Acute Otitis Media: Classification, Etiology, Diagnosis and Treatment

Acute otitis media (AOM) is an inflammation of the middle ear cavity accompanied by severe pain and hearing loss, lasting up to 1 month.

Exudative otitis media (ESO, serous, secretory) is a pathology characterized by the presence of exudate in the middle ear cavity, without pain syndrome. Clinically, acute (up to 3 weeks), subacute (3-8 weeks) and chronic (> 8 weeks) forms of exudative otitis media are distinguished. In practice, however, it is often difficult to establish the exact time of onset, and only acute and chronic forms are distinguished.

Myringitis is an inflammation of the eardrum.

Classification of acute otitis media

• Acute otitis media, catarrhal stage;
• Acute otitis media, preperforative stage;
• Acute otitis media, perforative stage (purulent otitis media);
• Acute otitis media, reparative stage;
• Acute otitis media in influenza;
• Acute otitis media in measles;
• Acute otitis media in scarlatina;
• Acute exudative otitis media;
• Myringitis.

Etiology

This disease is mostly caused by bacteria. The most common bacteria are Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae, less frequently Escherichia coli and Staphylococcus aureus, beta-hemolytic group A streptococci. In 10-30% of cases, viral etiology is assumed.

Pathogens enter the sterile middle ear cavity through the auditory tube. In infectious diseases such as measles, scarlet fever and influenza, the hematogenous route of infection is also possible.

Anatomy

The trigger for the development of otitis media is obstruction of the auditory tube caused by inflammation in the nasopharynx (adenoiditis, rhinitis, sinusitis).

When the auditory tube is blocked, the mucous membrane absorbs air from the middle ear cavity and a negative pressure is created, which causes transudate to leak out. Pathogenic microorganisms enter the middle ear cavity from the nasopharynx, for which the transudate is a good breeding ground for inflammation.

Acute otitis media is characterized by a staged process. Initially there is hyperemia of the middle ear mucosa (catarrhal stage), then a clear fluid component is detected.

With the progression of the process, the mucosa is infiltrated with leukocytes, the discharge is saturated with neutrophils, purulent exudate is formed (preperforative stage).

When the pressure of the purulent component is applied to the tympanic membrane, it ruptures (perforation stage), through which the pathologic content flows into the ear canal. After evacuation of the purulent content, the tympanic cavity is repaired and the perforation is scarred (reparative stage).

With an unfavorable course, purulent contents through the antrum can penetrate into the cells of the mastoid process, which leads to the spread of inflammation to the bone tissue and the development of a formidable complication – mastoiditis.

Acute otitis media are most characteristic of childhood due to anatomical features: wide and short auditory tube, more gentle angle between the bony and cartilaginous part of it, hypertrophied lymphoid tissue in the nasopharynx and the presence of myxoid tissue in the middle ear cavities.

Clinical picture

For each stage of acute otitis media is characterized by its own clinical picture, which changes sequentially. Most often, the pathological process develops against the background of inflammatory changes in the nasopharynx, such as rhinitis, adenoiditis, sinusitis.

Stages of the disease:

• Initial (catarrhal) stage: at the beginning of the disease there is acute sharp pain and stuffiness in the affected ear, autophony. Then the noise in the ear increases, the pain intensifies, becomes throbbing, may irradiate to the eyes, neck, temple.
• Purulent preperforative stage: conductive hearing loss progresses due to the fluid component. The general condition is disturbed, pronounced headache appears, body temperature rises to febrile values.
• Perforative stage: when perforation occurs and purulent contents leak into the ear canal, the patient’s condition improves significantly: pain decreases, temperature gradually decreases. Conductive hearing loss remains, but now due to the presence of perforation.

• Reparative stage (recovery): after evacuation of purulent contents and elimination of pathogens, the reparative stage begins. Patients may note the persistence of noise in the ear, especially when blowing their nose, swallowing, hearing gradually improves, the general condition is restored.

In case of unfavorable outcome, the disease may become chronic or lead to complications such as chronic purulent otitis media, mastoiditis, labyrinthitis etc.

For the development of a pronounced clinical picture is enough 4-6 hours, with a favorable course of recovery comes on 5-7 days.

