Middle Ear, Eustachian Tube, Inflammation/Infection 

Updated: Apr 18, 2018
Author: Robert B Meek, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Practice Essentials

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).[1, 2]

Workup

A computed tomography (CT) scan of the temporal bone is useful to evaluate it for extracranial complications of otitis media (OM). A magnetic resonance imaging (MRI) study is useful to evaluate for intracranial complications of otitis media (OM).

An impedance measurement (tympanogram) is an indirect measurement of eustachian tube and middle ear function that suggests the presence or absence of effusion or pressure in the middle ear space.

Audiometry is critical in determining any temporary effects that middle ear fluid may have on hearing sensitivities.

Management

In the United States, acute otitis media (AOM) is typically treated with antibiotics.[3] Treatment with amoxicillin for 10 days is the initial antibiotic therapy, or Bactrim is substituted if the patient is allergic to penicillin. In Europe, a more conservative approach to treating acute otitis media (AOM) is used. Given the alarming increase in antibiotic resistance, the routine usage of antibiotics in the United States should be reconsidered.

In the United States, otitis media with effusion (OME) can be treated with observation, antibiotics, or tympanostomy tube placement. However, a meta-analysis of controlled studies revealed only a 14% increase in the resolution rate when antibiotics are given.[4, 5] Antibiotic suppression is not indicated for OME, and multiple courses of antibiotics have no proven benefit. Consider surgical intervention after 3-4 months of effusion with a 20 dB or greater hearing loss.[6]

Eustachian tube dysfunction (ETD) can be treated primarily with a combination of time, autoinsufflation (eg, an Otovent), and oral and nasal steroids (budesonide, mometasone, prednisone, methylprednisolone).

Nasal and oral antihistamines can be beneficial in patients with allergic rhinitis. Leukotriene antagonists (eg, montelukast sodium [Singulair]) are helpful in some patients when oral steroids are not an option. Adequate control of laryngeal pharyngeal reflux helps to resolve eustachian tube dysfunction (ETD) in patients with an associated peritubal inflammation from reflux. Proton pump inhibitors (esomeprazole magnesium [Nexium], rabeprazole [Aciphex], omeprazole [Prilosec]) administered twice a day are often used.

The primary surgical treatment of all types of otitis media (OM) is myringotomy with tube placement.[7] The typical ventilation tube stays in place for a period of 8-12 months, with closure of the perforation occurring after tube extrusion. In a small percentage of patients with poor eustachian tube function or other complicating factors, the perforation may persist.

Adenoidectomy is indicated for refractory otitis media with effusion (OME) in children older than 4 years and in younger children when adenoid pathology is present (eg, chronic adenoiditis, adenoid hypertrophy).

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. See the image below.

Anatomy of the external and middle ear. Anatomy of the external and middle ear.

Epidemiology

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.

A study by Hasegawa et al, using a cross-sectional analysis of the Nationwide Emergency Department Sample, found that otitis media was the second most common cause of infectious disease – related emergency department visits in the United States in 2011. The study found that otitis media was diagnosed in 18% of such cases, compared with upper respiratory infection in 41% of cases.[8]

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.[9]

 

Presentation

History

See the list below:

  • Eustachian tube dysfunction (ETD): Symptoms usually follow the onset of an upper respiratory tract infection (URTI) or allergic rhinitis.[10] 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.

Studies also 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. 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.

A study by Martin et al looking at AOM cases between 1999 and 2014 in children aged 6-23 months found that, while nasopharyngeal colonization with S pneumoniae has reportedly decreased since pneumococcal conjugate vaccines (PCVs) were introduced, colonization with H influenzae in the study subjects initially increased before dropping back to levels seen prior to routine administration of 7-valent PCV (PCV7). The investigators obtained nasopharyngeal cultures from four cohorts of children with AOM. The first cohort was cultured in 1999-2000, before routine PCV7 use, while in the second (2003-2005) and third (2006-2009) cohorts, two or more doses of PCV7 were administered to 93% and 100% of children, respectively, and in the fourth cohort (2012-2014), 100% of the children received two or more doses of 13-valent PCV (PCV13). Nasopharyngeal colonization with H influenzae in cohorts 1, 2, 3, and 4 occurred in 26%, 41%, 33%, and 29% of children, respectively.[11]

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. Moreover, a study by Paltura et al suggested that smaller eustachian tube diameter is a factor in the development of chronic otitis media (COM). The study, which included 154 patients with unilateral chronic otitis media (COM), found that the mean diameter of the eustachian tube in diseased ears was 1788 mm, compared with 1947 mm in the healthy ears.[12]

Environmental factors, such as daycare attendance, passive smoke exposure, and pacifier usage, may contribute to nasopharyngeal and middle ear inflammation.[13]

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.[14] 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.

