Otitis media (Ear Infection) is one of the most common childhood diseases. The main symptoms are pain, hearing loss, and fever. Apart from the ailments, the disease can lead to permanent deterioration or loss of hearing, and even to paralysis of the facial nerve. Treatment should be started as soon as possible to prevent complications.

Otitismediais a common childhood disease. The data show that the incidence in children up to 24 months of age is over 60%. It is presumed that the reason for this is the different structure of the Eustachian tube –it is shorter, wider and more horizontal, which facilitates the penetration of microorganisms.

Middle ear – structure

The middle ear is part of the sound pathway between the outer and inner ear. The elements of its construction are:

• eardrum– oval structure, about 0.1 mm thick, that separates the outer ear from the middle ear (the border between the ear canal and the tympanic cavity),
• Eustachiantube – is a cartilage-bone structure approximately 3.5-4 cm long, which connects the tympanic cavity with the nasal part of the throat. The pharyngeal opening is surrounded by absorbent tissue that forms a structure known as the trumpet tonsil. In the cartilage part, the inferior wall and a fragment of the anterior wall are made up of only the mucosa, which means that the Eustachian tube is not open all the time. The connection with the flexor muscle of the soft palate results in the fact that the proboscis only opens during contractions of this muscle, e.g. when swallowing and yawning.The function of the trumpet is to equalize the pressure in the tympanic cavity with the atmospheric pressure, prevent the ingress of bacteria from the nasopharynx into the middle ear, as well as discharge the secretions from the tympanic cavity to the throat,
• tympanic cavity– is the main element of the middle ear. It is a space lined with a mucosa, creating numerous recesses and folds, and filled with air. In addition, its contents are the auditory bones:
  • hammer (partially fused with the eardrum),
  • anvil and stapes that transmit vibrations from the eardrum to the middle ear.

The tympanic cavity is filled with numerous small blood vessels, nerves and tendons. On the back wall of the tympanic cavity there is an opening connecting it with the pneumatic space, which is the mammary cavity,

• air spaces– this group includes the mammary cavity and mammary cells lined with the mucosa. They are located in themastoidpart of the temporal bone (the structure is easily examined posteriorly from the auricle). Pneumatization of these structures takes place in childhood and depends on the patency of the Eustachian tube.

Otitis media – morbidity

Otitis media is a common childhood disease. The data show that the incidence in children up to 24 months of age is over 60%.

It is presumed that the reason for this is the different structure of the Eustachian tube – it is shorter, wider and more horizontal, which facilitates the penetration of microorganisms.In adults, inflammation, especially acute inflammation, is less common. There are many classifications of otitis media. Most often they are divided into: acute and chronic inflammations.

Otitis media – causes

Factors that increase the risk of otitis media include:

• otitis in parents and other family members,
• male gender,
• race – higher incidence in Inuit, Indian,
• immunosuppression – patients with congenital and acquired (AIDS) immunity disorders, after organ transplants (immunosuppressants), patients treated with corticosteroids,
• passive and active smoking – tobacco smoke irritates the nasal mucosa and disrupts the function of the mucociliary apparatus,
• climatic factors – increased incidence in transition periods (fall-winter-spring),
• in children: artificial feeding of a child up to 6 months of age. Mother’s milk contains the so-called immunoglobulins, which are proteins that protect your baby from infection. Moreover, artificial feeding causes irritation of the mouth of the Eustachian tube,
• the structure of the child’s Eustachian tube – it is shorter and wider, which promotes the formation of infections,
• fracture of the temporal bone,
• sinusitis,
• undergoing tonsillectomy,
• congenital disease syndromes – Down’s syndrome, Kartagener’s syndrome, the basis of which are disorders in the cilia function, therefore the epithelium does not perform its task properly, which is conducive to more frequent inflammations,
• obstruction of the Eustachian tube, the causes of which may be:
  • frequent infections of the respiratory tract (colds,flu, childhood diseases), which contribute to the swelling of the mucosa of the Eustachian tube and the transfer of the pathogen from the nasopharynx to the middle ear;
  • adenoid hypertrophy;
  • cleft palate – causes disturbances in the functioning of the muscle of the soft palate tensor, which, working properly, causes periodic opening of the proboscis, e.g. during swallowing; nasopharyngeal tumor, mainly in adults.

