Otitis media

Otitis media: Excerpt from Handbook of Diseases

Inflammation of the middle ear, otitis media may be suppurative or secretory, acute or chronic. Acute otitis media is common in children; its incidence rises during the winter months, paralleling the seasonal rise in nonbacterial respiratory tract infections.

With prompt treatment, the prognosis for acute otitis media is excellent; however, prolonged accumulation of fluid within the middle ear cavity causes chronic otitis media, with possible perforation of the tympanic membrane. Chronic suppurative otitis media may lead to scarring, adhesions, and severe structural or functional ear damage; chronic secretory otitis media, with its persistent inflammation and pressure, may cause conductive hearing loss.

Causes

Otitis media results from disruption of eustachian tube patency. (See Sites of otitis media.)

Suppurative otitis media

In the suppurative form, respiratory tract infection, allergic reaction, nasotracheal intubation, or positional changes allow nasopharyngeal flora to reflux through the eustachian tube and colonize the middle ear. Suppurative otitis media usually results from bacterial infection with pneumococci, Haemophilus influenzae (the most common cause in children younger than age 6), Moraxella catarrhalis, beta-hemolytic streptococci, staphylococci (most common cause in children age 6 or older), or gram-negative bacteria.

Predisposing factors include genetic factors, such as susceptibility to infection; the normally wider, shorter, more horizontal eustachian tubes and increased lymphoid tissue in children; and anatomic anomalies. Chronic suppurative otitis media results from inadequate treatment of acute otitis episodes or from infection by resistant strains of bacteria or, rarely, tuberculosis.

Secretory otitis media

With secretory otitis media, obstruction of the eustachian tube causes a buildup of negative pressure in the middle ear that promotes transudation of sterile serous fluid from blood vessels in the membrane of the middle ear. Such effusion may be secondary to eustachian tube dysfunction from viral infection or allergy. It may also follow barotrauma (pressure injury caused by inability to equalize pressures between the environment and the middle ear), as can occur during rapid aircraft descent in a person with an upper respiratory tract infection or during rapid underwater ascent in scuba diving (barotitis media).

Chronic secretory otitis media follows persistent eustachian tube dysfunction from mechanical obstruction (adenoidal tissue overgrowth, tumors), edema (allergic rhinitis, chronic sinus infection), or inadequate treatment of acute suppurative otitis media.

Signs and symptoms

Signs and symptoms vary with the specific type of the disorder.

Suppurative otitis media

Signs and symptoms of acute suppurative otitis media include severe, deep, throbbing pain (from pressure behind the tympanic membrane); signs of upper respiratory tract infection (sneezing, coughing); mild to very high fever; hearing loss (usually mild and conductive); dizziness; nausea; and vomiting.

Other possible effects include bulging of the tympanic membrane with concomitant erythema and purulent drainage in the ear canal from tympanic membrane rupture. However, many patients are asymptomatic.

Secretory otitis media

With acute secretory otitis media, a severe conductive hearing loss varies, depending on the thickness and amount of fluid in the middle ear cavity — and, possibly, a sensation of fullness in the ear and popping, crackling, or clicking sounds on swallowing or with jaw movement. Accumulation of fluid may also cause the patient to hear an echo when he speaks and to experience a vague feeling of top-heaviness.

Chronic otitis media

The cumulative effects of chronic otitis media include thickening and scarring of the tympanic membrane, decreased or absent tympanic membrane mobility, cholesteatoma (a cystlike mass in the middle ear) and, in patients with chronic suppurative otitis media, a painless, purulent discharge. The extent of associated conductive hearing loss varies with the size and type of tympanic membrane perforation and ossicular destruction.

If the tympanic membrane has ruptured, the patient may state that the pain has suddenly stopped. Complications may include abscesses (brain, subperiosteal, and epidural), sigmoid sinus or jugular vein thrombosis, septicemia, meningitis, suppurative labyrinthitis, facial paralysis, and otitis externa.

Diagnosis

Diagnostic tests also vary with the specific type of otitis media.

Suppurative otitis media

With acute suppurative otitis media, otoscopy reveals obscured or distorted bony landmarks of the tympanic membrane. Pneumatoscopy can show decreased tympanic membrane mobility, but this procedure is painful with an obviously bulging, erythematous tympanic membrane. The pain pattern is diagnostically significant: With acute suppurative otitis media, for example, pulling the auricle doesn’t exacerbate the pain.

