Last updated date: 31-Mar-2023

Originally Written in English




Ear infections (Otitis) are quite frequent, especially in youngsters. Otitis is a broad word for ear inflammation or infection in humans and other animals. When infection occurs, it might be viral or bacterial.


Types of ear infections

There are different types of ear infections that subdivided into the following:

  • Otitis externa, often known as external otitis or "swimmer's ear," affects the outer ear and ear canal. When touched or dragged, the ear suffers from external otitis.
  • Otitis media, often known as middle ear infection, affects the middle ear. The ear is infected or clogged with fluid beneath the ear drum, in the typically air-filled middle-ear area, in otitis media. This is the most frequent infection, and it is most common in kids under 6 months old, necessitating a surgical procedure termed myringotomy and tube insertion.
  • Otitis interna, often known as labyrinthitis, affects the inner ear. Sensory organs for balance and hearing are located in the inner ear. Vertigo is a typical sign of inner ear inflammation. Other symptoms in adults include ear discomfort, discharge, and hearing loss.


What is Otitis Media?

Otitis Media

An infection of the middle ear space is classified as acute otitis media. There are three types of otitis media: acute otitis media (AOM), chronic suppurative otitis media (CSOM), and otitis media with effusion (OME). Following upper respiratory infections, acute otitis media is the second most prevalent pediatric diagnosis in the emergency room. Otitis media can develop at any age; however, it is most frequent between the ages of 6 and 24 months.

Infections in the middle ear can be viral, bacterial, or a combination of the two. Streptococcus pneumoniae is the most prevalent bacterial organism that causes otitis media, followed by non-typeable Haemophilus influenzae and Moraxella catarrhalis. Pneumococcal organisms evolved to non-vaccine serotypes after the introduction of conjugate pneumococcal vaccinations. The respiratory syncytial virus (RSV), coronaviruses, influenza viruses, adenoviruses, human metapneumovirus, and picornaviruses are the most prevalent viral pathogens causing otitis media.


Otitis media causes 

Otitis media is a condition with several causes. Otitis media is caused by infectious, allergy, and environmental causes.

These causes and risk factors include:

  • Decreased immunity due to human immunodeficiency virus (HIV), diabetes, and other immuno-deficiencies
  • Genetic predisposition
  • Anatomic abnormalities of the palate and tensor veli palatini
  • Ciliary dysfunction
  • Cochlear implants
  • Vitamin A deficiency
  • Bacterial pathogens, Streptococcus pneumoniae, Haemophilus influenza, and Moraxella (Branhamella) catarrhalis are responsible for more than 95%
  • Viral pathogens such as respiratory syncytial virus, influenza virus, parainfluenza virus, rhinovirus, and adenovirus
  • Allergies
  • Lack of breastfeeding
  • Passive smoke exposure
  • Lower socioeconomic status
  • Family history of recurrent AOM in parents or siblings


How prevalent is Otitis media? 

Otitis media is a worldwide condition that is somewhat more frequent in men than in women. Due to a lack of reporting and varying frequencies throughout many different geographical locations, determining the exact number of cases per year is challenging. Otitis media is most common between the ages of six and twelve months, and it gradually decreases after that.

Approximately 80% of all children will get otitis media at some point in their lives, and between 80% and 90% of all children will develop otitis media with effusion before reaching school age. Otitis media is less prevalent in adults than in children, although it is more common in some subpopulations, such as individuals with a history of recurrent OM in infancy, cleft palate, immunodeficiency, or immunocompromised state, and others.


Pathophysiology Otitis media

Following a viral upper respiratory tract infection, otitis media develops as an inflammatory condition affecting the mucosa of the nose, nasopharynx, middle ear mucosa, and Eustachian tubes. The edema generated by the inflammatory process obstructs the narrowest region of the Eustachian tube, resulting in a reduction in ventilation due to the limited anatomical space of the middle ear.

This sets off a chain of events that results in an increase in negative pressure in the middle ear, increased exudate from the inflamed mucosa, and mucosal secretion accumulation, allowing bacterial and viral species to colonize the middle ear. The proliferation of these bacteria in the middle ear space causes suppuration and, finally, frank purulence.

