Middle Ear Infection (Otitis Media)

A middle ear infection includes the eardrum and tissues behind it.

• Middle ear infections (otitis media) are inflammation usually caused by infection of ear tissue, including the eardrum and tissues behind it, but not the ear canal.
• It is the most common childhood condition for which antibiotics are prescribed.
• Signs and symptoms include:
  • Fever
  • Ear pain
  • A feeling of fullness in the ear
• Young children will have these symptoms and signs as well as fussiness and feeding problems.
• The infection or inflammation causes fluid buildup in the middle ear.
• A cold or other respiratory infection can lead to ear infections or inflammation.
• Those at a higher risk for middle ear infections are children exposed to other children's colds (as often occurs in daycare centers), and babies who are bottle-fed.
• Middle ear pus causes pain and temporary hearing loss.
• Rupture of the eardrum allows the pus and fluid to drain into the ear canal.
• Ear infections are treated with observation, antibiotics, or ear tubes.
• Routine childhood and yearly flu vaccinations may help prevent this type of infection.

Middle ear inflammation is also called otitis media. Otitis media is inflammation of the middle ear; however, many doctors consider otitis media to be either inflammation or infection of the middle ear, the area inside the eardrum (tympanic membrane -- see illustration). "Otitis" means inflammation of the ear, and "media" means middle. This inflammation often begins with infections that cause sore throats, colds, or other respiratory problems, and spreads to the middle ear. Infections can be caused by viruses or bacteria, and can be acute or chronic. Both ears can be infected at the same time (double ear infection). These infections are not "swimmer's ear" (also termed otitis externa or outer ear infection because it occurs in the ear canal up to the eardrum), but not beyond. However, some people can have swimmer's ear and a middle ear infection at the same time.

Acute middle ear infections usually are of rapid onset and short duration. They typically are associated with fluid accumulation in the middle ear, signs or symptoms of infections in the ear, a bulging eardrum usually accompanied by pain or a perforated eardrum, and drainage of purulent material (pus, also termed suppurative otitis media). The person also may have a fever.

Chronic middle ear infections are a persistent inflammation of the middle ear, typically for a minimum of three months. This is in distinction to an acute ear infection that usually lasts only several weeks. Following an acute infection, fluid (an effusion) may remain behind the eardrum (tympanic membrane) for up to three months before resolving. It may develop after a prolonged period of time with fluid (effusion) or negative pressure behind the eardrum (tympanic membrane). This type of infection can cause ongoing damage to the middle ear and eardrum, and there may be continuing drainage through a hole in the eardrum. Chronic middle ear infections often start painlessly without fever. Ear pressure or popping can be persistent for months. Sometimes a subtle loss of hearing can result from chronic middle ear infections.

• Serious otitis media is inflammation in the middle ear without infection. Typically, the Eustachian tube is not functioning and cannot ventilate the ear normally. As a result, fluid accumulates in the middle ear.
• This can lead to a dullness or fullness within the ear along with diminished hearing.

• The eardrum (tympanic membrane) has three delicate layers that help keep the eardrum thin but strong.
• A chronic middle ear infection causes changes in the eardrum that weaken it, and often lead to a hole in the eardrum (tympanic membrane perforation).
• Eventually, the eardrum loses its strength and begins to collapse into the middle ear space.
• When the eardrum collapses or retracts from negative pressure in the middle ear, it can attach to the other middle ear structures.
• The eardrum is frequently seen draped around the middle ear bones (ossicles) or the inner wall of the middle ear (promontory).
• This disrupts the conduction of sound through the middle ear and may diminish hearing.

• A hole that forms in the eardrum (tympanic membrane perforation) usually causes a chronic draining ear, or a condition called chronic otitis media with perforation.
• Often the drainage (otorrhea) will have a foul odor and can be seen draining from the ear.
• Hearing can improve after the middle ear fluid is released, or it may worsen secondary to the inflammation in the middle ear.

• This type of acute middle ear infection is an extremely common diagnosis.
• In the U.S., it is estimated that most children experience at least one middle ear infection before the age of three.

• The Eustachian tube, a canal that runs from the middle ear to the back of the nose and throat, is shorter and more horizontal in infants and young children than in older children and adults.
• This allows easier entry into the middle ear for the microorganisms that cause infection and leads to otitis media.
• Young children also have more immature immune systems.
• The result is that infants and young children are at greater risk of acquiring ear infections than adults.

