What is Acute Otitis Media (Ear Infection)?
Acute otitis media is an infection that occurs in the middle space of the ear and is often seen in a range of other related conditions. It’s the second most common reason kids are seen in emergency departments, with children aged 6 to 24 months being the most susceptible. This infection can be caused by viruses, bacteria, or a combination of the two.
The most frequent bacteria causing this ear infection are Streptococcus pneumoniae, followed by non-typeable Haemophilus influenzae (NTHi) and Moraxella catarrhalis. However, since the introduction of vaccines, these germs have evolved. Viruses causing otitis media are usually respiratory syncytial virus (RSV), coronaviruses, influenza viruses, adenoviruses, human metapneumovirus, and picornaviruses.
Otitis media is diagnosed through a physical ear exam and by considering the patient’s medical history and symptoms. Several tools like a pneumatic otoscope, tympanometry, and acoustic reflectometry are used to confirm diagnosis. The pneumatic otoscope is the most reliable and effective, but if it’s not available, other methods can be used as well.
The use of antibiotics to treat otitis media is debatable and greatly depends on the specific type of otitis media. Without correct treatment, infected fluid from the middle ear can spread to nearby areas and cause further complications such as eardrum perforation, mastoiditis, labyrinthitis, petrositis, meningitis, brain abscess, hearing loss, and others. This led to the establishment of guidelines for the treatment. As a standard treatment in the United States, high-dose amoxicillin is used especially effective for children under two. However, other countries like the Netherlands prefer to initially observe the patient and only prescribe antibiotics if things don’t improve. Despite that, this “wait and watch” approach is not widely accepted due to risks associated with prolonged ear fluid and its impact on hearing and speech. To manage the pain, non-steroidal anti-inflammatory medications like ibuprofen can be used.
What Causes Acute Otitis Media (Ear Infection)?
Otitis media, or middle ear infection, is caused by a combination of factors. These can include things like infections, allergies, and environmental aspects.
Several causes and risk factors are associated with this condition, such as:
* Weakened immune system from conditions like HIV, diabetes, or other immune deficiencies
* Inherited risk from family genes
* Differences in the expression of a gene known as MUC5B, which is involved in producing mucins, a type of protein
* Abnormalities in the structure of the palate or the tensor veli palatini muscle in the ear
* Problems with the tiny hair-like structures called cilia in the ear
* Having a cochlear implant
* Deficiency in Vitamin A
* Bacterial infections involving Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarrhalis, which account for over 95% cases
* Viral infections such as respiratory syncytial virus, influenza virus, parainfluenza virus, rhinovirus, and adenovirus
* Allergies
* Not being breastfed
* Exposure to secondhand smoke
* Attending daycare
* Living in a lower socioeconomic situation
Having a family history of recurrent middle ear infections in parents or siblings can also increase your risk.
Risk Factors and Frequency for Acute Otitis Media (Ear Infection)
Otitis media, or inflammation of the middle ear, is a worldwide issue that occurs slightly more in boys than girls. Pinpointing the exact number of cases each year is a challenge because not all cases are reported and rates differ across various regions. Otitis media primarily affects babies between six and twelve months, with the occurrence decreasing after they turn five years old.
- Around 4 out of 5 children will have some form of otitis media during their lifetime.
- 80% to 90% of children are likely to experience otitis media with fluid build-up in their ear before they start school.
- While otitis media is less common in adults, certain groups are at a higher risk, such as those who suffered recurrent ear infections in their childhood, have a cleft palate, compromised immune system, or other related conditions.
Signs and Symptoms of Acute Otitis Media (Ear Infection)
Otitis media, often known as a middle ear infection, can exhibit various symptoms that might make it challenging to diagnose. While ear pain is often considered a clear indicator, many children can display non-specific signs. These can include ear tugging, irritation, headaches, restless sleep, poor appetite, vomiting, or diarrhea. It’s worth noting that about two-thirds of patients might show low-grade fevers.
The diagnosis mainly depends on combining these signs and symptoms with clinical findings. According to the American Academy of Pediatrics, the condition may be confirmed if there’s a severe swelling of the eardrum or new outer ear discharge not caused by another ear condition. Alternatively, mild eardrum bulging along with recent ear pain or redness might also suggest acute otitis media. These factors are meant to help medical professionals make accurate diagnoses, but they aren’t intended to replace clinical judgment.
