Acute otitis media in adults (suppurative and serous)
- Charles J Limb, MD
Charles J Limb, MD
- Francis A Sooy Professor
- Chief, Division of Otology, Neurotology and Skull Base Surgery
- Director, Douglas Grant Cochlear Implant Center
- University of California, San Francisco School of Medicine
- Lawrence R Lustig, MD
Lawrence R Lustig, MD
- Howard W. Smith Professor and Chair of Otolaryngology-Head & Neck Surgery
- Columbia University Medical Center
- Jerome O Klein, MD
Jerome O Klein, MD
- Professor of Pediatrics
- Boston University School of Medicine
Otitis media (infection or inflammation of the middle ear) is one of the most common infections, and acute otitis media (AOM) is among the most common diseases that lead to treatment with antibiotics . AOM primarily occurs in childhood and the medical literature overwhelmingly focuses on the presentation, course, and treatment of AOM in children. The treatment of AOM  in adults is therefore largely extrapolated from studies in children.
Life-threatening complications, though infrequent, may develop because of the proximity of the middle ear and adjacent mastoid to the middle and posterior cranial fossa and related structures. Based upon its high prevalence and potential to cause serious harm, otitis media is a public health concern.
This topic will address the etiology, diagnosis, and treatment of AOM in adults. Issues related to AOM in children are discussed separately. (See "Acute otitis media in children: Diagnosis" and "Acute otitis media in children: Epidemiology, microbiology, clinical manifestations, and complications" and "Acute otitis media in children: Treatment" and "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis" and "Otitis media with effusion (serous otitis media) in children: Management".) Issues related to chronic otitis media in adults are also discussed separately. (See "Chronic otitis media, cholesteatoma, and mastoiditis in adults".)
CLASSIFICATION OF OTITIS MEDIA
A variety of terms, related to the area of involvement and underlying disease process, are used to categorize infectious or inflammatory conditions of the middle ear. The anatomy of the normal ear is shown in a figure (figure 1).
Acute otitis media (AOM) — Acute otitis media (AOM) is an acute illness marked by the presence of middle ear fluid and inflammation of the mucosa that lines the middle ear space (picture 1). The infection is often caused by obstruction of the eustachian tube, which results in fluid retention and suppuration of retained secretions. AOM may also be associated with purulent otorrhea if there is a ruptured tympanic membrane. AOM usually responds promptly to antimicrobial therapy.
- Gates GA. Acute otitis media and otitis media with effusion. In: Otolaryngology: Head & Neck Surgery, Cummings C, Frederickson J, Harker L (Eds), Mosby, Baltimore 1998. p.461.
- Bakaletz LO. Bacterial biofilms in otitis media: evidence and relevance. Pediatr Infect Dis J 2007; 26:S17.
- Samuels MA, Gonzalez RG, Kim AY, Stemmer-Rachamimov A. Case records of the Massachusetts General Hospital. Case 34-2007. A 77-year-old man with ear pain, difficulty speaking, and altered mental status. N Engl J Med 2007; 357:1957.
- Brownlee RC Jr, DeLoache WR, Cowan CC Jr, Jackson HP. Otitis media in children. Incidence, treatment, and prognosis in pediatric practice. J Pediatr 1969; 75:636.
- HOUSE HP. Otitis media; a comparative study of the results obtained in therapy before and after the introduction of the sulfonamide compounds. Arch Otolaryngol 1946; 43:371.
- Hafidh MA, Keogh I, Walsh RM, et al. Otogenic intracranial complications. a 7-year retrospective review. Am J Otolaryngol 2006; 27:390.
- Leskinen K, Jero J. Acute complications of otitis media in adults. Clin Otolaryngol 2005; 30:511.
- Celin SE, Bluestone CD, Stephenson J, et al. Bacteriology of acute otitis media in adults. JAMA 1991; 266:2249.
- Schwartz LE, Brown RB. Purulent otitis media in adults. Arch Intern Med 1992; 152:2301.
- Austrian R, Howie VM, Ploussard JH. The bacteriology of pneumococcal otitis media. Johns Hopkins Med J 1977; 141:104.
- Gray BM, Converse GM 3rd, Dillon HC Jr. Serotypes of Streptococcus pneumoniae causing disease. J Infect Dis 1979; 140:979.
- Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute otitis media. N Engl J Med 2001; 344:403.
- Benninger MS. Acute bacterial rhinosinusitis and otitis media: changes in pathogenicity following widespread use of pneumococcal conjugate vaccine. Otolaryngol Head Neck Surg 2008; 138:274.
