3.2 Otitis Media
3.2.1 Acute Otitis Media
Key Features
Acute otitis media occurs when there is a bulging tympanic membrane with middle ear fluid.
It is one of the most common childhood illnesses.
It may be accompanied by hearing loss, nausea, vomiting, otorrhea, and fever.
First-line treatment is amoxicillin. Watchful waiting is advocated in some patients.
Acute otitis media (AOM) is defined as middle ear inflammation lasting up to 3 weeks, accompanied by pain and bulging tympanic membrane (TM). Severe cases of AOM can be associated with high fever (≤ 39°C). The TM can spontaneously rupture, and purulent otorrhea can occur. AOM should be differentiated from otitis media with effusion (also known as serous otitis media), mucoid otitis media (“glue” ear), and chronic otitis media. The mainstay of treatment is oral antibiotics, but some children with recurrent AOM or complications associated with AOM may require surgical management with tympanostomy tubes.
Epidemiology
Sixty percent of all children under the age of one year will suffer at least one episode of AOM. That percentage increases to 85% by age 3. In children less than 10 years, AOM accounts for up to 20% of all clinic visits. Risk factors associated with AOM are daycare attendance, exposure to secondhand smoke, food or environmental allergies, and chronic rhinitis. Children between 3 and 18 months of age are the most susceptible.
Clinical
Signs
The most important diagnostic feature for AOM is a bulging or full and opaque TM associated with middle ear effusion. A ruptured TM can present with purulent otorrhea. If acute mastoiditis is present, the postauricular region may also be erythematous and edematous; the auricle may also protrude anteriorly. Fever can also occur.
Symptoms
AOM is more common in children than in adults. It can present with otalgia, otorrhea, irritability, fever, nausea, vomiting, and feeding difficulties. Children may also tug on the ear. Hearing loss, ear fullness, and tinnitus can also be present. An upper respiratory tract infection may precede onset of AOM.
Differential Diagnosis
The differential diagnosis of AOM is a differential diagnosis for ear pain. Temporomandibular joint disease is a common cause of referred otalgia in adults. Other conditions include herpes zoster oticus, primary temporal bone malignancy, referred pain from other head and neck malignancies, nasopharyngeal mass causing auditory (eustachian) tube obstruction, cerumen impaction, cholesteatoma, otitis externa, mastoiditis, and foreign body. A common cause of otalgia in children is AOM; however, other pediatric causes include otitis externa, ear canal trauma, mastoiditis, and ear canal foreign body. It is important to differentiate AOM with otitis media with effusion (middle ear fluid without infection).
Evaluation Physical Exam
The most important portion of the physical exam is inspecting the TM. The auricle and the external canal remain normal in appearance and are not tender to palpation.
The appearance of the TM will change as the disease process follows its usual course. Initially, the TM is engorged and hyperemic. The hyperemia is most prominent along the manubrium of the malleus and the periphery of the drum. The TM is sluggish to pneumatic otoscopy, but all normal topographic landmarks are visible. As the infection progresses and the middle ear fills with purulence, the TM thickens, bulges, and loses normal landmarks. There may be erythema, tenderness, and edema in the postauricular region, especially in small children. A tuning fork examination can demonstrate conductive hearing loss pattern.
If the infection progresses, the TM perforates in the pars tensa, and the patient experiences a resolution of pain and fever. If purulence is seen in the external canal, then cultures should be obtained. If the perforation heals and purulence reaccumulates, the infection may spread through the antrum into the mastoid; the mastoid trabeculae may begin to decalcify, leading to coalescent mastoiditis along with other complications. At this stage, the auricle displaces from the skull as postauricular edema increases. It is important to differentiate this from a severe otitis externa with painful cellulitis and swelling of the auricle.
Imaging
Imaging is usually not indicated unless coalescent mastoiditis or another complication of AOM is suspected. If a complication is suspected, a fine-cut temporal bone computed tomography (CT) scan is indicated.
