Otitis Media: Classification, Etiology, Clinical Features, Diagnosis & Management

Otitis media is an inflammation of the middle ear cleft i.e. the Eustachian tube, middle ear cavity, mastoid antrum and mastoid air cells. It is caused by various types of bacteria, depending on the age of the patient and the type of infection.

When the infection is sudden in onset and short in duration, the diagnosis is acute otitis media. When the infection is of more than 3 months duration, the condition is called chronic otitis media. It may be caused by the failure of an acute infection to resolve completely. Inflammation of the middle ear with a collection of fluid is called serous otitis media or otitis media with effusion (OME).

Classification of otitis media

  • Acute suppurative otitis media
  • Chronic suppurative otitis media
  1. Tubo-tympanic type – safe type
  2. Atti-conantral type- unsafe, dangerous type
  • Chronic Non-Suppurative otitis media
  1. Serous otitis media or otitis media with effusion

Acute suppurative otitis media

Acute suppurative otitis media is a common bacterial infection affecting the mucosa of the middle ear cleft. It usually occurs in an acute upper respiratory tract infection.


    1. Age: occurs at all ages. It is more common in children because their Eustachian tubes are shorter and wider and more horizontal than an adult; this makes the organisms pass easily from the nasopharynx into the middle ear.
    2. Causative organisms: Streptococcus pneumonia, Haemophilus influenza

Predisposing factors

  • Infections like adenoids, tonsillitis, rhinitis, sinusitis, pharyngitis
  • Nasopharyngeal tumors
  • By swimming and diving in contaminated water
  • Improper forceful blowing of the nose this pushes the infection into the ear through the Eustachian tube
  • Following traumatic perforations of the tympanic membrane
  • Feeling bottle. Using the feeling bottle for infants in the supine position it may allow the contaminated milk to enter the Eustachian tube

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Clinical Features

  • Sudden acute pain in the ear and this may awaken the child, crying or screaming from his sleep
  • Feeling of fullness in the ear
  • Hearing loss; conductive, mild to moderate
  • Tinnitus bubbling sounds are heard in the ear
  • Fever and malaise in children
  • Otoscopy reveal: red, congested and bulging tympanic membrane
  • Otorrhea and relief of pain after perforation of the eardrum


  • Otoscopy reveals congestion, redness, and bulging of the ear
  • Tuning fork tests reveal conduction deafness
  • Audiometry shows conductive deafness
  • Pus for culture and sensitivity may reveal the causative organisms




  • Antibiotics should be started as soon as possible and continued for 7-10 days
  • Decongestants- nasal decongestants may improve the drainage of the middle ear through the Eustachian tube
  • Antibiotic ear drops containing chloramphenicol, neomycin suflfamycin (after the rupture of tympanic membrane)
  • Ear cleaning
  • The ear discharge must be cleared by dry mopping with cotton buds or may be sucked out
  • Water should be prevented from entering the ear


Myringotomy may be rarely required

Myringotomy is an incision made in the tympanic membrane to release fluid under pressure in the middle ear

Chronic otitis media

Chronic otitis media is the chronic inflammation of the middle ear cleft mucosa causing drainage and permanent perforation. It may be caused by the failure of an acute infection to resolve completely or de novo.

Chronic suppurative otitis media

Chronic suppurative otitis media is a very common clinical condition. It is a continuous infection of the middle ear leaving ear discharge that persists beyond 3 months. It is usually preceded by neglected or recurrent acute otitis media and commonly occurs in persons who had ear disease during infancy or childhood.

Types of CSOM

Tubo tympanic type – safe type

It is regarded as a safe type though it is usually a complication of acute otitis media. The persisting or recurring infection ascends from the Eustachian tube to the tympanum and is therefore known as the tubo tympanic type. The perforation is in the central pars tensa and it is most unlikely to give rise to any serious complications


    • Age: occurs at all age
    • Causative organisms: streptococci pneumococci and staphylococci

Predisposing factors

  1. Acute otitis media not properly treated or fails to clear may persist as chronic otitis media. This happens in the following conditions:
  1. Upper respiratory tract infections as chronic tonsillitis, sinusitis, and enlarged adenoids
  2. Persistent and virulent type of infection
  3. Resistance of the body is low: poverty and undernourishment lowers the resistance
  • Traumatic perforation of a large size which often fails to heal and results in chronic otitis media
  • Acute necrotic otitis media which occurs when the resistance of patient becomes low due to exanthemata like smallpox, chicken pox, measles

Clinical features

  • Otorrhoea: intermittent, more profuse during upper respiratory tract infection and if water gets into the ear during bathing or swimming
  • Deafness, conductive, mild to moderate degree
  • Earache no ear pain. Ear pain caused by complications like acute mastoiditis
  1. Acute otitis media
  2. Acute mastoiditis
  • Central perforation
  • Polyps may be present occasionally


Conservative Treatment

  • Treatment of the infection consists of elimination of all upper respiratory tract infection
  1. Removal of septic foci like adenoids and tonsils
  2. Treatment of sinusitis, rhinitis
  • Topical antibiotics and corticosteroids if there is discharge from the ear
  • Ear cleaning with dry clean cotton buds or by suction
  • Nutrition of the patient should be improved to prevent recurrent respiratory tract infection

Surgical Treatment

  1. Polyps and granulations should be removed if they are present
  2. Myringoplasty: repair of the eardrum
  3. Tympanoplasty: reconstruction of the eardrum is done and the ossicular chain is performed after removing the diseased portion.

