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Acuteotitismediainadults(suppurativeandserous)
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Acuteotitismediainadults(suppurativeandserous)
Authors
CharlesJLimb,MD
LawrenceRLustig,MD
JeromeOKlein,MD

SectionEditor
DanielGDeschler,MD,FACS

DeputyEditor
AllysonBloom,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2016.|Thistopiclastupdated:Oct17,2014.

INTRODUCTIONOtitismedia(infectionorinflammationofthemiddleear)isoneofthemostcommoninfections,and
acuteotitismedia(AOM)isamongthemostcommondiseasesthatleadtotreatmentwithantibiotics[1].AOMprimarily
occursinchildhoodandthemedicalliteratureoverwhelminglyfocusesonthepresentation,course,andtreatmentofAOM
inchildren.ThetreatmentofAOM[2]inadultsisthereforelargelyextrapolatedfromstudiesinchildren.
Lifethreateningcomplications,thoughinfrequent,maydevelopbecauseoftheproximityofthemiddleearandadjacent
mastoidtothemiddleandposteriorcranialfossaandrelatedstructures.Baseduponitshighprevalenceandpotentialto
causeseriousharm,otitismediaisapublichealthconcern.
Thistopicwilladdresstheetiology,diagnosis,andtreatmentofAOMinadults.IssuesrelatedtoAOMinchildrenare
discussedseparately.(See"Acuteotitismediainchildren:Diagnosis"and"Acuteotitismediainchildren:Epidemiology,
microbiology,clinicalmanifestations,andcomplications"and"Acuteotitismediainchildren:Treatment"and"Otitismedia
witheffusion(serousotitismedia)inchildren:Clinicalfeaturesanddiagnosis"and"Otitismediawitheffusion(serousotitis
media)inchildren:Management".)Issuesrelatedtochronicotitismediainadultsarealsodiscussedseparately.(See
"Chronicotitismedia,cholesteatoma,andmastoiditisinadults".)
CLASSIFICATIONOFOTITISMEDIAAvarietyofterms,relatedtotheareaofinvolvementandunderlyingdisease
process,areusedtocategorizeinfectiousorinflammatoryconditionsofthemiddleear.Theanatomyofthenormalearis
showninafigure(figure1).
Acuteotitismedia(AOM)Acuteotitismedia(AOM)isanacuteillnessmarkedbythepresenceofmiddleearfluidand
inflammationofthemucosathatlinesthemiddleearspace(picture1).Theinfectionisoftencausedbyobstructionofthe
eustachiantube,whichresultsinfluidretentionandsuppurationofretainedsecretions.AOMmayalsobeassociatedwith
purulentotorrheaifthereisarupturedtympanicmembrane.AOMusuallyrespondspromptlytoantimicrobialtherapy.
OtitismediawitheffusionOtitismediawitheffusion(OME)isdefinedbythepresenceofmiddleearfluidwithout
acutesignsofillnessorinflammationofthemiddleearmucosa.OMEusuallyfollowsAOMbutcanresultfrom
barotraumasorallergy.Eustachiantubedysfunctionisoftenapredisposingfactor.Rarely,OMEiscausedbyobstruction
oftheeustachiantubeorificeinthenasopharynxbyamassorcancersuchasnasopharyngealcarcinoma,orasaresult
ofradiationtreatmentfornasopharyngealmalignancy.
OMEtypicallyleadstoaconductivehearinglossandcanbeaprecursortoretractionandperforationofthetympanic
membrane.
AcutemastoiditisThemastoidisthatportionofthepetroustemporalbonethatliessuperiortothemiddleearcavity
(figure1).Themastoidantrumservesasanairspaceconnectingthemiddleeartothemastoidaircells.Thus,most
casesofAOMareassociatedwithsomedegreeofmastoidinflammationorinfection("mastoiditis").However,the
incidenceofclinicallysignificantmastoiditisislowsincetheintroductionofantibacterialdrugs.
Whenpusdoesenterthemastoidaircellsunderpressure,itmayleadtothedissolutionofsurroundingbone.This
representsaseriousprocessthatoftenrequiresurgentsurgicalevacuationbecausetheinfectioncanspreadtoregional
structures,includingthecentralnervoussystemorneck.Mastoiditiscanoccuratanyagebutisfarmorecommonin
childrenthanadultswhenitoccursinolderadults,itmaybeparticularlysevere[3].(See'Mastoiditis'below.)

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ChronicotitismediaChronicotitismedia(COM)isdiagnosedinanearwithatympanicmembraneperforationinthe
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settingofchronicearinfections,suchasanearwithchronicpurulentdrainagedespiteappropriateantibiotictreatment.
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COMmaybebenignandisoftencharacterizedbyadrytympanicmembraneperforation.Continuousserousdrainage
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(typicallystrawcolored)istermedchronicserousotitismedia,andchronicpurulentdrainagethroughaperforatedtympanic
membraneistermedchronicsuppurativeotitismedia.(See"Chronicotitismedia,cholesteatoma,andmastoiditisin
adults".)
EPIDEMIOLOGYOFAOMEpidemiologicstudiesofacuteotitismedia(AOM)overwhelminglyinvolvepediatricor
mixedpopulations.DataareunavailabletodeterminetheincidenceofAOMinanadultpopulation.Surveysdemonstrate
that80percentofchildrenwillexperienceoneormoreepisodesofAOMbytheageofsix[4].TheincidenceofAOM
markedlydecreasesaftertheageofseven.
Priortotheintroductionofantibiotics,acutecoalescentmastoiditiscomplicatedAOMinapproximately20percentof