An ear examination using an otoscope can help discern the condition. In cases of acute otitis media, the eardrum might appear reddened, normal, or there might be fluid in the middle ear. In more severe cases involving pus (suppurative otitis media), the eardrum might bulge and pus could be visible. If there’s excessive swelling in the ear canal, it might signal an outer ear infection, which needs different treatment.
It’s crucial to check the condition of the eardrum when there’s swelling in the ear canal. If the eardrum is intact and the ear canal is red and painful, additional ear drops might be needed to treat the outer ear infection. This can happen alongside or independently of otitis media, so checking the middle ear is vital. If the eardrum is ruptured, the swelling in the ear canal is likely a reactive condition. In such cases, appropriate ear drops should be used, specifically those safe for use in the middle ear, such as ofloxacin, since other medications can potentially harm the ear.
Testing for Acute Otitis Media (Ear Infection)
If a doctor suspects a case of otitis media, or middle ear infection, they will begin with a physical exam using an instrument called an otoscope – preferably a pneumatic one. This allows them to look directly into the ear and check for signs of infection.
Lab tests are not typically needed to diagnose otitis media. However, they might be necessary for babies under 12 weeks old who have a fever and no clear cause other than a possible ear infection. The tests can help confirm or rule out any related diseases or conditions that are present from birth.
Most of the time, imaging scans like x-rays aren’t required unless there are concerns about complications that could affect the skull or brain. However, if the doctor suspects complications from otitis media, they might order a computed tomography (CT) scan of the temporal bones in the skull. This could help detect conditions such as mastoiditis (an infection in the bone behind the ear), abscesses (pockets of pus) around the brain, meningitis (inflammation of the protective membranes covering the brain and spinal cord), disease of the tiny bones in the ear, and cholesteatoma (a skin growth that occurs in the middle ear). On the other hand, a magnetic resonance imaging (MRI) scan can also expose fluid buildup, particularly in the middle ear.
In more severe or hard-to-treat cases, a procedure known as tympanocentesis might be performed. This involves taking a small sample of fluid from the middle ear using a needle, which can be tested to identify the cause of infection.
Other tests like tympanometry and acoustic reflectometry might also be used. These tests can help check for a buildup of fluid in the middle ear, which is a common sign of otitis media.
Treatment Options for Acute Otitis Media (Ear Infection)
Once a diagnosis of acute ear infection, known as otitis media, is confirmed, the main objectives of treatment are to alleviate pain and eliminate the infection using antibiotics. Pain relief can be achieved by using non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.
There are differing opinions on whether antibiotics should be prescribed immediately for early otitis media. Some European countries prefer a ‘watchful waiting’ approach, monitoring the patient closely without initiating treatment, and it hasn’t led to an increase in complications. However, this approach is less widely accepted in the United States.
If there’s clear evidence of a suppurative AOM, a type of ear infection with pus, oral antibiotics are needed to treat the bacterial infection. The first choice of treatment is usually high-dose amoxicillin or a second-generation cephalosporin antibiotic. In cases where a perforation, or hole, in the eardrum is present, topical ear drops like ofloxacin are preferred over systemic, or whole-body, antibiotics to deliver higher antibiotic concentrations without any system-wide side effects.
When the infection is thought to be bacterial, a high-dose of amoxicillin for ten days is the go-to option for children and adults not allergic to penicillin. Amoxicillin effectively treats otitis media as it concentrates well in the middle ear. For those with a penicillin allergy, alternative options include azithromycin, clarithromycin, or other antibiotics like cefdinir, cefpodoxime, or cefuroxime.
If a patient’s symptoms don’t improve despite treatment with high-dose amoxicillin, a combination of high-dose amoxicillin and clavulanate is often given. There are also certain circumstances, like if a child vomits frequently, where oral antibiotics may not be possible. In these cases, an injection of the antibiotic ceftriaxone for three consecutive days presents a suitable alternative. However, research shows that using systemic steroids or antihistamines doesn’t significantly aid in recovery.
According to the guidelines laid out by the American Academy of Pediatrics, patients who have had four or more bouts of AOM in the past year should be given consideration for a procedure known as myringotomy with tube (grommet) placement. This procedure, which involves making a small hole in the eardrum to relieve pressure and prevent fluid build-up, can help maintain normal hearing. Furthermore, if the patient contracts otitis media while the tube is in place, topical antibiotic drops can be used instead of systemic antibiotics.
What else can Acute Otitis Media (Ear Infection) be?
