Otitis media
Otitis media is a group of inflammatory diseases of the middle ear. One of the two main types is acute otitis media, an infection of rapid 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.
The other main type is otitis media with effusion, typically not associated with symptoms, although occasionally a feeling of fullness is described; it is defined as the presence of non-infectious fluid in the middle ear which may persist for weeks or months often after an episode of acute otitis media. Chronic suppurative otitis media is middle ear inflammation that results in a perforated tympanic membrane with discharge from the ear for more than six weeks. It may be a complication of acute otitis media. Pain is rarely present.
All three types of otitis media may be associated with hearing loss. If children with hearing loss due to OME do not learn sign language, it may affect their 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 among indigenous Australians and those who have cleft lip and palate or Down 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, breastfeeding, and avoiding tobacco smoke. The use of pain medications for AOM is important. This may include paracetamol, ibuprofen, benzocaine ear drops, or opioids. In AOM, antibiotics may speed recovery but may result in side effects. 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. The initial antibiotic of choice is typically amoxicillin. In those with frequent infections, surgical placement of tympanostomy tubes may decrease recurrence. In children with otitis media with effusion antibiotics may increase resolution of symptoms, but may cause diarrhoea, vomiting and skin rash.
Worldwide, AOM affects about 11% of people a year. Half the cases involve children less than five years of age and it is more common among males. Of those affected about 4.8% or 31 million develop chronic suppurative otitis media. The total number of people with CSOM is estimated at 65–330 million people. Before the age of ten, OME affects about 80% of children at some point. Otitis media resulted in 3,200 deaths in 2015 – down from 4,900 deaths in 1990.
Signs and symptoms
The primary symptom of acute otitis media is ear pain; other possible symptoms include fever, reduced hearing during periods of illness, tenderness on touch of the skin above the ear, purulent discharge from the ears, irritability, ear blocking sensation and diarrhea. Since an episode of otitis media is usually precipitated by an upper respiratory tract infection, there are often accompanying symptoms like a cough and nasal discharge. One might also experience a feeling of fullness in the ear.Discharge from the ear can be caused by acute otitis media with perforation of the eardrum, chronic suppurative otitis media, tympanostomy tube otorrhea, or acute otitis externa. Trauma, such as a basilar skull fracture, can also lead to cerebrospinal fluid otorrhea due to cerebral spinal drainage from the brain and its covering.
Causes
The common cause of all forms of otitis media is dysfunction of the Eustachian tube. This is usually due to inflammation of the mucous membranes in the nasopharynx, which can be caused by a viral upper respiratory tract infection, strep throat, or possibly by allergies.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 upper respiratory infection can itself be identified as the pathogen causing the infection.
Diagnosis
As its typical symptoms overlap with those of other conditions, such as acute external otitis, symptoms alone are insufficient to predict whether acute otitis media is present; they must be complemented by visualization of the tympanic membrane. Examiners may use a pneumatic otoscope with a rubber bulb attached to assess the mobility of the tympanic membrane. Other methods to diagnose otitis media are with a tympanometry, reflectometry, or a hearing test.In more severe cases, such as those with associated hearing loss or high fever, audiometry, tympanogram, temporal bone CT and MRI can be used to assess for associated complications, such as mastoid effusion, subperiosteal abscess formation, bony destruction, venous thrombosis or meningitis.
Acute otitis media in children with moderate to severe bulging of the tympanic membrane or new onset of otorrhea is not due to external otitis. Also, the diagnosis may be made in children who have mild bulging of the eardrum and a recent onset of ear pain or intense erythema of the eardrum. 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. It is important to attempt to differentiate between acute otitis media and otitis media with effusion, as antibiotics are not recommended for OME. It has been suggested that bulging of the tympanic membrane is the best sign to differentiate AOM from OME, with a bulging of the membrane suggesting AOM rather than OME.
Viral otitis may result in blisters on the external side of the tympanic membrane, which is called bullous myringitis. 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. 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, and Staphylococcus aureus. Worldwide, approximately 11% of the human population is affected by AOM every year, or 709 million cases.Otitis media with effusion
Otitis media with effusion, also known as serous otitis media or secretory otitis media, and colloquially referred to as 'glue ear', is fluid accumulation that can occur in the middle ear and mastoid air cells due to negative pressure produced by dysfunction of the Eustachian tube. This can be associated with a viral upper respiratory infection or bacterial infection such as otitis media. An effusion can cause conductive hearing loss if it interferes with the transmission of vibrations of middle ear bones to the vestibulocochlear nerve complex that are created by sound waves.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. These risk factors increase the incidence and duration of OME during the first two years of life.
Chronic suppurative otitis media
Chronic suppurative otitis media is a long-term middle ear inflammation causing persistent ear discharge due to a perforated eardrum. It often follows an unresolved upper respiratory infection leading to acute otitis media. Prolonged inflammation leads to middle ear swelling, ulceration, perforation, and attempts at repair with granulation tissue and polyps. This can worsen discharge and inflammation, potentially developing into CSOM, often associated with cholesteatoma. Symptoms may include ear discharge or pus seen only on examination. Hearing loss is common. Risk factors include poor eustachian tube function, recurrent ear infections, crowded living, daycare attendance, and certain craniofacial malformations.According to the World Health Organization, CSOM is a primary cause of hearing loss in children. Adults with recurrent episodes of CSOM have a higher risk of developing permanent conductive and sensorineural hearing loss.
About 0.5% of the population develop CSOM each year. In Britain, 0.9% of children and 0.5% of adults have CSOM, with no difference between the sexes. The incidence of CSOM worldwide varies dramatically, where high-income countries having a relatively low prevalence, while in low-income countries the prevalence may be up to three times as great. Each year, 21,000 people worldwide die due to complications of CSOM.
Adhesive otitis media
Adhesive otitis media occurs when a thin retracted eardrum becomes sucked into the middle-ear space and stuck to the ossicles and other bones of the middle ear.Prevention
AOM is far less common in breastfed infants than in formula-fed infants, and the greatest protection is associated with exclusive breastfeeding for the first six months of life. A longer duration of breastfeeding is correlated with a longer protective effect.Pneumococcal conjugate vaccines in early infancy decrease the risk of acute otitis media in healthy infants. PCV is recommended for all children, and, if implemented broadly, PCV would have a significant public health benefit. Influenza vaccination in children appears to reduce rates of AOM by 4% and the use of antibiotics by 11% over 6 months. However, the vaccine resulted in increased adverse effects such as fever and runny nose. The small reduction in AOM may not justify the side effects and inconvenience of influenza vaccination every year for this purpose alone. PCV does not appear to decrease the risk of otitis media when given to high-risk infants or for older children who have previously experienced otitis media.
Risk factors such as season, allergy predisposition and presence of older siblings are known to be determinants of recurrent otitis media and persistent middle-ear effusions. History of recurrence, environmental exposure to tobacco smoke, use of daycare, and lack of breastfeeding have all been associated with increased risk of development, recurrence, and persistent MEE. Pacifier use has been associated with more frequent episodes of AOM.
Long-term antibiotics, while they decrease rates of infection during treatment, have an unknown effect on long-term outcomes such as hearing loss. This method of prevention has been associated with the emergence of undesirable antibiotic-resistant otitic bacteria.
There is moderate evidence that the sugar substitute xylitol may reduce infection rates in healthy children who go to daycare.
Evidence does not support zinc supplementation as an effort to reduce otitis rates except maybe in those with severe malnutrition such as marasmus.
Probiotics do not show evidence of preventing acute otitis media in children.