Acute and chronic otitis media

Otitis media is an inflammation of the middle ear, i.e. the cavity between:

    • external auditory canal,
    • Inner ear.

The middle ear is formed by:

  • eardrum, a delicate membrane that vibrates when sound waves reach the ear;
  • ossicular chain (hammer, anvil and stirrup), which distribute the vibrations and transmit them to the inner ear;
  • The Eustachian tube is a thin tube that leads from the inner ear to the posterior nasal cavities and serves to:
    • Maintain normal air pressure in the inner ear,
    • Remove mucus and other secretion products from the middle ear.

If the tube swells or is blocked, the mucus cannot flow normally from the middle ear, which can easily lead to infection.

Most often, children between 3 months and 3 years are affected:

  1. Young children have an immature immune system,
  2. The Eustachian tube is laid out horizontally in them, while in adults it runs obliquely, since the throat is deeper and in adults catarrh and secretions drain to the throat, while in children remain in the middle ear.
  3. The Eustachian tube is short, so inflammation in the throat spreads faster.

In children, this is often done on both sides.
However, this can also occur in adults.


Development of acute otitis media – pathophysiology

Many middle ear diseases have their origin in infections of the upper respiratory tract, especially of the nose and rhinopharynx.
If a person has a cold:

The infection causes edema (swelling) of the Eustachian tube.

The consequences are:

  • obstructed air passage,
  • Formation of negative pressure in the middle ear, which attracts fluids from the outer walls (transudate).

The fluid accumulates and causes a serous or secretory ear infection.
This situation is typical in children with enlarged pharyngeal tonsils.
With bacterial superinfection (secondary), there is an ear infection with accumulation of pus in the tympanic cavity, which causes:

If the accumulation of pus is pronounced, the eardrum can be opened.
The result is otorrhea (pus discharge from the ear).
Usually, the acute otitis media passes without consequences, the perforation closes again, unless the germs are particularly aggressive and lead to partial necrosis of the eardrum.
Permanent perforation of the tympanic membrane by acute otitis media is very rare.

Otitis media in the child

A child with this condition suffers from hearing loss, but does not have:

The child:

  • Always keep your mouth open,
  • Breathes poorly,
  • Has a runny nose,
  • Is inattentive.

Pain occurs when the secretion of fluids is superimposed by an acute ear infection.
A child who secretes fluid from the ear often develops acute ear infection. However, some children never develop an ear infection in this situation.
The transudate accumulates as a liquid, but over time it becomes thick like glue or toothpaste.

Otitis media in adults

If a chronic ear infection develops in an adult, it is necessary to pay attention to the following:

  • In children, enlarged pharyngeal tonsils are almost always the cause,
  • In adults, unilateral chronic effusion (accumulation of fluid or exudate) with hearing loss and the feeling of a blocked ear may indicate a serious health problem, such as an aggressive malignant tumor.
  • These complaints do not cause pain, but are initially characterized only by an effusion or occlusion of the Eustachian tube.

Acute otitis media

The infection of the middle ear occurs abruptly, causing swelling and redness.
An acute otitis media can:

  • Associated with catarrh, when fluid and mucus are trapped behind the eardrum and there is a mild form of ear infection that heals spontaneously but can last for weeks and months.
  • Be purulent, with the most severe form of ear infection characterized by an infection that leads to the accumulation of pus behind the tympanic membrane. Symptoms and consequences for the child are high fever, pulsating earache, temporary hearing loss and perforation of the tympanic membrane.
  • Being bullously bleeding, a type of ear infection that often occurs as part of a flu, in which blisters form on the eardrum membrane that can rupture and cause bleeding from the ear canal.
  • Being barotraumatic, which occurs due to a sudden change in air pressure that the ear cannot compensate, for example, when diving or flying. If the pressure change occurs quickly, it can lead to damage to the eardrum and pain.

Chronic otitis media

This is a complication of acute otitis media. There is a chronic infection (or an infection that persists for at least six weeks) of the middle ear, which can lead to significant damage to the middle ear and eardrum with weakening of hearing.

Chronic ear infections are not painful (as opposed to acute ones), but if left untreated, it can cause serious damage.

The main property of ear infection is conductive hearing loss: the transudate fills the tympanic cavity, partially preventing sound transmission, thereby causing hearing loss and the feeling of blocked ears.
However, patients with this ear infection do not have a fever and pain.
The ear infection is divided into:

  1. With closed eardrum (not perforated),
  2. With open eardrum (perforated),
  3. Cholesteatomatous.

The term “otitis” does not always mean a bacterial infection or accumulation of pus, but only the accumulation of secretions.

