Otitis media is more commonly known as a middle ear infection. It involves inflammation and/or infection of the middle ear and is typically preceded by or associated with a viral upper respiratory tract infection. It is among the most common illnesses in children, affecting 75 percent of all boys and girls by their third birthday.

Middle ear infections begin when a cold, allergy or other condition causes inflammation and blockage of the eustachian tube, a narrow passageway that connects the back of the middle ear to the back of the nose and throat. This blockage leads to a buildup of fluid in the middle ear that becomes a breeding ground for trapped germs such as viruses and bacteria. The result is an infection that tends to be very painful and is often accompanied by symptoms such as fever, listlessness, hearing impairment and difficulty sleeping.

Children are at higher risk for ear infections than adults because their eustachian tubes are shorter and narrower, their adenoids (gland-like structures located in the back of the upper throat) are large enough to sometimes hamper the opening of their eustachian tubes, and their immune systems are not fully developed.

Diagnosis of otitis media begins with a physical examination and thorough medical history. The physician often uses an instrument called an otoscope to search for signs of eustachian tube blockage, such as air bubbles or fluid behind the eardrum. Other tests may include pneumatic otoscopy (visual examination of a patient’s eardrum) and tympanometry (a more precise test of a patient’s eardrum function).

In many cases, an ear infection will resolve on its own without the need for additional treatments. Ear infections resulting from bacteria can be treated with antibiotics. However, this is not always recommended, particularly when a child has mild symptoms. Overuse of antibiotics can create strains of antibiotic-resistant bacteria, and the medication may cause side effects in some children. Persistent fluid buildup in the middle ear is sometimes treated by inserting drainage tubes into an incision in the child’s eardrum.

More commonly known as a middle ear infection, otitis media involves fluid buildup in the middle ear that becomes infected with a germ such as a virus or bacteriu. Otitis media is among the most common illnesses affecting children. Symptoms may appear in one or both ears.

Each year, over five million cases of otitis media occur in U.S. children, according to the American Academy of Pediatrics (AAP). More than 75 percent of children usually have an ear infection by their third birthday, and over half have several ear infections before they are 12 years old, according to the National Institute on Deafness and other Communication Disorders. Children typically stop having ear infections by the time they reach school age.

The middle ear is a chamber behind the eardrum (tympanic membrane). It is about the size of a pea. A narrow passageway called the eustachian tube connects the back of the middle ear to the back of the nose and throat. The tube equalizes the pressure inside and outside the ear and drains fluids from the middle ear. The inner ear structures include the cochlea, which transmits sounds to the brain, and the labyrinth, which regulates balance.

A cold, allergy or other condition can cause the eustachian tube to become inflamed, which can partially or fully block the passageway. Children are particularly susceptible to such occurrences because their eustachian tubes are typically narrower and shorter than those of adults. When this blockage occurs, fluid that builds up as a result of a cold or allergy (just as it does in the nose) has nowhere to drain. This can cause a temporary decrease in the child’s hearing.

In most cases, this fluid clears on its own within weeks and creates no lasting symptoms. However, in some cases the fluid lingers, becoming a breeding ground for the viruses and bacteria that are trapped due to the blockage of the eustachian tube. The result is an ear infection.  

Acute otitis media is the most common form of ear infection. It involves pus-filled fluid in the middle ear that causes pain, redness of the eardrum and fever. Chronic otitis media occurs when the fluid is present for more than six weeks. Otitis media with effusion involves fluid buildup in the middle ear that is temporary (usually lasting less than three months, and only rarely lasting a year or longer) and that often does not involve infection.

In some cases, fungi or bacteria may cause an infection of the external ear, known as otitis externa or swimmer ear. In very rare cases, the inner ear may become infected. Ear infections can also spread to deeper tissues and to the mastoid bone, which is located behind the ears. This condition is known as acute mastoiditis.

Common colds are the most frequent source of otitis media. When a child has a cold, fluid may build up behind the eardrum. This fluid creates a breeding ground for bacteria and viruses that lead to ear infections. As pus builds up and pressures the eardrum, the child experiences significant pain. Allergies can also trigger the congestion, fluid buildup and swelling of the eustachian tube that lead to an ear infection.  

