Otitis media
1. Otitis
media is a group of inflammatory diseases of the middle ear. There are two main types - acute
variety and chronic category. In Acute there is “acute otitis
media (in short- AOM )”, and “otitis media with effusion (in
short- OME )”. In chronic variety there lies“ chronic otitis media ( in short
–CSOM)”. AOM is an infection of abrupt onset that usually
presents with ear pain, decreased appetite -eating and fever may
also be present. OME is typically not associated with these symptoms, occasionally
only a feeling of fullness is described. OME is defined as the presence of
non-infectious fluid in the middle ear for more than three months. Chronic
suppurative otitis media ( in short -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. All
three (AOM, OME, CSOM) may be associated with hearing loss. The cause of AOM is related
to anatomy and immune function. Either bacteria or viruses may
be involved. OME frequently occurs following AOM and may be related to viral upper
respiratory infections, irritants, 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, recent discharge also indicates the diagnosis of AOM.
2. A number of
measures decrease the risk of otitis media including pneumococcal and influenza vaccination, and avoiding
smoke. In OME antibiotics do not
generally get speedy recovery. The use of pain medications for AOM may include paracetamol (acetaminophen), 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. 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.
Signs and
symptoms
3. An integral
symptom of AOM is ear pain other possible
symptoms include fever, and irritability .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.
Mechanism of
occurrence of discharge - pathophysiology
4. When an
infection attacks the upper respiratory tract(URTI) the infection from the
Nasopharynx / Oropharynx (Throat/Nose) climbs-up to the Eustachian tube(
I,e.the tube connecting the throat, back of nose to the ear). Because of this
infection the Eustachian tube gets blocked and the gasses inside the middle ear
get’s absorbed into the tissues , thereby creating negative pressure ,and
accumulation of fluid in the middle ear. This fluid may or may not get infected
.When it gets infected it results into PUS (SLIDE A, B) . The pus creates pressure over the tympanic membrane, it
therefore bulges outwards ( SLIDE C). The bulging of tympanic membrane makes it
vulnerable to and the blood supply to the tympanic membrane gets
strangulated-cutting down the blood supply,(SLIDE D) leading to avascular
necrosis in a portion of the tympanic membrane- thus creating PERFORATION in
the tympanic membrane called ‘SPONTANEOUS PERFORATION”(SLIDE E). This
perforation allows the fluid/ infected fluid to flow out into external ear in
form of a DISCHARGE. Thus a discharge from the ear
precedes in AOM -acute otitis media with perforation of the ear drum . Other
conditions with ear discharge are:- CSOM- chronic suppurative otitis media,
tympanostomy tube otorrhea, or accompanying inflammation of the external ear -
acute otitis externa.
Slide A : diagrammatic
representation of the ear anatomy and pus in the middle ear.
Slide B – Diagrammatic
representation depicting the three parts of the ear viz external, middle and
internal ear, with inflammation, fluid accumulation of the middle ear.
Slide C : Bulging of tympanic
membrane due to accumulation of fluid in middle ear- acute otitis media- suppurative.
Slide D : depicting bulging leading
to avascular necrosis, just prior to perforation.
Slide E : Slide depicting the small central perforation.
5. 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.
Diagnosis
6. 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. Examiners use a
pneumatic otoscope with a rubber bulb attached to assess the mobility of the
tympanic membrane.
7. Acute otitis
media in children with moderate to severe bulging of the tympanic membrane or
new onset of otorrhea - drainage. 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.
8. 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 (OME), as antibiotics are not recommend
for OME. It has been suggested that bulging of the tympanic membrane is
the best sign to differentiate AOM from OME.
9. 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 /
a wire loop/ swab holder.
Acute otitis media
10.
The most common bacteria isolated from the middle ear in AOM
are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus.
Chronic suppurative otitis media
11.
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. Hearing impairment often accompanies this disease.
Prevention
12.
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 (MEE). 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. Thus, cessation of smoking in the home should be
encouraged, daycare attendance should be avoided or daycare facilities with the
fewest attendees should be recommended, avoidance of nose blowing/sniffing.
Management
13.
