Otitis Media

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

The ear consists of the outer, middle, and inner ear. The middle ear is located behind the eardrum, and is connected to the back of the nose by a small tube called the eustachian tube. This tube lets air into the middle ear and allows fluids to drain. Every time you swallow, the eustachian tube opens and keeps pressure equal on each side of the eardrum. However, allergies and viral or bacterial infections that irritate the nasal passages can cause swelling in the eustachian tube. The swelling limits its ability to drain fluids, which build up in the middle ear and create pressure. It's also easy for bacteria to grow in the trapped fluid.

Signs and symptoms

The following are the most common symptoms of otitis media. However, each child may experience symptoms differently. Symptoms may include:

• unusual irritability
• difficulty sleeping or staying asleep
• tugging or pulling at one or both ears
• fever
• fluid draining from ear(s)
• loss of balance
• hearing difficulties
• ear pain
• nausea and vomiting
• diarrhea
• decreased appetite
• congestion

Diagnosis

To diagnose an ear infection, your doctor will take your medical history and perform a thorough physical examination. He or she will use an instrument called an otoscope to check the inside of your ear for redness and swelling. The doctor will attach a small tube to the otoscope, through which he or she can blow a small puff of air to check for movement of the eardrum. The doctor may also use a procedure called tympanometry to check for fluid in the middle ear. When ear infections are chronic, your doctor may perform a procedure called tympanocentesis, which involves making a small hole in the eardrum to remove a sample of middle ear fluid. This fluid is then cultured to determine what type of bacteria is causing the infections.

Treatment

The type of otitis media dictates the treatment guidelines.

Suppurative otitis media

In acute suppurative otitis media, antibiotic therapy includes ampicillin or amoxicillin. In areas with a high incidence of beta-lactamase-producing H. inftuenzae 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 cotrimoxazole. 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.

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, such as amoxicillinlclavulanate potassium or cefuroxime, 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, possibly, mastoidectomy. Cholesteatoma requires excision.

Prevention

There is no way to totally eliminate all the risk factors associated with otitis media, but certain steps may be taken to lower the chance of developing this condition. Some of these include:

• Avoid feeding the child while he or she is laying flat
• Try to reduce the use of a pacifier
• Keeping children's immunizations up-to-date, because certain vaccines can help prevent ear infections.
• Avoid utilizing daycare (or moving the child from a large daycare center to a smaller home based place of care)
• Avoid exposure to secondhand tobacco smoke, which can increase the frequency and severity of 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.