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Otitis media (Latin) is inflammation of the middle ear, or a middle ear infection.

It occurs in the area between the tympanic membrane and the inner ear, including a duct known as the eustachian tube. It is one of the two categories of ear inflammation that can underlie what is commonly called an earache, the other being otitis externa. Diseases other than ear infections can also cause ear pain, including cancers of any structure that shares nerve supply with the ear and shingles which can lead to herpes zoster oticus. Though painful, otitis media is not threatening and usually heals on its own within 2–6 weeks.

Classification

Otitis media has many degrees of severity, and various names are used to describe each. The terminology is sometimes confusing because of multiple terms being used to describe the same condition. A common misconception with ear infection is that sufferers think that a symptom is itchy ear. Although sufferers may feel discomfort, an itchy ear is not a symptom of ear infection.

Acute

Acute otitis media (AOM) is most often purely viral and self-limited, as it usually accompanies viral URI (upper respiratory infection). There is congestion of the ears and perhaps mild discomfort and popping, but the symptoms resolve with the underlying URI. If the middle ear, which is normally sterile, becomes contaminated with bacteria, pus and pressure in the middle ear can result, and this is called acute bacterial otitis media. Viral acute otitis media can lead to bacterial otitis media in a very short time, especially in children, but it usually does not. The individual with bacterial acute otitis media has the classic "earache", pain that is more severe and continuous and is often accompanied by fever of 102 °F (39 °C) or more.[citation needed]. Bacterial cases may result in perforation of the ear drum, infection of the mastoid space (mastoiditis) and in very rare cases further spread to cause meningitis.^[1]

1st phase - exudative inflammation lasting 1–2 days, fever, rigors, meningism (occasionally in children), severe pain (worse at night), muffled noise in ear, deafness, sensitive mastoid process, ringing in ears (tinnitus)

2nd phase - resistance and demarcation lasting 3–8 days. Pus and middle ear exudate discharge spontaneously and afterwards pain and fever begin to decrease. This phase can be shortened with topical therapy.

3rd phase - healing phase lasting 2–4 weeks. Aural discharge dries up and hearing becomes normal.

Serous

Otitis media with effusion (OME), also called serous or secretory otitis media(SOM), is simply a collection of fluid that occurs within the middle ear space as a result of the negative pressure produced by altered Eustachian tube function. This can occur purely from a viral URI, with no pain or bacterial infection, or it can precede and/or follow acute bacterial otitis media. Fluid in the middle ear sometimes causes conductive hearing impairment, but only when it interferes with the normal vibration of the eardrum by sound waves. Over weeks and months, middle ear fluid can become very thick and glue-like (thus the name glue ear), which increases the likelihood of its causing conductive hearing impairment. Early-onset OME is associated with feeding while lying down and early entry into group child care, while parental smoking, too short a period of breastfeeding and greater amounts of time spent in group child care increased the duration of OME in the first two years of life.^[2]

Chronic suppurative

Chronic suppurative otitis media involves a perforation (hole) in the tympanic membrane and active bacterial infection within the middle ear space for several weeks or more. There may be enough pus that it drains to the outside of the ear (otorrhea), or the purulence may be minimal enough to only be seen on examination using a binocular microscope. This disease is much more common in persons with poor Eustachian tube function. Hearing impairment often accompanies this disease.

Signs and symptoms

When the middle ear becomes acutely infected, pressure builds up behind the eardrum (tympanic membrane), frequently causing intense pain. It may result in bullous myringitis, in which the tympanic membrane is inflamed and blistered.^[3]

In severe or untreated cases, the tympanic membrane may rupture, allowing the pus in the middle ear space to drain into the ear canal. If there is enough of it, this drainage may be obvious. Even though the rupture of the tympanic membrane suggests a traumatic process, it is almost always associated with the dramatic relief of pressure and pain. In a simple case of acute otitis media in an otherwise healthy person, the body's defenses are likely to resolve the infection and the ear drum nearly always heals.

Instead of the infection and eardrum perforation resolving, however, drainage from the middle ear can become a chronic condition. As long as there is active middle ear infection, the eardrum will not heal. The World Health Organization defines chronic suppurative otitis media (CSOM) as "a stage of ear disease in which there is chronic infection of the middle ear cleft, a non-intact tympanic membrane (i.e. perforated eardrum) and discharge (otorrhoea), for at least the preceding two weeks" (WHO 1998). (Notice WHO's use of the term serous to denote a bacterial process, whereas the same term is generally used by ear physicians in the United States to denote simple fluid collection within the middle ear behind an intact eardrum. Chronic otitis media is the term used by most ear physicians worldwide to describe a chronically infected middle ear with eardrum perforation.)^{[citation needed]}

Causes

Otitis media is most commonly caused by infection with viral, bacterial, or fungal pathogens. The most common bacterial pathogen is Streptococcus pneumoniae.^[4] Others include Pseudomonas aeruginosa, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. Among older adolescents and young adults, the most common cause of ear infections is Haemophilus influenzae. Viruses such as respiratory syncytial virus (RSV) and those that cause the common cold may also result in otitis media by damaging the normal defenses of the epithelial cells in the upper respiratory tract.

A major risk factor for developing otitis media is Eustachian tube dysfunction, which leads to the ineffective clearing of bacteria from the middle ear.

The role of the anti-H. influenzae vaccine that children are regularly given is to prevent invasive disease such as meningitis and pneumonia. This vaccine is active only against strains of serotype b, which has been found to cause meningitis and pneumonia in children under five years, with children between 4 and 18 months the most susceptible.^[5] Isolates of serotype b rarely cause otitis media.

Susceptibility is heritable, though the specific genetic markers are still under investigation. Casselbrant et al. found in 2009 that the "best-supported linkage regions may contain susceptibility genes that influence the risk for recurrent/persistent OM. Plausible candidates in 17q12 include AP2B1, CCL5, and a cluster of other CCL genes, and in 10q22.3, SFTPA2."^[6]

Progression

Typically, acute otitis media follows a cold: after a few days of a stuffy nose, the ear becomes involved and can cause severe pain. The pain will usually settle within a day or two, but can last over a week. Sometimes the ear drum ruptures, discharging pus from the ear, but the ruptured drum will usually heal rapidly.

At an anatomic level, the typical progression of acute otitis media occurs as follows: the tissues surrounding the Eustachian tube swell due to an upper respiratory infection, allergies, or dysfunction of the tubes. The Eustachian tube remains blocked most of the time. The air present in the middle ear is slowly absorbed into the surrounding tissues. A strong negative pressure creates a vacuum in the middle ear, and eventually the vacuum reaches a point where fluid from the surrounding tissues accumulates in the middle ear. This is seen as a progression from a Type A tympanogram to a Type C to a Type B tympanogram. The fluid may become infected. It has been found that dormant bacteria behind the tympanic membrane (eardrum) multiply when the conditions are ideal, infecting the middle ear fluid.

