Understanding Acute Otitis Media

The middle ear infection or acute otitis media is highly prevalent in children between the age of 6–24 months [1]. Although this infection can impact individuals of any age group, 80–90% of school-going children are diagnosed with this condition at least once in their lifetime [1].

The following bacterial pathogens are known to cause acute otitis media.

1. Streptococcus pneumoniae

2. Nontypeable Haemophilus influenzae (NTHi)

3. Moraxella catarrhalis (Branhamella)

Similarly, the following virus types can potentially trigger otitis media in children or adults.

1. Picornaviruses

2. Human metapneumovirus

3. Adenoviruses

4. Influenza viruses

5. Coronaviruses

6. Respiratory syncytial virus

7. Adenoviruses

8. Rhinoviruses

The occurrence of one or more of the following conditions increases the risk and incidence of acute otitis media, majorly in children.

1. Family history of recurrent otitis media

2. Underprivileged/low socioeconomic status

3. Exposure to smoke

4. Absence of breastfeeding 

5. Allergic conditions

6. Deficiency of vitamin A

7. Cochlear implants

8. Ciliary dysfunction

9. Genetic causes

10. Immunocompromised state

Clinical presentation

Patients suspected of acute otitis media can present with one or more of the following signs/symptoms [2, 3].

1. Low-grade fever, secondary to infection

2. Pulsating ear pain with high severity

3. Excessive ear pulling  

4. Irritability/restlessness  

5. Discharge of pus from the ear

6. Sleep disturbance

7. Poor feeding/anorexia

8. Headache

9. Hearing loss (in the elderly)

The discharge of pus from the ear is followed by the rupture of the tympanic membrane due to elevated middle ear pressure. The pain gradually subsides after the discharge of pus and subsequent pressure reduction in the middle ear. It is important to note that the middle ear discharge is initially mucoid, profuse, and blood-stained; however, it acquires a yellowish color and thick consistency. Hearing loss due to acute otitis media in aged patients is often due to the obstruction of sound waves by the middle ear fluid.     

Risk factors

The following conditions increase the risk of acute otitis media and its clinical complications [4].

1. Upper respiratory tract infections

2. Use of pacifier

3. Absence of breastfeeding

4. Immunodeficiency

5. Gastroesophageal reflux (or acid reflux)

6. Family history of acute (recurrent) otitis media

7. Group daycare exposure

8. Contact with respiratory irritants/environmental smoke

9. Craniofacial abnormalities (related to face and skull bones)

10. Allergies

11. Younger age

Assessment

The following findings assist in confirming the presence of acute otitis media in children/adults [5].  

1. Patients may report tenderness (pain on touch) as soon as the physician applies pressure on the inflamed mastoid antrum air cells (i.e., air-filled sac located between the temporal bone’s mastoid process). Of note, temporal bones occupy the left and right portions of the skull, covering the inner and middle ear, respectively.  

2. Body temperature ≥40 °C or 104F.

3. Immunocompromised patients with otitis media could experience bradycardia (slow heart rate)/tachycardia (rapid heart rate, >100 beats/minute) and hypotension (low blood pressure), along with ear discharge, indicating the development of systemic sepsis.

4. The elevated middle ear pressure may lead to the bulging of the intact tympanic membrane (or eardrum).

5. Tympanic membrane erythema could manifest as inflammation in the eardrum, revealed by the appearance of small reddish vessels at the eardrum’s periphery, near the malleus handle (i.e., the fourth part of the first ossicle or malleus connected with the eardrum).

6. The eardrum may lose its translucency and appear thicker, allowing the passage of light through it.  

7. The eardrum could lose its shine and texture.

Differential investigation

It is important to rule out the following conditions while confirming the occurrence of acute otitis media [6].  

1. Dental pain could appear as earache or toothache.  

2. External otitis could manifest as mucous discharge from the middle ear via the eardrum perforation.

3. Ear trauma could trigger ear discharge with blood stains.

4. Rheumatoid arthritis could result in movement-induced pain in the temporomandibular joint.

5. The upper respiratory tract infection could result in reduced feeding, irritability, and fever.  

6. Otitis media with effusion correlates with a retracted eardrum as well as the appearance of air bubbles in the middle ear, confirmed by otoscopic assessment.

Diagnostic evaluation

The diagnostic assessment of acute otitis media relies on the following parameters [7].

1. No lab/radiological assessment is necessary to diagnose acute otitis media.

2. The diagnosis could be confirmed by acute symptomatology, including middle ear inflammation and discharge (due to effusion). Additionally, ear swab culture and gram staining could be performed to select the appropriate antibiotic/antifungal treatment.

3. Acoustic immittance testing (or tympanometry) could help in assessing the sound absorption capacity of the eardrum, to analyze its stiffness level, indicative of middle ear effusion.    

Medical management

The medical management of acute otitis media is guided by one or more of the following approaches [4].

1. Symptomatic management via antipyretics and analgesics is routinely adopted for treating the middle ear pain and inflammation, associated with acute otitis media.

2. The combination of routine analgesics, including ibuprofen/acetaminophen and topical analgesics, assists in controlling mild-to-moderate ear pain.

3. Ear pain of high severity could be treated with pethidine or morphine.

4. The antibiotics of choice include intravenous penicillin or amoxicillin (in children ≤5 years of age, based on its sensitivity to Hemophilus influenzae).  

5. The uncomplicated acute otitis media is managed with watchful waiting in the absence of antibiotics

6. Ear drops are not recommended in patients with an intact eardrum.

7. The persistently bulging eardrum is treated with myringotomy (i.e., a small incision across the eardrum) to facilitate the drainage/cleansing of pus from the middle ear and minimize pain.    

References

1. Danishyar, A. and J.V. Ashurst, Acute Otitis Media, in StatPearls. 2023: Treasure Island (FL).

2. Leichtle, A., T.K. Hoffmann, and M.C. Wigand, Otitis media – Definition, Pathogenese, Klinik, Diagnose und Therapie. Laryngo-Rhino-Otologie, 2018. 97(07): p. 497-508.

3. Liese, J.G., et al., Incidence and clinical presentation of acute otitis media in children aged <6 years in European medical practices. Epidemiology and Infection, 2013. 142(8): p. 1778-1788.

4. Harmes, K.M., et al., Otitis media: diagnosis and treatment. Am Fam Physician, 2013. 88(7): p. 435-40.

5. Schilder, A.G.M., et al., Otitis media. Nature Reviews Disease Primers, 2016. 2(1).

6. Thomas, J.P., et al., Acute Otitis Media. Deutsches Ärzteblatt international, 2014.

7. Lieberthal, A.S., et al., The Diagnosis and Management of Acute Otitis Media. Pediatrics, 2013. 131(3): p. e964-e999.

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