MBBS Year
1st Year
Subject
What Is Usually Asked
Middle ear boundaries, Eustachian tube, mastoid antrum, facial nerve course
ReferenceAll Years (1st-Final)All UniversitiesOtitis Media
Otitis Media: Notes, PPT and PYQs for MBBS
Otitis media is inflammation of the middle ear cleft, which includes the middle ear cavity, Eustachian tube and mastoid air cells. It ranges from a short-lived acute infection in children to chronic suppurative disease with cholesteatoma and life-threatening complications. It is one of the most important topics in 3rd Year ENT, with links to Anatomy and Microbiology.
SME-reviewed. Updated 2026.
Open in GeckoMed for PPT slides and notes.Quick Summary: What You Need to Know for University Exams
- Otitis media is classified as acute otitis media (AOM), otitis media with effusion (OME) and chronic otitis media (CSOM).
- AOM is most common in children, whose Eustachian tube is shorter, wider and more horizontal.
- Common organisms in AOM: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.
- CSOM is divided into mucosal (tubotympanic, "safe") and squamosal (atticoantral, "unsafe") types.
- Cholesteatoma is keratinising squamous epithelium in the middle ear that erodes bone and causes complications.
- Complications may be intratemporal (mastoiditis, facial palsy, labyrinthitis) or intracranial (meningitis, brain abscess, lateral sinus thrombophlebitis).
- Squamosal disease needs surgery; mucosal disease is managed with aural toilet, drops and later tympanoplasty.
Otitis Media Across MBBS Subjects
| MBBS Year | Subject | What Is Usually Asked |
|---|---|---|
| 1st Year | Anatomy | Middle ear boundaries, Eustachian tube, mastoid antrum, facial nerve course |
| 2nd Year | Microbiology | Organisms causing ear infections |
| 3rd Year | ENT | Classification, clinical features, investigations, management, complications |
| Final Year | Paediatrics | Acute otitis media in children |
MBBS Year
2nd Year
Subject
What Is Usually Asked
Organisms causing ear infections
MBBS Year
3rd Year
Subject
What Is Usually Asked
Classification, clinical features, investigations, management, complications
MBBS Year
Final Year
Subject
What Is Usually Asked
Acute otitis media in children
Definition and Classification
Definition: Otitis media is inflammation of the mucoperiosteal lining of the middle ear cleft, which may be acute or chronic, with or without effusion or suppuration.
Classification
| Type | Key Features |
|---|---|
| Acute otitis media (AOM) | Acute infection with rapid onset, usually after an upper respiratory tract infection |
| Otitis media with effusion (OME) | Non-purulent fluid in the middle ear without acute infection ("glue ear") |
| Chronic otitis media, mucosal type (tubotympanic) | Permanent perforation of the pars tensa with intermittent discharge; active or inactive |
| Chronic otitis media, squamosal type (atticoantral) | Retraction pockets or cholesteatoma, usually in the attic or posterosuperior region; active or inactive |
Type
Acute otitis media (AOM)
Key Features
Acute infection with rapid onset, usually after an upper respiratory tract infection
Type
Otitis media with effusion (OME)
Key Features
Non-purulent fluid in the middle ear without acute infection ("glue ear")
Type
Chronic otitis media, mucosal type (tubotympanic)
Key Features
Permanent perforation of the pars tensa with intermittent discharge; active or inactive
Type
Chronic otitis media, squamosal type (atticoantral)
Key Features
Retraction pockets or cholesteatoma, usually in the attic or posterosuperior region; active or inactive
Stages of Acute Otitis Media
| Stage | Features |
|---|---|
| Tubal occlusion | Retracted tympanic membrane, blocked Eustachian tube |
| Presuppuration (hyperaemia) | Congested, red tympanic membrane; earache |
| Suppuration | Pus in the middle ear; bulging, red tympanic membrane; severe pain and fever |
| Resolution | Membrane ruptures and discharge drains, relieving pain; or infection settles with treatment |
| Complication | Spread of infection if virulence is high or resistance is low |
Stage
Tubal occlusion
Features