Children

Children younger than seven are much more prone to otitis media due to shorter Eustachian tubes, which are at a more horizontal angle than in the adult ear. They also have not developed the same resistance to viruses and bacteria as adults. Numerous studies have correlated the incidence in children with various factors such as nursing in infancy, bottle feeding when supine, parental smoking, diet, allergies, and automobile emissions; but the most obvious weakness of such studies is the inability to control the variable of exposure to viral agents during the studies^{[citation needed]}. Breastfeeding for the first twelve months of life is associated with a reduction in the number, and duration of all OM infections.^[7]

Pacifier use has been associated with more frequent episodes of AOM.^[8]

Diagnosis

Acute otitis media is usually diagnosed via visualization of the tympanic membrane in combination with the appropriate clinical history. The use of a monocular otoscope and perhaps a tympanometer may not be able to distinguish bacterial versus viral etiology, especially if the canal is small and there is wax in the ear that obscures a clear view of the eardrum. Also, an upset child's crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media.

The occurrence, duration, or severity of symptoms is not predictive of an ear infection in the absence of examination of the eardrum.^[9]

Otitis media acuta - Myringitis bullosa
Influenza
Otitis media acuta
Otitis media chronica mesotympanalis
Otitis media chronica mesotympanalis
Otitis media chronica mesotympanalis
Otitis media chronica mesotympanalis
The tympanic membrane as it appears in acute otitis media

Prevention

Pneumococcal conjugate vaccines when given during infancy decrease rates of acute otitis media by 6-7% and if implemented broadly would have a significant public health benefit.^[10] Evidence does not support zinc supplementation as an effort to reduce otitis rates except maybe in those with severe malnutrition such as marasmus.^[11] Long term antibiotics, while they decrease rates of infection during treatment, have an unknown effect on long term outcomes such as hearing loss.^[12]

Treatment

Symptomatic

Oral and topical analgesics are effective to treat the pain caused by otitis media. Oral agents include ibuprofen, acetaminophen, and narcotics. Topical agents shown to be effective include antipyrine and benzocaine ear drops.^[13] Decongestants and antihistamines either nasal or oral are not recommended due to the lack of benefit and concerns regarding side effects.^[14]

Antibiotics

Deferring the start of antibiotics in acute otitis media for one to three days if pain is manageable with the above measures is currently recommended as: two out of three children with acute otitis media resolve without antibiotic treatment,^[15]^[16] no adverse effect on long term outcomes have been found when treatment is withheld,^[17] antibiotics have significant rates of potential side effects, and a recent trial has found increased rates of recurrence of otitis in children who were treated with amoxicillin.^[18]

The first line antibiotic treatment, if warranted, is amoxicillin. If there is resistance, then amoxicillin-clavulanate or another penicillin derivative plus beta lactamase inhibitor is second line. While less than 7 days of antibiotics have less side effects more than seven days appear to be more effective.^[19] Among short-course antibiotics, long-acting azithromycin was found more likely to be successful than short-acting alternatives.^[20]

Tympanostomy tube

In chronic cases with effusions, insertion of tympanostomy tube (also called a "grommet") into the eardrum reduces recurrence rates in the 6 months after placement^[21] but have little effect on long term hearing.^[22] Thus tubes are recommended in those who have more than 3 episodes of acute otitis media in 6 month or 4 in a year associated with an effusion.^[23]

Alternative therapies

Complementary and alternative medicine is not recommended for otitis media with effusion because there is no evidence of benefit.^[24] There is an osteopathic manipulation technique called the Galbreath technique that can be done at home which is intended to improve drainage.^[25] The technique was evaluated in one randomized controlled clinical trial; one reviewer concluded that it was promising, but a 2010 evidence report found the evidence inconclusive.^[26]

Prognosis

Acute bacterial otitis media can cause pain that leads to sleepless nights for both children and parents, can cause eardrum perforations, not all of which heal, and can spread to cause mastoiditis and/or meningitis, brain abscess, and even death if a severe infection goes untreated long enough. High fever can occur and can cause febrile seizures. Appropriate antibiotic administration prevents most such complications.^{[citation needed]}

Hearing loss

Children with recurrent episodes of acute otitis media and those suffering from otitis media with effusion or chronic otitis media, have higher risks of developing conductive and sensorineural hearing loss.

This hearing loss is mainly due to fluid in the middle ear or rupture of the tympanic membrane. Prolonged duration of otitis media is associated with ossicular complications, and together with persistent tympanic membrane perforation contributes to the severity of both the disease and the hearing loss. When a cholesteatoma or granulation tissue is present in the middle ear, the degree of hearing loss and ossicular destruction is even greater.^[27]

Periods of conductive hearing loss from otitis media may have a detrimental effect on speech development in children.^[28] Recent studies have also linked otitis media to educational problems, attention disorders, and problems with social adaptation.^[29] Furthermore it has been demonstrated that patients suffering from otitis media have more depression/anxiety-related disorders compared to individuals with normal hearing.^[30] Once the infections resolve and hearing thresholds return to normal, childhood otitis media may still cause minor and irreversible damage to the middle ear and cochlea.^[31]

Epidemiology

Otitis media is very common in childhood, with the average toddler having two to three episodes a year, almost always accompanied by a viral upper respiratory infection (URI), mostly the common cold. The rhinoviruses (nose viruses) that cause the common cold infect the eustachian tube that goes from the back of the nose to the middle ear, causing swelling and compromise of pressure equalization, which is one of the normal functions of the tube. The other main function is the lateral drainage of fluids from tissues on either side of the skull. It has to be remembered that the eustachian tube is only the width of three to four hairs in places along its length. It also changes its anatomical and physiological appearance during the early growth period of the child. In the newborn the tube is horizontal making it more difficult to drain naturally, and the surface of the tube is 100% cartilage, with a lining of lymphatic tissue which is an extension of the adenoidal tissue from the back of the nose. As the early years pass by the superior (upper) part of the tube ossifies to bone but the lower remains the same. The angle of the tubes changes and descends to roughly a 45 degree angle increasing the downward flow of fluids. It should be noted that individuals with Down syndrome (DS) anatomically have more severe curves to their tubes, hence why DS children tend to have more grommet operations than other children. In general, the more severe and prolonged the compromise of eustachian tube function, the more severe the consequences are to the middle ear and its delicate structures. If a person is born with poor eustachian tube function, this greatly increases the likelihood of more frequent and severe episodes of otitis media. Progression to chronic otitis media is much more common in this group of people, who often have a family history of middle ear disease.^{[citation needed]}

