Joseph R. Anticaglia MD
Otitis Media (OM) is a serious disease. It is an inflammation or infection of the middle ear -namely- that air filled cavity located behind the eardrum and in front of the inner ear. Several vital structures occupy this middle ear space and one of them is important for our ability to hear and another is the nerve that controls facial movements. Also, the middle ear is extremely sensitive to pain.
Mothers know how agonizing it is to be waken in the middle of the night by a screaming child’s excruciating ear pain. The frustration can be high for this acute problem because no matter how hard she tries to alleviate the discomfort, the pain seems to increase in severity.
Another parent is perplexed as to what to do for her son’s chronic problem of fluid in the middle ear for months at a time with loss of hearing, no ear pain or temperature elevation yet uncharacteristically the child is irritable and having behavioral problems in school.
A father is concerned about her daughter’s recurrent episodes of otitis media. They total at least five episodes within twelve months and every time she gets off the antibiotic the infection seems to come back.
Middle ear infections are the most common infections affecting children in the first two or three years of their lives. Most earaches are short lived and resolve on their own. When they cause extreme pain, persist or are recurrent in nature, medical/surgical remedies are needed to treat the problem.
The space in the middle ear is about the size of a sugar cube and it houses important parts of our anatomy. It is carpeted with a mucosal lining that secretes fluid that exits through the Eustachian tube. This is the opening that connects the middle ear to the upper part of the throat (behind your nose). Under normal conditions the E-tube regulates the air pressure behind the eardrum in the middle ear so that it is the same as the atmospheric pressure outside the eardrum. When needed, it ventilates the middle ear space.
For example, if you descend in an airplane and pinch your nose and “pop” your ear in order to relieve ear fullness or pain, air crosses the E-tube to equalize the pressure in the middle ear. You just ventilated the middle ear. Under normal conditions when you yawn or swallow, the E-tube opens and functions as a pressure-equalizing valve for the middle ear.
The E-tube dysfunctions when I t becomes swollen, narrowed or blocked due to infections, growths or sudden changes in atmospheric pressure. The result, among other things, can be an accumulation of fluid (mucous or pus) in the middle ear with or without ear pain and loss of hearing.
The middle ear is also home to three of the tiniest bones in our body, the malleus (hammer), incus (anvil) and stirrup. The stirrup (stapes) is the smallest bone in our body measuring on average 2.81 millimeters by 1.21 millimeters. These bones conduct sound from the outer ear across the middle ear into the inner ear. If there is a problem in the transmission of sound across the middle ear (e.g. fluid) one experiences a loss of hearing.
ACUTE OTITIS MEDIA (AOM) is typically caused by viruses or bacteria following a cold or an upper respiratory infection (URI). It is more common during certain times of the year and in children there are predisposing factors to OM. Those who are exposed to cigarette smoke, bottle-fed or in day care centers seem to be more prone to middle ear infections. Cleft palate and Down’s syndrome children have a higher incidence of OM. In younger children, parents may notice the child scratching or tugging at the ear, irritability, not eating or sleeping well. Ear pain, fever, fluid in the middle ear and at times rupture of the eardrum with drainage can quickly follow.
Adults with AOM usually present with a history of previous URI that settled in the ear. The E-tube malfunctions as noted above and they often complain of fullness or pressure in the ear, loss of hearing, ear pain and at times dizziness or loss of balance.
OTITIS MEDIA WITH EFFUSION (OME) or SEROUS OTITIS MEDIA is the most common cause of hearing loss in preschool and elementary children. With OME there is an accumulation of ‘sterile’ fluid in the middle ear referred to as a ’transudate’ meaning there is no evidence of bacteria or viruses in this fluid. The fluid can be watery or viscous, the later referred to a as “glue ear”. There is no pain associated with OME and young children can have this condition for months or years before it is diagnosed accurately. If this happens there can be a delay in speech, learning and behavioral problems.
In adults, a red flag is raised when the patient complains of loss of hearing, fullness in the ear without a previous history of an upper respiratory infection and examination shows fluid in the middle ear. One must rule out cancer especially in the region of the Eustachian tube.
The fluid in OME can be a petri dish for the growth of viruses or bacteria with subsequent infection of the middle ear cavity. Since a part of the facial nerve courses through this space, the nerve can become swollen in its boney canal and a facial paralysis can happen with drooping of one side of the face (Bell’s Palsy).
RECURRENT OTITIS MEDIA is an ear infection that occurs three or more times within a six month period or four or more time within a twelve month period. They are treated by your physician, the infection goes away, the eardrum is normal in appearance but the infection recurs and the patient needs another round of antibiotics. A common complaint, “My child is always on antibiotics.”
TREATMENT;
Treatment focuses on an accurate diagnosis, relieving pain and re-ventilating the middle ear.
In the early stages of AOM parents can give their child acetaminophen or ibuprofen for the pain. In adults, stronger pain medication is usually needed. If the pain persists, make an appointment to see your physician as soon as possible. Antibiotics are often prescribed at this stage of the disease. If feasible, a few tests may be done in the office: a tympanogram measures the movement of the eardrum and the air pressure in the middle ear to get a better understanding of E-tube functioning and how well sound is being transmitted to the inner ear. A hearing test is done if the pain is not too severe and if the patient is old enough. In older children and adults, nasopharyngoscopy is performed (a small flexible tube with a light at the end of it) is passed through the nose to evaluate the opening/patency of the E-tube and to look for growths.
If the eardrum is bulging and associated with severe pain in spite of medical management, a myringotomy (an incision in the eardrum) may be performed to remove fluid if present, to relieve severe ear pain and to counter the buildup of middle ear pressure.
If the ear is discharging pus, ear drops and antibiotics are used to combat this infection. If medical treatment has not been successful in combating OM, one might consider in addition to the myringotomy, the insertion of ventilation tubes (they are placed in the incision of the eardrum) and in children an adenoidectomy. The tubes equalize the pressure on each side of the eardrum and the adenoidectomy potentially removes tissue located behind the nose that can block the opening of the Eustachian tube.
In Summary: Otitis media is a serious disease. Besides causing severe pain, if not treated in a timely manner it can cause significant complications. In adults it can be the first sign of nasopharyngeal cancer. In both children and adults if can be associated with facial paralysis, dizziness and profound loss of hearing. OM can spread to the mastoid and intracranially. Yes, OM is a serious disease, especially in an era when more and more bacteria are becoming resistant to antibiotics.