Otitis Media

Question 1

What is otitis media?

Answer 1

Otitis media is the name given to an infection in the middle ear. The middle ear is the space that sits between the tympanic membrane (eardrum) and the inner ear. This is where the cochlea, vestibular apparatus and nerves are found.

Question 2

What structures are found in the middle ear?

Answer 2

Otitis media is the name given to an infection in the middle ear. The middle ear is the space that sits between the tympanic membrane (eardrum) and the inner ear. This is where the cochlea, vestibular apparatus and nerves are found.

Question 3

What causes otitis media?

Answer 3

Bacteria enter from the back of the throat through the eustachian tube. A viral upper respiratory tract infection often precedesbacterial infection of the middle ear.

Question 4

What pathogens cause otitis media?

Answer 4

The most common bacterial cause of otitis media is streptococcus pneumoniae. This also commonly causes other ENT infections such as rhino-sinusitis and tonsillitis.

Other common causes include:

• Haemophilus influenzae
• Moraxella catarrhalis
• Staphylococcus aureus

Question 5

What are the clinical features of otitis media?

Answer 5

Ear pain is the primary presenting feature of otitis media in adults.

It may also present with:

• Reduced hearing in the affected ear
• Feeling generally unwell, for example with fever
• Symptoms of an upper airway infection such as cough, coryzal symptoms and sore throat

When the infection affects the vestibular system, it can cause balance issues and vertigo. When the tympanic membrane has perforated, there may be discharge from the ear.

Question 6

How will otitis media present on otoscopy?

Answer 6

An otoscope is used to visualise the tympanic membrane whilst gently pulling the pinna up and backwards. It may be challenging to visualise the tympanic membrane if there is significant discharge or wax in the ear canal.

A normal tympanic membrane is “pearly-grey”, translucent and slightly shiny. You should be able to visualise the malleus through the membrane. Look for a cone of light reflecting the light of the otoscope.

Otitis media will give a bulging, red, inflamed looking membrane. When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane.

Question 7

Briefly describe the management of otitis media

Answer 7

Most otitis media cases will resolve without antibiotics within around three days, sometimes up to a week. Antibiotics make little difference to symptoms or complications. Complications (mainly mastoiditis) are rare. Simple analgesia (e.g., paracetamol or ibuprofen) can be used for pain and fever.

Question 8

What are the 3 options for prescribing antibiotics for otitis media?

Answer 8

There are three options for prescribing antibiotics:

• Immediate antibiotics
• Delayed prescription
• No antibiotics

Question 9

Briefly describe the rationale for immediate and delayed antibiotic prescriptions for otitis media

Answer 9

Consider immediate antibiotics at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised.

Consider a delayed prescription that can be collected and used after three days if symptoms have not improved or have worsened at any time. This can be a helpful strategy in patients pressing for antibiotics or where you suspect the symptoms might worsen.

Question 10

What antibiotics are prescribed for otitis media?

Answer 10

The NICE clinical knowledge summaries suggest:

• Amoxicillin for 5-7 days first-line
• Clarithromycin (in pencillin allergy)
• Erythromycin (in pregnant women allergic to penicillin)

Question 11

What are the complications of otitis media?

Answer 11

• Otitis media with effusion
• Hearing loss (usually temporary)
• Perforated tympanic membrane (with pain, reduced hearing and discharge)
• Labyrinthitis (causing dizziness or vertigo)
• Mastoiditis (rare)
• Abscess (rare)
• Facial nerve palsy (rare)
• Meningitis (rare)