Inflammatory Diseases of the Middle Ear Clinical Presentation

The earliest clinical manifestation of acute suppurative otitis media is a sense of fullness in the ear with some conductive hearing loss. An earache may be present but is not severe.

In the exudative stage, the middle ear fills with an exudate, which is under pressure. Marked otalgia and fever are also present. In smaller children, anorexia, vomiting, and diarrhea may occur. Conductive hearing loss is noticeable. If the infection progresses, the tympanic membrane may perforate, initially producing hemorrhagic discharge and then mucopurulent discharge. The otalgia usually reduces after perforation.

The 2 classic symptoms of chronic suppurative otitis media (CSOM; mucosal disease) include otorrhea and hearing loss, which can affect one or both ears. The discharge varies in character, from serous or mucoid to frankly purulent, and the discharge may be intermittent or continuous. Blood-stained discharge is found in association with florid granulation tissue and aural polyps, and it is a common indicator of underlying cholesteatoma.

The predominant form of hearing loss associated with chronic middle ear disease is conductive in nature. More recently, the occurrence of sensorineural hearing loss in the ears with chronic discharge has been recognized. This hearing loss, which mainly involves high frequencies, is thought to result from the passage of bacterial toxins across the round window membrane to the cochlea.

The main symptom of CSOM with cholesteatoma is purulent otorrhea, with or without associated conductive hearing loss, similar to that of mucosal disease alone. Signs found during physical examination coupled with radiologic imaging findings are critical for the diagnosis of cholesteatoma because history symptoms are largely unreliable for determining the presence of cholesteatoma.

A study by McCormick et al indicated that during an infant’s first year, symptom severity in upper respiratory tract infection helps to predict whether concurrent AOM exists. Other factors that aid in the prediction include whether the child attends day care and whether earache and cough are present. ^[20]

Otoscopic examination in patients with AOM reveals a hyperemic, opaque, bulging tympanic membrane. Pneumatic otoscopy demonstrates reduced mobility. Mucopurulent otorrhea is a reliable sign.

When the diagnosis of otitis media with effusion (OME) is questionable, tympanometry can be beneficial in the examination of infants older than 4 months. Alternatively, acoustic reflectometry with spectral gradient analysis may also be used because it costs less and does not require an airtight seal in the ear canal.

Examination with an operating microscope and adequate suction equipment is required for CSOM diagnosis. In young children, a short-acting, general anesthetic is sometimes required, especially when suction is needed.

In ears without cholesteatoma, the perforation is usually of the central type. Perforations vary in size, and the activity of the disease relates to the degree of discharge. The discharge may be mucoid or purulent. Microbiological swabs should be obtained to identify aerobic and anaerobic pathogens. Pulsatile purulent discharge occurs in heavily infected cases with capillary engorgement of the middle ear mucosa.

If the size of the perforation permits, various middle ear structures can be visualized. The middle ear mucosa is either normal or edematous, and aural polyps may be present, arising from the middle ear mucosa or the margins of the perforation. The most common ossicular abnormalities include disruption of the incudostapedial joint, necrosis of the incus long process, and medial retraction and shortening of the malleus handle. Other features include secondary otitis externa in ears with profuse discharge and scars in patients who have previously undergone otologic surgery.

The hearing loss should be assessed clinically using Rinne and Weber tuning fork tests.

In patients with CSOM with cholesteatoma, the site and the extent of the tympanic membrane defect and the presence and the extent of squamous epithelium and keratin debris should be noted. The involvement of the ossicular chain and the presence of inflammatory polyps, granulation tissue, or osteitis should also be noted.

Rigid lens otoscopy is particularly useful in assessing the extent of cholesteatoma.

The use of angled endoscopes permits examination of the facial recess and the sinus tympani, which is often involved in pars tensa cholesteatoma.

Postnasal space masses can block the orifices of the eustachian tube and cause otitis media. Therefore, an examination of an adult with unilateral otitis media must include a postnasal evaluation with flexible fiberoptic nasopharyngoscopy.

Acute otitis media (AOM) prevalence varies by season, with an increased incidence in the colder months.

Day care is a major risk factor in the incidence of middle ear infections. Upper airway hygiene in children who attend day care is poor, and coughing, sneezing, and nasal dripping contaminate the environment with bacteria and viruses.

Anatomical variants, such as of the overt and submucous cleft palate, may cause recurrent episodes, often with subsequent complications.

Immunologic deficiencies and functional changes (eg, barotrauma, patulous eustachian tube) have an important influence on the incidence of middle ear infections.

Adenoid hypertrophy may be an important factor in the etiology of recurrent attacks, possibly because of its close relationship to the eustachian tube.

Passive smoking has been shown to be associated with the occurrence of otitis media, especially in preschool-aged children whose parents smoke.

Allergic rhinitis in children has been shown to be associated with higher prevalence of otitis media with effusion (OME). Inflammatory obstruction of the nasopharynx may lead to inflammatory swelling of the eustachian tube with resultant obstruction. This facilitates a reflux of bacteria-laden allergic nasopharyngeal secretions that can then enter the middle ear cavity to cause repeated bouts of otitis media.

Gastroesophageal reflux disease has also been recently implicated in the pathogenesis of OME. A recent study revealed higher concentrations (up to 1000-fold greater than serum levels) of pepsin/pepsinogen in children with OME. Although direct mechanistic causation has not been shown, the authors concluded that reflux of gastric juice into the middle ear may be the primary factor in the initiation of OME in children.

A study by Miura et al suggested that the presence of epithelium-derived thymic stromal lymphopoietin (TSLP) in the eustachian tube is essential to the development of eosinophilic otitis media. In patients with the condition, middle ear mucosa around the tympanic ostium of the eustachian tube showed immunoreactivity for TSLP, a cytokine that is key to the etiology of T-helper 2–type allergic disease. An animal model also showed immunoreactivity for TSLP, in the eustachian tube epithelium. ^[21]

Several studies have attempted to determine a genetic link to recurrent otitis media. A recent study examined the frequency of otitis media in infants hospitalized with respiratory syncytial virus (RSV) infection and found that a certain interferon gamma (IFN-γ) polymorphism may represent one member of a family of genes that contributes to the measured heritability of otitis media. Rates of otitis media are significantly concordant in monozygotic twins.