- Block SL, Hedrick J, Harrison CJ, et al. Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiology of acute otitis media. Pediatr Infect Dis J 2004; 23:829.
- Casey JR, Pichichero ME. Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J 2004; 23:824.
- Bodor FF, Marchant CD, Shurin PA, Barenkamp SJ. Bacterial etiology of conjunctivitis-otitis media syndrome. Pediatrics 1985; 76:26.
- Hartnick CJ, Shott S, Willging JP, Myer CM 3rd. Methicillin-resistant Staphylococcus aureus otorrhea after tympanostomy tube placement: an emerging concern. Arch Otolaryngol Head Neck Surg 2000; 126:1440.
- Segal N, Givon-Lavi N, Leibovitz E, et al. Acute otitis media caused by Streptococcus pyogenes in children. Clin Infect Dis 2005; 41:35.
- Ruohola A, Meurman O, Nikkari S, et al. Microbiology of acute otitis media in children with tympanostomy tubes: prevalences of bacteria and viruses. Clin Infect Dis 2006; 43:1417.
- Chonmaitree T, Revai K, Grady JJ, et al. Viral upper respiratory tract infection and otitis media complication in young children. Clin Infect Dis 2008; 46:815.
- Chonmaitree T, Owen MJ, Howie VM. Respiratory viruses interfere with bacteriologic response to antibiotic in children with acute otitis media. J Infect Dis 1990; 162:546.
- RIFKIND D, CHANOCK R, KRAVETZ H, et al. Ear involvement (myringitis) and primary atypical pneumonia following inoculation of volunteers with Eaton agent. Am Rev Respir Dis 1962; 85:479.
- Ibekwe AO, al Shareef Z, Benayam A. Anaerobes and fungi in chronic suppurative otitis media. Ann Otol Rhinol Laryngol 1997; 106:649.
- Macassey E, Dawes P. Biofilms and their role in otorhinolaryngological disease. J Laryngol Otol 2008; 122:1273.
- Post JC, Hiller NL, Nistico L, et al. The role of biofilms in otolaryngologic infections: update 2007. Curr Opin Otolaryngol Head Neck Surg 2007; 15:347.
- Chole RA, Faddis BT. Evidence for microbial biofilms in cholesteatomas. Arch Otolaryngol Head Neck Surg 2002; 128:1129.
- Post JC. Direct evidence of bacterial biofilms in otitis media. Laryngoscope 2001; 111:2083.
- Ilia S, Goulielmos GN, Samonis G, Galanakis E. Host's response in otitis media: understanding genetic susceptibility. Pediatr Infect Dis J 2008; 27:929.
- Wang SZ, Wang WF, Zhang HY, et al. Analysis of anatomical factors controlling the morbidity of radiation-induced otitis media with effusion. Radiother Oncol 2007; 85:463.
- Rothman R, Owens T, Simel DL. Does this child have acute otitis media? JAMA 2003; 290:1633.
- Karma PH, Penttilä MA, Sipilä MM, Kataja MJ. Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media. I. The value of different otoscopic findings. Int J Pediatr Otorhinolaryngol 1989; 17:37.
- Karma PH, Sipila MM, Kayaja MJ, Penttila MA. Pneumatic otoscopy and otitis media: The value of different tympanic membrane findings and their combinations. In: Recent advances in otitis media: proceedings of the Fifth International Symposium, Lim DJ, Bluestone CD, Klein JO, et al (Eds), Decker, Burlington, Ontario 1993. p.41.
- Dang PT, Gubbels SP. Is nasopharyngoscopy necessary in adult-onset otitis media with effusion? Laryngoscope 2013; 123:2081.
- Roberts DB. The etiology of bullous myringitis and the role of mycoplasmas in ear disease: a review. Pediatrics 1980; 65:761.
- Howie VM, Ploussard JH. The "in vivo sensitivity test"--bacteriology of middle ear exudate, during antimicrobial therapy in otitis media. Pediatrics 1969; 44:940.
- Kaleida PH, Casselbrant ML, Rockette HE, et al. Amoxicillin or myringotomy or both for acute otitis media: results of a randomized clinical trial. Pediatrics 1991; 87:466.
- van Buchem FL, Dunk JH, van't Hof MA. Therapy of acute otitis media: myringotomy, antibiotics, or neither? A double-blind study in children. Lancet 1981; 2:883.
- American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics 2004; 113:1451.