cases[5].Currentreportsindicatethatmastoiditisandotherinfectiouscomplicationsinadultsdevelopinlessthan0.5
percentofcasesofAOM[6,7].
ETIOLOGYOFAOM
EustachiantubedysfunctionThemostimportantfactorinthepathogenesisofmiddleearinfectionsisdysfunctionof
theeustachiantube(figure1).Descentofthesoftpalatemuscleslingrelativetotheeustachiantubeorificewith
adolescenceimprovesthepatencyoftheeustachiantube,resultinginthedecliningincidenceofAOMwithage.However,
poortubalfunctioncanpersistintoadulthood.
Persistenteustachiantubedysfunctioninducesarelativenegativepressureinthemiddleearspace.Thelackofaeration
andtheaccumulationofeffusionsprovideanenvironmentconducivetothedevelopmentofAOMorotitismediawith
effusion(OME).
AnyentityresultingineustachiantubedysfunctionorobstructioncanpredisposetoAOM.Commoncausesinclude
seasonalallergicrhinitisandupperrespiratorytractinfections.Othercausesofeustachiantubedysfunctionrelateto
mucosaldisease(inflammatory,immunologicimpairment,orimmotilecilia),extrinsiccompression(nasopharyngealtumor
orenlargedadenoid),orpalatalmuscledysfunction(cleftpalateandothercraniofacialanomalies).(See"Eustachiantube
dysfunction".)
Microbiology
BacteriologyThemicrobiologyofAOMhasbeendocumentedbyculturesofmiddleearfluidsobtainedbyneedle
aspiration.Datafromadultsidentifypatternssimilartoinfectionsinchildren,withdominancebyStreptococcus
pneumoniaeandnontypableHaemophilusinfluenzae(NTH.influenzae)[1,8,9].GroupAbetahemolyticstreptococcus,
Staphylococcusaureus,andMoraxellacatarrhalisarelessfrequentcauses.
S.pneumoniaeisthemostimportantbacterialcauseofAOMinadults.Relativelyfewserotypesareresponsiblefor
mostdisease,althoughtheremayberegionaldifferences.ThemostfrequentserotypesresponsibleforAOM,in
decreasingorder,areserotypes19F,14,6B,23F,6A,and3[10,11].
Thesevenserotypepneumococcalconjugatevaccine(PCV7)usedinchildrenincludestypes4,6B,9V,14,18C,
19F,and23F.Itwasdevelopedbaseduponthemostprevalentserotypesresponsibleforinvasivedisease,butalso
includesthemajorserotypesresponsibleforAOM,exceptfor6Aand3.A13valentconjugatevaccine(Prevnar13)
wasapprovedbytheUSFoodandDrugAdministrationinMarch2010,withadditionalserotypes1,3,5,6A,7Fand
19A.Sincetheconjugatepneumococcalvaccineprotectsagainstcarriageofvaccineserotypes,itislikelythatthe
prevalenttypesresponsibleforAOMwillchangeinimmunizedchildren[12].Asanexample,NTH.influenzaemay
replacepneumococcusasthemostfrequentlyisolatedpathogenofAOMinchildrenimmunizedwithPCV7[1315].
Thedurabilityofprotectionprovidedbytheinfantimmunizationscheduleisuncertain,butappearstobesufficientto
coverthepreschoolyearsofhighestattackratesforbothinvasivepneumococcaldiseaseandAOM.The
pneumococcalpolysaccharidevaccineavailableforolderchildrenandadultsdoesnotaltercarriageofpneumococci,
incontrasttotheefficacyofPCV7andPVC13indecreasingcarriageofvaccineserotypes.

AOMduetoNTH.influenzaeisassociatedwithnontypeablestrainsinthevastmajorityofpatientsofallages[8].
NTH.influenzaeistheprimarypathogenintheuniqueconjunctivitisAOMsyndromeinchildren[16].Thesyndrome
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hasnotbeenidentifiedinadults,butitispossiblethatstrainsofHinfluenzaeresponsibleforAOMinadultsinclude
thosethatcausethissyndrome.

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Staphylococcusaureus,includingmethicillinresistantstrains,areanuncommoncauseofAOMbutcanoccurin
patientswithchronicsuppurativeotitismediaandmaybeassociatedwithpersistentotorrheathatfollowsinsertionof
tympanostomytubes[17].
GroupAstreptococcus(GAS)wastheleadingcauseofAOMduringthepreantibioticera.Themiddleeardisease
wasseverewithfrequentperforationofthetympanicmembraneandmastoiditis.GASisanuncommoncauseof
AOMtoday,thoughthereasonforthisisnotknown[18].
OtherorganismsEpidemiologicdatasuggestthatviralinfectionoftheupperrespiratorytractisfrequentlyaninitial
eventinthedevelopmentofAOM.Respiratoryviruseshavebeenisolatedfromthenasopharynxinupto50percentof

childrenwithAOMandinapproximatelyonequarterofmiddleearfluidsfromchildrenwithAOM.Themostfrequently
isolatedvirusesarerespiratorysyncytialvirus,influenzaviruses,andrhinoviruses[19,20].Combinedbacterialandviral
infectionsappeartobemoreseverethanviralorbacterialepisodesofAOM[21].
ExperimentalinfectionofadultvolunteerswithMycoplasmapneumoniaeresultedinhemorrhagicbullousmyringitis[22].
However,inthemanystudiesofthemicrobiologyofAOM,M.pneumoniaehasrarelybeenidentified.Somepatientswith
lowerrespiratorytractinfectionduetoM.pneumoniaehaveconcurrentAOM,althoughtheetiologicroleofM.pneumoniae
intheAOMisuncertain.
Fungiarefrequentlyassociatedwithotitisexterna.CandidaandAspergillusspecies,althoughinfrequent,havebeen
isolatedfrommiddleearfluidsofpatientswhodevelopedchronicsuppurativeotitismedia[23].
OtheruncommoncausesofAOMinclude:

Chlamydiatrachomatis
Diphtheriticotitis
Tuberculousotitis
Otogenoustetanus

BiofilmsTheroleofbiofilmsinthepathophysiologyofinfectionsoftheupperaerodigestivetractisincreasingly
recognized,particularlyinantibioticresistantcases[2,24,25].Abiofilmbeginsasanaggregateofbacteriathatattachtoa
surface.Suchbacteriademonstratereducedmetabolismandreplicationrates.
Biofilmsaredifficulttoeradicatesinceantibioticscannotreadilypenetratetheformedmatrix.Theproblemisconfounded
bythedifficultyinculturingbiofilms.Biofilmshavebeenidentifiedincholesteatomas[26]andtympanostomytubes[27],
supportingtheirroleinresistantinfections.
ImmunologyTherespiratorymucosalmembranethatlinesthemiddleearspaceandmastoidaircellsprovidesan
immunologicdefensivebarrier.Theconstantlyrenewedmucusthatformsthisbarrierisrichinlysozyme,apotent
antibacterialenzyme[28].Mucusproductionincreasesinresponsetoaninvadingorganism.Inaddition,inflammatory
dilationofvessels,whitebloodcellmigration,proteolyticenzymeactivity,andantibodydepositioncontributetothe
formationofmucopurulentsecretions.
AllofthemajorclassesofimmunoglobulinshavebeenidentifiedinmiddleeareffusionsofpatientswithAOM.The
presenceoftypespecificantibodiesinmiddleeareffusionsisassociatedwithclearanceofmucopurulentsecretionsand
anearlyreturntonormalmiddleearfunction.
TheincidenceofAOMandrelatedcomplicationsisincreasedinchildrenwithcongenitaloracquiredimmunologic
deficiencies[28],ariskthatpersistsintoadulthood.TherisksofAOManditscomplicationsarealsoincreasedinpatients
whohaveaconcomitantmalignancy,useimmunosuppressivedrugs,orhaveahistoryofpreviousirradiationtothe
nasopharyngealregion[29].
CLINICALMANIFESTATIONSOFAOMTheonsetofAOMinadultsistypicallyassociatedwithotalgia(earpain)and
decreasedhearing.Fevermaynotbepresent.Aprecedingupperrespiratorytractinfectionorexacerbationofseasonal
allergicrhinitismayheraldtheonsetofAOMbyseveraldays.

