Ear infections are one of the most common childhood illnesses and are responsible for more sick-child visits to pediatricians than any other illness. Most children have had at least one ear infection by the time they are three years old. While the majority of ear infections resolve without any lasting effects, improper treatment or frequent recurrences with or without treatment may result in other more serious long-term problems.
How Ear Infections Develop
In order to understand the workings of an ear infection, it is important to first understand the anatomy of the ear.
Ear anatomy The ear can be divided into three main parts: the outer ear, the middle ear, and the inner ear. The outer ear includes the part outside of the head and the ear canal, up to the eardrum.
The eardrum is a small circle of tissue that separates the outer ear from the middle ear. The middle ear is normally filled with air. In the middle ear, there is a small tube, called the Eustachian tube, which connects the middle ear to the back of the throat and nose. Also in the middle ear are three small bones, the malleus, incus, and stapes, which connect the eardrum to the inner ear.
The inner ear is farther inside the head and assists in hearing and balance. In the healthy ear, sound waves travel through the ear canal and make the eardrum and the three bones in the middle ear move. This movement sends sound waves across the middle ear to the inner ear. The inner ear sends the sound messages to the brain.
When a child has a cold, throat infection, or allergy, the Eustachian tube may be blocked, causing fluid to build up in the middle ear. If this fluid becomes infected by bacteria or a virus, it can cause pain in the ear and swelling of the eardrum. This infection of the fluid in the middle ear is called acute otitis media.
Risk Factors for Ear Infection
There are several factors that may place a child at risk for developing an ear infection.
Age Infants and toddlers are more likely to get ear infections for a number of reasons. First, their immune systems are still developing, leaving them more susceptible to infections. As well, children s Eustachian tubes are shorter and more horizontal. Because of this positioning, it is easier for bacteria and viruses in the throat to track backwards into the middle ear and cause an infection. Finally, children s Eustachian tubes are less rigid than those of adults because they are supported by flexible cartilage instead of bone. This makes them more likely to collapse and cause fluid buildup in the middle ear, which is a predisposition for infection. Most children will outgrow ear infection tendencies by age four, as the position of their Eustachian tubes changes. The younger the child is at the time of the first ear infection, the more likely he is to have repeated ear infections.
Exposure to frequent colds in day care Children exposed to viruses in a group child-care setting may develop frequent colds that may lead to ear infections. Because children have not yet built up immunity to these cold viruses, the congestion that results can block the Eustachian tube and lead to fluid buildup in the middle ear.
Exposure to secondhand cigarette smoke Children who breathe in secondhand smoke have a higher chance of developing ear infections. Studies show that children exposed to smoke have more viral illnesses, which can lead to more ear infections.
Bottle-feeding and pacifiers Sucking on pacifiers or bottles may cause blockage of the Eustachian tube. Therefore, children who use pacifiers or who are bottle fed, especially while lying down, are more prone to ear infections than children who are breast-fed.
Allergies Children who have stuffy noses from allergies may develop a blockage of the Eustachian tube and are at increased risk of developing ear infections.
Family history Children who have a family history of frequent ear infections (parents or siblings) are more likely to develop them.
Symptoms of an Ear Infection
Knowing the following symptoms of an ear infection will help you to seek medical care if necessary.
Pain/Irritability The most common symptom of an ear infection is ear pain. While an older child is able to tell you that his ear hurts, a younger child may only act irritable and cry. There may be more pain during feedings or sleeping because lying down, sucking, and swallowing can cause pressure and discomfort. Your child may seem to have less of an appetite, and he may tug at his ear. However, there are other reasons besides an ear infection for ear pain. The pain may be caused by a sore throat, teething or sore gums, blocked Eustachian tubes from colds or allergies, or an infection of the skin of the external ear canal called swimmer s ear or otitis externa. Also, pulling on the ears may only be a habit, and does not always mean one of these problems in a child who is otherwise behaving well.
Fever Many, but not all, ear infections are associated with a temperature that may range from 100.5 to 104 degrees.
Ear drainage You may notice yellow or white fluid, possibly blood-tinged, draining from your child s ear. The fluid should look different from earwax (which looks orange-yellow or reddish-brown) and may have a foul odor. This fluid comes from the middle ear and is caused by a perforation of the eardrum.
Difficulty hearing Because the fluid behind the eardrum gets in the way of sound transmission, your child may have some trouble hearing during and after an ear infection. This is a temporary condition but may last a few weeks until the fluid in the middle ear drains away. There are several behavioral changes that you can look for to know if your child has difficulty hearing without other signs of an ear infection. It is important to look for these changes during or after a cold:
Your child may talk softly or in a muffled way.
Your child may say what? or huh? more than usual.
Your child may not respond to sounds.
Your child may have more trouble understanding language in noisy rooms.
Your child may listen to the TV or radio at a louder volume than usual.
Ear Infection Treatment
If your child has ear pain, fever, or other symptoms of an ear infection, it is important to see your pediatrician.
Treatment Your doctor will examine the inside of your child s ears to see if there is an infection. Frequently, if there is only fluid in the ear and mild redness, an antibiotic is not necessary. However, if there are symptoms from the inflammation, such as pain and fever, or bulging and distortion of the eardrum, your doctor will prescribe an antibiotic for your child. For an uncomplicated ear infection, the most common antibiotic used is amoxicillin. It treats the most common bacterial cause of ear infections Streptococcus pneumonia. For children allergic to penicillin, I use Azithromycin. As the infection clears, your child may feel a popping in his ears. This is a normal sign of healing. Your child s pain and fever should disappear within 48 to 72 hours after beginning a course of antibiotics. As soon as your child is feeling better, he may return to school or day care provided he continues his medication.