Diagnosis of acute otitis media

The gold standard for making this diagnosis is otoscopy.

Stages of acute otitis media, changes on otoscopy

3D Models of the stages of acute otitis media:

Acute purulent otitis media: preperforative stage (otoscopy)

Acute purulent otitis media: perforation stage (otoscopy)

Acute purulent otitis media: stage of repair (otoscopy)

Additionally performed:

• Chambertonaltests (to determine conductive hearing loss in the affected ear);
• Laboratory diagnosis (in the OAC is characterized by leukocytosis, increased levels of C-reactive protein);
• Microbiological examination of the detachment (to determine the causative agent and its sensitivity to antibacterial drugs).

In frequent, recurrent otitis media in children against the background of hypertrophied adenoids, adenotomy is indicated.

Treatment of acute otitis media

• Nasal decongestants, sanitation of the nasopharynx: necessarily prescribed, because acute otitis media develops against the background of edema and inflammation in the nasopharynx.
• Non-steroidal anti-inflammatory drugs (NSAIDs) orally: recommended for pain symptom control.
• Ear drops: prescribing remains controversial. A number of topical analgesics, which are prescribed in the preperforative stage to control pain symptoms, are weak and contraindicated in the presence of perforation (which the patient may not be aware of). Topical antibacterials are also questionable in the preperforative stage, as they do not penetrate through the intact tympanic membrane into the middle ear.
• Sanation of the tympanic cavity: recommended in the perforative stage through the ear canal with antiseptic solutions, which accelerates the evacuation of the contents.
• Antibacterial drugs: recommended in the presence of purulent inflammation (transition from the catarrhal stage). It is possible to delay their administration for up to 48-72 hours under otoscopic control. Penicillins or cephalosporins are the drugs of choice.
• Paracentesis (tympanic membrane puncture): performed when indicated to relieve tension and evacuate contents.

• Prophylaxis in children: vaccination against pneumococcus and Haemophilus influenzae is recommended.

Acute otitis media with the flu

Etiology of influenza otitis media

This type of otitis media is caused by the influenza virus and is more common during seasonal outbreaks. The virus enters the middle ear cavity through the auditory tube from the nasopharynx or hematogenously with the bloodstream.

Anatomy of influenza otitis media

The pathophysiology of this type of otitis media is generally no different from that of other etiologies.

Influenza otitis media is characterized by the following features:

• In the thickness of the epidermis of the bony part of the ear canal, the vessels are heavily congested with blood, which can lead to their rupture and the formation of hemorrhages (extravasations);
• On the surface of the tympanic membrane, the vessels are also fully bloody and may form hemorrhagic blisters (bullae) on its surface. For this reason, this otitis media has a second name – bullous otitis media;
• The influenza virus is neurotropic and can cause acute sensorineural hearing loss.

Clinical picture of influenza otitis media

The clinical picture is similar to that of common otitis media.

Main Symptoms:

• Severe ear pain lasting about 1-2 days;
• Hearing loss on the affected side;
• Rhinorrhea and nasal congestion

In addition to localized complaints, the manifestation of other symptoms of influenza infection is noted:

• Pyretic fever (body temperature rises to 39-40 °C);
• Severe myalgia and headache;
• Photophobia.

If the outcome is unfavorable, acute purulent otitis media develops, and mastoiditis and meningitis may also occur.

Diagnosis of influenza otitis media

To establish the diagnosis of acute otitis media, a complete otorhinolaryngologic examination (otorhinolaryngoscopy) is performed, if necessary – otomicroscopy.

From laboratory diagnostics, a blood test to determine inflammatory markers is mandatory. In the period of epidemic rise, the diagnosis of influenza is established clinically, but at low incidence of disease, PCR-study from the nasopharyngeal mucosa is performed.

A rapid test can be performed at home, but it has low sensitivity.

Treatment for flu otitis media.

Specific antiviral therapy (neuraminidase inhibitors) is used. The rest of the otitis media treatment is carried out in accordance with the above recommendations. Antibacterial therapy is prescribed if indicated.

Acute otitis media in measles

Etiology of otitis media

Measles infection is caused by the measles virus, which is transmitted by airborne droplets.