References

^ Affiliated Otoralyngologists. "Otitis Media".
^ Owen MJ, Baldwin CD, Swank PR, Pannu AK, Johnson DL, Howie VM (1993). "Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life". J. Pediatr. 123 (5): 702–11. doi:10.1016/S0022-3476(05)80843-1. PMID 8229477.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Roberts DB (1980). "The etiology of bullous myringitis and the role of mycoplasmas in ear disease: a review". Pediatrics. 65 (4): 761–6. PMID 7367083. {{cite journal}}: Unknown parameter |month= ignored (help)
^ "Management of chronic suppurative otitis media" (Letter). Med J Aust. 180 (2): 91–3. 2004.
^ "Haemophilus influenzae type B (HiB)". World Health Organization. December 2005. Retrieved 12 October 2010.
^ Casselbrant ML, Mandel EM, Jung J, Ferrell RE, Tekely K, Szatkiewicz JP, Ray A, Weeks DE (2009-09-03). "Otitis media: a genome-wide linkage scan with evidence of susceptibility loci within the 17q12 and 10q22.3 regions". BMC Medical Genetics. 10: 85. doi:10.1186/1471-2350-10-85. PMC 2751750. PMID 19728873.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
^ Dewey KG, Heinig MJ, Nommsen-Rivers LA (1995). "Differences in morbidity between breast-fed and formula-fed infants". J Pediatr. 126 (5 Pt 1): 696–702. doi:10.1016/S0022-3476(95)70395-0. PMID 7751991.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Rovers MM, Numans ME, Langenbach E, Grobbee DE, Verheij TJ, Schilder AG (2008). "Is pacifier use a risk factor for acute otitis media? A dynamic cohort study". Fam Pract. 25 (4): 233–6. doi:10.1093/fampra/cmn030. PMID 18562333. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
^ Laine MK, Tähtinen PA, Ruuskanen O, Huovinen P, Ruohola A (2010). "Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age". Pediatrics. 125 (5): e1154–61. doi:10.1542/peds.2009-2689. PMID 20368317. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
^ Jansen AG, Hak E, Veenhoven RH, Damoiseaux RA, Schilder AG, Sanders EA (2009). "Pneumococcal conjugate vaccines for preventing otitis media". Cochrane Database Syst Rev (2): CD001480. doi:10.1002/14651858.CD001480.pub3. PMID 19370566.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Abba K, Gulani A, Sachdev HS (2010). "Zinc supplements for preventing otitis media". Cochrane Database Syst Rev (2): CD006639. doi:10.1002/14651858.CD006639.pub2. PMID 20166086.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Leach AJ, Morris PS (2006). "Antibiotics for the prevention of acute and chronic suppurative otitis media in children". Cochrane Database Syst Rev (4): CD004401. doi:10.1002/14651858.CD004401.pub2. PMID 17054203.
^ Sattout, A.; Jenner, R. (2008). "Best evidence topic reports. Bet 1. The role of topical analgesia in acute otitis media". Emerg Med J. 25 (2): 103–4. doi:10.1136/emj.2007.056648. PMID 18212148. {{cite journal}}: Unknown parameter |month= ignored (help)
^ Coleman C, Moore M (2008). "Decongestants and antihistamines for acute otitis media in children". Cochrane Database Syst Rev (3): CD001727. doi:10.1002/14651858.CD001727.pub4. PMID 18646076.
^ Damoiseaux R (2005). "Antibiotic treatment for acute otitis media: time to think again". CMAJ. 172 (5): 657–8. doi:10.1503/cmaj.050078. PMC 550637. PMID 15738492.
^ Marchetti F, Ronfani L, Nibali S, Tamburlini G (2005). "Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care". Arch Pediatr Adolesc Med. 159 (7): 679–84. doi:10.1001/archpedi.159.7.679. PMID 15997003.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Little P, Moore M, Warner G, Dunleavy J, Williamson I (2006). "Longer term outcomes from a randomised trial of prescribing strategies in otitis media". Br J Gen Pract. 56 (524): 176–82. PMC 1828260. PMID 16536957.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Bezáková, N; Damoiseaux, RA; Hoes, AW; Schilder, AG; Rovers, MM (2009). "Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: survey of trial participants". BMJ (Clinical research ed.). 338: b2525. doi:10.1136/bmj.b2525. PMID 19567910.
^ Kozyrskyj A, Klassen TP, Moffatt M, Harvey K (2010). "Short-course antibiotics for acute otitis media". Cochrane Database Syst Rev (9): CD001095. doi:10.1002/14651858.CD001095.pub2. PMID 20824827.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Gulani A, Sachdev HP, Qazi SA (2010 Jan). "Efficacy of short course (<4 days) of antibiotics for treatment of acute otitis media in children: a systematic review of randomized controlled trials". Indian Pediatr. 47 (1): 74–87. PMID 19736367. {{cite journal}}: Check date values in: |date= (help)CS1 maint: multiple names: authors list (link)
^ McDonald S, Langton Hewer CD, Nunez DA (2008). "Grommets (ventilation tubes) for recurrent acute otitis media in children". Cochrane Database Syst Rev (4): CD004741. doi:10.1002/14651858.CD004741.pub2. PMID 18843668.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ (2010). "Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children". Cochrane Database Syst Rev (10): CD001801. doi:10.1002/14651858.CD001801.pub3. PMID 20927726.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Wilson SA, Mayo H, Fisher M (2003). "Clinical inquiries. Are tympanostomy tubes indicated for recurrent acute otitis media?" (PDF). J Fam Pract. 52 (5): 403–4, 406. PMID 12737775. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
^ Rosenfeld RM, Culpepper L, Yawn B, Mahoney MC (2004). "Otitis media with effusion clinical practice guideline". Am Fam Physician. 69 (12): 2776, 2778–9. PMID 15222643. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
^ Pratt-Harrington D (2000). "Galbreath technique: a manipulative treatment for otitis media revisited". J Am Osteopath Assoc. 100 (10): 635–9. PMID 11105452. {{cite journal}}: Unknown parameter |month= ignored (help)
^ Bronfort G, Haas M, Evans R, Leininger B, Triano J (2010). "Effectiveness of manual therapies: the UK evidence report" (PDF). Chiropr Osteopat. 18: 3. doi:10.1186/1746-1340-18-3. PMC 2841070. PMID 20184717.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
^ Da Costa SS (February 2009). "Sensorineural hearing loss in patients with chronic otitis media". Eur Arch Otorhinolaryngol. 266 (2): 221–4. doi:10.1007/s00405-008-0739-0. PMID 18629531.
^ Roberts K (June 1997). "A preliminary account of the effect of otitis media on 15-month-olds' categorization and some implications for early language learning". J Speech Lang Hear Res. 40 (3): 508–18. PMID 9210110.
^ Bidadi S, Nejadkazem M, Naderpour M (November 2008). "The relationship between chronic otitis media-induced hearing loss and the acquisition of social skills". Otolaryngol Head Neck Surg. 139 (5): 665–70. PMID 18984261.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Gouma P, Mallis A, Daniilidis V, Gouveris H, Armenakis N, Naxakis S (January 2011). "Behavioral trends in young children with conductive hearing loss: a case-control study". Eur Arch Otorhinolaryngol. 268 (1): 63–6. doi:10.1007/s00405-010-1346-4. PMID 20665042.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Yilmaz S, Karasalihoglu AR, Tas A, Yagiz R, Tas M (February 2006). "Otoacoustic emissions in young adults with a history of otitis media". J Laryngol Otol. 120 (2): 103–7. PMID 16359151.{{cite journal}}: CS1 maint: multiple names: authors list (link)

External links

Neff MJ (June 2004). "AAP, AAFP, AAO-HNS release guideline on diagnosis and management of otitis media with effusion". Am Fam Physician. 69 (12): 2929–31. PMID 15222658.

