OTITIS MEDIA
CLASSIFICATION OF OTITIS MEDIA
Acute otitis media (AOM) — (AOM) is an acute illness marked by the presence of
middle ear fluid and inflammation of the mucosa that lines the middle ear space



Caused by obstruction of the eustachian tube,
AOM may also be associated with purulent otorrhea if there is a ruptured
tympanic membrane.
AOM usually responds promptly to antimicrobial therapy.
Otitis media with effusion — (OME) is defined by the presence of middle ear
fluid without acute signs of illness or inflammation of the middle ear mucosa.

OME usually follows AOM , can result from barotraumas or allergy.

Eustachian tube dysfunction is often a predisposing factor.

Rarely, caused by obstruction of the eustachian tube orifice in the
nasopharynx.

Consider a mass or cancer such as nasopharyngeal carcinoma.

OME typically leads to a conductive hearing loss
Acute mastoiditis — The mastoid antrum serves as an air space connecting
the middle ear to the mastoid air cells. Thus, most cases of AOM are
associated
with
some
degree
of
mastoid
inflammation
or
infection
("mastoiditis").
Chronic otitis media — (COM) is diagnosed in an ear with a tympanic
membrane perforation in the setting of chronic ear infections, such as an ear
with chronic purulent drainage despite appropriate antibiotic treatment.

Chronic serous drainage (typically straw-colored) is termed chronic
serous otitis media.

Chronic purulent drainage is termed as chronic suppurative otitis media.
ETIOLOGY OF OTITIS MEDIA
Eustachian tube dysfunction (ETD)— Persistent eustachian tube
dysfunction-----induces negative pressure in the middle ear space, lack of
aeration and the accumulation of effusions--- causes-- AOM or otitis media with
effusion (OME).

Seasonal allergic rhinitis

Upper respiratory tract infections.

Other Causes of ETD are mucosal disease (inflammatory, immunologic
impairment, or immotile cilia), extrinsic compression (nasopharyngeal
tumor or enlarged adenoid), or palatal muscle dysfunction (cleft palate
and other craniofacial anomalies).
MICROBIOLOGY

S. pneumoniae is the most important bacterial cause of AOM in adults.

Staphylococcus aureus, including MRSA, are an uncommon cause of AOM but
can occur in patients with chronic suppurative otitis media and may be
associated with persistent otorrhea that follows insertion of tympanostomy tubes.

Group A streptococcus (GAS) was the leading cause of AOM during the
preantibiotic era.
CLINICAL MANIFESTATIONS OF AOM —

Otalgia (ear pain) and decreased hearing. ( usually relieved by perforation )

Fever may not be present.

A preceding URTI or exacerbation of seasonal allergic rhinitis may herald the
onset of AOM by several days.

Dysequilibrium is described infrequently.

Conductive hearing loss is usually transient.

High fever, severe pain behind the ear, or facial paralysis, suggest unusual
complications
DIAGNOSIS
Use pneumatic otoscopy to evaluate the eardrum for evidence of OME.

Tympanic membrane redness, opacification, bulging, and poor mobility when
pneumatic pressure is applied using a pneumatic otoscope.

Air fluid Level

Purulence in the ear canal if there is an associated tympanic membrane rupture.
Tympanometry

Techniques to predict the presence or absence of middle ear effusion. If
tympanometry is normal, acute otitis media is unlikely.
Consider other causes of hearing loss.

If the eardrum is mobile and tympanometry is negative, consider other causes of
hearing loss.
Evaluate hearing in patients with persistent OME for more than 3 months.

Hearing test in cases of persistent OME with a tuning fork examination (512 Hz)
may demonstrate conductive hearing loss.
.Fiberoptic nasopharyngoscopy should be performed to rule out nasopharyngeal
pathology in patients with recurrent unilateral serous otitis media.

( individuals from China, Southeast Asia, and Northern Africa are at increased
risk for nasopharyngeal carcinoma
TREATMENT
Choice of initial antibiotic — must be active against S. pneumoniae, NT H. influenzae,
and M. catarrhalis
Amoxicillin remains the drug of choice for initial therapy of AOM::
●Mild to moderate disease: 500 mg every 12 hours, or 250 mg every 8 hours
●Severe disease (eg, patients with fever, significant hearing loss, severe pain,
and/or marked erythema): 875 mg every 12 hours, or 500 mg every 8 hours
Streptococcus pneumoniae that are not fully susceptible to penicillin. Amoxicillinclavulanate should be considered for patients with severe otalgia or elevated
temperature to cover the possibility of beta-lactamase producing NT H. influenzae.
Duration of Treatment :

Mild to moderate disease be treated for five to seven days,

Severe disease receive a 10-day
Penicillin allergy — Choice depends upon the type of the previous hypersensitivity
reaction.
●If no type 1 hypersensitivity reaction (urticaria or anaphylaxis), consider the
following:
•Cefdinir (300 mg twice a day or 600 mg once daily)
•Cefpodoxime (200 mg twice a day)
•Cefuroxime (500 mg every 12 hours)
•Ceftriaxone (2 g IM or IV once)
● If known and severe allergy to beta-lactam antibiotics, a macrolide
(erythromycin combined with sulfisoxazole, or azithromycin, or clarithromycin)
is the preferred drug. Trimethoprim-sulfamethoxazole
Lack of initial response —

With appropriate antimicrobial therapy, most patients with AOM are significantly
improved within 48 to 72 hours.

If there is no improvement, the patient should be reexamined. Assess for a new
focus of infection or have received inadequate therapy.

When amoxicillin fails, consider second-line regimens include amoxicillinclavulanate or a second-generation cephalosporin such as cefuroxime axetil, or
a third-generation cephalosporin (such as oral cefdinir or intramuscular
ceftriaxone).
Effusions will resolve over the course of 12 weeks
Myringotomy with tympanostomy tubes may be considered for persistent symptomatic
effusions at 12 weeks, and earlier for selected patients with need for immediate
pressure equalization (eg, air travel that cannot be deferred)