Labs
Labs are rarely needed to treat routine AOM. Leukocytosis may be seen on complete blood count (CBC). Cultures can be obtained if the ear is draining, especially in infants less than 6 weeks of age. Routine tympanocentesis is not indicated in AOM but may be informative in patients who are immunocompromised or when suspicion for resistant or atypical pathogen is high.
Other Tests
An audiogram is not needed in the acute phase but can be helpful in evaluating children with recurrent AOM, especially in light of other cognitive delays. In cases where the presence of an effusion is in question, tympanograms will show low-volume flat (type B) or negative pressure (type C). Occasionally, the combination of a good pneumatic exam and an accurate tympanogram are needed to determine the presence of an effusion, even for an experienced otologist. Nasopharyngoscopy to evaluate for nasopharyngeal mass and auditory tube obstruction should be performed in adults with persistent unilateral middle ear effusion.
Pathology
Most commonly, AOM is caused by bacteria that gain entry into the middle ear cleft through the auditory tube. Infants are at higher risk for developing AOM because the auditory tubes are short and horizontal and feeding often occurs in the reclined position. As children grow, the auditory tubes become longer and more vertical, and the incidence of AOM declines. Other factors that contribute to AOM include allergic rhinitis, recurrent adenoiditis, adenoid (pharyngeal tonsil) hypertrophy, cleft palate, and immunodeficiency.
AOM in adults, especially if unilateral, may be ominous. The nasopharynx must be fully evaluated to identify the cause of the auditory tube blockage or dysfunction. A nasopharyngeal mass must be ruled out prior to attributing the cause to upper respiratory tract infection, allergic rhinitis, or recent flight.
Historically, the most common bacterial pathogens causing AOM have been Streptococcus pneumoniae (40–50%), nontypeable Haemophilus influenzae (20–30%), and Moraxella catarrhalis (10–15%). Vaccination with pneumococcal 13-valent conjugate vaccination (PCV13) can protect against many strains causing AOM. However, alterations in penicillin-binding proteins in S. pneumoniae and H. influenzae have increased the incidence of antibiotic resistance.
Histologically, middle ears display signs of inflammation and edema. The TM and middle ear mucosa are thickened and engorged with an inflammatory infiltrate. There is often frank purulence in the middle ear space.
Treatment Options
Medical
There has been a trend toward withholding antibiotic treatment and advocating “watchful waiting” for 72 hours in children with uncomplicated AOM (< 24 months with unilateral AOM or ≥ 24 months with unilateral or bilateral disease). Pain is treated symptomatically. If AOM persists for more than 72 hours, the first-line antibiotic is amoxicillin (80 to 90 mg/kg/day) because it is effective, well tolerated, and inexpensive. A beta-lactamase antibiotic should be prescribed if there is a history of AOM within the last month, failed amoxicillin initial therapy, or conjunctivitis. If patients are penicillin-allergic, second- or third-generation cephalosporins, macrolides, or clindamycin are all options. Breastfeeding for initial 6 months of life, pneumococcal conjugate vaccine, and annual influenza vaccination can help prevent AOM. Reducing risk factors such as secondhand smoke exposure and daycare may also prevent AOM.
Otitis media with effusion (OME, also referred to as serous otitis media and nonsuppurative otitis media) is defined as the presence of middle ear fluid without signs or symptoms of acute ear infection. OME can occur after an episode of AOM; 75% of children with OME following AOM resolve by 3 months. When OME does not resolve spontaneously within 3 months, tympanostomy tubes should be offered.
Surgical
In patients in whom empiric therapy has failed, diagnostic tympanocentesis may be done for culture. Removing the fluid from the middle ear may also relieve pain. Tympanostomy tube placement may be offered if AOM is recurrent, which is defined as 3 episodes of AOM in the last 6 months or >4 episodes of AOM in the past 1 year. Tympanostomy tubes with adenoidectomy are recommended in children ≥ 4 years of age for OME lasting more than 3 months. For children < 4 years of age, adenoidectomy is performed only when there is nasal obstruction and chronic adenoiditis.
