Otitis media, an inflammation of the middle ear associated with fluid accumulation, may be acute or chronic, suppurative or secretory.
Acute otitis media is most common in infants and children because they have a shorter and more horizontal eustachian tube than adults. which predisposes them to middle ear infections. The incidence peaks between ages 6 and 24 months and subsides after age 3. It occurs most frequently during the winter months, paralleling the seasonal increase in nonbacterial respiratory tract infections.
With prompt treatment, the prognosis for acuteotitis media is excellent. However, prolonged accumulation of fluid in the middle ear cavity can cause chronic serous otitis media. with possible perforation of the tympanic membrane. Chronic suppurative otitis media can lead to scarring, adhesions, and severe structural or functional ear damage. Chronic secretory otitis media, with its persistent inflammation and pressure, can cause conductive hearing loss.
Fluid may build up in the middle ear for 2 reasons. First, when a child has a cold, the middle ear may produce fluid just like the nose does, but the fluid doesn't drain out of the middle ear as easily as it does from the nose. Second, children who have a "regular" ear infection could have otitis media with effusion the next time, if the fluid stays in the middle ear for a long time.
Signs and Symptoms
The patient history may reveal an upper respiratory tract infection or history of allergies. The patient may complain of severe, deep, throbbing ear pain (from pressure behind the tympanic membrane) and dizziness, nausea, and vomiting. With acute secretory otitis media, the patient may describe a sensation of fullness in the ear and popping, crackling, or clicking sounds on swallowing or moving the jaw. The patient with an accumulation of fluid may describe hearing an echo when speaking and experiencing a vague feeling of top-heaviness.
If the tympanic membrane has ruptured, the patient may state that the pain suddenly stopped. A history of recent air travel or scuba diving suggests barotitis media.
Inspection may reveal sneezing and coughing due to an upper respiratory tract infection. Vital sign assessment may reveal mild to very high fever. In chronic suppurative otitis media, inspection may reveal a painless, purulent discharge.
In acute suppurative otitis media, otoscopic examination may show obscured or distorted bony landmarks of the tympanic membrane. In acute secretory otitis media, otoscopy reveals tympanic membrane retraction, which causes the bony landmarks to appear more prominent. Otoscopy also reveals clear or amber fluid behind the tympanic membrane, possibly with a meniscus and bubbles. If hemorrhage into the middle ear has occurred, as in barotrauma, otoscopy exposes a blue-black tympanic membrane.
In chronic otitis media, otoscopic examination may show thickening and scarring of the tympanic
In acute secretory otitis media, audiometric tests may reveal severe conductive hearing loss varying from 15 to 35 dB, depending on the thickness and amount of fluid in the middle ear cavity. In chronic suppurative otitis media, the associated conductive hearing loss varies with the size and type of tympanic membrane perforation and ossicular destruction.
Otoscopic or neuroscopic examination is used to diagnose the disorder, remove debris, and perform minor surgery.
Pneumatoscopy shows decreased tympanic membrane mobility. (This procedure is painful when the tympanic membrane is obviously bulging and erythematous.) Tympanometry is used to measure how well the tympanic membrane functions to detect hearing loss and evaluate the condition of the middle ear.
Culture and sensitivity tests of exudate are used to identify the causative organism.
Radiographic studies depict mastoid involvement. Audiometry is used to detect and measure the degree of hearing loss.
Biopsy is used to rule out malignancy and identify tissues and a complete blood count is used to identify infection.
In acute suppurative otitis media, antibiotic therapy includes ampicillin or amoxicillin and, also, amoxicillin clavulanate potassium (Augmentin) for infants, children, and adults. Therapy for patients allergic to penicillin derivatives may include sulfonamides, erythromycin, tetracycline, and other broad-spectrum antibiotics. Aspirin or acetaminophen controls pain and fever.
Severe, painful bulging of the tympanic membrane usually requires myringotomy. Codeine may be given for severe pain in adults, and sedatives may be given to small children.
Broad-spectrum antibiotics can help prevent acute suppurative otitis media in high-risk patients such as children with recurring episodes of otitis. In these patients, antibiotics must be used sparingly and with discretion to prevent development of resistant bacteria.
In acute secretory otitis media, performing Valsalva's maneuver several times a day to inflate the eustachian tube may be the only treatment required. If this isn't successful, nasopharyngeal decongestant therapy may be helpful; it should continue for at least 2 weeks and sometimes indefinitely, with periodic evaluation. If decongestant therapy fails, myringotomy and aspiration of middle ear fluid are necessary, followed by insertion of a polyethylene tube into the tympanic membrane to equalize pressure. This pressure-equalizing tube, called a tympanostomy tube, remains in place for 6 to 12 months, although it may fall out on its own. Concomitant treatment of the underlying cause (such as allergen elimination or adenoidectomy) also may be helpful.
Treatment for a patient with chronic otitis media may include antibiotics for exacerbations of acute otitis media, elimination of eustachian tube obstruction, treatment of otitis externa (when present), myringoplasty (tympanic membrane graft), tympanoplasty to reconstruct middle ear structures when thickening and scarring are present, mastoidectomy, or cholesteatoma excision.
A stapedectomy may be performed for a patient with otosclerosis.
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