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Otitis Media in Children
Introduction
Otitis media means inflammation of the middle ear. The
inflammation occurs as a result of a middle ear infection
and can affect one or both ears.
BERNARD TAWFIK, MD ♦ IDEL MOISA, MD
Diplomates, American Board of Otolaryngology
Specializing in
Adult and Pediatric
Disorders of the
Ears, Nose, Throat and Neck
■ Sinus Infections
Endoscopic Sinus Surgery
Computer Image Guided Surgery
Balloon Sinuplasty
■ Nasal / Sinus Allergies
■ Sleep Apnea
■ Snoring
■ Head & Neck Surgery
Thyroid Gland
Parathyroid Glands
Salivary Glands
Oral Cavity
Larynx
Esophagus
■ Acid Reflux Disease
■ Pediatric ENT
■ Hearing and Balance
■ Voice and Swallowing
FEESST
Trans-Nasal Esophagoscopy
Laryngeal Video Stroboscopy
■ Affiliations
New York University School of Medicine
Glen Cove Hospital
Winthrop University Hospital
ProHealth Ambulatory Surgery Center
DayOp Center of Mineola
Otitis media is more common in younger children and
occurs most often during the winter and early spring
months. This condition represents the most frequent
reason for a child's visit to the doctor's office, accounting
for approximately thirty million visits per year. It
unfortunately also represents the most common cause of
hearing loss in children. If your child has otitis media,
you're probably not alone. One out of two children have at
least one bout by age one, approximately seven out of ten
children have at least one middle ear infection by age
three and a third of all children have three or more
infections before their third birthday.
Is Otitis Media a Serious Condition?
Otitis media can be serious because of the resulting
hearing loss. In turn, such hearing loss may impair a
child's ability to learn and may delay proper speech
development. A child who cannot hear properly cannot
learn properly. Otitis media can also be serious because
infection can spread to nearby structures in the head.
These and other potentially serious complications of otitis
media will be discussed later.
However, otitis media need not be serious if it is treated
promptly, correctly and effectively. In the majority of
children, hearing can be restored to normal without
permanent deficit. It is thus important to recognize the
symptoms of otitis media and to obtain proper medical
attention promptly.
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In this article, the following aspects of otitis media will be discussed:
•
Understanding how the middle ear works
•
What causes otitis media?
•
Symptoms of otitis media
•
Visiting the doctor
•
Medical treatment of otitis media
•
Why treatment is important
•
What are ear tubes?
Understanding How the Middle Ear Works
The middle ear cavity is a pea-sized, air filled
space behind the eardrum. Attached to the
eardrum, which separates the middle ear
cavity from the outer ear, are three tiny ear
bones. Sound waves striking the eardrum
cause it to vibrate, setting these three bones
in motion. They, in turn, help transmit sound
waves to a part of the inner ear called the
cochlea, which generates nerve impulses
that are sent to the brain via the Auditory
nerve. In this manner, sound is perceived.
In order for these structures to vibrate freely
and conduct sound optimally, air pressure
inside a middle ear cavity must be the same
as air pressure outside the ear. This is
accomplished by the Eustachian tube which connects the middle ear to the nose and throat
and allows air to pass between these regions. In this manner, middle ear pressure is equalized
to outside air pressure whenever we swallow or yawn.
What Causes Otitis Media?
The anatomy of the Eustachian tube in children is different than in adults. This difference
represents the root of almost all childhood ear problems. The Eustachian tube in adults is fairly
rigid and slopes downward. This rigidity helps keep the tube open so air constantly moves
through it while the slope helps fluid drain away from the middle ear. In children, the
Eustachian tube lacks rigidity and is more horizontal. These factors make air movement and
drainage more difficult.
Acute otitis media results when bacteria (or viruses) from the nose or throat ascend through
the Eustachian tube to reach the middle ear. Because the Eustachian tube is shorter and
more horizontal in young children than in adults, bacteria from the back of the nose and throat
travel more easily up through the tube into the middle ear. When your child has a cold, the
lining of the Eustachian tube swells, closing off the tube and preventing proper fluid drainage.
