| ICD-9-CM: |
| 381 - | Otitis Media and Eustachian Tube Disorders, Nonsuppurative |
| 381.00 - | Otitis Media, Acute Nonsuppurative, Unspecified |
| 381.01 - | Otitis Media, Acute Serous |
| 381.1 - | Otitis Media, Chronic Serous; Chronic Tubotympanic Catarrh |
| 381.2 - | Otitis Media, Chronic Mucoid |
| 382 - | Otitis Media, Suppurative and Unspecified |
| 382.0 - | Otitis Media, Acute Suppurative |
| 382.00 - | Otitis Media, Acute Suppurative without Spontaneous Rupture of Ear Drum |
| 382.9 - | Otitis Media, Unspecified |
| Otitis media is an infectious inflammation of the lining of the middle ear, eardrum (tympanic membrane), and associated structures such as the small bones of the ear (ossicles) and the tube that connects it to the throat (eustachian tube). Because fluid buildup behind the eardrum can cause poor transmission of sound waves, otitis media may be associated with some degree of conductive hearing loss.
Different forms of acute otitis media (serous, secretory, and suppurative or purulent) are based on the severity of the infection and the involvement of different parts of the ear. In serous otitis media, the hearing or pressure equalization tube (eustachian tube) that extends between the eardrum and the back of the throat (nasopharynx) fails to open and close as it should. Continuous or intermittent pressure changes cause fluid to build up behind the eardrum, resulting in conductive hearing loss. Acute serous otitis media usually follows an upper respiratory infection or trauma to the ear but is sometimes associated with an allergy or enlarged adenoids.
In secretory otitis media, the lining of the middle ear (mucosa) changes and releases secretions that are thicker than normal. Acute secretory otitis media also follows an upper respiratory infection. Serous and secretory otitis media are the usual forms of the disease seen in individuals with acquired immunodeficiency syndrome (AIDS).
Suppurative otitis media is usually caused by a viral upper respiratory tract infection that creates swelling (edema) in the eustachian tube and an accumulation of fluid and mucus behind the eardrum. When it is caused by pus-producing bacteria introduced into the middle ear from the nasopharynx, the most common organisms (pathogens) are Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes.
Otitis media of less than 3 weeks duration (acute) is one of the most common infections of childhood, although it is also seen in adults. Recurrent acute otitis media becomes chronic when it persists for longer than 3 months and is accompanied by changes in the lining of the middle ear. Growth of new tissue (granulation tissue) may extend into the middle ear. Often the result of untreated ear infections, this disease is considered more dangerous because the slow, chronic effects can result in permanent damage. Chronic otitis media may not be noticed or cause enough discomfort to warrant immediate action until it is well established. It is more common in adults who have had recurrent childhood acute otitis.
Individuals at increased risk for otitis media are those on chemotherapy or antirejection drugs following organ transplantation or those who have weakened immune systems (immunosuppression) or chronic diseases like HIV/AIDS or leukemia. Individuals with upper respiratory infections who scuba dive or fly in an airplane may also develop otitis media caused by persistent negative middle ear pressure. |
Source: Medical Disability Advisor
| History: Individuals with acute otitis media may complain of moderate to severe ear pain (otalgia), pain behind the ear, fever, decreased hearing, fluid drainage from the ear, dizziness, or a sense of fullness in the ear (aural pressure).
Individuals with chronic otitis media often report a history of recurrent acute otitis media, long-term decreased hearing, and a chronically draining ear. Pain does not usually accompany chronic otitis media unless the individual has an upper respiratory infection. Physical exam: Physical findings will vary, depending on the type of infection present. When examined through an otoscope, the eardrum associated with acute otitis media is red (erythema), with slow or absent mobility. Painful blisters (bullae) occasionally form on the eardrum, or the drum will bulge outward because of the severe infection behind it. Without medical intervention, bulging eardrums may eventually rupture, and fluid will drain from the ear canal. This event brings an immediate decrease in the level of pain. When examined through an otoscope, the eardrum associated with chronic otitis media may be perforated or scarred, and drainage from the middle ear will be present in the ear canal. If the infection is very severe, neurological symptoms may also be present (signs of increased intracranial pressure, facial paralysis, or meningitis). Tests: Fluid drawn from behind the eardrum with a needle and syringe (tympanocentesis) may be sent to the laboratory for culture and sensitivity testing, which will identify the causative organism and determine the appropriate antibiotic to use in treating the infection. Audiometric studies may be performed to test the degree of conductive hearing loss. Tympanometry can be used to measure the middle ear pressure and mobility of the eardrum (tympanic membrane). An MRI or CT may be ordered if chronic otitis media is suspected. The temporal bone may reveal bone destruction, the absence of ossicles, or the presence of a cholesteatoma mass. If neurological symptoms are present, an MRI or CT may reveal inflammation of the lining of the brain and spinal cord (meninges). |
Source: Medical Disability Advisor
| Treatment of acute otitis media focuses on clearing the middle ear of infection. Acute otitis media is initially treated with a broad-spectrum antibiotic, pending the results of culture and sensitivity testing. If necessary, more specific antibiotic therapy may be ordered, depending on what organism is causing the infection. Standard medical therapy for acute otitis media includes prescribing antibiotics for 10 to 14 days.