Clinical signs include a bulging or erythematous tympanic membrane and purulent middle ear fluid. On otoscopic examination, this must be distinguished from chronic serous otitis media (CSOM), which is characterized by thick, amber-colored fluid in the middle ear cavity and a retracted tympanic membrane. On tympanometry or pneumatic otoscopy, both will show reduced TM mobility.

A number of risk factors can predispose children to acute otitis media. A previous upper respiratory tract infection is the most prevalent risk factor. Male gender, adenoid hypertrophy (obstructing), allergy, daycare attendance, ambient smoke exposure, pacifier usage, immunodeficiency, gastric reflux, parental history of recurrent childhood OM, and other genetic predispositions are also risk factors.


Otitis media symptoms

Although otalgia is one of the greatest indications of otitis media, many children with otitis media present with non-specific signs and symptoms, making diagnosis difficult. Pulling or straining at the ears, irritability, headache, disturbed or restless sleep, poor eating, anorexia, vomiting, or diarrhea are some of the symptoms. Approximately two-thirds of patients report with fever, which is usually mild.

The clinical findings together with the supportive signs and symptoms listed above are used to make the diagnosis of otitis media. There is no requirement for a lab test or imaging. According to the American Academy of Pediatrics, evidence of moderate to severe tympanic membrane bulging or a new beginning of otorrhea not caused by otitis externa, or mild TM bulging with recent onset of ear discomfort or erythema, is necessary for the diagnosis of acute otitis media. These criteria are meant to assist primary care providers in diagnosing and making appropriate clinical decisions, not to replace clinical judgment.

The otoscopic examination should be the first and most convenient method of checking the ear, and will provide the expert eye with the diagnosis. The TM may be erythematous or normal in AOM, and fluid may be present in the middle ear cavity. There will be apparent purulent fluid and a bulging TM in suppurative OM. The external ear canal (EAC) may be somewhat edematous, but severe edema should alert the doctor to the possibility of otitis externa (outer ear infection, AOE), which requires distinct treatment.


Otitis media diagnosis

Otitis media diagnosis

Otitis media should always be diagnosed with a physical exam and the use of an otoscope, preferably a pneumatic otoscope. 

  • Laboratory Studies

Laboratory testing is seldom required. In babies less than 12 weeks with fever and no clear cause other than concomitant acute otitis media, a thorough sepsis workup may be required. Laboratory tests may be required to confirm or rule out probable systemic or congenital illnesses.

  • Imaging Studies

Imaging investigations are not recommended unless there is a risk of intra-temporal or cerebral problems. When an otitis media consequence is suspected, temporal bone computed tomography may reveal mastoiditis, epidural abscess, sigmoid sinus thrombophlebitis, meningitis, brain abscess, subdural abscess, ossicular disease, and cholesteatoma.

Magnetic resonance imaging can detect fluid accumulation, particularly in the middle ear.

  • Tympanocentesis

Tympanocentesis can be performed to detect the presence of middle ear fluid, and culture can be used to identify infections. Tympanocentesis can increase diagnostic accuracy and guide treatment options, but it should only be used in the most severe or refractory patients.


Otitis media Treatment 

Otitis media Treatment

Once an acute otitis media diagnosis is made, the objective of therapy is to minimize discomfort while also treating the infectious process with antibiotics. To reduce pain, nonsteroidal anti-inflammatory medications (NSAIDs) or acetaminophen can be utilized. Antibiotics are controversial in the treatment of acute otitis media, and standards vary by nation.

In European countries, watchful waiting is performed with no known rise in problems. However, attentive waiting is not often practiced in the United States. However, if there is clinical evidence of suppurative AOM, oral antibiotics are recommended to treat this bacterial infection, with high-dose amoxicillin or a second-generation cephalosporin serving as first-line medicines. If there is a TM perforation, therapy should begin with ototopical antibiotics suitable for middle-ear usage, such as ofloxacin, rather than systemic medicines, since this provides considerably greater antibiotic concentrations with no systemic adverse effects.

When a bacterial etiology is suspected, the antibiotic of choice in both children and adults who are not allergic to penicillin is high-dose amoxicillin for ten days. Because of its high concentration in the middle ear, amoxicillin has considerable effectiveness in the treatment of otitis media. The American Academy of Pediatrics (AAP) recommends azithromycin as a single dosage in cases of penicillin allergy.

