Otitis Media

Otitis Media

Otitis Media (OM) is defined as the inflammation of the middle ear generally caused by a bacterial/viral infection. It can be acute, recurrent or chronic. Chronic OM is a persistent infection (> 6 weeks) leading to perforation of the eardrum causing pus discharge.


The causes of acute OM include viral infections, which lead to a secondary bacterial infection. In newborns, acute OM is typically caused by bacteria (Escherichia coli and Staphylococcus aureus), but these bacteria can cause chronic OM as well. Other bacteria are implicated in OM in older patients.


Smoking in the household is a major risk factor for acute OM. Other factors include a strong family history of OM, bottle feeding, and attending a daycare center. Chronic OM can result from acute OM, eustachian tube obstruction, physical trauma, thermal/chemical burns, blast injuries, or from medical procedures. Also, patients with Down syndrome, cleft lip and/or cleft palate, etc. have an increased risk of developing OM.


The clinical presentation of OM includes earache, often with hearing loss. There is likely fever, nausea, vomiting, and possibly diarrhea. Visualizing the ear (otoscopy) shows a bulging, reddened ear drum with indistinct landmarks. Pushing air into the ear (pneumatic otoscopy) shows poor mobility of the eardrum. The eardrum can perforate and cause watery or pus discharge. Chronic OM manifests with painless pus, sometimes foul-smelling ear discharge for 6 weeks or longer. It also causes hearing loss from obstruction in the middle ear.


Most cases resolve on their own, but antibiotics are still prescribed to reduce the chance of lingering hearing loss and other complications. Painkillers (oral or topical) should be provided as needed. In severe cases, intravenous antibiotic therapy is required, with more specific treatment based on culture and sensitivity results. Surgical repair of the eardrum (tympanoplasty) is needed for patients with eardrum perforations or damaged inner ear bones. Cholesteatomas must be removed surgically as well.


Cholesteatoma is a complication of OM, and refers to a white mass emerging from the middle ear into the ear canal through a ruptured eardrum. These are evaluated on a CT or MRI. If OM is untreated or poorly managed, it can result in the spread of infection into deeper skull bones. It can also spread into the skull to cause meningitis or brain infection. These complications are more common in patients with a weak immune system. Persistent chronic OM may result in destructive changes in the middle ear or create cholesteatoma.


Acute OM can occur at any age, but it is most common between ages 3 months and 3 years, mainly because the eustachian tube is structurally and functionally immature during this time, making it prone to infections spreading from the upper respiratory tract. OM is also common or more aggressive in immunocompromised individuals (AIDS, cancer patients, genetic conditions, etc.). It is important to keep in mind the possibility of OM even in adults and manage it in a timely manner to prevent complications.

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