• As a person ages, the Eustachian tube doubles in length and becomes more vertically positioned so that the nasopharyngeal orifice (opening) in the adult is significantly below the tympanic orifice (the opening in the middle ear near the ear drum) than in a child.
• The greater length and particularly the slope of the tube as it grows serves more effectively to protect, aerate and drain the middle ear.

• Bacteria and viruses can cause middle ear infections.
• Bacteria such as Streptococcus pneumoniae (pneumococcus), Hemophilus influenzae, Pseudomonas, and Moraxella account for about 85% of cases of acute otitis media.
• Viruses account for the remaining 15%.
• Affected infants under 6 weeks of age tend to have infections from a variety of different bacteria in the middle ear.

• Bottle-feeding: The position of the breastfeeding child is better than that of the bottle-feeding position in terms of the function of the Eustachian tube that leads into the middle ear. If an infant needs to be bottle-fed, it's better to hold babies rather than allowing them to lie down with the bottle. Ideally, they should not take the bottle to bed. (In addition to increasing the chance for acute infection, falling asleep with milk in the mouth enhances the risk of tooth decay.)
• Upper respiratory tract infection: Children often develop upper respiratory infections prior to developing this type of infection. Exposure to groups of children (as in childcare centers) results in more frequent colds, and therefore more earaches.
• Exposure to air with irritants, such as tobacco smoke
• Birth defects: Children with cleft palate or Down syndrome are more prone to ear infections.
• Eustachian tube problems: Any problems with the Eustachian tubes (for example, blockage, malformation, inflammation) will increase the risk of infection. If the individual has allergies, he or she may have swelling and blockage of one or both Eustachian tubes.
• Immunosuppressed: Individuals with suppressed immune response are at increased risk for ear infections.
• Ear infections later in childhood: Children who have episodes of acute infections before six months of age tend to have more later in childhood.

• The Eustachian tube normally prevents the accumulation of fluid by allowing fluid to drain through the tube.
• Chronic otitis media develops over time, and often starts with a chronic middle ear effusion (fluid) that does not resolve.
• This persistent fluid will often become contaminated with bacteria, and the bacteria found in chronic otitis media are often different from those found in acute otitis media.
• Therefore, anything that disturbs the function of the Eustachian tube can lead to chronic otitis media.
• In some individuals that are ill from other diseases, and there is pus draining from the ear, there is a danger that otitis media (especially bacterial-caused) may invade the mastoid bone and reach the brain.
• These individuals need to be seen urgently by a health care professional.
• Do not delay treatment by trying home remedies.

Signs and symptoms of middle ear infections in babies, toddlers, and children may include the following:

• Young nonverbal children may be irritable and pull or tug at their ear(s).
• Young children with middle ear infections may be irritable, fussy, or have problems feeding or sleeping.
• Older children may complain about pain and fullness in the ear (earache).
• A child of any age may have a fever.
• The buildup of pus within the middle ear causes pain and dampens the vibrations of the eardrum (so there is usually temporary hearing loss during the infection).
• Severe ear infections may cause the eardrum to rupture. The pus then drains from the middle ear into the ear canal.
• The hole in the eardrum from the rupture usually heals without medical treatment.

These symptoms are often associated with signs of upper respiratory infection such as a runny or stuffy nose, or a cough.

• Ear pain
• Difficulty hearing
• Ear(s) may feel plugged up
• Ringing in ears
• Dizziness
• Fever
• Headache
• Nausea and/or vomiting

• Ear infections are not contagious.
• However, many children develop infections following a cold or other viral infection, and those infections are contagious.

• The majority of children and adults are diagnosed and treated by either pediatricians, primary health care doctors, emergency or urgent care medical providers, or other health care professionals.
• Ear, nose, and throat (ENT) specialists may be consulted for some individuals.
• On rare occasions, a neurologist or neurosurgeon may be needed to treat a severe infection that may extend to other organ systems.

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) have determined the criteria needed to diagnose acute otitis media (AOM), acute onset, middle ear effusion (MEE), and middle ear inflammation.

• The new guidelines describe this as "moderate to severe bulging of the tympanic membrane (ear drum) or new onset of otorrhea (ear drainage) not due to external otitis (inflammation of the ear canal) or mild bulging of the ear drum, and recent ear pain (holding, tugging, rubbing ear in a nonverbal child) or intense reddening of the ear drum."
• The guideline also strongly recommends that clinicians should not diagnose AOM without the presence of MEE.
• Recurrent acute otitis media is defined as at least three well-documented and separate acute otitis media episodes in 6 months or four well-documented and separate AOM episodes in the past 12 months with at least one in the past 6 months.
• There is no definitive lab test for acute otitis media.

