Bacterial infections of

Ear

Dr. Ajit Kulkarni

 Anatomy of Ear
 Ear has three main parts which include the outer ear, middle ear and inner
ear.
 Tympanic membrane (eardrum) separates your outer ear and middle ear.
 Outer ear (external ear)
 Visible part.
 Also called the auricle or pinna,
 Outer ear consists of ridged cartilage and skin, and it contains glands that
secrete earwax.
 Its funnel-shaped canal leads to eardrum, or tympanic membrane.

 Middle ear
 Middle ear begins on the other side of tympanic membrane (eardrum).
 There are three tiny bones in this area — the malleus, incus and stapes. ( also
called ossicles).
 They transfer sound vibrations from eardrum to inner ear.
 Middle ears also house the Eustachian tubes, which help equalize the air
pressure in ears.
 Anatomy of ear
 Inner ear
 Inner ear contains two main parts: the cochlea and the semicircular canals.
 Cochlea is the hearing organ.
 This snail-shaped structure contains two fluid-filled chambers lined with tiny
hairs.
 When sound enters, the fluid inside of cochlea causes the tiny hairs to vibrate,
sending electrical impulses to brain.
 The semicircular canals, also known as the labyrinthine, are responsible for
balance.
 They tell the brain which direction the head is moving.
 Bacterial infections

 External ear – Otitis externa, Malignant otitis externa

 Middle ear – Acute otitis media, Chronic suppurative otitis media

 Inner ear – Labyrintitis,Vestibular neuronitis

 Otitis Externa
 Otitis Externa (OE) is refered to a spectrum of external ear
inflammation, which may also involve the pinna or external ear canal.

 It's often caused by water remaining in the ear after swimming, which
creates a moist environment that helps bacteria or fungi grow.

 The main symptom is redness in the outer ear accompanied by

warmth, pain and swelling; ear discharge.

 In case of severe infection, which is rare, fever can occur.

Etiology:
 Bacteria(90 %); Pseudomonas aeruginosa, Pseudomonas vulgaris, E.coli, S.aureus.

Clinical feature:

 Ear discomfort: Pain, itching, or irritation in or around the ear canal,

especially when moving the ear or jaw
 Discharge: Thin, watery, or thick, pus-like discharge from the ear
 Redness and swelling: Redness and swelling of the outer ear and ear canal
 Hearing loss: Muffled hearing or hearing loss
 Other symptoms: Tenderness in the throat, swollen glands in the neck or
around the ear, and a feeling of fullness in the ear
 As the infection progresses, pain may increase, and discharge may become
yellow or yellow-green pus.
 If left untreated, the infection can spread to nearby tissue and bone
 Some predisposing conditions / risk factors for otitis
externa include:

 Allergies

 Skin conditions – Eczema, Psoriasis, Seborrheic dermatitis

 Irritants like hair spray or hair dye

 Trauma- Inserting earplugs, keys or hard ear plugs, hearing aids that
aren't cleaned properly or don't fit correctly

 Water exposure

 Other risk factors include humidity, narrow ear canals, ear canal
obstruction, radiotherapy or chemotherapy, stress, and
immunocompromised patients.
Treatment:
 Ear cleaning (removes earwax, debris, and discharge)

 For bacterial aetiology, send for culture and sensitivity

 Common topical antibiotics indicated for otitis externa include:

 Polymyxin B, neomycin, hydrocortisone, Ofloxacin

Diagnosis:
 Otitis externa is a clinical diagnosis; therefore, a complete history and physical
examination are required.

 Physical examination should include evaluation of the auricle, assessment of

surrounding skin and lymph nodes, and pneumatic otoscopy.
 Malignant Otitis Externa
 It is rare condition that causes infection and damage to the ear canal bones and skull
base.
 also known as necrotizing otitis externa (NOE).
 It's caused by the spread of an outer ear infection, also known as swimmer's ear.

 Symptoms include:
 Ear pain: Deep, severe pain that may worsen at night and when you move your head
 Drainage:Yellow or green discharge from the ear that smells bad
 Hearing loss: Conductive hearing loss of varying degrees
 Other symptoms: Itching, fever, trouble swallowing, and facial muscle weakness
 In severe cases, the infection can spread along the skull base, causing facial nerve
paralysis or paralysis of lower cranial nerves.
 Severe infection due to Pseudomonas aeruginosa and MRSA causing osteomyelitis of the
skull base
 Common in immunocompromised and elderly diabetics.
 Life threatening.
Management:
Treatment can include a combination of local and systemic therapies,
and can take several months:

Medical therapy
 Sugar control
 Correction of immunosuppressive state
 Ciprofloxacin

Surgical treatment
 Debridement
Acute otitis media (AOM)
• Acute otitis media (AOM) is a bacterial or viral infection of the
middle ear.
• It can cause ear pain, swelling, and redness.
• It can also trap fluid and mucus in the ear, which can lead to a fever.
• In young children, AOM can also cause them to pull at their ear, cry
more, and have trouble sleeping.

