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Middle Ear Infection – Symptoms and Treatment

What is a Middle Ear Infection

Middle ear infections are very common in young children. New vaccines are helping to make them less common, and new scientific information is helping to change the ways doctors think about them. Still, these infections (doctors call them “otitis media” or OM) are still a big part of childhood for many kids.

The “middle ear” is the part of each ear between the ear canal (the opening we see in the ear) and the “inner ear” which translates sound into nerve impulses. The eardrum forms the outer wall of the middle ear. Just inside the eardrum are three tiny bones that amplify sound waves and push on the inner ear. The inner ear converts sound waves into electrical signals that go to the brain. The entire apparatus of the middle ear takes up a space of only about a fifth of a teaspoon. The only opening into the middle ear is one end of a thin tube called the “Eustachian” (you-station) tube. The other end of the tube is in the back of the nose. When we yawn or swallow, the tube opens briefly and lets air in or out. This keeps the pressure in the ears normal. Our ears “pop” in an airplane or when we go up a mountain because the Eustachian tube opens for a second.

The Eustachian tube is lined with the same kind of membrane that is in the nose. Anything that that causes congestion in the nose also causes swelling in the tube. These things include colds(upper respiratory infections) and sometimes allergies. When the tube swells, the middle ear pressure can’t adjust, and fluid builds up in it. This tiny amount of fluid, in the warm, dark space of the middle ear, is a fertile ground for germs to grow in. The germs come from the nose, up the Eustachian tube. Once the germs start to grow, the body sends white blood cells to the area to kill them. The dead germs and white blood cells cause pus to accumulate in the middle ear. This puts pressure on the eardrum, which hurts. A middle ear infection with pus in it is like a small pimple or abscess with no place to drain. Your child will let you know just how painful it is.

Most children with ear infections also have fevers. The fever can come either from the ear infection or from the germ that caused the cold or respiratory infection in the first place. Some children also have conjunctivitis, or “pink eye,” and most have a runny nose.

Viruses cause most middle ear infections. This means that antibiotics don’t help them get better, but that they clear up on their own. Doctors used to treat almost all ear infections with antibiotics “just in case” bacterial germs might grow. Before modern vaccines, dangerous bacteria were more likely to cause middle ear infections. Today, most doctors take care to treat only ear infections that have pus and inflammation present. These are the infections most likely to have a bacterial cause. Ear infections that cause pain but no pus are most often viral, and do not need treatment. Your doctor will explain his or her reasons for choosing whether or not to use an antibiotic for your child.

What is the biggest concern?

The most immediate concern for most parents is their child’s pain and fever. Doctors share those concerns, and also want to determine the cause of the infection if possible. They also want to be sure there is not another serious infection somewhere else in the child’s body. This is especially important in babies less than about three months old, who can have a serious infection with very few symptoms other than fever.

Sometimes the infection breaks through the eardrum, and pus leaks out of the ear. This can frighten and concern parents. It usually does not affect the child’s hearing in the long term, and it actually relieves the pain the minute it happens. Most children who have only a few ear infections have perfectly normal hearing. Children who have repeated episodes of serious ear infections or broken eardrums may have hearing problems later in life. Your doctor will help you decide if your child is prone to these infections, and what to do about them. Your doctor will also do regular hearing tests for your child to be sure s/he hears normally.

Middle Ear Infection treatment

You can use acetaminophen (Tylenol®) or ibuprofen (Advil® or Motrin®) to relieve fever andpain in children over 3 months. Check with your doctor about using them in younger babies. Fever is not dangerous, but it can make the child uncomfortable. If your child seems comfortable there is no reason to give any medication just for fever.

Eardrops containing anesthetics can dramatically ease the pain of ear infections. Your doctor may prescribe Auralgan®, Auroto®, or similar medications containing benzocaine. Please do not put any medication into an ear with drainage coming out of it unless your doctor instructs you to do so.

If your doctor thinks that your child’s ear infection has a bacterial cause, s/he will prescribe anantibiotic to give by mouth. Most doctors start with an antibiotic in the penicillin family, such as amoxicillin (many brand names). They may prescribe a different antibiotic if your child is allergic to any of those drugs, or if s/he has had many ear infections in the past. Please be sure that you understand the dosing directions and also how to store the medicine. Please remember to give all the doses of any antibiotic. Children often seem much better within a few days of starting antibiotics. This does not mean the infection is gone. If you stop too soon, your child can get sick again, and the germs can become resistant to the medicine. This would mean you would need to get an entirely different medicine and start all over.