ThereisconsiderablevariabilityinthesymptomsandsignsofAOM.Theinfectionistypicallybutnotalwaysunilateral.A
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bulgingtympanicmembranedistinguishesacuteotitismediafromotitismediawitheffusion.(picture1).Thetympanic
membranemayalsobeerythematousoropacified.Ifthetympanicmembranehasruptured(oftenreportedbythepatient

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asareliefoftheotalgia),theremayalsobeassociatedpurulentotorrhea.
Dysequilibriumisdescribedinfrequently.Conductivehearinglossisusuallytransient.Othersymptoms,suchashigh
fever,severepainbehindtheear,orfacialparalysis,suggestunusualcomplications(See'ComplicationsofAOM'below.)
DIAGNOSISOFAOMItisimportanttomakeanaccuratediagnosisofAOMtoavoidtheinappropriateuseof
antibioticsandtheassociatedincreaseinantibioticresistancerates.
ExaminationwithahandheldotoscopeisthestandardmethodofdiagnosisofAOM.Theadditionofpneumatoscopy
allowsevaluationoftympanicmembranemotionandisthushighlyrecommendedfordiagnosis.Otomicroscopy,available

inotorhinologyspecialtypractices,allowsevengreaterdefinitionofthetympanicmembrane.

Examinationtypicallydemonstratestympanicmembraneredness,opacification,bulging(picture1),andpoormobility
whenpneumaticpressureisappliedusingapneumaticotoscope(movie1andpicture2).Thetympanicmembraneis
normallytranslucent(picture3).Incontrast,thetympanicmembraneappearscloudyoropaquewhenthereisfluidinthe
middleear.Anairfluidlevelispresentwhenthetympanicmembraneappearstranslucentaboveandopaquebelowthe
lineofdemarcation(picture4).Inaddition,theremaybepurulenceintheearcanalifthereisanassociatedtympanic
membranerupture.
ThepredictivevalueandaccuracyofabnormalotoscopefindingshavenotbeenreportedforAOMinadultsbuthasbeen
studiedinchildren[3032].Inonestudy,flawedbythelackofbacterialculturesandselectiveperformanceofmyringotomy
toconfirmthediagnosis,thepredictivevalueofcombinationsofclinicalfindingswasestimated(table1)[32].Thetriadof
bulgingtympanicmembrane,impairedmobility,andrednessorcloudinessofthetympanicmembranepredictedthe
diagnosisofAOM,confirmedatmyringotomy,in83to99percentofcases.Anotherstudyfoundthatabulgingtympanic
membranewasmorelikelytopredictAOMthanadistinctlyredtympanicmembrane[30].
Atuningforkexamination(512Hz)maydemonstrateconductivehearingloss.TheWebertestisperformedbyplacingthe
forkonthevertexoftheforeheadtheperceivedsoundwillbelouderintheinfectedear(figure2).
Fiberopticnasopharyngoscopyshouldbeperformedtoruleoutnasopharyngealpathologyinpatientswithrecurrent
unilateralserousotitismedia.Therearelimiteddataregardingtheyieldofnasopharyngoscopyintheroutineworkupof
isolatedotitismediawitheffusion,butitshouldbeborneinmindthatindividualsfromChina,SoutheastAsia,andNorthern
Africaareatincreasedriskfornasopharyngealcarcinoma[33].(See"Epidemiology,etiology,anddiagnosisof
nasopharyngealcarcinoma",sectionon'Geographicandethnicdistribution'.)
BullousmyringitisBullousmyringitisisapresentationofAOMinwhichblisters(bullae)areseenonthetympanic
membrane.Despiteearlierbeliefthatthisconditionwasassociatedwithmycoplasmalinfection,morerecentevidence
indicatesthattheprevalenceofviral,bacterial,ormycoplasmalinfectionisthesameinbullousmyringitisasinnonbullous
otitismedia[34](picture5).Bullousmyringitiscanbeparticularlypainful.
DIFFERENTIALDIAGNOSISOFAOMThedifferentialdiagnosisofacuteotitismediaincludesotitisexterna,
eustachiantubedysfunction,nasopharyngealpathologyincludingherpeszosterinfection,andotherheadandneck
infections.
AOMcanusuallybedifferentiatedfromotitisexternainthatthelattertendstobemorepainful,especiallywithmild
tractionontheouterear,andthereisanormalappearingeardrumonexamination.
PatientswithrecurrentunilateralAOM(ie,morethantwoepisodesoverasixmonthtimeperiod)shouldundergo
investigationforeustachiantubeornasopharyngealpathology.Fiberopticnasopharyngoscopyand/orcontrastMRIof
theskullbaseandnasopharynxshouldbeperformedtoruleoutthepossibilityofamalignantprocessobstructingthe
eustachiantubeorifice.

Thediagnosisofherpeszosterisestablishedwithdevelopmentofatypicaldermatomalvesicularrashthatevolves
intocrustedlesions.Prodromalpainmayprecedetherashbyseveraldaysand,lesscommonly,aweekormore.
TheRamsayHuntsyndrome(herpeszosteroticus)ischaracterizedbythetriadofipsilateralfacialparalysis,ear
pain,andvesiclesinvolvingtheauditorycanalandauricle,andcanalsocausevertigo.(See"Clinicalmanifestations
ofvaricellazostervirusinfection:Herpeszoster",sectionon'Rash'and"Clinicalmanifestationsofvaricellazoster
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virusinfection:Herpeszoster",sectionon'RamsayHuntsyndrome(Herpeszosteroticus)'.)

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Deepspaceheadandneckinfectionsarediscussedseparately.(See"Deepneckspaceinfections".)