In exudative inflammation, risk factors also include:

• hypothyroidism_
• failure to cure bacterial inflammation (antibiotics sterilize the fluid in the ear but do not remove it),
• trauma caused by a sharp change in pressure, e.g. during an airplane flight,
• allergies (as evidenced by the coexistence of bronchial asthma, allergic rhinitis, eczema).

Otitis media – visit to the doctor

Otitis media is diagnosed and treated by family doctors and pediatricians. In the case of a prolonged inflammation process, unusual symptoms or complications, it is necessary to visit a specialist – an ENT specialist. Some of the questions that may arise for a patient during a visit to the doctor are:

1. Can acute inflammation recur?
2. Is it necessary to stay in bed during the acute period of the disease?
3. Do I need to particularly protect my ears, e.g. in winter?
4. Can i swim in the pool?
5. I’m afraid of incising the eardrum, so can I wait for it to rupture by itself and the pain subsides?
6. Will otitis and its treatment negatively affect pregnancy?
7. Is listening to music through headphones harmful in chronic otitis?
8. Do recurrent otitis media carry a risk of hearing loss?
9. Do all complications need to be treated surgically?

A patient with acute inflammation should see a doctor if the painkillers and anti-inflammatory drugs are not working and the patient’s general condition worsens. In the case of bacterial aetiology of inflammation, only an early initiation of the correct therapy gives a chance of a successful cure.An alarm signal should also be a recurrence of symptoms after a period of about 2 weeks. This may indicate that acute inflammation has not been healed and complications are developing.

All disturbing hearing abnormalities should be consulted with a doctor. You can do it in a traditional doctor’s office on the basis of NFZ services or use private,free examination programs. Hearing experts will test your hearing and will also suggest suitable ways to improve your hearing, if necessary.

Otitis media – research

Usually, the symptoms reported by the patient largely guide the doctor to the correct diagnosis.An indispensable element of diagnostics in this case is otoscopy. It is an examination that involves the use of a sight glass and a light source. The speculum is inserted through the ear canal, which sometimes requires prior cleaning of residual wax or exfoliated epidermis. The patient is in a sitting position.

Before inserting the otoscope, the doctor pulls the auricle up and back, which facilitates the insertion of the speculum. The examination is painless and requires no special preparation. It allows you to carefully examine the eardrum, find any perforations or fluid in the tympanic cavity.

A more precise observation of pathological changes is possible thanks to the use of an ear microscope, which can detect very small cholesteatoma or polyps. The blowing of the Eustachian tubes is important (both diagnostic and therapeutic). The most common methods of blowing the Eustachian tubes are:

• Valsalva method– the patient is asked to exhale through the nose, keeping the wings closed.If your earis blocked, the proboscis is not open.
• Politzer method– the patient is asked to pronounce the words “kiki”, “kuku” or swallow the liquid. It then separates the nasopharynx from the middle pharynx. During this time, the doctor uses a balloon-like pear to blow air through one nostril, blocking the other nostril.

Imaging methods, such as X-rays and computed tomography, are used in the diagnosis of bone changes (as complications of otitis media).

There are a number of studies available when it comes to determining hearing impairment; from the indicative hearing test, when the doctor asks the patient to repeat words spoken at different distances from the patient’s ear, through reed tests (using a tuning fork) to audiometric tests that allow the most accurate determination of the type and degree of hearing damage.

Acute otitis media – what is it?

As mentioned, otitis media most often occurs in the course of viral diseases, as well as inflammation in the nasopharynx. Transmission of the infection to the mucosa of the Eustachian tube and the middle ear causes impairment of proper ciliary transport, inflammation and the accumulation of exudate, which is the basis for bacterial growth.

Accumulating exudate causes pressure on the tympanic membrane, its ischemia, which may result in perforation and pain relief. The perforation is evidenced by discharge in the ear canal or leakage from the ear (first serous, then purulent).

Due to the important functions of the Eustachian tube, it is important to maintain its proper patency. In acute inflammation, the hearing loss is significant and conductive in nature.