[OtitisM-1] Affiliated Otoralyngologists. "Otitis Media".

[2] Owen MJ, Baldwin CD, Swank PR, Pannu AK, Johnson DL, Howie VM (1993). "Relation of infant feeding practices, cigarette smoke exposure, and group child care to the onset and duration of otitis media with effusion in the first two years of life". J. Pediatr. 123 (5): 702–11. doi:10.1016/S0022-3476(05)80843-1. PMID 8229477.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[bm-3] Roberts DB (1980). "The etiology of bullous myringitis and the role of mycoplasmas in ear disease: a review". Pediatrics. 65 (4): 761–6. PMID 7367083. {{cite journal}}: Unknown parameter |month= ignored (help)

[4] "Management of chronic suppurative otitis media" (Letter). Med J Aust. 180 (2): 91–3. 2004.

[5] "Haemophilus influenzae type B (HiB)". World Health Organization. December 2005. Retrieved 12 October 2010.

[6] Casselbrant ML, Mandel EM, Jung J, Ferrell RE, Tekely K, Szatkiewicz JP, Ray A, Weeks DE (2009-09-03). "Otitis media: a genome-wide linkage scan with evidence of susceptibility loci within the 17q12 and 10q22.3 regions". BMC Medical Genetics. 10: 85. doi:10.1186/1471-2350-10-85. PMC 2751750. PMID 19728873.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)

[pmid7751991-7] Dewey KG, Heinig MJ, Nommsen-Rivers LA (1995). "Differences in morbidity between breast-fed and formula-fed infants". J Pediatr. 126 (5 Pt 1): 696–702. doi:10.1016/S0022-3476(95)70395-0. PMID 7751991.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[8] Rovers MM, Numans ME, Langenbach E, Grobbee DE, Verheij TJ, Schilder AG (2008). "Is pacifier use a risk factor for acute otitis media? A dynamic cohort study". Fam Pract. 25 (4): 233–6. doi:10.1093/fampra/cmn030. PMID 18562333. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

[9] Laine MK, Tähtinen PA, Ruuskanen O, Huovinen P, Ruohola A (2010). "Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age". Pediatrics. 125 (5): e1154–61. doi:10.1542/peds.2009-2689. PMID 20368317. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

[10] Jansen AG, Hak E, Veenhoven RH, Damoiseaux RA, Schilder AG, Sanders EA (2009). "Pneumococcal conjugate vaccines for preventing otitis media". Cochrane Database Syst Rev (2): CD001480. doi:10.1002/14651858.CD001480.pub3. PMID 19370566.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[11] Abba K, Gulani A, Sachdev HS (2010). "Zinc supplements for preventing otitis media". Cochrane Database Syst Rev (2): CD006639. doi:10.1002/14651858.CD006639.pub2. PMID 20166086.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[12] Leach AJ, Morris PS (2006). "Antibiotics for the prevention of acute and chronic suppurative otitis media in children". Cochrane Database Syst Rev (4): CD004401. doi:10.1002/14651858.CD004401.pub2. PMID 17054203.

[13] Sattout, A.; Jenner, R. (2008). "Best evidence topic reports. Bet 1. The role of topical analgesia in acute otitis media". Emerg Med J. 25 (2): 103–4. doi:10.1136/emj.2007.056648. PMID 18212148. {{cite journal}}: Unknown parameter |month= ignored (help)

[14] Coleman C, Moore M (2008). "Decongestants and antihistamines for acute otitis media in children". Cochrane Database Syst Rev (3): CD001727. doi:10.1002/14651858.CD001727.pub4. PMID 18646076.

[15] Damoiseaux R (2005). "Antibiotic treatment for acute otitis media: time to think again". CMAJ. 172 (5): 657–8. doi:10.1503/cmaj.050078. PMC 550637. PMID 15738492.

[16] Marchetti F, Ronfani L, Nibali S, Tamburlini G (2005). "Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care". Arch Pediatr Adolesc Med. 159 (7): 679–84. doi:10.1001/archpedi.159.7.679. PMID 15997003.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[17] Little P, Moore M, Warner G, Dunleavy J, Williamson I (2006). "Longer term outcomes from a randomised trial of prescribing strategies in otitis media". Br J Gen Pract. 56 (524): 176–82. PMC 1828260. PMID 16536957.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[18] Bezáková, N; Damoiseaux, RA; Hoes, AW; Schilder, AG; Rovers, MM (2009). "Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: survey of trial participants". BMJ (Clinical research ed.). 338: b2525. doi:10.1136/bmj.b2525. PMID 19567910.

[19] Kozyrskyj A, Klassen TP, Moffatt M, Harvey K (2010). "Short-course antibiotics for acute otitis media". Cochrane Database Syst Rev (9): CD001095. doi:10.1002/14651858.CD001095.pub2. PMID 20824827.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[20] Gulani A, Sachdev HP, Qazi SA (2010 Jan). "Efficacy of short course (<4 days) of antibiotics for treatment of acute otitis media in children: a systematic review of randomized controlled trials". Indian Pediatr. 47 (1): 74–87. PMID 19736367. {{cite journal}}: Check date values in: |date= (help)CS1 maint: multiple names: authors list (link)

[21] McDonald S, Langton Hewer CD, Nunez DA (2008). "Grommets (ventilation tubes) for recurrent acute otitis media in children". Cochrane Database Syst Rev (4): CD004741. doi:10.1002/14651858.CD004741.pub2. PMID 18843668.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[22] Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ (2010). "Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children". Cochrane Database Syst Rev (10): CD001801. doi:10.1002/14651858.CD001801.pub3. PMID 20927726.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[23] Wilson SA, Mayo H, Fisher M (2003). "Clinical inquiries. Are tympanostomy tubes indicated for recurrent acute otitis media?" (PDF). J Fam Pract. 52 (5): 403–4, 406. PMID 12737775. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

[24] Rosenfeld RM, Culpepper L, Yawn B, Mahoney MC (2004). "Otitis media with effusion clinical practice guideline". Am Fam Physician. 69 (12): 2776, 2778–9. PMID 15222643. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

[25] Pratt-Harrington D (2000). "Galbreath technique: a manipulative treatment for otitis media revisited". J Am Osteopath Assoc. 100 (10): 635–9. PMID 11105452. {{cite journal}}: Unknown parameter |month= ignored (help)

[26] Bronfort G, Haas M, Evans R, Leininger B, Triano J (2010). "Effectiveness of manual therapies: the UK evidence report" (PDF). Chiropr Osteopat. 18: 3. doi:10.1186/1746-1340-18-3. PMC 2841070. PMID 20184717.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)

[27] Da Costa SS (February 2009). "Sensorineural hearing loss in patients with chronic otitis media". Eur Arch Otorhinolaryngol. 266 (2): 221–4. doi:10.1007/s00405-008-0739-0. PMID 18629531.