 

DDx

Diagnostic Considerations

These include the following:

  • Hyperemia of vascular strip observed with crying child

  • Otitis externa

  • Bullous myringitis

  • Barotrauma

  • Laryngeal pharyngeal reflux

 

Workup

Laboratory Studies

See the list below:

  • Lab studies are seldom necessary unless the patient is being evaluated for a complication of otitis media (OM).

    • In rare instances, tympanocentesis is performed, the specimen is cultured, and sensitivity tests are performed. These instances include refractory cases of acute otitis media (AOM), neonates with severe otitis media (OM), immunocompromised patients, and very ill children with otitis media (OM).

    • A CBC count may be useful in a patient who appears toxic, and a lumbar puncture is useful if concerns of meningitis secondary to otitis media (OM) have arisen.

Imaging Studies

Imaging studies are not typically applicable in cases of otitis media (OM). A computed tomography (CT) scan of the temporal bone is useful to evaluate it for extracranial complications of otitis media (OM). A magnetic resonance imaging (MRI) study is useful to evaluate for intracranial complications of otitis media (OM).

A prospective study by Tarabichi and Najmi indicated that in most persons with healthy ears, temporal bone CT scans performed during the Valsalva maneuver can visualize the distal third of the eustachian tube lumen, suggesting that this imaging strategy could help to localize disorders in patients with symptoms of eustachian tube obstruction. The study was performed on 38 patients (76 ears), with the distal third of the lumen visualized in 71 ears (93%) and the entire lumen visualized in 27 ears (36%).[15]

Other Tests

See the list below:

  • An impedance measurement (tympanogram) is an indirect measurement of eustachian tube and middle ear function that suggests the presence or absence of effusion or pressure in the middle ear space.

    • Type A tympanogram with little negative pressure suggests normal middle ear and eustachian tube function.

    • Type B tympanogram with low volume suggests middle ear fluid.

    • Type B tympanogram with a large volume suggests a patent tube or perforation. Small volume with visible perforation on examination suggests eustachian tube edema. Volume of 4-5 mL suggests a patent eustachian tube.

    • Type C tympanogram with high negative pressure suggests eustachian tube inflammation and dysfunction.

    • Type D tympanogram suggests a flaccid tympanogram with high negative pressure or ossicular discontinuity.

  • Audiometry is critical in determining any temporary effects that middle ear fluid may have on hearing sensitivities.

    • The method of audiological examination depends on the patient's age. Infants younger than 6 months typically undergo behavioral observation audiometry, while children aged 6 months to 2.5 years typically undergo visual reinforcement audiology. Children older than 2.5 years undergo play audiometry, while older children are evaluated using standard testing with hand raising.

    • Middle ear effusions can produce mild-to-moderate levels of conductive hearing loss, although threshold testing may be normal. Children with middle ear effusions may demonstrate problems with auditory processing despite normal thresholds.

Procedures

See the list below:

  • Myringotomy with tube placement is the primary treatment for persistent middle ear effusion. A tympanocentesis is useful for refractory cases of acute otitis media (AOM) and for research purposes.

    • Second-line surgical treatment of persistent OME involves adenoidectomy without tonsillectomy. Consider adenoidectomy in patients requiring a second set of ventilation tubes.

    • Mastoidectomy and tympanoplasty are also used to treat eustachian tube abnormalities and otitis media (OM).

Histologic Findings

A bony and cartilaginous structure separated by a tubal isthmus forms the eustachian tube. The isthmus is smaller in children (about 2.4 mm x 0.8 mm) than in adults (about 4.3 mm x 1.7 mm). Analysis of human eustachian tube mucosa reveals that it is similar to respiratory epithelium, which is found elsewhere. The cartilaginous portion contains many seromucoid glands.

