Diagnosis
History and physical
Acute otitis media (AOM)
Otalgia, fever, bulging and erythematous TM with decreased mobility, poor light reflex; duration < 3 weeks
Otitis media with effusion (OME)
Middle ear effusion without signs of acute infection; commonly follows episode of AOM but may develop in isolation; children with OME may present with parental concerns about hearing, language development, behavior, or school performance; immobile TM with air-fluid levels
Chronic otitis media (COM)
Recurrent or chronic ear infections that result in perforation of the TM +/− otorrhea; higher incidence in children with cleft palates, Down’s syndrome
Cholesteatoma
Often preceded by Eustachian tube dysfunction and COM; expansile collection of keratinized, desquamated epithelium in the middle ear
Labyrinthitis
Often preceded by a viral infection; acute onset of vertigo, gait instability, nausea, vomiting, and hearing loss; physical exam demonstrates nystagmus
Otitis externa or swimmer’s ear
Recent contact with warm water; presents with a tender, swollen pinna and erythematous ear canal with possible discharge
Congenital
Hearing loss since birth that may be hereditary or acquired; intrauterine (TORCH) infections
Miscellaneous
Cerumen impaction, foreign body, trauma
Watch Out
Cholesteatoma is a misnomer in that it does not contain fat or cholesterol but instead is secondary to desquamated keratinized epithelium.
What other diagnoses need to be considered in an adult with hearing loss?
Diagnosis | History and physical |
|---|---|
Exposure | Work related (e.g., construction worker, sound grip), prolonged or intense exposure to loud noises |
Drugs | Exposure to aminoglycosides, aspirin, loop diuretics, cisplatin |
Tumor | The most common is a vestibular schwannoma of the cerebellopontine angle; may present with trigeminal (paresthesias) and/or facial (paresis) nerve involvement; rarely, the only presenting symptom may be unilateral tinnitus or ringing in the ears |
Ménière’s disease | Triad of hearing loss, episodic vertigo, and tinnitus; vertigo may last for several hours (vs. seconds in BPPV); often with aural fullness |
What Is the Most Likely Diagnosis?
Otitis media with effusion (OME). Although this often occurs after an episode of acute otitis media (AOM), it may also develop in isolation (discussed in Pathophysiology). The predominant symptom is hearing loss and is typically discovered during school audiology screening exams or after behavioral patterns concerning for hearing loss (e.g., turning television volume louder, sitting closer to the television, replying often with “what?”). Otoscopic findings typically include an immobile TM and air-fluid levels with partial opacification. However, the patient should not have any signs of acute infection (more consistent with AOM). Additionally, the physical exam should be consistent with a conductive hearing loss.
Watch Out
Note that the term otitis media (middle ear infection) is often a general diagnostic term but does include 3 different subsets of pathologies involving the middle ear (AOM, OME, and COM, all of which may have very different etiologies). When describing middle ear disease, careful attention should be paid to using the most appropriate term.
History and Physical
What Is the Peak Age for OME?
The prevalence peaks at age two and sharply declines after age 6.
What Are the Risk Factors for OME?
Male, African American, cigarette smoke exposure, low birth weight, younger maternal age, lower socioeconomic index, shorter duration or absence of breastfeeding, and supine feeding position.
What Is the Implication of Regression in Language?
Hearing loss should be suspected in all children that present with regression or delay in language milestones. In toddlers, the typical history involves a child that could babble but stops suddenly. All such children should be evaluated for hearing loss with an audiology consult. Older children may also have poor scholastic performance from being hard of hearing with poor speech; they may benefit from sitting near the front of the class. Some persistent deficits include impairments in reading ability, hyperactive and inattentive behavior, and a lower intelligence quotient (IQ).
What Is the Implication of the Presence or Absence of Otalgia?
Otalgia, along with other acute signs or symptoms of infection (e.g., bulging and erythematous TM, fever, leukocytosis), is more consistent with AOM and less so with OME. Pain with manipulation of the outer ear suggests external canal inflammation (otitis externa).
Watch Out
Any pediatric patient with a unilateral aural fullness or otalgia should be suspected of having a foreign body obstruction. In fact, any unilateral ENT lesion in a pediatric patient (e.g., unilateral rhinorrhea, unilateral wheezing) should be appropriately evaluated for a foreign body.
What Is the Importance of Otorrhea?
Otorrhea is concerning for middle ear disease with TM perforation. Careful attention should be paid to the characteristics of the drainage which varies from appearing thin/clear/serous, mucoid, bloody, to purulent, all of which suggest different etiologies. Some patients with otalgia will report resolution of pain followed by new-onset otorrhea. This sequence of symptoms is highly suggestive of a TM perforation. Failure to resolve drainage after conservative management may require surgical intervention.
How Does One Distinguish on History and Physical Exam Between External Otitis and Otitis Media?
Otitis externa (“swimmers ear”) typically occurs in patients following exposure to warm water but may also appear after recent ear instrumentation. The most common symptoms include otalgia upon manipulation of the external ear, pruritus, and hearing loss. On otoscopic examination, a patient with otitis externa will appear to have an edematous and erythematous external ear canal. The TM is typically intact and freely mobile with no evidence of air-fluid levels (i.e., normal).
What are some abnormal features found in otoscopic examination that may signify AOM and/or OME?
Feature | AOM | OME |
|---|---|---|
Immobility | Yes | Yes
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