Otitis: symptoms, causes, diagnosis and treatment

Otitis is an inflammation of the ear generally caused by a bacterial, viral or fungal infection. It can sometimes heal spontaneously within a few days without the need for antibiotic treatment

Pain and fever, if present, can be relieved by using paracetamol and ibuprofen-based painkillers.

Types of otitis

Depending on the part of the organ involved, one can distinguish between external otitis, otitis media and chronic otitis media.

Otitis externa, otitis media and chronic otitis media

Otitis media is inflammation of the middle ear, i.e. the tympanic cavity or eardrum cavity that contains the ossicle chain (hammer, anvil, stirrup).

Acute otitis media is a bacterial or viral infection of the middle ear mucosa generally accompanied by an upper respiratory tract infection.

Chronic otitis and chronic otitis media

Chronic otitis is defined as all those forms of otitis that are protracted over time (>6 months) with predominant involvement of the middle ear portion and may extend to neighbouring areas.

Chronic otitis media is a chronic inflammation of the middle ear.

The presence or absence of otitis symptoms is related to the stage of the disease, possible involvement of the mastoid bone and the presence or absence of a tympanic perforation.

Swimmer’s otitis

Otitis externa, also known as swimmer’s otitis, is an inflammation of the external auditory canal, the canal that connects the auricle with the eardrum.

In particular, otitis externa affects the lining epithelium of the external auditory canal.

It is often caused by contact with water polluted with bacteria or irritants, but can also be generated by small wounds on the walls of the ear canal that may occur as a result of normal hygiene.

Anatomically, it is part of the rocca petrosa, a bony structure of the lateral skull base, which

  • contains in addition to the organ of hearing and balance the facial nerve, a tract of the internal carotid artery
  • Chronic forms of otitis are subdivided into
  • simple chronic media, which presents with a perforation of the eardrum
  • chronic exudative otitis media, which presents with an effusion of phlegm inside the middle ear and eardrum.
  • of the middle ear and intact eardrum (very frequent in children)
  • with retraction pocket or chronic atelectasis media, which presents with an adherence of the tympanic membrane towards the inner structures of the middle ear also involving the ossicles
  • chronic cholesteatomatous media, which presents as keratinous tissue (skin) that develops in the middle ear and erodes its bony structures involving in advanced stages
  • the inner ear and facial nerve

Symptoms of otitis externa

The symptoms commonly associated with otitis externa are

  • itching, which soon develops into more or less intense pain localised in the external auditory structures. The auricular pain is accentuated during chewing or simply by touching the ear
  • erythema
  • hyperemia (increased blood flow in the outer ear)
  • oedema
  • impaired hearing or otorrhea


Otorrhea is the discharge of material from the ear that often smells bad.

A hearing loss is the decrease in hearing, or buzzing, whistling, throbbing, dizziness, pain and rarely paralysis of the facial nerve.

In rare cases, acute or chronic exacerbated otitis media can lead to serious complications, e.g. endocranial (meningitis, brain abscess, cerebral venous sinus thrombophlebitis, etc.).

Chronic forms are characterised by recurrent episodes of otorrhea, or by constant and slowly worsening hearing loss, which often only partially respond to medication.

This occurs because the middle ear and nasopharynx are connected by a duct known as the Eustachian tube, whose job is to balance the air pressure inside the ear with that outside and facilitate the drainage of mucus from the middle ear.

In the event of an upper airway infection, germs present in the secretions of the nasopharynx can reach the middle ear and initiate the infection.

Otitis media

In other cases, obstructions and/or changes in the Eustachian tube cause the infection.

Otitis media is a typical disease of children, particularly common between 6 and 15 months of age.

Almost all pre-school children suffer from it at least once and just under 50% will have at least three episodes of otitis within the first three years of life.

Very often, fluid may be present in the ear of children with otitis media.

In this case we speak of otitis media with effusion, a form that affects about 90 per cent of preschoolers.

The main symptoms of the middle form are

  • ear pain and inflammation
  • nasal congestion
  • cough
  • sore throat
  • fever

When otitis media is not adequately treated, an aggravation of the clinical picture with perforation of the eardrum, impaired hearing and severe tinnitus is possible.


Otitis media is caused by the action of bacteria or viruses and is affected by subjective factors such as age, immune status and local factors.

These include adenoid hypertrophy, Eustachian tube insufficiency, sinusitis or chronic rhinitis.

The bacteria that most commonly cause this condition are: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.

The propagation and development of germs can take place via the Eustachian tube or the lymphatic-haematic route.

Other possible triggers of otitis media are:

  • pharyngitis
  • allergies
  • enlarged adenoids

In children with repeated (or recurrent) otitis media, it may be necessary to insert a small tube (ventilation tube) into the eardrum to facilitate drainage of the collected fluid.