When a doctor is trying to diagnose an ear infection (otitis media), they have to rule out a variety of conditions that show similar symptoms. These can include:
- Cholesteatoma (a skin growth in the middle ear)
- High temperature in infants and toddlers
- Unexplained fever
- Hearing loss
- Nasal polyps in children
- Nasopharyngeal cancer (a type of head and neck cancer)
- Otitis externa (an inflammation of the ear canal)
- Infections caused by human parainfluenza viruses and other similar viruses
- Health issues triggered by secondhand smoke
- Allergic rhinitis in children (a type of inflammation in the nose)
- Bacterial meningitis in children (an infection of the membranes surrounding the brain and spinal cord)
- Acid reflux in children
- The bacteria known as Haemophilus influenzae causing illness in children
- HIV infection in children
- Mastoiditis in children (an infection in the mastoid bone of the skull)
- Streptococcus pneumoniae infections in children
- Primary ciliary dyskinesia (a disorder that affects the cilia, tiny hair-like structures that move mucus and fluids through the body)
- Respiratory syncytial virus infection (a common virus that affects the respiratory tract)
- Rhinovirus infection (common cold)
- Teething
It’s important for the doctor to consider all these conditions and conduct the necessary tests to reach the correct diagnosis.
What to expect with Acute Otitis Media (Ear Infection)
The outlook is usually excellent for most patients with otitis media, or a middle ear infection.[39] In today’s time, deaths from this condition are pretty rare, especially with better healthcare available in developed countries. Early diagnosis and treatment have significantly improved outcomes. The primary treatment for this condition is effective antibiotic therapy. Many factors influence the progression of the disease. For example, children who have less than three episodes of otitis media are three times more likely to have their symptoms resolved after one course of antibiotics, compared to children who get ear infections in seasons other than winter.[40]
However, when complications happen, it can be tough to treat and often tends to come back. Complications inside the ear and brain, though very rare, can have significant mortality rates.[41]
Importantly, children who had otitis media before learning to speak can potentially face mild to moderate conductive hearing loss. Infants who had otitis media within the first 24 months can often have trouble hearing certain high-pitched sounds, like hissing sounds.[40]
Possible Complications When Diagnosed with Acute Otitis Media (Ear Infection)
Because the middle ear area is intricate and intricate, complications that occur can be difficult to manage. These complications can be broadly categorized into two types: intratemporal (inside the ear) and intracranial (inside the head).
Intratemporal complications can include:
- Hearing loss (either due to damage to the structures that conduct sound, or the nerve that senses it)
- Tympanic membrane perforation (rupture of the eardrum, can be sudden or long-term)
- Chronic suppurative otitis media (long term infection with pus in the middle ear, can be with or without bony growth, or cholesteatoma)
- Cholesteatoma (abnormal skin growth in the middle ear)
- Tympanosclerosis (hardening of the eardrum)
- Mastoiditis (infection of the hollow spaces in the skull behind the ear, called mastoid)
- Petrositis (infection of temporal bone)
- Labyrinthitis (inflammation of the inner ear)
- Facial paralysis
- Cholesterol granuloma (cysts filled with cholesterol crystals)
- Infectious eczematoid dermatitis (itchy skin condition cause by infection)
Ear infections can also impact hearing, notably in the critical 6 to 24-month age range – a key time for language development. Chronic ear infections can lead to conductive hearing loss and delay language development. This may impact speech and require speech therapy. That’s why aggressive early treatment of recurring ear infections is recommended by pediatric and ear specialists.
Intracranial complications can occur when the infection spreads beyond the ear:
- Meningitis (infection of the membranes covering brain and spinal cord)
- Subdural empyema (pus filled infection between the brain surface and its outer covering)
- Brain abscess (brain infection pocket)
- Extradural abscess (pus-filled infection outside the brain covering)
- Lateral sinus thrombosis (clot formation in the vein draining brain)
- Otitic hydrocephalus (increased spinal fluid pressure due to ear infection)
Preventing Acute Otitis Media (Ear Infection)
Vaccines for pneumonia and the flu can help prevent upper respiratory infections in children. Additionally, keeping youngsters away from tobacco smoke can lower their chances of developing these infections. This is because tobacco smoke can irritate the respiratory system and raise the risk of pneumonia in children. For babies suffering from ear infections, breastfeeding is highly recommended; this is because breast milk has special proteins known as immunoglobulins that can shield babies from harmful germs during their early stages of life outside the womb.
