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Acute otitis media
Last reviewed: 04.07.2025
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Acute otitis media is an acute inflammatory disease characterized by the involvement of the mucous membrane of the middle ear (auditory tube, tympanic cavity, cave and air cells of the mastoid process) in the pathological process.
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Epidemiology
Acute otitis media is one of the most common complications of community-acquired upper respiratory tract infections in children and currently occupies a dominant place in the structure of childhood pathology. This is due to the high prevalence of acute respiratory diseases, which play a significant role in the pathogenesis of acute otitis media and make up to 90% of all childhood infectious pathology. The incidence of influenza per 100,000 children under 1 year of age is 2,362 cases, 1-2 years - 4,408 and 3-6 years - 5,013 cases. Acute inflammation of the middle ear occurs in 18-20% of children suffering from acute respiratory viral infection.
During the first year of life, at least one episode of acute otitis media is diagnosed in 62% of children, and in 17% it is repeated up to three times. By the age of 3, 83% of children suffer from acute otitis media, by 5 years - 91%, and by 7 - 93% of children.
In Ukraine, about 1 million people suffer from acute inflammation of the middle ear every year. The incidence of acute otitis media among children in European countries reaches 10%, in the USA this disease is registered annually in 15% of the child population. The share of acute otitis media in the structure of diseases of the organ of hearing is 30%. Almost every fifth (18%) child with acute otitis media has a severe or complicated course of the disease. In 12% of patients, damage to the neuroepithelial cells of the spiral organ develops, followed by sensorineural hearing loss and deafness.
Causes acute otitis media
The main etiologic factors of acute otitis media are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pyogenes, Staphylococcus aureus. A certain role in the occurrence of acute otitis media is played by viral infection. This, in particular, is confirmed by data on the correlation of the frequency of respiratory infections and acute otitis media, a high frequency (59%) of detection of viruses in the nasopharynx of patients with acute inflammation of the middle ear.
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Risk factors
Risk factors for acute otitis media in children:
- the presence of myxoid tissue in the cavities of the middle ear (in young children);
- wide, straight, short and more horizontally located auditory tube;
- significant frequency of hypertrophy and chronic inflammation of the pharyngeal tonsil;
- incomplete pneumatization of the temporal bone.
In addition, it is necessary to take into account the failure of the immune mechanisms of the child’s body and physiological (transient) immunodeficiency states of newborns.
Pathogenesis
The impact of pathogens (viruses, bacteria) on the mucous membrane of the nose and nasopharynx in acute respiratory diseases initiates a cascade of morpho-functional shifts, which play a key role in the development of inflammatory changes in the middle ear and the formation of clinical manifestations of acute otitis media. The consistent development of inflammatory changes in the middle ear in acute respiratory diseases (the most common cause of acute otitis media) is associated with the damaging effect of viruses and bacteria on the ciliated epithelium of the initial sections of the respiratory tract and the auditory tube. The main role in the development of acute inflammation of the middle ear is played by proinflammatory mediators, which control the intensity and direction of immune reactions, and also ensure the implementation of the most important effects of the inflammatory reaction (increased vascular permeability, increased mucus secretion, migration of leukocytes to the site of inflammation and their degranulation, etc.).
The clinical equivalents of the listed disorders are hyperemia, edema of the mucous membrane of the nose and nasopharynx, disruption of the physiological pathways of transport of mucous membrane secretions, accumulation of nasopharyngeal secretion in the area of the pharyngeal opening of the auditory canal, formation of nasopharyngeal-tubal reflux and dysfunction of the auditory canal. A natural consequence of morphofunctional shifts is a rapid decrease in intratympanic pressure and partial pressure of oxygen in the tympanic cavity, disruption of air circulation, transudation of fluid from the microcirculatory bed, microbial contamination of the cavities of the middle ear, and the consistent development of acute inflammatory changes. Under these conditions, superinfection, protracted course of the inflammatory process and the formation of complications probably sharply increase.
Symptoms acute otitis media
Symptoms of acute otitis media are characterized by the appearance of complaints of pain, congestion and a sensation of noise in the ear, hearing loss, autophony. The following symptoms are observed in newborns and children in the first year of life: anxiety, sleep disturbance, screaming, a desire to lie on the sore side, refusal to eat, and possibly regurgitation. Body temperature reaches 38 °C and above. The progression of the inflammatory process is accompanied by increased pain, severe hearing loss, and an increase in intoxication symptoms. A persistent increase in temperature (up to 39-40 °C) is observed, the child becomes apathetic, does not respond to toys, refuses to eat, and nighttime restlessness and screaming occur. At this stage of development of acute otitis media, agitation can be replaced by adynamia, regurgitation becomes more frequent, "causeless" vomiting appears, twitching and short-term convulsions may occur. Otoscopic changes are characterized by pronounced hyperemia and bulging of the eardrum, caused by the pressure of the exudate.
