Otitis: Causes, Symptoms, and Treatment Insights

Otitis is an inflammation that affects the ear. Within the ear we distinguish three areas: the outer ear, which goes from the pinna to the eardrum; the middle ear, where the ossicles of the ear are found; and the inner ear, where sound is transformed into a nerve impulse and the sense of balance is partially controlled. When an inflammation of any of these areas occurs for different reasons, we speak of otitis, differentiating between external, middle or internal otitis. The different structures that are affected in each of the portions will lead to different symptoms.

How is it produced?

Most external otitis are infectious in origin.

The main forms of external otitis are:

• Circumscribed external otitis, also called furunculosis, is caused by bacterial infection of a hair follicle in the outer ear. It is usually caused by S. aureus.
• Diffuse external otitis, occurs especially in summer, as humidity, high temperature and frequent cleaning make the skin more exposed, without the earwax that protects it, so it is more susceptible to infection when in contact with contaminated water or when suffering erosion. The use of ear buds predisposes to suffer it.
• Malignant external otitis, caused by Pseudomonas aeruginosa, can appear in immunosuppressed, elderly, or diabetic patients. It is rare but very aggressive, with bone involvement.
• other external otitis are caused by fungi, eczematous, secondary to herpes zoster or streptococcal erysipelas.

Otitis media affects the tympanic cavity and is usually due to a defect in the ventilation of this cavity, which communicates with the rhinopharynx through the Eustachian tube.

Different forms of otitis media are:

• Acute serous and mucous otitis, produced by obstruction of the Eustachian tube, in children in general due to large adenoids and in adults due to rhinopharyngeal infections or allergic processes that obstruct the Eustachian tube. A serous secretion is produced that if it persists it becomes mucous.
• Acute otitis media, generally caused by bacteria, is very common in the first years of life, producing pus within the tympanic cavity that, in the long run, by pressure, can cause perforation of the tympanic membrane.
• Bullous myringitis, of viral origin, produces lesions in the form of blisters and vesicles at the level of the eardrum with a blood content that can also occur in the external auditory canal.
• Simple chronic otitis, also called suppurative, is usually due to a previous tympanic perforation secondary to acute otitis media or trauma. Recurrent episodes of otitis occur but at no time does bone involvement occur.
• chronic cholesteatomatous otitis, or simply cholesteatoma, which despite receiving this name is not a tumor, is usually due to a malfunction of the Eustachian tube; less frequently it is due to tympanic perforations and very occasionally it can be congenital. A change is generated in the epithelium that lines the middle ear, which creates a mass of white scales that secretes substances that are harmful to the bone.

Internal otitis is less frequent and since it affects the structure known as the labyrinth, it is called labyrinthitis and has an impact on both hearing and the sense of balance.

The main ways are:

• Serous labyrinthitis, without production of pus, infection reaching through the round window or the oval window.
• Purulent labyrinthitis, with pus, is due to the passage of bacteria through the meninges.

Symptoms

The symptoms present in otitis will differ depending on the portion of the ear canal that is affected. Broadly speaking, hearing impairment can occur, with hearing loss, autophonia and tinnitus, a feeling of occupation, itching, earache and otorrhea, which can be serous, mucous or purulent. There may be fever and general malaise in infectious otitis.

In acute external otitis usually there is significant earache and pain when pressing the tragus, as well as otorrhea, especially in malignant external otitis and fungal infection. The external auditory canal will be swollen and edematous; in the case of malignant external otitis, polyps and granulation tissue will be seen on otoscopy. In herpes zoster otitis externa, vesicles will be seen, which are very painful, and facial nerve paralysis may occur.

Otitis media will produce hearing loss, tamponade, and autophony. The serous and mucous membranes do not give earache, since the fluid that is produced is not under pressure. In contrast, acute bacterial otitis media produces significant earache that subsides when the tympanic membrane is perforated, at which point purulent otorrhea occurs. There may be fever and in infants the clinic is more nonspecific, with general malaise, nausea and vomiting. Chronic otitis media present with recurrent otitis episodes without earache and otorrhea, as the tympanic membrane is perforated; in the case of cholesteatoma the discharge is persistent and fetid. The hearing loss in chronic cholesteatomatous otitis media is severe, and bone fistulas occur frequently.

Both acute and chronic otitis media can have severe complications, such as the involvement of adjacent bone structures, the involvement of the inner ear, the appearance of fistulas, facial paralysis or intracranial involvement, which can cause meningitis or abscesses.

Otitis of the inner ear, in addition to causing more severe hearing loss, which in some cases can reach cofosis (absolute deafness), can cause vertigo and nystagmus.

Diagnosis

The diagnosis of otitis will be based initially on the clinic and on ocular inspection of the ear, both the pinna and the external auditory canal and the tympanic membrane through the otoscope.

In external otitis, an edematous external auditory canal can be seen, so much so that it is sometimes difficult to insert the otoscope. In the case of malignant external otitis, polyps and granulation tissue will be seen at otoscopy and a computerized axial tomography (CT) scan or bone scan will be necessary to assess bone involvement. In fungal infection, it will be seen how it colonizes the external auditory canal.

In acute otitis media we will see a bulging tympanic membrane, with an opaque eardrum in serous and mucous otitis, and reddened in purulent otitis, being able to appreciate the pus inside. Tympanic perforation will be seen in the otorrhea phase of acute and chronic otitis media. In the case of cholesteatoma, white scales will be seen inside the tympanic cavity. With the CT it will be possible to discern whether or not there is involvement of the bone structures. Both this test and nuclear magnetic resonance and bone scan will allow us to study the possible complications of otitis.

Treatment

The treatment of external otitis will be based on antibiotic and analgesic treatment. Proper hygiene of the external auditory canal is very important, sucking up the secretions that are produced and trying to keep the ear dry. Furunculosis will be treated with oral antibiotics, while diffuse external otitis will be treated with topical antibiotics and will only be given orally if there is no improvement. In the case of malignant external otitis, antibiotic treatment should be intravenous and for about 6 weeks.

Serous otitis media will be treated conservatively with anti-inflammatories and in the absence of improvement, grommets can be performed. Acute otitis media will require oral antibiotic treatment, being amoxicillin with clavulanic acid of choice. Also, antibiotic drops may be given for the external auditory canal. In simple chronic otitis media, antibiotic treatment will be given and after several months without infection, a surgical intervention can be considered. In the case of chronic cholesteatomatous otitis media, surgery will always be the treatment of choice.

Purulent labyrinthitis will require the use of intravenous antibiotics.

Precautionary measures

It is advisable to dry the ears well after showering or swimming and avoid the use of cleaning sticks, as they favor the appearance of otitis.