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Persons with poor eustachian tube function (eg, congenital narrowness or acquired mucosal edema) may be unable to equalize the barometric stress exerted on the middle ear by air travel, rapid altitudinal change, or underwater diving The problem is generally most acute during airplane descent, since the negative middle ear pressure tends to collapse and block the eustachian tube Several measures are useful to enhance eustachian tube function and avoid otic barotrauma The patient should be advised to swallow, yawn, and autoinflate frequently during descent, which may be painful if the eustachian tube collapses Systemic decongestants (eg, pseudoephedrine, 60 120 mg) should be taken several hours before anticipated arrival time so that they will be maximally effective during descent Topical decongestants such as 1% phenylephrine nasal spray should be administered 1 hour before arrival For acute negative middle ear pressure that persists on the ground, treatment includes decongestants and attempts at autoinflation Myringotomy (creation of a small eardrum perforation) provides immediate relief and is appropriate in the setting of severe otalgia and hearing loss Repeated



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Acute otitis media is a bacterial infection of the mucosally lined air-containing spaces of the temporal bone Purulent material forms not only within the middle ear cleft but also within the mastoid air cells and petrous apex when they are pneumatized Acute otitis media is usually precipitated by a viral upper respiratory tract infection that causes eustachian tube edema This results in accumulation of fluid and mucus, which becomes secondarily infected by bacteria The most common pathogens both in adults and in children are Streptococcus pneumoniae, Haemophilus influenzae, and Streptococcus pyogenes

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Acute otitis media is most common in infants and children, although it may occur at any age Presenting symptoms and signs include otalgia, aural pressure, decreased





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hearing, and often fever The typical physical findings are erythema and decreased mobility of the tympanic membrane Occasionally, bullae will be seen on the tympanic membrane Although it is taught that this represents infection with Mycoplasma pneumoniae, most cases involve more common pathogens Rarely, when middle ear empyema is severe, the tympanic membrane can be seen to bulge outward In such cases, tympanic membrane rupture is imminent Rupture is accompanied by a sudden decrease in pain, followed by the onset of otorrhea With appropriate therapy, spontaneous healing of the tympanic membrane occurs in most cases When perforation persists, chronic otitis media frequently evolves Mastoid tenderness often accompanies acute otitis media and is due to the presence of pus within the mastoid air cells This alone does not indicate suppurative (surgical) mastoiditis

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The treatment of acute otitis media is specific antibiotic therapy, often combined with nasal decongestants The first-choice oral antibiotic treatment is amoxicillin (20 40 mg/kg/d) or erythromycin (50 mg/kg/d) plus sulfonamide (150 mg/kg/d) for 10 days Alternatives useful in resistant cases are cefaclor (20 40 mg/kg/d) or amoxicillin-clavulanate (20 40 mg/kg/d) combinations Tympanocentesis for bacterial (aerobic and anaerobic) and fungal culture may be performed by any experienced physician A 20-gauge spinal needle bent 90 degrees to the hub attached to a 3-mL syringe is inserted through the inferior portion of the tympanic membrane Interposition of a pliable connecting tube between the needle and syringe permits an assistant to aspirate without inducing movement of the needle Tympanocentesis is useful for otitis media in immunocompromised patients and when infection persists or recurs despite multiple courses of antibiotics Surgical drainage of the middle ear (myringotomy) is reserved for patients with severe otalgia or when complications of otitis (eg, mastoiditis, meningitis) have occurred Recurrent acute otitis media may be managed with long-term antibiotic prophylaxis Single daily oral doses of sulfamethoxazole (500 mg) or amoxicillin (250 or 500 mg) are given over a period of 1 3 months Failure of this regimen to control infection is an indication for insertion of ventilating tubes

Rovers MM et al Otitis media Lancet 2004 Feb 7;363(9407):465 73 [PMID: 14962529]

500, 000,000 VA = 1203 A 3 ( 240,000 V )

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