Acute Otitis Media

UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA
JONELTA FOUNDATION SCHOOL OF MEDICINE
ENT SGD
Group 1
ALONZO, ASUNCION, BALUYOT, BANGALAN,
BASILIO, J., BASILIO, S., BEJOC, BELEN, BELLEN,
BUOT, CAPUNO, CERNA, CERVANTES, CLAVILLAS,
CLEMENTE, CONCEPCION

CASE:
ACUTE OTITIS MEDIA

CASE
A 3 year old female after a bout of runny nose presented with
39C fever, vomiting, tugging the right ear. The parents brought
her to the ER. The otoscopic findings were a red bulging Right
tympanic membrane

SALIENT FEATURES
● History
○ 3 year old female
○ runny nose
○ fever 39C
○ vomiting
○ child tugging her right ear
● Physical Exam
○ Otoscopic finding: Red bulging
right tympanic membrane

FURTHER QUESTIONS
IN HISTORY TAKING
● History of Present Illness
○ Was there any history of trauma to the ear?
○ Does the child complain of ear pain? <2yrs. Pulling or rubbing the ear?
○ Upper respiratory infection now or recently?
○ Febrile?
○ When did the first episode happen? How many episodes in the last 6
months? Does it get worse every episode?
● Past Medical History
○ Were there any surgical procedures done? What were the indications and
when was it done?
○ Past conditions and what were the treatment done?

● Immunization record
● Allergies
● Maternal and Birth History
○ Prenatal
■ age of the mother at the time of delivery
■ any relevant past maternal medical history
■ medications taken throughout the time of conception to delivery
○ Birth and Neonatal History
■ was labor induced or spontaneous? duration? method of delivery?
■ any signs of fetal distress or difficulty encountered during labor or
delivery
■ APGAR score or did the infant undergo resuscitation?
FURTHER QUESTIONS
IN HISTORY TAKING

■ anthropometric measurements
■ what was the gestational age? placental weight?
■ Was vitamin K given?
● Medications
○ what medications has the patient taken? is the patient currently on one?
● Social History
○ Parent’s job description, family income
● Family History
○ Genogram
● Review of Systems
FURTHER QUESTIONS
IN HISTORY TAKING

ELICIT FURTHER IN
PHYSICAL EXAMINATION
● Otoscopy
○ Every examination should include an evaluation and description of the
following four Tympanic membrane characteristics:
■ Color
■ Position
■ Mobility
■ Perforation

COMMON PRESENTATIONS OF
ACUTE OTITIS MEDIA
● Acute Otitis Media (AOM))
○ Otalgia
○ Otorrhea
○ Headache
○ Fever
○ Irritability
○ Loss of appetite
○ Vomiting
○ Diarrhea
● Otitis Media with Effusion (OME)
○ Hearing loss
○ Tinnitus
○ Vertigo
○ Otalgia

INITIAL IMPRESSION
Acute Otitis Media of the Right Ear

What is the stage of the patient’s AOM?
● Stage of Suppuration: Before Perforation
○ Patient had high fever (39 C) and ear ache (ear tugging)
○ Otoscopic findings showed a red and bulging tympanic
membrane of the right ear

AOM vs OME
Acute Otitis Media (AOM) Otitis Media with Effusion (OME)
Definition Acute inflammation of middle ear with
acute signs and symptoms
Presence of middle ear fluid without acute
signs and symptoms ; Without acute
inflammation
Symptoms ● Substantial ear pain (throbbing
nature), including unaccustomed
tugging or rubbing of the ear
● High fever
● Restlessness
● No acute signs and symptoms
● Can be accompanied by hearing loss
● Unsteadiness
Signs ● Marked redness of the tympanic
membrane
● Distinct fullness or bulging of the
tympanic membrane
● Bulging of the tympanic membrane is
absent or slight or the membrane may
be retracted.
● Erythema is also absent or slight
● Presence of the air fluid levels
With Middle Ear Effusion Yes Yes
Acute purulent Otorrhea
not due to otitis externa
Yes No