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TREATMENTOFAOMAntibioticsarethemainstayoftreatmentofuncomplicatedsuppurativeacuteotitismediain
adults.ConsistentresultsfrombacteriologicstudiesofmiddleeareffusionsinchildrenandadultswithAOMsuggestthat
thechoiceofantimicrobialagentsmaybebasedonknowledgeofthebacteriologyofAOM,ratherthanresultsofcultures
fromadjacentsitessuchasthethroatornasopharynx.
MicrobiologicresultsindicatethatatleastonequarterofchildrenhaveAOMduetoaviralrespiratorypathogen,andthat
someoftheepisodesofAOMresolvewithoutantibacterialagents.AmongchildrenwithAOM,approximately19percentof
pneumococcal,anduptoonehalfofnontypable(NT)H.influenzaeAOMcasesresolveandfluidsamplesfromthemiddle
earbecomesterilewithoutantibacterialdrugs[35,36].TheseresultspromptedsomeEuropeanclinicianstowithhold

antibiotictherapyfromchildrenwithearinfections[37].TheoptionofobservationofchildrenwithAOM,ratherthaninitial

antimicrobialtherapy,ispracticedextensivelyinWesternEurope.
In2004theAmericanAcademyofPediatricsandtheAmericanAcademyofFamilyPhysiciansproposedasimilarprotocol
forwithholdingantimicrobialtherapyforchildrenwhowereolderthantwoyearsofage,whosediagnosiswasuncertain,
andwhodidnothaveseveredisease(eg,moderatetosevereotalgiawithfever39C)[38].Therearenodataabout
withholdingantimicrobialdrugsfromadultpatientswithAOM.Atthistime,itisprudenttotreatadultswithantibiotic
therapyforadiagnosisofAOMtopreventthepotentialforcomplicationsofanuntreatedinfection.(See'Complicationsof
AOM'below.)
Whileawaitingresponsetoantibiotictherapy,itisimportanttoaddressthereliefofpain,whichcanbesignificant.Most
patientswillsymptomaticallyimprovewithamildanalgesic,suchasanonsteroidalantiinflammatorymedication,although
ashortcourseofopioidsisoccasionallyindicated.
ChoiceofinitialantibioticThepreferredantibacterialdrugforthepatientwithAOMmustbeactiveagainstS.
pneumoniae,NTH.influenzae,andM.catarrhalis[3942].A2001metaanalysisconcludedthatthereisnoevidenceto
supportanyparticularantibioticregimenversusanotherfortreatmentofAOM[43].
AmoxicillinremainsthedrugofchoiceforinitialtherapyofAOMbecauseofits25yearrecordofclinicalsuccess,
acceptability,limitedsideeffects,andrelativelylowcost.AmoxicillinisineffectiveagainstbetalactamaseproducingNT
H.influenzaeandM.catarrhalis,butthecurrentincidenceofampicillinresistantstrainsisnotsufficientlyhightorequirea
changeininitialtherapy.Oneobservationalstudyestimatedthat12percentofpatientswithacuteotitismediafailedinitial
antibiotictherapy[44].Amongpatientstreatedwithamoxicillin,10percentofpatientsfailedinitialtherapy.
Theusualdoseofamoxicillinis:
Mildtomoderatedisease:500mgevery12hours,or250mgevery8hours
Severedisease(eg,patientswithfever,significanthearingloss,severepain,and/ormarkederythema):875mg
every12hours,or500mgevery8hours
Someexpertsrecommenddosagesofamoxicillinforadultsupto2geveryeighthours[45].Suchhigherdosesmaybe
indicatedincommunitiesinwhichthereisasignificantprevalenceofstrainsofStreptococcuspneumoniaethatarenot
fullysusceptibletopenicillin.Amoxicillinclavulanateshouldbeconsideredforpatientswithsevereotalgiaorelevated
temperaturetocoverthepossibilityofbetalactamaseproducingNTH.influenzae.
Wesuggestthatpatientswithmildtomoderatediseasebetreatedforfivetosevendays,andthosewithmoresevere
diseasereceivea10daycourseofantibiotic.Thereislittleevidenceregardingoptimaldurationoftherapyforadultswith
AOM.
PenicillinallergyAcceptablealternativestoamoxicillininpatientswithallergytopenicillindependuponthetypeof
theprevioushypersensitivityreaction.
Inpatientswhoreportpenicillinallergybutwhodidnotexperienceatype1hypersensitivityreaction(urticariaor
anaphylaxis),wesuggestoneofthefollowing:
Cefdinir(300mgtwiceadayor600mgoncedaily)

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Cefpodoxime(200mgtwiceaday)
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Cefuroxime(500mgevery12hours)
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Ceftriaxone(2gIMorIVonce)
Forpatientswithknownandsevereallergytobetalactamantibiotics,amacrolide(erythromycincombinedwith
sulfisoxazole,orazithromycin,orclarithromycin)isthepreferreddrug.Trimethoprimsulfamethoxazolemaybeused
inregionswherepneumococcalresistancetothiscombinationisnotaconcern.
LackofinitialresponseWithappropriateantimicrobialtherapy,mostpatientswithAOMaresignificantlyimproved
within48to72hours.Ifthereisnoimprovement,thepatientshouldbereexamined.Thepatientmayhavedevelopeda
newfocusofinfectionorhavereceivedinadequatetherapy.

Whenamoxicillinfails,thepatientshouldbetreatedwithasubsequentcourseofanantibioticwithabroaderactivity

spectrumforanother10daycourse.Appropriatesecondlineregimensincludeamoxicillinclavulanate(combinationof
amoxicillinplusthebetalactamaseinhibitorclavulanate),asecondgenerationcephalosporinsuchascefuroximeaxetil,or
athirdgenerationcephalosporin(suchasoralcefdinirorintramuscularceftriaxone).

