History

Fact Explanation
Otalgia( ear pain) first 3 weeks of a process which includes rapid onset of symptoms, middle ear effusion, and signs and symptoms of middle ear inflammation is the diagnostic criteria for acute otitis media. Acute suppurative otitis media is distinguished from secretory (serous) otitis media by the presence of purulent fluid in the middle ear. acute otitis media is a common indication for medical attention specially the children younger than 5 years. Around 60% to 85% of children have AOM during the first year of life. acute onset pain in the ear is the most common symptom. pain is a result of inflammatory reaction[1][8]
Fever persistent or intermittent fever associated with ear pain is suggestive of acute otitis media[1]
symptoms of URTI allergy or upper respiratory tract infection causes congestion and swelling of the nasal mucosa, nasopharynx, and eustachian tube. Obstruction at the eustachian tube isthmus (i.e., the narrowest portion) results in accumulation of middle ear secretions; secondary bacterial or viral infection of the effusion causes suppuration and features of acute otitis media [2][3]
loss of hearing Hearing loss is a constant feature of older children and adults. Conductive type of hearing loss is commonly seen in recurrent acute otitis media due to effusion of the middle ear.[4] [5] otitis media with effusion may occur spontaneously as a result of eustachian tube dysfunction or as an inflammatory response after acute infection[6]
Fullness of the ear adults and older children presents with ear fullness during suppurative otitis media .[3] ear pressure or clogging sensation of the ear both are suggestive of aural fullness, otitis media due to effusion is the major diagnosis [7]
Ear tugging ear tugging or rubbing in younger children is indicative of pain in the ear. Otalgia (i.e., ear pain) is the most prevalent and important symptom of AOM[9]
Irritability In neonates , irritability , excessive crying , feeding difficulty may the only signs of acute infection leading to a difficult diagnosis[1]
Complications-Intracranial- symptoms of meningism(headache, neck stiffness, fever) , symptoms of raised intra cranial pressure , altered behaviour Intra cranial extension of acute infection results in complications such as Meningitis, encephalitis, brain abscess, otitis hydrocephalus etc [11] [8]
Complications-intra temporal facial nerve palsy, Intra temporal extension of acute infection very well known for complications including facial nerve palsy, acute coalescent mastoiditis, acute labyrinthitis, acute necrotic otitis, petrositis, or development of chronic otitis media[12]
Complications- systemic- symptoms of sepsis bacteremia and sepsis are rare but serious complication of acute otitis media, vague and inconclusive systemic signs such as fever, lethargy etc will mask the symptoms of acute middle ear infection.[13][4]
References
  1. KALYANAKRISHNAN RAMAKRISHNAN, RHONDA A. SPARKS, WAYNE E. BERRYHILL, Diagnosis and Treatment of Otitis Media, American family physician [online] 2007 Dec 1;76(11):1650-1658.[viewed 31 October 2014] Available from: http://www.aafp.org/afp/2007/1201/p1650.
  2. PETTIGREW MM, GENT JF, PYLES RB, MILLER AL, NOKSO-KOIVISTO J, CHONMAITREE T. Viral-Bacterial Interactions and Risk of Acute Otitis Media Complicating Upper Respiratory Tract Infection J Clin Microbiol [online] 2011 Nov, 49(11):3750-3755 [viewed 31 October 2014] Available from: doi:10.1128/JCM.01186-11
  3. CHONMAITREE T, REVAI K, GRADY JJ, CLOS A, PATEL JA, NAIR S, FAN J, HENRICKSON KJ. Viral upper respiratory tract infection and otitis media complication in young children Clin Infect Dis [online] 2008 Mar 15, 46(6):815-823 [viewed 31 October 2014] Available from: doi:10.1086/528685
  4. WORRALL G. Acute otitis media Can Fam Physician [online] 2007 Dec, 53(12):2147-2148 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231558
  5. SHARMA RK, NANDA V. Problems of middle ear and hearing in cleft children Indian J Plast Surg [online] 2009 Oct, 42(Suppl):S144-S148 [viewed 31 October 2014] Available from: doi:10.4103/0970-0358.57198
  6. AMERICAN ACADEMY OF FAMILY PHYSICIANS, AMERICAN ACADEMY OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY, AMERICAN ACADEMY OF PEDIATRICS SUBCOMMITTEE ON OTITIS MEDIA WITH EFFUSION. Otitis media with effusion. Pediatrics [online] 2004 May, 113(5):1412-29 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15121966
  7. PARK MS, LEE HY, KANG HM, RYU EW, LEE SK, YEO SG. Clinical Manifestations of Aural Fullness Yonsei Med J [online] 2012 Sep 1, 53(5):985-991 [viewed 31 October 2014] Available from: doi:10.3349/ymj.2012.53.5.985
  8. BROWNING GG. Childhood otalgia: acute otitis media. 1. Antibiotics not necessary in most cases. BMJ [online] 1990 Apr 14, 300(6730):1005-1006 [viewed 31 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1662707
  9. PARADISE JL, HOBERMAN A, ROCKETTE HE, SHAIKH N. Treating Acute Otitis Media in Young Children: What Constitutes Success? Pediatr Infect Dis J [online] 2013 Jul, 32(7):745-747 [viewed 31 October 2014] Available from: doi:10.1097/INF.0b013e31828e1417
  10. CIORBA A, BERTO A, BORGONZONI M, GRASSO D, MARTINI A. Pneumocephalus and meningitis as a complication of acute otitis media: case report Acta Otorhinolaryngol Ital [online] 2007 Apr, 27(2):87-89 [viewed 02 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640004
  11. MARANHãO AS, ANDRADE JS, GODOFREDO VR, MATOS RC, PENIDO NDE O. Intratemporal complications of otitis media. Braz J Otorhinolaryngol [online] 2013 Mar-Apr, 79(2):141-9 [viewed 02 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23670317
  12. MORRISON AW. Phenethicillin and Benzylpenicillin in Acute Otitis Media Br Med J [online] 1961 Jul 1, 2(5243):8-11 [viewed 02 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1968928

