Otitis Media/Externa

Ovid: 5-Minute Sports Medicine Consult, The

Otitis Media/Externa
Darin Rutherford
Craig C. Young
  • Acute otitis media (AOM): Rapid onset of signs and symptoms in the presence of a middle-ear effusion and with the signs and symptoms of middle-ear inflammation
    • Synonym(s): Suppurative otitis media
  • Recurrent otitis media: ≥3 episodes of acute otitis media in 6 mos
  • Otitis externa: Acute or chronic (>6 mos) infection or inflammation of the external auditory canal
    • Synonym(s): Swimmer's ear
  • Secretory otitis media
  • Catarrh of the middle ear, catarrhal otitis media, tubal catarrh, hydrops ex vacuo
  • AOM:
    • Almost all (93%) children experience ≥1 episode of otitis media by age 6 yrs.
    • Most frequent primary diagnosis at U.S. office visits in children <15 yrs
    • Most common infection for which antibacterial agents are prescribed for children in the U.S.
    • Direct and indirect cost ∼$3 billion in 1995
    • Peak incidence in children age 6–18 mos
  • Otitis externa:
    • Acute (bacterial): 4 in 1,000 persons U.S. 90% unilateral
    • Chronic (fungal or allergic): 3–5% of population
Risk Factors
  • AOM:
    • Recent upper respiratory infection (URI) with eustachian tube dysfunction
    • Bottle feeding
    • Pacifier use after 6 mos of age
    • Passive smoking
    • Group child-care facility attendance
    • Previous episodes of acute otitis media, especially if first when <1 yr old
    • Sibling history of recent infection
    • Nonmodifiable risk factors: Genetic predisposition, male gender, premature birth, Native American or Inuit ethnicity, family history of recurrent otitis media, presence of siblings in the household
  • Otitis externa:
    • Aquatic athletes
    • High humidity, warm temperature
    • Local trauma (cotton swab use or hearing aids)
    • Eczema, allergic rhinitis, asthma, diabetes
General Prevention
  • Otitis externa:
    • Measures that are related to ear hygiene:
      • Avoid using cotton swabs or inserting objects into the external canal, including earplugs.
      • Avoid frequent washing of the ears with soap (leaves an alkali residue that neutralizes the acidic pH of the ear canal).
      • Avoid swimming in polluted waters.
      • Empty water from the ear canals after swimming or bathing.
  • Prophylactic eardrops with a 2:1 ratio of 70% isopropyl alcohol and acetic acid assist in drying and acidifying the ear canal after swimming.
  • Usually eustachian tube dysfunction after viral URI, which results in fluid in the middle ear that acts a culture medium for bacterial superinfection:
    • Most common bacterial causes (account for 95% of bacterial AOM):
      • Streptococcus pneumoniae (increased incidence of drug resistance 30–60% in some communities)
      • Haemophilus influenzae
      • Moraxella catarrhalis
    • Less common bacterial causes:
      • Streptococcus pyogenes
      • Mycoplasma pneumoniae
  • Otitis externa:
    • Bacterial (91%): Pseudomonas aeruginosa (50%), Staphylococcus aureus (23%), anaerobes and gram-negative organisms (12.5%)
    • Fungal: Aspergillus (90%) and Candida
  • AOM:
    • Abrupt, rapid onset of signs and symptoms
    • Presence of middle ear effusion indicated by any of the following:
      • Bulging tympanic membrane (TM)
      • Limited/absent TM mobility
      • Air fluid level behind TM
      • Otorrhea: more specific to AOM
    • Signs or symptoms of middle ear inflammation indicated by:
      • Distinct erythema of TM, OR
      • Otalgia that interferes with normal activity or sleep, OR
      • Otalgia, irritability in an infant or toddler, fever, and URI symptoms (cough, nasal discharge, or stuffiness) are nonspecific and occur in 90% with AOM and 72% without AOM
  • Otitis media with effusion:
    • Absence of signs and symptoms of acute infection
    • Reduced hearing may be present
    • TM neutral or retracted in appearance; fluid in middle-ear space
  • Otitis externa:
    • Otalgia and discharge from external canal
  • AOM:
    • Patient with or without recent URI symptoms complains of otorrhea, otalgia, fever, decreased hearing, or occasional vertigo
    • Other complaints: Anorexia, irritability, vomiting, diarrhea
    • May have history of otitis media
    • TM may spontaneously rupture, leading to resolution of pain.
    • Clinical history alone is poorly predictive of AOM, especially in younger children.
  • Otitis externa:
    • Otalgia
    • Aural fullness
    • Itching
    • Discharge: Initially clear and odorless, but then becomes purulent and foul-smelling
    • Tinnitus
Physical Exam
  • AOM:
    • TM bulging, full, red, and immobile; may be cloudy
    • TM rupture may lead to signs of otorrhea on examination.
    • May have tenderness in mastoid area
  • Otitis media with effusion:
    • TM neutral or retracted
    • Fluid behind TM may be present.
    • May need tympanometry or acoustic reflectometry to confirm diagnosis
  • Otitis externa:
    • Tragal tenderness with manipulation
    • Erythematous and edematous external auditory canal
    • Purulent discharge
    • Eczema of auricle
    • Periauricular and cervical adenopathy


Diagnostic Tests & Interpretation
Tympanocentesis may be helpful in selected refractory or recurrent cases to make microbiologic diagnosis.
Differential Diagnosis
  • AOM:
    • Redness: Crying, fever, cerumen removal with irritation of external canal
    • Earache: Referred pain from throat, jaw, teeth, other nearby structures
    • Tympanosclerosis
  • Mastoiditis:
    • Tenderness in mastoid area may be due to otitis media.
  • Otitis externa:
    • Foreign body
    • Mastoiditis
    • Herpes zoster
Ongoing Care
  • Age 1–3 yrs:
    • If effusion present for >6 wks, consider hearing evaluation
    • If effusion present for >3 mos, need hearing evaluation and possible ENT referral for tympanostomy tube (grommet) placement
  • Older individuals:
    • May need grommet placement after 3 mos following complete ENT evaluation to exclude other causes of effusion
  • 380.10 Infective otitis externa, unspecified
  • 380.11 Acute infection of pinna
  • 380.12 Acute swimmers' ear

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