Otitis Media

Pathophysiology

• Textbook of Family Medicine 9e, p. 404

Classification

Common Causative Organisms

1. Streptococcus pneumoniae - 25-40% of cases
2. Haemophilus influenzae - 10-30%
3. Moraxella catarrhalis - 2-15%

• Textbook of Family Medicine 9e, p. 404; Rosen's Emergency Medicine, p. 514

Risk Factors

• Male gender
• Child care outside the home (daycare)
• Parental smoking
• Bottle feeding in the supine position
• Genetic and ethnic factors (Inuit, Native American)
• Allergy
• Craniofacial abnormalities (cleft palate)
• Use of a pacifier
• Previous episode of AOM within the preceding 3 months
• Winter season / exposure to URIs

Diagnosis

1. Acute onset of symptoms (otalgia, ear-tugging in infants, irritability)
2. Middle ear effusion (MEE) - confirmed by:
   • Visualization of air-fluid levels behind TM
   • Bulging drum
   • Reduced/absent movement on pneumatic otoscopy
   • Flat tympanogram
3. Signs of middle ear inflammation:
   • TM erythema, bulging, or new-onset otorrhea (not due to otitis externa)

Key distinction: Erythema of the TM without MEE = myringitis/tympanitis (not AOM). Otalgia with a normal, flaccid TM suggests referred otalgia from another source (dental abscess, TMJ, sore throat, etc.).

• Rosen's Emergency Medicine, p. 514-518; Textbook of Family Medicine 9e, p. 404

Treatment

AOM - Antibiotic Decision

Antibiotic Regimens

Pain Management

• Acetaminophen or ibuprofen (OTC analgesics)

Special Situations

• AOM with acute perforation/otorrhea: Treat same as standard AOM; perforations are typically small and self-resolve.
• Patients with tympanostomy tubes + increased otorrhea: Use ototopical fluoroquinolone drops (e.g., ofloxacin or ciprofloxacin/dexamethasone). Aminoglycoside drops are contraindicated with non-intact TM (ototoxic).
• Textbook of Family Medicine 9e, p. 405; Rosen's Emergency Medicine, p. 526-532

Otitis Media with Effusion (OME)

• Fluid in the middle ear without signs of acute infection
• Most common cause of acquired hearing loss in children
• Most cases resolve spontaneously within 3 months
• No role for antibiotics, antihistamines, or decongestants in OME
• Indications for tympanostomy tube insertion: bilateral OME with hearing loss >25 dB persisting >3 months, or associated developmental/speech delay

Chronic Suppurative Otitis Media (CSOM)

• Persistent purulent otorrhea through a perforated TM (or tympanostomy tube)
• Pathogens: S. pneumoniae, H. influenzae, S. aureus, Pseudomonas, anaerobes
• Ototopical antibiotics are superior to oral antibiotics (Cochrane evidence)
• Quinolone ototopicals are safe for middle ear use; aminoglycosides carry ototoxicity risk
• Aural toilet with dilute acetic acid solution may help
• Persistent perforation after resolution: consider tympanoplasty
• Refractory cases: tympanomastoidectomy

Recurrent AOM

• Definition: 3+ episodes in 6 months, or 4+ in 12 months
• Tympanostomy tubes (grommets): first-line surgical intervention - reduces frequency of episodes, restores hearing
• Adenoidectomy: considered when adenoiditis acts as a nidus for recurrent infection
• Antibiotic prophylaxis: generally not recommended (risk of resistance)

Complications

• Acute mastoiditis - most common suppurative complication; presents with post-auricular tenderness, erythema, edema, and fever; it is a clinical (not radiologic) diagnosis - CT changes must be correlated with exam
• Facial nerve paralysis - from inflammation along CN VII coursing through the middle ear
• Labyrinthitis / sensorineural hearing loss
• Tympanic membrane perforation, retraction, tympanosclerosis
• Cholesteatoma (keratin-filled sac causing bony erosion)

• Meningitis
• Epidural abscess
• Brain abscess
• Subdural abscess
• Lateral/sigmoid sinus thrombosis

Red flags for impending complication: increasing pain, vertigo, or facial palsy in a patient with CSOM - require urgent otolaryngology consultation.