According to the American Academy of Pediatrics, patients who have had four or more bouts of AOM in the previous twelve months should be considered candidates for myringotomy with tube (grommet) installation. Recurrent infections needing antibiotics are clinical signs of Eustachian tube malfunction, and tympanostomy tube implantation facilitates ventilation of the middle ear space while maintaining normal hearing. Furthermore, if the patient develops otitis media while using a tube, they can be treated with ototopical antibiotic drops rather than systemic antibiotics.


Otitis Externa

Otitis Externa

Otitis externa (OE) is an infection of the external auditory canal that can be infected or non-infectious. Inflammation can spread to the outer ear, such as the pinna or tragus, in some circumstances. OE is characterized as either acute (lasting less than 6 weeks) or chronic (lasts more than 3 months). It is also known as swimmer's ear since it is more common in the summer and in tropical climes, and having retained water in the ears makes it more likely. A bacterial infection is the most prevalent cause of acute otitis externa. It has been linked to allergies, eczema, and psoriasis.


Otitis Externa Causes

The most prevalent organisms implicated with otitis externa are Pseudomonas aeruginosa and Staphylococcus aureus. Otitis externa can also be caused by a polymicrobial infection or, in rare cases, by a fungal infection such as Candida or Aspergillus. Several variables can predispose people to developing OE. Swimming is one of the most prevalent risk factors, increasing the risk five times above non-swimmers. Other risk factors are:

  • Humidity
  • Trauma or external devices (cotton swabs, earplugs, hearing aids)
  • Dermatologic conditions such as eczema and psoriasis
  • Narrow external ear canals
  • Ear canal obstruction (cerumen obstruction, foreign body)
  • Radiotherapy or chemotherapy
  • Stress
  • Immunocompromised patients


Pathophysiology of Otitis Externa 

Hair follicles and cerumen-producing glands surround the external auditory canal. Cerumen creates an acidic environment that inhibits bacterial and fungal development by acting as a protective barrier. The inflammatory reaction in otitis externa is thought to be produced by a disturbance of the auditory canal's normal pH and protective components. This comprises a series of events such as epithelial degradation, loss of protective wax, and moisture buildup, which results in a higher pH and bacterial growth.


Otitis externa symptoms

Otitis externa symptoms

Otoscopy will show an erythematous and edematous ear canal with debris (yellow, white, or gray). The tympanic membrane may be erythematous or partially visible in some cases due to edema of the external auditory canal. When there is evidence of an air-fluid level along the tympanic membrane, concomitant otitis media is suggested (middle ear effusion).

Its clinical manifestation varies according on the stage or severity of the disease. Patients with OE will initially complain of pruritus and ear discomfort, which is generally exacerbated by manipulation of the tragus, pinna, or both. Ear discomfort is frequently disproportionate to physical exam results, and it is caused by irritation of the very sensitive periosteum underneath the bony ear canal's thin dermis. It may also be accompanied by otorrhea, fullness sensation, and hearing loss.

Systemic signs such as fever and malaise show that the infection has spread beyond the external ear canal. 


Otitis externa can be classified by severity as follows:

  • Mild: pruritus, mild discomfort, and ear canal edema
  • Moderate: ear canal is partially occluded
  • Severe: The external ear canal is completely occluded from edema. There is usually intense pain, lymphadenopathy, and fever.

For simple instances, routine laboratory tests and/or ear canal cultures are not required or advised. Cultures are indicated, however, for recurring or resistant episodes of otitis externa, especially in immunocompromised individuals. Blood glucose and human immunodeficiency virus (HIV) tests may be undertaken for people with severe symptoms.


Otitis externa Treatment 

Otitis externa Treatment

The majority of individuals with otitis externa will be treated in the outpatient setting. The mainstay of simple otitis externa therapy is generally topical antibiotic drops and pain relief. Because pain can be acute and severe, it must be controlled properly. For mild to severe pain, acetaminophen or nonsteroidal anti-inflammatory medications have been shown to be effective.

Additionally, opioids (e.g., oxycodone or hydrocodone) are advised for severe pain and should be administered in moderation because symptoms of uncomplicated OE should improve within 48 hours after starting topical antibiotic treatment. If pain does not improve within 48 to 72 hours, an evaluation by a primary care provider is strongly advised.

