Otitis Media

Question 1

What age group does acute otitis media affect?

Answer 1

Common young children – 50% children 3 or more episodes by age 3 – major concern is whether affects child’s speech/language development

Question 2

What are the risk factors of acute otitis media?

Answer 2

age, family history, day care attendance, exposure to smoke

Question 3

What is the pathophysiology of acute otitis media?

Answer 3

Viral upper resp tract infections typically precede – inflammatory oedema of respiratory mucosa and disturbs nasopharyngeal microbiome = obstruction of Eustachian tube and negative middle ear pressure = accumulation of fluid and microbial growth in fluid (suppuration)

Viral causes can be any viral URTI but especially RSV
Most infections are secondary to bacteria - Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
Also mycoplasma pneumoniae

Question 4

Clinical features of acute otitis media

Answer 4

Features
Otalgia
Some children tug/rub ear
Fever 50% cases
Hearing loss
Recent viral URTI common (e.g. coryza)
Ear discharge if tympanic membrane perforates

Question 5

What is seen in otoscopy?

Answer 5

Otoscopy:
Bulging tympanic membrane  loss light reflex
Opacification/erythema tympanic membrane
Perforation w/ purulent otorrhoea
Purulent otorrhoea can be cultured for bacterial presence
Decreased mobility if using pneumatic otoscope

Question 6

Criteria for diagnosis: acute

Answer 6

Guidelines vary but criteria for diagnosis:
Acute onset symptoms – otalgia/ear tugging
Presence middle ear effusion
Bulging tympanic membrane – fluid build up = results in conductive hearing loss (Rinne’s)
Otorrhoea
Decreased mobility on pneumatic otoscopy
Inflammation of tympanic membrane

Question 7

Management of acute otitis media

Answer 7

Generally self-limiting – doesn’t require antibiotics just analgesia
Seek medical help if symptoms worsen or don’t improve after 3 days

Antibiotics if:
Symptoms more than 4 days
Systematically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart/lung/kidney/liver/neuromuscular disease
Younger than 2 and bilateral
<3m old
With perforation and/or discharge in canal
5-7 day course amoxicillin = first-line
If penicillin allergy – erythromycin or clarithromycin

If recurrent episodes – insertion grommets which usually fall out on their own
Insertion of grommets twice indication for tonsillo-adenelectomy

Question 8

Common sequelae: acute

Answer 8

Perforation tympanic membrane  otorrhoea
Unresolved acute otitis media w/ perforation may develop into chronic suppurative otitis media (CSOM)
CSOM = perforation of tympanic membrane with otorrhoea for > 6 weeks
Hearing loss and vestibular dysfunction due to effusion
Labyrinthitis

Question 9

Complications: acute

Answer 9

Mastoiditis –
Initially managed with intravenous antibiotics and close monitoring
Requires imaging on CT in cases where there is suspicion of subperiosteal abscess, signs of intracranial complication or when no improvement after 48h of IV antibiotics
Presents with:
Pain on palpation mastoid process
Postauricular swelling pushing auricle out and forward
Laterally and inferiorly displaced pinna
Thick purulent discharge
Diabetes = risk factor for mastoiditis in adults
Cholesteatoma – abnormal growth squamous epithelium in middle ear
Meningitis – present with sepsis, headache, vomiting, photophobia and phonophobia
Brain abscess – present with sepsis, neurological signs due to compressed cranial nerves
Facial nerve palsy – lower motor neuron lesion of facial nerve, usually recover with treatment of otitis media

Question 10

Clinical features Otitis Media

Answer 10

Pain
Fever
Irritability
Anorexia
Vomiting
After viral URTI

Question 11

Features of acute otitis media

Answer 11

Pain, impaired haring with systemic illness an fever

Onset rapid with aural fullness followed by discharge when tympanic membrane perforate = relief of pain

Diffuse erythema tympanic membrane
Bacterial infection common particularly in young children

Question 12

Features benign chronic otitis media

Answer 12

Dry tympanic membrane perforation without chronic infection

Question 13

Features chronic secretory otitis media (glue ear)

Answer 13

• Persistent pain lasting couple weeks
• Drum look abnormal and reduced mobility of membrane

Question 14

Features chronic suppurative otitis media

Answer 14

Persistent purulent drainage through perforated tympanic membrane

Question 15

Management

Answer 15

Admit any children <3m with temp >=38 or children with suspected acute complications e.g. meningitis, mastoiditis, facial nerve palsy

Admit children systemically very unwell

Otherwise treat pain/fever with paracetamol/ibuprofen

Delayed antibiotic prescribing – ask patients/parents to start antibiotics if symptoms persist >4 days
Offer immediate antibiotic if children systemically unwell or at high risk complications

Question 16

Complications

Answer 16

Extra-cranial:
- Facial nerve palsy (see above)
- Mastoiditis (see above)
- Petrositis – infection spread to apex of petrous temporal bone, triad of symptoms leads to Gradenigo syndrome: otorrhoea, deep inner ear/eye pain and ipsilateral VI nerve palsy
- Labyrinthitis – inflammation semi-circular canals = vertigo, nausea, vomiting and imbalance

Intra-cranial:
Brain abscess (see above)
Meningitis (see above)
Sigmoid sinus thrombosis – present with sepsis, swinging pyrexia and meningitis