Acute otitis media in adults

Essentials

  • Eustachian tube dysfunction caused by an upper respiratory infection is the usual cause.
  • Barotrauma (e.g. during diving) (Middle ear barotrauma (ear problems associated with an increase in atmospheric pressure)) leads to serous otitis media where sterile secretion is found in the middle ear.
  • If middle ear infection becomes prolonged, the patient should be referred to an ENT specialist for diagnosing predisposing diseases and for removing middle ear discharge to improve hearing.
  • The first-line drug treatment for purulent acute otitis media is amoxicillin.

Symptoms and clinical findings

  • Ear pain and sensation of a block in the ear
  • The eardrum is opaque or cloudy and often also bulging and red (see Otitis media in children (Otitis media in children: definition, epidemiology and diagnosis)).
  • The mobility of the eardrum is impaired when examined with a pneumatic otoscope of sufficient size. Tympanometry (Tympanometry) is helpful in the diagnostics.
  • In tuning fork tests, there is conductive hearing loss; Rinne test (Rinne test) is indifferent or negative and Weber test (Weber test) lateralizes to the affected ear.
  • Severe otitis media may cause tympanic membrane perforation and ear discharge.

Treatment

  • Acute otitis media is in adults much rarer than in children.
  • In adults, the prevalence of viral origin is not known for sure, and antimicrobial therapy is always recommended 1 .
  • Acute otitis media rarely becomes complicated in adults, but complications are, however, more common than in children, and they may be severe.
  • The most common causative bacteria in acute media are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. In rare cases, group A streptococci may also be found; these may cause sensorineural hearing impairment and a more severe clinical picture.
  • The recommended first-line drug is amoxicillin 750 mg twice daily or amoxicillin-clavulanic acid 875 mg/125 mg twice daily, duration of treatment 5–7 days. If the causative agent is group A streptococcus, it should be treated with penicillin V 1 million IU three times daily for at least 10 days.
    • Alternative drugs include trimethoprim-sulfamethoxazole or second-generation cephalosporins (e.g. cefaklor, special regulations may apply).
  • If there is a tympanic membrane perforation, bacterial culture from the discharge can be taken, the ear can be gently irrigated with body-temperature sodium chloride solution, the ear can be dried with suction or cotton swabs, and ear drops (ciprofloxacin hydrocortisone or ciprofloxacin fluosinolone acetonide) can be started in addition to an oral antimicrobial. Because of the perforation, the ear must be protected from water until the hole in the tympanic membrane has closed.
  • Tympanocentesis is indicated in prolonged or severe otitis media, or if a sample for bacterial culture is needed (e.g immunocompromised patients). If group A streptococci are suspected to be the cause, a throat swab to detect these bacteria by either a rapid test or culture is warranted.
  • Serous otitis media caused by barotrauma is treated with NSAIDs, nasal decongestants and by aeration of the middle ear (Middle ear barotrauma (ear problems associated with an increase in atmospheric pressure)) and, if necessary, by tympanocentesis.
  • An adult may experience the blocking of the ear and the hearing loss as very annoying. The block may be relieved by ventilation of the middle ear with Valsalva manoeuvre (the pressure in the nasopharynx is increased by exhaling forcefully while keeping the nostrils and the mouth closed), glucocorticoid nasal sprays, vasoconstricting nasal sprays or pseudoephedrine antihistamine tablets..

Follow-up

  • A follow-up visit is not routinely needed if the symptoms start to alleviate within a few days and normal health and hearing are restored within a few weeks.
  • The patient's condition should be reassessed if the symptoms do not start alleviating within 2–3 days.
  • Following an acute otitis media, there may be fluid in the middle ear for several weeks, and consequently it is advisable to have a follow-up visit not earlier than 3–4 weeks after the infection, if there is hearing impairment or other postinfectious symptoms remain.
  • If there is a tympanic membrane perforation, a check-up is recommended after about 4 weeks.

Referral to specialized care

  • An urgent consultation with an ENT specialist is required if the patient has vertigo, facial nerve palsy, suspected recent/acute internal ear hearing loss or severe tinnitus, or if the patient's general condition is impaired, pain is intense or mastoiditis is suspected (Acute mastoiditis).
  • Non-urgent consultation of an ENT specialist is indicated if the middle ear discharge does not resolve within 3 months or the tympanic membrane perforation does not heal within 6 months.

References

1. Limb C, Lustig L, Durand, M. Acute otitis media in adults. In: UpToDate. Connor RF (Ed), Wolters Kluwer. Accessed 5 Jan 2022 https://www.uptodate.com/contents/acute-otitis-media-in-adults.
2. Rijk MH, Hullegie S, Schilder AGM, et al. Incidence and management of acute otitis media in adults: a primary care-based cohort study. Fam Pract 2021;38(4):448-453.  [PMID:33506857]
3. Laulajainen Hongisto A, Jero J, Markkola A, et al. Severe Acute Otitis Media and Acute Mastoiditis in Adults. J Int Adv Otol 2016;12(3):224-230.  [PMID:27895000].
4. Leskinen K, Jero J. Acute complications of otitis media in adults. Clin Otolaryngol 2005;30(6):511-6.  [PMID:16402975]
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