Due to the pressure and proteolytic activity of the exudate, the eardrum becomes thinner and perforates, causing purulent discharge from the ear. In this case, the intensity of pain decreases, the temperature gradually decreases, and the symptoms of intoxication disappear. Hearing loss persists. After removing pus from the external auditory canal, otoscopy often reveals a "pulsating reflex" - a jerky (pulsating) flow of pus from the tympanic cavity through a small perforation in the eardrum. Later, with a favorable course of the inflammatory process, a decrease and disappearance of purulent discharge from the ear is noted, and the general condition of the patient is normalized. Otoscopy reveals the absence of exudate in the external auditory canal, residual hyperemia, injection of the vessels of the eardrum, and a small perforation, which in most cases closes on its own. With a favorable course of the disease, hearing is gradually restored.
Atypical course of acute otitis media is not uncommon. In some cases, acute inflammation of the middle ear may be accompanied by the absence of pain syndrome, pronounced temperature reaction, the presence of a cloudy, slightly thickened eardrum with poorly defined identification landmarks. And in others - a rapid increase in temperature (up to 39-40 ° C), severe pain in the ear, pronounced hyperemia of the eardrum, rapid increase in intoxication, the appearance of neurological symptoms (vomiting, positive Kernig's symptoms, Brudzinsky's), signs of mastoiditis and other otogenic complications. Despite the favorable course of acute otitis media in most cases, there is a high probability of developing otogenic complications. This is largely due to the insufficiency of the immune response in young children, age-related features of the structure of the middle ear, pathogenicity and virulence of etiologically significant microflora.
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Stages
Acute otitis media is characterized by a certain sequence of development of the pathological process and symptoms. From a practical point of view, it is advisable to distinguish three stages of the typical course of acute otitis media.
Stage I of catarrhal inflammation
This stage is characterized by complaints of ear pain, increased body temperature, decreased hearing; examination reveals retraction and injection of vessels (hyperemia) of the eardrum. The general condition (weakness, malaise, etc.) is largely determined by the severity of the symptoms of acute respiratory disease.
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Stage II of purulent inflammation
- a) non-perforative. Patients note increasing pain, malaise, weakness, increased hyperthermia, and a marked decrease in hearing. Examination reveals a protrusion and intense hyperemia of the eardrum.
- b) perforative. This stage is characterized by the presence of purulent exudate in the external auditory canal, a “pulsating reflex”, decreased pain, decreased temperature, and decreased severity of intoxication symptoms.
Stage III of process resolution
Possible outcomes:
- recovery (restoration of the integrity of the eardrum and hearing function);
- chronization of the process;
- formation of otogenic complications (mastoiditis, tympanogenic labyrinthitis, etc.).
Diagnostics acute otitis media
The diagnosis of acute otitis media in typical cases is usually not difficult and is based on the results of the analysis of complaints, anamnestic information (ear pain, congestion, sensation of noise in the ear, hearing loss). Sharp ear pain in young children is accompanied by anxiety, hyperkinesis.
Laboratory diagnostics
Neutrophilic leukocytosis and increased ESR are detected in peripheral blood.
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Instrumental diagnostics
Depending on the stage of acute otitis media, otoscopy may reveal retraction and limited mobility of the eardrum with vascular injection (stage I catarrhal inflammation); pronounced hyperemia and bulging of the eardrum caused by exudate pressure (stage IIa purulent inflammation); a "pulsating reflex", which is a jerky (pulsating) flow of pus from the tympanic cavity through a small perforation in the eardrum into the external auditory canal (stage IIb purulent inflammation).
When examining patients with acute otitis media, one should keep in mind the high probability of developing various complications. In this regard, one should pay attention to the presence (absence) of such signs as pastosity of the skin in the retroauricular region, smoothness of the retroauricular fold, protrusion of the auricle, the presence of swelling (fluctuation) in the retroauricular region (antritis, mastoiditis); facial asymmetry (otogenic neuritis of the facial nerve); meningeal symptoms (otogenic meningitis, etc.).
Indications for consultation with other specialists
An indication for consultation with other specialists (neurologist, neurosurgeon, ophthalmologist, etc.) is a complicated course of acute otitis media.
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Treatment acute otitis media
The goals of treatment of acute otitis media are: regression of inflammatory changes in the middle ear, normalization of hearing and the general condition of the patient, restoration of working capacity.
Indications for hospitalization
Indications for hospitalization are the patient's age under two years, as well as, regardless of age, severe and/or complicated course of acute otitis media.
Non-drug treatment
Physiotherapeutic methods of influence have an anti-inflammatory and analgesic effect at the initial stages of the development of the inflammatory process in the middle ear: sollux, UHF, a warming compress on the parotid region.