DIFFERENTIAL DIAGNOSIS
Acute Otitis Media (AOM) Otitis Media with Effusion (OME)
Rule In ● (+) Runny nose
● (+) High fever (39C)
● (+) Vomiting
● (+) Tugging of the right ear (ear ache)
● PE:
○ Red and bulging tympanic
membrane of the right ear
● Bulging tympanic membranes
Rule Out ● (-) Hearing loss*
● (-) Anorexia*
● (-) Diarrhea*
*further investigation
● Presence of acute signs and
symptoms
● (-) air fluid levels
● (-) hearing loss
CANNOT BE TOTALLY RULED OUT RULED OUT

FINAL DIAGNOSIS
ACUTE OTITIS MEDIA OF THE
RIGHT EAR

PATHOPHYSIOLOGY:
STAGES OF OTITIS MEDIA

FIRST STAGE: STAGE OF HYPEREMIA
● Hyperemia of the mucous membrane of
the tympanic cavity, the mastoid air
cells & ET
● Infection of the ET: ET becomes
occluded by edema & hyperaemia ->
Changes in middle ear pressure,
mucociliary transport & surfactant-like
substance in ET -> retraction of TM

SECOND STAGE: STAGE OF EXUDATION
● Prolonged tubal occlusion -> invasion of pyogenic
organisms -> exudate in M.E. -> TM congestion & bulges
under pressure
● Symptoms:
○ Marked earache (throbbing nature)
○ Deafness & tinnitus (only complained in adults)
○ High fever & restlessness (in children)
● Systemic symptoms: anorexia, vomiting, diarrhea
● Signs
○ Congestion of pars tensa
○ Cartwheel appearance of TM
○ pars flaccida becomes red
○ Pneumatic otoscope -> reduce mobility

THIRD STAGE: STAGE OF SUPPURATION
(BEFORE PERFORATION)
● Symptoms:
○ Excruciating earache
○ Increasing deafness
○ High fever
● Signs:
○ TM read & bulging with loss of landmark
○ Handle of malleus engulfed by the
swollen & protruding TM
○ Yellow spot on TM -> rupture
○ Tenderness over mastoid antrum

● Symptoms:
○ Otalgia subsides with onset of discharge
○ Fever comes down
● Signs:
○ External auditory canal may contain
mucopurulent blood-tinged discharge
○ Pinhole perforation
THIRD STAGE: STAGE OF SUPPURATION
(AFTER PERFORATION)

FOURTH STAGE: STAGE OF RESOLUTION
● Inflammation resolves with drainage of the pus
and host defense/treatment
● Pin-hole perforation heals
● Symptoms:
○ Acute symptoms subside
○ Ear becomes dry
○ Eventually hearing restored
● Signs
○ Dry pin-hole perforation
○ Later – healed perforation

ETIOLOGY
● VIRUSES
○ most episodes of AOM are preceded by respiratory tract infection of viral
origin
○ Rhinovirus
○ Respiratory syncytial virus
● BACTERIA
○ Streptococcus pneumoniae (30%)
○ Haemophilus influenza (20%)
○ Moraxella catarrhalis (12%)

DIAGNOSTICS
● Laboratory evaluation is usually unnecessary.
● Imaging studies are not indicated in patients with OM.
● Complications
○ Contrast-enhanced computed tomography (CT)
○ Magnetic resonance imaging (MRI)
● Tympanocentesis
● Other tests
○ Tympanometry
○ Acoustic Reflectometry

DIAGNOSTICS

MEDICAL CARE
● should include an assessment of pain
○ analgesics- acetaminophen or ibuprofen
● First line medical treatment: Amoxicillin 80-90mg/kg/day
● Second line treatment:
○ High-dose oral amoxicillin-clavulanate (80-90 mg/kg/day of amoxicillin component, 6.4
mg/kg/day of clavulanate component)
○ Oral cefuroxime axetil (suspension, 30 mg/kg/day in divided doses; tablet, 250 mg twice
daily)
○ Intramuscular (IM) ceftriaxone (administered as a single IM injection of 50 mg/kg on 3
consecutive days)

MEDICAL CARE
:
:
::
Children six months or older with otorrhea or severe
signs or symptoms (moderate or severe otalgia,
otalgia for at least 48 hours, or temperature of
102.2°F [39°C] or higher)
antibiotic therapy for 10 days
Children six to 23 months of age with bilateral acute
otitis media without severe signs or symptoms
antibiotic therapy for 10 days
Children six to 23 months of age with unilateral acute
otitis media without severe signs or symptoms
observation or antibiotic therapy for 10 days
Children two years or older without severe signs or
symptoms
observation or antibiotic therapy for five to seven days