Children are at higher risk for ear infections than adults because their eustachian tubes are shorter and narrower, their adenoids (gland-like structures located in the back of the upper throat) are large enough to sometimes hamper the opening of their eustachian tubes, and their immune systems are not fully developed.

Boys are at greater risk for ear infections than girls. Children with a family history of ear infections also appear to be more susceptible to these conditions. Other risk factors include:

• Chronic respiratory diseases such as asthma and cystic fibrosis
  
  

• Facial or brain abnormalities such as cleft palate or Down syndrome

• Impaired immune system, such as from chronic disorders like diabetes
  
  
• Attending daycare or other type of childcare facility
  
  
• Having siblings who often experience ear infections
  
  
• Exposure to second-hand smoke
  
  
• Upper respiratory tract infections such as a cold, strep throat or tonsillitis
  

External ear infections (otitis externa) result when normal ear bacteria and fungi overgrow as a result of exposure to moisture. Inner ear infections typically result from viruses – such as those responsible for measles, mumps or influenza – that spread from the middle ear to the inner ear. Bacterial infections of the inner ear are often the result of a spreading middle-ear infection or the spread of meningitis (an inflammation of the protective covering of the brain and spinal cord) into the inner ear. However, in many cases acute otitis media is caused by both bacteria and viruses.

In addition, a new study has found that children who suffer from chronic otitis media have bacterial biofilms on the middle ear tissue. Biofilms are antibiotic-resistant colonizations of bacteria that attach to surfaces and form a strong barrier that effectively prevents the bacteria’s destruction. Therefore, although antibiotics are effective for children with acute otitis media – where biofilms have not yet formed – those with persistent ear infections generally will not benefit from use of the medication.

Acute otitis media tends to be very painful and is often accompanied by symptoms such as fever, listlessness, hearing impairment, irritability, difficulty sleeping, vomiting and diarrhea. Symptoms are typically most severe during the first 24 hours of an infection. Parents may suspect an ear infection if their child’s symptoms appear soon after a cold or allergy flare-up.

Older children may verbalize their symptoms, complaining of an earache or feeling of fullness or pressure in the ear. It can be more challenging for parents of very young children who cannot speak to pinpoint the source of the problem. Often, the cry of an infant experiencing an ear infection will sound distinct compared to the cry that is associated with tiredness or hunger. The response of an infant to a sudden noise may be reduced. Younger children may also pull at or rub their ears, and may not appear to hear as clearly.

Other symptoms associated with otitis media include loss of appetite (anorexia) and dizziness or loss of balance. In some cases, pus resulting from an eardrum infection causes so much pressure on the eardrum that it ruptures. Pus and blood may then drain from the ear. This rupture actually releases pressure, lessening a child’s pain. In most cases, the ruptured eardrum will heal on its own. 

Some cases of ear infection may occur without any noticeable symptoms. This is particularly true of children who have otitis media with effusion (in which fluid builds up in the ear). However, mild or moderate hearing loss may occur in children who have otitis media with effusion. Ear discomfort and behavioral changes may be other indicators of otitis media with effusion.

An ear infection that continues to linger can damage the eardrum, ear bones and structures of the middle ear, leading to hearing loss. Any form of hearing loss in a young child – even short-term, temporary impairment – can lead to delays in language development. This is especially true for children with learning disabilities, or genetic conditions that affect development such as Down syndrome.

External ear infections (swimmer ear) may cause itchiness of the ear and redness and inflammation of the outer part of the ear in addition to other symptoms typically associated with otitis media. Inner ear infections (labyrinthitis) may cause severe dizziness and vomiting in addition to other symptoms typically associated with ear infections. Inner ear infections related to a bacterial infection are particularly likely to cause permanent hearing loss.

However, in most cases, hearing loss associated with ear infections is temporary and clears four to six weeks after the infection is resolved.

