Otitis

What is Otitis?

Otitis is described in the dictionary as being an inflammation of the ear.

There are at least two types of Otitis:

• Otitis Media (OM): an infection of the middle ear space, behind the eardrum (tympanic membrane).
• Otitis Externa (OE): sometimes referred to as Swimmer's ear, which is an infection of the ear canal, the tube leading from the outside opening of the ear in towards the eardrum.

Description of Otitis Media

There are three main parts of the ear: the outer, middle, and inner. The outer ear is the opening outside of the body, the middle ear houses delicate bones that aid in hearing, and the inner ear contains organs that control hearing and balance. The external ear canal is the tube which leads from the outside to the structure called the tympanic membrane (ear drum). Behind the tympanic membrane is the space called the middle ear. Within the middle ear are three tiny bones, called ossicles. Sound, in the form of vibrations, causes movement in the eardrum, and then the ossicles. The ossicles transmit the sound to a structure within the inner ear, which sends it to the brain for processing.

The nasopharnyx is the passageway behind the nose, which takes inhaled air into the breathing tubes leading to the lungs. The Eustachian tube is a canal, which runs between the middle ear and the nasopharynx. One of the functions of the Eustachian tube is to keep the air pressure in the middle ear equal to that outside. This allows the eardrum and ossicles to vibrate appropriately, so that hearing is normal.

By the age of three, almost 85% of all children will have had otitis media at least once. Babies between the ages of six months and six years are most likely to develop otitis media. Otitis media is an important problem, because if often results in fluid accumulation with the middle ear (effusion). The effusion can last for weeks to months. Effusion with the middle ear can cause significant hearing impairment. When such hearing impairment occurs in a young child, it may interfere with the development of normal speech.

Symptoms of Otitis Media

The symptoms of Otitis Media include the following:

• Ear Pain: Children who are too young to express to the adult that they have ear pain often will be found pulling or rubbing on the ear lobe, or may have excessive crying.
• Loss of Appetite: This symptom is usually more apparent in young children, especially those who are bottle-fed. As the child swallows, the pressure changes in the middle ear can cause pain and lessen the desire to eat.
• Irritability: Children and adults are affected by the persistent pain, which in turn causes irritability.
• Poor sleep: When lying down, the pain may be more persistent due to the shift in the ear fluid.
• Fever: Ear infections can cause temperatures up to 104 degrees F.
• Drainage from the ear: Yellow, brown or white fluid seeping from the ear that is not earwax can indicate a rupture of the eardrum.
• Difficulty hearing: This is due to slow movement of the electrical signals that are transmitted by the bones in the middle ear. The fluid that accumulates behind the eardrum causes the slow movement.

Causes of Otitis Media

The cause of the ear infection depends on what type of infection it is. In acute otitis media, allergies, colds, respiratory infections and inflamed or enlarged adenoids can block the bottom of the Eustachian tube. This allows fluids to build up in the middle ear. Trapped fluid can then become infected by a virus or bacteria, causing pain and swelling of the eardrum. In otitis media with effusion, symptoms of acute otitis media disappear but the fluid may remain. The trapped fluid causes mild hearing loss that is temporary. This can last for up to three months and often indicates that the Eustachian tube is not functioning, as it should.

Diagnosis of Otitis Media

Looking at the eardrum through an instrument called an otoscope usually makes diagnosis. The eardrum may appear red, swollen, or abnormally drawn inward or outward. The ossicles create a particular pattern on the eardrum, referred to as "landmarks." These landmarks may be obscured. The light from the ostoscope usually reflects off the eardrum in a characteristic fashion called the "cone of light." When there is infection present this cone of light may be shifted or may even be absent. A special attachment to the otoscope allows a puff of air to be blown lightly into the ear, which normally would cause movement of the eardrum. When there is infection present, or when there is fluid behind the eardrum, the movement may be decreased or absent. Any fluid or pus that is draining from the ear is collected and then cultured in a laboratory to allow any organisms present to be viewed under a microscope and identified. Other tests might include audiological testing, pure tone air bone conduction threshold testing, acoustic immittance (tympanometry) testing, and speech audiometry. These tests provide the most diagnostically significant identification procedure.

Treatment for Otitis Media

Otitis media is usually treatable and hearing loss or damage to the ear is rare. Treatment might include the following:

Antibiotics

Pain Relief: this would include using Acetaminophen or ibuprofen to help relive the pain or fever that is over 102 degrees F.

NOTE: Never give aspirin to a child due to the possibility of Reyes Syndrome!

Myringotomy (Ear Tubes): These are sometimes used if the fluid remains in the ear for more than three months. This procedure is usually performed on children. General anesthesia is used in this outpatient procedure. The tubes remain in the ears from six to twelve months and normally fall out on their own. This procedure drains the ear of fluids and pus.

Middle ear infections are most often curable, with few complications, and it is especially important for children to be treated. Left untreated, possible long-term effects might include:

• Inner ear infection
• Scarring of the eardrum
• Hearing loss
• Mastoiditis (infection of the skull behind the ear)
• Meningitis (infection of the tissues around the brain and spinal cord)
• Speech development problems
• Facial paralysis

The healthcare provider should be called immediately if the child develops a stiff neck, acts lethargic, responds poorly or is inconsolable. The healthcare provider should also be called if there are any questions, or if the fever or pain has not subsided after antibiotics have been taken for 48 hours.