Risk factors include:

• Allergies or a cold
• Smoking in the household
• Family history of AOM
• Living in a low-resource or high air-pollution area
• Bottle feeding instead of breastfeeding
• Attending daycare.
Acute otitis media (AOM)
• Symptoms in children and adults:
• Ear pain
• Fever
• Headache
• Irritability
• Trouble sleeping
• Pulling or tugging at the ears
• Loss of appetite
• Vomiting
• Diarrhea
• Nasal congestion
• Cough
• Lethargy
• Fluid draining from the ear
• Loss of balance
 Hearing difficulties
 Sore throat
 Runny nose

Etiology
• BACTERIA :
• Streptococcus pneumoniae & pyogenes(30%)
• Haemophilus influenzae (20%)
• Moraxella catarrhalis (12%)
Predisposing factors:

 Environmental factors: Exposure to tobacco smoke, air

pollution, or upper respiratory tract infections
 Day care attendance, low socioeconomic status, and use of
pacifiers
 Prematurity and low birth weight
 Craniofacial abnormalities
 Neuromuscular disease
 Allergies
 Crowded living conditions
 Prone sleeping position (Sleeping on your stomach)
 Fall or winter season
 Absence of breastfeeding or prolonged bottle use
Clinical feature:
• Otalgia (ear pain), fever, conductive hearing loss
• Rarely tinnitus, vertigo or facial nerve palsy
• Otorrhea (drainage that comes out from ear) if tympanic
membrane perforated
• Ear tugging (ear pulling), vomiting, diarrhea, anorexia

Tinnitus - "ringing in the ears", is the medical term for hearing

sounds when there is no external source.
Vertigo is a sensation of motion or spinning.

 Acute symptoms usually resolve within 24 hours.

 However, complications can affect the inner ear, mastoid
bone, or brain, including hearing loss, perforation, and
infections.
Treatment:
 Analgesics
 Paracetamol
 Antibiotics - Amoxicillin or erythromycin
 Other treatments
 Nasal decongestants, steam, antihistamines, and surgical procedures to insert ear
tubes to allow air and fluid to drain

Diagnosis:
Otoscopy of AOM
 Red, yellow or cloudy tympanic membrane
 Bulging tympanic membrane or perforated membrane
 Air-fluid level behind the tympanic membrane
 Mastoiditis
• Mastoiditis is an infection and inflammation of the mastoid bone, which is located behind the
ear.

• It's caused by an infection that spreads from the middle ear to the mastoid air cells, which are
open spaces in the bone that contain air.

• Children are more likely to develop mastoiditis than adults because they're more prone to
middle ear infections.

• Symptoms of mastoiditis include:

• Ear pain or discomfort
• Drainage from the ear
• Fever
• Headache
• Hearing loss
• Redness behind the ear
• Swelling behind the ear
• Other symptoms include: Dizziness or vertigo, Facial paralysis, Meningitis, and
Spread of infection to the brain or throughout the body
 Mastoiditis
• Etiology:
• Bacteria :
• Streptococcus pneumoniae & pyogenes
• Haemophilus influenzae
• Moraxella catarrhalis

• Some risk factors for mastoiditis include:

• Untreated or recurrent middle ear infections
• Weak immune system
• Cholesteatoma: An abnormal skin growth in the middle ear
• Use of medical devices: Hearing aids or ear tubes can
increase the risk of developing mastoiditis
• Head or ear injury: Can damage the mastoid bone
• Allergies
• Upper respiratory tract infection
 Treatment
 Mastoiditis is a serious infection that requires early diagnosis and
treatment with antibiotics.
 Treatment can be difficult because the mastoid bone is deep in the ear,
making it hard for medicine to reach.
 Depending on the severity of the infection, treatment may include:
 Antibiotics
 Surgery

 Diagnosis:
 Otoscopic exam: for infection
 Ear discharge sample: to identify the bacteria causing the infection
 Fluid sample: If there's no discharge, the doctor may use a needle or
incision to take a sample of fluid from the middle ear
 Computed tomography (CT) scan
 Magnetic resonance imaging (MRI) scan
 Skull X-ray
 White blood cell count
 Chronic suppurative otitis media
• Chronic suppurative otitis media (CSOM) is a common childhood infection that
causes a persistent drainage from the middle ear.

