Prof. Dr. Lt Col. A. Ravi Kumar, MS (ENT), DNB, DLORCS.*
Head, Dept of ENT, Head and Neck Surgery, Sri Ramachandra Medical College & Research Institute (DU) Porur, Chennai - 600016, Tamilnadu. *
Otitis Media is defined as inflammation of the mucoperiosteal lining of the middle ear cleft. Middle ear cleft consists of the eustachian tube, tympanum, aditus and antrum, mastoid antrum and air cells (Fig. 1). Otitis media can be acute or chronic; suppurative or non suppurative (otitis media with effusion). Mostly otitis media has an acute onset and if not resolved progresses to chronic stage (Fig 1a). The correct clinical diagnosis with recognition of the stage of disease will help in early resolution of disease with appropriate therapy. In addition, complications can be prevented.

Fig. 1a Otitis Media Classification

The commonest mode of infection of the middle ear cleft is through the eustachian tube, by pathogens from the nose and the nasopharynx. Hence, otitis media is usually preceded by upper respiratory tract infection (ascending infection). The pathogens responsible are the ones that commonly infect the nasal passages, paranasal sinuses and nasopharynx, namely, streptococci, pneumococci, Haemophilus influenzae and viruses infecting the respiratory tract. (1,2) A small percentage of patients develop otitis media following trauma to the tympanic membrane, due to various causes such as diving while swimming, slap on the ear, head injury or self cleaning of the ear. Here, the pathogens are different and mostly are of the skin flora such as Staphylococcus aureus, Bacteroides etc. Therefore it is important to ascertain the mode of onset of infection to plan antibiotic therapy while awaiting culture report.
Role of Adenoids and Tonsils
It has been conclusively proved that adenoids have a major role to play in the causation and the persistence of otitis media.(3, 4) This is because of their location in the nasopharynx near the pharyngeal opening of the eustachian tube, the angulation of the eustachian tube in the child which is more horizontal when compared to adults and the frequent regurgitation of food and fluids in a child due to incomplete velopharyngeal closure. Hence the adenoids act as reservoir of infection in the nasopharynx. As a result of this the other lymphoid structures in the Waldeyer's ring also get inflamed, especially the 'tubal tonsil of Gerlach' which is adjacent to the eustachian tube. Currently the role of tonsils in the causation of otitis media is debated, unless it is also inflamed secondary to adenoid infection. As a result of the inflammation in the nasopharynx with all the lymphoid tissue hyperplasia, there is presence of infected mucus and mucopus in the region of the pharyngeal end of the eustachian tube. This causes inflammatory oedema leading to partial or complete occlusion of the eustachian tube and impediment of normal function. Due to ascending infection (salpingitis) through the eustachian tube, the tympanum gets inflamed. This causes negative pressure in the middle ear leading to exudation of serous fluid in the tympanum. Accordingly acute otitis media is caused by the former and otitis media with effusion is caused by the latter mechanism. The persistence of infection / effusion, depends on the virulence of the organisms, host immunity, the timing and adequacy of treatment to control infection as well as eustachian tube function.(5)
Clinical Presentation
This depends on the type of otitis media, acute or chronic. The catarrhal child, with sudden onset of earache and fever or an infant who is frequently pulling the ear should alert the clinician a possible diagnosis of otitis media. General symptoms such as fever, nausea, vomiting, malaise, etc may get masked due to treatment given. A high degree of clinical suspicion is needed to establish correct diagnosis. This becomes easier in recurrent cases, if the practitioner has treated the patient earlier.

After a quick general assessment which should include vital signs, degree of hydration and presence of neck rigidity, the focus should be on otoscopy and examination of nose and pharynx. The presence of pus, discharge or wax should not deter the clinician from performing otoscopy as these can be removed gently using headlight and sterile cotton swabs. However one should avoid traumatizing the external auditory canal. If purulent exudates are found in external auditory canal, swab for culture and sensitivity should be taken before starting therapy. The typical otoscopic picture in acute otitis media (Fig. 2) and otitis media with effusion (OME) also known as secretory otitis media depends on the stage of disease (Fig. 3). The method of examination of a child/infant for otoscopy is important as it leads to accurate diagnosis.

It is to be stressed here that the diagnosis is a clinical one. There is no need to subject the child to investigations immediately as they do not contribute to establishing a diagnosis. The only investigation which may be useful is estimation of total and differential white blood cell count (TC, DC). X-ray mastoids, audiometry (in children older than 3 years) and tympanometry can wait till the acute symptoms subside. These are more appropriate and required to be done in chronic otitis media. Tympanometry which measures the compliance of the middle ear, presence / absence of fluid and acoustic reflex is the most important test in otitis media with effusion or a OME (secretory otitis media) 6. However it is contraindicated in acute otitis media (AOM). It is useless in a perforated ear drum as in chronic suppurative otitis media (CSOM) (Figs. 4, 5).
The history and clinical signs, most often leads to the diagnosis of acute or chronic otitis media. The short history, presence of acute symptoms such as pain, fever, cold, cough, hearing loss points to acute otitis media, whereas the presence of hearing loss, with blocked ears and absence of pain points to OME. The presence of ear discharge (purulent, mucopurulent or mucoid) points to chronic otitis media. Foul smelling purulent discharge is indicative of unsafe otitis media with presence of cholesteatoma. Bloody ear discharge may be present in this as well as at times in a cute otitis media just when the tympanic membrane has perforated. In almost all cases, otoscopy confirms the diagnosis, though at times one may have to clean the discharge in external auditory meatus before viewing the tympanic membrane. In cases of complication arising out of otitis media one should look for increasing pain, fever, headache, giddiness (vertigo), altered sensorium. Local examination findings may reveal mastoid tenderness, fluctuant post aural swelling (in mastoid abscess), thick creamy ear discharge and at times cranial nerve palsy (VII N and VI N). Clinical suspicion of an impending complication is essential to make an early diagnosis.
The 3 goals of management is to achieve
  1. A safe ear
  2. A dry ear
  3. Restore normal function (hearing and vestibular function)