- Jacobs MR, Dagan R, Appelbaum PC, Burch DJ. Prevalence of antimicrobial-resistant pathogens in middle ear fluid: multinational study of 917 children with acute otitis media. Antimicrob Agents Chemother 1998; 42:589.
- Kaplan SL. The emergence of resistant pneumococcus as a pathogen in childhood upper respiratory tract infections. Semin Respir Infect 1995; 10:31.
- Pichichero ME, Casey JR. Acute otitis media disease management. Minerva Pediatr 2003; 55:415.
- Thanaviratananich S, Laopaiboon M, Vatanasapt P. Once or twice daily versus three times daily amoxicillin with or without clavulanate for the treatment of acute otitis media. Cochrane Database Syst Rev 2008; :CD004975.
- Takata GS, Chan LS, Shekelle P, et al. Evidence assessment of management of acute otitis media: I. The role of antibiotics in treatment of uncomplicated acute otitis media. Pediatrics 2001; 108:239.
- Currie CJ, Berni E, Jenkins-Jones S, et al. Antibiotic treatment failure in four common infections in UK primary care 1991-2012: longitudinal analysis. BMJ 2014; 349:g5493.
- Amsden GW. Tables of Antimicrobial Agent Pharmacology. In: Principles and Practice of Infectious Diseases, 7th ed., Mandell GL, Bennett JE, Dolin R (Eds), Churchill Livingstone, Philadelphia 2010. p.718.
- Stenfeldt K, Hermansson A. Acute mastoiditis in southern Sweden: a study of occurrence and clinical course of acute mastoiditis before and after introduction of new treatment recommendations for AOM. Eur Arch Otorhinolaryngol 2010; 267:1855.
- Smith JA, Danner CJ. Complications of chronic otitis media and cholesteatoma. Otolaryngol Clin North Am 2006; 39:1237.
- Kong SK, Lee IW, Goh EK, Park SE. Acute otitis media-induced petrous apicitis presenting as the Gradenigo syndrome: successfully treated by ventilation tube insertion. Am J Otolaryngol 2011; 32:445.
- Chole RA, Donald PJ. Petrous apicitis. Clinical considerations. Ann Otol Rhinol Laryngol 1983; 92:544.
- Sadoghi M, Dabirmoghaddam P. Otitic hydrocephalus: case report and literature review. Am J Otolaryngol 2007; 28:187.
- Lim ZM, Friedland PL, Boeddinghaus R, et al. Otitic meningitis, superior semicircular canal dehiscence, and encephalocele: a case series. Otol Neurotol 2012; 33:610.
- Perera R, Haynes J, Glasziou P, Heneghan CJ. Autoinflation for hearing loss associated with otitis media with effusion. Cochrane Database Syst Rev 2006; :CD006285.
- Cantekin EI, Mandel EM, Bluestone CD, et al. Lack of efficacy of a decongestant-antihistamine combination for otitis media with effusion ("secretory" otitis media) in children. Results of a double-blind, randomized trial. N Engl J Med 1983; 308:297.
- Luxford WM, Sheehy JL. Myringotomy and ventilation tubes: a report of 1,568 ears. Laryngoscope 1982; 92:1293.
- Xu YD, Ou YK, Zheng YQ, et al. The treatment for postirradiation otitis media with effusion: a study of three methods. Laryngoscope 2008; 118:2040.
- CLASSIFICATION OF OTITIS MEDIA
- Acute otitis media (AOM)
- Otitis media with effusion
- Acute mastoiditis
- Chronic otitis media
- EPIDEMIOLOGY OF AOM
- ETIOLOGY OF AOM
- Eustachian tube dysfunction
- - Bacteriology
- - Other organisms
- - Biofilms
- CLINICAL MANIFESTATIONS OF AOM
- DIAGNOSIS OF AOM
- Bullous myringitis
- DIFFERENTIAL DIAGNOSIS OF AOM
- TREATMENT OF AOM
- Choice of initial antibiotic
- - Penicillin allergy
- Lack of initial response
- Ruptured tympanic membrane
- COMPLICATIONS OF AOM
- Intratemporal complications
- - Mastoiditis
- - Facial paralysis
- - Labyrinthitis
- - Hearing loss
- - Petrositis
- Extratemporal complications
- - Epidural, subdural, and brain abscess
- - Otitic hydrocephalus
- - Otitic meningitis
- - Lateral sinus thrombosis
- OTITIS MEDIA WITH EFFUSION
- Treatment for OME
- SUMMARY AND RECOMMENDATIONS