The human ear is composed of three parts: the inner ear, the middle ear, and the external ear. Inflammation of the middle ear is called otitis media. It most commonly affects young children between the ages of 1-4, during the first year of life.¹ There are different types of otitis media, and it is important to treat each of them. This article aims to help identify what could happen if otitis media is left untreated for too long. 

Introduction

Otitis media is a term that encapsulates acute otitis media (AOM), otitis media with effusion (OME), and chronic otitis media (COM). Annually, there are an estimated 709 million new cases of AOM and an estimated 31 million new cases of chronic otitis media. 

Ear pain is the most prevalent symptom of AOM. The pain typically causes young children to pull, rub, or hold onto their ears and also causes disturbance to their sleep patterns in addition to excessive crying and irritability. 

The symptoms of OME are not as obvious as that of AOM. Patients may not experience the pain that is typical of AOM. They may instead exhibit more subtle signs, such as not performing well at school, clumsiness, or a delay in developing language. There may also be a degree of hearing problems and problems with sleeping. 

Although, both involve disturbance with fluid in the ear, AOM and OME differ by the location of said fluid. OME involves effusion (presence of fluid) behind the tympanic membrane in the middle ear. AOM does not always involve fluid but if it does, the fluid causes infection (most likely bacterial) of the middle ear area in front of the tympanic membrane. 

COM can develop from AOM. It can also develop from a blockage within the middle ear (specifically within the eustachian tube), bacterial infections, or from having a tympanostomy tube inserted. Symptoms are similar to that of AOM and OME; patients may also experience ringing in the ears (tinnitus) or a feeling of aural fullness.²

How does inflammation in otitis media lead to infection?

Inflammation in the middle ear typically starts after an upper respiratory tract infection. The constriction of the anatomical space within the middle ear and a build-up of fluid due to the inflammation will cause an increase in negative pressure in the middle ear - this leads to a cycle where further fluid is released into the space. The buildup of secretions builds an environment where bacterial and viral pathogens can thrive and cause bulging or irritation of the tympanic membrane.³

Typamnic membrane perforation

Untreated otitis media can cause perforation of the tympanic membrane - this is what is commonly referred to as a ‘burst eardrum’. This is caused by the change in pressure in the inner ear. The risk of spontaneous tympanic membrane perforation increases with each AOM infection. Recurrent AOM infections cause necrosis and death of the cells within the tympanic membrane, which leads to perforation.⁴ Tympanic membrane perforation could lead to hearing loss, with the severity of loss being dependent on the level of damage to the membrane. 

Hearing loss in otitis media

The ossicular chain is a series of small bones in the middle ear. Its function is to translate sound waves from the eardrum in the middle ear to the inner ear - i.e., it is essential in hearing. In 80% of cases of chronic otitis media, there is damage to this structure. This can lead to conductive hearing loss. Conductive hearing loss is the term used when sound waves cannot get through the middle ear, meaning soft sounds are hard to hear, and louder sounds will sound muffled. 

Sensorineural hearing loss results from damage to nerve fibres within the inner ear and is more common than conductive hearing loss.⁶ Evidence shows that 9% of cases of OME among children had sensorineural hearing loss.⁷ COM can also cause sensorineural hearing loss, with the likelihood of hearing loss increasing with the duration of the disease and age.⁸

With the reoccurrence of infections, sensorineural hearing loss threatens to become permanent. Hearing aids can be used to help with hearing in these cases. Conductive hearing loss, on the other hand, can be reduced with surgery. 

Mixed hearing loss is when the patient experiences a mixture of conductive and sensorineural hearing loss. It occurs when hearing loss is greater via air conduction when compared to bone conduction, and accounts for 43.33% of hearing loss associated with AOM.⁹

Speech and Language Development Implications (for Children)

When hearing loss is intermittent or prolonged, it can lead to speech and language development issues in young children. The ability to listen is essential in developing language skills and losing the ability to hear during a child’s formative years can also affect their ability to speak.¹⁰ This can also affect a child’s ability to read and write - ultimately affecting their performance at school. 

Other Long-Term Complications

COM can lead to the formation of a cholesteatoma, a type of growth that forms in the middle ear. It is a cyst made of dead cells that can affect hearing, balance, and facial muscles. It can be treated with surgery to remove the growth and fix the damage caused to the ear drum.¹¹

There is evidence that OME can cause balance issues in children, with one study showing that children with OME are more dependent on their vision to maintain balance than healthy children. Currently, the exact mechanism behind how OME causes balance issues is unknown, but symptoms have been shown to improve after ventilation of the middle ear.¹²

Tinnitus, or hearing ringing in the ear, is a common side effect of otitis media and is often associated with hearing loss. In a study with 927 people, roughly 61% were shown to have tinnitus secondary to otitis media.¹³

Prevention and Early Intervention

Early diagnosis and treatment can help avoid loss of hearing and other complications associated with otitis media. Initial treatment would be antibiotics to clear up the bacterial infection. Those with recurrent infections may be candidates to have a tube surgically fitted into the eardrum to avoid further infections. Patients may also have a tympanocentesis, where a needle is used to aspirate the fluid from the ear.¹⁴ 

Summary

In summary, otitis media is an ear infection that most commonly affects very young children. The side effects include a burst eardrum, speech and developmental delays, ringing in the ears, and hearing difficulties to varying degrees. Early detection and intervention are key in avoiding these long-term side effects of untreated otitis media.