• It's also known as chronic otitis media.

• CSOM is usually preceded by an episode of acute otitis media (AOM), and can
be caused by a blockage of the eustachian tube.

• Symptoms of CSOM include:

• Chronic drainage from the middle ear
• Perforated tympanic membrane (ear drum)
• Thickening of the middle ear mucosa
• Mucosal polyps
• Hearing loss, disability
• Lead to fatal intracranial infections and acute mastoiditis.
 Chronic suppurative otitis media
The pathophysiology of CSOM can be broken down into several steps:

1. Irritation and inflammation

• The pathogens irritate and inflame the middle ear mucosa, which causes
edema.
2. Ulceration and breakdown
• The inflammation eventually leads to mucosal ulceration and the breakdown
of the epithelial lining.
3. Perforation
• The inflammation can cause the tympanic membrane to spontaneously
perforate.
• The perforation becomes permanent when its edges are covered by
squamous epithelium.
4. Discharge
• The perforation causes recurrent or persistent discharge (otorrhea) from
the middle ear.
• The discharge is usually scanty and malodorous.
 Chronic suppurative otitis media
• Treatments for CSOM include:
• Cleaning the ear canal
• Ear drops
• Antibiotics
• Surgery for cholesteatoma
• Tympanoplasty to repair the eardrum perforation
• Steroid-containing drops

Diagnosis:
• Diagnosed clinically based on a history of persistent ear discharge for at least two weeks.

• If the ear can be dry mopped enough to see the eardrum, a perforation in the tympanic membrane
can confirm the diagnosis.

• CT Scan or MRI - may show intratemporal or intracranial processes, such as abscesses, labyrinthitis, or
temporal or ossicular erosion.

• Biopsies - may be performed if patients have persistent or recurrent granulation tissue to rule out a
neoplasm
 Labyrintitis
• Labyrinthitis affects the inner ear, or labyrinth, which is responsible for balance and
hearing.
• Inflammation of the inner ear or the nerves that connect the inner ear to the brain.
• Also known as vestibular neuritis.

Symptoms of labyrinthitis include:

• Vertigo: The feeling that you or your surroundings are spinning, even when you're
still
• Dizziness: Feeling unsteady or off balance, and having difficulty walking in a straight
line
• Hearing loss: Can range from mild to total loss of hearing in one ear
• Tinnitus: Ringing or other noises in the ears
• Nausea and vomiting
• A feeling of pressure inside the ears
• Eye movement: Eyes moving on their own, making it difficult to focus
Etiology:
• Bacterial:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Neisseria meningitidis
• Staphylococcus species
• Proteus species
• Bacteroides species
• Escherichia coli
• Mycobacterium tuberculosis
 PATHOPHYSIOLOGY
Bacteria enter the inner ear from middle ear, meninges, or through
bloodstream

Bacterial colonization and invasion of the inner ear

Bacterial multiplication and induction of inflammation

Intravascular damage and penetration of the blood vessels and

vestibulocochlear nerve

LABYRINTHITIS
 Treatment:
 Inflammation usually goes away within a few weeks.
 Treatment can help reduce symptoms like vertigo, nausea, and
vomiting, and may include:
 Antihistamines
 Corticosteroids: to reduce inflammation in the inner ear
 Antiemetics: help to stop nausea or vomiting
 Benzodiazepines: to reduce activity in the central nervous
system
 Antibiotics: if the infection is bacterial

 Diagnosis:
 Hearing tests: Labyrinthitis is more likely if you have hearing loss
 Neurological exam: To test your nervous system
 Blood tests: To see if another condition is the underlying issue
 Imaging tests: Such as an MRI or CT scan to record cranial
structural images of your head
 Vestibular neuritis
• Vestibular neuronitis, also known as vestibular neuritis, is a disorder that causes
inflammation of the vestibular nerve, which connects the inner ear to the brain.

Symptoms include:
• Sudden, severe vertigo
• Dizziness
• Imbalance
• Nausea and vomiting
• Inability to walk straight
• Jumping vision when moving your eyes
• Concentration problems

• Etiology:
• Vestibular neuritis is usually caused by viral infections, but in rare cases, it can be
caused by a bacterial infection.
• Bacterial labyrinthitis can be caused by an untreated middle ear infection or, in rare
cases, meningitis.
 Vestibular neuritis
Treatments include:
• Time and physical therapy
• Antiviral medications
• Prednisone or other steroids
• Vestibular suppressants
• Antiemetics
• Vasodilator therapy

Diagnosis:
• Balance and hearing tests
• Bithermal caloric test
• Vestibular-evoked myogenic potential test
• Nystagmus tests
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