Oral and topical pain killers are effective to treat the
pain caused by otitis media. Oral agents include ibuprofen, paracetamol (acetaminophen), and opiates. Topical agents shown to be effective
include antipyrine
and benzocaine ear drops. Half of cases of ear pain resolves without treatment in
three days and 90% resolves in seven or eight days.
Antibiotics
14.
It is important to weigh the benefits and harms before using
antibiotics for acute otitis media. As over 80% of acute episodes settle without
treatment, about 20 % must be treated to prevent one case of ear pain, 33 % to
prevent one perforation, and 11 % to
prevent one opposite-side ear infection. For every 14 %patient treated with
antibiotics, one has an episode of either vomiting, diarrhea or a rash. If
pain is present, treatment to reduce it should be initiated.
15.
Antibiotics should be prescribed for severe bilateral or
unilateral disease in all patients with severe signs and symptoms, such as
moderate to severe ear pain and high fever.
16.
When non-severe unilateral acute otitis media is diagnosed either
antibiotic therapy is given or observation with close follow-up based on joint
decision making between parent(s)/caregiver.
17.Patients with
non-severe disease can have either antibiotics or observation.
18.
The first line antibiotic treatment, if warranted, is amoxicillin. If there is resistance or
use of amoxicillin in the last 30 days then amoxicillin-clavulanate or another
penicillin derivative plus beta lactamase inhibitor is recommended. Taking
amoxicillin once a day may be as effective as twice or three times a day.
While less than 7 days of antibiotics have less side effects, more than seven
days appear to be more effective. If there is no improvement after
2–3 days of treatment a change in therapy may be considered.
Outcomes-Complications
19.
Complications of acute otitis media consists of perforation of the
ear drum, infection of the mastoid space behind the ear (mastoiditis), and more rarely intracranial
complications can occur, such as bacterial meningitis, brain abscess, or dural sinus thrombosis. It
is estimated that each year 21,000 people die due to complications of otitis
media.
Membrane
rupture
20.
In severe or untreated cases, the tympanic membrane may perforate,
allowing the pus in the middle-ear space to drain into
the ear canal. If there is enough, this drainage may
be obvious. The perforation of the tympanic membrane is almost always
associated with a dramatic relief of pressure and pain. In a simple case of
acute otitis media in an otherwise healthy person, the body's defenses are
likely to resolve the infection and the ear
drum nearly always heals. An option for severe AOM -acute otitis media in which
analgesics are not controlling ear pain is to perform a tympanocentesis, i.e.,
needle aspiration through the tympanic membrane to relieve the ear pain and to
identify the causative organism(s).
Hearing loss
21.
Patients with recurrent episodes of AOM-acute otitis media and those with OME-otitis
media with effusion or CSOM-chronic suppurative otitis media have higher risks
of developing conductive and sensorineural
hearing loss. Globally approximately 141 million people have
mild hearing loss due to otitis media (2.1% of the population). This
is more common in males (2.3%) than females (1.8%).
22.
This hearing loss is mainly due to fluid in the middle ear or
rupture of the tympanic membrane. Prolonged duration of otitis media is
associated with ossicular complications and, together with persistent tympanic
membrane perforation, contributes to the severity of the disease and hearing
loss. When a cholesteatoma or granulation tissue is present in the middle ear,
the degree of hearing loss and ossicular destruction is even greater.
23.
Periods of conductive hearing loss from otitis media may have a
detrimental effect. Some studies have linked otitis media to learning
problems, attention disorders, and problems with social
adaptation. Furthermore, it has been demonstrated that patients
with otitis media have more depression/anxiety-related disorders compared to
individuals with normal hearing. Once the infections resolve and hearing
thresholds return to normal, childhood otitis media may still cause minor and
irreversible damage to the middle ear and cochlea.
Epidemiology
24.
Acute otitis media is very common in childhood. It is the most
common condition for which medical care is provided in children under five
years of age, which at times has relapsing phenomenon linked to in adulthood. Acute
otitis media affects 11% of people each year (709 million cases) with half
occurring in those below five years. Chronic suppurative otitis media
affects about 5% or 31 million of these cases with 22.6% of cases occurring
annually under the age of five years. Otitis media resulted in 2,400
deaths in 2013 — down from 4,900 deaths in 1990.
Etymology
Otitis
media is Latin for "inflammation of the middle
ear"
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