Practice Essentials

Otitis media (OM) is any inflammation of the middle ear (see the images below),
without reference to etiology or pathogenesis. It is very common in children.
Acute otitis media with purulent effusion behind a
Acute otitis media with purulent effusion behind a bulging tympanic membrane.
Chronic otitis media with a retraction pocket of t
Chronic otitis media with a retraction pocket of the pars flaccida.
There are several subtypes of OM, as follows:

Acute otitis media (AOM)

Otitis media with effusion (OME)
Chronic suppurative otitis media
Adhesive otitis media
Signs and symptoms
AOM implies rapid onset of disease associated with one or more of the following
symptoms:

Otalgia
Otorrhea
Headache
Fever
Irritability
Loss of appetite
Vomiting
Diarrhea
OME often follows an episode of AOM. Symptoms that may be indicative of OME
include the following:

Hearing loss

Tinnitus
Vertigo
Otalgia
Chronic suppurative otitis media is a persistent ear infection that results in
tearing or perforation of the eardrum.

Adhesive otitis media occurs when a thin retracted ear drum becomes sucked
into the middle ear space and stuck.

See Clinical Presentation for more detail.

Diagnosis
OME does not benefit from antibiotic treatment. Therefore, it is critical for
clinicians to be able to distinguish normal middle ear status from OME or AOM.
Doing so will avoid unnecessary use of antibiotics, which leads to increased
adverse effects of medication and facilitates the development of antimicrobial
resistance.

Examination

Pneumatic otoscopy remains the standard examination technique for patients

with suspected OM. In addition to a carefully documented examination of the
external ear and tympanic membrane (TM), examining the entire head and neck
region of patients with suspected OM is important.

Every examination should include an evaluation and description of the following

four TM characteristics:

Color A normal TM is a translucent pale gray; an opaque yellow or blue TM is

consistent with middle ear effusion (MEE)
Position In AOM, the TM is usually bulging; in OME, the TM is typically retracted
or in the neutral position
Mobility Impaired mobility is the most consistent finding in patients with OME

Perforation Single perforations are most common

Adjunctive screening techniques for OM include tympanometry, which measures
changes in acoustic impedance of the TM/middle ear system with air pressure
changes in the external auditory canal, and acoustic reflectometry, which
measures reflected sound from the TM; the louder the reflected sound, the
greater the likelihood of an MEE.

See Workup for more detail.

Management
Most cases of AOM improve spontaneously. Cases that require treatment may be
managed with antibiotics and analgesics or with observation alone.

Guidelines from American Academy of Pediatrics

In February 2013, the American Academy of Pediatrics (AAP) and the American
Academy of Family Physicians released updated guidelines for the diagnosis and
management of AOM, including recurrent AOM, in children aged 6 months
through 12 years. The recommendations offer more rigorous diagnostic criteria
to reduce unnecessary antibiotic use.

According to the guidelines, management of AOM should include an assessment

of pain. Analgesics, particularly acetaminophen and ibuprofen, should be used to
treat pain whether antibiotic therapy is or is not prescribed.

Recommendations for prescribing antibiotics include the following:

Antibiotics should be prescribed for bilateral or unilateral AOM in children aged at

least 6 months with severe signs or symptoms (moderate or severe otalgia,
otalgia for 48 hours or longer, or temperature 39C or higher) and for nonsevere,
bilateral AOM in children aged 6 to 23 months
On the basis of joint decision-making with the parents, unilateral, nonsevere AOM
in children aged 6-23 months or nonsevere AOM in older children may be
managed either with antibiotics or with close follow-up and withholding
antibiotics unless the child worsens or does not improve within 48-72 hours of
symptom onset

Amoxicillin is the antibiotic of choice unless the child received it within 30 days,
has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases,
clinicians should prescribe an antibiotic with additional beta-lactamase coverage
Background
Otitis media (OM) is the second most common disease of childhood, after upper
respiratory infection (URI). OM is also the most common cause for childhood
visits to a physician's office. Annually, an estimated 16 million office visits are
attributed to OM; this does not include visits to the emergency department.

OM is any inflammation of the middle ear, without reference to etiology or

pathogenesis. It can be classified into many variants on the basis of etiology,
duration, symptomatology, and physical findings.

Acute OM (AOM) implies rapid onset of disease associated with one or more of
the following symptoms:

Otalgia
Fever
Otorrhea
Recent onset of anorexia
Irritability
Vomiting
Diarrhea
These symptoms are accompanied by abnormal otoscopic findings of the
tympanic membrane (TM), which may include the following:

Opacity
Bulging
Erythema
Middle ear effusion (MEE)
Decreased mobility with pneumatic otoscopy

AOM is a recurrent disease. More than one third of children experience six or
more episodes of AOM by age 7 years.

OM with effusion (OME), formerly termed serous OM or secretory OM, is MEE of

any duration that lacks the associated signs and symptoms of infection (eg,
fever, otalgia, and irritability). OME usually follows an episode of AOM.

Chronic suppurative OM is a chronic inflammation of the middle ear that persists

for at least 6 weeks and is associated with otorrhea through a perforated TM, an
indwelling tympanostomy tube (TT; see the image below), or a surgical
myringotomy.

Various tympanostomy tube styles and sizes.

Various tympanostomy tube styles and sizes
Pathophysiology
The most important factor in middle ear disease is eustachian tube (ET)
dysfunction (ETD), in which the mucosa at the pharyngeal end of the ET is part of
the mucociliary system of the middle ear. Interference with this mucosa by
edema, tumor, or negative intratympanic pressure facilitates direct extension of
infectious processes from the nasopharynx to the middle ear, causing OM.
Esophageal contents regurgitated into the nasopharynx and middle ear through
the ET can create a direct mechanical disturbance of the middle ear mucosa and
cause middle ear inflammation.

In children, developmental alterations of the ET, an immature immune system,

and frequent infections of the upper respiratory mucosa all play major roles in
AOM development. Studies have demonstrated how viral infection of the upper
respiratory epithelium leads to increased ETD and increased bacterial
colonization and adherence in the nasopharynx.[1]

Certain viral infections cause abnormal host immune and inflammatory

responses in the ET mucosa and subsequent microbial invasion of the middle ear.
The host immune and inflammatory response to bacterial invasion of the middle
ear produces fluid in the middle ear and the signs and symptoms of AOM.

