Otitis media
Otitis media | |
---|---|
Other names | Otitis media with effusion: serous otitis media, secretory otitis media |
tympanic membrane which is typical in a case of acute otitis media | |
Specialty | Otorhinolaryngology |
Symptoms | Ear pain, fever, hearing loss[1][2] |
Types | Acute otitis media, otitis media with effusion, chronic suppurative otitis media[3][4] |
Causes | Viral, bacterial[4] |
Risk factors | Smoke exposure, daycare[4] |
Prevention | Vaccination, breastfeeding[1] |
Medication | Paracetamol (acetaminophen), ibuprofen, benzocaine ear drops[1] |
Frequency | 471 million (2015)[5] |
Deaths | 3,200 (2015)[6] |
Otitis media is a group of inflammatory diseases of the middle ear.[2] One of the two main types is acute otitis media (AOM),[3] an infection of rapid onset that usually presents with ear pain.[1] In young children this may result in pulling at the ear, increased crying, and poor sleep.[1] Decreased eating and a fever may also be present.[1] The other main type is otitis media with effusion (OME), typically not associated with symptoms,[1] although occasionally a feeling of fullness is described;[4] it is defined as the presence of non-infectious fluid in the middle ear which may persist for weeks or months often after an episode of acute otitis media.[4] Chronic suppurative otitis media (CSOM) is middle ear inflammation that results in a perforated tympanic membrane with discharge from the ear for more than six weeks.[7] It may be a complication of acute otitis media.[4] Pain is rarely present.[4] All three types of otitis media may be associated with hearing loss.[2][3] If children with hearing loss due to OME do not learn sign language, it may affect their ability to learn.[8]
The cause of AOM is related to childhood
A number of measures decrease the risk of otitis media including
Worldwide AOM affects about 11% of people a year (about 325 to 710 million cases).[14][15] Half the cases involve children less than five years of age and it is more common among males.[4][14] Of those affected about 4.8% or 31 million develop chronic suppurative otitis media.[14] The total number of people with CSOM is estimated at 65–330 million people.[16] Before the age of ten OME affects about 80% of children at some point.[4] Otitis media resulted in 3,200 deaths in 2015 – down from 4,900 deaths in 1990.[6][17]
Signs and symptoms
The primary symptom of acute otitis media is
Discharge from the ear can be caused by acute otitis media with perforation of the eardrum, chronic suppurative otitis media, tympanostomy tube otorrhea, or acute otitis externa. Trauma, such as a basilar skull fracture, can also lead to cerebrospinal fluid otorrhea (discharge of CSF from the ear) due to cerebral spinal drainage from the brain and its covering (meninges).[citation needed]
Causes
The common cause of all forms of otitis media is dysfunction of the
By reflux or aspiration of unwanted secretions from the nasopharynx into the normally sterile middle-ear space, the fluid may then become infected – usually with bacteria. The virus that caused the initial upper respiratory infection can itself be identified as the pathogen causing the infection.[20]
Diagnosis
As its typical symptoms overlap with other conditions, such as acute external otitis, symptoms alone are not sufficient to predict whether acute otitis media is present; it has to be complemented by visualization of the
In more severe cases, such as those with associated hearing loss or high
Acute otitis media in children with moderate to severe bulging of the tympanic membrane or new onset of otorrhea (drainage) is not due to external otitis. Also, the diagnosis may be made in children who have mild bulging of the ear drum and recent onset of ear pain (less than 48 hours) or intense erythema (redness) of the ear drum.
To confirm the diagnosis, middle-ear effusion and inflammation of the eardrum (called myringitis or tympanitis) have to be identified; signs of these are fullness, bulging, cloudiness and redness of the eardrum.[1] It is important to attempt to differentiate between acute otitis media and otitis media with effusion (OME), as antibiotics are not recommended for OME.[1] It has been suggested that bulging of the tympanic membrane is the best sign to differentiate AOM from OME, with a bulging of the membrane suggesting AOM rather than OME.[24]
Viral otitis may result in blisters on the external side of the tympanic membrane, which is called
However, sometimes even examination of the eardrum may not be able to confirm the diagnosis, especially if the canal is small. If wax in the ear canal obscures a clear view of the eardrum it should be removed using a blunt cerumen curette or a wire loop. Also, an upset young child's crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media.
