Acute Otitis Media

Question 1

What is acute otitis media?

Answer 1

An acute onset inflammation of the middle ear, usually infective origin

*acute otitis media with effusion may be a sequele of acute otitis media but is regarded as a different, non-infective condition

=> occurs in all ages, but v common in infancy

Question 2

What are the risk factors of acute otitis media?

Answer 2

Lack of breastfeeding as a baby

Attending nursery/day care

Positive family Hx

Age between 6-18 months

Exposure to smoking

Question 3

What causes acute otitis media?

Answer 3

1. Upper respiratory tract infection => inflammation of the upper airways and swelling causing obstruction of the Eustachian tube

Ascending infection leads to hyperaemia of the middle ear mucosa with production of purulent exudate

2. 2/3 of acute otitis media = viral infections

=> respiratory syncytial virus

=> rhinovirus

=> enterovirus

3. Bacterial organisms:

=> strep. pneumoniae

=> haemophilus influenza

=> mortadella catarrhalis

Question 4

What are the signs and symptoms of acute otitis media?

Answer 4

1. Infants: 
=> fever, 
=> ear pulling, 
=> irritability, 
=> vomiting 

2. Children & adults: 
=> otalgia (ear pain), 
=> fever, 
=> generally unwell, 
=> hearing loss 
=> if tympanic membrane bursts the pain may suddenly improve but results in a purulent discharge 

3. On otoscopy:

=> bulging tympanic membrane - loss of light reflex

=> injected tympanic membrane (opacification or erythema)

=> tympanic membrane perforation = purulent discharge ± secondary otitis externa

Question 5

What are the complications of acute otitis media?

Answer 5

1. Intratemporal:
   => tympanosclerosis (white patch on eardrum due to scarring)

=> tympanic membrane perforation

=> hearing loss

=> mastoiditis

=> labyrinthitis

=> facial nerve palsy

2. Intracranial:

=> meningitis

=> intracranial abscess

=> lateral sinus thrombosis

=> cavernous sinus thrombosis

=> subdural empyema

Question 6

What are the common sequelae of acute otitis media?

Answer 6

1. Perforation of the tympanic membrane => otorrhoea

=> unresolved acute otitis media with perforation may develop into chronic suppurative otitis media

=> chronic suppurative otitis media is defined as perforation of the tympanic membrane with otorrhoea for >6 weeks

2. Hearing loss
3. Labyrinthitis

Question 7

How is acute otitis media diagnosed?

Answer 7

1. Acute onset of symptoms i.e. otalgia or ear tugging
2. Presence of a middle ear effusion
   => bulging of the tympanic membrane
   => otorrhoea
3. Inflammation of the tympanic membrane i.e. erythema

Question 8

What is the investigation for acute otitis media?

Answer 8

1. Swabs for microscopy, culture and sensitivity if ear discharging
2. Imaging (CT / MRI) for complications

Question 9

What is the treatment for acute otitis media?

Answer 9

Generally self-limiting and doesn’t require an antibiotic prescription

1. Analgesia for pain relief
2. Safeguarded to seek advice if symptoms worsen / do not improve after 3 days
3. Antibiotics prescribed immediately if:
   => symptoms >4 days or not improving

=> systemically unwell but not requiring admission

=> immunocompromised or high risk of complications secondary to significant heart, lung, liver or neuromuscular disease

=> younger than 2 with bilateral otitis media

=> otitis media with perforation and/or discharge into the canal

*1st line antibiotic = amoxicillin for 5-7d course

If penicillin allergy = erythromycin / clarithromycin