Examination

Fact Explanation
Pneumataic otoscopy- signs of middle ear effusion -colour change in the tympanic membrane It clearly demonstrate the signs of inflammation. it might be in red, grey or yelow [1] [2]
Pneumatic otoscopy- bulging of the ear drum this is a sign of middle ear effusion, commonly seen in suppurative otitis media, the bulge may be in the posterior quadrants, with the epithelial layer exhibiting a scalded appearance [1][2]
Pneumatic otoscopy-Perforation of tympanic membrane spontaneous perforation of the ear drum in acute otitis media is commonly seen among children[1] Acute suppurative otitis media or otitis media with effusion are common with persistent tympanic membrane perforation [3]
Pneumatic otoscopy- signs of middle ear effusion(presence of purulent fluid in the middle ear)-reduction of TM mobility this is either due to effusion or inflammation . studies have there is a TM mobility difference between the AOM and OME ears which is mainly caused by the middle ear ossicular structure changes during the bacterial infection in AOM.TM mobility in AOM ears was lower than OME ears at low frequencies [4]
Pneumatic otoscopy- signs of middle ear effusion-Loss of the bony landmarks behind the tympanic membrane this is a feature of middle ear effusion (presence of purulent fluid in the middle ear)[5]
Pneumatic otoscopy- signs of middle ear effusion- A visible air fluid level behind the tympanic membrane this is a feature of middle ear effusion(presence of purulent fluid in the middle ear)[5]
References
  1. APPELMAN CL, CLAESSEN JQ, TOUW-OTTEN FW, HORDIJK GJ, DE MELKER RA. Severity of inflammation of tympanic membrane as predictor of clinical course of recurrent acute otitis media. BMJ [online] 1993 Apr 3, 306(6882):895 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1677400
  2. PIROZZO S, MAR CD. Acute otitis media West J Med [online] 2001 Dec, 175(6):402-407 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1275975
  3. QUREISHI A, LEE Y, BELFIELD K, BIRCHALL JP, DANIEL M. Update on otitis media - prevention and treatment Infect Drug Resist [online] :15-24 [viewed 01 November 2014] Available from: doi:10.2147/IDR.S39637
  4. GUAN X, LI W, GAN RZ. Comparison of Eardrum Mobility in Acute Otitis Media and Otitis Media with Effusion Models Otol Neurotol [online] 2013 Sep, 34(7):1316-1320 [viewed 01 November 2014] Available from: doi:10.1097/MAO.0b013e3182941a95
  5. FORGIE S, ZHANEL G, ROBINSON J. Management of acute otitis media Paediatr Child Health [online] 2009 Sep, 14(7):457-460 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2786953

