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Acute Otitis Media

Humza Khizer

Overview

Acute otitis media refers to inflammation or infection located in the middle ear. Infections of the middle ear can be viral, bacterial, or a combination of the two. 
&nbsp;

Acute otitis media is the second-most frequently encountered pediatric finding in the emergency department after upper respiratory infections. Even though it can occur at any age, the condition is particularly prevalent in children aged 6-24 months1. Nearly 80% of all kids worldwide develop it before turning 3<a href="#accordion">&nbsp;[2]</a>.

&nbsp;

It is also more common in males than females3. However, it is more prevalent in certain subpopulations, such as people with a cleft palate or immunodeficiency&nbsp;<a href="#accordion">[3]</a>. 
&nbsp;

Signs and Symptoms

Nearly two-thirds of the patients present with fever, which is usually low-grade or mild<a href="#accordion">[1]</a>. 
&nbsp;

<h5>Symptoms In Infants And Children</h5>

<ul>
	<li>Inadequate Sleep</li>
</ul>

The pain feels worse while lying down due to increased pressure in the ear. 

<ul>
	<li>Appetite Loss</li>
</ul>

Loss of appetite is particularly noticeable in youngsters, specifically during bottle feeding. 

<ul>
	<li>Pain In Ear</li>
</ul>

Babies who are too young to speak exhibit ear pain by rubbing or tugging at the ears, crying more than normal, having difficulty sleeping, and acting irritable or restless.

<ul>
	<li>Drainage From The Ear</li>
</ul>

The ear leaks yellow, brown, or white fluid that is not earwax. This indicates that the eardrum has ruptured.

<ul>
	<li>Fever</li>
</ul>

Body temperatures ranging from 100 &deg;F to 104 &deg;F often indicate an ear infection.

&nbsp;

<h5>Other Symptoms</h5>

<ul>
	<li>Headache</li>
	<li>Vomiting</li>
	<li>Diarrhea</li>
	<li>Neck pain</li>
	<li>Ear pain </li>
	<li>A lack of balance</li>
	<li>A feeling of fullness in the ear 
	&nbsp;</li>
</ul>

Causes

An ear infection frequently follows a cold or some other kind of respiratory infection. The bacteria or virus enter the middle ear via the Eustachian tube (one is present in each ear). This tube connects the middle of the ear to the back of the throat. When the Eustachian tube becomes swollen or obstructed, it traps fluid in the middle ear. When this fluid cannot drain, it becomes a breeding ground for bacteria and viruses in the ear, leading to acute otitis media. 

Another major issue is that a child&rsquo;s Eustachian tubes are shorter and more horizontal than an adult&rsquo;s. This makes the Eustachian tubes in children more likely to be obstructed and more challenging to drain, thereby, more likely to be infected. 

&nbsp;

The Eustachian tube can also become inflamed or obstructed for other reasons, including:

<ul>
	<li><a href="https://merisehat.pk/disease/allergies">Allergies </a></li>
	<li><a href="https://merisehat.pk/disease/cold-flu">Cold</a></li>
	<li><a href="https://merisehat.pk/disease/influenza-116">Flu</a></li>
	<li>Sinus </li>
	<li>Cigarette smoke </li>
	<li>Drinking while lying down (in infants)</li>
	<li>Enlarged or infected adenoids 
	&nbsp;</li>
</ul>

Diagnosis

The doctor will ask for symptoms and perform the following tests to diagnose acute otitis media: 
&nbsp;

<ul>
	<li>Pneumatic Otoscope</li>
</ul>

A pneumatic otoscope is a lighted instrument that allows the doctor to look inside the ear and determine the presence of fluid behind the eardrum. 

The otoscope will carefully blow a puff of air into the ear, which should cause the eardrum to move. Slight or no eardrum movement alerts the doctor that the middle ear is clogged with fluid.

The doctor will also then use the instrument to examine the child&rsquo;s ear and detect:

<ul>
	<li>Blood</li>
	<li>Pus</li>
	<li>Redness</li>
	<li>Fluid in the middle ear</li>
	<li>Air bubbles</li>
	<li>Eardrum perforation</li>
	<li>Inflammation</li>
	<li>Tympanometry</li>
</ul>

During a tympanometry test, the healthcare practitioner uses a tiny instrument to measure the air pressure in the ear and determine if the eardrum is perforated. 
&nbsp;