Retracted tympanic membrane, blocked Eustachian tube
Stage
Presuppuration (hyperaemia)
Features
Congested, red tympanic membrane; earache
Stage
Suppuration
Features
Pus in the middle ear; bulging, red tympanic membrane; severe pain and fever
Stage
Resolution
Features
Membrane ruptures and discharge drains, relieving pain; or infection settles with treatment
Stage
Complication
Features
Spread of infection if virulence is high or resistance is low
Safe (Mucosal) Versus Unsafe (Squamosal) CSOM
| Feature | Mucosal (Safe) | Squamosal (Unsafe) |
|---|---|---|
| Discharge | Profuse, mucoid or mucopurulent, not foul-smelling | Scanty, purulent, often foul-smelling |
| Perforation | Central, in the pars tensa | Attic or posterosuperior marginal, or retraction pocket |
| Cholesteatoma | Absent | Often present |
| Granulations and polyps | Uncommon | Common |
| Bone erosion | Uncommon | Common |
| Risk of complications | Low | High |
| Treatment | Conservative, then tympanoplasty | Surgery (mastoidectomy) |
Feature
Discharge
Mucosal (Safe)
Profuse, mucoid or mucopurulent, not foul-smelling
Squamosal (Unsafe)
Scanty, purulent, often foul-smelling
Feature
Perforation
Mucosal (Safe)
Central, in the pars tensa
Squamosal (Unsafe)
Attic or posterosuperior marginal, or retraction pocket
Feature
Cholesteatoma
Mucosal (Safe)
Absent
Squamosal (Unsafe)
Often present
Feature
Granulations and polyps
Mucosal (Safe)
Uncommon
Squamosal (Unsafe)
Common
Feature
Bone erosion
Mucosal (Safe)
Uncommon
Squamosal (Unsafe)
Common
Feature
Risk of complications
Mucosal (Safe)
Low
Squamosal (Unsafe)
High
Feature
Treatment
Mucosal (Safe)
Conservative, then tympanoplasty
Squamosal (Unsafe)
Surgery (mastoidectomy)
Aetiology (Causes and Risk Factors)
Organisms:
| Type | Common Organisms |
|---|---|
| AOM | Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, respiratory viruses |
| CSOM | Pseudomonas aeruginosa, Staphylococcus aureus, Proteus species, anaerobes |
Type
AOM
Common Organisms
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, respiratory viruses
Type
CSOM
Common Organisms
Pseudomonas aeruginosa, Staphylococcus aureus, Proteus species, anaerobes
Risk factors:
- Childhood (Eustachian tube is shorter, wider and more horizontal)
- Recurrent upper respiratory tract infections
- Enlarged or infected adenoids
- Bottle feeding in the lying-down position
- Exposure to smoke and crowded living conditions
- Cleft palate and Down syndrome
- Allergy and sinusitis
Pathophysiology
Acute Otitis Media: Flowchart
- Upper respiratory tract infection causes Eustachian tube congestion and blockage
- Negative pressure develops in the middle ear
- Organisms ascend from the nasopharynx
- Inflammation and exudate fill the middle ear
- Pus builds up under pressure, causing the tympanic membrane to bulge
- The membrane may rupture, releasing discharge and relieving pain
Cholesteatoma: Theories of Formation
| Theory | Mechanism |
|---|---|
| Invagination (retraction pocket) | Negative middle ear pressure draws the pars flaccida inwards, forming a pocket that fills with keratin (primary acquired) |
| Epithelial migration | Squamous epithelium grows in through a marginal perforation (secondary acquired) |
| Squamous metaplasia | Middle ear mucosa changes to keratinising epithelium after chronic infection |
| Basal cell hyperplasia | Basal cells of the pars flaccida proliferate into the attic |
Theory
Invagination (retraction pocket)
Mechanism
Negative middle ear pressure draws the pars flaccida inwards, forming a pocket that fills with keratin (primary acquired)
Theory
Epithelial migration
Mechanism
Squamous epithelium grows in through a marginal perforation (secondary acquired)
Theory
Squamous metaplasia
Mechanism
Middle ear mucosa changes to keratinising epithelium after chronic infection
Theory
Basal cell hyperplasia
Mechanism
Basal cells of the pars flaccida proliferate into the attic
Cholesteatoma erodes bone through pressure and enzymes, destroying the ossicles and opening routes for complications.
(Examiner may ask you to draw the middle ear with its boundaries or a cholesteatoma in the attic.)
