Otitis Media

Ear: Anatomy

 External or outer ear, consisting of:

 Pinna or auricle. This is the outside part of the ear.
 External auditory canal or tube. This is the tube that connects
the outer ear to the inside or middle ear.
 Tympanic membrane (eardrum). The tympanic membrane divides
the external ear from the middle ear.

 Middle ear (tympanic cavity), consisting of:

Ossicles. Three small bones that are connected and transmit the sound
waves to the inner ear. The bones are called:
 Malleus
 Incus
 Stapes
 Ear: Anatomy

Eustachian tube. A canal that links the middle ear with the
back of the nose. The Eustachian tube helps to equalize the
pressure in the middle ear and equilizes proper sound wave
transfer.
 Inner ear, consisting of:
 Cochlea. This contains the nerves for hearing.
 Vestibule. This contains receptors for balance.
 Semicircular canals. This contains receptors for balance.
 Otitis Media (OM)

 Otitis media (OM) or inflammation of the middle

ear (comprising the middle ear cavity and ossicles;
Its an umbrella term that comprising of Acute OM
(AOM), OM with effusion (OME; ‘glue ear’) and
chronic Supurative OM (CSOM).
 Classification Based on Persistence

 Acute if its duration is less than 3 weeks,

 Subacute when it lasts more than 3 weeks but less than 3

months, and

 Chronic if it lasts more than 3 months

 Definitions based on Signs
 Acute otitis media (AOM):
 Is defined as an acute illness marked by presence of fluid in
middle ear; i.e Middle ear effusion (MEE) and inflammation
of mucosa lining it.

 Children having recurrent episodes causing acute ear pain, fever

and general illness and considerable distress to them and their
parents.

 Suppurative (pus-forming) complications of AOM, including acute

mastoiditis, meningitis and brain abscesses, are rare but potentially
serious complication of AOM.
 Otitis media effusion(OME)
 Otitis Media Effusion (OME)
 Defined as presence of fluid without presence of acute illness and
inflammation. It is Middle ear effusion (MEE) behind an intact
tympanic membrane.

 The main symptom of OME is a conductive hearing loss caused by

impaired transduction of sound waves in the middle ear.

 Recurrence of OME may have a negative impact on language,

behaviour and progress at school.

 OME is very common, with 80% of children having had one or more
episode of OME by 10 years of age.

 OME may occur as new-onset OME after a viral infection or after

AOM, when the inflammatory process subsides and MEE persists.
Chronic Supurative Otitis Media (CSOM)

 AOM along with blockage of Eustachian tube are among the causes
of the Chronic suppurative otitis media.
 Chronic Suppurative Otitis Media (CSOM):
 CSOM is defined as chronic inflammation of the middle ear and mastoid
cavity; persistent or recurrent ear discharge through a non-intact tympanic
membrane perforation or a ventilation tube is the most prominent symptom.

 Causes of TM perforation
 an ear infection.
 an injury to the eardrum, such as a blow to your ear or poking an object like
a cotton bud deep into your ear.
 changes in pressure, such as while flying or scuba diving.
 a sudden loud noise, such as an explosion.
 Fate of CSOM

 The point in time when AOM becomes CSOM is still

controversial.
 “Patients with tympanic perforations with continuously
discharging mucoid material for 6 weeks to 3 months, despite
medical treatment, are recognized as CSOM cases.”

 The WHO definition requires only 2 weeks of otorrhoea

 Although healing is often observed over prolonged periods, there

are more patients who develop either recurrent bouts of
otorrhoea (active CSOM) or a dry but permanent tympanic
perforation (inactive CSOM).
 Epidemiology AOM

 Peak incidence in the first two years of life (esp. 6-12 months)

 Boys more affected girls

 50% of children 1 yr of age will have at least 1 episode.

 1/3 of children will have 3 or more infections by age 3

 90% of children will have at least one infection by age 6.

 Occurs more frequently in the winter months

 Epidemiology

 AOM related complications; pose a threat in low-income

countries

 21,000 people die from complications of OM every year.

 The global prevalence of hearing loss associated with OM is

estimated at 30 per 10,000 individuals
 Predisposing factors of AOM

 Age factors:
 Infants and children are prone to have AOM H. Influenzae
and S. pneumoniae adhere better to the epithelial cells of
infants and children.

 Lower level of cytokines in infants and children nasopharynx

 Breast feeding:
 Nasopharyngeal secretion of infants deprived of breast
feeding poses decreased level of IgA compared to infants with
active breast feeding.
 Mechanism of Colonization of Middle Ear

 Aspiration:
 Negative middle ear pressure induced by sniffing opens the ET and
may induce an aspiration of pathogenic bacteria into the middle ear.

 Injection:
 Another possible way for bacteria to reach the middle ear is by
injection from the nasopharynx when its pressure increases, as
during nose blowing or sneezing.

