Otitis Media in Africa: Causes, Risk Factors, Treatment, Prevention and Complications

BruceBlaus, CC BY-SA 4.0, via Wikimedia Commons

Overview

Otitis media is inflammation of the tympanic membrane and middle ear. Approximately two-thirds of children of all ages are affected by otitis media.

Key facts:

Approximately 42 million people over the age of three years suffer hearing loss due to otitis media
90% of children experience this disorder before they enter the school system
Many attacks of otitis media spontaneously resolve within three months, but in 30% to 40% of children, the disorder becomes recurrent
Otitis media occurs in 75% of children at least three times in their frst three years of life.
Around 20,000 people, majorly children under 5 years of age, die every year with the associated complications.

Otitis media, especially with a chronic and recurrent form, is associated with complications such as hearing loss, decreased learning capability, and low educational achievement.

Causes of otitis media in Africa

Otitis media usually occurs as a result of acute upper respiratory tract infections. It can also be caused by allergies or abnormalities in the normal structure and function of the middle ear or Eustachian tube.

The most important bacteria causes are

non-typeable Haemophilus infuenzae
Streptococcus pneumoniae
Staphylococcus aureus
Streptococcus pyogenes
Pseudomonas aeruginosa
Proteus mirabilis
Escherichia coli, and
Moraxella catarrhalis

P. aeruginosa, S. aureus and P. mirabilis are the commonest bacterial pathogens responsible for otitis media in sub-Saharan Africa.

Viruses and fungi also cause otitis media.

The occurrence of otitis media is directly related to the colonization rate of the nasopharynx by the bacteria. Viral upper respiratory tract infections (URTI), disrupts the mucociliary system, a system of thick secretions (mucus) from the airways and hairlike projections that sweep the mucus. The disruption of the mucociliary system impairs the host’s primary mechanical defense for bacterial invasion and predisposes children to acute otitis media (AOM).

Types of otitis media

Acute otitis media (AOM)
- Description: This type of middle ear infection starts suddenly, causing swelling and redness.
- Symptoms: Fluid and mucus get trapped in the ear, leading to fever and ear pain.
Otitis media with effusion (OME)
- Description: Fluid and mucus remain in the middle ear after an initial infection has subsided.
- Symptoms: A sense of fullness in the ear, possible hearing impairment, or no symptoms at all.
Chronic otitis media with effusion (COME)
- Description: Fluid stays in the middle ear for an extended period or keeps coming back without infection.
- Symptoms: Difficulties in fighting new infections and potential hearing issues.

Symptoms of a middle ear infection

Ear pain:
- In older children and adults, there is ear pain.
- Babies may rub or pull at their ears, cry more than usual, have trouble sleeping, or be restless and irritable.
Loss of appetite:
- Especially noticeable in young children during bottle-feeding, as swallowing can increase ear pain due to pressure changes.
Irritability:
- Persistent pain can cause irritability.
Poor sleep:
- Pain can worsen when lying down due to increased ear pressure.
Fever:
- Temperatures can range from 38°C to 104°F, and about half of the children with an ear infection also have a fever.
Ear Drainage:
- Drainage of yellow, brown, or white (not earwax) fluid from the ear may indicate a ruptured eardrum.
Hearing problems:
- Fluid behind the eardrum can slow down the movement of sound signals through the inner ear, affecting hearing.

These symptoms can resemble other conditions, so it's important to consult a healthcare provider for an accurate diagnosis.

Risk factors

The risk factors for ear infections are:

cultural, such as use of feathers to clean the ears,
socioeconomic, and environmental (e.g., living in crowded places, living in large families, the duration of breastfeeding, smoking status),
genetic (e.g., craniofacial anomalies such as those characteristic in Down syndrome and cleft palate),
nutritional like how the infant is fed: Babies who are bottle-fed, particularly when lying down, are more prone to ear infections compared to breast-fed babies.
medical (e.g., age, gender, race, health status, history of several acute otitis episodes, rhinorrhea, allergic rhinitis, seasonal rhinitis, snoring, upper respiratory tract infections, and adenoid hypertrophy).