1) Chronic ear infection with closed eardrum

In chronic ear infection with closed eardrum, this is not perforated, but strongly retracted. It is divided into:

  • Transudative form,
  • Fibroadhäsive Form.

Chronic transudative otitis media

Chronic transudative otitis media (serous or seromukous) develops in children or adults with colds.

The diagnosis is difficult to make, because the tympanic membrane is not:

  • Reddened
  • Perforated.

You can only see the transudate in the tympanic cavity.

The membrane of the eardrum is “sucked inwards”. A pocket (limited area) forms in the retracted membrane.

This deviation develops over several years.

In the most severe cases, the tympanic membrane becomes opaque due to the effusion in the tympanic cavity (middle ear).

Almost always the cause is a disease of the nose or throat:

Other causes of chronic otitis media are anatomical malformations that affect the Eustachian tube:

  1. The cleft palate leads to muscle dysfunction: when swallowing, the tensor muscles of the palate open the Eustachian tube, but if a person has a cleft palate, this mechanism of tensor muscles does not work properly,
  2. Anatomical abnormalities such as Down syndrome.

Chronic fibroadhesive otitis media

This is the further development of a transudative otitis media.

A child who has suffered from effusion and stenosis (narrowing) of the Eustachian tube for a long time may have this degenerative change in the ear due to lack of air.

After many years, the effusion no longer has a liquid-sticky consistency, but can become a fibrous tissue and lead to scar-like adhesions.

The consequences are:

  • A retracted eardrum,
  • Loss of the fiber layer, so that the eardrum becomes thinner and thinner.

The figure on the left shows the examination with the otoscope in a patient with chronic adhesive ear infection.

The eardrum membrane is still present at the level of the annulus, but in the center it attaches to the middle wall and you can therefore see structures that are not normally visible:

  • Hammer
  • Anvil
  • Stirrup
  • tendon of the stirrup,
  • promontorium,
  • Round window,
  • Oval window,
  • Vulture nerve.

The patient has a significant hearing loss, because the air cavity no longer exists, which allows:

  • vibrations of the tympanic membrane,
  • Vibration transmission to the ossicular chain.

The bones can become immobile and form calcifications (calcium deposits).
Chronic transudative ear infection is irreversible, while fibroadhesive is reversible.

  1. conductive hearing loss or hearing loss of mixed degree,
  2. Tinnitus.

2) Chronic ear infection with open eardrum

It can occur in two ways:

  • Simple
  • Cholesteatomatous.

In this case, there is a perforation or hole.

Simple chronic otitis media

There are different types with different characteristics:

  • Existing damage: bottom, top, central, etc.
  • Central parts or ring areas are affected.

Perforation that affects only the central (marginal or paracentral) part, but leaves intact the ossicles and the annulus (fibrocartilage surrounding the eardrum membrane), leads to only mild hearing loss.

The patient does not need to have any discomfort, but should not swim in the sea or in the swimming pool, as this could cause a painful otitis media.

Sometimes the perforated eardrum is able to repair itself, but refractive pockets form without the intermediate fiber layer. Thus, only the following remain:

  • A layer of skin,
  • A layer of respiratory mucosa.

Since there is no intermediate layer, the eardrum retracts and adheres to the promontorium (the part of the middle ear that is in contact with the snail), the anvil and the tendon of the stirrup.

With chronic purulent ear infection (purulent or granulomatous), inflammation of the mastoid and chronic purulent secretion also occur. Exacerbation can easily occur.

The eardrum can also perforate by a powerful slap in the face if it creates a sufficiently high pressure.

Symptoms of chronic otitis media with open eardrum

  1. Conductive hearing loss/combined hearing loss, depending on:
    • site of perforation,
    • size of the perforation,
    • erosion of the ossicles.
  2. Secretions from the ear in purulent ear infection. If the person concerned finds the pillow soiled in the morning,
  3. tinnitus (buzzing in the ears),
  4. Earache (only if inflammation recurs)

With a non-purulent ear infection, the symptoms consist only of mild hearing loss and tinnitus. Mild pain may occur, but only when the patient is underwater.
Hearing loss depends on the size and location of the injury.
small eardrum perforation causes only a slight hearing loss.
In an advanced state, the ossicles (hammer, anvil and stirrup) are also destroyed, in such a case the hearing loss is striking.

Chronic cholesteatomatous otitis media

Cholesteatoma is a serious pathology that in the past could also be fatal if diagnosed too late.
The cholesteatoma is a squamous cell tissue that grows in the tympanic cavity instead of the cylindrical epithelium.
As a result, scaling of this tissue occurs.
The scales of keratin:

  • accumulate and form a mass of tissue that continues to grow,
  • They produce enzymes that lead to the destruction of the surrounding bony structures.

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