 Contiguous spreading:
 Facilitated by viruses infecting nasopharynx which leads to
exposure to repeated exposure of bacteria into middle ear.
 Etiological Agents

 In AOM the bacteria found are

 Streptococcus pneumoniae (30-50%)
 Haemophilus influenzae (20-35%)
 Micrococcus catarrhalis/Moraxella catarrhalis (15%–
20%)
 Staphylococcus aureus,

 Note: These are respiratory pathogens that gain access

from nasopharynx into the middle ear through the
Eustachian tube during course of upper respiratory
infections.
 Etiological Agents
In CSOM the bacteria may be
 Facultative anaerobes:
 Pseudomonas aeruginosa,
 Escherichia coli,
 S. aureus,
 Streptococcus pyogenes,
 Proteus mirabilis,
 Klebsiella species or

 Anaerobes
 Bacteroides,
 Peptostreptococcus,
 Proprionibacterium

 These bacteria may then gain entry to the middle ear through a chronic
perforation. Among these bacteria, P. aeruginosa has been particularly blamed for
the deep-seated and progressive destruction of middle ear and mastoid structures
through its toxins and enzymes.
 Pathogenesis: Acute OM
 The patient has an antecedent event (usually an upper
respiratory viral infection)

 Results in congestion of the respiratory mucosa of the

upper respiratory tract, (nasopharynx and eustachian tube)

 Results in obstruction of the tube; negative middle ear

pressure develops

 Prolonged state leads “aspiration” of potential pathogens

(viruses and bacteria) from the nasopharynx into the
middle ear.

 Clearance of the middle ear effusion caused by the

infection is impaired, and fluid accumulates in the middle
ear;

 Proliferation of microbials in the secretions, resulting in a

suppurative and symptomatic otitis media.
 Sign and Symptoms AOM

 Crying.
 irritability.
 sleeplessness.
 pulling on the ears.
 ear pain.
 a headache.
 neck pain.
 a feeling of fullness in the ear.
 Pathogenesis: CSOM

 First pathway: when the tympanic membrane is not intact, bacteria from the
nasopharynx can gain access to the middle ear through reflux of
nasopharyngeal secretions, especially when there is inflammation (secondary
to infection or possible allergy) of the nose, nasopharynx or paranasal sinuses,
through the eustachian tube, because the middle ear gas cushion is lost.

 In most instances these bacteria are initially the same as those isolated
when acute otitis occurs behind an intact tympanic membrane, such as S.
pneumoniae and Haemophilus influenzae, and when acute otorrhea develops
when tympanostomy tubes are in place.

 After the acute otorrhea, Pseudomonas aeruginosa, Staphylococcus

aureus and other organisms from the external ear canal enter the middle ear
through the non intact tympanic membrane.
 Pathogenesis: CSOM

 The second common way in which chronic otitis media

occurs is by contamination of the middle ear cleft from
organisms (e.g. P. aeruginosa) that are present in water that
enters through the nonintact eardrum during bathing and
swimming.
 Tubo-tympanic CSOM Vs Atticoantral
CSOM
 Tubo-tympanic CSOM:
 Middle ear cleft inflammation characterized by intermittent episodes of
profuse mucopurulent otorrhea
 There will be gradual conductive hearing loss
 Occurs during episodes of Upper respiratory tract infectintion when ascends
through Eustachian tube and infect entire middle ear cleft

 Atticoantral CSOM
 Middle ear inflammation characterized by cholesteatoma formation inside the
ear
 Potentially fatal complications may occur
 Occur due to persistent middle ear negative pressure indrawing skin
 Subsequent growth in middle ear may have bone eroding capacity
 The fatal complications comprise of intra temporal and intracranial conditions
as; Facial nerve palsy, Labyrinthitis, Meningitis Brain abscess etc.
 Diagnosis of Otitis media

Presence of fluid in middle ear:

 Pneumatic otoscopy, technique that permits
an assessment of the mobility of tympanic
membrane.

Interpretation:
 Normal: tympanic membrane moves rapidly
inward when positive pressure applied in
rubber bulb, and membrane move outward
with release of bulb (Negative pressure)

 Fluid or negative pressure in the middle ear

decrease mobility of tympani membrane.
 Laboratory Diagnosis

Specimen:
 Ear swab or drainage
 Collected by placing a cotton swab
gently in the ear canal. The sample is
sent to the laboratory for testing to
isolate and identify the type of organism
causing the ear infection.

 Tympanocentesis,
 A needle aspiration of the middle ear
effusion, for establishing the presence or
absence of an effusion and for
microbiologic study.
 Colonial and Biochemical features
(Pseudomonas aeruginosa)
 P. aeruginosa; Oxidase Positive
 Treatment

 AOM:
Antibiotic of choice;
 Initial treatment: Amoxycillin

 For beta lactamase producing strains of H. influenza & M.

catarrhalis
 Amoxycillin-clavulanate,
 Cotrimoxiazole,
 Macrolides (azithromycin, Clarithromycin)
 Cephalosporins (Cefaclor, Cefixime, Cefpodoxime, Ceftriaxone
etc.
 Treatment: CSOM

 CSOM is a chronic and often poly-microbial (involving more

than one micro‐organism) infection of the middle ear. Broad‐
spectrum antibiotics such as second‐generation quinolones
and aminoglycosides, which are active against the most
frequently cultured micro‐organisms (Pseudomonas
aeruginosa and Staphylococcus aureus), are therefore
commonly used
CSOM: Treatment (Pseudomonas aeruginosa)
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