Middle Ear Infections (Otitis Media)

Why middle ear infections happen

The middle ear is connected to the back of the nose by the Eustachian tube, which equalizes pressure and drains fluid. In young children this tube is shorter, narrower and more horizontal, so it blocks easily. During a cold or allergy flare, the tube swells, fluid builds up behind the eardrum, and viruses or bacteria (commonly Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis) multiply.

Risk factors

• age 6 months to 3 years
• attending child care
• frequent colds
• exposure to tobacco smoke
• bottle feeding while lying flat, and pacifier use
• not being breastfed
• enlarged adenoids (adenoid hypertrophy)
• family history of ear infections
• cleft palate and Down syndrome
• allergies

Symptoms

In babies and young children

• ear pain, often worse lying down
• tugging or rubbing the ear
• fever
• crying, irritability and trouble sleeping
• poor feeding
• not responding to quiet sounds
• fluid draining from the ear if the eardrum has burst (pain often eases suddenly)

In older children and adults

• earache
• muffled hearing and a feeling of fullness
• fever
• sometimes dizziness or ringing

Pulling at the ear alone, without other symptoms, is not a reliable sign; babies often play with their ears.

Types of otitis media

Middle ear infections are different from swimmer's ear, an infection of the ear canal outside the eardrum, which causes pain when the earlobe is pulled.

Diagnosis

A clinician looks at the eardrum with an otoscope. In acute otitis media, the eardrum is red, bulging and does not move normally. A pneumatic otoscope (puffing air) or tympanometry shows fluid behind the eardrum. Hearing tests are done for persistent fluid or recurrent infections.

Treatment

Pain relief

The most important treatment. Use acetaminophen (paracetamol) or ibuprofen at the correct dose for age and weight, following the label. Do not give aspirin to children or teenagers. A warm compress over the ear may help.

Antibiotics or watchful waiting

Many ear infections clear on their own. US pediatric guidelines recommend:

• Antibiotics for children under 6 months, children 6 to 23 months with infection in both ears, and any child with severe symptoms (high fever 39 °C or 102.2 °F or more, severe pain, or pain over 48 hours) or discharge from the ear.
• Watchful waiting for 48 to 72 hours as an option for children 6 to 23 months with mild infection in one ear, and for children 2 years and older with mild symptoms, with antibiotics started if they do not improve.

Amoxicillin is the usual first choice. Finish the prescribed course. Antibiotic ear drops are used when ear tubes are in place.

Things that do not help

Decongestants and antihistamines do not help middle ear infections in children. Avoid putting oil or cotton swabs in the ear.

Ear tubes (tympanostomy tubes)

Tiny tubes placed through the eardrum under brief anesthesia let air in and fluid out. They are considered for:

• recurrent ear infections (three or more in 6 months, or four in a year with one in the last 6 months) when fluid is present
• fluid in both ears for 3 months or longer with hearing loss or other problems

Tubes usually fall out on their own after 6 to 18 months. Removing enlarged adenoids is sometimes done at the same time in older children.

Complications

Most ear infections heal without problems. Possible complications include:

• temporary hearing loss from fluid, which can affect speech in young children if prolonged
• perforated eardrum, which usually heals within weeks
• mastoiditis: infection of the bone behind the ear
• cholesteatoma: a skin cyst in the middle ear after chronic infection
• rarely, meningitis or facial nerve weakness

Prevention

• Keep up with vaccines, including pneumococcal and yearly flu vaccines.
• Avoid tobacco smoke exposure.
• Breastfeed if possible, for at least 6 months.
• Feed babies upright, not lying flat with a bottle.
• Limit pacifier use after 6 months.
• Wash hands to reduce colds.

Frequently asked questions

What are the signs of an ear infection in a child?

Signs include ear pain, fever, irritability, crying more than usual, trouble sleeping, poor feeding, tugging at the ear, and not responding to quiet sounds. Fluid draining from the ear can mean the eardrum has burst, which often relieves pain.

Do all ear infections need antibiotics?

No. Many middle ear infections clear on their own within 2 to 3 days. Antibiotics are recommended for babies under 6 months, young children with infection in both ears, and severe or persistent cases. Pain relief is important for all.

How long does a middle ear infection last?

Pain and fever usually improve within 2 to 3 days, with or without antibiotics. Fluid behind the eardrum can remain for several weeks after the infection, causing muffled hearing, and usually clears by 3 months.

Are ear infections contagious?

The ear infection itself is not contagious. However, the colds and viruses that lead to ear infections spread easily between children. Handwashing and vaccinations reduce the number of colds and therefore ear infections.

When are ear tubes recommended?

Ear tubes are considered for children with repeated ear infections, such as three in 6 months or four in a year, or with fluid in both ears lasting 3 months or more along with hearing loss or speech concerns. An ENT specialist will advise.