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Acuteotitismediainadults(suppurativeandserous)
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Acuteotitismediainadults(suppurativeandserous)
Authors
CharlesJLimb,MD
LawrenceRLustig,MD
JeromeOKlein,MD
SectionEditor
DanielGDeschler,MD,FACS
DeputyEditor
AllysonBloom,MD
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2016.|Thistopiclastupdated:Oct17,2014.
INTRODUCTIONOtitismedia(infectionorinflammationofthemiddleear)isoneofthemostcommoninfections,and
acuteotitismedia(AOM)isamongthemostcommondiseasesthatleadtotreatmentwithantibiotics[1].AOMprimarily
occursinchildhoodandthemedicalliteratureoverwhelminglyfocusesonthepresentation,course,andtreatmentofAOM
inchildren.ThetreatmentofAOM[2]inadultsisthereforelargelyextrapolatedfromstudiesinchildren.
Lifethreateningcomplications,thoughinfrequent,maydevelopbecauseoftheproximityofthemiddleearandadjacent
mastoidtothemiddleandposteriorcranialfossaandrelatedstructures.Baseduponitshighprevalenceandpotentialto
causeseriousharm,otitismediaisapublichealthconcern.
Thistopicwilladdresstheetiology,diagnosis,andtreatmentofAOMinadults.IssuesrelatedtoAOMinchildrenare
discussedseparately.(See"Acuteotitismediainchildren:Diagnosis"and"Acuteotitismediainchildren:Epidemiology,
microbiology,clinicalmanifestations,andcomplications"and"Acuteotitismediainchildren:Treatment"and"Otitismedia
witheffusion(serousotitismedia)inchildren:Clinicalfeaturesanddiagnosis"and"Otitismediawitheffusion(serousotitis
media)inchildren:Management".)Issuesrelatedtochronicotitismediainadultsarealsodiscussedseparately.(See
"Chronicotitismedia,cholesteatoma,andmastoiditisinadults".)
CLASSIFICATIONOFOTITISMEDIAAvarietyofterms,relatedtotheareaofinvolvementandunderlyingdisease
process,areusedtocategorizeinfectiousorinflammatoryconditionsofthemiddleear.Theanatomyofthenormalearis
showninafigure(figure1).
Acuteotitismedia(AOM)Acuteotitismedia(AOM)isanacuteillnessmarkedbythepresenceofmiddleearfluidand
inflammationofthemucosathatlinesthemiddleearspace(picture1).Theinfectionisoftencausedbyobstructionofthe
eustachiantube,whichresultsinfluidretentionandsuppurationofretainedsecretions.AOMmayalsobeassociatedwith
purulentotorrheaifthereisarupturedtympanicmembrane.AOMusuallyrespondspromptlytoantimicrobialtherapy.
OtitismediawitheffusionOtitismediawitheffusion(OME)isdefinedbythepresenceofmiddleearfluidwithout
acutesignsofillnessorinflammationofthemiddleearmucosa.OMEusuallyfollowsAOMbutcanresultfrom
barotraumasorallergy.Eustachiantubedysfunctionisoftenapredisposingfactor.Rarely,OMEiscausedbyobstruction
oftheeustachiantubeorificeinthenasopharynxbyamassorcancersuchasnasopharyngealcarcinoma,orasaresult
ofradiationtreatmentfornasopharyngealmalignancy.
OMEtypicallyleadstoaconductivehearinglossandcanbeaprecursortoretractionandperforationofthetympanic
membrane.
AcutemastoiditisThemastoidisthatportionofthepetroustemporalbonethatliessuperiortothemiddleearcavity
(figure1).Themastoidantrumservesasanairspaceconnectingthemiddleeartothemastoidaircells.Thus,most
casesofAOMareassociatedwithsomedegreeofmastoidinflammationorinfection("mastoiditis").However,the
incidenceofclinicallysignificantmastoiditisislowsincetheintroductionofantibacterialdrugs.
Whenpusdoesenterthemastoidaircellsunderpressure,itmayleadtothedissolutionofsurroundingbone.This
representsaseriousprocessthatoftenrequiresurgentsurgicalevacuationbecausetheinfectioncanspreadtoregional
structures,includingthecentralnervoussystemorneck.Mastoiditiscanoccuratanyagebutisfarmorecommonin
childrenthanadultswhenitoccursinolderadults,itmaybeparticularlysevere[3].(See'Mastoiditis'below.)
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ChronicotitismediaChronicotitismedia(COM)isdiagnosedinanearwithatympanicmembraneperforationinthe
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settingofchronicearinfections,suchasanearwithchronicpurulentdrainagedespiteappropriateantibiotictreatment.
URL,DOI,
COMmaybebenignandisoftencharacterizedbyadrytympanicmembraneperforation.Continuousserousdrainage
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(typicallystrawcolored)istermedchronicserousotitismedia,andchronicpurulentdrainagethroughaperforatedtympanic
membraneistermedchronicsuppurativeotitismedia.(See"Chronicotitismedia,cholesteatoma,andmastoiditisin
adults".)
EPIDEMIOLOGYOFAOMEpidemiologicstudiesofacuteotitismedia(AOM)overwhelminglyinvolvepediatricor
mixedpopulations.DataareunavailabletodeterminetheincidenceofAOMinanadultpopulation.Surveysdemonstrate
that80percentofchildrenwillexperienceoneormoreepisodesofAOMbytheageofsix[4].TheincidenceofAOM
markedlydecreasesaftertheageofseven.
Priortotheintroductionofantibiotics,acutecoalescentmastoiditiscomplicatedAOMinapproximately20percentof
cases[5].Currentreportsindicatethatmastoiditisandotherinfectiouscomplicationsinadultsdevelopinlessthan0.5
percentofcasesofAOM[6,7].
ETIOLOGYOFAOM
EustachiantubedysfunctionThemostimportantfactorinthepathogenesisofmiddleearinfectionsisdysfunctionof
theeustachiantube(figure1).Descentofthesoftpalatemuscleslingrelativetotheeustachiantubeorificewith
adolescenceimprovesthepatencyoftheeustachiantube,resultinginthedecliningincidenceofAOMwithage.However,
poortubalfunctioncanpersistintoadulthood.
Persistenteustachiantubedysfunctioninducesarelativenegativepressureinthemiddleearspace.Thelackofaeration
andtheaccumulationofeffusionsprovideanenvironmentconducivetothedevelopmentofAOMorotitismediawith
effusion(OME).
AnyentityresultingineustachiantubedysfunctionorobstructioncanpredisposetoAOM.Commoncausesinclude
seasonalallergicrhinitisandupperrespiratorytractinfections.Othercausesofeustachiantubedysfunctionrelateto
mucosaldisease(inflammatory,immunologicimpairment,orimmotilecilia),extrinsiccompression(nasopharyngealtumor
orenlargedadenoid),orpalatalmuscledysfunction(cleftpalateandothercraniofacialanomalies).(See"Eustachiantube
dysfunction".)