Identification of the three criteria is dependent on clinical observation; middle ear effusion and middle ear inflammation are the most difficult to observe and as a consequence there are studies that suggest acute otitis media is overdiagnosed.

• One method that helps determine acute otitis media versus otitis media with effusion is pneumatic otoscopy (the normal eardrum moves readily with pressure changes) and the appearance of the tympanic membrane (acute otitis media has abnormal appearance; otitis media with effusion does not).
• However, not everyone is skilled at this technique; pediatricians, family practice physicians, ENT specialists, and ER doctors who work in pediatric ER's are likely to be skilled in the diagnostic procedure.

The treatment for acute otitis media varies depending upon the age and symptoms of the child. The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommend the following:

*Observation is an appropriate option only when follow-up can be ensured and antibacterial agents can be started if symptoms persist or worsen within 2-3 days. The guidelines also recommend "shared decision making" with the caregiver. Non-severe illness is represented by mild ear pain and fever <39 C (102.2 F) in the past 24 hours. Severe illness is defined as moderate to severe otalgia (ear pain) or any ear pain for at least 48 hours or fever 39 C. These 2013 guidelines are current.

If antibiotics are initiated, amoxicillin is usually recommended as the first line treatment. This is usually prescribed for 10 days. Some children do not respond within the first 48-72 hours of treatment, and antibiotic therapy may have to be changed. Even after antibiotic treatment, some children are left with some fluid in the middle ear, which can cause temporary hearing loss lasting for up to 3 to 6 weeks. In most children, this fluid eventually disappears spontaneously (on its own). Ceftriaxone (50mg/kg/d) injection is recommended for children who cannot take oral antibiotics; three days of this antibiotic is usually more effective than a single injection.

Children who have recurring bouts of otitis media may be referred to an otolaryngologist (ear, nose, and throat specialist or ENT). Some of these children may benefit from having an ear tube placed (tympanostomy tube) to permit fluid to drain from the middle ear. In addition, if a child has a bulging eardrum and is experiencing severe pain, a procedure to lance the eardrum (myringotomy) may be recommended to release the pus. The eardrum usually heals within a week. Prophylactic antibiotic therapy has not been shown to decrease the frequency of ear infections in those children with recurrent AOM.

Although treatment may cure an ear infection, it is possible for the ear to become re-infected.

• Initially, antibiotics may resolve the ear infection.
• If a tympanic membrane perforation also is present, topical antibiotic drops may be used.
• If eardrum or ossicle scarring has occurred, that will not be reversed with antibiotics alone.
• Surgery often is indicated to repair the tympanic membrane (eardrum) and remove the infected tissue and scar from the middle ear and the mastoid bone.
• Long-term prophylactic antibiotics are not recommended.

• The goals of surgery are to first remove all of the infected tissue so that it can be "safe" from recurrent infections.
• The second goal is to recreate a middle ear space with an intact eardrum.

Finally, hearing is to be restored.

• This may seem strange that hearing is the last priority, but if the first two priorities are not met, anything that is done to improve hearing will ultimately fail.
• If hearing is restored, but the infection returns, the hearing will be lost again.
• Likewise, if hearing is restored, but the middle ear space is not recreated, the eardrum will re-stick to the middle ear or the ossicles.

There are a number of suggested home remedies for the treatment of ear infections, including

• humidified air,
• homeopathic treatments,
• naturopathic ear drops,
• decongestants, and
• antihistamines. 

However, there are limited studies suggesting the benefits of these measures over accepted and recommended treatments.

• Both oral and topical analgesics are effective in controlling the pain associated with ear infections, but the use of decongestants or antihistamines has not been demonstrated to improve symptoms or speed the resolution of acute otitis media.

• Otitis media is not contagious (although the initial cold that caused it may be).
• A child with otitis media can travel by airplane but, if the Eustachian tube is not working well, the pressure change as the plane descends may cause the child pain.
• It is best not to fly (or swim) with a draining ear.
• You should always consult your doctor if you have specific concerns.

• Currently, the best way to prevent acute otitis media is to assure a child is vaccinated.
• Ensuring that your child receives an annual flu vaccine and is up to date with his/her pneumococcal vaccine is the best way to prevent the most common causes of middle ear infections (otitis media).
• In addition, both early and sustained breastfeeding (for at least 6 months) and avoidance of tobacco smoke exposure have been shown to be related to fewer ear infections.
• Recent studies suggest that Xylitol-based gum or lozenges may have a preventive impact on acute otitis media. Unfortunately, it cannot be used in young children, and must be used 3-5 times a day during the cold and flu season to be effective.