Otitis media

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Otitis Media

Otitis media (OM) is inflammation of the middle ear and represents a spectrum of disease. It is one of the most common conditions in clinical practice, particularly in children.

Classification

Type	Key Features
Acute Otitis Media (AOM)	Middle ear effusion + signs/symptoms of acute infection (also called acute suppurative or purulent OM)
Otitis Media with Effusion (OME)	Middle ear effusion WITHOUT signs of acute infection ("glue ear", serous OM)
Chronic Suppurative OM (CSOM)	Prolonged discharge from the ear through a tympanic membrane (TM) perforation
Recurrent AOM	3+ episodes in 6 months, or 4+ episodes in 1 year

Epidemiology and Risk Factors

AOM is one of the most common diseases in preschool children in the United States, with peak incidence between 6 and 15 months of age. By age 6, approximately 60% of children will have had at least one episode.

Risk factors:

Male sex
Non-Hispanic white race
Daycare attendance
Family history of recurrent OM
Parental smoking
Pacifier and bottle use
Anatomic abnormalities (cleft palate, Down syndrome - due to Eustachian tube dysfunction)

Protective: Breastfeeding. Pneumococcal vaccination has significantly decreased the incidence of both pneumococcal and non-pneumococcal AOM.

OME in adults should raise suspicion for head and neck malignancy (particularly nasopharyngeal carcinoma causing Eustachian tube obstruction).

Rosen's Emergency Medicine, p. 630-641

Anatomy and Pathophysiology

The Eustachian tube (ET) is central to OM pathogenesis. It connects the middle ear to the nasopharynx, serving three functions:

Ventilates the middle ear to equilibrate pressure
Provides drainage of middle ear secretions
Protects the middle ear from nasopharyngeal secretions

In young children, the ET is shorter and more horizontal, making it functionally inferior to that of older children and adults - explaining increased susceptibility.

Sequence of events in AOM:

Viral upper respiratory tract infection (URTI) causes nasopharyngeal inflammation
ET becomes mechanically or functionally obstructed
Reduced mucociliary clearance, altered mucous properties, changes in bacterial adherence
Negative middle ear pressure develops → fluid accumulates
Nasopharyngeal bacteria (and viruses) ascend into middle ear
Inflammation, further fluid accumulation, pressure rise → AOM

One third of children with a viral URTI develop AOM within four weeks of its onset. Viral-bacterial co-infection is found in up to 70% of middle ear aspirates.

Harrison's Principles of Internal Medicine 22e, p. 297; Rosen's Emergency Medicine, p. 644-648

Microbiology

AOM:

Streptococcus pneumoniae (most common, most virulent)
Haemophilus influenzae (non-typeable; increasingly common after widespread pneumococcal vaccination, especially in persistent AOM and treatment failures)
Moraxella catarrhalis
Less common: Streptococcus pyogenes, Staphylococcus aureus, gram-negative species
In neonates: add Group B Streptococcus, S. aureus, gram-negatives

Viral pathogens (in AOM): RSV, rhinovirus, adenovirus, coronavirus, parainfluenza virus (PIV), human metapneumovirus

CSOM: Often polymicrobial; Pseudomonas aeruginosa and S. aureus are common. Candida species are found in ~10-35% of ears treated with topical antibiotics (fungal overgrowth).

Rosen's Emergency Medicine, p. 650-652; Scott-Brown's Vol 2

Acute Otitis Media (AOM)

Clinical Features

Symptoms: Ear pain (otalgia) is the most important symptom. Also: fever, irritability, poor appetite, vomiting, pulling at ears (in infants), otorrhoea.

Severe AOM is defined by:

Moderate to severe otalgia
Otalgia lasting ≥ 48 hours
Temperature > 102.2°F (39°C)

Otoscopic findings:

Bulging, inflamed, cloudy tympanic membrane - the hallmark
Obscured landmarks
Loss of light reflex
Immobility on pneumatic otoscopy (also seen in perforation, adhesions, blocked auditory tube, middle-ear fluid)
Conductive hearing loss

Diagnosis requires:

Moderate to severe bulging of the TM, OR
New-onset otorrhoea (not due to OE), OR
Mild bulging + symptoms < 48h, OR
Mild bulging + intense TM erythema

AOM should NOT be diagnosed without middle-ear effusion.

