The classic signs and symptoms of acute otitis media include the following:

• Pain in one or both ears
• Hearing loss in one or both ears
• Discharge from the ear

These classic signs and symptoms may be accompanied by non-specific signs and symptoms such as fever, mild upper respiratory symptoms, malaise, vomiting and diarrhea.

In infants and neonates, the classic signs and symptoms can not be described. They may be asymptomatic or may present with only non-specific manifestations such as irritability, fever, diarrhea, vomiting; or they may pull at their ears.

Chronic otitis media has a pattern as compared to acute otitis media and presents with hearing impairment, perforation of the tympanic membrane and a foul smelling discharge from the ear canal; the latter persisting for longer than 6 weeks.

• Fever

  […] complications includes the following: Labyrinthitis - Fever, nystagmus, serous or suppurative otitis media Mastoiditis with subperiosteal abscess - Fever, fluctuance overlying the mastoid area, lateral displacement of pinna, otitis media Petrositis - [emedicine.com]

  If your child is younger than three months of age and has a fever, it’s important to always call your healthcare provider right away. [web.archive.org]

  The combination of these signs with ear pain or fever confirms the diagnosis of AOM. [medicalguidelines.msf.org]

  Around 60% to 85% of children have AOM during the first year of life. acute onset pain in the ear is the most common symptom. pain is a result of inflammatory reaction Fever persistent or intermittent fever associated with ear pain is suggestive of acute [medicaljoyworks.com]

  They may be asymptomatic or may present with only non-specific manifestations such as irritability, fever, diarrhea, vomiting; or they may pull at their ears. [symptoma.com]

• Fatigue

  This may also cause people to be irritable, as well as fatigued and have a decreased appetite. When the condition is particularly severe and often after inadequate treatment, it is possible for the tympanic membrane to rupture. [news-medical.net]

  The non-specific symptoms of otitis media include: fever (especially in infants), fatigue, intense malaise, nausea and vomiting. [ims.uniklinik-freiburg.de]

• Soft Tissue Mass

  The computerized tomography scan of the temporal bone showed an extensive soft tissue mass without any osteolysis. [ncbi.nlm.nih.gov]

  Magnetic resonance imaging (MRI) is especially useful in the workup for soft-tissue masses that may be contributing to middle ear effusions (MEE) because of its superior ability to delineate borders within soft tissues and to help determine the extent [emedicine.com]

• Mucosal Edema

  Many factors have been implicated in the failure of the clearance mechanism, including ciliary dysfunction; mucosal edema; hyperviscosity of the effusion; and, possibly, an unfavorable pressure gradient. [emedicine.com]

• Intermittent Fever

  Around 60% to 85% of children have AOM during the first year of life. acute onset pain in the ear is the most common symptom. pain is a result of inflammatory reaction Fever persistent or intermittent fever associated with ear pain is suggestive of acute [medicaljoyworks.com]

• Rhinitis

  Chronic postnasal drip, chronic hypertrophic rhinitis, and nasal polyps were correlated with the presence of middle ear pathologies; allergic rhinitis was negatively correlated. [ncbi.nlm.nih.gov]

  The duration and severity of symptoms were not predictive for AOM, although rhinitis lasted longer and conjunctivitis was more severe in children with AOM. [doi.org]

  Antibiotics should be given for bacterial rhinitis, sinusitis, and nasopharyngitis. Demonstrated allergens should be eliminated from the patient’s environment and immunotherapy should be considered. [msdmanuals.com]

  Fever, otalgia, headache, irritability, cough, rhinitis, listlessness, anorexia, vomiting, diarrhea, and pulling at the ears are common, but nonspecific symptoms. [aafp.org]

  The following is a brief list of evidence for and against the etiologic role of allergy in OM: Many patients with OM have concomitant allergic respiratory disease (eg, allergic rhinitis, asthma) Many patients with OM have positive results to skin testing [emedicine.com]

• Snoring

  Other symptoms include hearing loss, snoring, mouth breathing, fever, headache, vomiting, and diarrhea. Causes The Eustachian (pharyngotympanic) tube is a drain that connects the nose and throat to the middle ear. [nicklauschildrens.org]