Differential Diagnoses

Fact Explanation
Otitis externa Common disease of children, adolescents and adults . progressive severe pain may prominent , hearing loss is unlikely . pain over tragus upon palpation or pain when traction over the pinna are more suggestive of otitis externa than otitis media[1]
Temporo-mandibular joint pain- Temparo mandibular dysfunction syndrome causes the reffered pain to ear. for the distinguish purposes TMJ problems causes Pain and tenderness on palpation in the muscles of mastication, or of the joint itself and is usually aggravated by manipulation or function,such as when chewing, clenching.[2]
Dental infection in the upper jaw- in dental emergencies pain is usually reffered to the ipsilateral ear. middle ear accompanying symptoms like otorrhea , hearing loss etc and normal oral examination are help to distinguish between middle ear infections and dental problems [3]
Mastoditis is known complication of AOM, swelling and tenderness over mastoid region will be helpful in identification of the infection [4]
References
  1. HUI CP, CANADIAN PAEDIATRIC SOCIETY, INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE. Acute otitis externa Paediatr Child Health [online] 2013 Feb, 18(2):96-98 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3567906
  2. SPECK JE. The Temporomandibular Joint Pain Dysfunction Syndrome Can Fam Physician [online] 1988 Jun:1369-1374 [viewed 02 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219112
  3. ROBERTS G, SCULLY C, SHOTTS R. Dental emergencies West J Med [online] 2001 Jul, 175(1):51-54 [viewed 02 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071467
  4. VAN TOL A, VAN RIJSWIJK J. Aspergillus mastoiditis, presenting with unexplained progressive otalgia, in an immunocompetent (older) patient Eur Arch Otorhinolaryngol [online] 2009 Oct, 266(10):1655-1657 [viewed 13 November 2014] Available from: doi:10.1007/s00405-008-0877-4

Investigations - for Diagnosis

Fact Explanation
Tympanometry provides useful information about the presence of fluid in the middle ear, mobility of the middle ear system, and ear canal volume, pneumatic otoscopy with tympanometry is very useful in diagnosis of acute suppurative otitis media. Acute otitis media (AOM) is defined as the presence of middle ear effusion in conjunction with the recent, abrupt onset of one or more signs or symptoms of inflammation of the middle ear[1][2]
Tympanocentesis and culture Involves aspiration the middle ear cleft contents by piercing the membrane with a needle and collecting them for diagnostic examination. either from tympanocentesis or specimen from fresh perforation is cultured for organisms like typical aerobic bacteria, such as Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis or Streptococcus pyogenes, may be helpful.[3][4]
Acoustic reflectometry this investigation detects middle ear fluid by analyzing the spectral gradient of sound reflected off the tympanic membrane.this is generally easy test to perform and has a high success rate even among crying and struggling children.[1][5]
Inflammatory markers inflammatory markers such as ESR , CRP will be elevated in the situation, much higher values can be identified when the AOM is complicated with sepsis [4][7]
maging studies: CT scan or MRI Usually for the detection of complications but some situations it can be used for exclusion of trauma [6]
References
  1. KALYANAKRISHNAN RAMAKRISHNAN, RHONDA A. SPARKS, WAYNE E. BERRYHILL, Diagnosis and Treatment of Otitis Media, American family physician [online] 2007 Dec 1;76(11):1650-1658.[viewed 31 October 2014] Available from: http://www.aafp.org/afp/2007/1201/p1650.
  2. EDWARD ONUSKO,Tympanometry, Am Fam Physician[online]. 2004 Nov 1;70(9):1713-1720..[viewed 31 October 2014] Available from:http://www.aafp.org/afp/2004/1101/p1713.html
  3. BLOCK SL. Searching for the Holy Grail of acute otitis media Arch Dis Child [online] 2006 Dec, 91(12):959-961 [viewed 01 November 2014] Available from: doi:10.1136/adc.2006.097063
  4. SCHARER G, ZALDIVAR F, GONZALEZ G, VARGAS-SHIRAISHI O, SINGH J, ARRIETA A. Systemic Inflammatory Responses in Children with Acute Otitis Media Due to Streptococcus pneumoniae and the Impact of Treatment with Clarithromycin Clin Diagn Lab Immunol [online] 2003 Jul, 10(4):721-724 [viewed 13 November 2014] Available from: doi:10.1128/CDLI.10.4.721-724.2003
  5. TEPPO H, REVONTA M. Consumer acoustic reflectometry by parents in detecting middle-ear fluid among children undergoing tympanostomy Scand J Prim Health Care [online] 2009, 27(3):167-171 [viewed 01 November 2014] Available from: doi:10.1080/02813430903072165
  6. TROJANOWSKA A, DROP A, TROJANOWSKI P, ROSIńSKA-BOGUSIEWICZ K, KLATKA J, BOBEK-BILLEWICZ B. External and middle ear diseases: radiological diagnosis based on clinical signs and symptoms Insights Imaging [online] , 3(1):33-48 [viewed 01 November 2014] Available from: doi:10.1007/s13244-011-0126-z
  7. EDE LC, O’BRIEN J, CHONMAITREE T, HAN Y, PATEL JA. Lactate dehydrogenase as a marker of nasopharyngeal inflammatory injury during viral upper respiratory infection: implications for acute otitis media Pediatr Res [online] 2013 Mar, 73(3):349-354 [viewed 13 November 2014] Available from: doi:10.1038/pr.2012.179

