Introduction

Otitis Media is an umbrella term that can refer to several subtypes of middle ear infection and inflammation; acute otitis media, otitis media with effusion, and chronic suppurative otitis media.

It is important to clinically differentiate these causes as their treatment is different.

Acute Otitis Media (AOM) is very common in children, and less commonly seen in adults. The cause is usually viral (rhinovirus, adenovirus, enterovirus, RSV). In bacterial cases, the cause is usually haemophilia influenzae or streptococcus pneumoniae – although the latter is much less common since the introduction of pneumococcus vaccination. It typically presents with a deep ear pain and a sensation of a blocked ear.

Otitis Media with Effusion (OME) – aka glue ear refers to chronic inflammation of the middle ear, with collection of fluid in the Eustachian tube. It is the most common cause of hearing problems in childhood and although most cases resolve spontaneously, elective surgery (placement of grommets) is required in many cases. It is typically a complication of an episode of acute otitis media.

Chronic suppurative otitis media (CSOM) is a chronic disorder with persistent rupture of the tympanic membrane and subsequent otorrhoea (ear discharge). It is the most disabling of all types of otitis media. It is very common in the developing world and in some Aboriginal and Torres Straight Islander populations in Australia. It is associated with permanent hearing loss and poor educational performance.

Acute Otitis Media (AOM)

AOM is a very common disorder, with most children experiencing at least one episode. Most common in younger children <3 years old. In children >3 years old OME is more common. Be aware that AOM is a risk factor for OME and may present as co-existing conditions.

Epidemiology

• 75% of children have had a test one episode by school age
• Peak incidence is between 6-18 months
• Increased risk associated with smoke exposure in the home
• Incidence in adults 0.25% per year
• More common in winter months – probably due to association with URTI

Presentation

• Ear pain
  • Usually resolve spontaneously if TM perforates
• Fever
• Irritability
• Lethargy
• URTI symptoms
• Discharge from affected ear (if perforated)

Examination

• The infection typically begins in the upper outer quadrant and spreads down the handle of the malleus. In the early stage, the tympanic membrane (TM) may remain translucent.
• In later stages, the tympanic membrane bulges and becomes very oedematous. Often there is pus behind the TM.
• There may occasionally be blister on the TM – this is known as bullous myringitis – and is typically exquisitely painful, with pain received when the blisters pop. This is usually indicative of viral infection.
• A red angry-looking TM, without bulging or pus does not confirm a diagnosis of AOM – and is commonly seen with URTI
• Ear effusion also does not confirm diagnosis of AOM. It is often present after previous AOM, and may represent OME (otitis media with effusion – see below)
• Red flags
  • Cellulitis of the outer ear or surrounding skin
  • Mastoiditis (tender mastoid, often with cellulitis looking ear and ear appears to be pressed forwards)
  • Headache
  • Facial palsy
  • Fever in child under 3 months old

Investigations

• No investigations are routinely required. Diagnosis is clinical
• If any suspected intracranial complications, CT or MRI may be performed

Complications

• Mastoiditis
  • Rare
  • Pain, tenderness and swelling behind the ear, often pressing the ear forwards
  • Requires urgent ENT admission for IV antibiotics and some cases may require surgical drainage
• Bacterial labyrinthitis
  • Causes severe vertigo and persistent pain and fevers