  […] overweight and obesity may increase the risk for chronic otitis media with effusion (OME), or vice versa. [39] A study by Walker et al found that preschool children with chronic otitis media with effusion tended to be characterized by nasal obstruction, snoring [emedicine.com]

  Other indications for adenoidectomy included chronic rhinorrhea with associated rhinosinusitis or chronic mouth breathing with associated snoring. [jamanetwork.com]

  For the following symptoms, an AT is indicated: Nasal obstruction Recurrent infections of the upper airways with chronic adenoiditis Snoring High-risk patients The most important high-risk patients are children with a cleft palate, PCD, or Down’s syndrome [doi.org]

• Nasal Congestion

  Temporary hearing loss can result from middle ear infections, and he infection may occur in the presence of signs and symptoms of an upper respiratory infection, such as nasal congestion, runny nose, or cough. [medicinenet.com]

• Postnasal Drip

  Chronic postnasal drip, chronic hypertrophic rhinitis, and nasal polyps were correlated with the presence of middle ear pathologies; allergic rhinitis was negatively correlated. [ncbi.nlm.nih.gov]

• Vomiting

  We describe the youngest case to date of a 2 year old child who developed central skull base osteomyelitis (SBO) initially presenting with a fever, vomiting and sore throat. [ncbi.nlm.nih.gov]

  Adverse effects likely to be related to the use of antibiotics such as vomiting, diarrhoea or rash. [doi.org]

• Loss of Appetite

  Loss of appetite: This may be most noticeable in young children, especially during bottle feedings. Pressure in the middle ear changes as the child swallows, causing more pain and less desire to eat. [my.clevelandclinic.org]

  Symptoms of ear infections: Pain (earache) If you child cannot tell you he/she is in pain look for these symptoms: Drainage from the ear Pulling or rubbing the ears Loss of appetite Does not react to soft sounds Can’t sleep, wakes up at night Fever Cranky [chkd.org]

  […] of appetite (refusing to eat) Infants will not suck because it causes pain Vomiting Diarrhea Signs and Symptoms of Chronic Otitis Media With Effusion If your child is old enough to tell you, he may complain of: A feeling of fullness in the ears A popping [nationwidechildrens.org]

• Mouth Breathing

  Other symptoms include hearing loss, snoring, mouth breathing, fever, headache, vomiting, and diarrhea. Causes The Eustachian (pharyngotympanic) tube is a drain that connects the nose and throat to the middle ear. [nicklauschildrens.org]

  Other indications for adenoidectomy included chronic rhinorrhea with associated rhinosinusitis or chronic mouth breathing with associated snoring. [jamanetwork.com]

• Malocclusion

  Septic arthritis of the temporomandibular joint (SATMJ) is an extremely rare disease with characteristic features of preauricular pain, swelling, redness, and malocclusion. [ncbi.nlm.nih.gov]

• Otalgia

  Severe illness is defined as moderate to severe otalgia or temperature greater than 39 C, whereas nonsevere illness is defined as mild otalgia and temperature less than 39 C. [emedicine.com]

  Acute suppurative otitis media (ASOM) - A history of gradually increasing otalgia followed by the appearance of a discharge with some reduction in otalgia. Patients sometimes hear/feel a 'pop' just before the discharge appears. [entsho.com]

  To our knowledge, this is the first reported case of dural arteriovenous fistula presenting with conductive hearing loss and otalgia. [ncbi.nlm.nih.gov]

• Hearing Impairment

  Children can be impacted mainly with hearing impairment and/or co-occurring recurrent acute otitis media (AOM) thus requiring treatment. [ncbi.nlm.nih.gov]

  AOM: Acute Otitis Media; CSOM: Chronic Suppurative Otitis Media; HI: Hearing Impairment. [doi.org]

  Hearing Impairment Classification: A categorisation that describes the degree of disability associated with hearing loss in the better ear. Hearing impairment classification applies a graded scale of mild, moderate, severe and profound. [www1.health.gov.au]

• Tinnitus

  Presenting symptoms of the latter condition may include hearing loss, tinnitus, dizziness, vertigo and facial palsy. Otitis media with effusion secondary to eustachian tube dysfunction has also been reported. [ncbi.nlm.nih.gov]

