Otitis Media

Description

Otitis is the medical term for inflammation of the ear. This includes:

Otitis interna: inflammation of the inner ear, usually called labyrinthitis.

Otitis media: inflammation of the middle ear, both acute and chronic forms.

Otitis externa: inflammation of the acoustic meatus and/or the auricle.

If the middle ear is chronically inflamed or repeatedly becomes inflamed, it is called chronic otitis media. In most cases, the patient has a perforated tympanic membrane (hole in the eardrum). Physicians distinguish three forms of the middle ear disease: chronic suppurative otitis media, chronic suppurative otitis media and osteitis, and cholesteatoma. None of the three forms of chronic otitis media mentioned can heal without professional medical and surgical treatment.

Symptoms

Typical signs of the acute form of the disease are sudden, severe earaches, which can occur on one or both sides. A knocking or throbbing in the ear is also a common sign of otitis media. Symptoms such as hearing loss or dizziness may also occur.

If suppurative otitis media is present, the eardrum may tear. In this case, oozing bloody fluid emerges from the ear. Often any earache will then disappear abruptly.

The non-specific symptoms of otitis media include: fever (especially in infants), fatigue, intense malaise, nausea and vomiting.

Symptoms associated with chronic otitis media:

1) Symptoms of chronic suppurative otitis media: if the inflammation is limited to the mucous membrane of the middle ear, then during the active (secretory) phases a usually yellowish-creamy or slimy secretion, which can be either odorless or malodorous, flows outward into the auditory canal. This can lead to ear infections. However, the chronic mucosal inflammation can also spread to the bones in the middle ear, causing scarry or even bony adhesions to appear. This tympano fibrosis or tympano sclerosis causes a progressive loss of hearing in the middle ear. But frequently there is also a progressive sensorineural hearing loss, caused by bacteria (bacterial toxins) from the chronically inflamed middle ear mucosa invading the inner ear. A combined middle ear-inner ear hearing loss thus develops. Chronic suppurative otitis media generally causes no fever and no pain. Patients usually only seek help from an ear, nose and throat specialist with increasing discomfort: for example if the secretion phases become more frequent, the secretions turn fetid, hearing loss increases, tinnitus (ringing in the ears) appears, or if dizziness, loss of balance or worse complications appear.

2) Symptoms of chronic suppurative otitis media and osteitis: the increasingly frequent secretions are generally yellowish-creamy to slimy and usually malodorous. Patients often have a dull pressing sensation in the area of ​​the bone behind the ear (the mastoid). In case of acute exacerbation ("super-infection") of the chronic inflammation, pain and fever also occur. Here too the patient notices progressive hearing loss up to deafness, either with or without tinnitus. In rare cases there are feelings of dizziness, loss of balance or even paralysis of the facial nerve because this nerve passes through the inflamed bone. If the bones in the middle ear are inflamed, the pathogens can be transferred to the venous blood system in the cranial cavity. This can result in blood poisoning (sepsis) or phlebitis with thrombosis in the brain. If the bone inflammation in the brain "breaks through" there will be meningitis, encephalitis and/or a brain abscess.

3) Symptoms of cholesteatoma: the symptoms are vague and of varying extent: a dull pressing feeling in the depths of the ear, sometimes also in the bone behind the ear (the mastoid), sometimes neuralgia (passing sharp pains) in the ear, and in case of acute exacerbation ("super-infection") also persistent pain, secretions from the ear and fever. Here too the patient notices a progressive hearing loss up to deafness, with or without tinnitus (ringing in the ears), and in advanced stages dizziness, disturbances of equilibrium and/or facial nerve paralysis. Generally the disease progresses slowly. In the worst case, the enlarging cholesteatoma (a growth of keratinizing squamous epithelium) "eats" the bony boundary of the cranial fossa, leading to meningitis, encephalitis and/or a brain abscess or other complications.

Causes and Risks

Otitis media is often caused by a cold in the nasopharynx. The cause of acute otitis media is in 80 percent of cases a viral infection of the mucous membranes of the upper airways. Common pathogens include the rhino viruses, respiratory syncytial viruses and influenza (flu) viruses. At the same time though, the naturally occurring bacteria in the nasopharyngeal area and eustachian tube may quickly multiply, resulting in an additional bacterial infection. The most common of these bacteria are streptococcus pneumoniae and haemophilus influenzae.

Only 20 percent of acute middle ear infections have bacterial origins. These can migrate from the nasopharynx through the eustachian tube into the middle ear. This is mostly the case in patients with frequent or chronic inflammation of the nasal mucous membrane or sinuses.