RupturedtympanicmembraneWheninfectionresultsinacuteruptureofthetympanicmembrane,treatmentconsists
ofacombinationoforalandtopicalantibiotics,aswellaspreventingwaterentryintotheearcanal.Ototopicdrugsthat
havelowacidityandlowototoxicity,suchasFloxinotic,arepreferredacidic/antisepticagents,aswellastopicalagents
containingaminoglycosidesoralcohol,shouldbeavoidedwhenthemiddleearspaceisopen(table2).Althoughthereare
nodefinitivedatashowingthatpreparationssuchaspolymyxinneomycindropscausehearinglossinthese
circumstances,thereisanexplicitmanufacturerwarningnottouseneomycinpolymyxinBhydrocortisoneforanonintact
tympanicmembrane.
Inmostcases,therupturedtympanicmembranewillheal.Theperforationpermitsdrainageofthemiddleearabscessand
relievesincreasedmiddleearpressure.Withthereliefofmiddleearpressure,theextensivelyvascularizedtympanic
membraneusuallyhealsquickly,sealingtheperforationwithindays.Persistentsubjectivehearinglossfollowingresolution
oftheinfectionshouldbefollowedupwithanaudiogramandotolaryngologicconsultation.
Chronicperforationsmayoccur.Achronicallyinfectedmiddleearormastoidmayresultinpersistentsuppurativedrainage
(chronicsuppurativeotitismedia,CSOM).Patientswithperforationthatpersistsforsixweeksorlonger(withorwithout
suppurativedrainage)shouldbereferredtoanotolaryngologistforfurthermanagement.(See"Chronicotitismedia,
cholesteatoma,andmastoiditisinadults".)
COMPLICATIONSOFAOMComplicationsofacuteeardiseasecanoccurinthesettingofhostfactorssuchas
immunestatusandindividualanatomy,orincompletetreatment.Complicationsmayresultfromseedingofvascular
channelsandextensionalongpreformedpathways(suchastheovalwindow,roundwindow,internalauditorycanal,or
endolymphaticduct)andaretypicallydividedintointratemporalorextratemporalclassifications.
Intratemporalcomplications
MastoiditisAspectrumofdiseaseisassociatedwithmastoiditis.MastoideffusionisoftenseenonCTscanin
patientswithAOMandisnotusuallyclinicallysignificant.Symptomaticmastoiditisisararecomplicationofbothacute
andchronicotitismedia,butcanbeseriousduetoproximityofthemastoidtotheposteriorcranialfossa,lateralsinuses,
facialnervecanal,semicircularcanals,andthepetroustipofthetemporalbone.
Acutemastoiditisoccursmorecommonlyinchildrenthanadults,anditsincidencehasdeclineddramaticallyinthe
antibioticerawithroutineuseofantibioticsfortreatmentofotitismedia.Itisarareoccurrenceinadults.Inastudyof
patientswithacutemastoiditisadmittedtotwohospitalsinSwedenbetween1996and2000,only3ofthe42patients
wereolderthan18years[46].Twoofthethreeadultshadpriorcranialsurgeryonthesamesideasthemastoiditis.
Mastoiditismaybeclinicallymoresevereinolderadults,however[3].
Clinicalmastoiditismaypresentwithfever,posteriorearpainand/orlocalerythemaoverthemastoidbone,edemaofthe
pinna,oraposteriorlyanddownwarddisplacedauricle.Incoalescentmastoiditis,CTdemonstratescharacteristiclossof
thetrabecularbone[47].

CTscanshouldalwaysbeperformedwhenmastoiditisissuspected.Ifthereisaconcernforanintracranialprocess(ie,
sigmoidsinusthrombosis,intracranialabscess),thenanMRIscanshouldalsobeconsidered.Patientswithacute
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mastoiditisshouldbeadmittedtothehospitalandstartedonIVantibiotics.Whenmastoiditisoccursasacomplicationof
acuteotitismedia,antibioticswithactivityagainstStreptococcuspneumoniaeandHaemophilusinfluenzaeshouldbe
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started.Whenmastoiditispresentsasacomplicationofmorechronicdisease,coverageshouldincludeStaphylococcus
aureus,Pseudomonas,andentericgramnegativerods.
IfpatientsdonotrespondtoconservativetherapywithIVantibiotics,furtherinterventioniswarranted.Thisinvolves
mastoidectomyfordebridementofnecroticbone.Myringotomyisanadjuncttomastoidectomyforthetreatmentofacute
mastoiditis.(See"Chronicotitismedia,cholesteatoma,andmastoiditisinadults",sectionon'Surgicaltreatment'.)
FacialparalysisFacialparalysisisusuallyattributedtodirectneurocompressionthroughadehiscenceinthebone
coveringthefacialnerve,usuallyinthetympanicorverticalmastoidportions.Throughdestructionoftheoverlyingboneby
cholesteatomaorosteitis,endoneuritismaydevelop.Surgicaldecompressionoftheaffectedareaisrecommended.

LabyrinthitisLabyrinthitispresentsasnausea,vomiting,vertigo,tinnitus,andhearinglossinthesettingofboth
acuteandchronicearinfections.Apictureoflabyrinthitisinthesettingofacuteotitismediamayoccurasaresultof
serouslabyrinthitis,apresuppurativeconditioninwhichthelabyrinthundergoesinflammatorychangesinassociationwith
acutesuppurativeotitismedia.Serouslabyrinthitisisnotassociatedwithpermanentauditoryorvestibulardysfunction.
Treatmentispredominantlymedical,unlesspersistentgranulationtissueorcholesteatomaarepresent.Incontrast,
purulentlabyrinthitispresentswithintensevertigo,tinnitus,hearingloss,vomiting,nausea,andapictureofacutetoxicity.
(See"Treatmentofvertigo".)
HearinglossAvarietyofintratemporalchangescanproducehearinglossinthecontextofbothacuteandchronic
earinfections,thougharemorecommonlyseenincasesofchronicotitismedia.Thehearinglossisusuallyconductivein
natureduetoossicularerosionortympanicmembraneperforation.Sensorineuralhearinglossmayoccur,particularlyin
thesettingofanewinfectioninanadultwithoutapriorhistoryofearinfections.
PetrositisThepetrousapexofthetemporalboneisanatomicallycloselyrelatedtocriticalneuralandvascular
structures.Asaresult,infectionsofthepetrousapexcanresultinsevereneuralcompromise.Becauseoftheextensive
pneumatizationandpresenceofrichbonemarrowwithinthepetrousapex,itissusceptibletoinfectionorinflammation,
typicallyincombinationwithmastoiditis.TheinflammationmayextendintoDorelloscanaltransmittingtheVIthcranial
nerveandtheGasserianganglion,causingthetriadofsymptomsknownasGradenigoSyndrome:lateralrectuspalsy,
retroorbitalpain,andotorrhea.Thepresenceofbothotorrheaanddeeppainshouldleadonetosuspectpetrousapicitis.
ThemostcommonorganismresponsibleforpetrousapicitisisPseudomonasaeruginosa.Theacuteformtypically
developsoverarapidperiodoftimeandisduetosuddenobstructionofanormallypneumatizedpetrousapexaircell
system.DiagnosisisaffirmedbytemporalboneCT,demonstratingopacificationofthemastoidaircellssystemand
petrousapex,enhancementofthecavernoussinus,andbonyerosionwithinthepetrousapex.HighresolutionMRIwith
gadoliniumthroughthetemporalbonewilldemonstratealowintensitysignalonT1weightedimages,highintensitysignal
onT2weightedimages,andringenhancement.MRIfindingsareimportantindistinguishingpetrousapicitisfromother
lesionsofthepetrousapex.Treatmentconsistsofantibiotictherapy,withsurgicalexplorationreservedforthosewhodo
notrespondtoappropriateantibioticsordevelopcomplicationsfromtheinfection[48,49].Evenwithsurgicaldrainage,
prolongedpostoperativeantibioticsareusuallyrecommended,typicallyforaperiodofuptosixweeks.
Extratemporalcomplications
Epidural,subdural,andbrainabscessEpiduralabscessespresentmostcommonlyasheadachethatis
occasionallyrelievedbyprofusedrainagefromtheear.Treatmentrequiressurgicaldrainageafteridentificationofthe
abscessonMRIorCTimaging.Epiduralabscessesoccurmostcommonlysecondarytoerosionoftheposteriorfossa
plate.Lesscommonly,erosionofthetegmenmastoideumcanleadtoanepiduralabscess.(See"Spinalepidural
abscess".)
Thepresentationofasubduralabscessmaycloselymirrorthatofanepiduralabscess.Neurologicsignsaremorelikelyto
accompanyabscessesthatoccurinthesubduralspace,betweentheduraandarachnoidmeningeallayers.The
mechanismunderlyingthedevelopmentofasubduralabscessisthoughttobeboneerosionfollowedbythrombophlebitis.