Management

• Analgesia
• Watchful waiting is suitable for most children
  • 60% will resolve within 24 hours
  • 80% will resolve within 4 days
  • Antibiotics will improve symptoms 12-24 hours sooner than without, but carry the risk of GI upset and resistance
• Antibiotics
  • There is much debate and differing clinical guidelines
  • Antibiotic of choice is amoxicillin 50mg/Kg/day in 2-3 divided doses for 5 days
    • Studies show a 5 day course is as effective as a 10 day course
  • Indications for immediate antibiotics
    • AOM in the only hearing ear
    • Cochlear implant – discuss with ENT – may require IV abx
    • In Australia – Aboriginal children
  • Consider immediate antibiotics for
    • AOM in both ears in children <2
    • Any case with perforated TM
  • Consider antibiotics at 48 hours if symptoms not resolving
    • Some UK guidelines suggest to do this is on day 5, rather than at 48 hours
    • Consider giving a delayed script at initial consultation
    • In practice – I discuss the facts with the parents – I explain 80% will get better without antibiotics in 4 days or less, and to persist with analgesia. If parents particularly keen for antibiotics I explain that they help children get better about 12-24 hours sooner, but carry risks as above. Most parents choose not to give the antibiotics after this advice
  • In perforation with discharge, consider also using topical antibiotics for 2-3 days
• If TM perforation – Follow-up in 2 weeks to re-assess the tympanic membrane to ensure it is healing
• If no perforation, but multiple episodes of AOM – consider review at 8 weeks to assess for effusion – note that the normal time frame for resolution of effusion is 8-12 weeks
• Consider non-urgent ENT review if:
  • >= 6 episodes in 12 months
  • Persisting OME for >3 months (bilateral) or >6 months unilateral

Otitis media with Effusion (OME)

Epidemiology

• Common between ages of 1 and 6
  • Prevalence at age 2 is about 20%
  • By age 7 this has fallen to about 8%
• The most common cause of acquired hearing loss
• By the age of 10, 80% of children will have had at least one episode

Aetiology

• Usually in winter
• Typically follows an episode of AOM
• Chronic colonisation of adenoids / adenoidal hypertrophy
• Cleft palate
• Male gender
• Daycare attendance in children
• Frequent URTI
• Smoker or parents who smoke
• Gastro-Oesophageal reflux
• Eustachian tube dysfunction
• Allergic rhinitis
• Barotrauma (after diving or flying)
• Chronic sinusitis / other sinus disease
  • Accounts for 66% of cases in adults
  • Rare in children

Presentation

Children

• Hearing loss
  • Reduced communication – e.g. mispronouncing words, delay speech, delayed progress at school
  • Likes to have TV volume loud
  • Asks for things to be repeated frequently
• Ear pain
• Balance problems (rare)
• Often bilateral

Adults

• Usually unilateral
• Hearing loss
• Sensation of fullness in the ear
• Popping sounds, cracking sounds, tinnitus
• Ear pain – often mild and chronic. Acute ear pain is rare
• Balance problems (rare, and not usually true vertigo)

Examination

• Opaque ear drum
• Loss of light reflex
• Indrawn or retracted TM – rarely can be bulging
• Bubbles in fluid behind TM / fluid level visible behind TM

Investigations

• Hearing test – shows a mild conductive hearing loss
• Significant if >25dB hearing loss
  • A 30dB hearing loss reduces conversational speech to the equivalent of a quiet whisper
• Pneumatic tympanogram may show immobile eardrum (not routinely performed

Prognosis

• Spontaneously resolves in most cases – up to 90% by 12 weeks
• 30% of children will have recurrent cases
• Up to 10% of episodes last >1 year
• In children with other pre-existing co-morbidities (e.g. deafness, visual problems, speech problems, social developmental delay) surgical treatment is indicated sooner
• Worse prognosis in recurrent cases