Acute otitis media – symptoms

Acute inflammation:

• severe distressingpain in the ear(may worsen at night),
• a feeling of fullness in the ear,
• hearing impairment,
• tinnitus
• fever (in children up to 40 ° C, often with coexisting diarrhea, the child may be irritable, tearful),
• loss of appetite
• bad mood,
• profuse purulent discharge with an unpleasant odor,
• perforation of the eardrum may occur, which is associated with the alleviation or disappearance of pain,
• possible compressive soreness of the mastoid process.

Acute otitis media – treatment

In the early stages of the disease, when the otoscope does not yet show bulging of the tympanic membrane caused by fluid accumulation in the middle ear, the most important thing is to introduce antibiotics. Penicillins, sometimes cephalosporins, are most commonly used. Early discontinuation of the antibiotic may result in relapse of the disease, the risk of complications or the disease becoming chronic inflammations.

If the doctor detects a significant accumulation of exudate emphasizing the eardrum, which contributes toparalysis of the facial nerve, or symptoms of irritation and inflammation of the middle ear (dizziness, nausea, vomiting), an incision must be made, i.e. paracentesis.The procedure is usually performed under local anesthesia, which, unfortunately, is not completely painless. After the incision, an antibiotic filter is inserted into the ear canal. The incision site usually heals after 3-4 days.

Paracentesis prevents the spontaneous rupture of the drum, which is manifested in the cessation of pain and the appearance of fluid in the ear canal. In some patients, there is a permanent loss of membrane, which is a gateway to subsequent ear infections. In this case, it is necessary to protect the ear against water ingress, e.g. when swimming in a swimming pool.If, after parcentesis, leakage from the ear persists, it is advisable to test the discharge and re-select the antibiotic. Pain and fever are treated with over-the-counter preparations. Nasal decongestants are also used.

If the otitis media is not healed after 2-3 weeks (leakage does not stop, hearing does not return to normal), it can be assumed that:

• mastoiditis has occurred,
• inflammation of the nasopharynx or paranasal sinuses develops,
• chronic inflammation occurred.

In the case of influenza of the middle ear, treatment should begin with the use of anti-inflammatory drugs, analgesics, vitamin C, antihistamines. In the case of symptoms lasting more than 48 hours, we can speak of bacterial inflammation. Antibiotic therapy is then included in the treatment. After healed acute inflammation, a Politzer maneuver is performed to open the Eustachian tube.

Sometimes treatment may not bring the desired results as a result of: choosing the wrong antibiotic, using it at the wrong dose or for too short a period of time, failure to perform paracentesis (if indicated), bacterial resistance, superinfection with other strains, viral infection, failure to follow medical recommendations, untreated lesions of the upper respiratory tract, sinuses, mastoiditis, which before antibiotic therapy was one of the most frequent complications.

Chronic otitis media – types

Each chronic inflammation is characterized by a triad of symptoms, such as loss of the tympanic membrane, periodic ear discharge, and hearing impairment. It can also lead to the formation of polyps and cholesteatoma. Therefore, we can divide chronic inflammations into:

• Simple– this form is mild, without serious intracranial complications.The entire mucosa of the ear drum, including the ossicles, is inflamed.Leakage from the ear can be periodic or permanent. Increasing its intensity may indicate a bacterial overload, e.g. during a cold or water entering the ear.The discharge is muco-purulent, may have an unpleasant odor or may be odorless.Hearing damage depends on a loss in the eardrum, but in this form of chronic inflammation it is usually minor.
• With the formation of granulation tissue and polyps– in the middle ear, there is an overgrowth of granulation tissue that can fill the entire space of the tympanic cavity (leading to the destruction of the auditory ossicles) and its recesses, occupying the mammary cavity and mammary cells, and then transferring the inflammatory process to the bone.Polyps form and can grow anywhere within the tympanic cavity and even in the ear canal.It can be said that then we are dealing with a vicious circle, because the cause of the described productive changes is the residual secretion, in turn these changes impede its outflow. The discharge is usually profuse, always purulent, and usually has an unpleasant odor. Hearing impairment is much greater (conductive or mixed), usually reported by the patient, because apart from perforation of the membrane, the ossicles are destroyed, mucus is retained, and the aeration of the mastoid process is disturbed.