Investigations - Screening/Staging

Fact Explanation
Imaging studies: CT scan or MRI this investigations are usually not recommended, only in suspected cases of complications like intra-cranial extension of an infection or mastoid abscess.[1][2]
References
  1. TROJANOWSKA A, DROP A, TROJANOWSKI P, ROSIńSKA-BOGUSIEWICZ K, KLATKA J, BOBEK-BILLEWICZ B. External and middle ear diseases: radiological diagnosis based on clinical signs and symptoms Insights Imaging [online] , 3(1):33-48 [viewed 01 November 2014] Available from: doi:10.1007/s13244-011-0126-z
  2. AMI M, ZAKARIA Z, GOH BS, ABDULLAH A, SAIM L. Mastoid Abscess in Acute and Chronic Otitis Media Malays J Med Sci [online] 2010, 17(4):44-50 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216184

Management - General Measures

Fact Explanation
Antihistamines this may help with nasal congestion, but may prolongs the duration of middle ear efusion[1]
Nasal decongestant this is used to relieve nasal congestion. but does not improve healing or minimize complications of acute otitis media, [1][3]
Analgesics : NAIDS studies have found that are more effective in relieving pain than paracetamol[2]
Antipyretics effective in patients presents with fever[1][4]
Patient education Is very crucial in management AOM is self curing disease and Either a bacterial infection or a viral infection of the ear can cause AOM. the tendency of recurrence, risk factors , possible complications and importance of treatment and follow up[5]
Preventive measures 1. Day care, smoke, pacifier use- Exposure to day care, pacifier use, and tobacco smoke significantly increase the risk of AOM, OME and symptoms of upper respiratory infection. 2. Hand washing can be helpful in limiting spread. 3. Immunizations. The conjugated pneumococcal vaccine, reduces the risk of ear infections slightly. Children with recurrent ear infections should probably get an annual influenza vaccine. 3. Xylitol. -containing chewing gum significantly decreases the risk of recurrent ear infections. However, the use of such gum should be balanced by the risk of choking, especially in younger children, and children should not be allowed to chew gum when physically active. 4. Ear infections are not generally contagious, and children with isolated AOM can return to school whether or not they are receiving antibiotics. [1][5][6]
References
  1. KALYANAKRISHNAN RAMAKRISHNAN, RHONDA A. SPARKS, WAYNE E. BERRYHILL, Diagnosis and Treatment of Otitis Media, Am Fam Physician[online]. 2007 Dec 1;76(11):1650-1658.[viewed 01 November 2014] Available from:http://www.aafp.org/afp/2007/1201/p1650.html
  2. O’NEILL P. Acute otitis media BMJ [online] 1999 Sep 25, 319(7213):833-835 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1116665
  3. BARATI B, OMRANI MR, OKHOVAT AR, KELISHADI R, HASHEMI M, HASSANZADEH A, ABTAHI M, OMIDIFAR N, OKHOVAT H. Effect of nasal beclomethasone spray in the treatment of otitis media with effusion J Res Med Sci [online] 2011 Apr, 16(4):509-515 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3214356
  4. QUREISHI A, LEE Y, BELFIELD K, BIRCHALL JP, DANIEL M. Update on otitis media - prevention and treatment Infect Drug Resist [online] :15-24 [viewed 01 November 2014] Available from: doi:10.2147/IDR.S39637
  5. RODRIGO C. Prevention of acute otitis media. Clin Microbiol Infect [online] 1997 Jun:S55-S58 [viewed 02 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11869231
  6. QUREISHI A, LEE Y, BELFIELD K, BIRCHALL JP, DANIEL M. Update on otitis media - prevention and treatment Infect Drug Resist [online] :15-24 [viewed 02 November 2014] Available from: doi:10.2147/IDR.S39637