<ul>
	<li>Acoustic Reflectometry</li>
</ul>

The doctor uses a small instrument to produce a sound near the patient&rsquo;s ear during a reflectometry test. In most cases, the eardrum absorbs the majority of the sound. The doctor listens to the sound reflected from the ear to determine if there&rsquo;s fluid in the ear. The more pressure there is in the middle ear from fluid, the more sound the eardrum will bounce back. 
&nbsp;

<ul>
	<li>Tympanocentesis</li>
</ul>

Doctors perform tympanocentesis to collect fluid in the middle ear for culture. Tympanocentesis can significantly enhance diagnostic accuracy and guide medical decisions, but medical professionals should only use it in the most severe or refractory cases, including:

<ul>
	<li>Neonates younger than 6 weeks</li>
	<li>Immunocompromised or immunosuppressed patients</li>
	<li>Patients with a complication that requires culture for proper treatment 
	Patients who haven&rsquo;t responded to antimicrobial treatment and continue to show symptoms of local or systemic sepsis 
	&nbsp;</li>
	<li>Hearing Test</li>
</ul>

The doctor will order a hearing test done by an audiologist to detect potential hearing loss if the individual presents with chronic or recurring ear infections or fluid in the middle ears that is not draining. 
&nbsp;

<ul>
	<li>Laboratory Studies</li>
</ul>

&nbsp;A comprehensive sepsis workup may be required in babies younger than 12 weeks with fever and no apparent source other than underlying acute otitis media. Laboratory tests also help to verify or rule out other potential systemic or hereditary ailments. 
&nbsp;

<ul>
	<li>Imaging Studies</li>
</ul>

Imaging studies are not recommended unless there is a risk of intra-temporal or intracranial complications.

<ul>
	<li>A CT scan of the temporal bones may reveal complications, like meningitis, brain abscess, subdural abscess, and other related problems.</li>
	<li>An MRI can detect fluid collected in the middle ear.</li>
</ul>

A proper diagnosis is important to exclude other problems, such as dental pain, external otitis, acute viral pharyngitis, temporomandibular joint pain, and trauma to the ear, which can be confused with acute otitis media. 
&nbsp;

Treatment

The treatment of ear infections is determined by the following factors: 

<ul>
	<li>The age of the patient</li>
	<li>The severity of the infection</li>
	<li>The nature of the infection (e.g., is it a first-time infection, an ongoing infection, or a recurring infection)</li>
	<li>Whether the fluid stays in the middle ear for an extended period 
	&nbsp;</li>
</ul>

A majority of acute otitis media infections clear up without the use of antibiotics. Homecare (e.g., applying a warm, damp washcloth to the infected ear) and painkillers are typically advised before antibiotics to avoid antibiotic overuse and decrease the likelihood of harmful antibiotic reactions. 
&nbsp;

<h5>Pain-relieving Medications</h5>

<ul>
	<li>&nbsp;Over-the-counter Medicine</li>
</ul>

Over-the-counter (OTC) medications, like acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), help in alleviating ear pain or fever. These medicines typically begin to relieve pain within a couple of hours.

NOTE: Proceed with caution when giving aspirin to kids or adolescents; it has been associated with Reye&rsquo;s Syndrome. 
&nbsp;

<ul>
	<li>&nbsp; Antibiotic Drops</li>
</ul>

These may be used to alleviate pain if an ongoing or severe infection leads to a hole or tear in the eardrum. 
&nbsp;

<ul>
	<li>&nbsp; Antibiotics</li>
</ul>

Antibiotics may be recommended if bacteria are suspected to be the main reason for ear infections.

The American Academy of Pediatrics and the American Academy of Family Physicians suggest antibiotic treatment for an ear infection in the following circumstances<a href="#accordion">[5]</a>:

<ul>
	<li>Kids 6 months and older who have had moderate to extreme earache in one or both of their ears for at least 48 hours or a fever of 102.2 &deg;F (39 &deg;C).</li>
	<li>Kids aged 6 to 23 months who have had mild middle ear ache in one or both of their ears for less than 48 hours and have a fever of fewer than 102.2 &deg;F (39 &deg;C).</li>
	<li>Kids aged 24 months and up who have had mild middle ear ache in one or both of their ears for less than 48 hours and have a fever of fewer than 102.2 &deg;F (39 &deg;C).</li>
</ul>

&nbsp;

NOTE: DO NOT stop taking the medications even if the symptoms have subsided. Failure to take all medicines as instructed by your doctor may result in recurrent infection. 
&nbsp;

<h5>Surgery</h5>

If the condition does not improve following the aforementioned treatments or if the ear infection keeps recurring, the doctor may suggest surgery. 
&nbsp;