Anatomy of bark otitis media

Measles virus causes upper respiratory tract catarrh and a specific skin rash. The general changes in the development of otitis media in measles are similar to those in other etiologies, with no significant differences.

Measles otitis media is characterized by the following differences:

• Necrotic changes, which are associated with thrombosis of the middle ear vessels, affect both mucosa and bone tissue. The process proceeds in stages: catarrhal phenomena are quickly replaced by necrosis with the formation of purulent contents. Necrotic changes may spread to the labyrinth.
• Bilateral lesions. Otitis media often develops on both sides at the same time.
• Perforation of the tympanic membrane. More often subtotal, with remnants of hyperemic tympanic membrane remaining around the periphery.
• The nature of the discharge. There is abundant purulent discharge in the tympanic cavity and external ear canal. Bone sequestrations (pieces of auditory bone) may be present.
• The neurotropic nature of the virus. Measles virus is neurotropic and is capable of causing vestibulocochlear nerve damage.

The clinical picture of otitis measles

In this type of otitis media, the following symptoms predominate:

• Symptoms of general illness, intoxication, rash;
• Profuse suppuration on both sides with a pungent putrid odor;
• Bilateral mixed hearing loss;
• When the labyrinth is affected, vestibular symptoms develop, including marked vertigo;
• Complications with mastoiditis and meningitis are not uncommon;
• The process is often chronicized, which can lead to bilateral deafness.

Ear pain is not characteristic of this type of otitis media.

Diagnosis of otitis media

Diagnosis is based on otoscopy. Cameron tests are carried out, in which mixed hearing loss is determined, as well as vestibular tests with evaluation of nystagmus. In laboratory diagnosis, blood is tested for inflammatory markers, blood is tested for antibodies to measles virus.

Treatment for otitis media

The underlying disease is treated, but there is no specific treatment for measles at the moment, so symptomatic therapy is prescribed. Massive antibacterial therapy, sanitation of middle ear cavities, regular toileting are prescribed.

If complications occur, surgical treatment (anthromastoidotomy) is performed. Vaccination is recommended for prevention.

Acute otitis media in scarlet fever

Etiology of scarlatino otitis media

The causative agent of this disease is beta-hemolytic group A streptococcus, which is transmitted by airborne droplets. The pathogen enters the middle ear cavity by hematogenous route or through the auditory tube.

Anatomy of scarlatino otitis media

Against the background of general changes in the body (rash, tonsillitis) there are specific changes in the middle ear cavity:

• The process is more often unilateral;
• Otitis media occurs in stages: catarrhal changes are very quickly replaced by thrombosis of the middle ear vessels and the formation of necrosis;
• Necrotic changes affect the auditory ossicles, temporal bone, and labyrinth capsule;
• Perforation of the tympanic membrane is subtotal, with the remnant periphery brightly hyperemic with thickened vessels.

Clinical picture of scarlatino otitis media

In this type of otitis media, the following symptoms predominate:

• The pathologic process on the side of the ear is masked by a general disease;
• Painful sensations are usually uncharacterized;
• Patients complain of copious amounts of thick stinky discharge from the external auditory canal and hearing loss;
• The disease often takes on a chronic course;
• Complications such as mastoiditis, labyrinthitis and meningitis are characteristic.

Diagnosis of scarlatino otitis media

Diagnosis is based on otoscopy. Cameron tests are performed to determine conductive hearing loss in the affected ear, as well as vestibular tests to assess labyrinth function.

Obligatory laboratory diagnosis is carried out: the OAC is characterized by leukocytosis and an increase in the level of C-reactive protein. Microbiological examination determines the causative agent and its sensitivity to antibacterial drugs.

Treatment of scarlatino otitis media

The underlying disease is treated, massive antibacterial therapy is prescribed. Penicillins or cephalosporins are preferred. Sanitation of the middle ear is performed, toilet with antiseptic solutions. If complications occur, surgical treatment (anthromastoidotomy) is performed.

Acute exudative otitis media

Etiology of exudative otitis media

The underlying cause of this condition is obstruction of the auditory tube orifice in the nasopharynx, which can be either inflammatory or allergic in nature.

