eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Middle Ear & Mastoid

Middle Ear, Eustachian Tube, Inflammation/Infection

Author: Robert B Meek, MD, Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, Anne Arundel Medical Center
Contributor Information and Disclosures

Updated: May 27, 2009

Introduction

Background

Middle ear and eustachian tube inflammation are common denominators in various clinical conditions, namely, acute otitis media (AOM), chronic otitis media with effusion (COME), and eustachian tube dysfunction (ETD).

Pathophysiology

Acute otitis media (AOM) can be described on the cellular and molecular level as a transudation of neutrophils, serum, and inflammatory mediators into the middle ear space. This transudation is associated with mucosal edema of the middle ear and bacterial or viral infection of the eustachian tube and middle ear space.

Chronic otitis media (COM) involves a transudation of serum with less cellularity of the effusion material. The inflammatory mediators are less destructive, and bacteria and viral antigens may be less prevalent.

Anatomy of the external and middle ear.

Anatomy of the external and middle ear.

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Anatomy of the external and middle ear.

Anatomy of the external and middle ear.


Frequency

United States

Otitis media (OM) is the most common diagnosis made by office-based physicians of children younger than 15 years. Otitis media (OM) is the most common reason children are prescribed antibiotics and the most common indication for surgery in children. Otitis media (OM) accounted for 18% of physician visits from 1993-1995. Acute otitis media (AOM) accounts for 13% of all emergency room visits and 30 million clinic visits; $5,000,000 is spent annually on antibiotics for the treatment of acute otitis media (AOM).

International

Rates of otitis media (OM) equal to or higher than rates in the United States are noted internationally, especially in less developed countries. A delay is evident in the peak incidence of otitis media (OM) in European children, which may be attributable to the fact that European children enter childcare at a later age.

Mortality/Morbidity

In the era of modern medicine, middle ear infection rarely leads to mortality, except in rare cases of intracranial spread of infection.

eustachian tube dysfunction (ETD) and chronic otitis media with effusion (COME) affect 70% of children by age 7 years and are common causes of childhood hearing loss. Morbidity from otitis media (OM) primarily stems from the effect on hearing. In most cases the conductive hearing loss is entirely reversible with medical or surgical treatment. Children may have a speech/language acquisition delay from recurrent acute otitis media (AOM) or chronic otitis media with effusion (COME).

Otitis media (OM) has not clearly been shown to affect the long-term acquisition of language skills in children; however, studies have predicted that early recurrent otitis media (OM) and chronic otitis media with effusion (COME) may be predictive of future decreases in hearing as measured by school screening tests and a decrease in overall school achievement. These findings suggest a possible long-term effect on the central auditory pathway.

Race

American Indian and Native Alaskan children, including the Inuit, have higher rates of chronic otitis media (COM) than whites. Hispanic children have higher rates of otitis media (OM) than either whites or African American children.

The prevalence of chronic suppurative otitis media (OM) is highest in Inuits of Alaska, Canada, and Greenland; Australian Aborigines; and in American Indians. High prevalence is also found in Pacific Islanders and Africans. Low prevalence is found in residents of Korea, India, and Saudi Arabia. The lowest prevalence is found in residents of the United States, United Kingdom, Denmark, and Finland.

Sex

Males have a higher prevalence of acute otitis media (AOM) and undergo myringotomies and tympanoplasties more frequently than females do.

Age

Middle ear dysfunction and eustachian tube dysfunction (ETD) are more common in the pediatric age group. Peak incidence of otitis media (OM) is in the first 2 years of life.

Clinical

History

  • Eustachian tube dysfunction (ETD): Symptoms usually follow the onset of an upper respiratory tract infection (URTI) or allergic rhinitis.1 Symptoms include aural fullness, difficulty popping ears, intermittent sharp ear pain, hearing loss, tinnitus, and dysequilibrium.
  • Otitis media (OM): acute otitis media (AOM) can also be observed following URTI or secondary to any cause of eustachian tube inflammation or blockage. Symptoms include otalgia, hearing loss, fever, and dysequilibrium.
  • Chronic otitis media with effusion (COME): Symptoms include hearing loss, tinnitus, and dysequilibrium. Chronic otitis media with effusion (COME) is not associated with fever. Children may have speech/language delay.

Physical

Otoscopic findings of eustachian tube dysfunction (ETD) are usually normal. The pathologic condition is more often observed on rhinoscopy, which can reveal nasal obstruction with either a deviated septum or hypertrophied inferior turbinates. Nasopharyngoscopy may reveal peritubal inflammation or a mass. Chronic eustachian tube dysfunction (ETD) may reveal retraction pockets or atelectatic middle ear disease with incudostapediopexy having little or no middle ear aeration.