Complications
Complications of tube placement include otorrhea, conductive hearing loss, retained tubes, cholesteatoma, and postextrusion TM perforations. Posttympanostomy otorrhea occurs in 10% of patients and is treated with appropriate ototopical drops (i.e., fluoroquinolones, as they are not ototoxic). Most tubes will extrude spontaneously; however, removal of the tube may be necessary. TM perforations are estimated to occur 3 to 5% of the time and are followed conservatively. If they persist or cause considerable hearing loss, tympanoplasty may be recommended.
Outcome and Follow-Up
Children with tympanostomy tubes require little postoperative care, and physician preference is usually the driving force determining postoperative recommendations. Many otolaryngologists advocate the use of 5 days of antibiotic topical drops twice daily, such as Ciprodex (Alcon Laboratories, Fort Worth, TX) or Floxin Otic (Daiichi Pharmaceutical Corporation, Montvale, NJ), postoperatively only to children with mucoid or purulent effusions found at the time of tube placement. Many otolaryngologists also recommend ear plugs for children only when swimming in fresh water and not during bath or shower time. The children are otherwise followed with a postoperative audiogram and interval visits at 6 to 12 months until the tubes extrude.
3.2.2 Chronic Otitis Media
Key Features
Chronic otitis media is long-term inflammation or infection affecting the middle ear space.
Chronic otitis media may present with tympanic membrane perforation with otorrhea, retracted tympanic membrane with middle ear fluid, and cholesteatoma.
The goal of medical and surgical treatment is to create a dry, safe ear.
Chronic otitis media (COM) comprises several long-term inflammatory or infectious disease processes that affect the middle ear. It can occur with or without a tympanic membrane perforation, cholesteatoma, and active drainage. When middle ear fluid exists, it may be serous (“chronic serous otitis media” or “chronic otitis media with effusion”) or thick (“chronic mucoid otitis media”). Purulent drainage through a tympanic membrane (TM) perforation is often referred to as “chronic suppurative otitis media.” COM can also be associated with retracted TM, granulation tissue, polyps, and ossicular erosion. Conductive hearing and otorrhea are common occurrences. Chronic auditory (eustachian) tube dysfunction can be the underlying cause in many patients. Treatment can include medical and surgical options.
Epidemiology
The epidemiology of COM is not well defined. It affects males and females equally; however, there is a preference for certain populations: Native Americans, American Eskimos, and Australian Aborigines.
Clinical
Signs
Signs of COM include perforated or retracted tympanic membrane, middle ear fluid, otorrhea, polypoid granulation tissue, ossicular erosion, and cholesteatoma. In patients with severe infection or cholesteatoma, facial palsy, nystagmus, or signs of meningitis can be seen in severe cases.
Symptoms
Symptomatology is broad and depends on the nature of the COM. Common symptoms include chronic or intermittent painless otorrhea and hearing loss. When COM is associated with cholesteatoma or severe infection, the otic capsule may be breached and sensorineural hearing loss, tinnitus, vertigo, dizziness, and imbalance can occur. The facial nerve can be involved, and facial droop may be reported. In severe cases, meningitis can occur and patients will present with altered mental status, fever, headache, and stiff neck. A chronic history of sinus disease and auditory tube dysfunction may also be elicited.
Differential Diagnosis
The differential diagnoses for chronic otorrhea and TM perforation are foreign body, temporal bone malignancy, Wegener′s granulomatosis, and tuberculosis. Persistent polypoid tissue after medical treatment necessitates a biopsy. Wegener′s granulomatosis may present as COM with fluctuating hearing loss and cranial nerve palsy without a previous history of OM. Tuberculous otitis media should be considered in a draining ear that does not improve despite maximal medical and surgical treatment. The classic description of tuberculous otitis media is painless otorrhea with multiple TM perforations.
