Otitis media (Latin for "Middle otitis") is inflammation of the middle ear, or middle ear

infection.

Otitis media occurs in the area between the ear drum (the end of the outer ear) and the inner
ear, including a duct known as the eustachian tube. It is one of the two categories of ear
inflammation that can underlie what is commonly called an earache, the other being otitis
externa. Diseases other than ear infections can also cause ear pain, including cancers of any
structure that shares nerve supply with the ear and shingles which can lead to herpes zoster
oticus.

Classification
Otitis media has many degrees of severity, and various names are used to describe each. The
terminology is sometimes confusing because of multiple terms being used to describe the
same condition. A common misconception with ear infection is that sufferers think that a
symptom is itchy ear. Although sufferers may feel discomfort, an itchy ear is not a symptom
of ear infection.

Acute otitis media

Acute otitis media (AOM) is most often purely viral and self-limited, as is its usual
accompanying viral URI (upper respiratory infection). There is congestion of the ears and
perhaps mild discomfort and popping, but the symptoms resolve with the underlying URI. If
the middle ear, which is normally sterile, becomes contaminated with bacteria, pus and
pressure in the middle ear can result, and this is called acute bacterial otitis media. Viral acute
otitis media can lead to bacterial otitis media in a very short time, especially in children, but it
usually does not. The individual with bacterial acute otitis media has the classic "earache",
pain that is more severe and continuous and is often accompanied by fever of 102 °F (39 °C)
or more.[citation needed]. Bacterial cases may result in perforation of the ear drum, infection
of the mastoid space (mastoiditis) and in very rare cases further spread to cause meningitis.

Features: 1st phase - exudative inflammation lasting 1-2 days, fever, rigors, meningism
(occasionally in children), severe pain (worse at night), muffled noise in ear, deafness,
sensitive mastoid process.

2nd phase - resistance and demarcation lasting 3-8 days. Pus and middle ear exudate
discharge spontaneously and afterwards pain and fever begin to decrease. This phase can be
shortened with topical therapy.

3rd phase - healing phase lasting 2-4 weeks. Aural discharge dries up and hearing becomes
normal.

Otitis media with effusion

Otitis media with effusion (OME), also called serous or secretory otitis media (SOM), is
simply a collection of fluid that occurs within the middle ear space as a result of the negative
pressure produced by altered Eustachian tube function. This can occur purely from a viral
URI, with no pain or bacterial infection, or it can precede and/or follow acute bacterial otitis
media. Fluid in the middle ear sometimes causes conductive hearing impairment, but only
when it interferes with the normal vibration of the eardrum by sound waves. Over weeks and
months, middle ear fluid can become very thick and glue-like (thus the name glue ear),
which increases the likelihood of its causing conductive hearing impairment. Early-onset
OME is associated with feeding while lying down and early entry into group child care, while
parental smoking, too short a period of breastfeeding and greater amounts of time spent in
group child care increased the duration of OME in the first two years of life.

Chronic suppurative otitis media

Chronic suppurative otitis media involves a perforation (hole) in the tympanic membrane and
active bacterial infection within the middle ear space for several weeks or more. There may
be enough pus that it drains to the outside of the ear (otorrhea), or the purulence may be
minimal enough to only be seen on examination using a binocular microscope. This disease is
much more common in persons with poor Eustachian tube function. Hearing impairment
often accompanies this disease.

Signs and symptoms

When the middle ear becomes acutely infected by bacteria, pressure builds up behind the ear
drum, usually but not always causing pain. In severe or untreated cases, the tympanic
membrane may rupture, allowing the pus in the middle ear space to drain into the ear canal. If
there is enough of it, this drainage may be obvious. Even though the rupture of the tympanic
membrane suggests a traumatic process, it is almost always associated with the dramatic
relief of pressure and pain. In a simple case of acute otitis media in an otherwise healthy
person, the body's defenses are likely to resolve the infection and the ear drum nearly always
heals. Antibiotic administration can prevent perforation of the eardrum and hasten recovery
of the ear.

Instead of the infection and eardrum perforation resolving, however, drainage from the
middle ear can become a chronic condition. As long as there is active middle ear infection,
the eardrum will not heal. The World Health Organization defines Chronic Suppurative Otitis
Media (CSOM) as "a stage of ear disease in which there is chronic infection of the middle ear
cleft, a non-intact tympanic membrane (i.e. perforated eardrum) and discharge (otorrhoea),
for at least the preceding two weeks" (WHO 1998). (Notice WHO's use of the term serous to
denote a bacterial process, whereas the same term is generally used by ear physicians in the
United States to denote simple fluid collection within the middle ear behind an intact
eardrum. Chronic otitis media is the term used by most ear physicians worldwide to describe
a chronically infected middle ear with eardrum perforation.)