Brainabscessesinassociationwithchronicearinfectionswilltypicallyinvolvethetemporallobeorcerebellum.Treatment
requiresdrainageofthebrainabscessbyaneurosurgeon,followedbysurgicaleradicationofthemastoidinfection.
Successfulmanagementofbrainabscessestypicallyrequiresaprolongedcourseofpotentantibiotictherapy.(See
http://www.uptodate.com/contents/acuteotitismediainadultssuppurativeandserous?topicKey=
"Pathogenesis,clinicalmanifestations,anddiagnosisofbrainabscess"and"Treatmentandprognosisofbacterialbrain
abscess".)

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OtitichydrocephalusOtitichydrocephalusreferstoasyndromeofincreasedintracranialpressureandsuppurative
otitismediaintheabsenceofabrainabscessormeningitis[50].Thetypicalcaseofotitichydrocephalusoccursfollowing
prolongedotitismedia.Themostcommonsymptomisheadacheonthesideoftheinvolvedear.Papilledemaisnotedand
evidenceofhydrocephalusisseenoncranialimagingbyCTorMRI.Thepathogenesisbehindotitichydrocephalus
appearstoinvolveabnormalcerebrospinalfluidmetabolismfrominflamedmeninges.Appropriatemanagementoftheear
diseaseandconventionalmeasuresofloweringintracranialpressureareindicated.
OtiticmeningitisOtiticmeningitisinassociationwithbothacuteandchroniceardiseasemayprogresstogeneral
patternsofinvolvementofthemeninges.TheoffendingpathogenisusuallynontypableH.influenzae,althoughS.

pneumoniaeand,toalesserextent,Neisseriameningitidiscanalsobeimplicated.Themeningitismaybelocal,inwhich

casecerebrospinalfluidanalysismaybenegativeforbacteria.Usually,however,themeningitisisgeneralized,andlumbar
puncturewithspinalfluidstudiesdemonstratebacteria.Otiticmeningitisisthemostcommonintracranialcomplication
fromchronicotitisandmastoiditis,althoughmeningitismayoccurinassociationwithacuteotitismediaaswell.Allforms
ofotiticmeningitistypicallypresentwiththeclassicsignsofmeningitis,includingfever,neckpain,photophobia,and
mentalstatuschanges[51].Treatmentrequiresantibiosisandsurgicalremovalofcholesteatomaand/orgranulationtissue.
LateralsinusthrombosisThelateral,orsigmoidsinus,runsthroughtheposteriorportionofthemastoidcortex,
whereithasacharacteristiccurvatureandeventuallyformsthejugularbulbandinternaljugularvein.Septiclateralsinus
thrombosisisexclusivelyassociatedwithinfectionofthemastoidaircells.Lateralsinusthrombosisisoftensubacutein
onset,withapersistentearacheasthefirstsymptompersistingforseveralweeksbeforetheonsetofheadache.Anemia,
increasedsignsofincreasedintracranialpressure,lowercranialneuropathies,andGriesingerssign(postauricularedema
fromemissaryveinthrombophlebitis)mayresultinadvancedstagesofthedisease.Sigmoidthrombophlebitismayextend
tothejugularvein,withresultantinternaljugularveinthrombosis.Treatmentrequiresdrainageoftheperisinusabscessvia
atransmastoidapproach,exposureofthesigmoidsinus,andantibiotics.Iftherearesignsofsystemicembolization(eg,
pulmonaryembolus),anticoagulationmaybeindicated.(See"Septicduralsinusthrombosis",sectionon'Septiclateral
sinusthrombosis'.)
OTITISMEDIAWITHEFFUSIONOMEisoftencharacterizedbyhearinglossorauralfullness,andpossiblyahistory
ofrecurrentepisodesofAOM.Theremaybeanantecedentupperrespiratorytractinfection,exacerbationinseasonal
allergysymptoms,orairplanetravel.
OtoscopicfindingsofOMEarefluid(oftenyellowish,butsometimesclear),andvisiblebehindaretractedtympanic
membrane.Anormaltympanicmembraneisshowninaphotograph(picture3),tobecomparedwitharetractedtympanic
membrane(picture6).Viscousbubblesmayalsobeseen,particularlyduringpneumaticotoscopy.Pneumaticotoscopy
demonstratesreducedmobilityoftheeardrum.
Tympanometry,thebestmeansofdiagnosis,willdemonstrateaflat(typeB)configuration.Patientswithsymptomsofear
fullnessassociatedwithhearinglossand/orvisualizationofanopaqueoryellowishtympanicmembraneonpneumatic
otoscopyshouldbereferredfortympanometrywithaudiometry.Audiometrywillrevealthepresenceofamildtomoderate
conductivehearingloss.Ifsensorineuralhearinglossisdemonstrated,particularlyinthepresenceofnormal
tympanometry,immediatereferraltoanotolaryngologistiswarrantedforpossibletherapywithglucocorticoidsandtorule
outaretrocochlearlesion.
TreatmentforOMEInmostcases,OMEresolvesspontaneouslywithouttreatment.Inasmallpercentageofcases,
theeffusionpersistsandrequiresadditionalintervention,suchaspressureequalizationtubes.
Simplemaneuverssuchasautoinsufflation(pinchingthenosewhilegentlyexhaling,forcingairbackthroughthe
eustachiantubeandrepressurizingtheear)maybehelpful,althoughasystematicreviewofsmallstudiesof
autoinsufflationinchildrendidnotdemonstrateasignificantdifferenceintympanometryresultsbetweeninterventionand
controlpatients[52].Studiesarenotavailableinadults,butthemaneuverisofnocost,withoutadverseeffects,andmay
behelpfultosome.