Bullous myringitis: Bullae on the TM may be seen in some cases; treatment does not differ from non-bullous AOM.

Harrison's 22e, p. 298; Rosen's Emergency Medicine

Otitis Media with Effusion (OME)

Definition: Fluid in the middle ear without acute infection. Also called serous OM or "glue ear."

Epidemiology: >60% of cases occur in children < 2 years old; many children have recurrent episodes.

Causes/predisposing factors:

Post-viral AOM (most common sequela)
Allergies
Gastroesophageal reflux (GORD) - pepsin/pepsinogen has been detected in middle ear effusions; reflux impairs ciliary motility and ET function
Enlarged adenoids
Craniofacial abnormalities
Head/neck malignancy (in adults)

Symptoms and signs:

Decreased hearing, sound conduction loss
Impaired language development or communication difficulties in children
Intermittent ear fullness, tinnitus, balance problems (less common)
TM: translucent or gray, with fluid (colorless or amber), air-fluid levels, or bubbles visible behind it
Decreased TM mobility on pneumatic otoscopy

Natural history: OME usually resolves spontaneously within 4-6 weeks. If it persists > 3 months → chronic OME (chronic serous OM).

Treatment:

Watchful waiting for most cases
Myringotomy with tympanostomy tube insertion is the treatment when indicated
Adenoidectomy may be considered for young children with nasal obstruction or recurrent infection
Medications (antihistamines, glucocorticoids, antibiotics) do not reliably help
Children at risk for speech/language delay may need earlier, more aggressive treatment
Harrison's 22e, p. 298; Rosen's Emergency Medicine

Treatment of AOM

Pain Management (all patients)

NSAIDs (ibuprofen) or acetaminophen are effective for mild to moderate pain. Topical agents (benzocaine, lidocaine) may provide brief additional benefit. Antibiotics do not relieve pain in the first 24 hours.

Observation vs. Antibiotics

Up to 80% of AOM cases resolve without antibiotics. A watchful waiting approach of 2-3 days is appropriate in selected patients.

Indications for immediate antibiotics:

Age	Indication
< 6 months	Treat all
6 months - 2 years	Bilateral ear findings
≥ 6 months	Otorrhoea
> 2 years	Symptoms worsening/not improving within 48-72 h
All ages	Severe otalgia, otalgia ≥ 2 days, or temperature > 102.2°F

Note on benefit vs. harm: NNT = 20 patients treated for 1 patient to have decreased pain by day 2-3. NNH = 14 patients treated for 1 patient to have vomiting, diarrhea, or rash. NNT to prevent mastoiditis = ~5,000.

Antibiotic of Choice

Scenario	Antibiotic
First-line (no allergy, no recent penicillin)	Amoxicillin (high-dose: 80-90 mg/kg/day in children)
Penicillin-allergic (non-anaphylactic)	Cefdinir, cefuroxime, or cefpodoxime
Penicillin-allergic (anaphylactic)	Azithromycin or clarithromycin
Treatment failure after 48-72 h	Amoxicillin-clavulanate, 2nd/3rd gen oral cephalosporin, or IM ceftriaxone (3 days)

In adults: AOM is treated with antibiotics regardless of bilaterality. Amoxicillin is the drug of choice. Also treat with decongestants and analgesics. Adults with > 2 episodes/year or persistent effusion should be referred to an otolaryngologist.

Decongestants and antihistamines: A 2025 Cochrane review (PMID: 41307300) found these do not reliably benefit AOM in children.