Although interactions between the common pathogenic bacteria in AOM and

certain viruses are not fully understood, strong evidence indicates that these

interactions often lead to more severe disease, lowered response to antimicrobial

therapy, and OME development following AOM.
Etiology
A multitude of host, infectious, allergic, and environmental factors contribute to
the development of OM.

Host factors
Immune system

The immature immune systems of infants or the impaired immune systems of

patients with congenital immune deficiencies, HIV infection, or diabetes may be
involved in the development of OM.[2] OM is an infectious disease that prospers
in an environment of decreased immune defenses. The interplay between
pathogens and host immune defense plays a role in disease progression.

Patel et al found higher interleukin (IL)6 levels in patients with OM who also had
influenza and adenoviral infections, whereas IL-1 levels were higher in patients
who developed OM following URI.[3] In another study, Skovbjerg et al found that
middle ear effusions with culturable pathogenic bacteria were associated with
higher levels of IL-1 , IL-8, and IL-10 than sterile effusions.[4]

Familial (genetic) predisposition

Although familial clustering of OM has been demonstrated in studies that

examined genetic associations of OM, separating genetic factors from
environmental influences has been difficult. No specific genes have been linked
to OM susceptibility. As with most disease processes, effects of environmental
exposures on genetic expression probably play an important role in OM
pathogenesis.

Mucins

The role of mucins in OME has been described. Mucins are responsible for gel-like
properties of mucus secretions. The middle ear mucin gene expression is unique
compared with the nasopharynx. Abnormalities of this gene expression,

especially upregulation of MUC5B in the ear, may have a predominant role in

OME.

Anatomic abnormality

Children with anatomic abnormalities of the palate and associated musculature,

especially the tensor veli palantini, exhibit marked ETD and have higher risk for
OM. Specific anomalies that correlate with high prevalence of OM include cleft
palate, Crouzon syndrome or Apert syndrome, Down syndrome, and Treacher
Collins syndrome.

Physiologic dysfunction

Abnormalities in the physiologic function of the ET mucosa, including ciliary

dysfunction and edema, increase the risk of bacterial invasion of the middle ear
and the resultant OME. Children with cochlear implants have a high incidence of
OM, especially chronic OM and cholesteatoma formation. One study described a
relationship between laryngopharyngeal reflux and chronic OM (COM); the
authors concluded that reflux work-up should be performed as part of COM
investigations, and, if reflux is confirmed, reflux treatment should be initiated in
addition to treatment of primary disease.[5]

Other host factors

Vitamin A deficiency is associated with pediatric upper respiratory infections and

AOM.

Obesity has been linked to an increased incidence of OM, although the causal
factor is unknown. Speculations include alteration of intrinsic cytokine profile,
increased gastroesophageal reflux with alterations of the oral flora, and/or fat
accumulation; all of these have been linked with an increased incidence of OM.
Conversely, OM may increase the risk of obesity by altering the taste buds.[6]

Infectious factors
Bacterial pathogens

The most common bacterial pathogen in AOM is Streptococcus pneumoniae,

followed by nontypeable Haemophilus influenzae and Moraxella (Branhamella)
catarrhalis. These three organisms are responsible for more than 95% of all AOM
cases with a bacterial etiology.[7]

In infants younger than 6 weeks, gram-negative bacilli (eg, Escherichia coli,

Klebsiella species, and Pseudomonas aeruginosa) play a much larger role in AOM,
causing 20% of cases. S pneumoniae and H influenzae are also the most
common pathogens in this age group. Some studies also found Staphylococcus
aureus as a pathogen in this age group, but subsequent studies suggested that
the flora in these young infants may be that of usual AOM in children older than
6 weeks.

Many experts had proposed that the MEE associated with OME was sterile
because cultures of middle ear fluid obtained by tympanocentesis often did not
grow bacteria. This view is changing as newer studies show 30-50% incidence of
positive results in middle ear bacterial cultures in patients with chronic MEE.
These cultures grow a wide range of aerobic and anaerobic bacteria, of which S
pneumoniae, H influenzae, M catarrhalis, and group A streptococci are the most
common.

M catarrhalis induced AOM differs from AOM caused by other bacterial

pathogens in several ways. It is characterized by higher a proportion of mixed
infections, younger age at the time of diagnosis, lower risk of spontaneous
perforation of the tympanic membrane, and an absence of mastoiditis.[8]

Further evidence for the presence of bacteria in the MEE of patients with OME
was provided by studies using polymerase chain reaction (PCR) assay to detect
bacterial DNA in MEE samples that were determined to be sterile with standard
bacterial culture techniques. In one such study using PCR assay, 77.3% of the
MEE samples had positive results for one or more common AOM pathogens (eg, S
pneumoniae, H influenzae, M catarrhalis).

In chronic suppurative OM, the most frequently isolated organisms include P

aeruginosa, S aureus, Corynebacteriu m species, and Klebsiella pneumoniae. An
unanswered question is whether these pathogens invade the middle ear from the
nasopharynx via the ET (as do the bacteria responsible for AOM) or whether they
enter through the perforated TM or a TT from the EAC.

The role of Helicobacter pylori in children with OME has been increasingly
recognized. Evidence that this agent might be responsible for OME comes from
its isolation from middle ear and tonsillar and adenoidal tissue in patients with
OME.

Alloiococcus otitidis is a species of gram-positive bacterium that has been

discovered as a pathogen associated with OME.[9, 10] This organism is the most
frequent bacterium in AOM, as well as in OME. It has also been detected in
patients who had been treated with antibiotics, such as beta-lactams or
erythromycin, suggesting that these agents may not be sufficiently effective to
eliminate this organism. Further investigation is needed to reveal the clinical role
of the organism in OM.

Viral pathogens

Because acute viral URI is a prominent risk factor for AOM development, most
investigators have suspected a role for respiratory viruses in AOM pathogenesis.

Many studies have substantiated this suspicion by showing how certain

respiratory viruses can cause inflammatory changes to the respiratory mucosa
that lead to ETD, increased bacterial colonization and adherence, and,
eventually, AOM. Studies have also shown that viruses can alter the hostimmune response to AOM, thereby contributing to prolonged middle ear fluid
production and development of chronic OME.