With the formation of cholesteatoma– i.e. a formation made of exfoliated epithelium, which is arranged in layers (like in an onion) and is surrounded by keratinizing epithelium.The growing cholesteatoma (named after its characteristic color) occupies the air spaces of the middle ear and later destroys the bone elements.

Both the auditory bones are damaged (the stapes to the least extent: this prevents inflammation from reaching the inner ear),the facial nerve may be paralyzed, the labyrinth may be damaged and the balance disorders connected with it.

Sometimes cholesteatoma is released through the ear canal and it heals itself. More often, however, an infection develops and a fetid pyorrhoea develops. In this type of inflammation, there is always a marginal defect in the tympanic membrane and a more or less profuse discharge, but always purulent, dirty and strongly foul-smelling.

When it comes to hearing impairment, it can vary. A small cholesteatoma and a small perforation in the eardrum may not cause significant auditory disturbances. On the other hand, intensive growth of cholesteatoma, and with time involvement of the inner ear, leads to a very serious hearing impairment.

Chronic otitis media – symptoms

Chronic inflammations:

• perforation of the tympanic membrane,
• periodic discharge from the ear,
• deterioration of hearing over time,
• a feeling of splashing in the ear when you change the position of the head (called exudative inflammation).

Increased morbidity is observed in the fall-spring season. The cause of acute inflammation is bacteriasuch asStreptococcus penumoniae,Haemophilus influenzaeand other streptococci and staphylococci.

Infection can occur spontaneously or in the course of colds, flu, tonsillitis, sinusitis or viral diseases such as measles, scarlet fever, whooping cough. Inflammation occurs through direct transmission of the pathogen from the pharyngeal mucosa to the middle ear, through the blood, and also as a result of a defect in the tympanic membrane directly from the external environment.

In chronic inflammations, the main causes are:

• recurrent upper respiratory tract infections,
• too late or inadequate treatment of acute otitis media,
• viral diseases, e.g. in acute inflammations.

Chronic otitis media – treatment

The main goal of the treatment of chronic inflammations is to remove the lesion and restore hearing or at least prevent its loss.Before surgery, conservative treatment is important to reduce inflammation and achieve ear dryness.It is recommended to remove the foci of infection (e.g. inflammation of the tonsils, throat), open the nose, and protect the ear against water ingress. The bruised mucus may require suction or bandages for the ear, even for a long time.

When it comes to antibiotic treatment in chronic inflammations, it should always be confirmed by microbiological examination with culture, and by taking an antibiotic (determination of susceptibility to various antibiotics) and selection of the most effective drug. The use of disinfectants is recommended, but after removing the secretions from the ear. Lesions such as granulation tissue or polyps can be removed using an ear microscope. If the chronic inflammatory process also affects the mastoid cell lining, an anthromasteectomy is performed.

Tympanoplasty

Middle ear operations are generally known as tympanoplasty.

Open tympanoplasty involves joining into one large cavity: the mammary cavity, tympanic cavity and its recesses. After the operation, it is covered with epithelium over time, but in large cavities it is most often covered with muscle fascia.This radical operation is performed especially in the case of otitis with cholesteatoma and bone destruction. It is associated with significant hearing loss.What’s more, after such a procedure, postoperative care is extremely important. In radical modified surgery, the auditory ossicles remain intact and connected to the eardrum. Hearing impairment does occur, but it is less than in the case of radical surgery.

In closed tympanoplasty, the posterior, bony part of the ear canal is left, which enables the sound conducting system to be reconstructed in the next stage of the operation. The defect in the tympanic membrane is replaced (myringoplasty) and the ossicles are reconstructed (ossiculoplasty).In cholesteatoma, this type of treatment is associated with frequent relapses and difficulty in assessing the area affected by the disease.

Otitis media – unusual forms

Scarlet fever otitis– When the disease is caused by the bacteria that causes scarlet fever, the disease is severe. There is necrosis of the eardrum, mucosa and ossicles in the tympanic cavity. The mastoid is quickly involved. Serious intracranial complications and paralysis of the facial nerve are not uncommon.Characteristic of this inflammation is a foul purulent discharge.