[28] Roberts K (June 1997). "A preliminary account of the effect of otitis media on 15-month-olds' categorization and some implications for early language learning". J Speech Lang Hear Res. 40 (3): 508–18. PMID 9210110.

[29] Bidadi S, Nejadkazem M, Naderpour M (November 2008). "The relationship between chronic otitis media-induced hearing loss and the acquisition of social skills". Otolaryngol Head Neck Surg. 139 (5): 665–70. PMID 18984261.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[30] Gouma P, Mallis A, Daniilidis V, Gouveris H, Armenakis N, Naxakis S (January 2011). "Behavioral trends in young children with conductive hearing loss: a case-control study". Eur Arch Otorhinolaryngol. 268 (1): 63–6. doi:10.1007/s00405-010-1346-4. PMID 20665042.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[31] Yilmaz S, Karasalihoglu AR, Tas A, Yagiz R, Tas M (February 2006). "Otoacoustic emissions in young adults with a history of otitis media". J Laryngol Otol. 120 (2): 103–7. PMID 16359151.{{cite journal}}: CS1 maint: multiple names: authors list (link)

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@@ Line 39: / Line 39: @@
 ==Signs and symptoms==
-When the [[middle ear]] becomes acutely infected, [[pressure]] builds up behind the [[eardrum]] (tympanic membrane), frequently causing intense pain. It may result in ''bullous myringitis'', in which the tympanic membrane is inflamed and blistered.<ref name="bm">{{cite journal |author=Roberts DB |title=The etiology of bullous myringitis and the role of mycoplasmas in ear disease: a review |journal=Pediatrics |volume=65 |issue=4 |pages=761–6 |year=1980 |month=April |pmid=7367083 |doi= |url= |accessdate=2010-02-11}}</ref>
+When the [[middle ear]] becomes acutely infected, [[pressure]] builds up behind the [[eardrum]] (tympanic membrane), frequently causing intense pain. It may result in ''bullous myringitis'', in which the tympanic membrane is inflamed and blistered.<ref name="bm">{{cite journal |author=Roberts DB |title=The etiology of bullous myringitis and the role of mycoplasmas in ear disease: a review |journal=Pediatrics |volume=65 |issue=4 |pages=761–6 |year=1980 |month=April |pmid=7367083 }}</ref>
 In severe or untreated cases, the tympanic membrane may rupture, allowing the [[pus]] in the middle ear space to drain into the [[ear canal]]. If there is enough of it, this drainage may be obvious. Even though the rupture of the tympanic membrane suggests a traumatic process, it is almost always associated with the dramatic relief of pressure and pain. In a simple case of acute otitis media in an otherwise healthy person, the body's defenses are likely to resolve the [[infection]] and the ear drum nearly always heals.
@@ Line 67: / Line 67: @@
 Acute otitis media is usually diagnosed via visualization of the [[tympanic membrane]] in combination with the appropriate clinical history.  The use of a monocular [[otoscope]] and perhaps a [[tympanometer]] may not be able to distinguish bacterial versus viral etiology, especially if the canal is small and there is wax in the ear that obscures a clear view of the eardrum. Also, an upset child's crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media.
-The occurrence, duration, or severity of symptoms is not predictive of an ear infection in the absence of examination of the eardrum.<ref>{{cite journal |author=Laine MK, Tähtinen PA, Ruuskanen O, Huovinen P, Ruohola A |title=Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age |journal=Pediatrics |volume=125 |issue=5 |pages=e1154–61 |year=2010 |month=May |pmid=20368317 |doi=10.1542/peds.2009-2689 |url=}}</ref>
+The occurrence, duration, or severity of symptoms is not predictive of an ear infection in the absence of examination of the eardrum.<ref>{{cite journal |author=Laine MK, Tähtinen PA, Ruuskanen O, Huovinen P, Ruohola A |title=Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age |journal=Pediatrics |volume=125 |issue=5 |pages=e1154–61 |year=2010 |month=May |pmid=20368317 |doi=10.1542/peds.2009-2689 }}</ref>
 <gallery widths="100px" heights="100px" perrow="5">
@@ Line 82: / Line 82: @@
 ==Prevention==
-[[Pneumococcal conjugate vaccine]]s when given during [[infancy]] decrease rates of acute otitis media by 6-7% and if implemented broadly would have a significant [[public health]] benefit.<ref>{{cite journal |author=Jansen AG, Hak E, Veenhoven RH, Damoiseaux RA, Schilder AG, Sanders EA |title=Pneumococcal conjugate vaccines for preventing otitis media |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD001480 |year=2009 |pmid=19370566 |doi=10.1002/14651858.CD001480.pub3 |url=}}</ref> Evidence does not support [[zinc]] supplementation as an effort to reduce otitis rates except maybe in those with severe [[malnutrition]] such as [[marasmus]].<ref>{{cite journal |author=Abba K, Gulani A, Sachdev HS |title=Zinc supplements for preventing otitis media |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD006639 |year=2010 |pmid=20166086 |doi=10.1002/14651858.CD006639.pub2 |url=}}</ref> Long term antibiotics, while they decrease rates of infection during treatment, have an unknown effect on long term         outcomes such as [[hearing loss]].<ref>{{cite journal |author=Leach AJ, Morris PS |title=Antibiotics for the prevention of acute and chronic suppurative otitis media in children |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD004401 |year=2006 |pmid=17054203 |doi=10.1002/14651858.CD004401.pub2 |url=}}</ref>
+[[Pneumococcal conjugate vaccine]]s when given during [[infancy]] decrease rates of acute otitis media by 6-7% and if implemented broadly would have a significant [[public health]] benefit.<ref>{{cite journal |author=Jansen AG, Hak E, Veenhoven RH, Damoiseaux RA, Schilder AG, Sanders EA |title=Pneumococcal conjugate vaccines for preventing otitis media |journal=Cochrane Database Syst Rev |issue=2 |pages=CD001480 |year=2009 |pmid=19370566 |doi=10.1002/14651858.CD001480.pub3 }}</ref> Evidence does not support [[zinc]] supplementation as an effort to reduce otitis rates except maybe in those with severe [[malnutrition]] such as [[marasmus]].<ref>{{cite journal |author=Abba K, Gulani A, Sachdev HS |title=Zinc supplements for preventing otitis media |journal=Cochrane Database Syst Rev |issue=2 |pages=CD006639 |year=2010 |pmid=20166086 |doi=10.1002/14651858.CD006639.pub2 }}</ref> Long term antibiotics, while they decrease rates of infection during treatment, have an unknown effect on long term         outcomes such as [[hearing loss]].<ref>{{cite journal |author=Leach AJ, Morris PS |title=Antibiotics for the prevention of acute and chronic suppurative otitis media in children |journal=Cochrane Database Syst Rev |issue=4 |pages=CD004401 |year=2006 |pmid=17054203 |doi=10.1002/14651858.CD004401.pub2 }}</ref>
