discharge.^[12]

Discharge from the ear can be caused by acute otitis media with perforation of the ear drum, chronic suppurative otitis media, tympanostomy tube otorrhea, or acute otitis externa. Trauma, such as a basilar skull fracture, can also lead to discharge from the ear due to cerebral spinal drainage from the brain and its covering (meninges).

The common cause of all forms of otitis media is dysfunction of the Eustachian tube.^[13]This is usually due to inflammation of the mucous membranes in the nasopharynx, which can be caused by a viral URI, strep throat, or possibly by allergies.^[14] Because of the dysfunction of the Eustachian tube, the gas volume in the middle ear is trapped and parts of it are slowly absorbed by the surrounding tissues, leading to negative pressure in the middle ear. Eventually the negative middle-ear pressure can reach a point where fluid from the surrounding tissues is sucked in to the middle ear's cavity (tympanic cavity), causing a middle-ear effusion. This is seen as a progression from a Type A tympanogram to a Type C to a Type B tympanogram.

By reflux or aspiration of unwanted secretions from the nasopharynx into the normally sterile middle-ear space, the fluid may then become infected — usually with bacteria. The virus that caused the initial URI can itself be identified as the pathogen causing the infection.^[14]

 

Perforation of the right tympanic membrane resulting from a previous severe acute otitis media

As its typical symptoms overlap with other conditions, such as acute external otitis, clinical history alone is not sufficient to predict whether acute otitis media is present; it has to be complemented by visualization of the tympanic membrane.^[15][16] Examiners use a pneumatic otoscope with a rubber bulb attached to assess the mobility of the tympanic membrane.

Acute otitis media in children with moderate to severe bulging of the tympanic membrane or new onset of otorrhea (drainage) is not due to external otitis. Also, the diagnosis may be made in children who have mild bulging of the ear drum and recent onset of ear pain (less than 48 hours) or intense erythema (redness) of the ear drum.

To confirm the diagnosis, middle-ear effusion and inflammation of the eardrum have to be identified; signs of these are fullness, bulging, cloudiness and redness of the eardrum.^[12] It is important to attempt to differentiate between acute otitis media and otitis media with effusion (OME), as antibiotics are not recommend for OME.^[12] It has been suggested that bulging of the tympanic membrane is the best sign to differentiate AOM from OME ^[17]

Viral otitis may result in blisters on the external side of the tympanic membrane, which is called bullous myringitis (myringa being Latin for "eardrum").^[18]

However, sometimes even examination of the eardrum may not be able to confirm the diagnosis, especially if the canal is small. If wax in the ear canal obscures a clear view of the eardrum it should be removed using a blunt cerumen curette or a wire loop. Also, an upset young child's crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media.

Acute otitis media

The most common bacteria isolated from the middle ear in AOM are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis,^[12] and Staphylococcus aureus.^[19]

Otitis media with effusion

Otitis media with effusion (OME), also known as serous otitis media (SOM) or secretory otitis media (SOM), and commonly referred to as glue ear,^[20] is a collection of effusion (fluid) that occurs in the middle-ear space due to the negative pressure produced by dysfunction of the Eustachian tube. This can occur purely from a viral URI or bacterial infection, or it can precede and/or follow acute bacterial otitis media.^[21] Fluid in the middle ear frequently causes conductive hearing impairment but only when it interferes with the normal vibration of the eardrum by sound waves. Over weeks and months, middle-ear fluid can become very thick and glue-like, which increases the likelihood of its causing conductive hearing impairment.

Early-onset OME is associated with feeding of infants while lying down, early entry into group child care, parental smoking, lack, or too short a period of breastfeeding and greater amounts of time spent in group child care, particularly those with a large number of children, increases the incidences and duration of OME in the first two years of life.^[22]

Chronic suppurative otitis media

Chronic suppurative otitis media, incorrectly called chronic otitis media or chronic ear infection, involves a hole in the tympanic membrane and active bacterial infection within the middle-ear space for several weeks or more. There may be enough pus that it drains to the outside of the ear (otorrhea), or the pus may be minimal enough to only be seen on examination using the otoscope or, more effectively, with a binocular microscope. This disease is much more common in persons with poor Eustachian tube function and very common in certain races such as Native North Americans. Hearing impairment often accompanies this disease.