Description of Otitis Externa

The external ear canal is a tube approximately 1inch (2.5 cm) in length. It runs from the outside opening of the ear to the start of the middle ear (eardrum). The canal is part cartilage and part bone. In early childhood, the first two-thirds of the canal is made of cartilage, and the last one-third is bone. By late childhood, and throughout adulthood, the proportions are reversed. The lining of the ear canal is skin, which is attached directly to the covering of the bone. Glands within the skin of the canal produce a waxy substance called cerumen (earwax). Cerumen is designed to protect the ear canal, repel water, and keep the ear canal too acidic to allow bacteria to grow. Otitis externa is an infection of the outside ear canal and/or opening to the ear and is commonly called "swimmers ear."

Causes and Symptoms of Otitis Externa

Otitis externa is usually caused by scratching, inserting objects into the ear canal, or moisture, such as pool water but can also be caused by fungi, bacteria or viruses.

Types of Bacteria could include:

• Pseudomonas aeruginosa
• Enterobacter aerogenes
• Proteus mirabilis
• Klebsiella pneumoniae
• Staphylococcus

Types of Fungi could include:

• LCandid
• Aspergillus

Types of Viruses could include:

• Herpevirus hominis
• Varicella-zoster virus

Otitis externa usually occurs in the summer months, when people are frequenting swimming pools and lakes. Exposing the ear canal to moisture on a continual basis could cause significant loss of cerumen. The delicate skin of the ear canal, unprotected by cerumen might retain water and become irritated. Without cerumen, the ear canal can become alkaline, rather than acidic, which in turn would allow bacteria to grow.

Another cause could be the use of cotton swabs to clean the ear canal. This pushes the cerumen and normal skin debris back into the ear canal, instead of allowing the ear canal's normal cleaning mechanism to work. The normal cleaning process moves accumulations of cerumen and debris out of the ear. Putting other items into the ear to scratch the canal can also make it more susceptible to infection.

Itching is often the first symptom of otitis externa. Any touch, movement, or pressure on the outside structure of the ear (auricle) may cause severe pain. This is due to the way in which the skin lining the ear canal is directly attached to the cover of the underlying bone. If the canal is swollen, hearing may become muffled. The canal may appear swollen and red, and there may be evidence of greenish-yellow pus and in severe cases fever may be present. This usually indicates that the outside ear structure has become infected as well. It will be come red and swollen, and there may be enlarged and tender lymph nodes in front of, or behind, the auricle.

Malignant otitis externa is a serious and life-threatening infection, which most commonly affects patients who have diabetes, especially the elderly. It can also occur in patients who have weakened immune systems. A patient with malignant otitis externa usually has had the symptoms of otitis externa for months, accompanied by pain and drainage. The bacteria involved is usually Pseudomonas aeruginosa. This bacteria spreads from the external canal into all of the nearby tissues, including the bones of the skull. Swelling and destruction of these tissues may lead to damage of certain nerves, resulting in spasms of the jaw muscles or paralysis of the facial muscles. Complications that are more severe include meningitis (swelling and infection of the coverings of the spinal cord and brain), brain infection, or brain abscess (the development of a pocket of infection with pus).

Diagnosis of Otitis Externa

Diagnosis of uncomplicated otitis externa is usually based on the presence of ear pain that is worsened by touching the auricle. Examination of the ear will usually reveal redness and swelling and while this examination may be difficult, this difficulty in itself is diagnostic. The canal may be swabbed to obtain a specimen, if there is any confusion as to the types of organisms causing the infection. These specimens are cultured and examined under a microscope to allow identification of the organisms.

If malignant otitis externa is suspected, then a computed tomography scan (CT scan) or a magnetic resonance imaging (MRI) scan would be performed to determine how widely the infection has spread within the bone and tissue. The CT or MRI would not only help the healthcare provider decide where the most severe focus of infection is located, but would also will help to decide whether and where a biopsy should be made.

Treatment of Otitis Externa

Otitis Externa can sometimes be treated with topical antibiotics; antibiotics that can be applied directly to the skin of the ear canal. Many times these antibiotics are combined with a steroid medication. The steroid helps cut down on the inflammation and swelling. Decongestants and/or antihistamines may help relive the swelling of the Eustachian tube and help drain the fluid from the ear. A pain reliever might also be prescribed.

In malignant otitis externa, antibiotics sometimes need to be given through a needle in the vein (intravenously or IV). If the CT or MRI scans reveal that the infection has spread extensively, these IV antibiotics might need to be continued for six to eight weeks.

Otitis externa is usually easily treated. However, it may tend to recur in certain susceptible individuals. Malignant otitis externa, on the other hand, if left untreated, may spread sufficiently to cause death. However, the most serious complications can be avoided by careful attention to early symptoms of ear pain and drainage from the ear canal.

In any case, the healthcare provider needs to be contacted if an ear infection of any kind is suspected. This would apply to adults as well as children.