Otitis is a general term for inflammation or infection of the ear. It is subdivided into the following categories:
- Otitis externa: this condition affects the outer ear and the ear canal.
- Otitis media: this condition affects the space behind the eardrum.
- Otitis interna: this is an uncommon condition which involves the inner ear. The inner ear includes sensory organs for balance and hearing.
Otitis externa (swimmer's ear) is an infection or inflammation of the outer ear and ear canal. The inflammation can be secondary to dermatitis (eczema) without infection and typical symptoms include itching and mild pain. Infections are caused by bacteria or fungi and symptoms are usually more severe and include swelling inside the ear canal, reduced hearing, pain, itching, and tenderness when the ear is touched.
Our ears have a natural way of preventing infections by producing cerumen (wax). Cerumen is acidic which retards bacterial growth. It also provides a waterproof barrier and it contains enzymes which kill bacteria. Infections are often caused when the protective barrier is traumatized by cleaning or water exposure. The goal of treatment is to return the ear canal skin to a healthy condition. When external otitis is mild, water precautions for a few days and keeping all implements out of the ear usually results in a cure. If the infection is moderate to severe spontaneous improvement may not occur.
The first step in treatment is to clean the ear canal. This may be difficult because the ear is tender and swollen but a specialist is trained to do this properly. Topical solutions or powder are the mainstays of treatment and oral antibiotics are rarely used. Most infections resolved rapidly but severe infections may require several treatments.
Otitis media affects the space behind the eardrum and it is the most common infection in children. About 80% of children will have at least one ear infection before age two. Ear infections typically follow viral respiratory infections like colds or allergy attacks and some people are prone to ear infections because their eustachian tubes are immature and do not permit normal equalization of pressure between the nose and ear. These conditions cause swelling of the mucus membranes inside the nose, ear, and eustachian tube which cause accumulation of mucus within the ear, and then infection.
When the middle ear becomes acutely infected by bacteria, pressure builds up behind the ear drum which causes pain. In severe or untreated cases, the tympanic membrane may rupture, allowing the pus in the middle ear space to drain into the ear canal. Even though the rupture of the tympanic membrane suggests a traumatic process, it is almost always associated with the dramatic relief of pressure and pain and the perforation usually heals. In a simple case of acute otitis media the body's defenses are likely to resolve the infection. To treat pain caused by otitis media, oral medications are often used and include ibuprofen, acetaminophen, and / or narcotics. Topical numbing drops are also effective.
Antibiotic administration may hasten recovery of the ear and the choice to treat with antibiotics is made by a doctor after examining the ear. For infections that do not respond to symptomatic treatment, oral antibiotics or shots are used. Typically the antibiotic is taken for ten days. With otitis media, infected fluid is present behind the eardrum. Antibiotics kill the germs within the fluid but it may take weeks before the fluid resolves and the ear returns to normal. About 50% of ears are normal at two weeks but 10% of ears still have fluid after three months. If the antibiotic fails to work, another antibiotic may be used. In some cases, the infection fails to respond even after several treatments and for these patients tubes may be placed in order to resolve the infection or to restore hearing. In some children, the ear infection resolves after treatment but they tend to get frequent infections. In these patients, tubes may also be useful.
For ear infections that do not resolve with treatment or in patients who have an excessive number of ear infections, tubes may be offered. Ear infections are often the result of a dysfunctional eustachian tube. Young children naturally have underdeveloped eustachian tubes and full maturity is reached at about age twelve. Some people have defects of their nose or throat, or large adenoids or a cleft palate which cause poor function of the eustachian tubes. When the eustachian tubes are obstructed the ear cannot equalized pressure and mucus becomes trapped within the middle ear.
By lancing the eardrum, the infection and fluid may drain or the fluid can be removed by suction, but because the eardrum heals rapidly the infection may not be cured. Tubes were designed to keep the hole in the eardrum open so the infection can resolve and they also permit equalization of air pressure inside the middle ear which tends to reduced mucus accumulation and ear infections. Tubes come in different styles and most are made of plastic and are intended to last about one year, but some tubes are semi-permanent. Placement of tubes has shown to result in an improved quality of life by reducing the rate of ear infections and eliminating fluid behind the eardrum.
For children tubes are placed in a simple procedure in the hospital under anesthesia and in adults they may be placed in the office with local anesthesia. Tubes are an effective way to resolve ear infections, restore hearing caused by fluid, and reduce the frequency of ear infections. If an infection occurs with tubes in place, the ear will drain but hearing loss, fever, and pain are uncommon; treatment is often simpler as well because most infections respond rapidly to antibiotic ears drops. The risks of tubes are low but include failure of the tube to fall out of the eardrum and perforation of the eardrum.
Best Clinical Practice Guidelines for placement of ear tubes were defined by the American Academy of Otolaryngology in 2013 in order to improve consistency of care and to reduce unnecessary procedures. In a small percentage of children, allergies and acid reflux or large adenoids are a factor and may cause ear infections, but routine nasal endoscopy, restrictive diets, and extensive allergy work-up is not recommend in the Best Clinical Practice Guidelines because yield is low, patient cost is high, and outcomes have not been shown to differ.
Practice guidelines include treatment of acute ear infections or fluid behind the eardrums. If the fluid or infection fails to resolve and the child is at risk (history of permanent hearing loss, autism, syndromes, visual impairment, and developmental delay) or they have significant symptoms despite treatment, then tubes may be offered. If they are not at risk and symptoms are mild, observation is indicated with follow-up in 3 months. If fluid has been present for more than three months, a hearing test should be obtained and if abnormal, tubes may be offered. If hearing is normal and they have no symptoms, observation is continued with follow-up in 3 to 6 months. If hearing is normal and they have symptoms, tubes may be offered.
Otitis interna is uncommon and symptoms are usually violent with vertigo or acute sudden hearing loss.
Labyrinthitis is thought to be caused by a viral infection. Patients usually present with the sudden onset of severe vertigo, nausea, and vomiting. The symptoms can be severe and disabling such that patients often seek urgent care and require sedatives to suppress symptoms. Severe symptoms typically subside over a week, but vague symptoms of imbalance may last for months. Hearing loss rarely accompanies vertigo. Occasionally a bacterial infection of the middle ear can spread to the inner ear and cause this disease and this is a serious condition which results in deafness.