Recurrent acute otitis media may be managed with long-term antibiotic prevention for 1 to 3 months. If this regimen fails to control the infection, insertion of ventilating tubes into the eardrum through a surgical drainage incision (myringotomy) may be required. Eardrums rupturing spontaneously usually heal by themselves. Persistent perforation frequently evolves into chronic otitis media.
Persistent serous otitis media may be treated with a course of oral corticosteroids and antibiotics, separately or in combination. Placement of a ventilating tube (tympanostomy tube) through a myringotomy incision in the eardrum may restore hearing and alleviate the sense of fullness in the ear. In adults, this is usually an office procedure.
A myringotomy for acute middle ear infections is reserved for individuals with severe ear pain or complications such as inflammation or infection of the mastoid process of the temporal bone (mastoiditis) or the lining of the brain and spinal cord (meningitis), involvement of the facial nerve, or signs of brain abscess.
Treatment of chronic otitis media requires the regular removal of infected debris from the middle ear through the perforation (an outpatient procedure), use of earplugs to protect against water exposure, and topical antibiotic drops to help dry chronic ear drainage and reduce ear infection. Surgery (myringoplasty or tympanoplasty) is usually required to repair the perforation or remove a cholesteatoma (cyst-like mass) that eventually grows in the middle ear, mastoid process, or mastoid region; erodes bone; and invades the middle ear structures. |
Source: Medical Disability Advisor
| Most individuals with acute otitis media improve after 48 hours on antibiotic therapy and may be symptom-free after several days. However, full recovery depends on the individual's compliance with a complete course of antibiotic therapy, regardless of how well the individual feels after a few doses. Disruption in antibiotic therapy before the individual has taken the entire prescription can result in a recurrence of the infection and may contribute to the growth of antibiotic-resistant organisms. Outcomes for chronic otitis media are less predictable, and outpatient treatment tends to be ongoing. At some point, surgery is often required to reconstruct the perforated eardrum (tympanoplasty), clear the mastoid air cells of infection (mastoidectomy), and remove the growth of excess tissue in the ear canal (removal of cholesteatoma). |
Source: Medical Disability Advisor
| Because the middle and inner ear not only allow an individual to hear but also contribute to balance, rehabilitation is important if any problems with steadiness and equilibrium (center of gravity) occur. Once the initial inflammation or infection of otitis media resolves, individuals may need a physical therapist trained in vestibular rehabilitation to help regain any loss of balance. The physical therapist begins by evaluating the individual to determine if the balance problem is a result of an inner ear dysfunction or from other areas such as the brain's center for balance. Once this is determined, the therapist establishes a plan of care. Much of the therapy focuses on balance exercises that challenge the individual's balance with and without the help of visual and sensory stimuli.
An example of this technique includes walking straight ahead while rotating the head side-to-side and focusing visually on an object. Another technique involves standing on a soft surface (limited sensory stimulus) with the eyes closed (limited visual stimulus) and trying to remain balanced. Initially the individual does this while standing on both legs and progresses to standing on one leg only. The exercise is timed and the duration increased as tolerated. Such techniques increase and retrain balance without the aid of sensory and visual input. The physical therapist may need to modify the program for individuals who have undergone surgery, those with hearing loss due to birth defects, or those who have a long-standing infection.