Microbiology
BacteriologyThemicrobiologyofAOMhasbeendocumentedbyculturesofmiddleearfluidsobtainedbyneedle
aspiration.Datafromadultsidentifypatternssimilartoinfectionsinchildren,withdominancebyStreptococcus
pneumoniaeandnontypableHaemophilusinfluenzae(NTH.influenzae)[1,8,9].GroupAbetahemolyticstreptococcus,
Staphylococcusaureus,andMoraxellacatarrhalisarelessfrequentcauses.
S.pneumoniaeisthemostimportantbacterialcauseofAOMinadults.Relativelyfewserotypesareresponsiblefor
mostdisease,althoughtheremayberegionaldifferences.ThemostfrequentserotypesresponsibleforAOM,in
decreasingorder,areserotypes19F,14,6B,23F,6A,and3[10,11].
Thesevenserotypepneumococcalconjugatevaccine(PCV7)usedinchildrenincludestypes4,6B,9V,14,18C,
19F,and23F.Itwasdevelopedbaseduponthemostprevalentserotypesresponsibleforinvasivedisease,butalso
includesthemajorserotypesresponsibleforAOM,exceptfor6Aand3.A13valentconjugatevaccine(Prevnar13)
wasapprovedbytheUSFoodandDrugAdministrationinMarch2010,withadditionalserotypes1,3,5,6A,7Fand
19A.Sincetheconjugatepneumococcalvaccineprotectsagainstcarriageofvaccineserotypes,itislikelythatthe
prevalenttypesresponsibleforAOMwillchangeinimmunizedchildren[12].Asanexample,NTH.influenzaemay
replacepneumococcusasthemostfrequentlyisolatedpathogenofAOMinchildrenimmunizedwithPCV7[1315].
Thedurabilityofprotectionprovidedbytheinfantimmunizationscheduleisuncertain,butappearstobesufficientto
coverthepreschoolyearsofhighestattackratesforbothinvasivepneumococcaldiseaseandAOM.The
pneumococcalpolysaccharidevaccineavailableforolderchildrenandadultsdoesnotaltercarriageofpneumococci,
incontrasttotheefficacyofPCV7andPVC13indecreasingcarriageofvaccineserotypes.
AOMduetoNTH.influenzaeisassociatedwithnontypeablestrainsinthevastmajorityofpatientsofallages[8].
NTH.influenzaeistheprimarypathogenintheuniqueconjunctivitisAOMsyndromeinchildren[16].Thesyndrome
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hasnotbeenidentifiedinadults,butitispossiblethatstrainsofHinfluenzaeresponsibleforAOMinadultsinclude
thosethatcausethissyndrome.
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Staphylococcusaureus,includingmethicillinresistantstrains,areanuncommoncauseofAOMbutcanoccurin
patientswithchronicsuppurativeotitismediaandmaybeassociatedwithpersistentotorrheathatfollowsinsertionof
tympanostomytubes[17].
GroupAstreptococcus(GAS)wastheleadingcauseofAOMduringthepreantibioticera.Themiddleeardisease
wasseverewithfrequentperforationofthetympanicmembraneandmastoiditis.GASisanuncommoncauseof
AOMtoday,thoughthereasonforthisisnotknown[18].
OtherorganismsEpidemiologicdatasuggestthatviralinfectionoftheupperrespiratorytractisfrequentlyaninitial
eventinthedevelopmentofAOM.Respiratoryviruseshavebeenisolatedfromthenasopharynxinupto50percentof
childrenwithAOMandinapproximatelyonequarterofmiddleearfluidsfromchildrenwithAOM.Themostfrequently
isolatedvirusesarerespiratorysyncytialvirus,influenzaviruses,andrhinoviruses[19,20].Combinedbacterialandviral
infectionsappeartobemoreseverethanviralorbacterialepisodesofAOM[21].
ExperimentalinfectionofadultvolunteerswithMycoplasmapneumoniaeresultedinhemorrhagicbullousmyringitis[22].
However,inthemanystudiesofthemicrobiologyofAOM,M.pneumoniaehasrarelybeenidentified.Somepatientswith
lowerrespiratorytractinfectionduetoM.pneumoniaehaveconcurrentAOM,althoughtheetiologicroleofM.pneumoniae
intheAOMisuncertain.
Fungiarefrequentlyassociatedwithotitisexterna.CandidaandAspergillusspecies,althoughinfrequent,havebeen
isolatedfrommiddleearfluidsofpatientswhodevelopedchronicsuppurativeotitismedia[23].
OtheruncommoncausesofAOMinclude:
Chlamydiatrachomatis
Diphtheriticotitis
Tuberculousotitis
Otogenoustetanus
BiofilmsTheroleofbiofilmsinthepathophysiologyofinfectionsoftheupperaerodigestivetractisincreasingly
recognized,particularlyinantibioticresistantcases[2,24,25].Abiofilmbeginsasanaggregateofbacteriathatattachtoa
surface.Suchbacteriademonstratereducedmetabolismandreplicationrates.
Biofilmsaredifficulttoeradicatesinceantibioticscannotreadilypenetratetheformedmatrix.Theproblemisconfounded
bythedifficultyinculturingbiofilms.Biofilmshavebeenidentifiedincholesteatomas[26]andtympanostomytubes[27],
supportingtheirroleinresistantinfections.
ImmunologyTherespiratorymucosalmembranethatlinesthemiddleearspaceandmastoidaircellsprovidesan
immunologicdefensivebarrier.Theconstantlyrenewedmucusthatformsthisbarrierisrichinlysozyme,apotent
antibacterialenzyme[28].Mucusproductionincreasesinresponsetoaninvadingorganism.Inaddition,inflammatory
dilationofvessels,whitebloodcellmigration,proteolyticenzymeactivity,andantibodydepositioncontributetothe
formationofmucopurulentsecretions.
AllofthemajorclassesofimmunoglobulinshavebeenidentifiedinmiddleeareffusionsofpatientswithAOM.The
presenceoftypespecificantibodiesinmiddleeareffusionsisassociatedwithclearanceofmucopurulentsecretionsand
anearlyreturntonormalmiddleearfunction.
TheincidenceofAOMandrelatedcomplicationsisincreasedinchildrenwithcongenitaloracquiredimmunologic
deficiencies[28],ariskthatpersistsintoadulthood.TherisksofAOManditscomplicationsarealsoincreasedinpatients
whohaveaconcomitantmalignancy,useimmunosuppressivedrugs,orhaveahistoryofpreviousirradiationtothe
nasopharyngealregion[29].
