Diagnosis

Otitis media

Etiology

Cause [nyt]

• Bacteria: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis

• Virus: Respiratory syncytial virus (RSV), coronaviruses, influenza virus, parainfluenza virus, rhinovirus, adenoviruses, human metapneumovirus, and picornaviruses

• Allergic

Classification [nyt]

1. Acute purulent otitis media: Acute infection with edema, hyperemia, pus and fever

2. Serous otitis media: Postinfectious stasis/fluid accumulation without signs of infection

3. Chronic otitis media: Persistent inflammation with perforation or long-lasting fluid in the middle ear space and a retracted tympanic membrane

4. Otitis media with effusion: Fluid in the middle ear without signs of a new infection

Pathophysiology [nyt]

1. Preceding upper respiratory infection --> edema in the mucosa

2. Eustachian tube obstruction --> decrease in ventilation and increasing exudate from theinflamed mucosa --> risk of infection in the middle ear

3. Purulence in the middle ear space:

   • Bulging or erythematous tympanic membrane with decreased mobility

   • Hearing loss:

     • Conductive hearing loss

       Cerumen, foreign body, neoplasm, swelling/stenosis of the canal, Perforated tympanic membrane, Ossicular discontinuity, Otosclerosis, Fluid, scarring

     • Sensorineural hearing loss:

       Neuronal damage by intense noise, barotrauma, viral infection, ototoxic drugs (aminoglycosides), Presbyacusis, Iatrogenic, Temporal bone fracture, Meningitis, Cochlear otosclerosis, Menieres disease, Acoustic neuroma

Risk factors [nyt]

• Immunodeficiency (HIV, diabetes)

• Genetic predisposition

• Anatomic abnormalities: adenoid hypertrophy

• Pacifier use

• Gastroesophageal reflux

• Ciliary dysfunction

• Cochlear implants

• Vitamin A deficiency

• Allergies

• Lack of breastfeeding

• Passive smoke exposure

• Daycare attendance

• Lower socioeconomic status

• Family history of recurrent otitis media in parents or siblings

Complications [nyt]

• Tympanic membrane perforation

• Hearing loss

• Chronic suppurative otitis media

• Cholesteatoma

• Tympanosclerosis

• Mastoiditis

• Petrositis

• Labyrinthitis

• Facial paralysis

• Cholesterol granuloma

• Infectious eczematoid dermatitis

• Meningitis

• Subdural empyema

• Brain abscess

• Lateral and cavernous sinus thrombosis

• Otitic hydrocephalus

Epidemiology

Incidence per 100.000 [top][3hn][is2][rfs]

Approach

• Otoscopy

• Pneumatic otoscopy has a higher sensitivity and specificity [nyt]

• Tympanometry

• Acoustic reflectometry

• CT

• MRI: mastoiditis, epidural abscess, sigmoid sinus thrombophlebitis, meningitis, brain abscess, subdural abscess, ossicular disease, and cholesteatoma

Treatment

1. Prophylaxis: pneumococcal vaccine

2. Watchful waiting or antibiotic therapy: [nyt]

   • Amoxicillin or a 2nd gen cephalosporin

   • Tympanic Membrane perforation: topical antibiotics (ofloxacin)

3. Pain: NSAIDs or acetaminophen

4. Surgery:

   • Myringotomy

   • Tympanocentesis: tympanostomy tube placement

Differential diagnoses

Acute sinusitis, Allergic rhinosinusitis, Cerumen, Cholesteatoma, Gastroesophageal reflux disease, HIV, Influenza, Mastoiditis, Meningitis, Nasal polyps, Nasopharyngeal carcinoma, Otitis externa