Drug treatment
In the first stage of the disease, it is recommended to prescribe ear drops with local anti-inflammatory and analgesic effects, intranasal vasoconstrictors (decengestants), which ensure the restoration of nasal breathing and patency of the auditory tube.
The effectiveness of topical antibiotics in the form of ear stones in acute otitis media requires confirmation. First of all, this is due to the fact that when instilling an antibiotic solution into the external auditory canal, its concentration in the middle ear cavities does not reach therapeutic values. In addition, one should remember the risk of complications in the inner ear when using drops containing ototoxic antibiotics.
In the presence of inflammatory changes in the nasal cavity, careful rinsing of the nose with a 0.9% sodium chloride solution and evacuation (aspiration) of nasal secretions are advisable.
Antipyretic drugs are used when the temperature rises to 39º C and above.
Systemic antibacterial therapy is indicated in all cases of moderate and severe acute otitis media, as well as in children under 2 years of age and in patients with immunodeficiency states. In mild cases [absence of pronounced symptoms of intoxication, pain syndrome, hyperthermia (up to 38 °C)], antibiotics may be avoided. However, if there are no positive changes in the development of the disease within 24 hours, antibiotic therapy should be used. In empirical antibiotic therapy for acute otitis media, preference should be given to drugs whose spectrum of action covers the resistance of the most likely pathogens. In addition, an antibiotic in an effective concentration should accumulate in the site of inflammation, have a bactericidal effect, be safe and well tolerated. It is also important that oral antibiotics have good organoleptic properties and are convenient for dosing and administration.
In empirical antibacterial therapy of acute otitis media, the drug of choice is amoxicillin. Alternative drugs (prescribed for allergies to beta-lactams) are modern macrolides. In the absence of clinical efficacy within 2 days, as well as in patients who have received antibiotics over the past month, it is advisable to prescribe amoxicillin + clavulanic acid, alternative drugs are cephalosporins of the II-III generations.
In mild and moderate cases, oral antibiotics are indicated. In severe and complicated cases, antibacterial therapy should be started with parenteral administration of the drug, and after the patient's condition improves (after 3-4 days), it is recommended to switch to oral administration (the so-called step antibiotic therapy).
The duration of antibacterial therapy in uncomplicated cases is 7-10 days. In children under 2 years of age, as well as in patients with a complicated medical history, severe course of the disease, presence of otogenic complications, the duration of antibiotic use can be increased to 14 days or more.
It is necessary to evaluate the effectiveness of antibiotic therapy after 48-72 hours. If there is no positive dynamics during acute otitis media, it is necessary to change the antibiotic.
An important component of pathogenetic correction of changes in the mucous membrane of the auditory tube and middle ear cavities is limiting the action of proinflammatory mediators; for this purpose, fenspiride may be prescribed.
Surgical treatment of acute otitis media
In the absence of spontaneous perforation of the eardrum in patients with acute purulent otitis media (acute otitis media, stage IIa), increasing (persisting) hyperthermia and signs of intoxication, paracentesis of the eardrum is indicated.
Approximate periods of incapacity for work in the case of uncomplicated disease are 7-10 days, in the presence of complications - up to 20 days or more.
Further management
In case of recurrent acute otitis media, examination of the nasopharynx is indicated to assess the condition of the pharyngeal tonsil, eliminate nasal obstruction and ventilation disorders of the auditory tube associated with adenoid vegetations. Consultations with an allergist and immunologist are also necessary.
Information for the patient should contain recommendations on the correct implementation of medical prescriptions and manipulations (use of ear drops, nasal lavage) at home, and measures to prevent colds.
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Prevention
Primary prevention of acute otitis media consists of preventing acute respiratory diseases. Of great importance is the implementation of sanitary and hygienic measures aimed at eliminating hypothermia, observing personal hygiene rules, and hardening the body.
Secondary prevention is a set of measures aimed at preventing exacerbations of existing chronic diseases of the upper respiratory tract, restoring the physiological mechanisms of nasal breathing and the ventilation function of the auditory tube. First of all, we are talking about patients with disorders of the intranasal anatomical structures, hypertrophy of the pharyngeal tonsil, chronic focal infection in the paranasal sinuses and palatine tonsils. In this regard, timely elimination of foci of chronic infection (caries, tonsillitis, sinusitis), correction of immune deficiency and other systemic disorders are of great importance.
An important role is played by medical examinations, systematic medical examinations, the level of patient awareness about the causes and clinical manifestations of acute otitis media, and possible complications of this disease.
Forecast
The prognosis for uncomplicated and adequately treated acute otitis media is favorable. In the presence of complications, concomitant diseases, the prognosis is determined by the prevalence of the process, the severity of the patient's condition, the degree of compensation for concomitant diseases, as well as the timeliness and adequacy of treatment measures.