CLINICALMANIFESTATIONSOFAOMTheonsetofAOMinadultsistypicallyassociatedwithotalgia(earpain)and
decreasedhearing.Fevermaynotbepresent.Aprecedingupperrespiratorytractinfectionorexacerbationofseasonal
allergicrhinitismayheraldtheonsetofAOMbyseveraldays.
ThereisconsiderablevariabilityinthesymptomsandsignsofAOM.Theinfectionistypicallybutnotalwaysunilateral.A
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bulgingtympanicmembranedistinguishesacuteotitismediafromotitismediawitheffusion.(picture1).Thetympanic
membranemayalsobeerythematousoropacified.Ifthetympanicmembranehasruptured(oftenreportedbythepatient
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asareliefoftheotalgia),theremayalsobeassociatedpurulentotorrhea.
Dysequilibriumisdescribedinfrequently.Conductivehearinglossisusuallytransient.Othersymptoms,suchashigh
fever,severepainbehindtheear,orfacialparalysis,suggestunusualcomplications(See'ComplicationsofAOM'below.)
DIAGNOSISOFAOMItisimportanttomakeanaccuratediagnosisofAOMtoavoidtheinappropriateuseof
antibioticsandtheassociatedincreaseinantibioticresistancerates.
ExaminationwithahandheldotoscopeisthestandardmethodofdiagnosisofAOM.Theadditionofpneumatoscopy
allowsevaluationoftympanicmembranemotionandisthushighlyrecommendedfordiagnosis.Otomicroscopy,available
inotorhinologyspecialtypractices,allowsevengreaterdefinitionofthetympanicmembrane.
Examinationtypicallydemonstratestympanicmembraneredness,opacification,bulging(picture1),andpoormobility
whenpneumaticpressureisappliedusingapneumaticotoscope(movie1andpicture2).Thetympanicmembraneis
normallytranslucent(picture3).Incontrast,thetympanicmembraneappearscloudyoropaquewhenthereisfluidinthe
middleear.Anairfluidlevelispresentwhenthetympanicmembraneappearstranslucentaboveandopaquebelowthe
lineofdemarcation(picture4).Inaddition,theremaybepurulenceintheearcanalifthereisanassociatedtympanic
membranerupture.
ThepredictivevalueandaccuracyofabnormalotoscopefindingshavenotbeenreportedforAOMinadultsbuthasbeen
studiedinchildren[3032].Inonestudy,flawedbythelackofbacterialculturesandselectiveperformanceofmyringotomy
toconfirmthediagnosis,thepredictivevalueofcombinationsofclinicalfindingswasestimated(table1)[32].Thetriadof
bulgingtympanicmembrane,impairedmobility,andrednessorcloudinessofthetympanicmembranepredictedthe
diagnosisofAOM,confirmedatmyringotomy,in83to99percentofcases.Anotherstudyfoundthatabulgingtympanic
membranewasmorelikelytopredictAOMthanadistinctlyredtympanicmembrane[30].
Atuningforkexamination(512Hz)maydemonstrateconductivehearingloss.TheWebertestisperformedbyplacingthe
forkonthevertexoftheforeheadtheperceivedsoundwillbelouderintheinfectedear(figure2).
Fiberopticnasopharyngoscopyshouldbeperformedtoruleoutnasopharyngealpathologyinpatientswithrecurrent
unilateralserousotitismedia.Therearelimiteddataregardingtheyieldofnasopharyngoscopyintheroutineworkupof
isolatedotitismediawitheffusion,butitshouldbeborneinmindthatindividualsfromChina,SoutheastAsia,andNorthern
Africaareatincreasedriskfornasopharyngealcarcinoma[33].(See"Epidemiology,etiology,anddiagnosisof
nasopharyngealcarcinoma",sectionon'Geographicandethnicdistribution'.)
BullousmyringitisBullousmyringitisisapresentationofAOMinwhichblisters(bullae)areseenonthetympanic
membrane.Despiteearlierbeliefthatthisconditionwasassociatedwithmycoplasmalinfection,morerecentevidence
indicatesthattheprevalenceofviral,bacterial,ormycoplasmalinfectionisthesameinbullousmyringitisasinnonbullous
otitismedia[34](picture5).Bullousmyringitiscanbeparticularlypainful.
DIFFERENTIALDIAGNOSISOFAOMThedifferentialdiagnosisofacuteotitismediaincludesotitisexterna,
eustachiantubedysfunction,nasopharyngealpathologyincludingherpeszosterinfection,andotherheadandneck
infections.
AOMcanusuallybedifferentiatedfromotitisexternainthatthelattertendstobemorepainful,especiallywithmild
tractionontheouterear,andthereisanormalappearingeardrumonexamination.
PatientswithrecurrentunilateralAOM(ie,morethantwoepisodesoverasixmonthtimeperiod)shouldundergo
investigationforeustachiantubeornasopharyngealpathology.Fiberopticnasopharyngoscopyand/orcontrastMRIof
theskullbaseandnasopharynxshouldbeperformedtoruleoutthepossibilityofamalignantprocessobstructingthe
eustachiantubeorifice.
Thediagnosisofherpeszosterisestablishedwithdevelopmentofatypicaldermatomalvesicularrashthatevolves
intocrustedlesions.Prodromalpainmayprecedetherashbyseveraldaysand,lesscommonly,aweekormore.
TheRamsayHuntsyndrome(herpeszosteroticus)ischaracterizedbythetriadofipsilateralfacialparalysis,ear
pain,andvesiclesinvolvingtheauditorycanalandauricle,andcanalsocausevertigo.(See"Clinicalmanifestations
ofvaricellazostervirusinfection:Herpeszoster",sectionon'Rash'and"Clinicalmanifestationsofvaricellazoster
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virusinfection:Herpeszoster",sectionon'RamsayHuntsyndrome(Herpeszosteroticus)'.)
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Deepspaceheadandneckinfectionsarediscussedseparately.(See"Deepneckspaceinfections".)
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TREATMENTOFAOMAntibioticsarethemainstayoftreatmentofuncomplicatedsuppurativeacuteotitismediain
adults.ConsistentresultsfrombacteriologicstudiesofmiddleeareffusionsinchildrenandadultswithAOMsuggestthat
thechoiceofantimicrobialagentsmaybebasedonknowledgeofthebacteriologyofAOM,ratherthanresultsofcultures
fromadjacentsitessuchasthethroatornasopharynx.