Acute otitis media
The most common bacteria isolated from the middle ear in AOM are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis,[1] and Staphylococcus aureus.[26]
Otitis media with effusion
Otitis media with
Early-onset OME is associated with feeding of infants while lying down, early entry into group child care, parental smoking, lack or too short a period of breastfeeding, and greater amounts of time spent in group child care, particularly those with a large number of children. These risk factors increase the incidence and duration of OME during the first two years of life.[30]
Chronic suppurative otitis media
Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid cavity that is characterised by discharge from the middle ear through a perforated tympanic membrane for at least 6 weeks. CSOM occurs following an upper respiratory tract infection that has led to acute otitis media. This progresses to a prolonged inflammatory response causing mucosal (middle ear) oedema, ulceration and perforation. The middle ear attempts to resolve this ulceration by production of granulation tissue and polyp formation. This can lead to increased discharge and failure to arrest the inflammation, and to development of CSOM, which is also often associated with
]Worldwide approximately 11% of the human population is affected by AOM every year, or 709 million cases.[14][15] About 4.4% of the population develop CSOM.[15]
According to the World Health Organization, CSOM is a primary cause of hearing loss in children.[31] Adults with recurrent episodes of CSOM have a higher risk of developing permanent conductive and sensorineural hearing loss.
In Britain, 0.9% of children and 0.5% of adults have CSOM, with no difference between the sexes.[31] The incidence of CSOM across the world varies dramatically where high income countries have a relatively low prevalence while in low income countries the prevalence may be up to three times as great.[14] Each year 21,000 people worldwide die due to complications of CSOM.[31]
Adhesive otitis media
Adhesive otitis media occurs when a thin
Prevention
AOM is far less common in breastfed infants than in formula-fed infants,[32] and the greatest protection is associated with exclusive breastfeeding (no formula use) for the first six months of life.[1] A longer duration of breastfeeding is correlated with a longer protective effect.[32]
Pneumococcal conjugate vaccines (PCV) in early infancy decrease the risk of acute otitis media in healthy infants.[33] PCV is recommended for all children, and, if implemented broadly, PCV would have a significant public health benefit.[1] Influenza vaccination in children appears to reduce rates of AOM by 4% and the use of antibiotics by 11% over 6 months.[34] However, the vaccine resulted in increased adverse-effects such as fever and runny nose.[34] The small reduction in AOM may not justify the side effects and inconvenience of influenza vaccination every year for this purpose alone.[34] PCV does not appear to decrease the risk of otitis media when given to high-risk infants or for older children who have previously experienced otitis media.[33]
Risk factors such as season, allergy predisposition and presence of older siblings are known to be determinants of recurrent otitis media and persistent middle-ear effusions (MEE).[35] History of recurrence, environmental exposure to tobacco smoke, use of daycare, and lack of breastfeeding have all been associated with increased risk of development, recurrence, and persistent MEE.[36][37] Pacifier use has been associated with more frequent episodes of AOM.[38]
Long-term antibiotics, while they decrease rates of infection during treatment, have an unknown effect on long-term outcomes such as
There is moderate evidence that the sugar substitute xylitol may reduce infection rates in healthy children who go to daycare.[40]
Evidence does not support zinc supplementation as an effort to reduce otitis rates except maybe in those with severe malnutrition such as marasmus.[41]
Probiotics do not show evidence of preventing acute otitis media in children.[42]
Management
Oral and topical
Antibiotics
Use of antibiotics for acute otitis media has benefits and harms. As over 82% of acute episodes settle without treatment, about 20 children must be treated to prevent one case of ear pain, 33 children to prevent one perforation, and 11 children to prevent one opposite-side ear infection. For every 14 children treated with antibiotics, one child has an episode of vomiting, diarrhea or a rash.[49] Analgesics may relieve pain, if present. For people requiring surgery to treat otitis media with effusion, preventative antibiotics may not help reduce the risk of post-surgical complications.[50]
For bilateral acute otitis media in infants younger than 24 months, there is evidence that the benefits of antibiotics outweigh the harms.[12] A 2015 Cochrane review concluded that watchful waiting is the preferred approach for children over six months with non severe acute otitis media.[12]
Summary[12] | |||
---|---|---|---|
Outcome | Findings in words | Findings in numbers | Quality of evidence |
Pain | |||
Pain at 24 hours | Antibiotics causes little or no reduction to the chance of experiencing the outcome when compared with placebo for acute otitis media in children. Data are based on high quality evidence. | RR 0.89 (0.78 to 1.01) | High