Individuals with permanent conductive hearing loss may require vocational or occupational therapy to help prepare them for a different job. Amplification (use of hearing aids) may be required, depending on the severity of the hearing loss. |
Source: Medical Disability Advisor
| If treatment of acute or chronic otitis media fails, the infection can spread to other areas of the head and neck, causing serious, even life-threatening complications. Acute suppurative mastoiditis requires surgical drainage. Infection of the petrous bone (petrous apicitis), situated between the inner and middle ear, requires prolonged antibiotic therapy and surgical drainage. Infection of the skull base (osteomyelitis) requires antibiotic therapy and possible surgical débridement of the infected bone. Facial paralysis caused by inflammation of the facial nerve requires drainage of the middle ear and intravenous antibiotic therapy. Facial palsy caused by chronic pressure on the facial nerve requires steroid and antibiotic therapy, a myringotomy, and occasionally more aggressive surgical correction of the underlying disease (removal of cholesteatoma or mastoidectomy).
Complications involving the nervous system can be particularly dangerous. Thrombosis of the sigmoid sinus can lead to sepsis and increased intracranial pressure. Treatment for this condition includes administration of intravenous antibiotics based on culture and sensitivity testing, surgical drainage, or tying off the vein in the neck. Central nervous system infections include epidural abscess, brain abscess, and meningitis.
Permanent hearing loss can be a complication of chronic otitis media. |
Source: Medical Disability Advisor
| Work restrictions and accommodations for individuals with acute or chronic otitis media are related to the degree of hearing loss. Because hearing loss caused by acute otitis media is usually temporary, accommodations are also temporary. Hearing will most often return to normal levels when the infection clears, the normal pressure resumes in the eustachian tube, and the fluid behind the eardrum is absorbed. This may take a few weeks. Hearing loss associated with chronic otitis media lasts longer and may become permanent, requiring a long-term or permanent accommodation in the workplace, in addition to the use of hearing aids. Balance disorders resulting from ear infections may require work restrictions for the safety of the individual and co-workers. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has individual recently had an upper respiratory tract infection?
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Does individual have a history of allergies or enlarged adenoids? History of recurrent acute otitis media, long-term decreased hearing, and a chronically draining ear?
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Has individual recently experienced trauma to the ear?
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Does individual have a suppressed immune system?
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Does individual participate in activities that cause negative middle ear pressure, such as scuba diving or flying?
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Does individual complain of moderate to severe ear pain (otalgia), pain behind the ear, fever, decreased hearing, fluid drainage from the ear, dizziness, or a sense of fullness in the ear (aural pressure)?
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Was a culture done of fluid drawn from behind the eardrum with a needle and syringe (tympanocentesis)?
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What was the causative organism of the otitis?
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Were audiometric studies performed to determine the degree of conductive hearing loss?
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Did tympanometry measure the middle ear pressure and mobility of the eardrum (tympanic membrane)? Was MRI or CT done if chronic otitis media was suspected?
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Was the diagnosis of acute or chronic otitis media confirmed?
Regarding treatment:
- Was acute otitis media treated initially with a broad-spectrum antibiotic? Did the antibiotic need to be changed when the organism was identified? Was individual compliant with the antibiotic regimen?
-
Was recurrent acute otitis media managed with long-term antibiotic prevention?
-
If that regimen failed, did individual require insertion of ventilating tubes into the eardrum through a surgical drainage incision (myringotomy)?
-
Was persistent serous otitis media treated with oral corticosteroids and antibiotics, separately or in combination?
-
Was placement of a ventilating tube (tympanostomy tube) through a myringotomy incision in the eardrum required to restore hearing and alleviate the sense of fullness in the ear?
-
Was chronic otitis media treated with removal of infected debris from the middle ear and antibiotic drops?
-
Was surgery (myringoplasty or tympanoplasty) required to repair perforation or remove a cyst-like mass (cholesteatoma) in the middle ear?
Regarding prognosis:
- Is this an acute or recurrent infection?
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Was the reason for recurrent infection established?
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Has an antibiotic sensitivity test indicated a better option or effective combination?
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Is there lack of compliance with antibiotic regimen? What is being done to ensure compliance?
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Are underlying medical conditions affecting the individual's ability to recover?
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Have complications developed, such as thrombosis of the sigmoid sinus, sepsis, or increased intracranial pressure?
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Have central nervous system infections developed, such as epidural abscess, brain abscess, or meningitis? Does individual have permanent hearing loss?
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What treatment is available for complications and what is the expected outcome with treatment?
|
Source: Medical Disability Advisor
| Waitzman, Ariel A. "Otitis Externa." eMedicine. Eds. Orval Brown, et al. 28 Oct. 2004. Medscape. 17 Feb. 2005 <http://emedicine.com/ped/topic1688.htm>. |
Source: Medical Disability Advisor
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