Treatment dos and don ts Until the pain and fever are gone, your child should not fly on an airplane or swim under water. It is imperative to follow your doctor s advice and finish the entire course of antibiotics. Stopping the antibiotics early may allow some bacteria to regrow and cause recurrent infections that may be resistant to the original antibiotic.
If your child does not respond to treatment If your child has not improved in three days, you should call your pediatrician because some bacteria that cause ear infections (Streptococcus pneumonia, Haemophilus influenzae, Moraxella catarrhalis) can be resistant to amoxicillin. For these children, I either prescribe a higher dose of amoxicillin, a different antibiotic (e.g. Augmentin or Ceftin), or an injectible antibiotic (e.g. Ceftriaxone). It is important to understand that this does not mean that your child is immune to amoxicillin, but rather that this particular infection does not respond to it. Amoxicillin is still the first choice antibiotic for subsequent ear infections. There is no effective treatment for the viruses that cause ear infections. Your child s immune system will eliminate these infections itself. Because it is difficult to distinguish a viral ear infection from a bacterial one, all serious ear infections are treated with antibiotics. Unfortunately, this does not mean that all will respond.
Pain relief You can give your child nonaspirin acetaminophen (Tylenol) or ibuprofen (Advil, Motrin, or PediaCare fever) to help with the pain and fever. You may want to try warm compresses around the ear, unless your child is a young baby. Children less than one year may overheat with the compresses. For an older child, chewing gum may be helpful to alleviate the pressure in the middle ear. Also, keeping your child s head elevated by keeping him sitting or placing a pillow under his head may help the pain. I usually recommend a prescription anesthetic ear drop, called Auralgan. It numbs the ear canal and may help alleviate the pain for some children. Saline nose drops, a bulb syringe, and a humidifier may help with nasal congestion. Over-the-counter cold medicines (decongestants and antihistamines) should be avoided, as they do not help ear infections. As always, aspirin should never be given to children for pain or fever as it has been associated with Reye syndrome, a disease that affects the liver and brain.
Check up Once the ear infection is better, it is important for young children to have a follow-up ear check. For infants, I schedule follow-ups at two and six weeks to look for fluid in the middle ear. Some physicians may schedule follow-ups at four weeks or even six weeks. For older children, I schedule follow-ups at six weeks. The fluid after an ear infection may remain in the middle ear normally for up to three months, but eventually it should resolve. Persistent fluid may affect hearing and speech development.
Complications From Untreated Ear Infections
Although they are rare, complications from untreated ear infections may develop.
Mastoiditis is an infection of the skull behind the ear which must be treated with intravenous antibiotics.
Perforation of the eardrum is caused by pressure in the middle ear. Your child may have a yellowish ear drainage. The eardrum will heal spontaneously leaving only a residual scar, which may be detected on follow-up exams. If you think your child has a perforation, consult with your doctor before using any ear drops.
Hearing loss can be subtle in young children. Long periods of hearing loss from ear infections may cause delays in speech and language development. This is especially critical in the first years of life when your child is learning to talk. If you think your child may have a hearing loss, ask your doctor about a formal hearing test.
Labrynthitis is an infection of the inner ear that causes vertigo, a sensation of dizziness and imbalance.
Facial paralysis can be related to an ear infection. The infection may affect the nerves that pass through the middle ear and cause weakness of the facial muscles, also called Bell s palsy. Usually, this will resolve with time.
Preventing Ear Infections
Limiting the risk factors is one way to prevent ear infections. I suggest that you:
minimize exposure to secondhand smoke.
consider breast-feeding instead of using formula if ear infections are common in your family.
avoid contact with children who are sick with viruses (daycare).
eliminate pacifier use.
Certain immunizations can help prevent ear infections. They are:
Influenza vaccine: This vaccine is available for children older than six months in the fall and winter months. Because the flu virus changes yearly, it is recommended that a child with frequent or chronic ear infections receive a dose every year.
Pneumococcal vaccine: At present, this vaccine is only available to children older than two years of age. However, there is a new conjugate vaccine called Prevnar that is licensed for children starting at age two months. It should be in your doctor s office soon. The new vaccine will require multiple doses depending on the age of the child.
Repeated Ear Infections
It is quite common for children to have several ear infections when they are young. However, if your child has three or more episodes in six months or four or more in one year, you should talk to your pediatrician about preventive treatment and surgically inserted tubes.
Some doctors use an antibiotic at a low dosage once a day for a period of several months to prevent ear infections from developing. However, there is concern that this therapy may promote the spread of more dangerous antibiotic-resistant bacteria. Most recent studies indicate only minimal benefit with this type of therapy and that nine months of therapy would be needed to prevent one ear infection.
Surgically Inserted Tubes
The method of last resort for the prevention of repeated ear infections is a minor operation in which tubes are inserted through the eardrums. The tube is inserted using anesthesia in an otolaryngologist s office or a hospital. Otolaryngologists (ENTs) are doctors who specialize in surgery on the ear, nose, and throat. This procedure is becoming more common in the era of increasing antibiotic resistance. The tube acts as a ventilator, allowing air to get into the middle ear and preventing the buildup of any fluid. This reduces the risk of bacteria getting trapped in the middle ear and causing another ear infection. In the past, children s tonsils were removed at the same time, as it was thought to be beneficial for the prevention of ear infections. However, studies show that a tonsillectomy does not affect ear infections and is not necessary for this purpose. If you think your child may need tubes, ask your doctor for more information.
Although repeated ear infections are extremely frustrating for you and your child, they are usually only a temporary problem. With proper care, you and your doctor can manage these infections when your child is young. Most commonly they will stop altogether as your child gets older.