|
Pain at 2 to 3 days | Antibiotics slightly reduces the chance of experiencing the outcome when compared with placebo for acute otitis media in children. Data are based on high quality evidence. | RR 0.70 (0.57 to 0.86) | High
|
Pain at 4 to 7 days | Antibiotics slightly reduces the chance of experiencing the outcome when compared with placebo for acute otitis media in children. Data are based on high quality evidence. | RR 0.76 (0.63 to 0.91) | High
|
Pain at 10 to 12 days | Antibiotics probably reduces the chance of experiencing the outcome when compared with placebo for acute otitis media in children. Data are based on moderate quality evidence. | RR 0.33 (0.17 to 0.66) | Moderate
|
Abnormal tympanometry | |||
2 to 4 weeks | Antibiotics slightly reduces the chance of experiencing the outcome when compared with placebo for acute otitis media in children. Data are based on high quality evidence. | RR 0.82 (0.74 to 0.90) | High
|
3 months | Antibiotics causes little or no reduction to the chance of experiencing the outcome when compared with placebo for acute otitis media in children. Data are based on high quality evidence. | RR 0.97 (0.76 to 1.24) | High
|
Vomiting | |||
Diarrhoea or rash | Antibiotics slightly increases the chance of experiencing the outcome when compared with placebo for acute otitis media in children. Data are based on high quality evidence. | RR 1.38 (1.19 to 1.59) | High
|
Most children older than 6 months of age who have acute otitis media do not benefit from treatment with antibiotics. If antibiotics are used, a
Tympanostomy tube
Oral antibiotics should not be used to treat uncomplicated acute tympanostomy tube otorrhea.[58] They are not sufficient for the bacteria that cause this condition and have side effects including increased risk of opportunistic infection.[58] In contrast, topical antibiotic eardrops are useful.[58]
Otitis media with effusion
The decision to treat is usually made after a combination of physical exam and laboratory diagnosis, with additional testing including
Chronic suppurative otitis media
Topical antibiotics are of uncertain benefit as of 2020.[67] Some evidence suggests that topical antibiotics may be useful either alone or with antibiotics by mouth.[67] Antiseptics are of unclear effect.[68] Topical antibiotics (quinolones) are probably better at resolving ear discharge than antiseptics.[69]
Alternative medicine
Outcomes
no data < 10 10–14 14–18 18–22 22–26 26–30 | 30–34 34–38 38–42 42–46 46–50 > 50 |
Complications of acute otitis media consists of perforation of the ear drum, infection of the mastoid space behind the ear (
Membrane rupture
In severe or untreated cases, the tympanic membrane may
Hearing loss
Children with recurrent episodes of acute otitis media and those with otitis media with effusion or chronic suppurative otitis media have higher risks of developing conductive and sensorineural hearing loss. Globally approximately 141 million people have mild hearing loss due to otitis media (2.1% of the population).[74] This is more common in males (2.3%) than females (1.8%).[74]
This hearing loss is mainly due to fluid in the middle ear or rupture of the tympanic membrane. Prolonged duration of otitis media is associated with ossicular complications and, together with persistent tympanic membrane perforation, contributes to the severity of the disease and hearing loss. When a cholesteatoma or granulation tissue is present in the middle ear, the degree of hearing loss and ossicular destruction is even greater.[75]
Periods of conductive hearing loss from otitis media may have a detrimental effect on speech development in children.[76][77][78] Some studies have linked otitis media to learning problems, attention disorders, and problems with social adaptation.[79] Furthermore, it has been demonstrated that individuals with otitis media have more depression/anxiety-related disorders compared to individuals with normal hearing.[80] Once the infections resolve and hearing thresholds return to normal, childhood otitis media may still cause minor and irreversible damage to the middle ear and cochlea.[81] More research on the importance of screening all children under 4 years old for otitis media with effusion needs to be performed.[77]
Epidemiology
Acute otitis media is very common in childhood. It is the most common condition for which medical care is provided in children under five years of age in the US.[20] Acute otitis media affects 11% of people each year (709 million cases) with half occurring in those below five years.[14] Chronic suppurative otitis media affects about 5% or 31 million of these cases with 22.6% of cases occurring annually under the age of five years.[14] Otitis media resulted in 2,400 deaths in 2013 – down from 4,900 deaths in 1990.[17]
Etymology
The term otitis media is composed of otitis, Ancient Greek for "inflammation of the ear", and media, Latin for "middle".
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External links
- Neff MJ (June 2004). "AAP, AAFP, AAO-HNS release guideline on diagnosis and management of otitis media with effusion". American Family Physician. 69 (12): 2929–2931. PMID 15222658.