Causes
Streptococcus pneumoniae and nontypable Haemophilus influenzae are the most common
bacterial causes of otitis media. Tubal dysfunction leads to the ineffective clearing of bacteria
from the middle ear. In older adolescents and young adults, the most common cause of ear
infections during their childhoods was Haemophilus influenzae. The role of the anti-H.
influenzae vaccine that children are regularly given in changing patterns of ear infections is
unclear, as this vaccine is active only against strains of serotype b, which rarely cause otitis
media.
As well as being caused by Streptococcus pneumoniae and Haemophilus influenzae it can
also be caused by the common cold. Colds indirectly cause many cases of otitis media by
damaging the normal defenses of the epithelial cells in the upper respiratory tract.

Another common culprit of otitis media includes Moraxella catarrhalis, a gram-negative,

aerobic, oxidase positive diplococcus. Less commonly otitis media can be caused by
Mycobacterium tuberculosis.

If none of the above bacteria is found to be in the serum, the next possible organism
responsible is the Respiratory Syncytial Virus (RSV).

Progression

Typically, acute otitis media follows a cold: after a few days of a stuffy nose the ear becomes
involved and can cause severe pain. The pain will usually settle within a day or two, but can
last over a week. Sometimes the ear drum ruptures, discharging pus from the ear, but the
ruptured drum will usually heal rapidly.

At an anatomic level, the typical progression of acute otitis media occurs as follows: the
tissues surrounding the Eustachian tube swell due to an upper respiratory infection, allergies,
or dysfunction of the tubes. The Eustachian tube remains blocked most of the time. The air
present in the middle ear is slowly absorbed into the surrounding tissues. A strong negative
pressure creates a vacuum in the middle ear, and eventually the vacuum reaches a point
where fluid from the surrounding tissues accumulates in the middle ear. This is seen as a
progression from a Type A tympanogram to a Type C to a Type B tympanogram. The fluid
may become infected. It has been found that dormant bacteria behind the tympanic membrane
(eardrum) multiply when the conditions are ideal, infecting the middle ear fluid.

Susceptibility in children

Children below the age of seven years are much more prone to otitis media since the
Eustachian tube is shorter and at more of a horizontal angle than in the adult ear. They also
have not developed the same resistance to viruses and bacteria as adults. Numerous studies
have correlated the incidence of acute otitis media in children with various factors such as
nursing in infancy, bottle feeding when supine, parental smoking, diet, allergies, and
automobile emissions; but the most obvious weakness of such studies is the inability to
control the variable of exposure to viral agents during the studies. One must also keep in
mind that correlation does not establish causation. Breastfeeding for the first twelve months
of life is associated with a reduction in the number, and duration of all OM infections.

Well pacifier use is associated with more frequent episodes of AOM.

Diagnosis
The tympanic membrane as it appears in someone with acute otitis media

Acute otitis media is usually diagnosed via visualization of the tympanic membrane in
combination with the appropriate clinical history.

Treatment
Acute otitis media

Management of pain

To treat the pain caused by otitis media oral as well as topical analgesics are effective. Oral
agents may include ibuprofen, acetaminophen, and / or narcotics. Topical agents shown to be
effective include antipyrine and benzocaine ear drops.

Antibiotics

Many guidelines suggest deferring the start of antibiotics in acute bacterial otitis media for
one to three days if pain is manageable with the above measures. This is recommended for a
number of reasons including: two out of three children with acute otitis media resolve without
antibiotic treatment, no adverse effect on long term outcomes have been found when
treatment is withheld, antibiotics have significant rates of potential side effects, and a recent
trial has found increased rates of recurrence of otitis in children who were treated with
antibiotics.

The first line antibiotic treatment, if warranted, is amoxicillin. If the bacteria is resistant, then
amoxicillin-clavulanate or another penicillin derivative plus beta lactamase inhibitor is
second line. Five days of treatment has been found to be as effective as ten days in otherwise
healthy children.

Chronic cases or with effusion

In chronic cases or with effusions present for months, surgery is sometimes performed by an
otolaryngologist or by an otologist, to insert a tympanostomy tube (also called a "grommet")
into the eardrum to allow air to pass through into the middle ear, and thus release any
pressure buildup and help clear excess fluid within.

Alternative therapies
There are claims that a variety of unproven techniques provide benefit to otitis media,
including osteopathic and chiropractic manipulation, Eardoc, dietary exclusions, herbal
supplements, acupuncture, traditional Chinese medicine, and homeopathy. The efficacy these
alternative therapies can only be evaluated with randomised controlled trials with adequate
sample sizes. None exist for otitis media: only anecdotal evidence is available.

One small clinical trial investigated the osteopathic Galbreath technique for improving
drainage, which it found promising. The technique was described in a 2000 article. A 2006
review of 346 patients found no complications with pediatric osteopathic treatments.