Parents are urged to consult a physician, preferably a pediatrician, if their child complains of earache or ear pressure that lasts longer than a day or that is accompanied by fever. A child who discharges blood or pus from the ear requires prompt medical attention. Such symptoms often indicate that the eardrum has been punctured.

Diagnosis begins with a physical examination and thorough medical history. The physician often uses an instrument called an otoscope to search for signs of eustachian tube blockage, such as air bubbles or fluid behind the eardrum. Children who have otitis media with effusion (in which fluid builds up in the ear) may not have noticeable symptoms, and the condition may be diagnosed during the regular well-child visits.

Pneumatic otoscopy can be used to confirm suspicions that a patient may have fluid in the middle ear as a result of eustachian tube blockage. This procedure allows a physician to visually examine a patient’s eardrum (tympanic membrane) to see how well it moves in response to pressure changes inside the ear. Poor movement indicates that fluid is behind the middle ear. Discoloration such as redness of the eardrum or a bulging of the eardrum may also indicate an ear infection.

Tympanometry is a more precise test of a patient’s eardrum function. During the test, a probe is placed inside the ear and an airtight seal is created. Air pressure inside the ear then is increased and decreased at intervals to detect how well the eardrum responds. The results are recorded in a machine called a tympanometer. Ear infections suspected from an examination using an otoscope may be confirmed with a tympanometry.

The physician may also look for signs of strep throat or the presence of tonsillitis.

If otitis media with effusion has been present for longer than three months, a hearing test may be performed. If hearing is abnormal in at least one ear, antibiotic therapy should at least be considered. If hearing loss is detected in both ears, antibiotic therapy is recommended.

In many cases, both acute otitis media and otitis media with effusion (in which fluid builds up in the ear) resolve on their own without the need for additional treatments. Ear infections caused by viruses must be allowed to run their course, because drugs such as antibiotics are not effective in treating viruses. Parents can help reduce their child’s discomfort while waiting for an ear infection to clear by giving their child an over-the-counter non-aspirin pain reliever, applying a warm and moist cloth to the child’s ear, or using prescription eardrops that contain an anesthetic that relieves pain. None of these remedies should be used without a physician’s prior approval. Aspirin should never be used in children due to the rare occurrence of Reye syndrome.

Ear infections caused by bacteria can be treated with antibiotics. However, this is generally not recommended, especially if symptoms are not severe (e.g., mild fever) or there is no underlying medical condition, such as immune system disorders. Overuse of antibiotics has created strains of antibiotic-resistant bacteria that are more difficult to treat. Continued antibiotic overuse may create many more strains of antibiotic-resistant bacteria in the future. In addition, antibiotics may cause side effects in some children, including nausea, discoloration of permanent teeth, diarrhea, rashes and in rare cases, life-threatening allergic reactions. Antibiotics also have no effect on the fluid accumulation that triggers the infection in the first place.

Around 50 percent of all antibiotic prescriptions for preschoolers are intended to treat ear infections, according to the American Academy of Pediatrics (AAP). The organization has stated concerns that this high rate of antibiotic use will lead to an increase in resistant bacteria. As a result, the AAP recommends that when appropriate (e.g., symptoms are mild) children should not be given antibiotics for up to 72 hours and watched to determine if the infection will heal on its own. Observing the child during this time is called “watchful waiting.”

If a child’s physician and parents agree that antibiotics should be prescribed, it is important to ensure that the child takes the full dosage of the medication. This will help prevent the infection from recurring and will lessen the chances of developing antibiotic-resistant strains.

After a child is treated, either with medication or with watchful waiting, another consultation with the physician is necessary. This will help determine whether the ear infection has healed or if further treatment is required. A hearing test may be performed in assessment.