Antibiotic otic drops are generally safe and well tolerated. Their safety and efficacy in comparison to placebo have been demonstrated in randomized studies and meta-analyses with great findings. Some research suggests that topical antibiotic drops with steroids may reduce inflammation and discharges while also hastening pain alleviation. Regardless of the topical antibiotic employed, clinical remission occurs in around 65 to 90 % of patients within 7 to 10 days.

Common topical antibiotics indicated for otitis externa include:

  • Polymyxin B, neomycin, and hydrocortisone 3 to 4 drops to the affected ear four times a day
  • Ofloxacin 5 drops to the affected ear twice daily
  • Ciprofloxacin with hydrocortisone 3 drops to the affected ear twice daily 

To ease medicine distribution and alleviate ear canal edema, patients with severe ear canal edema require the implantation of an ear wick (compressed hydrocellulose or ribbon gauze). The wick is put in the ear canal after being soaked with antibiotic drops. The wick will normally come out on its own, but if required, it should be removed by a physician within two to three days.

If tympanic membrane perforation is suspected, avoid neomycin/polymyxin B/hydrocortisone drops, alcohols, and ototoxic drops (aminoglycosides). Because fluoroquinolones have no ototoxicity and are the only FDA-approved antibiotic for use in the middle ear, they are suggested for the treatment of uncomplicated OE with concomitant tympanic membrane perforation.

Although it is not commonly used in basic care, the American Academy of Otorhinolaryngology recommends aural toilet or cleansing of the external ear canal for the treatment of acute OE. If there is no evidence or suspicion of tympanic membrane perforation, gentle lavage or suctioning should be undertaken. It should also be avoided in diabetic people since it has the potential to cause malignant otitis externa.

Oral antibiotics have not been shown to be effective, and their improper administration will build resistance among common otitis externa microorganisms. Oral antibiotics have the following indications:

  • Patients with diabetes and increased morbidity
  • Patients with HIV/AIDS
  • Suspected malignant otitis externa
  • Concomitant acute otitis media

Topical antifungal medications are not recommended as first-line therapy for OE. They should only be used if a fungal etiology is suspected based on otoscopic examination or culture results.


Otitis Interna (Labyrinthitis)

Otitis Interna (Labyrinthitis)

Otitis interna is caused by the progression of otitis media. It can develop with or without osteomyelitis of the temporal bone's petrous section. Lesions move retrograde through the internal auditory meatus into the cranial cavity with time and severity, culminating in meningitis, ventriculitis, and encephalitis. There is usually a middle ear exudate that ranges from serosanguineous to suppurative to granulomatous.

In the middle ear, the inflammatory infiltration is generally constituted of neutrophils, macrophages, lymphocytes, and plasma cells. Smaller quantities of neutrophils combined with fibrin can be observed in the perilymph of the membranous labyrinth. Fewer lymphocytes and plasma cells may enter the osseous labyrinth's lamina propria. The most likely point of entrance is through the cochlear window's membranous coating.


Ear infection prevention

Ear infection prevention

Middle ear infections are frequently caused by nasal congestion from a regular cold. Otitis externa risk can be decreased by requiring children to drain water from their ears after swimming in pools or by using ear plugs if they are prone to swimmer's ear.

Children who suffer ear infections frequently may require 'grommets' in their eardrums to avoid infection. Small plastic tubes are surgically implanted in the ear drum to let air into the middle ear. An ear, nose, and throat expert will perform this procedure.

Here are some things to avoid.

  • Don’t put anything into your ear, not even a cotton bud, even if your ear feels blocked or painful.
  • Don’t use ear drops unless they’re prescribed by a doctor or you’ve talked to a pharmacist about them.

Consult your doctor if the pain persists or worsens, or if you become ill or have a fever.



Ear infections are prevalent, particularly among youngsters. They induce ear pain as well as transient hearing loss. While there are many distinct forms of ear infections, the most frequent is a middle ear infection. Babies and children are more vulnerable to otitis media.

The other prevalent kind is otitis externa, which is an infection of the outer ear (ear canal) and is commonly known as the swimmer's ear.