Otitis media is the name given to an infection in the middle ear. The middle ear is the space that sits between the tympanic membrane (eardrum) and the inner ear. This is where the cochlea, vestibular apparatus and nerves are found. Bacteria enter from the back of the throat through the eustachian tube. A viral upper respiratory tract infection often precedes bacterial infection of the middle ear.
Bacteria
The most common bacterial cause of otitis media is streptococcus pneumoniae. This also commonly causes other ENT infections such as rhino-sinusitis and tonsillitis.
Other common causes include:
- Haemophilus influenzae
- Moraxella catarrhalis
- Staphylococcus aureus
Presentation
Ear pain is the primary presenting feature of otitis media in adults.
It may also present with:
- Reduced hearing in the affected ear
- Feeling generally unwell, for example with fever
- Symptoms of an upper airway infection such as cough, coryzal symptoms and sore throat
When the infection affects the vestibular system, it can cause balance issues and vertigo. When the tympanic membrane has perforated, there may be discharge from the ear.
Examination
An otoscope is used to visualise the tympanic membrane whilst gently pulling the pinna up and backwards. It may be challenging to visualise the tympanic membrane if there is significant discharge or wax in the ear canal.
A normal tympanic membrane is “pearly-grey”, translucent and slightly shiny. You should be able to visualise the malleus through the membrane. Look for a cone of light reflecting the light of the otoscope.
Otitis media will give a bulging, red, inflamed looking membrane. When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane.
Management
Most otitis media cases will resolve without antibiotics within around three days, sometimes up to a week. Antibiotics make little difference to symptoms or complications. Complications (mainly mastoiditis) are rare. Simple analgesia (e.g., paracetamol or ibuprofen) can be used for pain and fever.
There are three options for prescribing antibiotics:
- Immediate antibiotics
- Delayed prescription
- No antibiotics
Consider immediate antibiotics at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised.
Consider a delayed prescription that can be collected and used after three days if symptoms have not improved or have worsened at any time. This can be a helpful strategy in patients pressing for antibiotics or where you suspect the symptoms might worsen.
The NICE clinical knowledge summaries (updated January 2021) suggest:
- Amoxicillin for 5-7 days first-line
- Clarithromycin (in pencillin allergy)
- Erythromycin (in pregnant women allergic to penicillin)
Always safety-net, offering education and advice to patients on when to seek further medical attention.
Complications
- Otitis media with effusion
- Hearing loss (usually temporary)
- Perforated tympanic membrane (with pain, reduced hearing and discharge)
- Labyrinthitis (causing dizziness or vertigo)
- Mastoiditis (rare)
- Abscess (rare)
- Facial nerve palsy (rare)
- Meningitis (rare)
Last updated July 2021