Otitis Media

An infection or inflammation of the middle ear space behind the eardrum

Table of Contents

Overview

Otitis media is one of the most common childhood illnesses, though it can affect people of all ages. It occurs when the middle ear becomes infected or inflamed, typically due to bacteria or viruses. The condition often develops following an upper respiratory infection, such as a common cold or flu, when pathogens travel from the nasopharynx through the Eustachian tube to the middle ear space.

The middle ear is an air-filled space located behind the eardrum (tympanic membrane) that contains the tiny bones responsible for transmitting sound vibrations. When this space becomes infected, fluid and pus can accumulate, causing pressure, pain, and temporary hearing difficulties. While most cases of otitis media resolve without serious complications, recurrent or chronic infections can lead to more significant problems, including permanent hearing loss, speech and developmental delays in children, and rarely, spread of infection to nearby structures.

Otitis media is classified into several types, including acute otitis media (AOM), otitis media with effusion (OME), and chronic otitis media. Understanding these distinctions is important for proper treatment and management of the condition.

Symptoms

The symptoms of otitis media can vary depending on the type of infection, the age of the patient, and the severity of the condition. In children, symptoms may be more difficult to identify, especially in infants who cannot verbally communicate their discomfort.

Common Symptoms

  • Ear pain - Often severe and may worsen when lying down
  • Fever - Typically 100.4°F (38°C) or higher
  • Diminished hearing - Due to fluid accumulation in the middle ear
  • Fluid drainage from the ear - May occur if the eardrum ruptures
  • Irritability - Especially common in infants and young children
  • Pulling or tugging at the affected ear - A classic sign in young children

Less Common Symptoms

Symptoms in Infants

Infants with otitis media may exhibit:

  • Excessive crying, especially when lying down
  • Difficulty sleeping or frequent waking
  • Loss of appetite or difficulty feeding
  • Pulling or rubbing the affected ear
  • Unusual fussiness or irritability
  • Failure to respond to quiet sounds

Causes

Otitis media typically develops when bacteria or viruses from the upper respiratory tract migrate to the middle ear through the Eustachian tube. This tube normally helps drain fluid from the middle ear and equalize pressure, but when it becomes blocked or swollen, pathogens and fluid can become trapped.

Bacterial Causes

The most common bacterial causes include:

  • Streptococcus pneumoniae - The most frequent bacterial cause
  • Haemophilus influenzae - Non-typeable strains
  • Moraxella catarrhalis
  • Streptococcus pyogenes - Less common but can cause severe infections

Viral Causes

Viruses responsible for upper respiratory infections often precede bacterial otitis media:

  • Respiratory syncytial virus (RSV)
  • Rhinoviruses
  • Influenza viruses
  • Adenoviruses
  • Coronaviruses

Contributing Factors

Several factors can contribute to the development of otitis media:

  • Eustachian tube dysfunction - Due to anatomy, inflammation, or allergies
  • Upper respiratory infections - Create conditions favorable for bacterial growth
  • Adenoid hypertrophy - Enlarged adenoids can block Eustachian tube drainage
  • Immune system immaturity - Particularly in young children
  • Environmental factors - Tobacco smoke exposure, air pollution

Risk Factors

Several factors can increase the likelihood of developing otitis media. Understanding these risk factors can help in prevention and early intervention strategies.

Age-Related Factors

  • Young age - Children between 6 months and 2 years are at highest risk
  • Premature birth - Associated with increased susceptibility to infections

Environmental Factors

  • Daycare attendance - Increased exposure to respiratory infections
  • Secondhand smoke exposure - Irritates respiratory passages
  • Air pollution - Can compromise respiratory health
  • Seasonal factors - Higher incidence during fall and winter months

Medical Conditions

Lifestyle Factors

  • Bottle feeding while lying down - Can allow milk to enter Eustachian tubes
  • Pacifier use - May increase risk in some children
  • Poor hand hygiene - Facilitates spread of respiratory infections

Diagnosis

Diagnosing otitis media typically involves a combination of symptom assessment and physical examination. Healthcare providers use various tools and techniques to confirm the diagnosis and determine the appropriate treatment approach.

Medical History

The diagnostic process begins with a thorough medical history, including:

  • Duration and severity of symptoms
  • Recent upper respiratory infections
  • Previous episodes of ear infections
  • Current medications and allergies
  • Vaccination history
  • Environmental exposures

Physical Examination

Otoscopic Examination

The primary diagnostic tool is the otoscope, which allows visualization of the eardrum. Signs of acute otitis media include:

  • Bulging tympanic membrane
  • Erythema (redness) of the eardrum
  • Loss of normal landmarks
  • Decreased or absent mobility
  • Presence of fluid or pus behind the eardrum

Additional Diagnostic Tests

Pneumatic Otoscopy

This technique uses gentle air pressure to assess eardrum mobility, helping confirm the presence of fluid in the middle ear.

Tympanometry

A test that measures the movement of the eardrum in response to changes in air pressure, providing objective evidence of middle ear effusion.

Acoustic Reflectometry

Uses sound waves to detect fluid in the middle ear, particularly useful in uncooperative children.