Measles otitis– the early form of the disease is usually caused by a blood-borne infection, often with the appearance of skin rashes. The late form, on the other hand, is most often caused by pneumococci via the Eustachian tube. It is characterized by a more severe course and more frequent complications and the possibility of transforming into chronic inflammation.

Otitis media with effusion

This type of inflammation is also called serous or muco-serous inflammation. It can be both acute and chronic.It occurs quite often, especially in children up to 10 years of age who have had acute otitis. It occurs quite often, and especially in children up to 10 years of age who have arrived acute otitis.The essence of the disease is the presence of non-purulent fluid in the middle ear with impaired patency of the Eustachian tube. There are several mechanisms for the formation of sterile fluid:

• The drop in pressure in the middle earcauses the vessels in the middle ear to dilate and leak.
• Infectious agents, especially in the course of the upper respiratory tract, trigger the inflammatory reaction as they pass through the Eustachian tube.
• The epithelium lining the earbecomes metaplasia and becomes richer in glands that produce a thick mucus.

The diseaseis usually long-term and is characterized by varying degrees of hearing loss, usually bilateral, and the disease is usually painless and fever-free. In the course of the disease, there are adhesions within the tympanic membrane, its thinning, which impairs the mobility of the membrane. In addition, the Eustachian tube is partially or completely obstructed. Hearing damage is usually of a mixed nature.

Acute mastoiditis

Symptoms of acute mastoiditis include:

• throbbing pain in the back of the ear and swelling in this area
• leakage from the ear
• poor general condition of the patient,
• progressive deafness, as well as perforation of the eardrum.

These symptoms usually appear 2-3 weeks after the otitis has been left untreated. The examination shows tactile pain in the mastoid process.This condition is an indication for urgent hospitalization and antibiotic and surgical treatment (mastoidectomy).Late initiation of treatment results in intracranial complications or significant hearing loss.

Sometimes this purulent process breaks through in different directions. Puncture in the anterior direction results in the formation of a fistula in the external auditory canal, medial: it involves the rocky part of the temporal bone. Downward spreading along the sternocleidomastoid muscle causes abscesses in the deep tissues of the necks.

Otitis media – hearing damage

There are 3 types of hearing loss:

Conductive– the cause is impaired conduction of the sound wave due to pathology of the outer or middle ear.

Reception– occurs when the inner ear is damaged, the vestibulocochlear nerve (which conducts sound impulses to the brain) or the part of the brain responsible for hearing.

Mixed– conductive-receiving.

Otitis media – complications

Diffuse labyrinthitis– is often the result of acute middle ear inflammation. In the serous type of inflammation, there is dizziness (spinning), vomiting, nystagmus, and sensorineural hearing impairment.If left untreated, it can turn into purulent inflammation with more severe symptoms, and consequently cause deafness and permanent damage to the inner ear.Various methods are used in treatment (depending on the severity of the disease): from antibiotic therapy and paracentesis to radical surgery.

Facial nerve paralysis– the main cause is otitis media, especially in children (within 2-4 days of the disease), and chronic cholesteatoma.Symptoms of nerve paralysis are: non-closing of the eyelid and drooping corner of the mouth. Acute treatment in inflammation is antibiotic therapy for 10-14 days and paracentesis. In chronic inflammations with cholesteatoma / granulation tissue palsy of the facial nerve is an indication for a surgical operation, which should be performed within 48 hours of the onset of paralysis.

Otitis media – intracranial complications

Epidural abscess– forms between the temporal bone and the meninges of the brain, especially in mastoiditis and cholesteatitis. Symptoms include a dull headache, increased temperature, and mastitis-like symptoms. Surgery.

Meningitis– is the result of purulent inflammation entering the soft meninges of the brain with: acute otitis media (through the bloodstream), cholesteatoma, mastoiditis or labyrinthitis. The following symptoms can then be observed:

• headache,
• neck stiffness (other meningeal symptoms are also positive),
• fever,
• photophobia,
• vomiting,
• and even loss of consciousness.

The diagnosis is confirmed by the result of the cerebrospinal fluid analysis. Therapy usually consists of a combination of antibiotics and surgery.