What is otitis media?

Otitis media is an infection or inflammation of the middle ear. This inflammation often begins when infections
that cause sore throats, colds, or other respiratory or breathing problems spread to the middle ear. These can be
viral or bacterial infections. Seventy-five percent of children experience at least one episode of otitis media by
their third birthday. Almost half of these children will have three or more ear infections during their first 3
years. It is estimated that medical costs and lost wages because of otitis media amount to $5 billion* a year in
the United States. Although otitis media is primarily a disease of infants and young children, it can also affect
adults.

*Gates GA. Cost-effectiveness considerations in otitis media treatment. Otolaryngol Head Neck Sur. April 1996.
114 (4): 525-530.

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How do we hear?
The ear consists of three major parts: the outer ear, the middle ear, and the inner ear. The outer ear includes the
pinna--the visible part of the ear--and the ear canal. The outer ear extends to the tympanic membrane or
eardrum, Image of the inner
ear
which separates the outer ear from the middle ear. The middle ear is an air-filled space
that is located behind the eardrum. The middle ear contains three tiny bones, the
malleus, incus, and stapes, which transmit sound from the eardrum to the inner ear. The
inner ear contains the hearing and balance organs. The cochlea contains the hearing
organ which converts sound into electrical signals which are associated with the origin
of impulses carried by nerves to the brain where their meanings are appreciated.
larger image
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Why are more children affected by otitis media than adults?

There are many reasons why children are more likely to suffer from otitis media than adults. First, children have
more trouble fighting infections. This is because their immune systems are still developing. Another reason has
to do with the child's eustachian tube. The eustachian tube is a small passageway that connects the upper part of
the throat to the middle ear. It is shorter and straighter in the child than in the adult. It can contribute to otitis
media in several ways.

The eustachian tube is usually closed but opens regularly to ventilate or replenish the air in the middle ear. This
tube also equalizes middle ear air pressure in response to air pressure changes in the environment. However, a
eustachian tube that is blocked by swelling of its lining or plugged with mucus from a cold or for some other
reason cannot open to ventilate the middle ear. The lack of ventilation may allow fluid from the tissue that lines
the middle ear to accumulate. If the eustachian tube remains plugged, the fluid cannot drain and begins to collect
in the normally air-filled middle ear.
One more factor that makes children more susceptible to otitis media is that adenoids in children are larger than
they are in adults. Adenoids are composed largely of cells (lymphocytes) that help fight infections. They are
positioned in the back of the upper part of the throat near the eustachian tubes. Enlarged adenoids can, because
of their size, interfere with the eustachian tube opening. In addition, adenoids may themselves become infected,
and the infection may spread into the eustachian tubes.

Bacteria reach the middle ear through the lining or the passageway of the eustachian tube and can then produce
infection, which causes swelling of the lining of the middle ear, blocking of the eustachian tube, and migration
of white cells from the bloodstream to help fight the infection. In this process the white cells accumulate, often
killing bacteria and dying themselves, leading to the formation of pus, a thick yellowish-white fluid in the
middle ear. As the fluid increases, the child may have trouble hearing because the eardrum and middle ear bones
are unable to move as freely as they should. As the infection worsens, many children also experience severe ear
pain. Too much fluid in the ear can put pressure on the eardrum and eventually tear it.

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What are the effects of otitis media?

Otitis media not only causes severe pain but may result in serious complications if it is not treated. An untreated
infection can travel from the middle ear to the nearby parts of the head, including the brain. Although the
hearing loss caused by otitis media is usually temporary, untreated otitis media may lead to permanent hearing
impairment. Persistent fluid in the middle ear and chronic otitis media can reduce a child's hearing at a time that
is critical for speech and language development. Children who have early hearing impairment from frequent ear
infections are likely to have speech and language disabilities.

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How can someone tell if a child has otitis media?

Otitis media is often difficult to detect because most children affected by this disorder do not yet have sufficient
speech and language skills to tell someone what is bothering them. Common signs to look for are

• unusual irritability
• difficulty sleeping
• tugging or pulling at one or both ears
• fever
• fluid draining from the ear
• loss of balance
• unresponsiveness to quiet sounds or other signs of hearing difficulty such as sitting too close
to the television or being inattentive

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Can anything be done to prevent otitis media?

