Otitis media

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Otitis media
Classification & external resources
ICD-10 H65-H67
ICD-9 381-382
eMedicine EMERG/351 

Otitis media is an inflammation of the middle ear: the space behind the ear drum. It is one of the two conditions that are commonly thought of as ear infections, the other being otitis externa. Otitis media is very common in childhood, and includes acute and chronic conditions; all of which involve inflammation of the ear drum (tympanic membrane), and are usually associated with a buildup of fluid in the space behind the ear drum (middle ear space).

Contents

[edit] Types

There are several kinds of otitis media:

  1. Acute otitis media is an infection that produces pus, fluid, and inflammation within the middle ear. It is frequently associated with signs of upper respiratory infection, such as a runny nose or stuffy nose. It is painful, but usually self-limiting. The most serious, but rare, complication Mastoiditis - an infection of the bone around the ear.
  2. Otitis media with effusion, (or Glue Ear) formerly termed serous Otitis Media or secretory Otitis Media, is Middle Ear Effusion of any duration that lacks the associated signs and symptoms of infection (eg, fever, otalgia, irritability), but causes hearing problems. Otitis Media with Effusion usually follows an episode of Acute Otitis Media.
  3. Chronic suppurative otitis media is when discharge from the infection persists for more than two weeks.

[edit] Progression

Typically, acute otitis media follows a cold: after a few days of a stuffy nose the ear becomes involved and can cause severe pain. The pain will usually settle within a day or two but can last over a week. Sometimes the ear drum ruptures discharging pus from the ear, but usually the ruptured drum will heal rapidly.

At an anatomic level, the typical progression of acute otitis media occurs as follows: the tissues surrounding the Eustachian tube swell due to an upper respiratory infection, allergies, or dysfunction of the tubes. The Eustachian tube remains blocked most of the time. The air present in the middle ear is slowly absorbed into the surrounding tissues. A strong negative pressure creates a vacuum in the middle ear. The vacuum reaches a point where fluid from the surrounding tissues accumulates in the middle ear. This is seen as a progression from a Type A tympanogram to a Type C to a Type B tympanogram. The fluid may become infected. It has been found that dormant bacteria behind the Tympanum (eardrum) multiply when the conditions are ideal infecting the middle ear fluid.

[edit] Otorrhea: Infected Drainage from the Middle Ear

When the middle ear becomes acutely infected, pressure builds up behind the ear drum and, in severe cases, the tympanic membrane may rupture. Once perforated, the pus drains out into the ear canal. If there is enough of it, this drainage may be obvious. Even though the rupture of the tympanic membrane suggests a dramatic and traumatic process, the opening may or may not be painful, and can be associated with the dramatic relief of pressure and pain. In a simple case of acute otitis media in an otherwise healthy person, the body's defenses are likely to resolve the infection and the ear drum nearly always heals up again.

Instead of resolution of the infection, however, drainage from the middle ear can become a chronic condition. The World Health Organization defines CSOM as 'a stage of ear disease in which there is chronic infection of the middle ear cleft, a non-intact tympanic membrane (i.e. perforated eardrum) and discharge (otorrhoea), for at least the preceding two weeks' (WHO 1998).

[edit] Causes

Streptococcus pneumoniae and nontypable Haemophilus influenzae are the most common bacterial causes of otitis media. Tubal dysfunction leads to the ineffective clearing of bacteria from the middle ear. In older adolescents and young adults, the most common cause of ear infections during their childhoods was Haemophilus influenzae. The role of the anti-H. influenzae vaccine that children are regularly given in changing patterns of ear infections is unclear, as this vaccine is active only against strains of serotype b, which rarely cause otitis media.

As well as being caused by Streptococcus pneumoniae and Haemophilus influenzae it can also be caused by the common cold. Colds indirectly cause many cases of otitis media by damaging the normal defenses of the epithelial cells in the upper respiratory tract.

Another common culprit of otitis media includes Moraxella catarrhalis, a gram-negative, aerobic, oxidase positive diplococcus.