The viruses most commonly associated with AOM are respiratory syncytial virus
(RSV), influenza viruses, parainfluenza viruses, rhinovirus, and adenovirus.
Human parechovirus 1 (HPeV1) infection is associated with OM and cough in
pediatric patients.[11] OM developed in 50% of 3-month follow-up periods that
yielded evidence of HPeV1 infection but in only 14% of the HPeV1-negative
periods; in recurring OM, the middle ear fluid samples were positive for HPeV in
15% of episodes.

Factors related to allergies

The relation between allergies and OM remains unclear. In children younger than
4 years, the immune system is still developing, and allergies are unlikely to play
a role in recurrent AOM in this age group. Although much evidence suggests that

allergies contribute to the pathogenesis of OM in older children, extensive

evidence refutes the role of allergies in the etiology of middle ear disease.

The following is a brief list of evidence for and against the etiologic role of allergy
in OM:

Many patients with OM have concomitant allergic respiratory disease (eg, allergic
rhinitis, asthma)
Many patients with OM have positive results to skin testing or
radioallergosorbent testing (RAST)
Although mast cells are found in the middle ear mucosa, most studies fail to
show significant levels of immunoglobulin E (IgE) or eosinophils in the MEE of
patients with OM
OM is most common in the winter and early spring, yet most major allergens (eg,
tree and grass pollens) peak in the late spring and early fall
Most patients with concomitant OM and allergy show no marked improvement in
middle ear disease with aggressive allergy management, despite marked
improvements to nasal and other allergy-related symptoms
Environmental factors
Infant feeding methods

Many studies report that breastfeeding protects infants against OM. The best of
these studies indicates that this benefit is evident only in children who are
breastfed exclusively for the first 3-6 months of life. Breastfeeding of this
duration reduces the incidence of OM by 13%. The protective effects of
breastfeeding for the first 3-6 months persist for 4-12 months after breastfeeding
ceases, possibly because delaying onset of the first OM episode reduces
recurrence of OM in these children.

Passive smoke exposure

Many studies have shown a direct relation between passive smoke exposure and
risk of middle ear disease. A systematic review of 45 publications dealing with
OM and parental smoking showed pooled odds ratios of 1.48 (95% confidence
interval [CI] of 1.08-2.04) for recurrent OM, 1.38 (95% CI of 1.23-1.55) for MEE,
and 1.3 (95% CI of 1.3-1.6) for AOM.[12]

Group daycare attendance

Daycare centers create close contact among many children, which increases the
risks of respiratory infection, nasopharyngeal colonization with pathogenic
microbes, and OM.

Many researchers have used meta-analysis to confirm that exposure to other

young children (including siblings) in group daycare settings is a major risk factor
for OM.[13] A meta-analysis reported that care outside the home conferred a 2.5fold risk for OM. Other critical reviews of studies on OM and group childcare show
heightened odds ratios of 1.6-4.0:1 for center care versus home care.

Children who attend daycare centers frequently acquire antibacterial-resistant

organisms in their nasopharynx, leading to AOM that may be refractory to
antibacterial treatment. American Academy of Pediatrics and American Academy
of Family Physicians' guidelines recommend high-dose amoxicillin-clavulanate as
the antibiotic of choice in the treatment of AOM in children who attend daycare.

Socioeconomic status

Socioeconomic status encompasses many independent factors that affect both

the risk of OM and the likelihood that OM will be diagnosed.[14]

In general, lower socioeconomic status confers higher risk for environmental

exposure to parental smoking, bottle-feeding, crowded group daycare, crowded
living conditions, and viruses and bacterial pathogens. Compared with children
from middle-income and high-income families, children from lower
socioeconomic groups use health care resources less frequently, which decreases
the likelihood that OM cases will be diagnosed.
Epidemiology
United States statistics
OM, the most common specifically treated childhood disease, accounts for
approximately 20 million annual physician visits. Various epidemiologic studies
report the prevalence rate of AOM to be 17-20% within the first 2 years of life,
and 90% of children have at least one documented MEE by age 2 years. OM is a

recurrent disease. One third of children experience six or more episodes of AOM
by age 7 years.

International statistics
Incidence and prevalence in other industrialized nations are similar to US rates.
In less developed nations, OM is extremely common and remains a major
contributor to childhood mortality resulting from late-presenting intracranial
complications. International studies show increased prevalence of AOM and
chronic OM (COM) among Micronesian and Australian aboriginal children.

Age-related demographics
Peak prevalence of OM in both sexes occurs in children aged 6-18 months. Some
studies show bimodal prevalence peaks; a second, lower peak occurs at age 4-5
years and corresponds with school entry. Although OM can occur at any age, 8090% of cases occur in children younger than 6 years. Children who are diagnosed
with AOM during the first year of life are much more likely to develop recurrent
OM and chronic OME than children in whom the first middle ear infection occurs
after age 1 year.

Sex-related demographics
Several studies have now shown equal AOM prevalence in males and females;
many previous studies had shown increased incidence in boys.

Race-related demographics
For some time, the prevalence of OM in the United States was reported to be
higher in black and Hispanic children than in white children. However, a study
that controlled for socioeconomic and other confounding factors showed equal
incidence in blacks and whites. Hispanic children and Alaskan Inuit and other
American Indian children have higher prevalence of AOM than white and black
children in the United States.
Prognosis
US mortality is extremely low in this era of antimicrobial therapy (< 1 death per
100,000 cases). In developing nations with limited access to primary medical
care and modern antibiotics, mortality figures are similar to those reported in the
United States before antibiotic therapy. A study that examined the causes of
death in Los Angeles County Hospital from 1928-1933, years before the advent
of sulfa, showed that 1 in 40 deaths was caused by intracranial complications of
OM.

Morbidity from this disease remains significant, despite frequent use of systemic
antibiotics to treat the illness and its complications. Intratemporal and
intracranial complications of OM are the two major types.

Intratemporal complications include the following:

Hearing loss (conductive and sensorineural)

TM perforation (acute and chronic)
Chronic suppurative OM (with or without cholesteatoma)
Cholesteatoma
Tympanosclerosis
Mastoiditis
Petrositis
Labyrinthitis
Facial paralysis
Cholesterol granuloma
Infectious eczematoid dermatitis
Intracranial complications include the following:

Meningitis
Subdural empyema
Brain abscess
Extradural abscess
Lateral sinus thrombosis
Otitic hydrocephalus
The prognosis for almost all patients with OM is excellent; the exceptions are
patients in whom OM involves intratemporal and intracranial complications (<
1%).