 ==Treatment==
 ===Symptomatic===
-Oral and topical [[analgesics]] are effective to treat the pain caused by otitis media. Oral agents include [[ibuprofen]], [[acetaminophen]], and [[narcotics]]. Topical agents shown to be effective include [[antipyrine and benzocaine ear drops]].<ref>{{cite journal |author= |title=Best evidence topic reports. Bet 1. The role of topical analgesia in acute otitis media |journal=Emerg Med J |volume=25 |issue=2 |pages=103–4 |year=2008 |month=February |pmid=18212148 |doi=10.1136/emj.2007.056648 |url= |last1= Sattout |first1= A. |last2= Jenner |first2= R.}}</ref> [[Decongestants]] and [[antihistamine]]s either nasal or oral are not recommended due to the lack of benefit and concerns regarding side effects.<ref>{{cite journal |author=Coleman C, Moore M |title=Decongestants and antihistamines for acute otitis media in children |journal=Cochrane Database Syst Rev |volume= |issue=3 |pages=CD001727 |year=2008 |pmid=18646076 |doi=10.1002/14651858.CD001727.pub4 |url=}}</ref>
+Oral and topical [[analgesics]] are effective to treat the pain caused by otitis media. Oral agents include [[ibuprofen]], [[acetaminophen]], and [[narcotics]]. Topical agents shown to be effective include [[antipyrine and benzocaine ear drops]].<ref>{{cite journal |title=Best evidence topic reports. Bet 1. The role of topical analgesia in acute otitis media |journal=Emerg Med J |volume=25 |issue=2 |pages=103–4 |year=2008 |month=February |pmid=18212148 |doi=10.1136/emj.2007.056648 |last1= Sattout |first1= A. |last2= Jenner |first2= R.}}</ref> [[Decongestants]] and [[antihistamine]]s either nasal or oral are not recommended due to the lack of benefit and concerns regarding side effects.<ref>{{cite journal |author=Coleman C, Moore M |title=Decongestants and antihistamines for acute otitis media in children |journal=Cochrane Database Syst Rev |issue=3 |pages=CD001727 |year=2008 |pmid=18646076 |doi=10.1002/14651858.CD001727.pub4 }}</ref>
 ===Antibiotics===
-Deferring the start of antibiotics in acute otitis media for one to three days if pain is manageable with the above measures is currently recommended as: two out of three children with acute otitis media resolve without antibiotic treatment,<ref>{{cite journal | author = Damoiseaux R | title = Antibiotic treatment for acute otitis media: time to think again | journal = [[CMAJ]] | volume = 172 | issue = 5 | pages = 657–8 | year = 2005 | pmid = 15738492 | doi = 10.1503/cmaj.050078 | pmc = 550637}}</ref><ref>{{cite journal | author = Marchetti F, Ronfani L, Nibali S, Tamburlini G | title = Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care | journal = [[Arch Pediatr Adolesc Med]] | volume = 159 | issue = 7 | pages = 679–84 | year = 2005 | pmid = 15997003 | doi = 10.1001/archpedi.159.7.679}}</ref> no adverse effect on long term outcomes have been found when treatment is withheld,<ref>{{cite journal | author = Little P, Moore M, Warner G, Dunleavy J, Williamson I | title = Longer term outcomes from a randomised trial of prescribing strategies in otitis media | journal = [[Br J Gen Pract]] | volume = 56 | issue = 524 | pages = 176–82 | year = 2006 | pmid = 16536957 | pmc = 1828260}}</ref> antibiotics have significant rates of potential side effects, and a recent trial has found increased rates of recurrence of otitis in children who were treated with [[amoxicillin]].<ref>{{cite journal |last1=Bezáková |first1=N |last2=Damoiseaux |first2=RA |last3=Hoes |first3=AW |last4=Schilder |first4=AG |last5=Rovers |first5=MM |title=Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: survey of trial participants. |journal=BMJ (Clinical research ed.) |volume=338 |pages=b2525 |year=2009 |pmid=19567910 |doi=10.1136/bmj.b2525}}</ref>
+Deferring the start of antibiotics in acute otitis media for one to three days if pain is manageable with the above measures is currently recommended as: two out of three children with acute otitis media resolve without antibiotic treatment,<ref>{{cite journal | author = Damoiseaux R | title = Antibiotic treatment for acute otitis media: time to think again | journal = [[CMAJ]] | volume = 172 | issue = 5 | pages = 657–8 | year = 2005 | pmid = 15738492 | doi = 10.1503/cmaj.050078 | pmc = 550637}}</ref><ref>{{cite journal | author = Marchetti F, Ronfani L, Nibali S, Tamburlini G | title = Delayed prescription may reduce the use of antibiotics for acute otitis media: a prospective observational study in primary care | journal = [[Arch Pediatr Adolesc Med]] | volume = 159 | issue = 7 | pages = 679–84 | year = 2005 | pmid = 15997003 | doi = 10.1001/archpedi.159.7.679}}</ref> no adverse effect on long term outcomes have been found when treatment is withheld,<ref>{{cite journal | author = Little P, Moore M, Warner G, Dunleavy J, Williamson I | title = Longer term outcomes from a randomised trial of prescribing strategies in otitis media | journal = Br J Gen Pract | volume = 56 | issue = 524 | pages = 176–82 | year = 2006 | pmid = 16536957 | pmc = 1828260}}</ref> antibiotics have significant rates of potential side effects, and a recent trial has found increased rates of recurrence of otitis in children who were treated with [[amoxicillin]].<ref>{{cite journal |last1=Bezáková |first1=N |last2=Damoiseaux |first2=RA |last3=Hoes |first3=AW |last4=Schilder |first4=AG |last5=Rovers |first5=MM |title=Recurrence up to 3.5 years after antibiotic treatment of acute otitis media in very young Dutch children: survey of trial participants. |journal=BMJ (Clinical research ed.) |volume=338 |pages=b2525 |year=2009 |pmid=19567910 |doi=10.1136/bmj.b2525}}</ref>
-The first line antibiotic treatment, if warranted, is [[amoxicillin]]. If there is [[antibiotic resistance|resistance]], then [[co-amoxiclav|amoxicillin-clavulanate]] or another penicillin derivative plus beta lactamase inhibitor is second line.  While less than 7 days of antibiotics have less side effects more than seven days appear to be more effective.<ref>{{cite journal |author=Kozyrskyj A, Klassen TP, Moffatt M, Harvey K |title=Short-course antibiotics for acute otitis media |journal=[[Cochrane Database Syst Rev]] |volume=9 |issue= 9|pages=CD001095 |year=2010 |pmid=20824827 |doi=10.1002/14651858.CD001095.pub2 }}</ref> Among short-course antibiotics, long-acting [[azithromycin]] was found more likely to be successful than short-acting alternatives.<ref>{{cite journal |journal=[[Indian Pediatr]] |date=2010 Jan |volume=47 |issue=1 |pages=74–87 |title=Efficacy of short course (<4 days) of antibiotics for treatment of acute otitis media in children: a systematic review of randomized controlled trials |author=Gulani A, Sachdev HP, Qazi SA |pmid=19736367}}</ref>