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As fluid forms, it remains trapped
in the middle ear cavity, a
condition called serous otitis
media. If this situation persists,
and the fluid can’t drain through
the Eustachian tube, the fluid
forms a perfect breeding ground
for bacteria. At this stage, a
middle ear infection, called acute
otitis media, results.
Predisposing factors for the
development of otitis media
include situations that impair the
already compromised pediatric
Eustachian tube. Inflammation
from
an
upper
respiratory
infection such as a cold, sinus infection, throat infection or allergy are the more common
causes. Children with large adenoids are also likely candidates for ear infections.
Another factor that may increase a child's chances of getting otitis media is lying flat during
bottle feeding. In this position, formula may enter the middle ear and cause irritation. To help
prevent this from happening, it is advisable to keep your baby's head slightly upright during
feeding. Bottle-fed babies may be at greater risk than breast-fed babies, who receive
immunities from their mother's milk. Second-hand cigarette smoke and day care center
attendance are associated with more frequent episodes of otitis media. By reducing a child's
exposure to these risk factors, the likelihood of developing otitis media may be reduced.
The three pictures below demonstrate a normal eardrum, an ear drum with fluid behind it
(serous otitis media), and infection in the middle ear space behind the eardrum (acute otitis
media).
Symptoms of Otitis Media
The most common symptom of acute otitis media is an earache that is associated with a
feeling of ear pressure and blockage. Infants or young children who cannot describe these
sensations may simply tug or rub the affected ear. Fever and irritability often, but not always,
accompany the earache.
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Hearing is usually muffled since the fluid in the middle ear prevents the eardrum from vibrating
normally. With proper treatment, this hearing loss is temporary; once the fluid drains, the
hearing is fully restored. Without proper treatment, however, hearing loss may become chronic
or permanent.
Because the same nerves serving the eardrum and ear canal also serve the nose and throat,
the brain cannot always pinpoint the source of the problem. What seems to be an earache
may be acute otitis media, an infection of the ear canal such as swimmer's ear, dental disease
or a throat infection. Young children may thus feel an earache during teething. Your doctor will
determine whether your child's earache is due to a middle ear problem or whether it is
originating from another source.
Visiting the Doctor
During the examination, the doctor looks inside the ears using an instrument called an
otoscope. Each eardrum is
evaluated for motion, color and fluid. An intact, transparent, vibrating eardrum is normal. The
infected eardrum, on the other hand, does not move well and appears red and bulging due to
fluid in the middle ear cavity.
Special tests are often performed to help the doctor evaluate your child's condition. An
Audiogram or hearing test determines if your child is experiencing hearing impairment, the
type of hearing loss and whether the hearing nerve has been affected. A Tympanogram is a
test that can determine if the eardrum is moving normally, if it has a hole, if fluid is present in
the middle ear and how well the Eustachian tube is functioning. These two tests help the
doctor determine the severity of the problem and decide on an appropriate course of
treatment.
Medical Treatment of Otitis Media
Once the examination and tests are completed, appropriate medications may be prescribed.
An antibiotic, a medication which fights infection, is often prescribed in the initial treatment of
otitis media. Although the antibiotic may help the earache go away rapidly and although a child
may appear well after a day or two, the infection itself may take longer to clear up. In fact, it
may take several weeks before the middle ear fluid resolves completely and the hearing
returns to normal. It is therefore advisable to complete the antibiotic course for the full time it is
prescribed, which is usually 10-14 days.
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Medications to relieve pain and reduce fever are often prescribed. Sometimes analgesic (painrelieving) ear drops may be recommended. An antihistamine (especially if your child suffers
with allergies) or a decongestant may be helpful in the presence of a cold or an allergy.
Always read the label on the prescription bottle and follow the instructions carefully. If your
child is worse or still in pain after taking medications for two or three days, call your doctor as
the prescriptions may need to be changed.