SURGICAL CARE
● Tympanocentesis
● Tympanostomy tubes
● Adenoidectomy and Tonsillectemy
● Surgery for children with cleft palate
● Surgery for children with Down Syndrom

PREVENTION
● Elimination of risk factors
○ Daycare attendance
○ Tobacco smoke exposure
○ Pacifier use
○ Breastfeeding for less than 3 months
● Passive and active immunizations
○ Passive immunization with RSV-IGIV in selected infants
○ Pneumococcal vaccine
○ Influenza vaccine
● Antibiotic prophylaxis

LONG-TERM MONITORING
● Inpatient care for patients with intratemporal or intracranial complications of OM
● Most will resolve with antibiotic therapy, but recurrences are frequent
○ By age 7, more than ⅓ have experienced 6 or more episodes of AOM
● Can develop asymptomatic OME
● Monitoring, follow-up care, and therapy to prevent hearing loss, and resultant speech and
learning disabilities
○ Follow-up after 4-6 weeks
○ Second follow-up 4-6 weeks after the first
■ If OME has not resolved
● Hearing test
○ If effusion persists as long as 12 weeks

LONG-TERM MONITORING
● Hearing loss of >20 dB in both ears
○ Bilateral myringotomy
○ TT placement
● If <20 dB and MEE persists beyond 12 weeks
○ Monitored
○ Antibiotic therapy with beta-lactam-stable agent
○ Improvement of MEE after 12 weeks is unlikely

Prognosis
● PROGNOSIS IS EXCELLENT FOR ALMOST ALL PATIENT WITH OM
● <1% DEVELOP INTRACRANIAL AND INTRATEMPORAL COMPLICATION
Intratemporal Intracranial
● Hearing loss (conductive and sensorineural)
● TM perforation (acute and chronic)
● Chronic suppurative OM (with or without
cholesteatoma)
● Cholesteatoma
● Tympanosclerosis
● Mastoiditis
● Petrositis
● Labyrinthitis
● Facial paralysis
● Cholesterol granuloma
● Infectious eczematoid dermatitis
● Meningitis
● Subdural empyema
● Brain abscess
● Extradural abscess
● Lateral sinus thrombosis
● Otitic hydrocephalus

CASE:
MENIERE’S DISEASE

ETIOLOGY
❏ By definition, Ménière disease is idiopathic.
❏ In other words, if the cause is known, the disease process can no longer be called
Ménière disease.
❏ However, because the root of the problem is elevated endolymphatic pressure, it is
worthwhile to consider other causes of endolymphatic hydrops. Ménière disease must
be distinguished from these causes.
❏ Disorders that may give rise to elevated endolymphatic pressure include metabolic
disturbances, hormonal imbalance, trauma, and various infections (eg, otosyphilis and
Cogan’s syndrome [interstitial keratitis]).
https://emedicine.medscape.com/article/1159069-overview#a5

❏ Some authors have questioned whether endolymphatic hydrops is actually a marker of
disease rather than a cause. A study looking at temporal bones found that all patients
with Ménière’s disease had hydrops in at least 1 ear but that hydrops was also found in
patients who exhibited no signs of the disease.
https://www.medscape.com/answers/1159069-82755/what-is-the-pathophysiology-of-mnire-disease-idiopathic-endolymphatic-hydrops
ETIOLOGY

❏ Autoimmune diseases, such as lupus and rheumatoid arthritis, may cause an
inflammatory response within the labyrinth. An autoimmune etiology was postulated
after there was found to be an association with the presence of thyroid autoantibodies
in patients with Ménière disease.
❏ In addition, allergy has been implicated in many patients with difficult-to-treat Ménière
disease. Food triggers are also important factors in the generation of hydrops.
https://emedicine.medscape.com/article/1159069-overview#a5
ETIOLOGY