+The first line antibiotic treatment, if warranted, is [[amoxicillin]]. If there is [[antibiotic resistance|resistance]], then [[co-amoxiclav|amoxicillin-clavulanate]] or another penicillin derivative plus beta lactamase inhibitor is second line.  While less than 7 days of antibiotics have less side effects more than seven days appear to be more effective.<ref>{{cite journal |author=Kozyrskyj A, Klassen TP, Moffatt M, Harvey K |title=Short-course antibiotics for acute otitis media |journal=[[Cochrane Database Syst Rev]] |issue= 9|pages=CD001095 |year=2010 |pmid=20824827 |doi=10.1002/14651858.CD001095.pub2 }}</ref> Among short-course antibiotics, long-acting [[azithromycin]] was found more likely to be successful than short-acting alternatives.<ref>{{cite journal |journal=Indian Pediatr |date=2010 Jan |volume=47 |issue=1 |pages=74–87 |title=Efficacy of short course (<4 days) of antibiotics for treatment of acute otitis media in children: a systematic review of randomized controlled trials |author=Gulani A, Sachdev HP, Qazi SA |pmid=19736367}}</ref>
 ===Tympanostomy tube===
-In chronic cases with effusions, insertion of [[tympanostomy tube]] (also called a "grommet") into the [[eardrum]] reduces recurrence rates in the 6&nbsp;months after placement<ref>{{cite journal |author=McDonald S, Langton Hewer CD, Nunez DA |title=Grommets (ventilation tubes) for recurrent acute otitis media in children |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD004741 |year=2008 |pmid=18843668 |doi=10.1002/14651858.CD004741.pub2 |url=}}</ref> but have little effect on long term hearing.<ref>{{cite journal |author=Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ |title=Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children |journal=Cochrane Database Syst Rev |volume= |issue=10 |pages=CD001801 |year=2010 |pmid=20927726 |doi=10.1002/14651858.CD001801.pub3 |url=}}</ref> Thus tubes are recommended in those who have more than 3 episodes of acute otitis media in 6 month or 4 in a year associated with an effusion.<ref>{{cite journal |author=Wilson SA, Mayo H, Fisher M |title=Clinical inquiries. Are tympanostomy tubes indicated for recurrent acute otitis media? |journal=J Fam Pract |volume=52 |issue=5 |pages=403–4, 406 |year=2003 |month=May |pmid=12737775 |doi= |url=https://mospace.umsystem.edu/xmlui/bitstream/handle/10355/2911/AreTympanostomyTubesIndicatedOtitis.pdf?sequence=1}}</ref>
+In chronic cases with effusions, insertion of [[tympanostomy tube]] (also called a "grommet") into the [[eardrum]] reduces recurrence rates in the 6&nbsp;months after placement<ref>{{cite journal |author=McDonald S, Langton Hewer CD, Nunez DA |title=Grommets (ventilation tubes) for recurrent acute otitis media in children |journal=Cochrane Database Syst Rev |issue=4 |pages=CD004741 |year=2008 |pmid=18843668 |doi=10.1002/14651858.CD004741.pub2 }}</ref> but have little effect on long term hearing.<ref>{{cite journal |author=Browning GG, Rovers MM, Williamson I, Lous J, Burton MJ |title=Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children |journal=Cochrane Database Syst Rev |issue=10 |pages=CD001801 |year=2010 |pmid=20927726 |doi=10.1002/14651858.CD001801.pub3 }}</ref> Thus tubes are recommended in those who have more than 3 episodes of acute otitis media in 6 month or 4 in a year associated with an effusion.<ref>{{cite journal |author=Wilson SA, Mayo H, Fisher M |title=Clinical inquiries. Are tympanostomy tubes indicated for recurrent acute otitis media? |journal=J Fam Pract |volume=52 |issue=5 |pages=403–4, 406 |year=2003 |month=May |pmid=12737775 |url=https://mospace.umsystem.edu/xmlui/bitstream/handle/10355/2911/AreTympanostomyTubesIndicatedOtitis.pdf?sequence=1 |format=PDF}}</ref>
 ===Alternative therapies===
-[[Complementary and alternative medicine]] is not recommended for otitis media with effusion because there is no evidence of benefit.<ref>{{cite journal |author=Rosenfeld RM, Culpepper L, Yawn B, Mahoney MC |title=Otitis media with effusion clinical practice guideline |journal=Am Fam Physician |volume=69 |issue=12 |pages=2776, 2778–9 |year=2004 |month=June |pmid=15222643 |doi= |url=}}</ref> There is an osteopathic [[Joint manipulation|manipulation]] technique called the Galbreath technique that can be done at home which is intended to improve drainage.<ref>{{cite journal |author=Pratt-Harrington D |title=Galbreath technique: a manipulative treatment for otitis media revisited |journal=J Am Osteopath Assoc |volume=100 |issue=10 |pages=635–9 |year=2000 |month=October |pmid=11105452 |doi= |url=http://www.jaoa.org/cgi/pmidlookup?view=long&pmid=11105452}}</ref> The technique was evaluated in one randomized controlled clinical trial; one reviewer concluded that it was promising, but a 2010 evidence report found the evidence inconclusive.<ref>{{cite journal |author=Bronfort G, Haas M, Evans R, Leininger B, Triano J |title=Effectiveness of manual therapies: the UK evidence report |journal=Chiropr Osteopat |volume=18 |issue= |pages=3 |year=2010 |pmid=20184717 |pmc=2841070 |doi=10.1186/1746-1340-18-3 |url=http://www.biomedcentral.com/content/pdf/1746-1340-18-3.pdf}}</ref>
+[[Complementary and alternative medicine]] is not recommended for otitis media with effusion because there is no evidence of benefit.<ref>{{cite journal |author=Rosenfeld RM, Culpepper L, Yawn B, Mahoney MC |title=Otitis media with effusion clinical practice guideline |journal=Am Fam Physician |volume=69 |issue=12 |pages=2776, 2778–9 |year=2004 |month=June |pmid=15222643 }}</ref> There is an osteopathic [[Joint manipulation|manipulation]] technique called the Galbreath technique that can be done at home which is intended to improve drainage.<ref>{{cite journal |author=Pratt-Harrington D |title=Galbreath technique: a manipulative treatment for otitis media revisited |journal=J Am Osteopath Assoc |volume=100 |issue=10 |pages=635–9 |year=2000 |month=October |pmid=11105452 |url=http://www.jaoa.org/cgi/pmidlookup?view=long&pmid=11105452}}</ref> The technique was evaluated in one randomized controlled clinical trial; one reviewer concluded that it was promising, but a 2010 evidence report found the evidence inconclusive.<ref>{{cite journal |author=Bronfort G, Haas M, Evans R, Leininger B, Triano J |title=Effectiveness of manual therapies: the UK evidence report |journal=Chiropr Osteopat |volume=18 |pages=3 |year=2010 |pmid=20184717 |pmc=2841070 |doi=10.1186/1746-1340-18-3 |url=http://www.biomedcentral.com/content/pdf/1746-1340-18-3.pdf}}</ref>
