Essentials

• Eustachian tube dysfunction caused by an upper respiratory infection is the usual cause.
• If the middle-ear infection becomes prolonged the patient should be referred to an ENT specialist for ruling out a nasopharyngeal tumour.
• 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.
• Radiotherapy of the pharynx region may predispose to functional disorder of the Eustachian tube and middle-ear infections.

Symptoms and clinical findings

• Ear pain and sensation of a block in the ear
• The eardrum is opaque or cloudy and usually also 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.

Treatment

• Acute otitis media is in adults much rarer than in children.
• In children, the infection is often of viral origin, and the need for antimicrobial therapy is considered individually.
• 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 1.5–2.0 million IU twice daily for at least 10 days.
  • Alternative drugs include trimethoprim-sulfamethoxazole or second-generation cephalosporins.
• 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 can be treated with vasoconstrictor drugs and by aeration of the middle ear (Middle ear barotrauma (ear problems associated with an increase in atmospheric pressure)) and, if necessary, by tympanocentesis. Antibiotics are indicated only if a secondary infection is suspected.
• An ENT specialist should be consulted if the patient has vertigo or intensive tinnitus, the general condition has deteriorated, the pain is intensive or there is a suspicion of mastoiditis (Acute mastoiditis).
• 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 (Valsalva manoeuvre: the pressure in the nasopharynx is increased by exhaling forcefully while keeping the nostrils and the mouth closed).

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.

References