Specific prevention strategies applicable to all infants and children such as immunization against viral
respiratory infections or specifically against the bacteria that cause otitis media are not currently available.
Nevertheless, it is known that children who are cared for in group settings, as well as children who live with
adults who smoke cigarettes, have more ear infections. Therefore, a child who is prone to otitis media should
avoid contact with sick playmates and environmental tobacco smoke. Infants who nurse from a bottle while
lying down also appear to develop otitis media more frequently. Children who have been breast-fed often have
fewer episodes of otitis media. Research has shown that cold and allergy medications such as antihistamines and
decongestants are not helpful in preventing ear infections. The best hope for avoiding ear infections is the
development of vaccines against the bacteria that most often cause otitis media. Scientists are currently
developing vaccines that show promise in preventing otitis media. Additional clinical research must be
completed to ensure their effectiveness and safety.
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How does a child's physician diagnose otitis media?

The simplest way to detect an active infection in the middle ear is to look in the child's ear with an otoscope, a
lightinstrument that allows the physician to examine the outer earand the eardrum. Inflammation of the eardrum
indicates aninfection. There are several ways that a physician checks for middle ear fluid. The use of a special
type of otoscopecalled a pneumatic otoscope allows the physician to blow a puff of air onto the eardrum to test
eardrum movement. (An eardrum with fluid behind it does not move as well as an eardrum with air behind it.)

A useful test of middle ear function is called tympanometry. This test requires insertion of a small soft plug into
the opening of the child's ear canal. The plug contains a speaker, a microphone, and a device that is able to
change the air pressure in the ear canal, allowing for several measures of the middle ear. The child feels air
pressure changes in the ear or hears a few brief tones. While this test provides information on the condition of
the middle ear, it does not determine how well the child hears. A physician may suggest a hearing test for a
child who has frequent ear infections to determine the extent of hearing loss. The hearing test is usually
performed by an audiologist, a person who is specially trained to measure hearing.

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How is otitis media treated?

Many physicians recommend the use of an antibiotic (a drug that kills bacteria) when there is an active middle
ear infection. If a child is experiencing pain, the physician may also recommend a pain reliever. Following the
physician's instructions is very important. Once started, the antibiotic should be taken until it is finished. Most
physicians will have the child return for a followup examination to see if the infection has cleared.

Unfortunately, there are many bacteria that can cause otitis media, and some have become resistant to some
antibiotics. This happens when antibiotics are given for coughs, colds, flu, or viral infections where antibiotic
treatment is not useful. When bacteria become resistant to antibiotics, those treatments are then less effective
against infections. This means that several different antibiotics may have to be tried before an ear infection
clears. Antibiotics may also produce unwanted side effects such as nausea, diarrhea, and rashes.**

Once the infection clears, fluid may remain in the middle ear for several months. Middle ear fluid that is not
infected often disappears after 3 to 6 weeks. Neither antihistamines nor decongestants are recommended as
helpful in the treatment of otitis media at any stage in the disease process. Sometimes physicians will treat the
child with an antibiotic to hasten the elimination of the fluid. If the fluid persists for more than 3 months and is
associated with a loss of hearing, many physicians suggest the insertion of "tubes" in the affected ears. This
operation, called a myringotomy, can usually be done on an outpatient basis by a surgeon, who is usually an
otolaryngologist (a physician who specializes in the ears, nose, and throat). While the child is asleep under
general anesthesia, the surgeon makes a small opening in the child's eardrum. A small metal or plastic tube is
placed into the opening in the eardrum. The tube ventilates the middle ear and helps keep the air pressure in the
middle ear equal to the air pressure in the environment. The tube normally stays in the eardrum for 6 to 12
months, after which time it usually comes out spontaneously. If a child has enlarged or infected adenoids, the
surgeon may recommend removal of the adenoids at the same time the ear tubes are inserted. Removal of the
adenoids has been shown to reduce episodes of otitis media in some children, but not those who are under 4
years of age. Research, however, has shown that removal of a child's tonsils does not reduce occurrences of
otitis media. Tonsillotomy and adenoidectomy may be appropriate for reasons other than middle ear fluid.

Hearing should be fully restored once the fluid is removed. Some children may need to have the operation again
if the otitis media returns after the tubes come out. While the tubes are in place, water should be kept out of the
ears. Many physicians recommend that a child with tubes wear special ear plugs while swimming or bathing so
that water does not enter the middle ear.

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What research is being done on otitis media?

Several avenues of research are being explored to further improve the prevention, diagnosis, and treatment of
otitismedia. For example, research is better defining those children who are at high risk for developing otitis
media and conditions that predispose certain individuals to middle ear infections. Emphasis is being placed on
discovering the reasons why some children have more ear infections than other children. The effects of otitis
media on children's speech and language development are important areas of study, as is research to develop
more accurate methods to help physicians detect middle ear infections. How the defense molecules and cells
involved with immunity respond to bacteria and viruses that often lead to otitis media is also under
investigation. Scientists are evaluating the success of certain drugs currently being used for the treatment of
otitis media and are examining new drugs that may be more effective, easier to administer, and better at
preventing new infections. Most important, research is leading to the availability of vaccines that will prevent
otitis media.