  Learn More About Topic Tinnitus Over 50 million Americans have experienced tinnitus, or ringing in ears, which is the perception of sound without an external source being present. [entnet.org]

• Ear Fullness

  fullness during suppurative otitis media. ear pressure or clogging sensation of the ear both are suggestive of aural fullness, otitis media due to effusion is the major diagnosis Fullness of the ear adults and older children presents with ear fullness [medicaljoyworks.com]

  However, sometimes there is enough fluid in the middle ear space that you will notice one or more of the following symptoms: Pain Hearing loss Ear fullness Child pulling at their ear Child has a change in behavior If you notice a prolonged behavior change [verywellhealth.com]

  Symptoms of acute otitis media (AOM) The following are symptoms of acute otitis media: fever ear pulling complaints of ear pain, ear fullness, or hearing loss by older children fussiness, irritability, or difficulties in hearing, feeding, or sleeping [healthofchildren.com]

• Otorrhagia

  We report a case of a 3-year-old child presenting with a 1-year history of otorrhea and otorrhagia followed by a 6-month history of postauricular swelling in the right ear. Imaging demonstrated a large mass of organized tissue. [ncbi.nlm.nih.gov]

• Irritability

  OME is more common than AOM, and may be caused by viral upper respiratory infections, allergies, or exposure to irritants (such as cigarette smoke). [web.archive.org]

  ear pain) is the most prevalent and important symptom of AOM Irritability In neonates, irritability, excessive crying, feeding difficulty may the only signs of acute infection leading to a difficult diagnosis Irritability In neonates, irritability, [medicaljoyworks.com]

  Irritability: Any kind of continuing pain may cause irritability in children and adults. Poor sleep: Pain may be worse when the child is lying down, as fluid is shifting. Fever: Ear infections can cause temperatures up to 104 F. [my.clevelandclinic.org]

• Vertigo

  Presenting symptoms of the latter condition may include hearing loss, tinnitus, dizziness, vertigo and facial palsy. Otitis media with effusion secondary to eustachian tube dysfunction has also been reported. [ncbi.nlm.nih.gov]

  Benign Paroxysmal Positional Vertigo (BPPV) Benign paroxysmal positional vertigo, or BPPV, is the most common inner ear problem and cause of vertigo, or false sense of spinning. [entnet.org]

• Papilledema

  The following signs or symptoms are suggestive of intracranial complications: Fever associated with a chronic perforation Lethargy Focal neurologic signs (eg, ataxia, oculomotor deficits, seizure) Papilledema Meningismus Altered mental status Severe headaches [emedicine.com]

In addition to the clinical features, the following investigations are needed to establish the diagnosis of otitis media.

Otoscopy and tympanometry: Otoscopy and tympanometry will reveal several abnormal features characteristic of otitis media including the following.

• There is an abnormal contour of tympanic membrane (which consists of fullness, bulging and/or extreme retraction).
• Erythema of tympanic membrane is often present. Presence of liquid in the middle ear cavity may impart a pale yellow color in the tympanic membrane.
• There may be opacification in the tympanic membrane.
• Structural changes in the tympanic membrane such as scars or perforation may also be seen.
• The mobility of the tympanic membrane is also impaired. Mobility is the most sensitive and specific indicator to detect the presence or absence of effusion in the middle ear.

Culture of the ear discharge: Culture of the ear discharge may be done to determine the presence and type of the causative agent.

Needle aspiration with culture (or PCR) of middle ear contents: Aspiration and culture of the contents of the middle ear contents may be done in cases when there is no discharge from the ear. It is the most reliable method for confirming the presence of infection and identifying the causative agent. In place of culture, polymerase chain reaction (PCR) may also be used to detect the bacteria with high sensitivity and specificity [5] [6].

• Hyperviscosity

  Many factors have been implicated in the failure of the clearance mechanism, including ciliary dysfunction; mucosal edema; hyperviscosity of the effusion; and, possibly, an unfavorable pressure gradient. [emedicine.com]

The treatment of various types of otitis media is as below.

