Approach to the Patient with Otitis

Neil Bhattacharyya

Ear discomfort from otitis media accompanying an upper respiratory tract infection is one of the more common complaints encountered in primary care practice, particularly in pediatric settings. Adults are less susceptible but no less uncomfortable when otitis sets in. Symptoms range from vague fullness to frank pain and may be accompanied by diminution in hearing. Patients may present out of concern about the safety of upcoming air travel or underwater activities, especially if overthe-counter remedies have not brought improvement. The primary care physician should be able effectively to manage most cases. Knowing the roles of antibiotics and decongestants in the treatment of otitis media is essential. Discomfort referable to the ear may also be a consequence of otitis externa. Inspection often reveals signs of otitis media or external otitis. The primary care provider should know how to recognize and treat these common conditions.

PATHOPHYSIOLOGY AND CLINICAL PRESENTATION (1, 2, 3, 4, 5 and 6)

Acute Otitis Media

Acute otitis media may be the consequence of abnormal eustachian tube reflux or obstruction that permits nasopharyngeal bacteria to infect the middle ear, which is normally free of organisms. Obstruction can result from mucosal edema and/or excessive mucus due to allergic or infectious etiologies.
Viral nasopharyngitis is the most common cause, especially in the winter. It may produce little more than a serous otitis, which is generally sterile. If there is bacterial invasion, a purulent otitis media may ensue. Of the bacterial species that can be isolated, the most common are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Viruses, Staphylococcus aureus, Streptococcus pyogenes, and other, less-virulent organisms are less frequently etiologic.

The principal clinical findings are ear pain, hearing loss, and mild-to-moderate fever. The tympanic membrane appears bulging, and an opaque effusion may be noted behind the drum if a purulent exudate develops in the middle ear. If pressure builds excessively, the tympanic membrane may perforate with consequent spontaneous otorrhea. A translucent effusion is characteristic of serous otitis; one may also observe apparent foreshortening of the manubrium, enhanced whiteness of the stria mallearis, and retraction of the tympanic membrane in the attic region. Most patients make a full recovery. In some patients, recurrent purulent otitis, sustained hearing loss, chronic serous otitis, or chronic otitis media may ensue.

Patients may also develop acute serous otitis media from the negative pressure changes imparted by airplane flight. In rare cases, hemorrhage may be evident within the drum and the middle ear space. In the absence of significant vertigo, these patients may be managed conservatively by limiting their airplane flights until resolution. Pain management may be required.

External Otitis

External otitis develops in the setting of skin breakdown in the external auditory canal, leading to inflammation of the surrounding tissues. Skin breakdown is a common denominator, whether from trauma (e.g., from a fingernail or cotton swab), excessive moisture (e.g., swimmer’s ear), infection of a hair follicle, or chronic eczema. Itching, crusting, pain, redness, and/or discharge may be reported. Movement of the pinna or tragus is characteristically painful. Gram-positive bacteria, gramnegative bacteria, and fungi can be variably isolated as infectious agents.

Malignant (Necrotizing) External Otitis

Malignant external otitis is seen in immunocompromised patients and older diabetics. It develops deep in the external canal and usually represents as a Pseudomonas cellulitis of the canal and adjacent tissues. Characteristics include purulent discharge, granulation tissue in the external auditory canal, severe ear pain, and temporomandibular joint pain. Signs of facial nerve involvement may follow.

Chronic Otitis Media

Chronic otitis media is a consequence of untreated or recurrent acute otitis media. Bony destruction or sclerosis of mastoid air cells may result, and the tympanic membrane is often perforated, draining purulent fluid. (Marginal and attic perforations may be associated with invasive cholesteatoma.) Both aerobes and anaerobes can be cultured from the drainage, including Staphylococcus, Streptococcus, Pseudomonas, enteric gram-negative organisms, and Bacteroides. Patients report little pain or fever, except during exacerbation, but hearing loss and chronic foul otorrhea are common. Again, water exposure of a perforated tympanic membrane may spur the infectious otorrhea. Computed tomography of the temporal bone may be helpful in revealing the extent of disease of the middle ear and mastoid.

DIAGNOSIS (1, 2, 3, 4, 5 and 6)

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