The middle ear mucosa consists of tall columnar cells near the tube and hypotympanum and cuboidal and simple squamous mucosal cells throughout the remainder of the middle ear. Collagen fibers, blood and lymph capillaries, and nerve fibers predominantly form the subepithelial space. A relative paucity of immunocompetent and seromucoid glands are found in the noninfected middle ear.

 

Treatment

Medical Care

In the United States, acute otitis media (AOM) is typically treated with antibiotics.[3] Treatment with amoxicillin for 10 days is the initial antibiotic therapy, or Bactrim is substituted if the patient is allergic to penicillin. In Europe, a more conservative approach to treating acute otitis media (AOM) is used. Given the alarming increase in antibiotic resistance, the routine usage of antibiotics in the United States should be reconsidered.

A meta-analyses from 30 articles written in English and 3 articles written in a language other than English revealed that acute otitis media (AOM) achieved complete clinical resolution without treatment 81% of the time as compared with resolution 95% of the time with the use of antimicrobials. Criteria for withholding or delaying antibiotic therapy for acute otitis media (AOM) include (1) patient older than 2 years, (2) normal host, (3) intact tympanic membrane, (4) at least 3-6 months since last episode of otitis media (OM), (5) receptive parents, and (6) assurance of medical follow-up care.

A study by Tawfik et al indicated that since the introduction of pneumococcal vaccination, hospital admissions for pediatric acute otitis media (AOM)/complications of acute otitis media (AOM) in the United States have decreased in prevalence, as have admission rates for pneumococcal meningitis with acute otitis media (AOM)/complications of acute otitis media (AOM). Using information from the Kids’ Inpatient Database from between 2000 and 2012, the study found particularly sharp declines in admissions for children under age 1 years, from 22.647 to 8.715 per 100,000 persons, and for children aged 1-2 years, from 13.652 to 5.554 per 100,000 persons.[16]

In the United States, otitis media with effusion (OME) can be treated with observation, antibiotics, or tympanostomy tube placement. However, a meta-analysis of controlled studies revealed only a 14% increase in the resolution rate when antibiotics are given.[4, 5] Antibiotic suppression is not indicated for otitis media with effusion (OME), and multiple courses of antibiotics have no proven benefit. Consider surgical intervention after 3-4 months of effusion with a 20 dB or greater hearing loss.[6]

Eustachian tube dysfunction (ETD) can be treated primarily with a combination of time, autoinsufflation (eg, an Otovent), and oral and nasal steroids (budesonide, mometasone, prednisone, methylprednisolone). The results of one study suggest that intranasal steroid sprays alone do not help eustachian tube dysfunction.[17]

Decongestants (eg, pseudoephedrine, oxymetazoline, phenylephrine) are also helpful, but not as useful for chronic eustachian tube dysfunction (ETD). Consider the cardiovascular effects of oral decongestants and the early development of tachyphylaxis observed with the use of nasal decongestants; limit the use of the decongestant to short-term symptomatic relief (ie, no more than 3-5 d).

Nasal and oral antihistamines can also be beneficial in patients with allergic rhinitis. Leukotriene antagonists (eg, montelukast sodium [Singulair]) are helpful in some patients when oral steroids are not an option. Adequate control of laryngeal pharyngeal reflux helps to resolve eustachian tube dysfunction (ETD) in patients with an associated peritubal inflammation from reflux. Proton pump inhibitors (esomeprazole magnesium [Nexium], rabeprazole [Aciphex], omeprazole [Prilosec]) administered twice a day are often used. Myringotomy with tube insertion is reserved for the refractory patient with debilitating symptoms.

An international consensus statement on the management of pediatric OME, stemming from the 2017 International Federation of Oto-rhino-laryngological Societies World Congress, maintains that the underlying problems of age-dependent eustachian tube dysfunction are poorly addressed by nonsurgical treatment. The only exception, according to the statement, appears to be autoinflation, which the statement identified as an effective, low-risk, low-cost therapy. In addition, the statement recommended against steroid, antibiotic, decongestant, or antihistamine use in OME management, citing side effects, cost issues, and a lack of convincing evidence regarding long-term effectiveness.[18]

Surgical Care

The primary surgical treatment of all types of otitis media (OM) is myringotomy with tube placement.[7] The typical ventilation tube stays in place for a period of 8-12 months, with closure of the perforation occurring after tube extrusion. In a small percentage of patients with poor eustachian tube function or other complicating factors, the perforation may persist.