Management

• Reassure parents with verbal and written advice:
  • 90% of children have complete resolution within one year
  • No medication has been proven to be effective
  • Parental smoking increases the risk
• Tips for children with hearing loss
  • Look at child when speaking to them
  • Speak more slowly
  • Speak clearly
  • Speak more loudly
  • Turn off other sound sources (e.g. TV)
  • Encourage daily reading to assist with language development
• Medical treatments – have no proven benefit and are NOT recommended. This includes antibiotics, antihistamines, decongestants.
• Most cases resolve spontaneously
• Observe for 2-3 months (“active observation”)
• >50% will recover within 3 months
• Consider repeat hearing test in 3 months to confirm resolution of symptoms
• If remains symptomatic (e.g. with language development, or other symptoms) at 3 months, OR has reduced hearing at three months – refer for ENT assessment – for consideration for grommets
  • Many cases referred will have resolved by the time they see an ENT specialist!
  • High risk cases (such as Down Syndrome, cleft palate or other causes of developmental delay) should be referred sooner (do not wait 3 months)
  • Consider referral for any case bilateral OME at 3 months and for any case that is unilateral at 6 months and still persisting
• Surgical management 
  • Indications:
    • Persistent bilateral OME lasting >3 months, OR
    • Hearing loss >25dB in the best ear, OR
    • Language, education or social developmental delay
  • Both commonly used options – grommets and adenoidectomy reduce the duration of OME and improve hearing in the short-term – but by 6-9months most studies have shown no difference between surgical and non-surgically managed patients (i.e. the OME resolved anyway by this time in the non-surgical patients)
  • Grommets
    • First line surgical treatment
    • These are small plastic ventilation tubes, placed into the tympanic membrane which allow fluid to drain into the external ear canal
    • Proven to improve hearing loss
    • NOT proven to improve speech and language development over the “watch and wait” approach – no studies have ever assessed this effect
    • Risk of tympanosclerosis – although the clinical significance of this is uncertain
    • Usually done under GA, but can be done with local anaesthetic
    • By 6-9 months most studies show little benefit in comparison to those who didn’t undergo surgery
  • Adenoidectomy
    • Recommended if frequent URTIs are implicated
  • Laser Myringotomy
    • A incision made by laser into the tympanic membrane
    • Doesn’t require anaesthetic
    • Allows fluid to drain from the middle ear
    • Quick, safe and painless
    • However, the hole heals up within 3-4 weeks – which is not long enough to allow for clearance of OME. As such, it is rarely used
  • Adults
    • Need to have a more sister cause excluded first. If no cause is identified, often treated similarly to children

Complications

• There is only weak evidence for the link between OME and speech and language developmental delay – and even then the effect is only temporary
• Increased risk of psychological disorder – such as depression, anxiety and, in children, behaviour disorders

Prevention

• Influenza vaccination associated with reduced risk (between 2-9x reduced risk)
• Pneumococcal vaccination provides no benefit

Chronic Suppurative Otitis Media (CSOM)

A chronic inflammatory disorder of the middle ear, associated with frequent tympanic membrane perforation and associated otorrhoea (discharge from the ear).

It is very common in the developing world, and in Australia is seen frequently in Aboriginal and Torres Straight Islander populations (ATSI). CSOM is thought to cause 80% of hearing impairment world-wide.

The definition is not universally agreed upon – some guidelines suggest a minimum of 2 weeks of discharge, other suggest 6 weeks.

CSOM is caused by recurrent infection of the middle ear, resulting in ulceration and oedema of the mucosa with subsequent breakdown of the epithelial lining.

It can result in permanent hearing loss, is associated with poor school performance, and can cause cholasteoatoma – a destructive lesion affecting the base of the skull

Clinically, it is important to define the location of the perforation of the TM.

• “Safe” CSOM – occurs with perforation in the centre of the TM
• “Unsafe” CSOM – occurs with proration near the periphery of the TM. This predisposes to cholesteatoma

Epidemiology

• Affects about 1% of children and 0.5% of adults in the UK
• In some ATSI populations in Australia, affects up to 15% of children (down from 25% in 2001)
  • In one study, only 7% of ATSI children in the Northern Territory had normal ears. The rest had various forms of OM
• In the developing world, up to 60% of patients will develop permanent hearing loss as a result of CSOM
• CSOM is associated with poor educational performance

Aetiology

• Multiple episodes of AOM
• Living in crowded environment
• Daycare attendance
• Congenital cranial deformities
  • Cleft lip or palate
  • Down Sydnrome
  • Microcephaly
  • Many others