Possible Causes:
❏ Defective absorption by endolymphatic sac
❏ Allergies
❏ Sodium and water retention
❏ Hypothyroidism
❏ Autoimmune and viral etiologies
❏ Mumps
❏ Syphilis
❏ Head trauma
❏ Previous infection
❏ Hormonal (pregnant females are more prone)
Risk Factors:
❏ Metabolic disorder
❏ Toxicity
❏ Allergies
❏ Emotional factor
❏ Circulatory disorder
❏ Anatomical Abnormalities
ETIOLOGY

PATHOPHYSIOLOGY

CLINICAL PRESENTATION
● Fluctuation in hearing loss with a low-tone tinnitus
● Dizziness, vertigo, pressure or fullness in one ear
● Can occur any time
● Lasts from several minutes to hours
● Losses are temporary but can become permanent over longer
periods of time

DIFFERENTIAL DIAGNOSIS
● Labyrinthitis
○ Vertigo, hearing loss, aural fullness, tinnitus
○ Otorrhea, otalgia, nausea/vomiting, fever, facial weakness, neck pain, URTI
● BPPV or Benign Paroxysmal Positional Vertigo
○ sudden vertigo from seconds to minutes but no hearing loss
● Vestibular Schwannoma
○ Hearing loss (unilateral), tinnitus, disequilibrium
● Vestibular Neuritis
○ Vertigo
○ Nausea, vomiting, generalized imbalance.

DIAGNOSTICS
Audiometry
● assesses how well you detect sounds at different pitches and volumes and how well you
distinguish between similar-sounding words. People with Meniere's disease typically
have problems hearing low frequencies or combined high and low frequencies with
normal hearing in the midrange frequencies.

Balance Tests
● ENG (electronystagmography)
○ most commonly used
● VNG
○ evaluates balance function by assessing eye movement
● Rotary-chair Testing
○ less often used
○ additional test for ENG
● VEMP Testing
○ measures sound sensitivity of your vestibule in your inner ear
DIAGNOSTICS

Balance Tests
● Posturography
○ determines which part of your balance system you rely on the most
● vHIT
○ test reaction of eyes to abrupt movements
● ECoG
○ determines if there is abnormal build up of fluids
DIAGNOSTICS

Laboratory Tests and Imaging Modalities
● TSH
● Glucose
● ESR, ANA
● Urinalysis
● CBC
● Electrolytes
● CBC
● VDRL-FTA ABS
● MRI and CT scan
DIAGNOSTICS

MANAGEMENT AND TREATMENT
● Medical therapy is directed toward treatment of the actual symptoms of
the acute attack or prophylactic prevention of the attacks.
● Salt-restricted diet, steroids, and the use of diuretics are first-line
therapies.
● Intravenous (IV) or intramuscular (IM) diazepam provides vestibular
suppression and anti-nausea effects.
● Steroids can be given for anti-inflammatory effects in the inner ear.
● Vestibulosuppressants and anti-nausea medications (eg, meclizine,
prochlorperazine) are prescribed for prn use.

● Avoiding trigger substances (eg, salt, chocolate, caffeine) alone may be sufficient.
● Smoking cessation also is recommended.
● It is suggested that patients should avoid loud noises and to make use of stress-
reduction techniques.
● Surgical therapy for Ménière disease is reserved for medical treatment failures.
● Nondestructive surgical procedures are directed toward improving the state of
the inner ear and the generally accepted management options are:
○ Endolymphatic sac decompression or shunt placement
○ Vestibular nerve section
○ Labyrinthectomy
○ Intratympanic injection of medications such as gentamicin or steroids.
MANAGEMENT AND TREATMENT

PROGNOSIS
● Ménière disease is said to “burn out” over time. The spontaneous remission
rate is high: over 50% within 2 years and over 70% after 8 years. However,
many patients are left with poor balance and poor hearing.
● Most of the patients are well managed with medications.
● Surgical treatment is required for 5-10% of patients.
● Ménière disease is not directly associated with mortality, however, it is
associated with drop attacks, which could lead to accidental trauma.

REFERENCES
● Abdulsalam, A., et al. 2021. Textbook of Otolaryngology. Springer.
● Boston, M. E. (2020, September 2). Labyrinthitis Clinical Presentation: History,
Physical. Medscape.com; Medscape.
https://emedicine.medscape.com/article/856215-clinical
● Lalwani A. 2020. Otolaryngology Head and Neck Surgery: Current Diagnosis
and Treatment. McGraw Hill

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