[edit] Susceptibility in children

Children below the age of seven years are much more prone to otitis media since the Eustachian tube is shorter and at more of a horizontal angle than in the adult ear. They also have not developed the same resistance to viruses and bacteria as adults. There is also an association with maternal smoking habits.[1]

Recent research by German and Dutch scientists indicate a link between automobile emissions and the suceptibility to otitis media in children. The report in the December 2006 issue of the Hearing Review published the findings of the study which was conducted over two years and tested approximately 3,000 children from birth to age two. The studies found that 33% of the children exposed to higher than average levels of vehicle emmissions developed ear infections sometime during the study.[citation needed]

[edit] Treatment

Most episodes simply require analgesics to manage the pain and fever. Acute otitis media will usually settle without treatment. Whilst antibiotics were previously routinely immediately started, this practice is diminishing. Antibiotics do shorten the illness by around 1/3 compared to the illness's natural history, but this is a small gain for most children. However, very young children, those with bilateral otitis, and those with a high fever are likely to have a more severe course and hence benefit more from antibiotics[2][3][4]

Many guidelines now suggest deferring the start of antibiotics for 24 to 72 hours.[5] This results in 2 out of 3 children avoiding the need to start antibiotics,[6] and no adverse effect on longterm outcomes for those whose treatment is deferred.[7] First line antibiotic treatment, if warranted, is amoxicillin. If the bacteria is resistant, then Augmentin or another penicillin derivative plus beta lactimase inhibitor is second line.

In chronic cases or with effusions present for months, surgery is sometimes performed to insert a grommet (called a "tympanostomy tube") into the eardrum to allow air to pass through into the middle ear, and thus release any pressure buildup and help clear excess fluid within.

Prior to the invention of antibiotics, severe acute otits media was mainly remedied surgically by Myringotomy. An outpatient procedure, it consists of making a small incision in the tympanic membrane to relieve pressure build-up.

For chronic cases (glue ear), it is possible to use the Valsalva maneuver to reestablish middle ear ventilation.

[edit] Alternative treatment

[edit] Homeopathy

Homeopathy aims to strengthen the immune system and reduce the susceptibility to disease using individualised treatment. Homeopaths claim they can treat both acute episodes of otitis media and reduce its recurrence. Although there are only a few studies of homeopathic treatment of patients with this condition, results are promising and warrant futher research [8] [9] [10] One study showed that homeopathy is more effective in treating otitis media than conventional medicine. It demonstrated that homeopathic treatment was more effective in reducing pain and recurrence of infection, and also reduced the need for antibiotics, when compared to conventional treatment. It concluded that homeopathy should be the first line of treatment in acute otitis media [11] [Abstracts of these articles are available here [12]]


[edit] Footnotes

  1. ^ Ilicali O, Keleş N, Değer K, Savaş I (1999). "Relationship of passive cigarette smoking to otitis media.". Arch Otolaryngol Head Neck Surg 125 (7): 758-62. PMID 10406313. 
  2. ^ Damoiseaux R, van Balen F, Hoes A, Verheij T, de Melker R (2000). "Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years.". BMJ 320 (7231): 350-4. PMID 10657332. 
  3. ^ Arroll B (2005). "Antibiotics for upper respiratory tract infections: an overview of Cochrane reviews.". Respir Med 99 (3): 255-61. PMID 15733498. 
  4. ^ Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA, Gaboury I, Little P, Hoes AW. (2006). "Antibiotics for acute otitis media: a meta-analysis with individual patient data.". Lancet. 368 (9545): 1429-35. PMID 17055944. 
  5. ^ Damoiseaux R (2005). "Antibiotic treatment for acute otitis media: time to think again.". CMAJ 172 (5): 657-8. PMID 15738492. 
  6. ^ Marchetti F, Ronfani L, Nibali S, Tamburlini G (2005). "Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care.". Arch Pediatr Adolesc Med 159 (7): 679-84. PMID 15997003. 
  7. ^ Little P, Moore M, Warner G, Dunleavy J, Williamson I (2006). "Longer term outcomes from a randomised trial of prescribing strategies in otitis media.". Br J Gen Pract 56 (524): 176-82. PMID 16536957. 
  8. ^ Jacobs J, Springer DA, Crothers D. Homeopathic treatment of acute otitis media in children: a preliminary randomized placebo-controlled trial. Pediatr Infect Dis J 2001; 20: 177–183.
  9. ^ Frei H, Thurneysen A. Homeopathy in acute otitis media in children: treatment effect or spontaneous resolution? Br Homeopath J 2001; 90: 180–182.
  10. ^ Harrison H, Fixsen A, Vickers A. A randomized comparison of homoeopathic, standard care for the treatment of glue ear in children. Compl Therap Med 1999; 7: 132–135.
  11. ^ Friese K-H, Kruse S, Ludtke R, Moeller H "Homeopathic treatment of otitis media in children: comparisons with conventional therapy". Int J Clin Pharmacol Ther. 1997; 35: 296-301.
  12. ^ http://www.homeopathy-soh.org/whats-new/documents/Positivehomeopathy.PDF

[edit] External links

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