• Textbook of Family Medicine 9e, p. 405-406

Prevention

• Pneumococcal conjugate vaccine (PCV13/PCV15) - reduces AOM due to S. pneumoniae
• Influenza vaccine - annual vaccination reduces AOM episodes linked to influenza
• Breastfeeding (protective)
• Avoiding supine bottle-feeding
• Avoiding passive smoke exposure
• Reducing pacifier use after 6 months

Recent Evidence (2024-2026)

• A 2025 Cochrane review (PMID 41307300) confirmed that decongestants and antihistamines have no benefit in treating AOM in children and should not be used.
• A 2026 systematic review (PMID 41764103) examined shorter vs. longer antibiotic courses - evidence supports 5-day courses for low-risk children over 2 years; 10-day courses remain preferred for younger or high-risk children.
• A 2026 meta-analysis (PMID 42359822) found RSV is a significant contributor to AOM in children under 5, suggesting RSV vaccination may reduce AOM burden.
• A 2024 systematic review/meta-analysis (PMID 38666491) confirmed significant quality-of-life improvements after tympanostomy tube surgery in pediatric patients.

Adenoids

Terminology

• Bailey & Love's Short Practice of Surgery, 28th ed., p. 9580

Anatomy & Histology

• Location: Posterior wall/roof of the nasopharynx, above the level of the soft palate
• Lies adjacent to the Eustachian tube orifices on each side - this proximity explains why adenoid hypertrophy causes eustachian tube dysfunction and otitis media
• Covered by pseudostratified ciliated columnar epithelium (respiratory type)
• Composed of lymphoid follicles with germinal centers (B-cell zones) surrounded by T-cell zones
• No capsule (unlike tonsils) - this is clinically relevant for surgical removal
• The tubal tonsils (lymphoid tissue around the Eustachian tube opening) can also hypertrophy and obstruct the Eustachian tube

Normal Development & Involution

• Adenoid tissue is present from birth and grows through childhood
• Hypertrophy most commonly occurs between ages 4 and 10 years
• Spontaneous involution begins in adolescence - the adenoid typically regresses significantly by the mid-teens
• In an adult, a prominent adenoid is abnormal and should raise suspicion for:
  • Lymphoproliferative disorder (lymphoma)
  • HIV infection
  • Nasopharyngeal carcinoma (NPC - especially in endemic populations)
• Textbook of Family Medicine 9e, p. 417; Bailey & Love's, p. 9622

Endoscopic View of Adenoid Hypertrophy

Clinical Features of Adenoid Hypertrophy

Nasal / Upper Airway Symptoms

• Chronic nasal obstruction - persistent mouth breathing
• Rhinorrhea and post-nasal drip
• Nasal voice (hyponasality / "adenoid voice")
• Snoring and disturbed sleep
• Chronic cough (from post-nasal drip)

Ear Symptoms

• Otitis media with effusion (OME / "glue ear") - adenoid acts as a bacterial reservoir and blocks eustachian tube drainage
• Recurrent acute otitis media (AOM)
• Conductive hearing loss

Sleep-Disordered Breathing

• Obstructive sleep apnoea (OSA) - especially when adenoid hypertrophy coexists with tonsillar hypertrophy
  • Irregular snoring with apnoeic pauses and loud inspiratory snorts
  • Restless sleep, unusual sleep positions
  • Daytime somnolence, behavioural problems, poor school performance
  • Long-term: secondary cardiac complications (cor pulmonale, pulmonary hypertension)

Adenoid Facies

• Open-mouth posture (mouth breathing)
• Crowded/malocclused teeth
• High-arched palate
• Underdeveloped nostrils
• Periorbital edema
• Long, narrow face
• KJ Lee's Essential Otolaryngology, p. 1509; Textbook of Family Medicine 9e, p. 1080

Grading of Adenoid Hypertrophy

The gold standard for assessing adenoid size is nasopharyngoscopy (flexible nasoendoscopy). Mirror examination underestimates choanal occlusion. Palpation is a poor measure. When endoscopy is not tolerated (young children), a lateral soft-tissue neck radiograph is a practical alternative.