  • Adenoidectomy is indicated for refractory OME in children older than 4 years and in younger children when adenoid pathology is present (eg, chronic adenoiditis, adenoid hypertrophy).

  • Tonsillectomy has not been shown to prevent otitis media (OM) either alone or in conjunction with adenoidectomy.

  • Mastoidectomy, both canal wall up and canal wall down, can be used to treat complications of middle ear infection and eustachian tube dysfunction (ETD).

Consultations

Consult with an otolaryngologist if the patient has any evidence of complications of otitis media (OM), if the effusion persists for longer than 3 months, if a 20 dB or greater hearing loss exists, or if a patient has more than 3 episodes of otitis media (OM) in 4 months or 6 episodes of otitis media (OM) in 1 year.

Neurosurgery consultation may be required for intracranial complications such as a brain abscess.

Activity

Patients with eustachian tube dysfunction (ETD) must be careful when flying or diving because of the risk of barotrauma. Instruct patients with significant eustachian tube dysfunction (ETD) to use oral and topical decongestants 30 minutes before landing. An Otovent may be used to assist with autoinsufflation in the treatment of eustachian tube dysfunction (ETD).

 

Medication

Medication Summary

Antimicrobials are frequently chosen for the treatment of acute otitis media (AOM) and OME.

Topical nasal decongestants, oral decongestants, nasal steroids, and antihistamines can be used to treat ETD.

Antimicrobials

Class Summary

These agents are used to eradicate middle ear bacteria and prevent mastoiditis in acute otitis media (AOM) and to help speed the resolution of inflammation and effusion in COME.

Amoxicillin (Trimox, Biomox)

DOC for first-line OM in patients not allergic to penicillin. Administered for a total of 7-10 d for AOM.

Trimethoprim/sulfamethoxazole (Bactrim DS, Septra DS)

Useful in penicillin-allergic patients. Administered q12h for 10d to treat OM. High incidence of resistance.

Amoxicillin/clavulanate (Augmentin)

Drug combination treats bacteria resistant to beta-lactam antibiotics. Useful in patients who have failed first-line treatment of OM.

Cefuroxime (Ceftin, Kefurox, Zinacef)

Second-line antimicrobial agent for OM. Also for non type I penicillin allergic patients

Oral decongestants

Class Summary

These agents are used to decrease swelling of eustachian tube and sinus mucosa.

Pseudoephedrine (Actifed, Sudafed, Afrin)

Used in patients with ETD. Not helpful in OME.

Nasal corticosteroids

Class Summary

These agents are used to decrease perieustachian tube inflammation.

Mometasone (Nasonex)

Nasal spray; may decrease number and activity of inflammatory cells, resulting in decreased nasal inflammation. Demonstrated no mineralocorticoid, androgenic, antiandrogenic, or estrogenic activity in preclinical trials. Decreases rhinovirus-induced up-regulation in respiratory epithelial cells and modulate pretranscriptional mechanisms. Reduces intraepithelial eosinophilia and inflammatory cell infiltration (eg, eosinophils, lymphocytes, monocytes, neutrophils, plasma cells).

Budesonide inhaled (Pulmicort Turbuhaler, Rhinocort)

This nasal steroid is useful in ETD especially in patients who are also diagnosed with allergic rhinitis.

Fluticasone (Flonase, Flovent, Veramyst)

Has extremely potent vasoconstrictive and anti-inflammatory activity. Has a weak hypothalamic-pituitary-adrenocortical axis inhibitory potency when applied topically.

Triamcinolone inhaled (Azmacort, Nasacort AQ)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Ciclesonide (Omnaris)

Corticosteroid nasal spray indicated for allergic rhinitis. Prodrug that is enzymatically hydrolyzed to pharmacologic active metabolite C21-desisobutyryl-ciclesonide following intranasal application. Corticosteroids have a wide range of effects on multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines, eicosanoids, leukotrienes, cytokines) involved in allergic inflammation. Each spray delivers 50 mcg.

