Dr. Hazenfield -- Ear, Nose, and Throat Doctor in Hawaii

Otitis Media

(Ear Infections)

Hugh N. Hazenfield, M.D., F.A.C.S.

• Types of otitis media

  • Acute otitis media:

  

  Right Tympanic Membrane

   

  • Erythema (or redness) of tympanic membrane (ear drum)

  • Bulging of tympanic membrane

  • Pus in middle ear (bacteria in the middle ear effusion)

         

  • Otitis media with effusion:

   

  

  Right Tympanic Membranes

   

  • Tympanic membrane (ear drum) is dull and retracted (usually not bulging)

  • Straw or tan color of ear drum

  • Sterile fluid in middle ear

   

   

• Symptoms of acute otitis media

  • Pain

  • Fever

  • Tugging at ears

  • Hearing loss

• Symptoms of otitis media with effusion

  • Hearing loss

  • Fullness in ear

  • Tugging at ear or repeatedly inserting finger in ear

  • Delayed speech and language development or unclear speech

  • In young children, an unsteady gait may occur

  • Pain rarely occurs

   

• Diagnosis of acute otitis media (AOM)

  • Note symptoms listed above in taking a history of the illness

    • Pain

    • Fever

    • Tugging at ears

    • Hearing loss

   

  • Documented fever when patient examined

  • Bulging, usually erythematous tympanic membrane which does not move on pneumatic otoscopy

  

   

  (Wait for patient to take in a breath while observing the tympanic membrane.  A struggling, crying child's ear drum can be erythematous and bulging.)

• If the tympanic membrane is transparent, an opaque purulent exudate (pus) can be seen in the middle ear

• Occasional use of tympanocentesis (puncturing the tympanic membrane)

  • To document the precise pathogen 

  • This is sometimes required if the otitis media is unresponsive to empiric therapy or if there are complications of the AOM such as facial nerve paralysis

In May, 2004, new guidelines for the diagnosis and treatment of otitis media with effusion (OME) were published by a subcommittee of the following professional societies:

• American Academy of Pediatrics

• American Academy of Family Physicians

• American Academy of Otolaryngology - Head & Neck Surgery

• Diagnosis and documentation of otitis media with effusion (OME) by the 2004 guidelines:

  • Pneumatic otoscopy is the single most recommended diagnostic method to establish the diagnosis of otitis media with effusion

  • Tympanometry, or measurement of the movement of the ear drum with a special instrument, is optional

  • Screening of all children is recommended against due to the following:

    • Inaccurate diagnosis with false positives and false negatives

    • Over-treating a self-limiting disease

    • Parental anxiety

    • Cost of screening

    • Unnecessary treatment

     

  • Documentation is recommended:

    • Laterality (which ear)

    • Duration of the middle ear effusion

    • Presence and severity of associated symptoms:

      • "Popping" in ear or mild pain

      • Sleep disturbance

      • Failure of infants to respond appropriately to voices or environmental sounds, such as not turning accurately toward the sound source

      • Recurrent episodes of acute otitis media (AOM) with persistent middle ear effusion (OME) between episodes

      • Problems with school performance

      • Balance problems

      • Delayed speech or language development

       

  • Child at risk:

    • If risk factors are present, the child may be less tolerant of hearing loss and should have hearing, speech and language evaluated with earlier intervention

      • Permanent hearing loss independent of otitis media with effusion

      • Suspected or diagnosed speech and language delay or disorder

      • Autism-spectrum disorder or other pervasive developmental disorders

      • Syndromes (e.g., Down) or craniofacial disorders that include cognitive, speech, and language delays

      • Blindness or uncorrectable visual impairment

      • Cleft palate, with or without associated syndrome

      • Developmental delay

       

• Treatment of otitis media with effusion (OME) by the 2004 guidelines:

   

  • Watchful waiting

    • No treatment for three months after onset

    • No hearing testing in first three months

    • 75 - 90% resolve spontaneously in 3 months

    • If the middle ear effusion lasts longer than 3 months, 30% resolve within 12 months

  • During the "watchful waiting" period, do the following:

    • Speak in close proximity to the child

    • Face the child when speaking, and speak clearly

    • Repeat phrases when misunderstood

    • Preferential seating in the classroom

     

  • Medication:

    • Antihistamines and decongestants are of no value and are not recommended

    • Antibiotics and steroids do not have long-term efficacy

     

  • Hearing testing:

    • After three months of "watchful waiting", hearing should be tested

    • Language testing should be conducted for children with hearing loss

     

  • Surveillance:

    • Re-examination at 3- to 6-month intervals until the effusion is resolved, hearing loss is identified, or structural abnormalities of the tympanic membrane or middle ear are suspected

     

  • Surgery (tympanostomy and tube) is recommended under the following circumstances:

     

    

    Tube in right ear drum

     

    • Hearing loss greater than or equal to 40 decibels

    • If hearing loss is 30 - 40 decibels, surgery is a consideration

    • Retraction pocket in the superior aspect of the tympanic membrane

    • Erosion of the ossicles (small bones in the middle ear)

    • Adhesive atelectasis (the ear drum is thinned and retracted against the medial wall of the middle ear with little or no air in the middle ear

    • Retraction pockets with keratin debris (pockets in the ear drum with an accumulation of dead cells)

    • Surgery improves vestibular function (equilibrium), behavior, and quality of life

    • Initially, only tubes are inserted

    • If the surgery must be repeated, adenoidectomy should be performed

    • Tonsillectomy is not indicated for otitis media with effusion unless there is a distinct indication for tonsillectomy itself

These recommendations do not preclude clinical judgment in these patients.  There are circumstances that may be reason for a more aggressive approach, including suspicion of parental non-compliance, suspected underlying sensorineural hearing loss, very poor speech development, and a family history of hearing loss in childhood.  For both the clinician and the parent, "doing nothing" can be a very difficult course to follow.