The first goal is to treat effectively to prevent complications or limit severity of complications, if already existing. The second is to stop the ear discharge and the third is to achieve complete resolution of disease leading to normal function. To this end, treatment and investigations should proceed simultaneously in order to avoid loss of valuable time. The rapid progression or regression of disease depends on the timely and effective intervention and close follow up. Delay will cause persistence of disease leading to complications.

After clinical assessment and diagnosis, a quick assessment of hearing status is made in older child (3-5 years and above) by Tuning fork tests, before starting treatment. The only other investigation of importance at this time is aural swab for culture, if there is pus discharge. The swab must be taken by the clinician using aseptic technique and avoiding skin contamination. Imaging of the mastoids, middle ear, audiometry etc can wait till the acute symptoms have subsided. They can be ordered at the initial visit in chronic cases and in cases of OME.

All acute cases have to be started on systemic antibiotics.(7) The preferred antibiotic for respiratory pathogen is amoxicillin or amoxicillin/clavulanate in appropriate dose.(8) Depending on the severity, it can be given orally or parenterally, but must be continued for one week at the least. All cases with complications must be treated with parenteral (IV) antibiotics. Alternative antibiotic would be 3rd or 4th generation cephalosporins. Quinolones are avoided in children.

Non-sedative antihistamines, decongestants, both oral and topical are started simultaneously with aim of restoring eustachian tube function. The common antihistamines used are cetirizine or fexofenadine and topical decongestants such as oxymetazoline and xylometazoline in half strength paediatric formulations. Mucolytics are valuable in cases of OME to reduce viscosity of secretions. Bromhexine in appropriate doses for one week is recommended. Topical antibiotics with or without steroids is to be used when there is a perforated tympanic membrane with discharge. This helps in reducing mucosal inflammation in middle ear and relieves pain. The method of instilling the drops (pulling the ear back and down and then exerting tragal pressure) should be explained to the mother. Usually 5-7 days course is sufficient. Analgesics are given in appropriate doses especially in acute otitis media.

General Measures
  1. Keeping child at home.
  2. Avoidance of contact with other children with respiratory infections especially in school.
  3. Ingestion of warm fluids frequently to promote swallowing for restoration of eustachian tube function.
  4. Steam inhalation especially in older children.
  5. Avoidance of sniffing, to prevent ascending infection, through eustachian tube.
  6. Avoidance of blast of cold air on face, e.g., sleeping in front of Air-con

Follow up
It is important to follow up these patients and record the progress. Over 90% of middle ear infections resolve completely within 10-15 days. Persistence of infections, middle ear effusions or perforation are indications for referral to otorhinolaryngologist for further management. Thus unfortunate patients, who develop complications (e.g., mastoiditis, facial palsy) despite initial treatment, also need the prompt referral for surgical management. Recurrent middle ear infections and persistent hearing impairment between acute episodes also call for audiological investigations and further treatment such as insertion of ventilation tubes in OME (Figure 6).

Otitis media is fairly common in childhood. Almost every child will have one or two episodes of otitis media in varying forms of severity before attaining 3 years of age. Early recognition by awareness, otoscopy and timely management of the condition by the primary care physician/pediatrician will result in complete resolution in over 90% of cases. In the modern antibiotic era, with availability of medical and surgical treatment, there is no justification for letting these children carry on with draining ears (CSOM) or with persistent hearing impairment (OME)
References :
  1. Klein JO. Microbiology of Otitis media, Ann Otol, Rhinol Laryngol. 1980 (Suppl);68-98.
  2. Henderson, FW, Collier, et al. A longitudinal study of respiratory viruses and bacteria in aetiology of acute otitis media with effusion. New Eng J Med 1982;306:1377-1383.
  3. Quanberg Y. Acute Otitis media. A prospective clinical study of myringotomy and antimicrobial treatment. Acta-Oto-Laryngologica 1981;375 (Supply); 1-157.
  4. Maw AR. Factors affecting adenoidectomy for Otitis media with effusion. J Roy Soc Med 1985;87:1014-1018.
  5. Bluestone CD, Cantekin EI. Eustachian Tube Dysfunction In: Otolaryngology, ed G English, Hagerstown. 1979; pp 1-40.
  6. Bluestone CD, Klein JO. Otitis media with effusion, Atelectasis and Eustachian tube dysfunction. In: Paediatric Otolaryngology, Bluestone and Stool 1983;pp 356-512.
  7. Rosen Field RM, Vertrees JE, Carr J, et al. Clinical efficacy of antimicrobial drugs for acute Otitis media. Meta analysis of 5400 children from randomized trials. J Paediatr 1994;124:355-367.
  8. Block SL. Causative pathogens, antibiotic resistance and therapeutic considerations in acute Otitis media. Paediatr Infect Dis J 1997;16:449-456.
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