Otitis Media Symptoms
Otitis media symptoms
There are two form of otitis media. These are acute otitis media and otitis media with effusion. Acute otitis media or acute suppurative otitis media is an infection of the middle ear space characterized by pus in the middle ear.
Children with acute otitis media usually present with severe ear pain. They may be irritable, tug at the ear, and have disturbed sleep. Fever is common and may be the only sign. As the eardrum bulges, pain reaches a crescendo.
If the eardrum then ruptures, pus is seen at the external auditory meatus and the symptoms resolve quickly. Associated symptoms of an upper respiratory tract infection may be present with rhinorrhoea, coughing and vomiting.
Otoscopy is difficult in irritable and distressed children. Often it is only possible to obtain a glimpse of the ear-drum. The eardrum will appear hyperaemic, bulging and featureless. If the eardrum has ruptured, there will be pus in the ear canal and this is occasionally misdiagnosed as otitis externa.
Upper respiratory tract infections cause hyperaemia and oedema of the respiratory mucosa of the middle ear and eustachian tube. An exudate forms in the middle earspace and negative middle ear pressures develop. This sucks an infected bolus of mucus from the nasopharynx into the middle ear via the eustachian tube. The most common causative organisms are Streptococcus pneumoniae and Haemophilus influenzae, which are nasopharyngeal commensals.
A purulent effusion develops and increases middle ear pressures. This increases pressure on the eardrum and produces rapidly escalating pain. In a third of cases, the bulging tympanic membrane then ruptures. Acute otitis media is common in children, particularly after an upper respiratory tract infection. Incidence in the first year of life approaches 50 000 per 100 000, and remains high for the first 5 years of life. The incidence is marginally higher in boys, and episodes are more frequent in winter when upper respiratory tract infections are more common. Recurrent episodes of acute otitis media occur in a minority of children. The risk of recurrent acute otitis media is highest in children who attend a nursery and have multiple siblings, allergies or parents who smoke.
The treatment may include analgesia.Good analgesia is critical as the child will suffer significant earache. It is important to give the child a good dose at bedtime as pain is often worst at night. Non-steroidal anti-inflammatory drugs (NSAIDs) delivered per rectum often provide better analgesia in a vomiting child than paracetamol. The child should be kept well hydrated and in a well-humidified room.
Whilst there may be clinical improvement or rapid resolution of symptoms with antibiotics, this is at a risk of increased vomiting, diarrhoea and rashes. A recent meta-analysis of six trials concluded that children under two with bilateral acute otitis media, and children with both acute otitis media and otorrhoea (ear discharge) benefit most from antibiotics.
In these groups, 4 children need to be treated to prevent an extended course of disease in one. When antibiotics are indicated, amoxicillin is sufficient unless there is a high prevalence of β-lactamase microbes, when co-amoxiclav is a suitable first line agent. In cases of recurrent acute otitis media, daily low-dose antibiotics for 6-12 weeks may help break the cycle of re-infection.
Patients who develop complications such as a facial nerve palsy or acute mastoiditis (without a subperiosteal abscess) require urgent myringotomy (incision of the eardrum) to drain the middle ear space. A ventilation tube or grommet may be inserted to ensure good middle ear ventilation. Routine myringotomy and drainage of pus from the middle ear in patients without complications is practised in the United States, but is not common in the United Kingdom.
Recurrent acute otitis media that has failed long-term low-dose antibiotic prophylaxis can be effectively treated with grommet insertion. The outlook after a single episode of acute otitis media is excellent.
In most cases, spontaneous resolution occurs regardless of whether the eardrum ruptures or antibiotics are prescribed. Surgery for the development of facial palsy as a complication has a favourable outcome, usually with complete resolution of facial weakness. In all cases, there is a residual effusion in the middle ear that clears within 3 months. Children who suffer recurrent acute otitis media are prone to complications and may suffer tympanosclerosis or middle ear adhesions that affect hearing in the long term.
Otitis media with effusion (OME), better known as 'glue ear', is characterized by the presence of sterile, thick and tenacious fluid in the middle ear space. It is considered chronic if the fluid is present for more than 12 weeks.
Children with otitis media with effusion suffer hearing loss that may be covert or manifest. Parents may report that they are inattentive or repetitively question instructions. Perceptive teachers may pick up this inattention in the classroom. Otalgia is often less dramatic. The child may pull at this or her ear, or occasionally insert foreign bodies into the ear.
On otoscopy, the eardrum appears featureless, dull and immobile. Often, prominent radial vessels are noted ). Occasionally, air bubbles in the middle ear may be seen through
The pathogenesis of otitis media with effusion is incompletely understood. In children, the most popular theoryis underventilation of the middle ear space (due to poor eustachian tube function) with negative middle ear pressure allowing a transudate to form. Adenoidal hypertrophy may worsen eustachian tube function and predispose to chronic middle ear effusions.
Other contributing factors include exposure to other children, allergy, impaired immune defences and unresolved acute otitis media. The pathogenesis in adults is probably different: predisposing factors include post-nasal tumours, radiation of the head and neck, barotrauma and AIDS. In addition to the accumulation of thick fluid in the middle ear, metaplasia occurs in the respiratory mucosa of the middle ear and mastoid air cells. Cuboidal mucosais replaced by pseudostratified mucus-secreting mucosa, rich with goblet cells. Ciliary function appears to be less effective. The effusion contains all types of inflammatory cells, and bacteria are isolated in approximately 20% of patients.
The investigations may include audiometry and tympanometry. Audiometry often reveals a mild conductive hearing loss in excess of 20 dB, which is more significant in the low tones. Tympanometry is an easy and effective way of demonstrating middle ear effusions.
The management will focus on medication, patient education and surgical approach.There is no evidence to substantiate the use of antibiotics, decongestants, mucolytics, antihistamines or steroids in the treatment of glue ear. Any resolution of glue with these drugs appears to be short-lived.
In children under 3 years of age with persistent bilateral effusions, thresholds better than 25 dB and no obvious consequence for development, there are strong grounds for the adoption of a watchful waiting approach, and reassurance is required for the parents. In children over 3 years of age, or in those with adverse development consequences or losses of more than 25 dB, referral to a specialist is necessary.
Auto-inflation of the eustachian tube with an Otovent balloon has been shown to produce short-term improvement in older children who are able to use this device. Surgical treatment of bilateral effusions comprises the insertion of ventilation tubes or grommets.In children with gross upper airway obstruction, adenoidectomy to improve eustachian tube function or possibly remove a sump of infection is advisable.
Complications associated with chronic middle ear effusions are uncommon. They include thinning and collapse of the eardrum into the middle ear (atelectasis), retraction pockets of the drum , erosion of ossicles and recurrent acute otitis media. Undiagnosed hearing loss in children with otitis media with effusion may result in impairment of speech, language and cognitive development, and behavioural difficulties. The child may appear uninterested in his or her environment and is described as a 'silent child'.
The outcome following treatment of glue ear is good. Unfortunately, half of all those treated with ventilation tubes will require re-insertion. Speech or developmental delay often corrects itself quickly.
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