Otitis media
Otitis media: Excerpt from Professional Guide to Diseases (Eighth Edition)
Otitis media, inflammation of the middle ear, may be suppurative or secretory, acute, persistent, unresponsive, or chronic. 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 and, possibly, perforation of the tympanic membrane. (See Site of otitis media.)
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.
Recurrent otitis media is defined as three near-acute otitis media episodes within 6 months or four episodes of acute otitis media within 1 year.
Otitis media with complications involves damage to middle ear structures (such as adhesions, retraction, pockets, cholesteatoma, and intratemporal and intracranial complications).
Causes and incidence
Otitis media results from disruption of eustachian tube patency. 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 pneumococcus, 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 the normally wider, shorter, more horizontal eustachian tubes and increased lymphoid tissue in children, as well as anatomic anomalies. Chronic suppurative otitis media results from inadequate treatment for acute otitis episodes or from infection by resistant strains of bacteria or, rarely, tuberculosis.
Secretory otitis media results from obstruction of the eustachian tube. This 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 the inability to equalize pressures between the environment and the middle ear), as occurs 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 or tumors), edema (allergic rhinitis or chronic sinus infection), or inadequate treatment for acute suppurative otitis media.
Acute otitis media is common in children; its incidence rises during the winter months, paralleling the seasonal rise in nonbacterial respiratory tract infections. Chronic secretory otitis media most commonly occurs in children with tympanostomy tubes or those with a perforated tympanic membrane.
Signs and symptoms
Clinical features of acute suppurative otitis media include severe, deep, throbbing pain (from pressure behind the tympanic membrane); signs of upper respiratory tract infection (sneezing or coughing); mild to very high fever; hearing loss (usually mild and conductive); tinnitus; 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.
Acute secretory otitis media produces a severe conductive hearing loss — which varies from 15 to 35 dB, 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.
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 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.
PEDIATRIC TIP The following factors increase a child’s risk of developing otitis media:
❑ acute otitis media in the first year of life (recurrent otitis media)
❑ day care
❑ family history of middle ear disease
❑ formula feeding
❑ male gender
❑ sibling history of otitis media
❑ smoking in the household.
Acute otitis media may not produce any symptoms in the first few months of life; irritability may be the only indication of earache.
Diagnosis
In 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: For example, in acute suppurative otitis media, pulling the auricle doesn’t exacerbate the pain. A culture of the ear drainage identifies the causative organism.
In 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.
In chronic otitis media, patient history discloses recurrent or unresolved otitis media. Otoscopy shows thickening, sometimes scarring, and decreased mobility of the tympanic membrane; pneumatoscopy shows decreased or absent tympanic membrane movement. A history of recent air travel or scuba diving suggests barotitis media.
Tympanocentesis for microbiologic diagnosis is recommended for treatment failures and may be followed by myringotomy. Tympanometry, acoustic reflex measurement, or acoustic reflexometry may be needed to document the presence of fluid in the middle ear. White blood cell count is higher in bacterial otitis media than in sterile otitis media. Mastoid X-rays or computed tomography scan of the head or mastoids may show the spreading of the infection beyond the middle ear.
Treatment
In acute suppurative otitis media, antibiotic therapy includes amoxicillin. In areas with a high incidence of beta-lactamaseproducing H. influenzae and in patients who aren’t responding to ampicillin or amoxicillin, amoxicillin/clavulanate potassium may be used. For those who are allergic to penicillin derivatives, therapy may include cefaclor or co-trimoxazole. Severe, painful bulging of the tympanic membrane usually necessitates myringotomy. Broad-spectrum antibiotics can help prevent acute suppurative otitis media in high-risk patients. A single dose of ceftriaxone 50 mg/kg is effective against major pathogens but is expensive and is reserved for very sick infants. In the patient with recurring otitis media, antibiotics must be used with discretion to prevent development of resistant strains of bacteria.
In acute secretory otitis media, inflation of the eustachian tube using 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 for the underlying cause (such as elimination of allergens, or adenoidectomy for hypertrophied adenoids) may also be helpful in correcting this disorder.
Treatment for chronic otitis media includes broad-spectrum antibiotics, such as amoxicillin/clavulanate potassium or cefuroxime, for exacerbations of acute otitis media; elimination of eustachian tube obstruction; treatment for otitis externa; myringoplasty and tympanoplasty to reconstruct middle ear structures when thickening and scarring are present and, possibly, mastoidectomy. Cholesteatoma requires excision.
Special considerations
❑ Explain all diagnostic tests and procedures. After myringotomy, maintain drainage flow. Don’t place cotton or plugs deeply into 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 and report headache, fever, severe pain, or disorientation.
❑ After tympanoplasty, reinforce dressings, and observe for excessive bleeding from the ear canal. Administer analgesics 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. If nasopharyngeal decongestants are ordered, teach correct instillation.
❑ Suggest application of heat to the ear to relieve pain.
❑ Advise the patient with acute secretory otitis media to watch for and immediately report pain and fever — signs of secondary infection.
To prevent otitis media:
❑ Teach the patient how to recognize upper respiratory tract infections, and encourage early treatment.
❑ Instruct the parents not to feed the 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: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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