Otitis Media

Some of the percentages in this presentation

may not reflect current thinking. Please see accompanying
Article.
 Otitis Media
Definition
This is infection and inflammation of the tympanic cavity
(middle ear) and often occurs as a sequelae of an RTI.

Aetiology

(1) Congenital malformation of the pharyngotympanic ( ie

auditory or Eustachian) tube.

(2) a cold or allergy or other respiratory illnesses esp URTI

Otitis Media
Anatomy
 Otitis Media
Common Pathogens

A. Streptococcus Pneumoniae
1. Incidence : 38%
2. Beta lactamase producing : 15-25%
B. Hemophilus Influenzae
1. Incidence : 27%
2. Beta lactamase producing : 35%
C. Moraxella catarrhalis
1. Incidence : 10%
2. Beta lactamase producing : 85- 100%
D. Group A- Beta Hemolytic Streptococcus
1. Incidence : 3%
E. Staphylococcus aureus
1. Incidence : 2%
 Otitis Media
Classification

Acute Otitis Media (AOM) -

the middle ear infection occurs abruptly causing swelling and
redness. Fluid and mucous become trapped inside the ear
leading to a fever, ear pain and hearing loss.

Otitis Media with effusion (OME) -

fluid and mucous continue to accumulate in the middle ear after
an initial infection subsides. The patient may experience a
feeling of fullness in the ear and hearing loss.
 Otitis Media
Epidemiology

- incidence of infection is 62% by 1 y.o. and 83% by 3 y.o.

- average of 1.5 AOM episodes per year.
- can affect adults but primarily a condition in children
- most common diagnosis in children in the USA.
- equivalent to about 30 million visits to the ped. per year
- occurs most often < 7 y.o. & esp. between 6 mths and 3 years

- more common in boys than girls

 Otitis Media
Epidemiology con’t

- more common in boys than girls

- more often in winter and early spring

- in USA 3-4 billion dollars spent each year on care of patients
- mortality is rare
- recurrences of AOM relatively common
- race : more frequent in Inuit American Indians than others
- less common in groups with high rates of breast feeding
 Otitis Media
Risk Factors

- Age < 5 yrs ( 5 fold relative risk)

- Day care setting (4x)
- respiratory illness (4x)
- smokers in home (3x)
- bottle propped babies (2x)
- males (2x)
- pacifiers
- family history of ear infections
- poor immune system
- absence of breastfeeding
- AOM in first year of life is a risk factor for recurrent AOM
- otitis prone patients ( see below)
 Otitis Media
Otitis Prone Patients

- age at first episode of OM < 6 yrs

- > 3 episodes in the last 6 mths
- Race : Native American -higher incidence
: African American - lower incidence
- sibling history of frequent ear infections
- Down’s syndrome
- cleft palate
- immune deficiency
 Otitis Media
Pathophysiology

- Antecedent Event : URI - bacterial, or viral and /or sec

bacterial.
- Congestion of resp. mucosa
- Obstruction : isthmus - narrowest part of tube
- Increased tube -ve pressure due to the absorption of the air by
the middle ear mucosa into the mastoid air cells
- Development of effusion (serum pulled in)
- Effusion colonization (fertile medium for microbial growth)
- rapid growth causes infection
- persistent infection and inflammatory rxn causes perforation
of the tympanic membrane or extension into the adjacent
mastoid air cells.
 Otitis Media
Clinical Features

- unusual irritability
- difficulty sleeping or staying asleep
- tugging or pulling at one or both ears
- fever
- fluid draining from ear(s)
- loss of balance
- hearing difficulties
- ear pain (otalgia)
- nausea and vomiting
- diarrhea
- decreased appetite
- congestion
- URTI
 Otitis Media
Diagnosis

-Complete medical history and examination

- special attention paid to examination of the outer ear(s) and

eardrum(s) using an otoscope
- Pneumatic otoscope may be used to blow a puff of air into
the ear to test the movement of the eardrum.
- tympanometry to test middle ear functioning- difficult to
perform younger children because child must remain still and
not cry ,talk, or move.
- NB: may need to remove cerumen (earwax) by irrigation or
with soft plastic curettes.
 Otitis Media
See accompanying article for results of a recent study
with respect to these figures