  • Acute otitis media (AOM) reveals an erythematous bulging tympanic membrane that is sluggish to pneumatic otoscopy and contains obscured landmarks. Fever may also be present.
  • Chronic otitis media (COM) is associated with a dull-appearing tympanic membrane that is sluggish to pneumatic otoscopy. Always use pneumatic otoscopy because it greatly increases the accuracy of diagnosis. Tuning fork examination may reveal lateralization to the ipsilateral side in the absence of sensorineural hearing loss. Bone conduction is also greater than air conduction in the affected ear.

Causes

The prevailing theory of the development of middle ear inflammation and effusion has been that eustachian tube inflammation leads to the build up of bacteria and a resultant secondary bacterial infection of the middle ear space.

  • URTIs caused by rhinovirus, respiratory syncytial virus, influenza virus, and adenovirus have been implicated in the pathophysiology of eustachian tube inflammation and middle ear inflammation.
  • Most studies agree that viruses directly damage eustachian tube lining and can result in decreased mucociliary clearance.
  • Recent studies suggest a more direct role of viruses in the development of middle ear inflammation. Research has demonstrated direct viral invasion of middle ear mucosa without evidence of bacterial secondary infection. Recent animal studies have concluded that the immune response to middle ear and eustachian tube viral infection continues to propagate the resultant inflammation long after clearance of viral antigen.
    • Purely immune-mediated cases of otitis media (OM) have been developed in animal studies.
    • Multiple cytokines have been investigated as contributing to otitis media (OM) and have been started in middle ear effusions. These cytokines include interleukin-1beta, tumor necrosis factor-alpha, and gamma-interferon.
    • Other cytokines and cell surface markers have been described in animal studies, including interleukin-1alpha and intracellular adhesion molecule (ICAM).
    • This theory of a persistent sterile effusion following viral URTI gives credence to the expectant management of nonsevere otitis media (OM) as practiced in the Netherlands and elsewhere in Europe.
  • Other theories include reflux of nasopharyngeal bacteria through the eustachian tube causing infection of the middle ear cleft.
  • Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis are the most commonly isolated bacteria of middle ear infections. Less frequent isolates include group A streptococci, Staphylococcus aureus, and enteric bacteria found in newborns such as Escherichia coli, species of Klebsiella, Enterobacter, and Pseudomonas aeruginosa.
  • Historically, allergy has been associated with the development of eustachian tube and middle ear inflammation; however, clear evidence has not been elucidated.
  • Anatomic abnormalities, such as those observed in patients with cleft palate or other cranial facial abnormalities, may lead to middle ear and eustachian tube inflammation by a direct effect on eustachian tube function.
  • Environmental factors, such as daycare attendance, passive smoke exposure, and pacifier usage, may contribute to nasopharyngeal and middle ear inflammation.2
  • The method of feeding infants may contribute to middle ear infection. Maternal immunoglobulin G (IgG) in breast milk may be protective against the development of middle ear infection. With breastfeeding, any detrimental effects of bottle feeding may be avoided, although conclusive data regarding these effects are unavailable.
  • Gastroesophageal reflux has also been implicated as an etiological agent in the development of middle ear and eustachian tube inflammation.3 Nasopharyngeal pH has been noted to be lower in a subset of patients with adenoiditis and otalgia, although the degree of decreased pH required for pathology has not been standardized.

More on Middle Ear, Eustachian Tube, Inflammation/Infection

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Differential Diagnoses & Workup: Middle Ear, Eustachian Tube, Inflammation/Infection
Treatment & Medication: Middle Ear, Eustachian Tube, Inflammation/Infection
Follow-up: Middle Ear, Eustachian Tube, Inflammation/Infection
Multimedia: Middle Ear, Eustachian Tube, Inflammation/Infection
References
Further Reading
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References

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Further Reading

Clinical guidelines

Evidence based clinical practice guideline for medical management of acute otitis media in children 2 months to 13 years of age.

Cincinnati Children's Hospital Medical Center; 2004 Oct (reviewed for currency 2006 Aug) 16 pages. NGC:003958

Gastroesophageal reflux disease (GERD).
University of Michigan Health System - Academic Institution. 2002 Mar (revised 2007 Jan). 10 pages. NGC:005568

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Keywords

eustachian tube dysfunction, middle ear, eustachian tube inflammation, eustachian tube infection, middle ear infections, otitis media, OM, middle ear infection, acute otitis media, AOM, chronic otitis media, COM, chronic otitis media with effusion, COME, eustachian tube, middle ear inflammation, eustachian tube dysfunction, ETD, mucosal edema of the middle ear, middle ear space, middle ear effusion

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Contributor Information and Disclosures

Author

Robert B Meek, MD, Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, Anne Arundel Medical Center
Robert B Meek, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and Association for Research in Otolaryngology
Disclosure: Nothing to disclose.

Medical Editor

Ari J Goldsmith, MD, Chief of Pediatric Otolaryngology, Long Island College Hospital; Associate Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, State University of New York Downstate Medical Center
Ari J Goldsmith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gregory C Allen, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Gregory C Allen, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Medical Association, Christian Medical & Dental Society, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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