MicrobiologicresultsindicatethatatleastonequarterofchildrenhaveAOMduetoaviralrespiratorypathogen,andthat
someoftheepisodesofAOMresolvewithoutantibacterialagents.AmongchildrenwithAOM,approximately19percentof
pneumococcal,anduptoonehalfofnontypable(NT)H.influenzaeAOMcasesresolveandfluidsamplesfromthemiddle
earbecomesterilewithoutantibacterialdrugs[35,36].TheseresultspromptedsomeEuropeanclinicianstowithhold
antibiotictherapyfromchildrenwithearinfections[37].TheoptionofobservationofchildrenwithAOM,ratherthaninitial
antimicrobialtherapy,ispracticedextensivelyinWesternEurope.
In2004theAmericanAcademyofPediatricsandtheAmericanAcademyofFamilyPhysiciansproposedasimilarprotocol
forwithholdingantimicrobialtherapyforchildrenwhowereolderthantwoyearsofage,whosediagnosiswasuncertain,
andwhodidnothaveseveredisease(eg,moderatetosevereotalgiawithfever39C)[38].Therearenodataabout
withholdingantimicrobialdrugsfromadultpatientswithAOM.Atthistime,itisprudenttotreatadultswithantibiotic
therapyforadiagnosisofAOMtopreventthepotentialforcomplicationsofanuntreatedinfection.(See'Complicationsof
AOM'below.)
Whileawaitingresponsetoantibiotictherapy,itisimportanttoaddressthereliefofpain,whichcanbesignificant.Most
patientswillsymptomaticallyimprovewithamildanalgesic,suchasanonsteroidalantiinflammatorymedication,although
ashortcourseofopioidsisoccasionallyindicated.
ChoiceofinitialantibioticThepreferredantibacterialdrugforthepatientwithAOMmustbeactiveagainstS.
pneumoniae,NTH.influenzae,andM.catarrhalis[3942].A2001metaanalysisconcludedthatthereisnoevidenceto
supportanyparticularantibioticregimenversusanotherfortreatmentofAOM[43].
AmoxicillinremainsthedrugofchoiceforinitialtherapyofAOMbecauseofits25yearrecordofclinicalsuccess,
acceptability,limitedsideeffects,andrelativelylowcost.AmoxicillinisineffectiveagainstbetalactamaseproducingNT
H.influenzaeandM.catarrhalis,butthecurrentincidenceofampicillinresistantstrainsisnotsufficientlyhightorequirea
changeininitialtherapy.Oneobservationalstudyestimatedthat12percentofpatientswithacuteotitismediafailedinitial
antibiotictherapy[44].Amongpatientstreatedwithamoxicillin,10percentofpatientsfailedinitialtherapy.
Theusualdoseofamoxicillinis:
Mildtomoderatedisease:500mgevery12hours,or250mgevery8hours
Severedisease(eg,patientswithfever,significanthearingloss,severepain,and/ormarkederythema):875mg
every12hours,or500mgevery8hours
Someexpertsrecommenddosagesofamoxicillinforadultsupto2geveryeighthours[45].Suchhigherdosesmaybe
indicatedincommunitiesinwhichthereisasignificantprevalenceofstrainsofStreptococcuspneumoniaethatarenot
fullysusceptibletopenicillin.Amoxicillinclavulanateshouldbeconsideredforpatientswithsevereotalgiaorelevated
temperaturetocoverthepossibilityofbetalactamaseproducingNTH.influenzae.
Wesuggestthatpatientswithmildtomoderatediseasebetreatedforfivetosevendays,andthosewithmoresevere
diseasereceivea10daycourseofantibiotic.Thereislittleevidenceregardingoptimaldurationoftherapyforadultswith
AOM.
PenicillinallergyAcceptablealternativestoamoxicillininpatientswithallergytopenicillindependuponthetypeof
theprevioushypersensitivityreaction.
Inpatientswhoreportpenicillinallergybutwhodidnotexperienceatype1hypersensitivityreaction(urticariaor
anaphylaxis),wesuggestoneofthefollowing:
Cefdinir(300mgtwiceadayor600mgoncedaily)
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Cefuroxime(500mgevery12hours)
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Ceftriaxone(2gIMorIVonce)
Forpatientswithknownandsevereallergytobetalactamantibiotics,amacrolide(erythromycincombinedwith
sulfisoxazole,orazithromycin,orclarithromycin)isthepreferreddrug.Trimethoprimsulfamethoxazolemaybeused
inregionswherepneumococcalresistancetothiscombinationisnotaconcern.
LackofinitialresponseWithappropriateantimicrobialtherapy,mostpatientswithAOMaresignificantlyimproved
within48to72hours.Ifthereisnoimprovement,thepatientshouldbereexamined.Thepatientmayhavedevelopeda
newfocusofinfectionorhavereceivedinadequatetherapy.
Whenamoxicillinfails,thepatientshouldbetreatedwithasubsequentcourseofanantibioticwithabroaderactivity
spectrumforanother10daycourse.Appropriatesecondlineregimensincludeamoxicillinclavulanate(combinationof
amoxicillinplusthebetalactamaseinhibitorclavulanate),asecondgenerationcephalosporinsuchascefuroximeaxetil,or
athirdgenerationcephalosporin(suchasoralcefdinirorintramuscularceftriaxone).
RupturedtympanicmembraneWheninfectionresultsinacuteruptureofthetympanicmembrane,treatmentconsists
ofacombinationoforalandtopicalantibiotics,aswellaspreventingwaterentryintotheearcanal.Ototopicdrugsthat
havelowacidityandlowototoxicity,suchasFloxinotic,arepreferredacidic/antisepticagents,aswellastopicalagents
containingaminoglycosidesoralcohol,shouldbeavoidedwhenthemiddleearspaceisopen(table2).Althoughthereare
nodefinitivedatashowingthatpreparationssuchaspolymyxinneomycindropscausehearinglossinthese
circumstances,thereisanexplicitmanufacturerwarningnottouseneomycinpolymyxinBhydrocortisoneforanonintact
tympanicmembrane.
Inmostcases,therupturedtympanicmembranewillheal.Theperforationpermitsdrainageofthemiddleearabscessand
relievesincreasedmiddleearpressure.Withthereliefofmiddleearpressure,theextensivelyvascularizedtympanic
membraneusuallyhealsquickly,sealingtheperforationwithindays.Persistentsubjectivehearinglossfollowingresolution
oftheinfectionshouldbefollowedupwithanaudiogramandotolaryngologicconsultation.
Chronicperforationsmayoccur.Achronicallyinfectedmiddleearormastoidmayresultinpersistentsuppurativedrainage
(chronicsuppurativeotitismedia,CSOM).Patientswithperforationthatpersistsforsixweeksorlonger(withorwithout
suppurativedrainage)shouldbereferredtoanotolaryngologistforfurthermanagement.(See"Chronicotitismedia,
cholesteatoma,andmastoiditisinadults".)