Tympanostomy Tubes

Indicated for recurrent AOM: 3 episodes in 6 months or 4 episodes in 1 year
Middle-ear effusions are present in 60-70% of children with AOM; they should resolve over 3 months
For patients with tympanostomy tubes presenting with acute otorrhoea: ototopical fluoroquinolone drops (not systemic antibiotics)
Harrison's 22e, p. 298; Rosen's Emergency Medicine; Rosen's Emergency Medicine, p. 516-533

Complications of AOM

Tympanic Membrane Perforation

AOM with otorrhoea from acute perforation is treated identically to AOM without perforation
Most perforations are small and resolve spontaneously
If perforation persists → progresses to CSOM

Mastoiditis (most common suppurative complication)

Rare in the modern antibiotic era, but potentially serious
Spread of organisms through aditus ad antrum into mastoid air cells
Incipient mastoiditis: fluid in mastoid cells, no bony destruction
Coalescent mastoiditis: bony septal destruction
Organisms: S. pneumoniae, S. pyogenes, H. influenzae, S. aureus (including MRSA), P. aeruginosa
Signs: Post-auricular erythema, tenderness, warmth, fluctuation, protrusion of the auricle
Complications of mastoiditis: facial nerve palsy, labyrinthitis, skull osteomyelitis, temporal/cerebellar abscess, meningitis, epidural/subdural abscess, venous sinus thrombosis, Bezold's abscess (tracks under sternocleidomastoid into deep cervical fascia)
Management: Hospital admission, IV antibiotics, myringotomy ± tympanostomy tubes; mastoidectomy if no improvement in 48h

Facial Nerve Paralysis

May complicate both AOM and CSOM
Mechanisms: direct nerve involvement through Fallopian canal dehiscences; osteitis with bone erosion; inflammatory oedema compressing vasa nervorum; bacterial toxin-induced demyelination
AOM with facial palsy: Antibiotics are mainstay; myringotomy + ventilation tube if no spontaneous perforation; CT scan and cortical mastoidectomy if mastoiditis suspected; usually full recovery
CSOM with facial palsy: Mastoid exploration and facial nerve decompression essential
In neonates, the most common pathogen is S. pneumoniae (80%)

Cholesteatoma

Accumulation of keratinizing squamous epithelium in the middle ear that can:

Enlarge and erode ossicles
Perforate the TM
Cause labyrinthitis, hearing loss, cranial nerve palsies, vertigo
Lead to meningitis, extradural/brain abscess, lateral sinus thrombophlebitis
Harrison's 22e, p. 298-299; Scott-Brown's Vol 2; Rosen's Emergency Medicine

Hearing Loss in OM

Conductive hearing loss is the expected finding in both AOM and OME
Sensorineural hearing loss (SNHL) is rarely associated with acute OM
Patients with long-standing chronic OM commonly have mixed hearing loss (conductive + sensorineural)
Whether SNHL in chronic OM is from the infection itself or from surgery/ototoxic topical antibiotics remains debated
Cummings Otolaryngology, p. 1443

Chronic Suppurative Otitis Media (CSOM)

Defined by persistent ear discharge through a TM perforation
Common organisms: P. aeruginosa, S. aureus, polymicrobial; fungal overgrowth (Candida) is common after prolonged topical antibiotic use
Management includes aural toilet, topical antibiotics (ototopical fluoroquinolones preferred; aminoglycosides are ototoxic and contraindicated with non-intact TM)
A 2025 Cochrane systematic review (PMID: 40484405) specifically examined systemic antibiotics for CSOM
Surgical options: tympanoplasty (TM repair), mastoidectomy if mastoid disease is present
CSOM is no longer considered an absolute contraindication to cochlear implantation; staged approaches exist (disease eradication first, implantation when ear is dry)

Key Differentials

Otitis externa - pain on tragal pressure/pinna movement; external canal involved; TM usually normal
Referred otalgia - dental pain, TMJ, throat pathology
Bullous myringitis - vesicles on TM; same treatment as AOM
Nasopharyngeal carcinoma - in adults with unilateral OME, especially with risk factors (Southeast Asian origin, EBV exposure)

Sources:

Harrison's Principles of Internal Medicine, 22e (2025), Ch. 37
Rosen's Emergency Medicine, 10e, Ch. 10
Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol 1 & 2
Cummings Otolaryngology Head and Neck Surgery, 7e

Recent evidence note: A 2025 Cochrane review (PMID 41307300) found no meaningful benefit from decongestants or antihistamines for AOM in children, consistent with current guidelines recommending against their routine use.

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