Anti-inflammatory Agent

Class Summary

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Methylprednisolone (Medrol Dose Pack)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

 

Follow-up

Further Outpatient Care

After 3 months, re-evaluate patients treated conservatively for otitis media with effusion (OME). Ninety percent of effusions that are going to clear without surgical treatment do so by 90 days. If no resolution of effusion occurs, consider myringotomy and ventilation tube insertion.

Further Inpatient Care

Inpatient care is seldom required for uncomplicated otitis media (OM). Patients may need admission for IV antibiotics and surgical drainage for extracranial/intracranial complications of acute or chronic otitis media (OM).

Inpatient & Outpatient Medications

See the list below:

  • First-line antimicrobials used for otitis media (OM) include amoxicillin, trimethoprim/sulfamethoxazole, and erythromycin/sulfisoxazole. Despite the prevalence of resistant strains, the low cost and effectiveness in most patients supports continued use of these drugs.

  • Second-line antimicrobials for otitis media (OM) include amoxicillin/clavulanate, cefuroxime, clarithromycin, and azithromycin. These antibiotics and others in their class offer a broader spectrum of coverage. A 2- to 3-week course of a second-line antibiotic has been shown to improve the resolution of OME in 15% more patients compared with no treatment at all. Multiple courses of antibiotics have shown no benefit.

  • Pseudoephedrine is an ingredient found in oral decongestants. Oral decongestants are used in the treatment of eustachian tube dysfunction (ETD) and can help decrease peritubal edema provoked by allergies or URI.

  • Oxymetazoline is an ingredient found in topical decongestants. Topical decongestants can be used acutely for eustachian tube dysfunction (ETD) but must be discontinued after a maximum of 5 days to prevent rebound swelling.

  • Budesonide, fluticasone, beclomethasone, mometasone, triamcinolone, and flunisolide are steroids used in nasal sprays. Steroid nasal sprays are used in the hope of decreasing the peritubal edema on a long-term basis. These agents are most helpful in patients with allergic rhinitis. The results of one study suggest that intranasal steroid sprays alone do not help eustachian tube dysfunction.[17]

Transfer

Evaluation by an otolaryngologist is recommended for any signs of extracranial/intracranial complications or for chronic effusions with hearing loss.

Deterrence/Prevention

See the list below:

  • Environmental modification is recommended.

    • Breastfeeding is recommended for at least 3-6 months. A meta-analysis reported a 13% reduction in the frequency of otitis media (OM) associated with breastfeeding for this period of time.

    • Smoking in proximity to the children is not recommended. Two meta-analyses reported the relative risks (1.2-1.7) of passive smoke in the development of otitis media (OM).

    • Limit pacifier use to the moments when the child is falling asleep. A recent study revealed a 29% lower rate of acute otitis media (AOM) in children with limited pacifier usage.

    • Limit daycare exposure when possible; limited exposure can help decrease the frequent development of URTIs. Daycare enrollment is a greater risk factor for otitis media (OM) than parental smoking.

  • Vaccination is the main form of prevention currently available.

    • Haemophilus influenzae type B vaccination is administered to infants for prevention of meningitis and other invasive infections. H influenzae type B causes only approximately 2% of otitis media (OM). Nontypeable H influenzae accounts for a larger percentage of otitis media (OM); however, a common antigen that would cross protect against the various strains of this bacteria has not been developed.

    • Heptavalent pneumococcal conjugate vaccines currently are administered to infants at age 2, 4, and 6 months with a booster dose administered at age 2 years. A significant reduction in otitis media (OM) caused by the serotypes contained in the vaccine was demonstrated in a 2000 Kaiser Permanente vaccine study.[19] Ambulatory visits were reduced by 42.7% for acute otitis media (AOM), and antibiotic prescriptions were reduced 41.9% from 1997-99 to 2004.

    • With the decrease in pneumococcal infections, B-lactamase–producing H influenzae has increased. Luckily, the disease course has been less virulent although more difficult to eradicate with first-line antibiotics.

    • A vaccine for Moraxella catarrhalis is currently being investigated. M catarrhalis has been isolated in approximately 10% of patients with acute otitis media (AOM). URTI is the common denominator in many causes of otitis media (OM).

    • Viral vaccines are currently under investigation including vaccines against adenovirus, respiratory syncytial virus, and influenza. A Finnish study investigating an influenza vaccine showed a reduction in the incidence of URTI and acute otitis media (AOM) in infants who attended daycare during an influenza epidemic.