COMPLICATIONSOFAOMComplicationsofacuteeardiseasecanoccurinthesettingofhostfactorssuchas
immunestatusandindividualanatomy,orincompletetreatment.Complicationsmayresultfromseedingofvascular
channelsandextensionalongpreformedpathways(suchastheovalwindow,roundwindow,internalauditorycanal,or
endolymphaticduct)andaretypicallydividedintointratemporalorextratemporalclassifications.
Intratemporalcomplications
MastoiditisAspectrumofdiseaseisassociatedwithmastoiditis.MastoideffusionisoftenseenonCTscanin
patientswithAOMandisnotusuallyclinicallysignificant.Symptomaticmastoiditisisararecomplicationofbothacute
andchronicotitismedia,butcanbeseriousduetoproximityofthemastoidtotheposteriorcranialfossa,lateralsinuses,
facialnervecanal,semicircularcanals,andthepetroustipofthetemporalbone.
Acutemastoiditisoccursmorecommonlyinchildrenthanadults,anditsincidencehasdeclineddramaticallyinthe
antibioticerawithroutineuseofantibioticsfortreatmentofotitismedia.Itisarareoccurrenceinadults.Inastudyof
patientswithacutemastoiditisadmittedtotwohospitalsinSwedenbetween1996and2000,only3ofthe42patients
wereolderthan18years[46].Twoofthethreeadultshadpriorcranialsurgeryonthesamesideasthemastoiditis.
Mastoiditismaybeclinicallymoresevereinolderadults,however[3].
Clinicalmastoiditismaypresentwithfever,posteriorearpainand/orlocalerythemaoverthemastoidbone,edemaofthe
pinna,oraposteriorlyanddownwarddisplacedauricle.Incoalescentmastoiditis,CTdemonstratescharacteristiclossof
thetrabecularbone[47].
CTscanshouldalwaysbeperformedwhenmastoiditisissuspected.Ifthereisaconcernforanintracranialprocess(ie,
sigmoidsinusthrombosis,intracranialabscess),thenanMRIscanshouldalsobeconsidered.Patientswithacute
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mastoiditisshouldbeadmittedtothehospitalandstartedonIVantibiotics.Whenmastoiditisoccursasacomplicationof
acuteotitismedia,antibioticswithactivityagainstStreptococcuspneumoniaeandHaemophilusinfluenzaeshouldbe
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started.Whenmastoiditispresentsasacomplicationofmorechronicdisease,coverageshouldincludeStaphylococcus
aureus,Pseudomonas,andentericgramnegativerods.
IfpatientsdonotrespondtoconservativetherapywithIVantibiotics,furtherinterventioniswarranted.Thisinvolves
mastoidectomyfordebridementofnecroticbone.Myringotomyisanadjuncttomastoidectomyforthetreatmentofacute
mastoiditis.(See"Chronicotitismedia,cholesteatoma,andmastoiditisinadults",sectionon'Surgicaltreatment'.)
FacialparalysisFacialparalysisisusuallyattributedtodirectneurocompressionthroughadehiscenceinthebone
coveringthefacialnerve,usuallyinthetympanicorverticalmastoidportions.Throughdestructionoftheoverlyingboneby
cholesteatomaorosteitis,endoneuritismaydevelop.Surgicaldecompressionoftheaffectedareaisrecommended.
LabyrinthitisLabyrinthitispresentsasnausea,vomiting,vertigo,tinnitus,andhearinglossinthesettingofboth
acuteandchronicearinfections.Apictureoflabyrinthitisinthesettingofacuteotitismediamayoccurasaresultof
serouslabyrinthitis,apresuppurativeconditioninwhichthelabyrinthundergoesinflammatorychangesinassociationwith
acutesuppurativeotitismedia.Serouslabyrinthitisisnotassociatedwithpermanentauditoryorvestibulardysfunction.
Treatmentispredominantlymedical,unlesspersistentgranulationtissueorcholesteatomaarepresent.Incontrast,
purulentlabyrinthitispresentswithintensevertigo,tinnitus,hearingloss,vomiting,nausea,andapictureofacutetoxicity.
(See"Treatmentofvertigo".)
HearinglossAvarietyofintratemporalchangescanproducehearinglossinthecontextofbothacuteandchronic
earinfections,thougharemorecommonlyseenincasesofchronicotitismedia.Thehearinglossisusuallyconductivein
natureduetoossicularerosionortympanicmembraneperforation.Sensorineuralhearinglossmayoccur,particularlyin
thesettingofanewinfectioninanadultwithoutapriorhistoryofearinfections.
PetrositisThepetrousapexofthetemporalboneisanatomicallycloselyrelatedtocriticalneuralandvascular
structures.Asaresult,infectionsofthepetrousapexcanresultinsevereneuralcompromise.Becauseoftheextensive
pneumatizationandpresenceofrichbonemarrowwithinthepetrousapex,itissusceptibletoinfectionorinflammation,
typicallyincombinationwithmastoiditis.TheinflammationmayextendintoDorelloscanaltransmittingtheVIthcranial
nerveandtheGasserianganglion,causingthetriadofsymptomsknownasGradenigoSyndrome:lateralrectuspalsy,
retroorbitalpain,andotorrhea.Thepresenceofbothotorrheaanddeeppainshouldleadonetosuspectpetrousapicitis.
ThemostcommonorganismresponsibleforpetrousapicitisisPseudomonasaeruginosa.Theacuteformtypically
developsoverarapidperiodoftimeandisduetosuddenobstructionofanormallypneumatizedpetrousapexaircell
system.DiagnosisisaffirmedbytemporalboneCT,demonstratingopacificationofthemastoidaircellssystemand
petrousapex,enhancementofthecavernoussinus,andbonyerosionwithinthepetrousapex.HighresolutionMRIwith
gadoliniumthroughthetemporalbonewilldemonstratealowintensitysignalonT1weightedimages,highintensitysignal
onT2weightedimages,andringenhancement.MRIfindingsareimportantindistinguishingpetrousapicitisfromother
lesionsofthepetrousapex.Treatmentconsistsofantibiotictherapy,withsurgicalexplorationreservedforthosewhodo
notrespondtoappropriateantibioticsordevelopcomplicationsfromtheinfection[48,49].Evenwithsurgicaldrainage,
prolongedpostoperativeantibioticsareusuallyrecommended,typicallyforaperiodofuptosixweeks.
Extratemporalcomplications
Epidural,subdural,andbrainabscessEpiduralabscessespresentmostcommonlyasheadachethatis
occasionallyrelievedbyprofusedrainagefromtheear.Treatmentrequiressurgicaldrainageafteridentificationofthe
abscessonMRIorCTimaging.Epiduralabscessesoccurmostcommonlysecondarytoerosionoftheposteriorfossa
plate.Lesscommonly,erosionofthetegmenmastoideumcanleadtoanepiduralabscess.(See"Spinalepidural
abscess".)
