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

Complications of Otitis Media

Author: Debbie A Eaton, MD, Private Practice
Coauthor(s): Alan D Murray, MD, Pediatric Otolaryngologist, ENT for Children; Full-Time Staff, Medical City Dallas Children's Hospital; Consulting Staff, Department of Otolaryngology, Medical Center of Lewisville, Children's Medical Center at Dallas, Cook Children's Medical Center; Full-Time Staff, Texas Pediatric Surgery Center, The Pediatric Surgery Center
Contributor Information and Disclosures

Updated: Sep 3, 2009

Introduction

Background

Otitis media is the most common bacterial infection in children. Approximately 70% of children are affected by the age of 3 years. Antibiotics have produced an overall decline in the frequency of complications of otitis media relative to the preantibiotic era. However, severe complications still occur and may be associated with high mortality.¹

Both intracranial and extracranial complications of acute and chronic otitis media are possible. A discussion of the diagnosis and management of these complications is the focus of this article. The complications of otitis media include the following:

• Chronic suppurative otitis media
• Postauricular abscess
• Facial nerve paresis
• Labyrinthitis
• Labyrinthine fistula
• Mastoiditis
• Temporal abscess
• Petrositis
• Intracranial abscess
• Meningitis
• Otitic hydrocephalus
• Sigmoid sinus thrombosis
• Encephalocele
• CSF leak

Pathophysiology

Spread of infection from the ear and temporal bone causes intracranial complications of otitis media. Spread of infection occurs through 3 routes, namely, direct extension, thrombophlebitis, and hematogenous dissemination. Extracranial complications are usually direct sequelae of localized acute or chronic inflammation.

Frequency

United States

Otitis media is most common in children between the neonatal period and age 7 years, with approximately 70% of children having 1 or more episodes by their third birthday.

The overall incidence of all complications of otitis media has decreased since the advent of effective antimicrobial treatment. For example, in the preantibiotic era, the incidence of mastoiditis requiring surgical treatment was 25-50%. In the 1980s, the incidence decreased to approximately 0.02%. In 1995, Kangsanarak et al conducted a review of 24,321 patients with otitis media.² This review revealed an intracranial complication rate of 0.36%.

The most common extracranial complication is postauricular abscess, and the most common intracranial complication is meningitis, though complications often occur together.

Mortality/Morbidity

In the preantibiotic era, the mortality rate from intracranial complications of otitis media was reported to be as high as 76.4%. A recent review of 24,321 patients (from 1978-1990) who had intracranial complications associated with otitis media identified a mortality rate of 18.4%.

Sex

No sex predilection exists.

Age

Otitis media occurs most commonly between the neonatal period and age 7 years, and complications of otitis media more commonly are observed in children. One large series of South African patients found that nearly 80% of extracranial complications and 70% of intracranial complications occurred in children in their first two decades of life.

Clinical

History

The risk for complications associated with otitis media increases if an acute episode of otitis media persists longer than 2 weeks, or symptoms recur within a 2-to 3-week period. Headache and fever are the most frequently observed early manifestations of complications associated with otitis media. Other manifestations are as follows:

• Severe otalgia
• Vertigo
• Lethargy
• Nausea and vomiting
• Mental status changes
• Fetid otorrhea

Physical

A high index of suspicion is necessary in order to diagnose a complication of otitis media. The persistence or recurrence of acute infection within 2 weeks of treatment suggests impending complications.

• Complications typically are associated with subacute or chronic infections, but acute otitis media remains the most common cause of meningitis. Meningitis in the setting of acute suppurative otitis media in a child may suggest an anatomical abnormality such as a Mondini malformation. A Mondini deformity is a specific type of inner ear dysplasia, which may present as a spontaneous perilymphatic fistula due to a stapes footplate deficiency. This anatomical abnormality may predispose the patient to recurrent meningitis and profound sensorineural hearing loss.
• The following signs or symptoms are suggestive of intracranial complications:
  • Fever associated with a chronic perforation
  • Lethargy
  • Focal neurologic signs (eg, ataxia, oculomotor deficits, seizure)
  • Papilledema
  • Meningismus
  • Altered mental status
  • Severe headaches
• The following signs or symptoms are suggestive of extracranial complications:
  • Fever associated with a chronic perforation
  • Postauricular edema or erythema
• Facial nerve paresis or paralysis
• Fetid otorrhea
• Retro-orbital pain on the side of the infected ear
• Vertigo
• Spontaneous nystagmus associated with sensorineural hearing loss
• An infected ear
• Presentation of extracranial complications includes the following:
  • Labyrinthitis - Fever, nystagmus, serous or suppurative otitis media
  • Mastoiditis with subperiosteal abscess - Fever, fluctuance overlying the mastoid area, lateral displacement of pinna, otitis media
  • Petrositis - Retro-orbital pain, otorrhea, abducens paralysis, fever
• Presentation of intracranial complications includes the following:
  • Brain abscess - Fever, possibly seizures or focal neurologic signs, headache
  • Meningitis - Fever, meningismus
  • Otitic hydrocephalus - Headache, signs of increased intracranial pressure in setting of otitis media
  • Sigmoid sinus thrombosis - Spiking fever, otitis media, edema and tenderness over mastoid cortex, headache

Causes

• Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis are the most common pathogens that cause acute suppurative otitis media. An increasing incidence of penicillin-resistant S pneumoniae has been observed and may be responsible for an increasing rate of acute mastoiditis noted by some authors.
• Although less than 5% of otitis media is caused by H influenzae type B, this organism often is identified in pediatric patients with meningitis or other CNS infections occurring simultaneously with otitis media.
• Pseudomonas aeruginosa, Staphylococcus aureus, and other gram-negative organisms such as Proteus species, Klebsiella species, and Escherichia coli typically are cultured from uncomplicated chronic otorrhea.
• Bacteroides fragilis often is found in mastoiditis associated with chronic suppurative otitis media.
• Multiple organisms (average 3) are identified in 50-60% of chronically draining ears associated with cholesteatoma. Foul-smelling discharge tends to signify the presence of multiple organisms, including both anaerobes and aerobes.
• M catarrhalis, S aureus, H influenzae, and Bacteroides species are beta-lactamase–producing organisms, which also may protect other penicillin-susceptible pathogens from beta-lactam antibiotics. Resistant organisms, particularly S pneumoniae, also are becoming increasingly frequent.
• Intracranial abscesses typically are polymicrobial, with a predominance of anaerobic organisms such as Bacteroides species. Gram-negative organisms such as Proteus mirabilis and P aeruginosa are found often in intracranial complications. Streptococcus faecalis is a gram-positive organism that commonly is cultured from intracranial abscesses of otogenic origin.

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