Data on cognitive and educational outcomes of OM in the literature are limited.

The impact of OM on child development depends on numerous factors. OM in
infants younger than 12 months predisposes to long-term speech and language
problems. OM has also been reported to negatively affect preexisting cognitive or
language problems. Careful follow-up and early referral are key to management.
Patient Education
Patient education topics should include the following:

Avoiding risk factors

Appropriate use of antibiotics
Understanding the implications of antibiotic-resistant bacteria in OM
Education for health care providers should focus on the following topics:

Antibiotic-resistant bacteria and the need to avoid overprescribing antibiotics

Importance of pneumatic otoscope examination to distinguish AOM from OME
Treatment differences between AOM and OME
For patient education resources, see the Ear, Nose, and Throat Center, as well as
Earache.

Otitis media
From Wikipedia, the free encyclopedia
Otitis media
Otitis media entdifferenziert2.jpg
A bulging tympanic membrane which is typical in a case of acute otitis media
Classification and external resources
Specialty

Otorhinolaryngology

ICD-10

H65-H67

ICD-9-CM

017.40, 055.2, 381.0, 381.1, 381.2, 381.3, 381.4, 382

DiseasesDB
29620 serous,
9406

suppurative
MedlinePlus 000638 acute, 007010 with effusion, 000619 chronic

eMedicine

emerg/351

ent/426 complications, ent/209 with effusion, ent/212 Medical treat., ent/211

Surgical treat. ped/1689
MeSH D010033
[edit on Wikidata]
Otitis media is a group of inflammatory diseases of the middle ear.[1] The two
main types are acute otitis media (AOM) and otitis media with effusion (OME).[2]
AOM is an infection of abrupt onset that usually presents with ear pain. In young
children this may result in pulling at the ear, increased crying, and poor sleep.
Decreased eating and a fever may also be present. OME is typically not
associated with symptoms.[3] Occasionally a feeling of fullness is described. It is
defined as the presence of non-infectious fluid in the middle ear for more than
three months. Chronic suppurative otitis media (CSOM) is middle ear
inflammation of greater than two weeks that results in episodes of discharge
from the ear. It may be a complication of acute otitis media. Pain is rarely
present.[4] All three may be associated with hearing loss.[1][2] The hearing loss
in OME, due to its chronic nature, may affect a child's ability to learn.[4]

The cause of AOM is related to childhood anatomy and immune function. Either
bacteria or viruses may be involved. Risk factors include exposure to smoke, use
of pacifiers, and attending daycare. It occurs more commonly in those who are
Native American or who have Down syndrome.[4] OME frequently occurs
following AOM and may be related to viral upper respiratory infections, irritants
such as smoke, or allergies.[2][4] Looking at the eardrum is important for making
the correct diagnosis.[5] Signs of AOM include bulging or a lack of movement of
the tympanic membrane from a puff of air.[3][6] New discharge not related to
otitis externa also indicates the diagnosis.[3]

A number of measures decrease the risk of otitis media including pneumococcal

and influenza vaccination, exclusive breastfeeding for the first six months of life,
and avoiding tobacco smoke.[3] In those with otitis media with effusion
antibiotics do not generally speed recovery.[6][7] The use of pain medications for
AOM is important.[3] This may include paracetamol (acetaminophen), ibuprofen,
benzocaine ear drops, or opioids.[3] In AOM, antibiotics may speed recovery but
may result in side effects.[8] Antibiotics are often recommended in those with
severe disease or under two years old. In those with less severe disease they
may only be recommended in those who do not improve after two or three days.
[6] The initial antibiotic of choice is typically amoxicillin. In those with frequent
infections tympanostomy tubes may decrease recurrence.[3]

Worldwide AOM affect about 11% of people a year (about 710 million cases).[9]
Half the cases involve children less than five years of age and it is more common
among males.[4][9] Of those affected about 4.8% or 31 million develop chronic
suppurative otitis media.[9] Before the age of ten OME affects about 80% of
children at some point.[4] Otitis media resulted in 2,400 deaths in 2013 down
from 4,900 deaths in 1990.[10]

Contents [hide]
1

Signs and symptoms

Causes

Diagnosis

3.1

Acute otitis media

3.2

Otitis media with effusion

3.3

Chronic suppurative otitis media

3.4

Adhesive otitis media

Prevention

Management

5.1

Antibiotics

5.2

Tympanostomy tube

5.3

Alternative medicine

Outcomes

6.1

Membrane rupture

6.2

Hearing loss

Epidemiology

Etymology

References

10

External links

Signs and symptoms[edit]

Otitis media.

An integral symptom of acute otitis media is ear pain; other possible symptoms
include fever, and irritability (in infants). Since an episode of otitis media is
usually precipitated by an upper respiratory tract infection (URI), there often are
accompanying symptoms like cough and nasal discharge.[11]

Discharge from the ear can be caused by acute otitis media with perforation of
the ear drum, chronic suppurative otitis media, tympanostomy tube otorrhea, or
acute otitis externa. Trauma, such as a basilar skull fracture, can also lead to
discharge from the ear due to cerebral spinal drainage from the brain and its
covering (meninges).

Causes[edit]
The common cause of all forms of otitis media is dysfunction of the Eustachian
tube.[12] This is usually due to inflammation of the mucous membranes in the
nasopharynx, which can be caused by a viral URI, strep throat, or possibly by
allergies.[13] Because of the dysfunction of the Eustachian tube, the gas volume
in the middle ear is trapped and parts of it are slowly absorbed by the
surrounding tissues, leading to negative pressure in the middle ear. Eventually
the negative middle-ear pressure can reach a point where fluid from the
surrounding tissues is sucked in to the middle ear's cavity (tympanic cavity),
causing a middle-ear effusion. This is seen as a progression from a Type A
tympanogram to a Type C to a Type B tympanogram.

