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OTITIS MEDIA and other ear inflammations

Timothy C. Hain, MD Page last modified: October 18, 2013

Main Points:



Children with AOM (acute otitis media) usually present with a history of rapid onset of signs and symptoms such as ear pain and/or fever.


The presence of middle ear effusion (fluid) is indicated by fullness or bulging of the tympanic membrane, an air-fluid level behind the membrane, or fluid coming out of the ear (this means there is a perforation).

Otoscopic findings of a bulging tympanic membrane with impaired mobility is highly predictive of AOM. A red tympanic membrane is less predictive since the redness may be a flush that comes from crying. However, in an adult, a red TM is very helpful.

Both AOM and OME have fluid in the middle ear cavity. In AOM -- the fluid is infected and often pus. In OME, it is clear or straw colored fluid without an infection. Factors that help differentiate between AOM and OME are as follows:

Factor AOM OME
Fluid, hearing loss, fullness Yes Yes
Bulging Yes Often
Color Green, yellow or white Clear or straw
Pain Yes No

Chronic otitis media is associated with hearing loss ranging from 5 to 12.55 dB (Luntz et al, 2013)

Causes of Otitis Media


AOM is generally caused by one of three bacteria: streptococcus pneumoniae, hemophilus influenzae, and moraxella catarrhalis. About 40-50% of AOM is caused by strep, about 20-30 by hemophilus, and about 10-15 by M. Catarrhalis. Resistance of these bacteria to antibiotics are increasing and also there is a change in flora related to use of pneumococcal vaccine, with an increase in H influenzae to roughly 50-60%.

Otitis media with effusion (non microbial)

OME is not generally due to an infection but rather caused by eustachian tube blockage or other non-infective causes (e.g. radiation as an example).

There is some evidence that OME may be triggered by non-infectious processes. The eustachian tube is a conduit for substances in the nose to enter the middle ear. In addition to bacteria or viruses, this also includes nasal and mouth secretions as well as potentially, stomach acid and enzymes in persons who have gastric reflux. In children, the presence of Pepsin (a digestive enzyme) is correlated with OME (O'Reilley et al, 2008). Refux into the middle ear of the contents of the throat may be especially a problem in situations where the compliance of the middle ear is lowered by a PE tube.

OME likely has little effect on balance, but treatment of it with tubes is associated with a small and slow increase in balance over 6 months (Cohen et al, 2011).


TREATMENT of Acute Otitis Media

Observation of otitis media without antibiotics but with pain control is an appropriate option for many children with uncomplicated AOM. Antibiotics are recommended in children under 6 months of age as well as patients with severe illness.

Drugs that are often used are as following:

Alternatives for persons with penicillin allergy

If treatment fails at 48-72 hours switch to higher dose of antibiotics, such as ceftriaxone or clindamycin




Right sided mastoiditis (white blotch on the left side of this image). On MRI films, the right side of the head is shown on the left side of the image.


Otitis media may be accompanied by mastoiditis - -inflammation of the sinus which is attached to the middle ear. This can be seen on imaging studies (see above)

There are several types of Mastoiditis

Severe mastoiditis is characterized by a swollen external auditory canal. Mild mastoiditis, may be silent, and only seen on imaging (as above).

There are several treatment approaches --

Meredith and Boyev (2008) recently wrote on mastoditis on MRI, and suggested that the term is most often applied to the observation of fluid in the mastoid, which may be clinically insignificant. Neverthless, they note that the literature indicates that only 4/1000 temporal bones have fluid on MRI in the mastoid in asymptomatic volunteers, and in TMJ MRI, only 10 patients had fluid out of 2700. Thus fluid in the mastoid is generally rare, and in our view, it is unlikely to be "insignificant".

Facial Paralysis associated with mastoiditis

An acute lower motor neuron facial palsy is rare even though dehiscence of the facial canal is very common. When this happens, there should be a myringotomy with PE tube placement, Infectious disease consultation, intravenous antibiotics, and consideration of mastoidectomy. Once the infection resolves, facial nerve function usually recovers over several months.

Labyrinthitis associated with mastoiditis

This comes in several stages.

In patients believed to have labyrinthitis associated with AOM, one should image the brain, obtain a lumbar puncture, place a PE tube, administer IV antibioitics, and consider mastoidectomy.

Gradenigo's syndrome (Petrous apicitis)

The symptoms of this include severe frontal headache, eye pain, diplopia, dizziness, nausea, and 6th nerve palsy. There should be otitis media seen on otoscopy. MRI shows inflammation of the petrous apex and mastoids. CT may show bone erosion in the petrous apex.

Treatment is with myringotomy with PE tube, and culture-directed IV antibiotic therapy.

Mimickers of mastoidits


Copyright April 21, 2015 , Timothy C. Hain, M.D. All rights reserved. Last saved on April 21, 2015