 Attico-antral Type: dangerous

Type of CSOM

This disease involves the bone of the attic, antrum or mastoid process along with the mucosa of the middle ear cleft. The perforation is in the attic or marginal area of the pars tensa, having foul smell and white flakes. This can give rise to serious complications (brain abscess, meningitis, labyrinthitis, etc.) due to the presence of destructive cholesteatoma spread beyond the middle ear cleft.


In the majority of cases, the problem is due to cholesteatoma which is the presence of desquamated squamous epithelium in the middle ear cleft. The cholesteatoma has a bone eroding property which can give rise to various complications. Usually, the cholesteatoma is infected by mixed bacterial flora.

Clinical features

  • Otorrhea, persistent or recurrent having scanty and foul smell discharge
  • Deafness: severe hearing loss due to frequent involvement of ossicular chain
  • Bleeding or blood stained discharge may occur if granulations or polyps are present
  • Earache may be caused by complications like:
  1. Acute otitis media
  2. Acute otitis external
  3. Mastoiditis or intracranial complications
  • Tinnitus
  • Swelling and tenderness in the mastoid region suggest an involvement of the mastoid bone. Examples are acute Mastoiditis and mastoid abscess
  • Presence of polyps, granulations, and cholesteatoma which is visible through the perforation on otoscopic examination  
  • Perforation is marginal or attic


  • hearing tests
  • bacteriological examination
  • x-ray of the mastoid


Conservative Treatment

  • keep ear dry with suction cleaning of small cholesteatoma cavity and large perforation permitting thorough cleaning  under microscope
  • treat precipitating factors, e.g. tonsillitis, sinusitis
  • analgesics if pain is caused by complication, e.g. acute Mastoiditis
  • antibiotics, ear drop locally and systematically to control infection
  • treatment of complications

Surgical Treatment

Majority of the patients with cholesteatoma need surgery.

The objectives of operation are:

  1. to eradicate the disease thus making the ear safe
  2. make the ear dry
  3. to preserve hearing


  1. polyps and granulations should be removed
  2. mastoidectomy
  3. modified radical mastoidectomy is performed to eradicate the disease and to prevent serve the hearing
  4. Radical mastoidectomy is performed when a disease is with sensorineural hearing loss or the patient has complications because of CSOM. This operation eradicates the disease but doesn’t preserve hearing.


Extracranial complications

  • Acute Mastoiditis
  • Mastoid abscess
  • Facial nerve palsy
  • Labyrinthitis

Intracranial complications

  • Extradural abscess
  • Subdural abscess
  • Meningitis
  • Brain abscess
  • Sigmoid sinus thrombophlebitis

Chronic Non- suppurative Otitis Media

Serous Otitis Media or Otitis Media with effusion (OME).

Serous otitis media is characterized by the accumulation of a serous fluid within the middle ear which interferes with hearing. It may be acute or chronic and the fluid may remain in the ear for a long time.


    • Age:  Any age from infancy to adulthood but common in children
  • Predisposing factors:
  1. An obstruction of the Eustachian tube which prevents normal ventilation of the middle ear often by enlarged adenoids or nasopharyngeal tumors.
  2. Inappropriate use of antibiotics for treating ear infections resulting in a collection of sterile fluid
  3. Associated with the viral infection of the upper respiratory tract; infectious, e.g. tonsillitis, sinusitis.
  4. An allergic exudate of serous fluid into the middle ear, allergies cause hyperplasia of the secretory cells and increased secretions
  5. Excessive nose blowing

Clinical features

  • Feeling of fullness and discomfort in the affected ear
  • Deafness: may vary in degree with the changing positions of the head
  • Sensations of fluid: the patient may feel as if there is fluid moving in the ear
  • Tinnitus: bubbling noises especially on blowing nose and swallowing
  • Otoscopy reveals:
  1. behind the drum can see fluid level or air bubbles
  2. Tympanic membrane is dull and retracted


  1. For causative factors: the disease of the nose, paranasal sinuses or pharynx adenoids which cause Eustachian tube obstruction should be treated
  2. Antibiotic therapy
  3. Nasal decongestants may help restore function of the Eustachian tube


Most of the OME completely resolve within 3 months. About 10% need surgery because of persistent fluid in the middle ear.

  • Myringotomy: it is incision of the tympanic membrane to release fluid from the middle ear
  • Aspiration of middle ear fluid after Myringotomy
  • Grommet: temporary ventilation of the middle ear is provided by inserting a polyethylene tube called “grommet” through the eardrum
  • The tube is left in position until patency of the auditory tube reestablished and the tube rejected spontaneously after few months
  • This operation is known as ventilation tube insertion (VTI). This is one of the most common pediatric operations.

For more detailed information, check out the video below:

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