Otitis media is a condition referring to the inflammation of the middle ear cleft. This region includes the middle cavity, the aditus, the antrum, and the eustachian tube.

NOTE- Refer to the Anatomy of the Ear Blog for better understanding.

Acute Suppurative Otitis Media(ASOM)

Acute suppurative otitis media is caused by infections from pyogenic organisms and suppuration refers to pus formation. The eustachian tube is the most common root of infection, which is shorter and wider in infants and children, thus accounting for higher chances of infection in them. The second most common root of infection is from external ear infection or trauma associated with tympanic membrane rupture. Bloodborne infections to the middle ear cleft are mostly uncommon.

Otitis media

Pathology and associated clinical features

There are 4 stages in the development of ASOM due to infections from the eustachian tube.

Tubal occlusionExudation in middle ear cleftSuppuration of formed exudateStage of resolution or typmanic membrane rupture
Caused by infection at the nasopharyngeal end  of the eustachian tube which leads to inflammation at the nasopharyngeal end. Inflammation leads to edema and hyperemia of  mucosa which leads to eustachian tube block.As the infection spreads into the middle ear cavity, inflammation of the middle ear cavity occurs which is associated with formation of exudate and hyperemia of mucosal blood vessels. Hyperemia causes congestion of blood vessels.In this stage the exudate turns into pus. In ASOM there is always a complication of  associated mastoiditis.The bulging of the tympanic membrane due to increased fluid in the middle ear cleft causes the rupture of the tympanic membrane.
Eustachian tube block causes tympanic membrane retraction which is visible on otoscopic examination. Retraction causes loss of light reflex, the lateral process of malleus becomes prominent and the handle of malleus becomes horizontalOtoscope examination reveals congestion of pars tensa around the handle of millions and periphery tympanic membrane imparting a cartwheel appearance. Later all of the tympanic membrane becomes uniformly redExamination reveals red bulging tympanic membrane with an yellow spot which is often said as “nipple -like protrusion”. The yellow spot indicates the site of future rupture. Tenderness present all the mastoid regionThe rupture of the tympanic membrane causes blood or mucopurulent fluid in external auditory canal. After its rupture, the congestion of the tympanic membrane subsides and hence regains its normal anatomical landmarks and it’s and it’s normal color.
Patient is asymptomatic with slight degree of hearing loss and earachePatient complaints of earachae which is throbbing in nature(due to exudation) associated with hearing loss and tinnitus . Childrens have associated fever.Severe earache is present. Children have associated high grade fever.Earache is relived, fever subsides, presence of discharge from external auditory canal    

The major complications of ASOM include acute mastoiditis, fascial paralysis, labyrinthitis, petrositis, meningitis,etc

MRI image of otitis media


  1. Antibacterial Therapy. Since the most common organisms are S. pneumoniae and H. influenzae, the most commonly used drugs are ampicillin and amoxicillin. In cases of ß-lactamase-producing H. influenzae or M. catarrhalis are suspected, antibiotics like amoxicillin clavulanate or cefixime be used. Antibacterial therapy must be continued till tympanic membrane regains normal appearance and hearing returns to normal. Early discontinuance of therapy with relief of earache and fever, or therapy given in inadequate doses may lead to otitis media with effusion
  2. Nasal decongestant can be given to relieve eustachian tube block.
  3. Analgesics and antipyretics like dolo or other NSAID’s can be given to supress pain and fever
  4. Myringotomy – incision and drainage of pus across the tympanic membrane.

Otitis Media with effusion

Here there is no pus, instead there is serous or mucoid effusion. Occurs due to increase secretory activity of middle ear mucosa or improper drainage by the eustachian tube. Clinical symptoms include earache and hearing loss. Mostly affects children between 5 to 8 years. Otoscopic findings include dull tympanic membrane with varying degree of retractions or bulging in its posterior part.

Thin leash of blood vessels around the anal of malleus and Periphery due to air absorption by blood vessels. X-ray mastoid or CT Temporal bone shows clouding of air cells of the mastoid. Treatment include decongestants and antibiotics(in case of viral infections or unresolved otitis media). Surgical management include myringotomy, tympanoplasty, grommet insertion or removing the impeading factor for eustachian tube.

Causes for eustachian tube obstruction include adenoid hyperplasia, tonsillitis, chronic rhinitis or sinusitis, cleft palate, palatal paralysis and downs syndrome.

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