Diagnosis

Diagnostic criteria for acute otitis media include:

rapid onset of symptoms,
middle ear effusion, and
signs and symptoms of middle

Antibacterial resistance in Africa

A high level of resistance was observed to commonly used antibacterial agents such as Ampicillin, cotrimoxazole, Amoxicillin, and Amoxicillin-clavulanate however, isolates were less resistant to Ciprofoxacin, Gentamycin, and Chloramphenicol.

Thus, drugs like Ampicillin, amoxicillin, Amoxicillin-clavulanate, and cotrimoxazole should not be used as a first-line treatment in sub-Saharan countries since countries in Sub-Saharan Africa are commonly dependent on clinical data for treatment with the absence of microbiology laboratory. Without proper treatment, otitis media could lead to intracranial and intratemporal complications with higher and complex management.

Management and treatment of otitis media

Treatment of ear infections depends on age, severity of the infection, the nature of the infection (is the infection a first-time infection, ongoing infection or repeating infection) and if fluid remains in the middle ear for a long period of time.

Your healthcare provider will recommend medications to relieve your child’s pain and fever. If the ear infection is mild, depending on the age of the child, your healthcare provider may choose to wait a few days to see if the infection goes away on its own before prescribing an antibiotic.

Antibiotics

Antibiotics may be prescribed if bacteria are thought to be the cause of the ear infection. Your healthcare provider may want to wait up to three days before prescribing antibiotics to see if a mild infection clears up on its own when the child is older. If your or your child’s ear infection is severe, antibiotics might be started right away.

Pain-relieving medications

Over-the-counter pain relievers such as acetaminophen/paracetamol or ibuprofen can help relieve earache or fever. Pain-relieving ear drops can also be prescribed. These medications usually start to lessen the pain within a couple hours.

Never give aspirin to children. Aspirin can cause a life-threatening condition called Reye’s syndrome.

Ear tubes (tympanostomy tubes)

If your child has experienced frequent ear infections (three ear infections in six months or four infections in a year), had ear infections that weren’t resolved with antibiotics, or experienced hearing loss from fluid buildup behind the eardrum, he or she may be a candidate for ear tubes.

Ear tubes are small tubes inserted into the eardrum to drain fluid from the middle ear, relieve the pressure there, and allow air to pass through. They provide immediate relief and are sometimes recommended for small children who are developing their speech and language skills.

You may be referred to an ear, nose and throat (ENT) specialist for this outpatient surgical procedure, which is called a myringotomy with placement of tube. During the procedure, a small metal or plastic tube is inserted through a tiny incision (cut) in the eardrum. The tube lets air into the middle ear and allows fluid to drain.

The procedure is very short — approximately 10 minutes — and there’s a low complication rate.

The ear tube usually stays in place from six to 12 months. It often falls out on its own, but it can also be removed by your doctor. The outer ear will need to be kept dry and free of dirty water, until the hole in the eardrum heals completely and closes.

What can I do to prevent ear infections in my child?

Don’t smoke. Studies have shown that second-hand smoking increases the likelihood of ear infections. Be sure no one smokes in the house or car — especially when children are present — or at your daycare facility.
Control allergies. Inflammation and mucus caused by allergic reactions can block the eustachian tube and make ear infections more likely.
Prevent colds. Reduce your child's exposure to colds during the first year of life.
Maintain adequate hygiene. Don’t share toys, foods, drinking cups or utensils. Wash your hands frequently.
Breastfeed your baby. Antibodies in breast milk reduce the rate of ear infections.
Bottle feed baby at an upright angle. If you bottle feed, hold your baby in an upright angle (head higher than stomach). Feeding in the horizontal position can cause the fluids to flow back into the eustachian tube..
Watch for mouth breathing or snoring. Constant snoring or breathing through the mouth may be caused by large adenoids. These may contribute to ear infections. An exam by an otolaryngologist, and even surgery to remove the adenoids (adenoidectomy), may be necessary.
Get vaccinations. Make sure your child’s immunizations are up to date, including yearly influenza vaccine (flu shot) for those 6 months and older. Ask your doctor about the pneumococcal, meningitis and other vaccines too. Preventing viral infections and other infections help prevent ear infections..