Tympanocentesis

In severe or recurrent cases, fluid may be aspirated from the middle ear for culture and sensitivity testing.

Treatment Options

Treatment for otitis media depends on several factors, including the patient's age, severity of symptoms, and whether the infection is bacterial or viral. Current guidelines emphasize judicious use of antibiotics to prevent resistance.

Watchful Waiting

For many cases of acute otitis media, especially in children over 2 years with mild symptoms, a watchful waiting approach may be recommended:

  • Close monitoring for 48-72 hours
  • Pain management with acetaminophen or ibuprofen
  • Follow-up if symptoms worsen or don't improve
  • Delayed antibiotic prescription if needed

Antibiotic Therapy

Antibiotics are recommended for:

  • Children under 6 months of age
  • Children 6-23 months with bilateral acute otitis media
  • Severe symptoms (temperature ≥39°C, severe ear pain)
  • Symptoms persisting beyond 48-72 hours

Common Antibiotics

  • Amoxicillin - First-line treatment for most cases
  • Amoxicillin-clavulanate - For treatment failures or recent antibiotic use
  • Cefdinir or cefuroxime - Alternative for penicillin allergies
  • Azithromycin - For severe penicillin allergies

Pain Management

Pain relief is crucial for patient comfort:

  • Acetaminophen - Safe for all ages
  • Ibuprofen - For children over 6 months
  • Topical anesthetic drops - May provide temporary relief
  • Warm compresses - Applied to the affected ear

Surgical Interventions

Myringotomy with Tube Insertion

For recurrent or chronic otitis media:

  • Small incision in the eardrum to drain fluid
  • Placement of ventilation tubes (grommets)
  • Helps prevent fluid accumulation
  • Usually falls out naturally after 6-12 months

Adenoidectomy

May be considered for children with:

  • Chronic otitis media with effusion
  • Recurrent acute otitis media
  • Enlarged adenoids contributing to Eustachian tube dysfunction

Prevention

While not all cases of otitis media can be prevented, several strategies can significantly reduce the risk of developing ear infections.

Vaccination

  • Pneumococcal vaccine (PCV13) - Protects against common bacterial causes
  • Influenza vaccine - Annual vaccination reduces respiratory infections
  • Haemophilus influenzae type b (Hib) vaccine - Part of routine immunization

Environmental Modifications

  • Avoid exposure to secondhand smoke
  • Limit pacifier use after 6 months of age
  • Practice good hand hygiene
  • Avoid bottle feeding while lying flat
  • Breastfeed for at least 6 months when possible

Managing Risk Factors

  • Treat allergies effectively
  • Address chronic sinusitis
  • Consider smaller daycare settings when possible
  • Maintain good overall health and nutrition

When to See a Doctor

While many ear infections improve on their own, certain symptoms warrant immediate medical attention.

Seek Immediate Care If:

  • Severe ear pain that doesn't respond to pain medication
  • High fever (over 104°F or 40°C)
  • Discharge of blood or pus from the ear
  • Symptoms of meningitis (stiff neck, severe headache, confusion)
  • Facial weakness or asymmetry
  • Swelling or redness behind the ear
  • Sudden hearing loss

Schedule an Appointment If:

  • Symptoms persist for more than 2-3 days
  • Recurrent ear infections (3 or more in 6 months)
  • Hearing problems persist after infection clears
  • Speech or developmental delays in children
  • Balance problems or persistent dizziness

Frequently Asked Questions

Can otitis media go away without antibiotics?

Yes, many cases of acute otitis media resolve on their own within 2-3 days without antibiotics. This is why watchful waiting is often recommended for older children with mild symptoms. However, antibiotics may be necessary for severe cases, very young children, or when symptoms persist.

Is otitis media contagious?

Otitis media itself is not contagious, but the upper respiratory infections that often precede it are. The bacteria or viruses causing the initial cold or flu can spread from person to person, potentially leading to ear infections in susceptible individuals.

Can swimming cause otitis media?

Swimming does not directly cause otitis media (middle ear infection). However, swimming can lead to otitis externa (swimmer's ear), which affects the outer ear canal. Water trapped in the ear canal creates a moist environment conducive to bacterial growth.

How long does otitis media typically last?

Acute otitis media symptoms usually improve within 2-3 days and resolve completely within 1-2 weeks. However, fluid may remain in the middle ear for several weeks or even months after the infection clears, potentially affecting hearing temporarily.

Can adults get otitis media?

Yes, while otitis media is most common in children, adults can develop ear infections too. Adult cases may be associated with upper respiratory infections, allergies, smoking, or Eustachian tube dysfunction. Adults typically experience similar symptoms but may have better ability to describe their discomfort.

References

  1. Lieberthal AS, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-99.
  2. Rosenfeld RM, et al. Clinical practice guideline: Otitis media with effusion (update). Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41.
  3. Schilder AG, et al. Otitis media. Nat Rev Dis Primers. 2016;2:16063.
  4. Venekamp RP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2015;(6):CD000219.
  5. National Institute on Deafness and Other Communication Disorders. Ear Infections in Children. Updated 2023.