By reflux or aspiration of unwanted secretions from the nasopharynx into the

normally sterile middle-ear space, the fluid may then become infected usually
with bacteria. The virus that caused the initial URI can itself be identified as the
pathogen causing the infection.[13]

Diagnosis[edit]

Perforation of the right tympanic membrane resulting from a previous severe

acute otitis media
As its typical symptoms overlap with other conditions, such as acute external
otitis, clinical history alone is not sufficient to predict whether acute otitis media
is present; it has to be complemented by visualization of the tympanic
membrane.[14][15] Examiners use a pneumatic otoscope with a rubber bulb
attached to assess the mobility of the tympanic membrane.

Acute otitis media in children with moderate to severe bulging of the tympanic
membrane or new onset of otorrhea (drainage) is not due to external otitis. Also,
the diagnosis may be made in children who have mild bulging of the ear drum
and recent onset of ear pain (less than 48 hours) or intense erythema (redness)
of the ear drum.

To confirm the diagnosis, middle-ear effusion and inflammation of the eardrum

have to be identified; signs of these are fullness, bulging, cloudiness and redness
of the eardrum.[11] It is important to attempt to differentiate between acute
otitis media and otitis media with effusion (OME), as antibiotics are not
recommend for OME.[11] It has been suggested that bulging of the tympanic
membrane is the best sign to differentiate AOM from OME [16]

Viral otitis may result in blisters on the external side of the tympanic membrane,
which is called bullous myringitis (myringa being Latin for "eardrum").[17]

However, sometimes even examination of the eardrum may not be able to

confirm the diagnosis, especially if the canal is small. If wax in the ear canal
obscures a clear view of the eardrum it should be removed using a blunt
cerumen curette or a wire loop. Also, an upset young 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.

Acute otitis media[edit]

The most common bacteria isolated from the middle ear in AOM are
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis,[11]
and Staphylococcus aureus.[18]

Otitis media with effusion[edit]

Otitis media with effusion (OME), also known as serous otitis media (SOM) or
secretory otitis media (SOM), and commonly referred to as glue ear,[19] is a
collection of effusion (fluid) that occurs in the middle-ear space due to the
negative pressure produced by dysfunction of the Eustachian tube. This can
occur purely from a viral URI or bacterial infection, or it can precede and/or follow
acute bacterial otitis media.[20] Fluid in the middle ear frequently 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, which increases the likelihood of its
causing conductive hearing impairment.

Early-onset OME is associated with feeding of infants while lying down, early
entry into group child care, parental smoking, lack, or too short a period of
breastfeeding and greater amounts of time spent in group child care, particularly
those with a large number of children, increases the incidences and duration of
OME in the first two years of life.[21]

Chronic suppurative otitis media[edit]

Chronic suppurative otitis media, incorrectly called chronic otitis media or chronic
ear infection, involves a 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 pus may be
minimal enough to only be seen on examination using the otoscope or, more
effectively, with a binocular microscope. This disease is much more common in
persons with poor Eustachian tube function and very common in certain races
such as Native North Americans. Hearing impairment often accompanies this
disease.

It is a primary cause of hearing loss that newly develops in children. An ear wick
may be effective or, if not, antibiotics.[22]

Adhesive otitis media[edit]

Adhesive otitis media occurs when a thin retracted ear drum becomes sucked
into the middle-ear space and stuck (i.e., adherent) to the ossicles and other
bones of the middle ear.

Acute otitis media

Acute otitis media, myringitis bullosa

Myringitis bullosa in influenza

Chronic otitis media (otitis media chronica mesotympanalis)

Otitis media chronica mesotympanalis

Otitis media chronica mesotympanalis

Otitis media chronica mesotympanalis

Prevention[edit]
Long-term antibiotics, while they decrease rates of infection during treatment,
have an unknown effect on long-term outcomes such as hearing loss.[23] This
method of prevention has been associated with emergence of antibiotic-resistant
otitic bacteria. They are thus not recommended.[11]

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.[11][24][needs update] Influenza vaccine is
recommended annually.[11]

Risk factors such as season, allergy predisposition and presence of older siblings
are known to be determinants of recurrent otitis media and persistent middle-ear
effusions (MEE).[25] History of recurrence, environmental exposure to tobacco
smoke, use of daycare, and lack of breastfeeding have all been associated with
increased risk of development, recurrence, and persistent MEE.[26][27] Thus,
cessation of smoking in the home should be encouraged, daycare attendance
should be avoided or daycare facilities with the fewest attendees should be
recommended, and breastfeeding should be promoted.[26][27]

There is some evidence that breastfeeding for the first year of life is associated
with a reduction in the number and duration of OM infections.[28][29] Pacifier

use, on the other hand, has been associated with more frequent episodes of
AOM.[30]

Evidence does not support zinc supplementation as an effort to reduce otitis

rates except maybe in those with severe malnutrition such as marasmus.[31]

Management[edit]
Oral and topical pain killers are effective to treat the pain caused by otitis media.
Oral agents include ibuprofen, paracetamol (acetaminophen), and opiates.
Topical agents shown to be effective include antipyrine and benzocaine ear
drops.[32] Decongestants and antihistamines, either nasal or oral, are not
recommended due to the lack of benefit and concerns regarding side effects.[33]
Half of cases of ear pain in children resolves without treatment in three days and
90% resolves in seven or eight days.[34]

Antibiotics[edit]
It is important to weigh the benefits and harms before using antibiotics for acute
otitis media. As over 80% of acute episodes settle without treatment, about 20
children must be treated to prevent one case of ear pain, 33 children to prevent
one perforation, and 11 children to prevent one opposite-side ear infection. For
every 14 children treated with antibiotics, one child has an episode of either
vomiting, diarrhea or a rash.[35][needs update] If pain is present, treatment to
reduce it should be initiated.