Otitismediawitheffusiondevelopsprimarilyfromamechanical/obstructivephenomenon.Thereisnoevidencethat
decongestantsandantihistaminesarebeneficialinthetreatmentofOMEinchildren[53].However,inadults,seasonal
allergicrhinitisornasopharyngealswellingfromanupperrespiratorytractinfectioncaninduceeustachiantube
dysfunction.Asaresult,mostpatientsaretreatedwithdecongestants,antihistamines,ornasalsteroidsdespitealackof
http://www.uptodate.com/contents/acuteotitismediainadultssuppurativeandserous?topicKey=
datademonstratingaclearbenefitinOME.Decongestantsmightcausesomesymptomreliefbyalleviatingnasal

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congestion.Amajorityofeffusionswillresolveoverthecourseof12weeks,andmostpatientscanbeobservedoverthis
timeperiod.
Iftheeffusiondoesnotresolveoverthistimeperiod,oriftherearepressingneedstoprovidepressureequalizationor
improvedhearing(eg,anticipatedairplanetravelthatcannotbedeferreduntilOMEresolves),thenmyringotomywithtube
placementshouldbeperformed.CaseserieshaveshownmyringotomyforOMEtobeeffectivewithfewadverseeffects
[54]therearenoavailablerandomizedtrialsofmyringotomyforthetreatmentofOMEinadults.
Myringotomyiscontraindicatedinpatientswithirreversibleeustachiantubedysfunctionsecondarytoetiologiessuchas
cancerorradiationtherapyinvolvingtheeustachiantube.Placementofatubeinsuchpatientscanpotentiallyresultin

chronicotorrhea.Hearinglossfromaneffusioninthesepatientsmustbeweighedagainstthepotentialdevelopmentofa

chronicallydrainingearwithtympanostomytubeplacement[55].
SUMMARYANDRECOMMENDATIONS
Acuteotitismedia(AOM)isanacuteillnesswithmiddleearfluidandinflammationofthemucosalliningofthe
middleearspace.Purulentotorrheamaybepresentthrougharupturedtympanicmembrane.Otitismediawith
effusion(OME)isthepresenceofmiddleearfluidwithoutinflammation,andusuallyresultsfrombarotraumasor
allergy.Acutemastoiditis,inflammationofthepetrousboneadjacenttothemiddleear,isinfrequentlyclinically
significant,butmaybesevereinolderadults.Chronicsuppurativeotitismedia(CSOM)occurswithaperforated
tympanicmembraneinthesettingofchronicearinfections.(See'Classificationofotitismedia'above.)
Eustachiantubedysfunction,commonlyrelatedtoseasonalallergicrhinitisorupperrespiratorytractinfection,isthe
mostimportantfactorinthepathogenesisofmiddleearinfections.(See'EtiologyofAOM'above.)
CommonbacteriacausingAOMinbothchildrenandadultsareStreptococcuspneumoniaeandHaemophilus
influenzae.GroupAbetahemolyticstreptococcus,Staphylococcusaureus,andMoraxellacatarrhalisareless
frequentcauses.Childhoodimmunizationwithconjugatepneumococcalvaccinemayaffectcurrentmicrobial
prevalencedata.Respiratoryviruseshavebeenisolatedfromaquarterofmiddleearfluidssampledfromchildren
withAOM.(See'Microbiology'above.)
TheonsetofAOMisassociatedwithotalgiaanddecreasedhearing.AOMistypicallyunilateralanddrainagemaybe
presentifthetympanicmembranehasruptured.Thetympanicmembraneisred,opacified,bulgingandimmotile,and
aconductivehearinglossmaybedemonstrated.(See'ClinicalmanifestationsofAOM'aboveand'Diagnosisof
AOM'above.)
WesuggestthatadultswithAOMbemanagedwithantibiotictreatmentratherthan"watchfulwaiting"(Grade2B).
ThepreferredantibacterialdrugforthepatientwithAOMmustbeactiveagainstS.pneumoniae,nontypableH.
influenzae,andM.catarrhalis.Thereisnoevidencetosupportanyparticularantibioticregimenversusanotherfor
treatmentofAOM.Basedonitsacceptabilityandlowcost,wetypicallyuseamoxicillin500mgthreetimesadayfor
fivetosevendaysasinitialtherapyforAOMinpatientswithoutpenicillinallergy.Amacrolide(erythromycin
combinedwithsulfisoxazole,orazithromycin,orclarithromycin)isthepreferreddrugforpenicillinallergicpatients.
(See'TreatmentofAOM'above.)
Patientswhodonotrespondsymptomaticallywithin48to72hoursshouldbereexamined.Treatmentregimensfor
patientswhodidnotrespondtotheinitialantibioticcourseincludeamoxicillinclavulanateorasecondgeneration
cephalosporin.(See'Lackofinitialresponse'above.)
Otitismediawitheffusion(OME)ischaracterizedbyhearinglossorauralfullnessandpossiblyahistoryofrecurrent
episodesofAOM.Otoscopyrevealsfluidandanimmobileretractedmembranetympanometryisthebestmeansof
diagnosis.(See'Otitismediawitheffusion'above.)

Amajorityofeffusionswillresolveoverthecourseof12weeks,andmostpatientswithOMEcanbeobservedover
thistimeperiod.Wesuggestatrialoforaldecongestantsduringthistime(Grade2C).Patientsshouldbeinstructed
inautoinsufflationasalowcostintervention.Myringotomywithtympanostomytubesmaybeconsideredfor
persistentsymptomaticeffusionsat12weeks,andearlierforselectedpatientswithneedforimmediatepressure
equalization(eg,airtravelthatcannotbedeferred).(See'TreatmentforOME'above.)
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Topic6872Version31.0

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GRAPHICS
Normalearanatomy

Thisfigureshowsthenormalstructuresoftheouter,middle,andinnerear.
Graphic63141Version3.0

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Acuteotitismedia

Examplesofthewhite,bulgingtympanicmembraneseeninacuteotitismedia.The"B"
panelalsodemonstratesmarkederythemaalongthehandleofthemalleusandanair
fluidlevelintheanterosuperiorportionofthetympanicmembrane.
CourtesyofAlejandroHoberman,MD.
Graphic63268Version3.0

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Pneumaticotoscope

CourtesyofLauraGoguen,MD.
Graphic93798Version1.0

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Acuteotitismediainadults(suppurativeandserous)

Normaltympanicmembrane

Normallefttympanicmembranewithpearlygraycolor.
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Acuteotitismediainadults(suppurativeandserous)

Tympanicmembranewithairfluidlevels

Anairfluidlevelisappreciatedwhenthetympanicmembraneappears
translucentaboveandopaquebelowalinedemarcatingthe
separation.
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Acuteotitismediainadults(suppurativeandserous)

Predictivevalueofcombinationsofotoscopicfindingsinchildrenwith
acuteearsymptoms
PositionofTM