Secretory otitis media

With acute secretory otitis media, otoscopic examination reveals tympanic membrane retraction, which causes the bony landmarks to appear more prominent.

Examination also detects clear or amber fluid behind the tympanic membrane. If hemorrhage into the middle ear has occurred, as in barotrauma, the tympanic membrane appears blue-black.

Chronic otitis media

In patients with chronic otitis media, the history discloses recurrent or unresolved otitis media. Otoscopy shows thickening (and sometimes scarring) and decreased mobility of the tympanic membrane, whereas pneumatoscopy shows decreased or absent tympanic membrane movement. Mastoid X-rays or computed tomography scans may show spreading infection beyond the middle ear. History of recent air travel or scuba diving suggests barotitis media.

Treatment

The type of otitis media dictates the treatment guidelines.

Suppurative otitis media

With acute suppurative otitis media, antibiotic therapy may be prescribed if the disease is bacterial in origin. Nasal spray, nose drops, oral decongestants, or antihistamines may be used to promote drainage of fluid through the eustachian tube. Eardrops may be prescribed to relieve pain, as may analgesics such as acetaminophen. Oral corticosteroids may be used to reduce inflammation.

Severe, painful bulging of the tympanic membrane usually necessitates myringotomy. Broad-spectrum antibiotics can help prevent acute suppurative otitis media in high-risk patients. In patients with recurring otitis, antibiotics must be used with discretion to prevent development of resistant strains of bacteria.

CLINICAL TIP: Most patients who are receiving antibiotic therapy for acute otitis media have significant improvement in 48 hours.

Secretory otitis media

For patients with acute secretory otitis media, inflation of the eustachian tube by performing Valsalva’s maneuver several times a day may be the only treatment required. Otherwise, nasopharyngeal decongestant therapy may be helpful. It should continue for at least 2 weeks and sometimes indefinitely, with periodic evaluation.

If decongestant therapy fails, myringotomy and aspiration of middle ear fluid are necessary, followed by insertion of a polyethylene tube into the tympanic membrane, for immediate and prolonged equalization of pressure. The tube falls out spontaneously after 9 to 12 months. Concomitant treatment of the underlying cause (such as elimination of allergens, or adenoidectomy for hypertrophied adenoids) may also be helpful in correcting this disorder.

Chronic otitis media

Treatment of chronic otitis media includes broad-spectrum antibiotics for exacerbations of acute otitis media, elimination of eustachian tube obstruction, treatment of otitis externa, myringoplasty and tympanoplasty to reconstruct middle ear structures when thickening and scarring are present, and mastoidectomy. Cholesteatoma requires excision.

Special considerations

❑  Explain all diagnostic tests and procedures to the patient.

❑  After myringotomy, maintain drainage flow. Don’t place cotton or plugs deep in the ear canal; however, sterile cotton may be placed loosely in the external ear to absorb drainage.

❑  To prevent infection, change the cotton whenever it gets damp, and wash hands before and after giving ear care. Watch for headache, fever, severe pain, or disorientation.

❑  After tympanoplasty, reinforce dressings and observe the patient for excessive bleeding from the ear canal. Administer an analgesic as needed. Warn the patient against blowing his nose or getting the ear wet when bathing.

❑  Encourage the patient to complete the prescribed course of antibiotic treatment. Teach correct instillation of eardrops, if prescribed.

CLINICAL TIP: Most children will have an effusion present at the completion of a 10- to 14-day course of antibiotic therapy. Effusion may last up to 12 weeks before spontaneous clearance can be expected.

❑  Suggest application of heat to the ear (warm cloth or warm water bottle) to relieve pain.

❑ Advise the patient to contact his health care provider if symptoms don’t improve. Instruct him to watch for and immediately report pain and fever — indications of secondary infection.

To prevent otitis media:

❑  Teach the patient to recognize upper respiratory tract infections, and encourage early treatment.

❑  Instruct parents not to feed their infant in a supine position or put him to bed with a bottle. This prevents reflux of nasopharyngeal flora.

❑  To promote eustachian tube patency, instruct the patient to perform Valsalva’s maneuver several times daily.

❑  Identify and treat allergies.

Pictures

Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5

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