 ==Prognosis==
@@ Line 105: / Line 105: @@
 Children with recurrent episodes of acute otitis media and those suffering from otitis media with effusion or chronic otitis media, have higher risks of developing conductive and sensorineural hearing loss.
-This hearing loss is mainly due to fluid in the middle ear or rupture of the tympanic membrane. Prolonged duration of otitis media is associated with ossicular complications, and together with persistent tympanic membrane perforation contributes to the severity of both the disease and the hearing loss. When a cholesteatoma or granulation tissue is present in the middle ear, the degree of hearing loss and ossicular destruction is even greater<ref>Da Costa SS. Sensorineural hearing loss in patients with chronic otitis media. European archives of oto-rino-laryngology. 2009 Feb;266(2):221-4.</ref>.
+This hearing loss is mainly due to fluid in the middle ear or rupture of the tympanic membrane. Prolonged duration of otitis media is associated with ossicular complications, and together with persistent tympanic membrane perforation contributes to the severity of both the disease and the hearing loss. When a cholesteatoma or granulation tissue is present in the middle ear, the degree of hearing loss and ossicular destruction is even greater.<ref>{{cite journal |author=Da Costa SS |title=Sensorineural hearing loss in patients with chronic otitis media |journal=Eur Arch Otorhinolaryngol |volume=266 |issue=2 |pages=221–4 |date=February 2009 |doi=10.1007/s00405-008-0739-0 |pmid=18629531}}</ref>
-Periods of conductive hearing loss from otitis media may have a detrimental effect on speech development in children<ref>Roberts K. A preliminary account of the effect of otitis media on 15-month-olds’ categorization and some implications for early language learning. Journal of speech, language and hearing research. 1997 Jun;40(3):508-18.</ref>. Recent studies have also linked otitis media to educational problems, attention disorders, and problems with social adaptation<ref>Bidadi S, Nejadkazem M, Naderpour M. The relationship between chronic otitis media-induced hearing loss and the acquisition of social skills. Otolaryngology -- head and neck surgery. 2008 Nov;139(5):665-70.</ref>. Furthermore it has been demonstrated that patients suffering from otitis media have more depression/anxiety-related disorders compared to individuals with normal hearing<ref>Gouma P, Mallis A, Daniilidis V, Gouveris H, Armenakis N, Naxakis S. Behavioral trends in young children with conductive hearing loss: a case-control study. European archives of oto-rino-laryngology. 2011 Jan;268(1):63-6.</ref>. Once the infections resolve and hearing thresholds return to normal, childhood otitis media may still cause minor and irreversible damage to the middle ear and cochlea<ref>Yilmaz S, Karasalihoglu AR, Tas A, Yagiz R, Tas M. Otoacoustic emissions in young adults with a history of otitis media. J Laryngol Otol. 2006 Feb;120(2):103-7.</ref>.
+Periods of conductive hearing loss from otitis media may have a detrimental effect on speech development in children.<ref>{{cite journal |author=Roberts K |title=A preliminary account of the effect of otitis media on 15-month-olds’ categorization and some implications for early language learning |journal=J Speech Lang Hear Res |volume=40 |issue=3 |pages=508–18 |date=June 1997 |pmid=9210110 |url=http://jslhr.asha.org/cgi/pmidlookup?view=long&pmid=9210110}}</ref> Recent studies have also linked otitis media to educational problems, attention disorders, and problems with social adaptation.<ref>{{cite journal |author=Bidadi S, Nejadkazem M, Naderpour M |title=The relationship between chronic otitis media-induced hearing loss and the acquisition of social skills |journal=Otolaryngol Head Neck Surg |volume=139 |issue=5 |pages=665–70 |date=November 2008 |url=http://oto.sagepub.com/cgi/pmidlookup?view=long&pmid=18984261 |pmid=18984261}}</ref> Furthermore it has been demonstrated that patients suffering from otitis media have more depression/anxiety-related disorders compared to individuals with normal hearing.<ref>{{cite journal |author=Gouma P, Mallis A, Daniilidis V, Gouveris H, Armenakis N, Naxakis S |title=Behavioral trends in young children with conductive hearing loss: a case-control study |journal=Eur Arch Otorhinolaryngol |volume=268 |issue=1 |pages=63–6 |date=January 2011 |pmid=20665042 |doi=10.1007/s00405-010-1346-4 }}</ref> Once the infections resolve and hearing thresholds return to normal, childhood otitis media may still cause minor and irreversible damage to the middle ear and cochlea.<ref>{{cite journal |author=Yilmaz S, Karasalihoglu AR, Tas A, Yagiz R, Tas M |title=Otoacoustic emissions in young adults with a history of otitis media |journal=J Laryngol Otol |volume=120 |issue=2 |pages=103–7 |date=February 2006 |pmid=16359151 }}</ref>
 ==Epidemiology==
@@ Line 129: / Line 129: @@
 ==References==
+{{Reflist}}
-{{Reflist|3}}
 ==External links==
+*{{cite journal |author=Neff MJ |title=AAP, AAFP, AAO-HNS release guideline on diagnosis and management of otitis media with effusion |journal=Am Fam Physician |volume=69 |issue=12 |pages=2929–31 |date=June 2004 |pmid=15222658 |url=http://www.aafp.org/afp/2004/0615/p2929.html}}
-*[http://www.aafp.org/afp/20040615/practice.html AAFP guidelines]
 {{Diseases of the ear and mastoid process}}

v t e Diseases of the outer and middle ear
Outer ear	Otitis externa Otomycosis
Middle ear and mastoid	Cholesteatoma Eustachian tube dysfunction Patulous Eustachian tube Mastoiditis Bezold's abscess Gradenigo's syndrome Middle ear barotrauma Otitis media Perforated eardrum Tympanosclerosis
Symptoms	Ear pain Hearing loss
Tests	Otoscope pneumatic tympanometry

v t e Common cold
Viruses	Adenovirus Coronavirus Enterovirus Rhinovirus
Symptoms	Cough Fatigue Fever Headache Loss of appetite Malaise Muscle aches Nasal congestion Rhinorrhea Sneezing Sore throat Weakness
Complications	Acute bronchitis Bronchiolitis Croup Otitis media Pharyngitis Pneumonia Sinusitis Strep throat
Drugs	Antiviral drugs Pleconaril (experimental)