MobilityofTM

ColorofTM

Predictivevalue,percent

Combinationswith>80percentpredictivevalueofAOMcomparedwithmyringotomy
Bulging

Distinctlyimpaired

Cloudy

99

Bulging

Slightlyimpaired

Cloudy

99

Bulging

Distinctlyimpaired

Distinctlyred

94

Bulging

Slightlyimpaired

Slightlyred

93

Bulging

Distinctlyimpaired

Slightlyred

85

Bulging

Slightlyimpaired

Distinctlyred

83

Normal

Distinctlyimpaired

Cloudy

97

Normal

Distinctlyimpaired

Distinctlyred

89

Combinationswith<50percentpredictivevalueofAOMcomparedwithmyringotomy
Normal

Slightlyimpaired

Distinctlyred

47

Normal

Slightlyimpaired

Slightlyred

41

Normal

Normal

Cloudy

37

Normal

Normal

Distinctlyred

15

Normal

Normal

Slightlyred

Normal

Normal

Normal

0.1

Retracted

Distinctlyimpaired

Normal

29

Retracted

Slightlyimpaired

Normal

TM:tympanicmembrane.
Datafrom:
Pelton,SI.Otoscopyforthediagnosisofotitismedia.PediatrInfectDisJ199817:540.
Karma,PH,Sipila,MM,Kayaja,MJ,Penttila,MA.Pneumaticotoscopyandotitismedia:Thevalueofdifferent
tympanicmembranefindingsandtheircombinations.In:Recentadvancesinotitismedia:proceedingsofthe
FifthInternationalSymposium,Lim,DJ,Bluestone,CD,Klein,JO,etal(Eds),Decker,Burlington,Ontario,
Canada,1993.p.41.
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Acuteotitismediainadults(suppurativeandserous)

Evaluationofhearingloss,WeberandRinnetests

Webertest:Placethebaseofastrucktuningforkonthebridgeofthe
forehead,nose,orteeth.Inanormaltestthereisnolateralizationofsound.
Withunilateralconductiveloss,soundlateralizestowardsaffectedear.With
unilateralsensorineuralloss,soundlateralizestothenormalorbetterhearing
side.
Rinnetest:Placethebaseofastrucktuningforkonthemastoidbonebehind
theear.Havethepatientindicatewhensoundisnolongerheard.Movefork
(heldatbase)besideearandaskifnowaudible.Inanormaltest,AC>BC
patientcanhearforkatear.Withconductiveloss,BC>ACpatientwillnot
hearforkatear.
AC:airconductionBC:boneconduction.
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Acuteotitismediainadults(suppurativeandserous)

Bullousmyringitis

Bullousmyringitisischaracterizedbypainfulvesiclesthatappearon
thetympanicmembrane.
CourtesyofGlennCIsaacson,MD,FAAP,FACS.
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Acuteotitismediainadults(suppurativeandserous)

Topicalpreparationsforexternalotitis

Topical
preparation

Trade
name
(United
States)

Antiseptic

Glucocorticoid

pH

Preservative

Acidifying/antisepticsolution
Aceticacid2
percentotic
solution

Generic
(formerly
Acetasol)

Aceticacid

None

Notes

3.5to5

Noadditional

Avoiduseof
acidifying
antiseptic
agentsif
tympanic
membraneis
knownor
suspectedtobe
nonintact
containsboric
acid

Hydrocortisone

2to4

Noadditional

Avoiduseof
acidifying
antiseptic
agentsif
tympanic
membraneis
knownor
suspectedtobe
nonintact
contains
propyleneglycol
(dryingagent)
and
benzethonium
forpromoting
tissue
penetration

Acidifying/antisepticandglucocorticoidcombination
Aceticacid2
percentand
hydrocortisone
1percentotic
solution

Acetasol
HC,VoSol
HCotic

Aceticacid

Antibioticandglucocorticoidcombinations
Ciprofloxacin
0.3percentand
dexamethasone
0.1percentotic
suspension

Ciprodex

None

Dexamethasone

Buffered

Benzalkonium
chloride

Containsboric
acid

Ciprofloxacin
0.2percentand
hydrocortisone
1percentotic
suspension

CiproHC
otic

None

Hydrocortisone

Buffered

Benzylalcohol

Neomycin0.35

URL,DOI,
Cortisporin
None
Hydrocortisone
Acidic

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Avoiduseof

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percent,
polymyxinB
10,000
units/mL,and
hydrocortisone
0.5percentotic

otic

metabisulfite

solution

topical
aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact

Neomycin0.33
percent,colistin
0.3percent,
and
hydrocortisone
1percentotic
suspension

ColyMycin
S,
Cortisporin
TC

None

Hydrocortisone

Thimerosal

Avoiduseof
topical

aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact
contains
thonzoniumfor
promoting
tissue
penetration

Gentamicin0.3
percentand
prednisolone1
percent
ophthalmic
suspension

PredG

None

Prednisolone

5.4to
6.6

Benzalkonium
chloride

Avoiduseof
topical
aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact

Tobramycin0.3
percentand
dexamethasone
0.1percent
ophthalmic
suspension

TobraDex

None

Dexamethasone

Buffered

Benzalkonium
chloride

Avoiduseof
topical
aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact

Gentamicin0.3
percentand
betamethasone
0.1percentotic
solution

Garasone*
(not
available
inUnited
States)

None

Betamethasone

Buffered

Benzalkonium
chloride

Avoiduseof
topical
aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact
containsboric
acid

Cetraxal
otic

None

None

Buffered

Nonesingleuse
container

Suppliedas0.5

Antibioticsolutions
Ciprofloxacin
0.2percentotic
solution

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contains
povidone
Ofloxacin0.3
percentotic
solution

Generic
(formerly
Floxinotic)

None

None

6.5

Benzalkonium
chloride

None

Dexamethasone

Buffered

Benzalkonium
chloride

Glucocorticoidsuspension
Dexamethasone
0.1percent
ophthalmic
suspension

Maxidex

*NotavailableintheUnitedStates.ProductshownisavailableinCanadaandothercountries.
Preparedwithdatafrom:
1.RosenfeldRM,SchwartzSR,CanonCR,etal.Clinicalpracticeguideline:Acuteotitisexterna.Otolaryngol
HeadNeckSurg2014150:S1.
2.UnitedStatesprescribinginformationavailableatNationalLibraryofMedicineDailyMedwebsite(Accessed
onMarch17,2014).
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Retractedtympanicmembrane

Whenthereisanegativepressureinthemiddleearcavity,the
positionofthetympanicmembranewillberetracted.
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Acuteotitismediainadults(suppurativeandserous)

ContributorDisclosures
CharlesJLimb,MDNothingtodisclose.LawrenceRLustig,MDNothingtodisclose.JeromeOKlein,MD
Consultant/AdvisoryBoards:GlaxoSmithKline[proteinpneumococcalconjugatevaccine(DataandSafetyMonitoring
Board)].DanielGDeschler,MD,FACSNothingtodisclose.AllysonBloom,MDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedby
vettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.
AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.

Conflictofinterestpolicy

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