Possible causes of chronic otitis media are allergic diseases of the mucous membranes of the upper airways or (rarely) a tumor in the nasopharynx. Cholesteatoma - a special form of chronic otitis media - can in rare cases be congenital ("genuine" cholesteatoma) or else acquired, for example after a longitudinal temporal bone fracture ("post-traumatic" cholesteatoma). In most cases, cholesteatoma develops over time ("secondary acquired" cholesteatoma) from a chronic ventilation and pressure equalization disorder of the middle ear through the eustachian tube.

Examination and Diagnosis

In order to detect acute otitis media, the ear, nose and throat specialist (otorhinolaryngologist) examines the eardrum, nose, nasopharyngeal area, throat and sinuses. In some cases, the sense of balance must also be checked. In this way possible complications - e.g. labyrinthitis with toxic inner ear damage - can be detected in good time. Examination methods such as tympanometry, acoustic reflex threshold measurements and audiometry can for example be used here.

A hearing test must be carried out. Sometimes laboratory examination of the emerging secretion is required. If a concomitant inflammation (mastoiditis) or other complications are suspected, an X-ray examination can be useful. An X-ray of the mastoid or a computed tomography (CT) of the temporal bone and the adjacent cranial fossa is then made. This allows sufficient time to determine whether surgery is needed.

Treatment

Treatment of otitis media is generally symptomatic, meaning that the symptoms are dealt with and not the actual cause. This is in part because different pathogens can cause otitis media: for example antibiotics are not effective against viruses, and not every antibiotic helps against all kinds of bacteria.

With incipient otitis media, decongestant nasal sprays should be used. In addition, the doctor often recommends taking anti-inflammatory and herbal decongestant remedies such as tablets containing the active substance bromelain. Tablets containing the allopathic drug diclofenac have also proven effective, which acts as an anti-inflammatory and decongestant as well as an analgesic. Those who cannot tolerate or take diclofenac may instead resort to ibuprofen, if that agent is acceptable. For children (in consultation with a doctor), paracetamol is recommended, which has analgesic and antipyretic (pain- and fever-reducing) properties. For otitis treatment, analgesic ear drops in the auditory canal can be used. This is only if prescribed by an ear, nose and throat specialist. In any case, patients should not apply it themselves as the symptoms may thus be obscured.

Doctors often prescribe antibiotics for ear infections in order to reduce the risk of possible lifelong or even life-threatening consequences. Important: antibiotics should be taken exactly as directed and over the entire prescribed period.

If the eardrum has not already torn on its own and the middle ear secretion is not decreasing, the ear, nose and throat specialist may make a small incision in the front lower portion of the eardrum and extract the fluid through this opening. This procedure - paracentesis - occurs in adults under local anesthesia or in children under general anesthesia. If there is already toxic inner ear damage, with or without tinnitus or dizziness, the procedure should take place regardless. Because the surgical opening of the eardrum will close on its own within a few days, the doctor often inserts a small plastic, titanium or gold tube (tympanostomy tube) into the cut. This allows the secretion produced to continue to flow, so the middle ear can be ventilated and heal under normal pressure. If the tube is not ejected from the auditory canal within six to twelve months, or the hole is always clogged with thickened secretions or earwax, the tube is removed surgically. In most cases the eardrum then heals by itself.

If frequent ear infections occur in children who have anatomically or chronically-inflamed enlarged nasopharyngeal tonsils (adenoids), these should be removed. If by the teenage years the nasopharyngeal tonsils have not regressed, or there is frequent or chronic inflammation of the nasal mucous membrane or infection of the paranasal sinuses and middle ear (otitis media), this should also be operated on. Then there will be a so-called surgical restoration of the nasal pharynx, nose and sinuses. None of these forms of chronic otitis media heals by itself using the above measures: middle ear surgery, when feasible, is required in most cases.

Course and Prognosis

Usually otitis media heals without any negative consequences. About 80 percent of patients are free of symptoms after 2 to 7 days.

Sometimes however,chronic otitis media develops or there are other complications. The most common otitis media complication is an inflammation of the mastoid process (mastoiditis). This is a part of the skull adjacent to the middle ear, which likewise is filled with air. In mastoiditis the bone is often damaged, and the inflammation may spread to the meninges (brain linings) or the brain.

Furthermore, it can lead via repeated middle ear infections in infancy to hearing loss and thus to delayed speech development. An inflammation of the inner ear (labyrinthitis) as a result of middle ear infection is also possible.

Miscellaneous/Other Comments

Special forms: acute otitis media sometimes arises in the context of certain infections, which in turn cause symptoms. Examples are scarlet otitis media and otitis media measles.