Clinical Features
Acute Otitis Media
- Earache, often severe, and worse at night
- Fever and irritability in children
- Hearing loss and a feeling of fullness
- Ear discharge after perforation, with relief of pain
- Tympanic membrane: congested, then bulging; later perforated with pulsatile discharge
Otitis Media With Effusion
- Painless hearing loss, often noticed by parents or teachers
- Delayed speech or poor school performance in children
- Tympanic membrane: dull, retracted, amber-coloured, sometimes with air bubbles or a fluid level
Chronic Otitis Media
- Intermittent or persistent ear discharge
- Hearing loss (usually conductive)
- Perforation or retraction pocket on examination
- In squamosal disease: foul-smelling discharge, cholesteatoma flakes, granulations
Warning signs of complications: headache, fever, vomiting, vertigo, facial weakness, pain behind the ear or neck stiffness in a patient with ear discharge.
Diagnosis
| Investigation | Findings or Purpose |
|---|---|
| Otoscopy or otomicroscopy | Tympanic membrane appearance, perforation, cholesteatoma |
| Tuning fork tests | Rinne negative and Weber lateralised to the affected ear in conductive hearing loss |
| Pure tone audiometry | Type and degree of hearing loss |
| Tympanometry | Type A normal; Type B (flat) in middle ear effusion; Type C (negative pressure) in Eustachian tube dysfunction |
| Pus culture and sensitivity | Guides antibiotic choice in chronic discharge |
| X-ray mastoid (Schuller's view) | Mastoid sclerosis or cavity, now largely replaced by CT |
| HRCT of the temporal bone | Extent of disease, bone erosion, cholesteatoma |
| MRI or contrast CT of the brain | Suspected intracranial complications |
Investigation
Otoscopy or otomicroscopy
Findings or Purpose
Tympanic membrane appearance, perforation, cholesteatoma
Investigation
Tuning fork tests
Findings or Purpose
Rinne negative and Weber lateralised to the affected ear in conductive hearing loss
Investigation
Pure tone audiometry
Findings or Purpose
Type and degree of hearing loss
Investigation
Tympanometry
Findings or Purpose
Type A normal; Type B (flat) in middle ear effusion; Type C (negative pressure) in Eustachian tube dysfunction
Investigation
Pus culture and sensitivity
Findings or Purpose
Guides antibiotic choice in chronic discharge
Investigation
X-ray mastoid (Schuller's view)
Findings or Purpose
Mastoid sclerosis or cavity, now largely replaced by CT
Investigation
HRCT of the temporal bone
Findings or Purpose
Extent of disease, bone erosion, cholesteatoma
Investigation
MRI or contrast CT of the brain
Findings or Purpose
Suspected intracranial complications
Management
Acute Otitis Media
- Antibiotics when indicated; amoxicillin is commonly the first choice
- Analgesics and antipyretics
- Nasal decongestants to improve Eustachian tube function
- Dry mopping and ear hygiene if discharging
- Myringotomy for a persistently bulging membrane or severe pain
Otitis Media With Effusion
- Watchful waiting, since many cases resolve on their own
- Treat associated causes such as enlarged adenoids or allergy
- Myringotomy with grommet (ventilation tube) insertion for persistent effusion with hearing loss
- Adenoidectomy in selected children
Chronic Otitis Media, Mucosal Type
- Aural toilet (dry mopping or suction cleaning)
- Topical antibiotic ear drops; systemic antibiotics in selected cases
- Keep the ear dry
- Treat sources of infection in the nose and throat
- Tympanoplasty or myringoplasty to close the perforation once the ear is dry
Chronic Otitis Media, Squamosal Type
| Procedure | Key Points |
|---|---|
| Canal wall down mastoidectomy (modified radical) | Removes disease and exteriorises the mastoid cavity |
| Canal wall up mastoidectomy | Preserves the posterior canal wall; needs close follow-up for recurrence |
| Radical mastoidectomy | For extensive disease |
| Tympanoplasty with ossicular reconstruction | Restores hearing where possible |
Procedure
Canal wall down mastoidectomy (modified radical)
Key Points
Removes disease and exteriorises the mastoid cavity
Procedure
Canal wall up mastoidectomy
Key Points
Preserves the posterior canal wall; needs close follow-up for recurrence
Procedure
Radical mastoidectomy
Key Points
For extensive disease
Procedure
Tympanoplasty with ossicular reconstruction
Key Points
Restores hearing where possible
Surgery is the main treatment for squamosal disease, because cholesteatoma does not resolve with medicines.
