Otitis media - Causes, Symptoms and treatments
An inflammation of the middle ear, otitis media may be suppurative or secretory, acute or chronic. Acute otitis media is common in children; its incidence rises during the winter months, paralleling the seasonal rise in nonbacterial respiratory tract infections. It occurs most commonly between ages 6 months and 24 months due to developmental changes involving the eustachian tube.
With prompt treatment, the prognosis for acute otitis media is excellent; however, prolonged accumulation of fluid within the middle ear cavity causes chronic otitis media, with possible perforation of the tympanic membrane.
Chronic suppurative otitis media may lead to scarring, adhesions, and severe structural or functional ear damage; chronic secretory otitis media, with its persistent inflammation and pressure, may cause conductive hearing loss.
Causes of Otitis media:
Otitis media results from disruption of eustachian tube patency.
In the suppurative form, respiratory tract infection, allergic reaction, nasotracheal intubation, or positional changes allow nasopharyngeal flora to reflux through the eustachian tube and colonize the middle ear. Suppurative olitis media usually results from bacterial infection with pneumococci, Haemophilus influenzae (the most common cause in children under age 6), Moraxella catarrhalis, beta-hemolytic streptococci, staphylococci (most common cause in children age 6 or older), or gram-negative bacteria.
Predisposing factors include the normally wider, shorter, more horizontal eustachian tubes and increased lymphoid tissue in children as well as anatomic anomalies. Chronic suppurative otitis media results from inadequate treatment of acute otitis episodes or from infection by resistant strains of bacteria or, rarely, tuberculosis.
Secretory otitis media results from obstruction of the eustachian tube. This causes a buildup of negative pressure in the middle ear that promotes transudation of sterile serous fluid from blood vessels in the membrane of the middle ear. Such effusion may be secondary to eustachian tube dysfunction from viral infection or allergy. It may also follow barotrauma (pressure injury caused by inability to equalize pressures between the environment and the middle ear), as can occur during rapid aircraft descent in a person with an upper respiratory tract infection or during rapid underwater ascent in scuba diving (barotitis media).
Chronic secretory otitis media follows persistent eustachian tube dysfunction from mechanical obstruction (adenoidal tissue overgrowth, tumors), edema (allergic trinities, chronic sinus infection), or inadequate treatment of acute suppurative otitis media.
Generally, risk factors include male sex; genetic factors; adenoid hypertrophy; bottle feeding, especially in the supine position; exposure to upper respiratory tract infections (such as in day-care settings or during the winter season); history of allergies; exposure to cigarette smoke; craniofacial abnormalities (such as cleft palate); and previous episodes of acute otitis media.
Signs and symptoms of Otitis media:
Clinical features vary with the specific type of the disorder. Symptoms of acute suppurative otitis media include severe, deep, throbbing pain (from pressure behind the tympanic membrane); signs of upper respiratory tract infection (sneezing, coughing); mild to very high fever; hearing loss (usually mild and conductive); dizziness; nausea; and vomiting. Other possible effects include bulging of the tympanic membrane, with concomitant erythema and purulent drainage in the ear canal from tympanic membrane rupture. However, many patients are asymptomatic.
In acute secretory otitis media, a severe conductive hearing loss varies from 15 to 35 decibels, depending on the thickness and amount of fluid in the middle ear cavity and, possibly, a sensation of fullness in the car, and popping, crackling, or clicking sounds on swallowing or with jaw movement. Accumulation of fluid may also cause the patient to hear an echo when he speaks and to experience a vague feeling of top-heaviness.
The cumulative effects of chronic otitis media include thickening and scarring of the tympanic membrane, decreased or absent tympanic membrane mobility, cholesteatoma (a cyst-like mass in the middle car) and, in chronic suppurative otitis media, a painless, purulent discharge. The extent of associated conductive hearing loss varies with the size and type of tympanic membrane perforation and ossicular destruction.
If the tympanic membrane has matured, the patient may state that the pain has suddenly stopped. Complications may include abscesses (brain, subperiosteal, and epidural), sigmoid sinus or jugular vein thrombosis, septicemia, meningitis, suppurative labyrinthitis, facial paralysis, and otitis extema.
Diagnosis for Otitis media:
Diagnostic tests vary with the specific type of otitis media. In acute suppurative otitis media, otoscopy reveals obscured or distorted bony landmarks of the tympanic membrane. Pneumatoscopy can show decreased tympanic membrane mobility, but this procedure is painful with an obviously bulging, erythematous tympanic membrane. The pain pattern is diagnostically significant: In acute suppurative otitis media, for example, pulling the auricle doesn't exacerbate the pain.
In acute secretory otitis media, otoscopic examination reveals tympanic membrane retraction, which causes the bony landmarks to appear more prominent.
Examination also detects clear or amber fluid behind the tympanic membrane. If hemorrhage into the middle ear has occurred, as in barotrauma, the tympanic membrane appears blue-black.
In patients with chronic otitis media, the history discloses recurrent or unresolved otitis media. Otoscopy shows thickening and sometimes scarring, and decreased mobility of the tympanic membrane; pneumatoscopy shows decreased or absent tympanic membrane movement. History of recent air travel or scuba diving suggests barotitis media.
Other conditions to consider are infectious myringitis, pharyngitis, tonsillitis, teething, and temporomandibular joint syndrome.
Treatment of Otitis media:
The type of otitis media dictates the treatment guidelines. In acute suppurative otitis media, antibiotic therapy includes ampicillin or amoxicillin for 10 days. In areas with a high incidence of beta lactamaseproducing H. influenzae and in patients who are not responding to ampicillin or arnoxicillin, amoxicillin/clavulanate potassium may be used.
For those who are allergic to penicillin derivatives, therapy may include cofactor, cefuroximc axctil, cefixime, erythromycin. sulfisoxazole, or cotrimoxazole. Severe painful bulging of the tympanic membrane usually necessitates myringotomy. Broad-spectrum antibiotics can help prevent acute suppurative otitis media in high-risk patients. In patients with recurring otitis, antibiotics must be used with discretion to prevent development of resistant strains of bacteria. Acetaminophen may be used for pain. Systemic decongestants and expectorants may also be of benefit. However, antihistamines should not be used.
For patients with acute secretory otitis media, inflation of the eustachian tube by performing Valsalva's maneuver several times a day may be the only treatment required. Otherwise, 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, for immediate and prolonged equalization of pressure. The tube falls out spontaneously after 9 to 12 months. Concomitant treatment of the underlying cause (such as elimination of allergens, or adenoidectomy for hypertrophied adenoids) may also be helpful in correcting this disorder.
Treatment of chronic otitis media includes broad-spectrum antibiotics, such as amoxicillin/clavulanate potassium or cefuroxime, for exacerbations of acute otitis media; elimination of eustachian tube obstruction; treatment of otitis externa; myringoplasty and tympanoplasty to reconstruct middle ear structures when thickening and scarring are present; and, possibly, mastoidectomy. Cholesteatoma requires excision.
Special considerations and prevention tips of Otitis media:
To prevent otitis media, teach recognition of upper respiratory tract infections and encourage early treatment. Instruct parents not to feed their infant in a supine position or put him to bed with a bottle. This prevents reflux of nasopharyngeal flora. To promote eustachian tube patency, instruct the patient to perform Valsalva's maneuver several times daily. Parents should be advised that tobacco smoke increases the risk of middle ear infections in children. Allergens in the home, such as pets, house dust, and mold, should be eliminated as much as possible.
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