Antibiotics should be prescribed for severe bilateral or unilateral disease in all

infants and children with severe signs and symptoms, such as moderate to
severe ear pain and high fever.
For bilateral acute otitis media in infants younger than 24 months of age, without
severe signs and symptoms, antibiotics should be prescribed.
When non-severe unilateral acute otitis media is diagnosed in young children
either antibiotic therapy is given or observation with close follow-up based on
joint decision making between parent(s)/caregiver in infants 6 to 23 months of
age. If the child worsens or fails to improve in 2 to 3 days antibiotics should be
administered.
Children 24 months or older with non-severe disease can have either antibiotics
or observation.
The first line antibiotic treatment, if warranted, is amoxicillin.[11] If there is
resistance or use of amoxicillin in the last 30 days then amoxicillin-clavulanate or

another penicillin derivative plus beta lactamase inhibitor is recommended.[11]

Taking amoxicillin once a day may be as effective as twice[36] or three times a
day. While less than 7 days of antibiotics have less side effects, more than seven
days appear to be more effective.[37] If there is no improvement after 23 days
of treatment a change in therapy may be considered.[11]

A treatment option for chronic suppurative otitis media with discharge is topical
antibiotics. A Cochrane review found that topical quinolone antibiotics can
improve discharge better than oral antibiotics.[38] Safety is not really clear.[38]

Tympanostomy tube[edit]
Tympanostomy tubes (also called "grommets") are recommended in those people
who have three or more episodes of acute otitis media in 6 months or four or
more in a year, with at least one episode or more attacks in the preceding 6
months.[11] In chronic cases with effusions, insertion of tympanostomy tube into
the eardrum reduces recurrence rates in the 6 months after placement[39] but
has little effect on long-term hearing.[40] A common complication of having a
tympanostomy tube is otorrhea, which is a discharge from the ear.[41]

Oral antibiotics should not be used to treat uncomplicated acute tympanostomy

tube otorrhea.[41] Oral antibiotics are not a sufficient response to bacteria that
cause this condition and have significant side effects including increased risk of
opportunistic infection.[41] In contrast, topical antibiotic eardrops can treat this
condition.[41]

Alternative medicine[edit]
Complementary and alternative medicine is not recommended for otitis media
with effusion because there is no evidence of benefit.[20] An osteopathic
manipulation technique called the Galbreath technique[42] was evaluated in one
randomized controlled clinical trial; one reviewer concluded that it was
promising, but a 2010 evidence report found the evidence inconclusive.[43]

Outcomes[edit]

Disability-adjusted life year for otitis media per 100,000 inhabitants in 2004.
no data

< 10
10-14
14-18
18-22
22-26
26-30
30-34
34-38
38-42
42-46
46-50
> 50
Complications of acute otitis media consists of perforation of the ear drum,
infection of the mastoid space behind the ear (mastoiditis), and more rarely
intracranial complications can occur, such as bacterial meningitis, brain abscess,
or dural sinus thrombosis.[44] It is estimated that each year 21,000 people die
due to complications of otitis media.[45]

Membrane rupture[edit]
In severe or untreated cases, the tympanic membrane may perforate, allowing
the pus in the middle-ear space to drain into the ear canal. If there is enough,
this drainage may be obvious. Even though the perforation of the tympanic
membrane suggests a highly painful and traumatic process, it is almost always
associated with a 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. An option for severe
acute otitis media in which analgesics are not controlling ear pain is to perform a
tympanocentesis, i.e., needle aspiration through the tympanic membrane to
relieve the ear pain and to identify the causative organism(s).

Hearing loss[edit]
Children with recurrent episodes of acute otitis media and those with otitis media
with effusion or chronic suppurative otitis media have higher risks of developing
conductive and sensorineural hearing loss. Globally approximately 141 million

people have mild hearing loss due to otitis media (2.1% of the population).[46]
This is more common in males (2.3%) than females (1.8%).[46]

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 the disease and 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.[47]

Periods of conductive hearing loss from otitis media may have a detrimental
effect on speech development in children.[48] Some studies have linked otitis
media to learning problems, attention disorders, and problems with social
adaptation.[49] Furthermore, it has been demonstrated that patients with otitis
media have more depression/anxiety-related disorders compared to individuals
with normal hearing.[50] 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.[51]

Epidemiology[edit]
Acute otitis media is very common in childhood. It is the most common condition
for which medical care is provided in children under five years of age in the US.
[13] Acute otitis media affects 11% of people each year (709 million cases) with
half occurring in those below five years.[45] Chronic suppurative otitis media
affects about 5% or 31 million of these cases with 22.6% of cases occurring
annually under the age of five years.[45] Otitis media resulted in 2,400 deaths in
2013 down from 4,900 deaths in 1990.[10]

Etymology[edit]
Otitis media is Latin for "inflammation of the middle ear".

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Introduction

Otitis media is an infection of the middle ear that is particularly common in

young children.
Although anyone can develop a middle ear infection, 75% of cases occur in
children under 10. Infants between 6 and 15 months old are most commonly
affected.
It's estimated that around one in every four children will have had at least one
middle ear infection by the time they are 10 years old.
Signs and symptoms of a middle ear infection
Signs that a young child might have an ear infection include:
pulling, tugging, or rubbing their ear

a high temperature (fever)

irritability
poor feeding
restlessness at night
a lack of response to quiet sounds
Older children and adults may have earache, be sick and experience slight
hearing loss.
Read more about the symptoms of middle ear infections.
When to seek medical advice
Most cases of otitis media pass within a few days, so there's usually no need to
see your GP.
However, you should take your child to see a GP if their symptoms show no sign
of improvement after two or three days, they seem to be in a lot of pain, or you
notice a discharge of pus or fluid from their ear.
You should also contact your GP if your child has an underlying health condition,
such as cystic fibrosis or congenital heart disease, which could make them more
vulnerable to complications.
Read more about diagnosing middle ear infections.
How middle ear infections are treated
Most ear infections clear up within three to five days and don't need any specific
treatment. If necessary, paracetamol or ibuprofen (appropriate for the child's
age) should be used to relieve pain and a high temperature.
Antibiotics are not routinely used to treat middle ear infections, although they
may occasionally be prescribed if symptoms persist or are particularly severe.
Read more about treating middle ear infections.
What causes middle ear infections?
The middle ear is located directly behind the eardrum. It contains three tiny
bones that transmit sound vibrations from the eardrum to the hearing organ in
the inner ear.
Most middle ear infections occur when a viral or bacterial infection such as a cold
causes mucus to build up in the middle ear, which then becomes infected.
Younger children are particularly vulnerable to this type of infection because the
tube that allows fresh air into the middle ear (the Eustachian tube) is smaller
than it is in adults.

Read more about the causes of middle ear infections.