Brain abscess –most often it is a complication of otitis media with the formation of cholesteatoma or the consequence of a supra- or subdural abscess. Symptoms depend on the location of the abscess.The temporal lobe involvement is manifested by the paralysis of the speech center.

An abscess located in the cerebellum manifests itself with nystagmus and difficulties in maintaining balance.In both cases, there is an increase in intracranial pressure, which results in vomiting, drowsiness, impaired consciousness or headaches (the pain intensifies when coughing, sneezing, defecating, covers the entire head).

The diagnosis is made using diagnostic imaging methods. An abscess may be emptied during ear surgery, but in some cases intracranial surgery is required.

Thrombotic sigmoid sinusitis– a parisinoid abscess (in the course of chronic otitis media) contributes to the formation of a blood clot in the sigmoid sinus (dural sinus), which may become infected. Inflammation is characterized by a fever of up to 40 ° C, chills, and soreness on the side of the neck affected by the inflammation.Over time, a systemic inflammatory reaction and septic shock may develop.

There is tachycardia, increased respiratory rate, and significant leukocytosis is visible in the blood test. The diagnosis is complemented by a positive blood culture result, although it may be negative in 1/3 of patients (due to earlier administration of an antibiotic). Currently, this complication is not common, although it is very serious. The mortality in thrombosis is about 20%, and if symptoms of septic shock are added to it, it can even reach 60%.

In acute inflammation, it is important that the patient remains in bed and complies with medical advice. In addition to antibiotics, he should take painkillers and antipyretics. However, for non-pharmacological methods, it is recommended to heat the ear with a hot water bottle or a special lamp. However, it must be remembered that it must not be performed in the event of complications.It is also not recommended to use camphor oil in the ear. It causes maceration of the eardrum and the skin of the ear canal, which makes it difficult to properly assess the disease image.

It is noteworthy that as a result of long-term use of ear drops containing antibiotics and steroids, otitis may be caused by fungi.The symptoms are so similar to cholesteatoma that sometimes patients are qualified for surgery. Fungal inflammation can also develop after surgery. Diagnostics is difficult, it requires growing the fungus on a special substrate, because only then is effective therapy possible.

It happens that with the first episode of acute otitis media, ending with perforation of the tympanic membrane and symptom relief, the patient does not seek medical advice. A specialist goes to a specialist when symptoms worsen or when hearing loss progresses. Nevertheless, visiting a doctor should not be delayed.

You can decide when to perform surgery to improve your hearing. Surgical treatment of any complications should be performed urgently due to the high risk of damage to health or even loss of life and only requires the patient’s written consent to the procedure. In case of hypersensitivity to a given drug (mainly antibiotics), ask your doctor to change to another one that is equally effective and has fewer side effects.

Otitis media – prevention

Otitis media prevention is based on reducing risk factors. Some of them, such as:

• sex,
• race,
• weather factors,
• congenital disease syndromes,
• ear anatomy in infancy,
• the presence of the disease in the patient’s family,

however, we have no influence.

In prophylaxis, it is recommended to:

• quitting smoking,
• treatment of rhinitis (decongestants), colds, sinusitis, adenoid hypertrophy (adenoidectomy may be considered).

In the case of chronic inflammation prophylaxis, it is important not to ignore the symptoms of acute inflammation, to see a specialist quickly and to treat it properly. In the prevention of recurrence of otitis, especially in children, prophylactic administration of low doses of antibiotics is sometimes used, especially in the period of severe upper respiratory tract infection.

Symptoms of acute inflammation usually appear suddenly, and very intense pain and general well-being have an impact on the proper functioning of the patient. Moreover, the basis of acute treatment is staying in bed, taking medications and observing the progress of the disease, which also excludes the patient from daily activities.

During antibiotic therapy, you should take into account possible side effects of the drug. The most common are: diarrhea and skin rashes.In the event of more serious symptoms, you should immediately inform your doctor, as it may be necessary to change the antibiotic to another. Hearing damage is also a discomfort, which may vary in severity depending on the type and severity of the inflammation. In complicated chronic inflammations, it may even be completely lost.

In addition, you should be careful when bathing in water reservoirs and avoid sudden changes in temperature. Apart from the aforementioned acute mastoiditis, the patient should be aware of possible, much more serious complications.