Acute otitis media:

• Dry mopping of the ear should be done.
• Analgesics are given to relieve pain.
• Antipyretics are given to reduce fever.
• The initial treatment is directed against the most common organisms (Streptococcus pneumonia and Hemophilus influenza). Amoxicillin is the drug of choice while alternative drugs include erythromycin, cefaclor, cefuroxime and trimethoprim-sulfamethoxazole. Later on, if needed, antibiotics can be changed according to the culture and sensitivity report.
• The patients who are not cured after a second course of antibiotics, or those who become severely ill may be considered for tympanocentesis to identify the causal pathogen so that the appropriate antibiotic can be used.

Recurrent otitis media:
Patients with recurrent otitis media may be placed on daily doses of an antibiotic such as sulfisoxazole or amoxicillin prophylaxis for 3 to 6 months after acute infection has cleared.

Chronic suppurative otitis media:
The pathogens are usually mixed in this case and commonly include S. aureus and P. aeuroginosa, or both [7]. Initial therapy with oral antibiotic that is effective against Staphylococcus is tried but optimal therapy is based on middle ear cultures and may require intravenous antibiotics against Psuedomonas.

Chronic otitis media with effusion:
In this case, a 2 to 4 weeks course of oral antbiotics is usually effective. In resistant cases, the placement of tympanostomy tubes is recommended for more than 2 months.

With proper treatment, the majority of the cases of otitis media recover completely. Untreated and complicated otitis media can lead to the development of a number of serious complications including meningitis, mastoiditis and permanent hearing loss.

Bacteria are the most common agents causing otitis media [1] [2]. In around 25 to 40% of the cases, the underlying agent is Streptococcus pneumonia. Hemophilus influenza causes otitis media in around 15 to 25% of causes. Otitis media caused by Hemophilus influenza is often recurrent. 12 to 20% of the cases are caused by Moraxella catarrhalis. Other agents include group A streptococci, staphylococcus aureus and Pseudomonas aeruginosa; the latter being a cause of chronic otitis media.

Viruses are not important direct causes of otitis media; however, viral upper respiratory tract infections commonly result in the obstruction of the Eustachian tube which allow bacteria to multiply in the middle ear space.

The following factors are associated with an increased incidence of otitis media in childhood:

• Age less than 1 year
• Immunodeficiency
• Down’s syndrome
• Structural defects that impair Eustachian tube function (such as cleft palate)
• Siblings with recurrent otitis media
• Passive smoking
• Low socioeconomic status and poor living conditions

Breast feeding reduces the incidence of acute respiratory tract infections and prevents colonization with otitis pathogens through selective IgA antibodies.

Otitis media is one of the most common infections of childhood. It is particularly common between the ages of 6 months and 3 years. It is also relatively common in adults.

Bacteria gain access to the middle ear usually from the nasopharynx. When the normal patency of the Eustachian tube is blocked by local infection, pharyngitis or hypertrophied adenoids [3], obstruction to the flow of secretions from the middle ear to the pharynx results in the development of an effusion in the middle ear. This effusion then becomes infected by bacteria leading to otitis media [4].

Proper care of the patients suffering from upper respiratory infections, structural defects of the Eustachian tube or immunodeficiency can prevent otitis media from occurring. Vaccines against Streptococcus pneumonia may prevent otitis media [8] [9]. The use of Xylitol syrup may also prevent otitis media [10].

Otitis media is defined as the inflammation of the middle ear which is the second part of the ear. It is the cavity in the temporal bone comprising the cavitas tympani, auditory ossicles and tube auditiva. On the basis of the pattern of the disease, otitis media may be classified as acute, chronic or recurrent.

• Acute otitis media presents with rapid onset of symptoms such as pain and hearing loss in one or both of the ears.
• Recurrent otitis media can be defined as three or more new episodes of acute otitis media within a 6 months period. It may also be defined as four or more episodes of acute otitis media during a period of one year. 
• Chronic otitis media is defined as persistent discharge from the ear for a duration longer than 6 weeks.

Otitis media refers to the the infection and swelling of the middle part of the ear. If treated properly and early, it has a good prognosis. Untreated cases may develop serious complications such as hearing loss and life threatening infection of the membranes around the brain. Common symptoms include ear pain, hearing loss and discharge from the ear. 

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3. Bluestone CD. Pathogenesis of otitis media: role of eustachian tube. The Pediatric infectious disease journal. Apr 1996;15(4):281-291.
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