Children get sick more often due to a higher proportion of hyperplasia of the lymphoepithelial tissue of the nasopharynx. In adults, this pathology may indicate inflammatory processes in the nasopharynx. It is also necessary to take into account the possibility of neoplasms in the vault of the nasopharynx, obstructing the lumen of the aperture of the auditory tube.

Anatomy of exudative otitis media

The pathogenesis of the disease has a similar beginning with the development of otitis media, but the inflammation in this case is aseptic in nature.

Against the background of obstruction of the auditory tube in the middle ear cavity creates negative pressure, which contributes to the flow of transudate into its spaces.

The situation is aggravated by the fact that the squamous epithelium degenerates into secretory epithelium (the number of bocaloid cells and secretory glands increases). This process contributes to the transformation of transudate into exudate, due to the impregnation of the protein component and an increase in the viscosity of the contents.

Without adequate treatment, the process becomes chronic.

Clinical picture of exudative otitis media

Clinically, the disease remains unrecognized for a long time, especially when the pathological process is present on both sides. The main symptoms are gradually progressive conductive hearing loss and ear stuffiness. Pain syndrome is usually not characteristic, but there may be tinnitus and autophony. The general condition is not impaired.

Diagnosis of exudative otitis media

First of all, otoscopy is performed. On examination, a dense gray tympanic membrane with thickened vessels is visualized, which may be slightly retracted in the upper parts. The light cone is not defined. Transparent contents are visualized behind the tympanic membrane, sometimes with a level of exudate, and air bubbles may also be seen.

If exudate is suspected, tympanometry is performed, which is fundamental to the diagnosis. In the presence of contents, the tympanogram corresponds to type B. Cameron tests are performed to determine the nature of the hearing loss. Nasopharyngeal endoscopy is recommended to determine the cause of the disease. In doubtful cases, CT scan of temporal bones and nasopharynx is indicated.

Treatment of exudative otitis media

First of all, it is necessary to eliminate the cause of the disease. Sanitation of the nasopharynx is performed. Systemic mucolytics are prescribed to improve secretion. It is also recommended that the patient perform a set of exercises to blow the auditory tube.

If it is impossible to master this technique, the doctor performs balloon blowing of the auditory tubes (according to Politzer) or their catheterization with the subsequent introduction of air.

Antibacterial drugs are prescribed very rarely, if indicated.

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Myringitis

Etiology of myringitis

The cause of the disease is the impact of pathogenic microflora or activation of opportunistic microflora. Among the main causative agents distinguish:

• Bacteria: streptococci, staphylococci, pneumococci, hemophilus or pseudomonas bacillus;
• Viruses: influenza virus, parainfluenza virus, MS virus, adenovirus, measles;
• Fungi: Candida albicans, Aspergillus niger.

Myringitis as an independent disease is rare and more often develops in conjunction with otitis media or otitis externa. It can also be the result of careless removal of foreign bodies from the ear canal, as well as exposure to thermal or chemical factors.

Anatomy of myringitis

As a result of irritating factors (including hematogenous or contact route of infection), inflammatory changes occur on the tympanic membrane. As a result, there is full blood vessels and pronounced infiltration in the thickness of the membrane.

Serous or hemorrhagic blisters (bullae) may form on its surface. A serous discharge is secreted into the lumen of the ear canal.

Clinical picture of myringitis

Patients notice a sharp severe throbbing pain in the ear. There may be noise, crackling, itching in the affected ear, as well as scanty transparent or hemorrhagic discharge. There may be a decrease in hearing. In some cases, there is a pronounced general symptomatology, body temperature rises to 38-39 °C, accompanied by headache and weakness.

Diagnosis of myringitis

Diagnosis is based on otoscopy data. Hyperemic, infiltrated tympanic membrane with sharply thickened vessels is detected, bullae may be visualized on its surface. The identifying contours of the membrane are blurred.

Cameron tests and audiograms reveal conductive type hearing loss of varying degrees.

The general blood test reveals leukocytosis with a left shift in the formula and an increase in C-reactive protein (CRP). A swab of the tympanic membrane surface is also performed to determine the causative agent.

Treatment of myringitis

Anti-inflammatory drugs are prescribed to control pain and reduce inflammation, and antibacterial drugs are prescribed if indicated. Topical irrigation with antiseptic solutions is recommended to prevent the spread of infection and keep the ear canal clean.