A. Ear pain (otalgia) - (40 - 60 %

1. Predicts < 50% of OM
2. Predicts 80% of OM in presence of URTI
3. Only 12% of children pulling ear have OM
4. Other causes of otalgia : URTI, cerumen impaction, sterile
effusion

B. Rhinitis (90%)
C. cough (78%)
D. constitutional symptoms ( 60- 80%) : poor appetite, irritable
E. Low-grade fever (22 - 69% ) - temp under 101 F for <24 hrs
F. Difficulty sleeping in infants (35- 50%)
 Otitis Media
Diagnosis con’t

G. ear drainage (5%)

1. Liquefied cerumen from fever or
2. Pus from perforated tympanic membrane

H. unilateral hearing loss

I. URI -incidence of OM after 5 days of URI - 40%

 Otitis Media
Diagnosis con’t

Tympanic membrane findings by otoscopy:

A. Color
1. Cloudy opacified tympanic membrane - PPV-80%
2. Red tympanic membrane
(a) multiple causes (non specific findings)
- crying
- viral illness
(b) positive predictive value
1. Distinctly red TM : 65%
2. Slightly red TM : 16%
 Otitis Media
Diagnosis con’t

B. Position

1. TM bulging- PPV- 89%

-first occurs in posterior-superior quadrant
-TM most compliant in posterior-superior quadrant

2. Loss of landmarks (cannot see umbo)- 80% PPV

3. Light reflex may be absent from bulging TM

 Otitis Media
Diagnosis con’t

C. Mobility

1. TM immobile by pneumatic otoscopy - PPV-78%

2. Tympanometry
(a) normal tympanogram suggets no AOM
(b) middle ear effusion - test sensitivity - 90%
- test specificity - 80%
- neg. predictive value -77%
 Otitis Media
Diagnosis con’t

Normal TM TM with AOM

 Otitis Media
Differential Diagnosis

Brain abscess mastoiditis

Dysbarism otitis externa

foreign bodies in ear peritonsillar abscess

herpes zoster sinusitis

herpes zoster oticus labyrinthitis

 Otitis Media
Other problems to be considered :

-Co-existent conjunctivitis
-acute hearing loss
-tympanoslerosis
-erythema caused by crying
-pain referred from the teeth or jaw
-bullous myringitis
-parotitis (ie mumps)
-cavernous sinus thrombosis
 Otitis Media
Investigations

-WBC may increase due to infection

-blood culture is +ve in 3% of febrile patients with AOM

-tympanometry ( especially in difficult examinations)

-nasopharyngoscopy to define anatomic factors eg @ the

eustachian tube opening

-tympanocentesis with needle & syringe in immunocompromised

pt or one with persistent fever
 Otitis Media
Management

Drugs

A.Antibiotics
Check most recent resources on net and discuss with
consultant
 Otitis Media
Management

B. Analgesics
 Otitis Media
Management con’t

3. Myringotomy for patients with intractable pain or chronic OM

and use of ventilation tubes (grommets) for drainage and
aeration
 Otitis Media
Complications

A. Intracranial B. Extracranial
1. Meningitis 1. Hearing loss

2. Subdural empyema 2. Chronic suppurative OM

3. Brain abscess 3. TM perforation

4. Lateral sinus thrombosis 4. Mastoiditis

5. Focal otitis encephalitis 5. cholesteatoma

6. Facial nerve paralysis
7. Tympanosclerosis
8. Labyrinthitis
 Otitis Media
Prognosis

Excellent with early and effective treatment but patients must be

encouraged to finish prescribed medication and to keep follow-
up appointments.

Symptoms usually improve within 24hrs and almost always

within 48 - 72 hrs.

Patient education has proved to be beneficial in reducing the

incidence of recurrence of OM
 Otitis Media
Medical/Legal Pitfalls

Failure to diagnose meningitis with associated OM can lead to

inadequate treatment and possible legal implications for the
provider.

Therefore further diagnostic work must be done to eliminate

these possible pitfalls.