Complications
Intratemporal Complications
| Complication | Key Points |
|---|---|
| Acute mastoiditis | Pain, tenderness and swelling behind the ear; may form a subperiosteal abscess |
| Bezold's abscess | Pus tracks deep to the sternocleidomastoid muscle |
| Petrositis (Gradenigo's syndrome) | Ear discharge, deep retro-orbital pain (trigeminal) and abducent nerve palsy |
| Facial nerve palsy | From inflammation or erosion of the facial canal |
| Labyrinthitis | Vertigo, nausea and sensorineural hearing loss |
Complication
Acute mastoiditis
Key Points
Pain, tenderness and swelling behind the ear; may form a subperiosteal abscess
Complication
Bezold's abscess
Key Points
Pus tracks deep to the sternocleidomastoid muscle
Complication
Petrositis (Gradenigo's syndrome)
Key Points
Ear discharge, deep retro-orbital pain (trigeminal) and abducent nerve palsy
Complication
Facial nerve palsy
Key Points
From inflammation or erosion of the facial canal
Complication
Labyrinthitis
Key Points
Vertigo, nausea and sensorineural hearing loss
Intracranial Complications
| Complication | Key Points |
|---|---|
| Meningitis | The most common intracranial complication |
| Extradural and subdural abscess | Headache, fever, focal signs |
| Brain abscess | Temporal lobe or cerebellar abscess; headache, vomiting, focal deficits |
| Lateral (sigmoid) sinus thrombophlebitis | "Picket fence" fever, oedema over the mastoid (Griesinger's sign) |
| Otitic hydrocephalus | Raised intracranial pressure |
Complication
Meningitis
Key Points
The most common intracranial complication
Complication
Extradural and subdural abscess
Key Points
Headache, fever, focal signs
Complication
Brain abscess
Key Points
Temporal lobe or cerebellar abscess; headache, vomiting, focal deficits
Complication
Lateral (sigmoid) sinus thrombophlebitis
Key Points
"Picket fence" fever, oedema over the mastoid (Griesinger's sign)
Complication
Otitic hydrocephalus
Key Points
Raised intracranial pressure
Prevention
- Early treatment of upper respiratory tract infections
- Breastfeeding and proper feeding position for infants
- Avoiding exposure to smoke
- Vaccination against pneumococcus and Haemophilus influenzae type b under India's immunisation programme
- Early referral of chronic ear discharge
See the national immunisation schedule for India.
Prognosis
Most cases of AOM resolve fully. Mucosal CSOM has a good outlook with treatment and surgery. Squamosal disease has a higher risk of hearing loss and complications, but timely surgery and follow-up greatly reduce this risk.
Quick Viva Questions
Q: Why is otitis media more common in children? A: The Eustachian tube in children is shorter, wider and more horizontal, so nasopharyngeal infection reaches the middle ear more easily.
Q: What is the most common intracranial complication of otitis media? A: Meningitis.
Q: What is Gradenigo's syndrome? A: Ear discharge, deep retro-orbital pain and abducent nerve palsy, due to petrositis.
Q: What tympanogram is seen in otitis media with effusion? A: Type B (flat).
Q: Why is squamosal disease called "unsafe"? A: Cholesteatoma erodes bone and can lead to intratemporal and intracranial complications.
How Otitis Media Appears in MBBS University Exams
Typical question styles (not attributed to specific papers or years):
- "Describe the aetiology, stages, clinical features and management of acute otitis media." (Long essay)
- "Classify chronic otitis media. Describe the clinical features and management of the squamosal type." (Long essay)
- "Enumerate the complications of chronic otitis media. Describe brain abscess of otogenic origin." (Long essay)
- "Write a short note on cholesteatoma." (Short note)
- "Write a short note on otitis media with effusion." (Short note)
- "Write a short note on Gradenigo's syndrome." (Short note)
Frequently Asked Questions
What is the difference between safe and unsafe CSOM?
Safe (mucosal) CSOM has a central perforation with profuse, non-foul discharge and a low risk of complications. Unsafe (squamosal) CSOM involves the attic or posterosuperior region, often with cholesteatoma and foul discharge, and carries a high risk of complications.
Which antibiotic is commonly used for acute otitis media?
Amoxicillin is commonly the first choice, with alternatives depending on allergy, response and local guidelines.
Can I download the otitis media PPT for my presentation?
Yes. Use the Download PPT button at the top of this page. The GeckoMed app also gives offline access to the slides and notes.
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