Thepresentationofasubduralabscessmaycloselymirrorthatofanepiduralabscess.Neurologicsignsaremorelikelyto
accompanyabscessesthatoccurinthesubduralspace,betweentheduraandarachnoidmeningeallayers.The
mechanismunderlyingthedevelopmentofasubduralabscessisthoughttobeboneerosionfollowedbythrombophlebitis.
Brainabscessesinassociationwithchronicearinfectionswilltypicallyinvolvethetemporallobeorcerebellum.Treatment
requiresdrainageofthebrainabscessbyaneurosurgeon,followedbysurgicaleradicationofthemastoidinfection.
Successfulmanagementofbrainabscessestypicallyrequiresaprolongedcourseofpotentantibiotictherapy.(See
http://www.uptodate.com/contents/acuteotitismediainadultssuppurativeandserous?topicKey=
"Pathogenesis,clinicalmanifestations,anddiagnosisofbrainabscess"and"Treatmentandprognosisofbacterialbrain
abscess".)
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OtitichydrocephalusOtitichydrocephalusreferstoasyndromeofincreasedintracranialpressureandsuppurative
otitismediaintheabsenceofabrainabscessormeningitis[50].Thetypicalcaseofotitichydrocephalusoccursfollowing
prolongedotitismedia.Themostcommonsymptomisheadacheonthesideoftheinvolvedear.Papilledemaisnotedand
evidenceofhydrocephalusisseenoncranialimagingbyCTorMRI.Thepathogenesisbehindotitichydrocephalus
appearstoinvolveabnormalcerebrospinalfluidmetabolismfrominflamedmeninges.Appropriatemanagementoftheear
diseaseandconventionalmeasuresofloweringintracranialpressureareindicated.
OtiticmeningitisOtiticmeningitisinassociationwithbothacuteandchroniceardiseasemayprogresstogeneral
patternsofinvolvementofthemeninges.TheoffendingpathogenisusuallynontypableH.influenzae,althoughS.
pneumoniaeand,toalesserextent,Neisseriameningitidiscanalsobeimplicated.Themeningitismaybelocal,inwhich
casecerebrospinalfluidanalysismaybenegativeforbacteria.Usually,however,themeningitisisgeneralized,andlumbar
puncturewithspinalfluidstudiesdemonstratebacteria.Otiticmeningitisisthemostcommonintracranialcomplication
fromchronicotitisandmastoiditis,althoughmeningitismayoccurinassociationwithacuteotitismediaaswell.Allforms
ofotiticmeningitistypicallypresentwiththeclassicsignsofmeningitis,includingfever,neckpain,photophobia,and
mentalstatuschanges[51].Treatmentrequiresantibiosisandsurgicalremovalofcholesteatomaand/orgranulationtissue.
LateralsinusthrombosisThelateral,orsigmoidsinus,runsthroughtheposteriorportionofthemastoidcortex,
whereithasacharacteristiccurvatureandeventuallyformsthejugularbulbandinternaljugularvein.Septiclateralsinus
thrombosisisexclusivelyassociatedwithinfectionofthemastoidaircells.Lateralsinusthrombosisisoftensubacutein
onset,withapersistentearacheasthefirstsymptompersistingforseveralweeksbeforetheonsetofheadache.Anemia,
increasedsignsofincreasedintracranialpressure,lowercranialneuropathies,andGriesingerssign(postauricularedema
fromemissaryveinthrombophlebitis)mayresultinadvancedstagesofthedisease.Sigmoidthrombophlebitismayextend
tothejugularvein,withresultantinternaljugularveinthrombosis.Treatmentrequiresdrainageoftheperisinusabscessvia
atransmastoidapproach,exposureofthesigmoidsinus,andantibiotics.Iftherearesignsofsystemicembolization(eg,
pulmonaryembolus),anticoagulationmaybeindicated.(See"Septicduralsinusthrombosis",sectionon'Septiclateral
sinusthrombosis'.)
OTITISMEDIAWITHEFFUSIONOMEisoftencharacterizedbyhearinglossorauralfullness,andpossiblyahistory
ofrecurrentepisodesofAOM.Theremaybeanantecedentupperrespiratorytractinfection,exacerbationinseasonal
allergysymptoms,orairplanetravel.
OtoscopicfindingsofOMEarefluid(oftenyellowish,butsometimesclear),andvisiblebehindaretractedtympanic
membrane.Anormaltympanicmembraneisshowninaphotograph(picture3),tobecomparedwitharetractedtympanic
membrane(picture6).Viscousbubblesmayalsobeseen,particularlyduringpneumaticotoscopy.Pneumaticotoscopy
demonstratesreducedmobilityoftheeardrum.
Tympanometry,thebestmeansofdiagnosis,willdemonstrateaflat(typeB)configuration.Patientswithsymptomsofear
fullnessassociatedwithhearinglossand/orvisualizationofanopaqueoryellowishtympanicmembraneonpneumatic
otoscopyshouldbereferredfortympanometrywithaudiometry.Audiometrywillrevealthepresenceofamildtomoderate
conductivehearingloss.Ifsensorineuralhearinglossisdemonstrated,particularlyinthepresenceofnormal
tympanometry,immediatereferraltoanotolaryngologistiswarrantedforpossibletherapywithglucocorticoidsandtorule
outaretrocochlearlesion.
TreatmentforOMEInmostcases,OMEresolvesspontaneouslywithouttreatment.Inasmallpercentageofcases,
theeffusionpersistsandrequiresadditionalintervention,suchaspressureequalizationtubes.
Simplemaneuverssuchasautoinsufflation(pinchingthenosewhilegentlyexhaling,forcingairbackthroughthe
eustachiantubeandrepressurizingtheear)maybehelpful,althoughasystematicreviewofsmallstudiesof
autoinsufflationinchildrendidnotdemonstrateasignificantdifferenceintympanometryresultsbetweeninterventionand
controlpatients[52].Studiesarenotavailableinadults,butthemaneuverisofnocost,withoutadverseeffects,andmay
behelpfultosome.
Otitismediawitheffusiondevelopsprimarilyfromamechanical/obstructivephenomenon.Thereisnoevidencethat
decongestantsandantihistaminesarebeneficialinthetreatmentofOMEinchildren[53].However,inadults,seasonal
allergicrhinitisornasopharyngealswellingfromanupperrespiratorytractinfectioncaninduceeustachiantube
dysfunction.Asaresult,mostpatientsaretreatedwithdecongestants,antihistamines,ornasalsteroidsdespitealackof
http://www.uptodate.com/contents/acuteotitismediainadultssuppurativeandserous?topicKey=
datademonstratingaclearbenefitinOME.Decongestantsmightcausesomesymptomreliefbyalleviatingnasal
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congestion.Amajorityofeffusionswillresolveoverthecourseof12weeks,andmostpatientscanbeobservedoverthis
timeperiod.
