Otitis media, or an infection of the middle part of the ear, is one of the most common medical problems of childhood.  Otitis media can affect any child or infant, however kids from age 6 to 24 months of age are the most commonly affected.  The symptoms of an ear infection are fever, pain, fussiness (in infants) and decreased hearing in the affected ear.  Normal hearing returns once the ear infection improves.  Most cases of otitis media will resolve without treatment, however due to concern about complications and the child's discomfort, antibiotics are commonly prescribed.

What is otitis media?

Otitis media is the "classic" ear infection that affects more than half of children by 2 years of age.  It involves the middle part of the ear.  Here, bacteria can cause inflammation that results in a fluid collection behind the ear drum which may cause fever and pain.  Doctors classify otitis media into 3 basic categories:

• Acute otitis media - a red, swollen, pus-filled middle ear infection
• Otitis media with effusion - a fluid-filled middle ear that often has no symptoms
• Chronic suppurative otitis media - persistent inflammation of the middle ear, perforation of the ear drum, and drainage of pus

What is otitis externa?

Otitis externa is an infection of the outer ear canal.  It is commonly called "swimmer's ear."  When water enters the ear canal and washes out the normal protective acid, bacteria can cause an infection.  The ear canal becomes red, swollen and extremely painful.  See otitis externa.

What causes ear infections?

Collection of fluid behind the ear drum often develops after viral upper respiratory infections or due to seasonal allergies.  Inflammation in the draining tube of the ear (the eustachian tube) blocks drainage of this fluid and bacteria can contaminate the area.  Fluid and/or pus fills the area and pushs on the ear drum from the inside.  This causes pain and a temporary hearing loss.  Occasionally the ear drum will rupture and pus will leak from the ear. 

The commone viral causes of otitis media include:

• respiratory syncytial virus
• influenza
• adenovirus
• rhinovirus
• coronavirus
• enterovirus
• parainfluenza
• metapneumovirus

The common bacteria that cause otitis media are:

• Streptococcus pneumoniae in approximately 40% of cases
• Haemophilus influenzae (non-typable) in approximately 30%
• Moraxella catarrhalis in approximately 15%

What are the symptoms of an ear infection?

• Ear pain (or ear tugging in infants)
• Irritability or fussiness (in infants)
• Fever
• Drainage from the ear (if the ear drum has ruptured)
• Hearing loss (this is temporary unless it is a severe, complicated infection)

Red Flags (seek medical care immediately)

• Severe or persistent symptoms
• High fever
• Symptoms in an infant
• Dizziness or clumbsiness
• Visible swelling around the ear
• Lethargy or unsual behavior

How is an ear infection diagnosed?

Otitis media is diagnosed by a medical practicioner with an pneumatic otoscope, a device used to look in the ear.  A bulging red ear drum is evident.  This evaluation can be difficult due to: an unhappy child, wax or fluid in the ear canal, or a small or bendy ear canal.  Debris in the ear canal may have to be removed with a plastic stylette or ear wash solution in order to see the ear drum.  Air can be blown against the ear drum to deterimine if it is mobile (like a sailboat's sail blowing in the wind).  In an infection, the ear drum will not move due to fluid in the middle ear.

A tympanometer is a handheld device that determines how the ear drum responds to sound.  This can be helpful for determining if the middle ear is free of fluid and if the ear drum is moving appropriately.

How are ear infections treated?

Most ear infections will resolve without medications.  However, antibiotics can shorten the course of the infection and can reduce the likelihood of developing complications.  The fear of developing resistant bacteria has prompted many physicians to wait 2-3 days before prescribing an antibiotic for otitis media.  Often a family will be given a prescription to be fill if symptoms do not improve.  Antibiotics can be given by mouth, by an intramuscular shot, or intravenously (in severe cases).  Most ear infections will respond to oral amoxicillin for 7 to 10 days.  If symptoms persist, a resistant type of bacteria may require a second course of antibiotics and a different antibiotic choice.

Does my child need myringotomy tubes (and what is a myringotomy tube anyway)?

Myringotomy tubes (a.k.a. - ear tubes, pressure equalization or PE tubes) are small plastic tubes that are placed surgically, usually by an Ear, Nose & Throat doctor.  The child is placed under anesthesia or deep sedation and the tube is placed in the ear drum.  This allows for drainage of fluid from the middle ear with the goal of reducing the incidence of further ear infections.

What are the complications of otitis media?

Complications of otitis media are uncommon, however, they include:

• Chronic ear infection
• Mastoiditis - infection in the bone around the ear
• Cholesteatoma - a growth in the middle ear that can permanently affect hearing
• Inner ear infection - causing dizziness, clumbsiness, nausea, vomiting, and/or hearing loss
• Meningitis

Can ear infections be prevented?

The following things can help:

• Breast feeding in infants
• Pneumococcal vaccine
• Influenza vaccine

References

Acute and chronic otitis media. Morris PS - Pediatr Clin North Am - 01-DEC-2009; 56(6): 1383-99

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