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.

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].

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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