Presentation

• Chronic (>2 weeks) of ear discharge, usually on background of AOM
• Hearing loss in affected ear
  • May be associated speech development
• Usually NO fever and NO ear pain
• Red flags for urgent referral to exclude intracranial complications
  • Fever
  • Vertigo – suggest labyrinthitis which can lead to meningitis and encephalitis
  • Ear pain
  • Facial paralysis – suggests cholesteatoma

Examination

• External canal often oedematous
• Discharge in external canal
• Granulation tissue may be seen
• TM perforation
  • Beware the differentiation between “safe” (middle of TM perforation) and “unsafe” (periphery of CSOM perforation) CSOM. The latter may required more prompt imaging and referral due to risk of cholesteatoma
• It is usually fairly obvious that there is something very wrong with the TM and external canal!

Differentials

• Otitis externa
• Foreign body
• Impacted ear wax
• Cholesteatoma
• Wegeners granulomatosis
• Neoplasm

Investigations

• Swab for MC+S – usually not useful and not indicated
• Audiogram
  • Often shows conductive hearing loss
  • Mixed loss suggests more extensive disease
• CT scan is indicated in failed treatment or “unsafe” CSOM. Can show:
  • Cholesteatoma
  • Foreign body
  • Malignancy
• MRI more useful for suspected intracranial complications such as labyrinthitis or abscess

Complications

• Cholesteatoma
  • This is abnormal growth of skin within the ear canal, usually secondary to dysfunctional healing of the tympanic membrane (occasionally congenital). It is noncancerous, but is often locally invasive, and can invade the mastoid and the base of the skill. Nearly always requires surgical intervention
• Mastoiditis
• Chronic hearing loss
• Abscess formation
• Facial paralysis
• Labyrinthitis – potentially leading to meningitis or encephalitis
• Lateral sinus thrombophlebitis
• Tympanosclerosis

Management

• If any red flags (see presentation above) – urgent referral for admission under ENT
• Any other diagnosis of CSOM should be considered for non-urgent outpatient ENT assesment
  • Use of micro suction by an ENT specialist in clinic allows for better visualisation of TM
  • In the UK, NICE guidelines suggest all CSOM patients be referred to ENT
  • In Australia, advice differs. I have seen some places suggest that cases not responsive to topical antibiotics after 4 weeks should be referred
• Antibiotics – topical usually preferred
  • Topical quinolone thought to be most effective – e.g. ciprofloxacin
  • Aminoglycosides are frequently used – despite their risk of ototoxicity – because this is thought to be outweighed by the risk of CSOM (e.g. neomycin)
  • Common organisms are pseudomonas and staphylococcus aureus
  • Systemic antibiotica are reserved for cases that fail to respond to treatment – and often need to be given IV to obtain sufficient concentrations in the middle ear
• Topical steroids
  • Can reduce granuloma formation
  • Frequently used in combination with antibiotics (e.g. sofradex)
• Regular aural toilet (microscution) to remove debris from external ear canal
  • Antibiotics and aural toilet cure otorrhoea, but their effect on long-term healing of TM is not proven
• Removal of granulation tissue
• Keep the ear dry – avoid swimming (not good evidence but seems common sense)
• Surgery
  • Reserved for cases that have failed to respond to medical management
  • Myringoplasty  – repair of the TM – is the most commonly performed procedure
  • Mastoidectomy – various type of procedure – often required if cholesteatoma is present. The aim of the surgery is to remove all of the cholesteatoma to dry to ear canal and return function to the ear
  • Cochlear implants – can be used to retire hearing – but it is essential to ensure all disease is eradicated prior to the insertion

Prognosis

• Good in developed countries
• Can be fatal if left untreated – one study suggests it causes about 3-4,000 deaths annually worldwide
• Earlier onset is associated with worse developmental and educational prognosis

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Acute Otitis Media in Adults - patient.info
• Otitis Media with Effusion - Patient.info
• Otitis Media - Health Pathways
• Chronic suppurativee otitis media and cholesteatoma in Australia's refugee population
• Managing Otitis Media - an evidence based approach - nps
• Acute otitis Media in Children
• Acute Otitis Media - RCH

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