It is a primary cause of hearing loss that newly develops in children. An ear wick may be effective or, if not, antibiotics.^[23]

Adhesive otitis media

Adhesive otitis media occurs when a thin retracted ear drum becomes sucked into the middle-ear space and stuck (i.e., adherent) to theossicles and other bones of the middle ear.

There are several subtypes of OM, as follows:

·         Acute OM (AOM)

·         OM with effusion (OME)

·         Chronic suppurative OM

·         Adhesive OM

AOM implies rapid onset of disease associated with one or more of the following symptoms:

·         Otalgia

·         Otorrhea

·         Headache

·         Fever

·         Irritability

·         Loss of appetite

·         Vomiting

·         Diarrhea

OME often follows an episode of AOM. Symptoms that may be indicative of OME include the following:

·         Hearing loss

·         Tinnitus

·         Vertigo

·         Otalgia

Chronic suppurative otitis media is a persistent ear infection that results in tearing or perforation of the eardrum.

Adhesive otitis media occurs when a thin retracted ear drum becomes sucked into the middle ear space and stuck.

OME does not benefit from antibiotic treatment. Therefore, it is critical for clinicians to be able to distinguish normal middle ear status from OME or AOM. Doing so will avoid unnecessary use of antibiotics, which leads to increased adverse effects of medication and facilitates the development of antimicrobial resistance.

Examination

Pneumatic otoscopy remains the standard examination technique for patients with suspected OM. In addition to a carefully documented examination of the external ear and tympanic membrane (TM), examining the entire head and neck region of patients with suspected OM is important.

Every examination should include an evaluation and description of the following four TM characteristics:

·         Color – A normal TM is a translucent pale gray; an opaque yellow or blue TM is consistent with middle ear effusion (MEE)

·         Position – In AOM, the TM is usually bulging; in OME, the TM is typically retracted or in the neutral position

·         Mobility – Impaired mobility is the most consistent finding in patients with OME

·         Perforation – Single perforations are most common

Otitis media is an infection of the middle ear that causes inflammation (redness and swelling) and a build-up of fluid behind the eardrum.

Anyone can develop a middle ear infection but infants between six and 15 months old are most commonly affected.

It's estimated that around one in every four children experience at least one middle ear infection by the time they're 10 years old.

Symptoms of a middle ear infection

In most cases, the symptoms of a middle ear infection (otitis media) develop quickly and resolve in a few days. This is known as acute otitis media. The main symptoms include:

• earache
• a high temperature (fever)
• being sick
• a lack of energy
• slight hearing loss – if the middle ear becomes filled with fluid, hearing loss may be a sign of glue ear, also known as otitis media with effusion

In some cases, a hole may develop in the eardrum (perforated eardrum) and pus may run out of the ear. The earache, which is caused by the build-up of fluid stretching the eardrum, then resolves.

Signs in young children

As babies are unable to communicate the source of their discomfort, it can be difficult to tell what's wrong with them. Signs that a young child might have an ear infection include:

• pulling, tugging or rubbing their ear
• irritability, poor feeding or restlessness at night
• coughing or a runny nose
• diarrhoea
• unresponsiveness to quiet sounds or other signs of difficulty hearing, such as inattentiveness
• loss of balance

When to seek medical advice

Most cases of otitis media pass within a few days, so there's usually no need to see your GP.

However, see your GP if you or your child have:

• symptoms showing no sign of improvement after two or three days
• a lot of pain
• a discharge of pus or fluid from the ear – some people develop a persistent and painless ear discharge that lasts for many months, known as chronic suppurative otitis media
• an underlying health condition, such as cystic fibrosis or congenital heart disease, which could make complications more likely

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  Acute otitis media

 
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  Acute otitis media, myringitis bullosa

 
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  Myringitis bullosa ininfluenza

 
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  Chronic otitis media (otitis media chronica mesotympanalis)

 
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  Otitis media chronica mesotympanalis

 
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  Otitis media chronica mesotympanalis

 
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  Otitis media chronica mesotympanalis