Chronic otitis media should not be treated with antibiotics. A new study has found that children who suffer from chronic otitis media have bacterial biofilms on the middle ear tissue. These biofilms are resistant to antibiotic treatment. Chronic otitis media can be effectively treated by inserting drainage (tympanostomy) tubes into incisions in the child’s eardrums. This procedure is known as myringotomy and is usually performed on children between the ages of 6 months and 2 years. Myringotomy is often performed on children with genetic conditions such as cleft palate or Down syndrome earlier than other children. During the procedure, the child is put under a general anesthetic and is not conscious. A small incision is made in each eardrum, and the tubes are inserted. This facilitates drainage of fluid and equalizes pressure between the middle and outer ears.

Myringotomy usually takes about 30 minutes, and a hospital stay is not required. The tubes may remain in place for nine months to a year. As the child grows and the eardrums become larger, the tubes are pushed out and the drainage holes heal. Myringotomy is considered safe for young children, and children who have had a myringotomy often experience a significant improvement in hearing. However, some children may need the surgery a second or third time before it is successful. Children who have this surgery are often advised to refrain from swimming, or to wear earplugs whenever they are going to immerse their heads under water.

Pressure related to otitis media sometimes causes the eardrum to rupture. In most cases, this rupture heals on its own. However, some children may experience repeated rupturing that requires surgery to repair the eardrum.

Surgery may also be necessary to remove a child’s adenoids or tonsils if these organs are too large and are blocking the eustachian tubes. The adenoids are located between the nasal airway and the back of the throat (nasopharynx).

If allergies are causing the ear infections, it becomes important to find the source of the allergies. For instance, an allergy skin test may be performed, in which the skin is pricked with several potential allergens. If a rash or small bump develops, the patient is most likely allergic to that substance.

When an allergen is identified, the most effective treatment is to avoid the allergen, if possible. In addition, prescription medications such as antihistamines, decongestants, and corticosteroids may be prescribed to reduce allergy symptoms. However, the use of allergy medications is not recommended for children who have persistent fluid in the middle ear (otitis media with effusion). According to a recent review of various studies, allergy medications are not effective in alleviating symptoms or avoiding complications of otitis media with effusion and, instead, can increase children’s risk of experiencing drug-related side effects. Successful treatment of allergies may make eustachian tube problems – and thus otitis media – much less likely.

Children can practice several habits that will help keep their eustachian tubes open. Swallowing activates muscles at the back of the throat that help pull open the tube. Eating, drinking and chewing gum can all activate this process. Babies may also open their eustachian tubes by sucking on a bottle or pacifier. Yawning has an even more pronounced effect on the throat muscles that open the tube.

Children can also take a deep breath, close their mouth, pinch their nostrils and blow. This often will force open the eustachian tube. However, this should be done with caution, because blowing too hard can damage the eardrums. Children can often safely open the tubes by blowing up balloons.

Parents can also take several steps to reduce the risk of ear infection in their child. These include:

• Breastfeed for at least four months. Breastfeeding passes immunity that helps protect children from ear infections.
  
  
• Ask a physician about the pneumonococcal 7-valent conjugate (PCV7) vaccine. This series of four injections provided between ages 2 months and 15 months can prevent a form of bacterium that causes some ear infections.
  
  
• Choose a childcare facility with fewer children. Children who spend time in close quarters with many children are at higher risk of ear infections due to the larger number of infectious viruses and bacteria they are exposed to.

Reduce their child’s exposure to second-hand smoke. Breathing in second-hand smoke significantly increases the risk of ear infection, and also slows recovery time once infection has set in. If possible, do not allow smoking in the home or any car that the child travels in.

Preparing questions in advance can help parents have more meaningful discussions with physicians regarding their child’s treatment options. The following questions related to otitis media may be helpful:

1. What signs should I look for that indicate my child has an ear infection?
   
   
2. How will I know if my child’s condition requires medical attention?
   
   
3. What may be causing my child’s ear infection?
   
   
4. What treatments are available to my child?
   
   
5. Should my child take antibiotics? What are the pros and cons?
   
   
6. Would my child benefit from having tubes placed in his/her ears?
   
   
7. Can you recommend any home remedies?
   
   
8. What over-the-counter medications are safe for my child to take?
   
   
9. How can I help prevent future ear infections in my child?
   
   
10. Are there any activities my child should avoid until symptoms subside?