Can middle ear infections be prevented?
It's not possible to prevent middle ear infections, but there are some things you
can do that may reduce your child's risk of developing the condition. These
include:
make sure your child is up-to-date with their routine vaccinations particularly
the pneumococcal vaccine and the DTaP/IPV/Hib (5-in-1) vaccine
avoid exposing your child to smoky environments (passive smoking)
don't give your child a dummy once they are older than 6 to 12 months old
don't feed your child while they are lying flat on their back
if possible, feed your baby with breast milk rather than formula milk
Avoiding contact with other children who are unwell may also help reduce your
child's chances of catching an infection that could lead to a middle ear infection.
Further problems
Complications of middle ear infections are fairly rare, but can be serious if they
do occur.
Most complications are the result of the infection spreading to another part of the
ear or head, including the bones behind the ear (mastoiditis), the inner ear
(labyrinthitis), or the protective membranes surrounding the brain and spinal
cord (meningitis).
If complications do develop, these often need to be treated immediately with
antibiotics in hospital.
Read more about the complications of middle ear infections.

Media last reviewed:

Next review due:
Glue ear
In some cases, the middle ear can become filled with fluid for long periods,
causing hearing difficulties. This is known as otitis media with effusion, or "glue
ear".
Read more about glue ear.
Symptoms of middle ear infection

In most cases, the symptoms of a middle ear infection (otitis media) develop
quickly and resolve in a few days. This is known as acute otitis media.
The main symptoms of acute otitis media include:
earache
a high temperature (fever)
being sick
a lack of energy
slight hearing loss
In some cases, a hole may develop in the eardrum (perforated eardrum) and pus
may run out of the ear. The earache, which is caused by the build-up of fluid
stretching the eardrum, then resolves.
Although it's less common than acute otitis media, some children have a
persistent and painless discharge from their ear that lasts for many months as a
result of an ear infection. This is known as chronic suppurative otitis media
(CSOM).
Symptoms in babies
As babies are unable to communicate the source of their discomfort, it can be
difficult to tell what is wrong with them. Signs your baby may have an ear
infection include:
pulling, tugging or rubbing their ear
irritability
poor feeding
restlessness at night
coughing
a runny nose
diarrhoea
unresponsiveness to quiet sounds or other signs of difficulty hearing, such as
inattentiveness
loss of balance
When to seek medical advice
As most cases of otitis media pass within a few days, there's usually no need to
see your GP.

However, you should take your child to see a GP if their symptoms show no sign
of improvement after two or three days, they seem to be in a lot of pain, or you
notice a discharge of pus or fluid from their ear.
You should also contact your GP if your child has an underlying health condition,
such as cystic fibrosis or congenital heart disease, which could make them more
vulnerable to complications.
Causes of middle ear infections

Most middle ear infections (otitis media) are caused by a viral or bacterial
infection spreading into the middle ear.
They often occur when an infection, such as a cold, leads to a build-up of mucus
in the middle ear and causes part of the ear called the Eustachian tube to
become swollen or blocked.
The Eustachian tube is a thin tube that runs from the middle ear to the back of
the nose. Its main functions are to help maintain normal air pressure within the
ear and to help drain away mucus and other debris from the middle ear.
If the tube becomes swollen or blocked, mucus can't drain away properly, which
makes it easier for an infection to spread into the middle ear.
An enlarged adenoid (soft tissue at the back of the throat) can also block the
Eustachian tube, which can cause a build-up of mucus and lead to a middle ear
infection. The adenoid can be removed if it causes persistent or frequent ear
infections. Read more about removing adenoids.
Who's most at risk?
As a child's Eustachian tubes are smaller than an adult's, they are more likely to
become blocked and infected. A child's adenoids are also much larger than an
adult's in relative terms.
These are the main reasons why more than 75% of middle ear infections occur in
children younger than 10, with most cases affecting infants between 6 and 15
months old.
Other factors that can increase the risk of developing a middle ear infection
include:
attending a nursery or day care centre this increases the chances of a child
being exposed to infections from other children
being exposed to tobacco smoke (passive smoking)
being fed formula milk, rather than breast milk
having a family history of middle ear infections

feeding your child while they are lying flat on their back
using a dummy
having a cleft palate a type of birth defect where a child has a split in the roof
of their mouth
having Down's syndrome a genetic condition that typically causes some level of
learning disability and a characteristic range of physical features
Diagnosing middle ear infection

A middle ear infection (otitis media) can usually be diagnosed using an

instrument called an otoscope.
An otoscope is a small handheld device that has a magnifying glass and a light
source at the end. It is used to examine the ear. Using an otoscope, a doctor can
detect certain signs that indicate fluid in the middle ear, which in turn may
indicate an infection.
Signs of fluid in the middle ear can include the ear drum bulging, being an
unusual colour (usually red or yellow) or having a cloudy appearance. In some
cases, a hole may have developed in the eardrum (perforated ear drum) and
there may be fluid in the ear canal (the tube between the outer ear and
eardrum).
Some otoscopes can also be used to blow a small puff of air into the ear to check
for any blockages in the middle ear, which could be a sign of an infection. If the
Eustachian tube (the tube that connects the throat and middle ear) is clear, the
eardrum will move slightly. If it is blocked, the eardrum will remain still.
Further tests
Further tests are normally only required if treatment is not working or
complications develop. These tests will usually be carried out at your local ear,
nose and throat (ENT) department.
Some of the tests that may be carried out are described below.
Tympanometry
Tympanometry is a test that measures how the ear drum reacts to changes in air
pressure. A healthy ear drum should move easily if there is a change in air
pressure. If your child's ear drum moves slowly or not at all, it usually suggests
that there is fluid behind it.
During a tympanometry test, a probe is placed into your child's ear. The probe
changes the air pressure at regular intervals while transmitting a sound into the
ear. A measuring device is attached to the probe to record how the drum moves
and how changes in air pressure affect this movement.