Many antibiotics can cause mild diarrhea. If your child develops diarrhea, please check with your doctor. Often it is better to finish off the antibiotic than to change medications. You can keep up with your baby’s liquid needs using an oral rehydration solution like Pedialyte® or Infalyte®. Antibiotics can also make children likely to get a diaper rash with yeast. If you see a diaper rash developing, please check with your doctor. Our article on Diaper Rash may be helpful.

Dangerous Middle Ear Infection Symptoms

Most middle ear infections begin to clear up within 2 – 3 days of starting treatment, and are completely gone by 7 – 10 days. The fever is usually better after the first 48 hours. In a small number of cases ear infections can get worse, or can be hiding some other more serious condition. Here are a few things to look out for:

  • Fever that lasts more than 48 hours after starting antibiotics
  • Fever that comes back after being gone for at least 48 hours
  • New pain or pain that lasts more than 2-3 days after starting medicine
  • Extreme sleepiness (lethargy) or irritability (worse than just fussy)
  • Redness or swelling around the ear or the back of the head
  • Difficulty swallowing
  • Worsening cough or trouble breathing
  • Stiff neck, or crying when light shines in the eyes
  • Vomiting without diarrhea
  • Ear drainage (this may be normal, but your doctor should know about it and you should not put drops in the ear until you have spoken with your doctor)

If any of these occur, please be sure to call your doctor’s office right away. If your child or infant is difficult to awaken or seems unconscious, go directly to the emergency room.

Other points of concern

Children who have more than one ear infection in a year probably just have bad luck, but some may have minor problems with their immune systems. Your doctor may want to do some blood tests if your child seems exceptionally prone to infections. In some children, large tonsils and adenoids (lymph glands in the nose and throat) can block the Eustachian tube and cause ear infections. If your child snores or often has nasal congestion, please check with your doctor about your child’s tonsils. Please avoid “bottle propping,” that is, letting the baby fall asleep on his or her back with a bottle propped in the mouth. This can allow liquid to enter the Eustachian tube and cause infections. It is also bad for the baby’s teeth.

If your child continues to have infections, your doctor may recommend removing the tonsils and adenoids, or placing tiny tubes through the eardrum to ventilate the middle ear. Some doctors recommend both procedures. The tubes allow air to flow in and out of the middle ear. This prevents the changes of pressure that cause fluid to accumulate. Many people (including some doctors) think that these tubes work by draining fluid from the ears. This is not true – they should prevent the fluid from developing in the first place. This means that if your child with tubes has fluid or pus draining from the ear, the tube is not working, and your child probably has an ear infection. Please call your doctor if this happens.

Children who have multiple ear infections should have close follow up for hearing and speech development. Hearing is important by itself, and children who don’t hear well as infants can develop speech impairments later in childhood. Your doctor will advise you about the best times to test your infant or child’s hearing.

Other Conditions that Might Be Present with a Middle Ear Infection

Most ear infections happen in children with a respiratory infection like a cold or the flu. Some children may develop more serious infections such as pneumonia. In very severe (and unusual) cases, children can develop dangerous infections like meningitis, a bacterial infection of the brain and spinal cord. Please read over the list of things to look out for, above, to be sure you’ll recognize signs of a serious infection.

Not all children with ear pain have infections. Toddlers often put small objects into their ears. These can cause pain or irritation. If you think there’s something in your child’s ear, please don’t try to remove it yourself. This is very uncomfortable for the child and can cause damage. It is best to call your doctor and arrange a time for your child to see an ear, nose, and throat specialist who can easily remove the object with special equipment. Most objects in the ear canal, if they aren’t causing severe pain, are not emergencies. A trip to the emergency room for removal can be frustrating for everyone, so it’s best to avoid it. The one exception is if the object is a piece of vegetable matter that can swell. These kinds of objects can be harder to remove a few days later.

Swimmer’s ear, or “otitis externa,” can also be a cause of ear pain, especially in active children. You can read our care Instruction on Swimmer’s Ear here. About 10 percent of children who complain of ear pain wind up not having any condition that a doctor can diagnose. This can be frustrating but will pass with time.