Complications

See the list below:

  • Tympanic membrane perforation

  • Hearing loss

  • Cholesteatoma

  • Meningitis

  • Brain abscess

  • Subdural empyema

  • Subperiosteal abscess

  • Petrositis

  • Labyrinthitis

  • Sigmoid sinus thrombophlebitis

  • Otitic hydrocephalus

  • Facial paralysis

  • Death

Prognosis

Prognosis is excellent if infection is not permitted to spread beyond the middle ear and eustachian tube. Permanent sequelae are usually rare.

Patient Education

Education of parents in the form of risk factor reduction is useful. Modifiable risk factors include breastfeeding exclusively for at least 3 months, avoidance of parental cigarette smoke, feeding the baby in an upright position, limiting pacifier usage to just when the infant is falling asleep, and avoidance of daycare attendance, if possible.

 

Questions & Answers

Overview

What are middle ear and eustachian tube inflammation/infections?

How are middle ear and eustachian tube inflammation/infections diagnosed?

How are middle ear and eustachian tube inflammation/infections treated?

What is the pathophysiology of middle ear and eustachian tube inflammation/infections?

What is the prevalence of middle ear and eustachian tube inflammation/infection in the US?

What is the global prevalence of middle ear and eustachian tube inflammation/infection?

What is the morbidity associated with middle ear and eustachian tube inflammation/infection?

What are the racial predilections of middle ear and eustachian tube inflammation/infection?

What are the sexual predilections of middle ear and eustachian tube inflammation/infection?

Which age groups have the highest prevalence of middle ear and eustachian tube inflammation/infection?

Presentation

What is the clinical history of middle ear and eustachian tube inflammation/infection?

Which physical findings are characteristic of middle ear and eustachian tube inflammation/infections?

What causes middle ear and eustachian inflammation/infections?

What is the role of bacteria in the etiology of middle ear and eustachian inflammation/infection?

What are the risk factors for middle ear and eustachian inflammation/infections?

DDX

Which conditions should be included in the differential diagnoses of middle ear and eustachian inflammation/infections?

Workup

What is the role of lab testing in the diagnosis of middle ear and eustachian inflammation/infections?

What is the role of imaging studies in the diagnosis of middle ear and eustachian inflammation/infections?

What is the role of tympanogram in the diagnosis of middle ear and eustachian inflammation/infections?

What is the role of audiometry in the diagnosis of middle ear and eustachian inflammation/infections?

What is the role of myringotomy in the diagnosis of middle ear and eustachian inflammation/infections?

Which histologic findings are characteristic of middle ear and eustachian inflammation/infections?

Treatment

How are middle ear and eustachian inflammation/infections treated?

What is the role of surgery in the treatment of middle ear and eustachian inflammation/infections?

Which specialist consultations are beneficial to patients with middle ear and eustachian inflammation/infection?

Which activity modifications are advised during the treatment of middle ear and eustachian inflammation/infection?

Medications

Which medications are used in the treatment of middle ear and eustachian inflammation/infections?

Which medications in the drug class Anti-inflammatory Agent are used in the treatment of Middle Ear, Eustachian Tube, Inflammation/Infection?

Which medications in the drug class Nasal corticosteroids are used in the treatment of Middle Ear, Eustachian Tube, Inflammation/Infection?

Which medications in the drug class Oral decongestants are used in the treatment of Middle Ear, Eustachian Tube, Inflammation/Infection?

Which medications in the drug class Antimicrobials are used in the treatment of Middle Ear, Eustachian Tube, Inflammation/Infection?

Follow-up

What is included in long-term monitoring of middle ear or eustachian tube inflammation/infections?

When is inpatient care indicated for middle ear or eustachian tube inflammation/infections?

Which medications are used in the treatment of middle ear or eustachian tube inflammation/infections?

What is the role of an otolaryngologist in the evaluation of middle ear or eustachian tube inflammation/infections?

How are middle ear or eustachian tube inflammation/infections prevented?

What is the role of vaccinations in the prevention of middle ear or eustachian tube inflammation/infections?

What are the possible complications of middle ear or eustachian tube inflammation/infections?

What is the prognosis of middle ear or eustachian tube inflammation/infections?

What is included in patient education about middle ear or eustachian tube inflammation/infections?