<h5>Adenoid Removal</h5>

The doctor may suggest surgical removal of adenoids in case the patient&rsquo;s adenoids are infected or increased in size and causing recurring ear infections. 
&nbsp;

<h5>Ear Tubes Replacement</h5>

Tympanostomy involves the surgical replacement of the ear tubes. Ear tubes can provide instant comfort and are occasionally advised for young kids learning to speak and communicate. 
&nbsp;

The doctor suggests it for those who:

<ul>
	<li>Have frequent ear infections (three ear infections in 6 months or 4 infections in 12 months)</li>
	<li>Have ear infections that weren&rsquo;t resolved by antibiotics</li>
	<li>Have experienced hearing loss from fluid buildup behind the eardrum 
	&nbsp;</li>
</ul>

The procedure takes about 10 minutes and has a limited complication rate. Some tubes are designed to remain in position for 6-12 months before falling out on their own. Other tubes are intended to stay in place for a prolonged period and may require surgical removal.

After the tube falls out or is removed, the eardrum typically closes again. The outer ear must be kept dry and free of dirty water until the small opening in the eardrum heals and closes entirely. 
&nbsp;

Acute otitis media can lead to complications, usually linked to high mortality: 
&nbsp;

<ul>
	<li><a href="https://merisehat.pk/disease/bacterial-meningitis">Meningitis</a></li>
	<li>Delayed speech and language development</li>
	<li>Tear in the eardrum</li>
	<li>Brain abscesses</li>
	<li>Epidural abscesses</li>
	<li>Mastoiditis</li>
	<li>Irreversible hearing loss 
	&nbsp;</li>
</ul>

The following are risk factors for AOM: 
&nbsp;

<ul>
	<li>Aged 6-36 months</li>
	<li>Overuse of pacifier&nbsp;</li>
	<li>Exposure to infection at a childcare</li>
	<li>Being bottle-fed (in infants)</li>
	<li>Drinking while lying down (in infants)</li>
	<li>Exposure to cigarette smoke</li>
	<li>Exposure to air pollution at an extreme level</li>
	<li>Experience a change in altitude level</li>
	<li>Living in a cold climate</li>
	<li>A recent bout of flu, ear, sinus, or cold</li>
	<li>Genetics 
	&nbsp;</li>
</ul>

The following can help lower the risk of developing acute otitis media: 
&nbsp;

<ul>
	<li>Cleaning hands and toys frequently to avoid contracting a cold or another respiratory infection</li>
	<li>Avoiding smoking cigarettes</li>
	<li>Getting pneumococcal vaccines and seasonal flu shots</li>
	<li>Breastfeeding the child if possible; also, refrain from giving them a pacifier as and when possible. 
	&nbsp;</li>
</ul>

Standard of care is based on pharmaceutical and surgical treatment.

They believe that the changes brought on by an unbalanced diet are a major reason why the mucosa that lines the entire ENT area is not only in a state of pro-inflammatory but a hyper-reactive state, too. The goal of the study was to evaluate how the Traditional Mediterranean Diet (TMD) affects those with recurrent acute otitis media (RAOM). 
&nbsp;

Reportedly, there was a significant decrease in the use of antimicrobial medications and symptomatic therapeutic interventions. The use of antibiotics decreased from 4.30 occasions per patient per year to 0.66, and the consumption of symptomatic treatments decreased from 7.63 to 2.75 (p 0.001). This implies that TDM can be used to treat patients diagnosed with RAOM.<a href="#accordion">[4]</a> 
&nbsp;

Key Points

<ul>
	<li>Acute Otitis media refers to inflammation or infection located in the middle ear.</li>
	<li>It can occur as a result of a cold, sore throat, or respiratory infection.</li>
	<li>Treatment of the condition depends on the symptoms. 
	&nbsp;</li>
</ul>

[1] Danishyar A, Ashurst J V. Acute Otitis Media. In Treasure Island (FL); 2022.

[2] Usonis V, Jackowska T, Petraitiene S, Sapala A, Neculau A, Stryjewska I, et al. Incidence of acute otitis media in children below 6 years of age seen in medical practices in five East European countries. BMC Pediatr. 2016;16(1):1–7.

[3] Schilder AGM, Chonmaitree T, Cripps AW, Rosenfeld RM, Casselbrant ML, Haggard MP, et al. Otitis media. Nat Rev Dis Prim. 2016;2(1):1–18.

[4] Calatayud-Sáez FM, Calatayud B, Calatayud A. Recurrent acute otitis media could be related to the pro-inflammatory state that causes an incorrect diet. Sinusitis. 2022;6(2):36–48.