In the case of enlarged adenoids that generate recurrent episodes of otitis media, their removal through surgery may be considered.


Serious complications

Serious complications of otitis media are not frequent. However, very young children (in whom the body’s defence system is underdeveloped) are at risk of local, regional or endocranial complications such as:

  • labyrinthitis, an inflammatory disorder of the inner ear or labyrinth. It causes balance disorders, hearing loss and tinnitus
  • mastoiditis, inflammation of the bone located behind the ear (mastoid) due to direct spread of infection.

This condition is characterised by high fever, swelling and pain behind the ear, headaches and hearing loss.

Usually, it resolves by administering antibiotics but, in some rare cases, it may be necessary to resort to cholesteatoma surgery, chronic inflammation of the middle ear associated with abnormal skin growth with erosion of bone structures.

A surgical approach is necessary

  • speech disorders, may occur in very young children with repeated otitis media that has transiently impaired their ability to hear
  • facial paralysis, swelling associated with otitis that can generate compression of the facial nerve. However, this condition generally resolves as the infection heals
  • meningitis, a serious but, fortunately, very rare complication of otitis media. It can occur if the infection spreads from the ear to the meninges (protective membranes covering the brain and spinal cord)
  • cerebral abscess, a collection of pus inside the brain. This is a very rare and serious complication that requires surgery.

Although it is not possible to prevent otitis media in children, certain behaviours can help reduce the risk of infection

  • ensure that the child has had his or her vaccinations according to the national vaccination calendar, with particular reference to the hexavalent and pneumococcal vaccines
  • vaccinate the child against influenza
  • avoid exposing the child to cigarette smoke
  • prefer breastfeeding rather than formula feeding where possible
  • try to avoid feeding your baby while he or she is lying on their back and avoid using a dummy between 6 and 12 months of age


In the case of chronic otitis, complications occur very rarely thanks to pharmacological treatment.

From an aetiological point of view, the pathogens involved in otitis externa are mainly bacteria and viruses (especially herpes viruses), and in some cases some mycetes.

Acute otitis externa, typical of children, is often a consequence of eczema or purulent otitis media, responsible for the progressive maceration of the skin lining the external auditory canal.

Otitis externa can be facilitated by certain elements such as cold, humidity, dryness of the ear canal or accumulation of earwax. In the case of allergy-induced otitis externa, the elimination of anything that may cause the allergy (e.g. hearing aids, ear plugs, earrings) is recommended.

If, after a few days of treatment with painkillers, symptoms persist and/or worsen, the doctor may decide to prescribe antibiotics.

Antibiotic treatment is recommended, in the doctor’s opinion, especially in children under the age of 6 months and/or adults with other illnesses.

If an otitis externa caused by fungi is established (diagnosed), the doctor may decide to administer so-called antifungal drugs.

Otitis externa rarely causes complications, however, with a very low incidence one can experience

  • narrowing of the ear canal due to accumulation of dead epithelial cells inside it
  • infections of a bacterial nature, such as abscesses or cellulitis, near or within the external auditory canal damaged by otitis
  • perforation of the eardrum due to otitis media
  • malignant otitis externa, a very rare complication in which the infection spreads to the bone surrounding the ear canal.


Several elements can play a preventive role with respect to the occurrence of otitis externa:

  • keep the ears dry and clean
  • use earplugs if you swim frequently
  • avoid using cotton swabs or other objects to clean the ear canal to avoid microtrauma
  • have any earwax plugs removed by a doctor
  • remove hearing aids, earplugs or earrings if an allergic reaction occurs.

In some forms of chronic relapsing otitis, it may be necessary to complete the diagnosis with radiological investigations (CT petrous cavity).

This is done in order to better define the extent of the inflammatory phenomenon and any damage that cannot be detected in order to exclude the involvement of important structures such as the labyrinth (seat of the balance organ), the cochlea (seat of the hearing organ), the facial nerve (cranial nerve responsible for the movement of the facial mimic muscles), and the meninges (the membrane lining the brain tissue).

Other treatments

The treatment of chronic forms is usually surgical and depending on the type, previously indicated, an indication is given for a specific surgical procedure.

In simple chronic forms (with tympanic perforation), the eardrum is reconstructed with fascia from the temporalis muscle or with cartilage taken from the auricular pavilion.

In exudative forms, incision of the eardrum and placement of a drainage tube usually solve the problem.

In atelectasis forms the eardrum together with the ossicles are reconstructed and cartilage and titanium or Teflon ossicular prostheses are used.

In cholesteatoma forms, a mastoidectomy and reconstruction not only of the eardrum but also of the cavity with fibro-muscular flaps (closed, open and open obliterative tympanoplasty) is usually performed.

With the application of new endoscopic surgical techniques, it is now possible in many cases to perform the operation without any external cuts.

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