• Scott-Brown's Otorhinolaryngology, Vol. 2, p. 331

Diagnosis

• Clinical history and examination - usually sufficient
• Flexible nasopharyngoscopy - gold standard for direct visualisation
• Lateral neck radiograph - shows "pad" of adenoid tissue in the postnasal space (soft-tissue film); practical when endoscopy not tolerated
• Polysomnography (sleep study) - for suspected OSA to quantify apnoea-hypopnoea index (AHI)
• Do NOT routinely use MRI or acoustic rhinomanometry in clinical practice (research tools only)

Role of Adenoids in Chronic Rhinosinusitis (CRS)

• 88-99% of adenoid mucosal surface in children with CRS is covered by dense biofilm, compared to only 0-6.5% in controls (children with sleep apnoea only)
• Adenoid bacterial flora mirrors that of the middle meatus in children with chronic/recurrent sinusitis
• This explains why adenoidectomy improves CRS symptoms even when adenoid size is not the main problem - it is the reservoir function, not just the obstructive size, that matters
• Cummings Otolaryngology, p. 3784

Management

Conservative (Watchful Waiting)

• Appropriate for mild, well-tolerated symptoms
• Most adenoid hypertrophy will involute with age

Medical Treatment

• Intranasal corticosteroid sprays - evidence from meta-analyses of RCTs shows reduction in adenoid size and improvements in:
  • Middle ear effusion and audiometric thresholds
  • Nasal obstruction, rhinorrhoea, cough, snoring, and sleep apnoea
  • Trials were judged as moderate quality; further RCTs needed
  • Two 2025 systematic reviews (PMIDs 40609250 and 41056645) support intranasal steroids as an effective, safe option for adenoid hypertrophy in children
• Scott-Brown's Otorhinolaryngology, Vol. 2, p. 6283

Surgical: Adenoidectomy

Note: For OME, the adenoid size is not an indication for removal - its role as a bacterial reservoir is the rationale. KJ Lee's, p. 9083: "Adenoidectomy, regardless of adenoidal size, is helpful in children with chronic OM with effusion requiring multiple sets of tubes."

• Cleft palate or submucous cleft palate - risk of velopharyngeal insufficiency (VPI) and hypernasal speech post-operatively; if surgery needed, partial adenoidectomy preserving an inferior ridge is performed
• Bleeding disorders

• Scott-Brown's Otorhinolaryngology, Vol. 2, p. 6296-6323

• Avoid sedative premedications and opiate analgesics post-operatively - they can further depress the child's respiratory drive in a patient already predisposed to apnoea
• Bailey & Love's, p. 9601

• Routine investigations not indicated for ASA grade 1-2 children
• Specific testing warranted for: sickle cell disease, thalassaemia, Down syndrome, congenital heart disease

Recent Evidence (2025-2026)

• Two independent 2025 meta-analyses (PMID 40609250 and PMID 41056645) confirm that intranasal corticosteroids are effective and safe for adenoid hypertrophy, reducing both adenoid size and associated symptoms - supporting them as a first-line medical option before surgery.
• A 2025 meta-analysis (PMID 40958230) found a bidirectional association between adenoid hypertrophy and laryngopharyngeal reflux (LPR) - each condition may exacerbate the other, and LPR treatment should be considered in refractory adenoid hypertrophy.
• A 2026 systematic review (PMID 41344444) highlights the growing importance of adenoid biofilms in driving recurrent and chronic ENT disease in children - supporting adenoidectomy as a reservoir-eliminating strategy.