Iftheeffusiondoesnotresolveoverthistimeperiod,oriftherearepressingneedstoprovidepressureequalizationor
improvedhearing(eg,anticipatedairplanetravelthatcannotbedeferreduntilOMEresolves),thenmyringotomywithtube
placementshouldbeperformed.CaseserieshaveshownmyringotomyforOMEtobeeffectivewithfewadverseeffects
[54]therearenoavailablerandomizedtrialsofmyringotomyforthetreatmentofOMEinadults.
Myringotomyiscontraindicatedinpatientswithirreversibleeustachiantubedysfunctionsecondarytoetiologiessuchas
cancerorradiationtherapyinvolvingtheeustachiantube.Placementofatubeinsuchpatientscanpotentiallyresultin
chronicotorrhea.Hearinglossfromaneffusioninthesepatientsmustbeweighedagainstthepotentialdevelopmentofa
chronicallydrainingearwithtympanostomytubeplacement[55].
SUMMARYANDRECOMMENDATIONS
Acuteotitismedia(AOM)isanacuteillnesswithmiddleearfluidandinflammationofthemucosalliningofthe
middleearspace.Purulentotorrheamaybepresentthrougharupturedtympanicmembrane.Otitismediawith
effusion(OME)isthepresenceofmiddleearfluidwithoutinflammation,andusuallyresultsfrombarotraumasor
allergy.Acutemastoiditis,inflammationofthepetrousboneadjacenttothemiddleear,isinfrequentlyclinically
significant,butmaybesevereinolderadults.Chronicsuppurativeotitismedia(CSOM)occurswithaperforated
tympanicmembraneinthesettingofchronicearinfections.(See'Classificationofotitismedia'above.)
Eustachiantubedysfunction,commonlyrelatedtoseasonalallergicrhinitisorupperrespiratorytractinfection,isthe
mostimportantfactorinthepathogenesisofmiddleearinfections.(See'EtiologyofAOM'above.)
CommonbacteriacausingAOMinbothchildrenandadultsareStreptococcuspneumoniaeandHaemophilus
influenzae.GroupAbetahemolyticstreptococcus,Staphylococcusaureus,andMoraxellacatarrhalisareless
frequentcauses.Childhoodimmunizationwithconjugatepneumococcalvaccinemayaffectcurrentmicrobial
prevalencedata.Respiratoryviruseshavebeenisolatedfromaquarterofmiddleearfluidssampledfromchildren
withAOM.(See'Microbiology'above.)
TheonsetofAOMisassociatedwithotalgiaanddecreasedhearing.AOMistypicallyunilateralanddrainagemaybe
presentifthetympanicmembranehasruptured.Thetympanicmembraneisred,opacified,bulgingandimmotile,and
aconductivehearinglossmaybedemonstrated.(See'ClinicalmanifestationsofAOM'aboveand'Diagnosisof
AOM'above.)
WesuggestthatadultswithAOMbemanagedwithantibiotictreatmentratherthan"watchfulwaiting"(Grade2B).
ThepreferredantibacterialdrugforthepatientwithAOMmustbeactiveagainstS.pneumoniae,nontypableH.
influenzae,andM.catarrhalis.Thereisnoevidencetosupportanyparticularantibioticregimenversusanotherfor
treatmentofAOM.Basedonitsacceptabilityandlowcost,wetypicallyuseamoxicillin500mgthreetimesadayfor
fivetosevendaysasinitialtherapyforAOMinpatientswithoutpenicillinallergy.Amacrolide(erythromycin
combinedwithsulfisoxazole,orazithromycin,orclarithromycin)isthepreferreddrugforpenicillinallergicpatients.
(See'TreatmentofAOM'above.)
Patientswhodonotrespondsymptomaticallywithin48to72hoursshouldbereexamined.Treatmentregimensfor
patientswhodidnotrespondtotheinitialantibioticcourseincludeamoxicillinclavulanateorasecondgeneration
cephalosporin.(See'Lackofinitialresponse'above.)
Otitismediawitheffusion(OME)ischaracterizedbyhearinglossorauralfullnessandpossiblyahistoryofrecurrent
episodesofAOM.Otoscopyrevealsfluidandanimmobileretractedmembranetympanometryisthebestmeansof
diagnosis.(See'Otitismediawitheffusion'above.)
Amajorityofeffusionswillresolveoverthecourseof12weeks,andmostpatientswithOMEcanbeobservedover
thistimeperiod.Wesuggestatrialoforaldecongestantsduringthistime(Grade2C).Patientsshouldbeinstructed
inautoinsufflationasalowcostintervention.Myringotomywithtympanostomytubesmaybeconsideredfor
persistentsymptomaticeffusionsat12weeks,andearlierforselectedpatientswithneedforimmediatepressure
equalization(eg,airtravelthatcannotbedeferred).(See'TreatmentforOME'above.)
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Topic6872Version31.0
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GRAPHICS
Normalearanatomy
Thisfigureshowsthenormalstructuresoftheouter,middle,andinnerear.
Graphic63141Version3.0
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Acuteotitismedia
Examplesofthewhite,bulgingtympanicmembraneseeninacuteotitismedia.The"B"
panelalsodemonstratesmarkederythemaalongthehandleofthemalleusandanair
fluidlevelintheanterosuperiorportionofthetympanicmembrane.
CourtesyofAlejandroHoberman,MD.
Graphic63268Version3.0
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Pneumaticotoscope
CourtesyofLauraGoguen,MD.
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Acuteotitismediainadults(suppurativeandserous)
Normaltympanicmembrane
Normallefttympanicmembranewithpearlygraycolor.
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Acuteotitismediainadults(suppurativeandserous)
Tympanicmembranewithairfluidlevels
Anairfluidlevelisappreciatedwhenthetympanicmembraneappears
translucentaboveandopaquebelowalinedemarcatingthe
separation.
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Acuteotitismediainadults(suppurativeandserous)
Predictivevalueofcombinationsofotoscopicfindingsinchildrenwith
acuteearsymptoms
PositionofTM
MobilityofTM
ColorofTM
Predictivevalue,percent
Combinationswith>80percentpredictivevalueofAOMcomparedwithmyringotomy
Bulging
Distinctlyimpaired
Cloudy
99
Bulging
Slightlyimpaired
Cloudy
99
Bulging
Distinctlyimpaired
Distinctlyred
94
Bulging
Slightlyimpaired
Slightlyred
93
Bulging
Distinctlyimpaired
Slightlyred
85
Bulging
Slightlyimpaired
Distinctlyred
83
Normal
Distinctlyimpaired
Cloudy
97
Normal
Distinctlyimpaired
Distinctlyred
89
Combinationswith<50percentpredictivevalueofAOMcomparedwithmyringotomy
Normal
Slightlyimpaired
Distinctlyred
47
Normal
Slightlyimpaired
Slightlyred
41
Normal
Normal
Cloudy
37
Normal
Normal
Distinctlyred
15
Normal
Normal
Slightlyred
Normal
Normal
Normal
0.1
Retracted
Distinctlyimpaired
Normal
29
Retracted
Slightlyimpaired
Normal
TM:tympanicmembrane.