Management - Specific Treatments

Fact Explanation
Antibiotics Antibiotics improving patient outcomes in early and late phases of AOM has been demonstrated in studies. current guidelines suggest that antibiotics should be used in children aged over 6 months when unilateral or bilateral when the condition is severe. Uncomplicated AOM in patients older than 2 years treated with a 5-7 day course of antimicrobials High-dosage amoxicillin which has excellent middle ear penetration is recommended as first-line antibiotic therapy in children with AOM. (80-90 mg per kg per day, for 10 days in divided doses) Cephalosporin or macrolides can be used as secondary drugs if there is allergy. early use of antimicrobials have proven to reduce serious complications of AOM, such as mastoiditis, meningitis and intracranial abscesses Symptoms should improve within one to two days and resolve within two to three days of starting antimicrobials if not change of the antimicrobial agent should be considered, Combination therapy may help in preventing the emergence of resistance by means of mutation, provided that the pathogen is initially sensitive to both of the components in combination therapy[1][2][3][4][5]
Surgical management-Tympanocentesis Tympanocentesis, , is primarily a diagnostic procedure and can also be a therapeutic one. tympanocentesis and associated antimicrobial therapy has provrn to reduce the recurrence as well as the need for tympanostomy tube surgery Specially considered in suppressed or those who failed to respond for an appropriate antibiotic treatment.[1][6]
Surgical management-tympanostomy tubes Ventilation/drainage of the ear cleft for an extended period is beneficial in some patients especially those with complications and recurrent acute attacks. Surgical intervention is more considered with increasing antimicrobial resistance. otorrhea is a frequent sequela.complication of surgical interventions are as followed Injury to the skin of the ear canal and ossicular chain are the immediate complications where Persistent otorrhea, implantation cholesteatoma, external otitis from persistent drainage consist of intermediate ones Long-term complications include Persistent perforation of the membrane with or without otorrhea and ear canal stenosis [7][8]
References
  1. QUREISHI A, LEE Y, BELFIELD K, BIRCHALL JP, DANIEL M. Update on otitis media - prevention and treatment Infect Drug Resist [online] :15-24 [viewed 01 November 2014] Available from: doi:10.2147/IDR.S39637
  2. KALYANAKRISHNAN RAMAKRISHNAN, RHONDA A. SPARKS, WAYNE E. BERRYHILL, Diagnosis and Treatment of Otitis Media, Am Fam Physician[online]. 2007 Dec 1;76(11):1650-1658.[viewed 01 November 2014] Available from:http://www.aafp.org/afp/2007/1201/p1650.html
  3. FORGIE S, ZHANEL G, ROBINSON J. Management of acute otitis media Paediatr Child Health [online] 2009 Sep, 14(7):457-460 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2786953
  4. WORRALL G. Acute otitis media Can Fam Physician [online] 2007 Dec, 53(12):2147-2148 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231558/
  5. Antibiotic management of acute otitis media Paediatr Child Health [online] 1998, 3(4):265-267 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851349
  6. PICHICHERO ME, CASEY JR, ALMUDEVAR A. Reducing the Frequency of Acute Otitis Media by Individualized Care Pediatr Infect Dis J [online] 2013 May, 32(5):473-478 [viewed 01 November 2014] Available from: doi:10.1097/INF.0b013e3182862b57
  7. SCHMELZLE J, BIRTWHISTLE RV, TAN AK. Acute otitis media in children with tympanostomy tubes Can Fam Physician [online] 2008 Aug, 54(8):1123-1127 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515237
  8. MCISAAC WJ, COYTE PC, CROXFORD R, ASCHE CV, FRIEDBERG J, FELDMAN W. Otolaryngologists' perceptions of the indications for tympanostomy tube insertion in children CMAJ [online] 2000 May 2, 162(9):1285-1288 [viewed 01 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232410