Evaluation
Physical Exam
A focused head and neck examination is performed, concentrating primarily on the otologic exam. The external auditory canal may be filled with moist debris that requires meticulous cleaning; at times, medical treatment of an inflamed ear canal is necessary to be able to visualize the TM. The TM should be inspected for retraction (e.g., myringoincudostapediopexy), bulging, perforation, cholesteatoma, and granulation tissue. Debris and granulation tissue should be cleaned thoroughly with an otomicroscope. Abnormal tissue can be sent to pathology for review. The presence of middle ear fluid should be evaluated with pneumatic otoscopy. A tuning fork exam can indicate presence of conductive hearing loss. Cranial nerve examination, particularly the facial nerve (CN VII), should be performed. A nasopharyngoscopy is recommended when there is unilateral COM with effusion in an adult patient in order to rule out nasopharyngeal mass.
Imaging
When COM is associated with cholesteatoma or intracranial or intratemporal complications, high-resolution computed tomography (CT) imaging of the temporal bones is recommended. Additional imaging such as magnetic resonance imaging (MRI) of the brain with and without gadolinium contrast is necessary when there are intracranial complications of COM. Uncomplicated COM may not require imaging.
Labs
Otorrhea, especially if recalcitrant to empiric therapy, should be cultured. Aerobic and fungal cultures are routinely sent. Additional blood work is rarely indicated. If the onset of symptoms is bilateral, recent, and accompanied by fluctuating hearing loss or cranial nerve palsy, then c-ANCA (cytoplasmic anti–neutrophil cytoplasmic autoantibody) is ordered to rule out Wegener′s granulomatosis.
Other Tests
An audiogram is obtained once the ear is dry and prior to any surgical intervention. A conductive hearing loss is expected, and a mixed loss is not uncommon. Any granulation retrieved from the ear is sent to pathology to rule out malignancy.
Pathology
Historically, the most common pathogens were Pseudomonas aeruginosa and Proteus. Today, the most common pathogen is methicillin-resistant Staphylococcus aureus (MRSA). Pathogens gain access to the middle ear through the perforated TM. They then spread from the middle ear to the mastoid process. These same pathogens can also colonize the avascular debris collecting within a cholesteatoma. The middle ear mucosa becomes thick, fibrotic, and infiltrated with inflammatory cells. Mucosal edema leads to polyp formation and granulation. Bony vascular channels embolize secondary to chronic inflammation, leading to bone erosion, particularly involving the ossicular chain. Cholesteatoma may erode bone by additional local inflammatory response and osteolytic enzymes.
Treatment Options
The goals of treatment are elimination of infection and restoration of function. The primary goal is to restore a “safe and dry ear.”
Medical
COM may be initially treated with empiric ototopical antibiotic drops. Awareness of ototoxicity has made fluoroquinolone drops the preferred method of treatment. Ototopical drops reach the middle ear in such high concentrations that resistance is rarely an issue. See Table 3.4 for topical treatment options. If the drainage does not respond, then cultures are indicated to rule out a resistant strain such as MRSA or a fungal infection. Vinegar washes or 2% acetic acid drops may be effective. There are several topical powders that also may periodically be applied if drops do not work. One such mixture includes ciprofloxacin, boric acid, dexamethasone, and fluconazole. Appropriate long-term IV antibiotics may also be indicated if an osteitis is suspected. Another effective topical powder preparation to help dry the chronically draining ear that is unresponsive to drops consists of chloramphenicol 50 mg, p-aminobenzenesulfonamide 50 mg, and amphotericin 5 mg, with or without hydrocortisone 1 mg; this is mixed and delivered in 1 or 2 puffs via a powder insufflator (e.g., Sheehy–House insufflator Otomed, Grace Medical, Memphis, TN) twice daily. Another option for office management is aqueous gentian violet, which has antifungal properties and may be “painted” over inflamed areas under the otomicroscope.
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