Acute Otitis Media (Middle Ear Infection)
 

What Causes Acute Otitis Media (AOM)?
 

AOM can be caused by viruses, bacteria, or both. It frequently develops during or shortly after an upper respiratory infection, such as a cold. The middle ear connects to the back of the nose and throat via the eustachian tube. Inflammation can cause the eustachian tube to become swollen or blocked, leading to higher risk for middle ear infection.  AOM is particularly common in young children because their eustachian tubes are shorter, narrower, and more horizontal than those of adults.

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What are the Risk Factors?
 

• Less than 3 years of age

• Daycare attendance 

• Frequent respiratory infections

• Exposure to tobacco smoke

• Frequent pacifier use 

• Bottle feeding while lying flat

• Family history of recurrent ear infections

• Nonbreastfed Infants

• Allergic rhinitis

• Cleft palate

• Structural abnormalities affecting the nose, nasopharynx, or eustachian tube (cleft palate, enlarged adenoids, Down's syndrome, deviated septum)
   

What are the Symptoms?
 

• Ear pain or pulling

• Reduced hearing

• Fever

• Irritability

• Difficulty sleeping

• Reduced appetite
   

What are Suggestive Signs and Symptoms of Acute Bacterial Otitis Media?
 

• Significant bulging and redness of the eardrum

• Purulent fluid behind the eardrum

• High fever (>102.2 F)

• Severe pain​
   

*Viral ear infections, crying, and fever can also cause a red eardrum. Viral infections are typically much more milder: milder fever, pain, redness and buldging.  

How Is Acute Otitis Media Treated?
 

-Fever and Pain management
 

• Acetaminophen (Tylenol)

• Ibuprofen (Advil, Motrin)

-Bacterial cases can be treated with antibiotics. Many organizations including the American Academy of Pediatrics advise that for mild cases (fever less than 102.2 F, mild pain, no drainage, no toxic appearance, children over 6 months old, only one effected ear in those under 2 years of age, symptoms less than 48-72 hours), observation for approximately 48–72 hours may be recommend.

-Children with recurrent AOM should be referred to an ENT specialist. Tympanostomy tubes (ear tubes) may be considered. Recurrent AOM is commonly defined as:
 

• 3 or more episodes within 6 months, or

• 4 or more episodes within 12 months, with at least one episode during the previous 6 months.

Complications of Acute Otitis Media

Eardrum Perforation

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• Sudden drainage of clear fluid, pus, or blood from the ear

• A sudden decrease in pressure within the ear

• Improvement in ear pain

• Temporary reduction in hearing

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Most small, uncomplicated eardrum perforations heal naturally, often within several weeks. A perforation that is still present after approximately 6–8 weeks should be reassessed and may require evaluation by an ear, nose, and throat (ENT) specialist.

-Keep the affected ear dry while it is healing. You may shower, but place a petroleum-jelly-coated cotton ball at the entrance of the ear canal and keep the ear away from the direct shower stream. Avoid swimming, submerging the ear, ear irrigation, and inserting cotton swabs or other objects into the ear until symptoms have resolved.

Mastoiditis

Mastoiditis, a rare complication, can happen when AOM spreads to the bone right behind the ear. Redness, swelling, or significant tenderness over the bone behind the ear—particularly if the ear begins protruding outward—requires urgent medical evaluation. ED referral is appropriate. 

Other serious complications can include:
 

• Facial nerve weakness or paralysis

• Meningitis

• Intracranial abscess

• Infection or clotting involving veins within the skull

• Permanent hearing damage

Non-infectious = Otitis Media With Effusion
 

Otitis media with effusion (OME) is when there is fluid behind the eardrum without an active middle-ear infection. It commonly occurs after an ear infection, a respiratory infection, or allergies. This middle-ear fluid can remain for weeks or even months. Both ears will usually have fluid. 

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What are the Signs and Symptoms?
 

• Ear fullness

• Popping

• Muffled or temporarily reduced hearing

• Dull ear drum appearance

• Bubbles behind ear drum

• Amber fluid behind ear drum
   

How is Otitis Media With Effusion Treated?

*Oral or nasal steroids, antihistamines, and decongestants have shown no significant benefit and thus are not recommended by major organizations. 

-Risk Avoidance (avoid smoke, smoking, allergens, & feeding baby while lying flat = traps fluid in middle ear)

-Observation - Monitor fluid levels and hearing every 3 to 6 months

-Tympanostomy tubes and sometimes adenoidectomy may be considered if it lasts 3 months or longer with hearing loss.
 

What Is Otitis Externa (Swimmer's Ear)?
 

Otitis externa is inflammation or infection of the external ear canal, the passage between the outer ear and the eardrum. Many cases are bacterial, but fungal infections can also occur, especially after prolonged antibiotic ear-drop use or under certain environmental conditions.

What are the Risk Factors & Causes of Otitis Externa?
 

• Swimming

• Water trapped in the ear

• Humid environments

• Frequent use of earbuds or hearing aids

• Scratching the ear canal

• Objects inserted into the ear

• Eczema or other skin conditions

• Excessive removal of earwax

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What Are the Symptoms?

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• Ear pain, especially when pulling or pushing on the outer ear

• Itching

• Ear canal swelling

• Redness

• Drainage

• Feeling that the ear is blocked

How Is Otitis Externa Treated?

-Ear Drops that may contain:
 

• An antibiotic or antifungal

• A corticosteroid to decrease inflammation

• An acidifying solution

Certain ear drops should not be used when the eardrum is perforated because certain ones can damage the inner ear.

An ear wick may be used to help distribute the medication.

If symptoms are worsening or not beginning to improve within 48-72 hours, then the ear should be reassessed.

Keep the affected ear dry while otitis externa is healing. You may shower, but place a petroleum-jelly-coated cotton ball at the entrance of the ear canal and keep the ear away from the direct shower stream. Avoid swimming, submerging the ear, ear irrigation, and inserting cotton swabs or other objects into the ear until symptoms have resolved.

Complications
 

Necrotizing Otitis Externa
 

Rarely, infection can spread from the external ear canal into the surrounding tissue and bone. This serious condition is called necrotizing otitis externa. NOE is potentially life-threatening and can progress to skull-base osteomyelitis, cranial nerve palsies, meningitis, intracranial abscess, or venous sinus thrombosis. ED referral is appropriate. 
Symptoms include:
 

• Severe, persistent deep ear pain, especially pain disproportionate to the canal findings

• Pain that is particularly severe at night

• Persistent otorrhea despite appropriate topical treatment

• Granulation tissue in the external auditory canal

• Cranial nerve abnormalities, particularly facial weakness

• Infection extending beyond the ear canal

• A patient with diabetes or significant immunocompromise whose OE is severe, persistent, or worsening

                                                                             References
 

• American Academy of Pediatrics (AAP)

• American Academy of Family Physicians (AAFP)

• American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF)

• Centers for Disease Control and Prevention (CDC)