Datafrom:
Pelton,SI.Otoscopyforthediagnosisofotitismedia.PediatrInfectDisJ199817:540.
Karma,PH,Sipila,MM,Kayaja,MJ,Penttila,MA.Pneumaticotoscopyandotitismedia:Thevalueofdifferent
tympanicmembranefindingsandtheircombinations.In:Recentadvancesinotitismedia:proceedingsofthe
FifthInternationalSymposium,Lim,DJ,Bluestone,CD,Klein,JO,etal(Eds),Decker,Burlington,Ontario,
Canada,1993.p.41.
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Acuteotitismediainadults(suppurativeandserous)
Evaluationofhearingloss,WeberandRinnetests
Webertest:Placethebaseofastrucktuningforkonthebridgeofthe
forehead,nose,orteeth.Inanormaltestthereisnolateralizationofsound.
Withunilateralconductiveloss,soundlateralizestowardsaffectedear.With
unilateralsensorineuralloss,soundlateralizestothenormalorbetterhearing
side.
Rinnetest:Placethebaseofastrucktuningforkonthemastoidbonebehind
theear.Havethepatientindicatewhensoundisnolongerheard.Movefork
(heldatbase)besideearandaskifnowaudible.Inanormaltest,AC>BC
patientcanhearforkatear.Withconductiveloss,BC>ACpatientwillnot
hearforkatear.
AC:airconductionBC:boneconduction.
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Acuteotitismediainadults(suppurativeandserous)
Bullousmyringitis
Bullousmyringitisischaracterizedbypainfulvesiclesthatappearon
thetympanicmembrane.
CourtesyofGlennCIsaacson,MD,FAAP,FACS.
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Acuteotitismediainadults(suppurativeandserous)
Topicalpreparationsforexternalotitis
Topical
preparation
Trade
name
(United
States)
Antiseptic
Glucocorticoid
pH
Preservative
Acidifying/antisepticsolution
Aceticacid2
percentotic
solution
Generic
(formerly
Acetasol)
Aceticacid
None
Notes
3.5to5
Noadditional
Avoiduseof
acidifying
antiseptic
agentsif
tympanic
membraneis
knownor
suspectedtobe
nonintact
containsboric
acid
Hydrocortisone
2to4
Noadditional
Avoiduseof
acidifying
antiseptic
agentsif
tympanic
membraneis
knownor
suspectedtobe
nonintact
contains
propyleneglycol
(dryingagent)
and
benzethonium
forpromoting
tissue
penetration
Acidifying/antisepticandglucocorticoidcombination
Aceticacid2
percentand
hydrocortisone
1percentotic
solution
Acetasol
HC,VoSol
HCotic
Aceticacid
Antibioticandglucocorticoidcombinations
Ciprofloxacin
0.3percentand
dexamethasone
0.1percentotic
suspension
Ciprodex
None
Dexamethasone
Buffered
Benzalkonium
chloride
Containsboric
acid
Ciprofloxacin
0.2percentand
hydrocortisone
1percentotic
suspension
CiproHC
otic
None
Hydrocortisone
Buffered
Benzylalcohol
Neomycin0.35
URL,DOI,
Cortisporin
None
Hydrocortisone
Acidic
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Potassium
Avoiduseof
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Acuteotitismediainadults(suppurativeandserous)
percent,
polymyxinB
10,000
units/mL,and
hydrocortisone
0.5percentotic
otic
metabisulfite
solution
topical
aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact
Neomycin0.33
percent,colistin
0.3percent,
and
hydrocortisone
1percentotic
suspension
ColyMycin
S,
Cortisporin
TC
None
Hydrocortisone
Thimerosal
Avoiduseof
topical
aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact
contains
thonzoniumfor
promoting
tissue
penetration
Gentamicin0.3
percentand
prednisolone1
percent
ophthalmic
suspension
PredG
None
Prednisolone
5.4to
6.6
Benzalkonium
chloride
Avoiduseof
topical
aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact
Tobramycin0.3
percentand
dexamethasone
0.1percent
ophthalmic
suspension
TobraDex
None
Dexamethasone
Buffered
Benzalkonium
chloride
Avoiduseof
topical
aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact
Gentamicin0.3
percentand
betamethasone
0.1percentotic
solution
Garasone*
(not
available
inUnited
States)
None
Betamethasone
Buffered
Benzalkonium
chloride
Avoiduseof
topical
aminoglycosides
iftympanic
membraneis
knownor
suspectedtobe
nonintact
containsboric
acid
Cetraxal
otic
None
None
Buffered
Nonesingleuse
container
Suppliedas0.5
Antibioticsolutions
Ciprofloxacin
0.2percentotic
solution
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Acuteotitismediainadults(suppurativeandserous)
contains
povidone
Ofloxacin0.3
percentotic
solution
Generic
(formerly
Floxinotic)
None
None
6.5
Benzalkonium
chloride
None
Dexamethasone
Buffered
Benzalkonium
chloride
Glucocorticoidsuspension
Dexamethasone
0.1percent
ophthalmic
suspension
Maxidex
*NotavailableintheUnitedStates.ProductshownisavailableinCanadaandothercountries.
Preparedwithdatafrom:
1.RosenfeldRM,SchwartzSR,CanonCR,etal.Clinicalpracticeguideline:Acuteotitisexterna.Otolaryngol
HeadNeckSurg2014150:S1.
2.UnitedStatesprescribinginformationavailableatNationalLibraryofMedicineDailyMedwebsite(Accessed
onMarch17,2014).
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Acuteotitismediainadults(suppurativeandserous)
Retractedtympanicmembrane
Whenthereisanegativepressureinthemiddleearcavity,the
positionofthetympanicmembranewillberetracted.
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Acuteotitismediainadults(suppurativeandserous)
ContributorDisclosures
CharlesJLimb,MDNothingtodisclose.LawrenceRLustig,MDNothingtodisclose.JeromeOKlein,MD
Consultant/AdvisoryBoards:GlaxoSmithKline[proteinpneumococcalconjugatevaccine(DataandSafetyMonitoring
Board)].DanielGDeschler,MD,FACSNothingtodisclose.AllysonBloom,MDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedby
vettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.
AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
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