If the movement of the eardrum is restricted, it usually indicates that there is

fluid in the middle ear.
Audiometry
Audiometry is a hearing test that uses a machine called an audiometer to
produce sounds of different volume and frequency. This can help determine if
your child has any hearing loss as a result of their condition.
During the test, your child listens to the sounds through headphones and they
are asked to say when they can hear a sound and when they cannot.
Scans
On the very rare occasions where there is a possibility the infection has spread
out of the middle ear and into the surrounding area, a computerised tomography
(CT) scan or a magnetic resonance imaging (MRI) scan may be carried out.
A CT scan takes a series of X-rays and uses a computer to assemble the scans
into a more detailed image, whereas an MRI scan uses strong magnetic fields
and radio waves to produce images of the inside of the body.
Treating middle ear infection

Most middle ear infections (otitis media) will clear up within three days and don't
need any specific treatment.
You can relieve any pain and a high temperature using over the counter
painkillers such as paracetamol and ibuprofen. However, aspirin should not be
given to children under 16 years of age.
Placing a warm flannel or washcloth over the affected ear may also help relieve
pain until the condition passes.
Antibiotics
The routine use of antibiotics to treat middle ear infections is not recommended
as there is no evidence that they speed up the healing process. Many cases are
caused by viruses, which antibiotics are ineffective against.
Using antibiotics to treat minor bacterial infections also increases the likelihood
of bacteria becoming resistant to them over time. This means more serious
infections could become untreatable in the future. Read about antibiotic
resistance for more information.
Antibiotics are therefore usually only considered if:
your child has a serious health condition that makes them more vulnerable to
complications, such as cystic fibrosis or congenital heart disease

your child is less than three months old, or they are less than two years old and
have an infection in both ears
your child's symptoms are severe
your child has discharge coming from their ear
your child's symptoms show no signs of improvement after four days
If antibiotics are needed, a five-day course of an antibiotic called amoxicillin is
usually prescribed. This is often given as a liquid suspension that your child has
to drink. Common side effects of amoxicillin include a rash, feeling sick and
diarrhoea.

If your child is allergic to amoxicillin, an alternative antibiotic such as

erythromycin may be used.
In some cases, your GP may give you a prescription that you can choose to pick
up a few days later if your child's condition hasn't improved by then.
Adults and children who develop a long-term middle ear infection (chronic
suppurative otitis media) may benefit from short courses of antibiotic ear drops.
Grommets
For children with recurrent severe middle ear infections, tiny tubes may be
inserted into the eardrum to help drain fluid. These tubes are called grommets.
Grommets are inserted under general anaesthetic, which means your child will
be asleep and won't feel any pain. The procedure usually only takes about 15
minutes and your child should be able to go home the same day.
A grommet will help keep the eardrum open for several months. As the eardrum
starts to heal, the grommet will slowly be pushed out of the eardrum and will
eventually fall out. This process happens naturally and should not be painful.
Most grommets will fall out within 6 to 12 months of being inserted.
Some children will need another procedure to replace the grommets if they are
still experiencing problems.
Complications of middle ear infection

Serious complications of middle ear infections (otitis media) are much rarer now
than they were in the past.
However, very young children are still at risk of developing complications
because their immune systems are still developing.

Some of the main complications associated with middle ear infections are
detailed below.
Mastoiditis
Mastoiditis can develop if an infection spreads out of the middle ear and into the
area of bone underneath the ear (the mastoids).
Symptoms of mastoiditis can include:
a high temperature (fever)
swelling behind the ear, which pushes it forward
redness and tenderness or pain behind the ear
a creamy discharge from the ear
headache
hearing loss
Mastoiditis is usually treated in hospital with antibiotics given through a drip
directly into a vein. In some cases, surgery may be required to drain the ear and
remove the infected mastoid bone.
Cholesteatoma
A cholesteatoma is an abnormal collection of skin cells inside the ear that can
sometimes develop as a result of recurring or persistent middle ear infections.
If it is not treated, a cholesteatoma can eventually damage the delicate
structures deep inside your ear, such as the tiny bones that are essential for
hearing.
Symptoms of a cholesteatoma can include:
hearing loss
weakness in half your face
dizziness
tinnitus (hearing sounds from inside their body rather than from an outside
source)
In most cases, surgery is required to remove a cholesteatoma.
Labyrinthitis
In some cases, an infection in the middle ear can spread into the inner ear and
affect the delicate structure deep inside the ear called the labyrinth. This is
known as labyrinthitis.

Symptoms of labyrinthitis can include:

dizziness
vertigo (the feeling that you, or the environment around you, is moving or
spinning)
loss of balance
hearing loss
The symptoms of labyrinthitis usually pass within a few weeks, although
medication to relieve the symptoms and treat the underlying infection may
sometimes be prescribed. Read more about treating labyrinthitis.
Problems with speech and language development
If your child has frequent ear infections that affect their hearing while they are
very young, there is a risk their speech and language development may be
affected.
Contact your GP for advice if you are concerned about your child's development
at any point.
Facial paralysis
In very rare cases, the swelling associated with otitis media can cause the facial
nerve to become compressed. The facial nerve is a section of nerve that runs
through the skull and is used by the brain to control facial expressions.
Compression of the nerve can lead to a person being unable to move some or all
of their face. This is known as facial paralysis.
This can be frightening when it first occurs, as many parents are concerned their
child may have experienced a stroke. However, the condition usually resolves
once the underlying infection has passed and rarely causes any long-term
problems.
Meningitis
A very rare and serious complication of a middle ear infection is meningitis. This
can occur if the infection spreads to the protective outer layer of the brain and
spinal chord (the meninges).
Symptoms of meningitis can include:
severe headache
being sick
a high temperature (fever)
stiff neck

sensitivity to light
rapid breathing
a blotchy red rash that does not fade or change colour when you place a glass
against it (although this is not always present)
If you think your child may have meningitis, call 999 and ask for an ambulance.
Meningitis caused by a bacterial infection is usually treated in hospital with
antibiotics given through a drip directly into a vein. Read more about treating
meningitis.
Brain abscess
Another very rare and serious complication of a middle ear infection is a brain
abscess. This is a pus-filled swelling that develops inside the brain.
Symptoms of a brain abscess can include:
a severe headache
changes in mental state, such as confusion
weakness or paralysis on one side of the body
a high temperature (fever)
seizures (fits)
If you suspect that you or someone you know may have a brain abscess, call 999
for an ambulance.
A brain abscess is usually treated using a combination of antibiotics and surgery.
The surgeon will usually open the skull and drain the pus from the abscess or
remove the abscess entirely. Read more about treating brain abscesses.
Meningitis real story

Tracey Chambers talks about the effects of meningitis on her daughter

Courteney. Meningitis is an infection that can lead to serious damage to the
nerves and brain. If you think your child has symptoms of meningitis, it is vital to
seek immediate medical attention.