Why Treatment is Important
Otitis media results in an accumulation of pus and mucus in the middle ear. Sometimes the
eardrum ruptures and pus drains out of the ear. More commonly, however, the pus and mucus
remain in the middle ear because a swollen, inflamed Eustachian tube cannot open to allow
natural drainage. This stage is called middle ear fluid, middle ear effusion or serous otitis
media. This process often becomes chronic, lasting for weeks or months after the acute,
painful part of the infection is over. Furthermore, persistent middle ear fluid makes the child
subject to frequent recurrences of the acute infection. In fact, studies have demonstrated that
bacteria may often be present in middle ear fluid that does not appear to be infected during an
examination.
How soon the fluid in the middle ear begins to clear up depends in part on the severity of the
infection. With a first ear infection, about half of all children notice clearing in a number of
weeks. In some children, the symptoms of infection disappear, but healing is incomplete and
the infection reappears. Other children may have repeated middle ear infections with normal
periods in between. At times the fluid may take several weeks or even months to resolve. This
latter condition should be monitored closely since fluid that persists for longer that two months
may thicken, become a breeding ground for bacteria and may need to be drained.
Although otitis media can lead to complications, some of which may be serious, problems are
rare with prompt medical attention.
Even if the eardrum develops holes or perforations, it usually heals once the infection is
treated. When the eardrum does not heal, an operation may be required to close the holes.
Thickening of the eardrum and the tissue around the little bones of the middle ear can occur if
ear disease persists. This process, called tympanosclerosis, can lead to permanent hearing
loss if it is severe enough to affect sound transmission.
Part or all of the eardrum may be pulled inward into the middle ear cavity, forming a pocket. If
skin or debris collects in the middle ear cavity, this pocket or cholesteatoma can cause erosion
of the tiny middle ear bones. This condition frequently requires surgery.
In extreme cases, severe and unchecked infection may damage the bony cavity behind the
ear. If infection spreads to the inner ear, dizziness and permanent hearing loss may result.
Rarely, infection spreads from the middle ear cavity toward the brain.
With modern methods of diagnosis and treatment, there is very little risk that ear infections or
fluid in the ears will lead to serious complications or permanent damage. However, if an ear
infection is neglected, there is a greater possibility that it will lead to hearing loss or other
serious problems.
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What are Ear Tubes?
In situations where otitis media does not readily clear up
with proper medications, a minor procedure routinely
performed by Ear, Nose and Throat Surgeons may be
advisable. This involves placement of a tiny tube through
a small opening in the eardrum, thereby promoting fluid
drainage and helping to equalize air pressure. This
ventilatory or pressure equalization tube takes over the
work of the child's poorly functioning Eustachian tube.
As a result, hearing is rapidly restored, pain is
relieved, subsequent fluid accumulation in the
middle ear is decreased and the rate of active middle
ear infections is dramatically reduced. The procedure
can be performed in an outpatient center, with the child
going home an hour or two after the operation.
The ventilation tubes usually remains in place for several months and fall out by themselves.
While they are in place, you must keep water out of your child's ears in order to prevent further
infections. The status of the tubes should be checked by your doctor at regular intervals.
Otherwise, ventilatory tubes rarely cause problems. Like most parents, you will probably notice
a remarkable improvement in your child's hearing and a welcome decrease in the frequency of
ear infections following ventilatory tube placement. The child tends to feel better, is less
irritable and may sleep more soundly.
Most parents of young children also notice rapid improvement in their child's speech.
Otitis media may recur from time to time as a result of chronically infected adenoids and
tonsils. If this is found to be a recurring problem for your child, the doctor may recommend
removing the adenoids, tonsils, or both at the same time the ventilatory tubes are inserted.
In some children, allergies may impair Eustachian tube function and lead to otitis media. If this
is suspected in your child, an allergy evaluation should be considered.
Summary
Otitis media is a common childhood illness. All babies and younger children are of developing
this condition because of their underdeveloped Eustachian tubes.
Upper respiratory infections, enlarged adenoids, allergies, exposure to cigarette smoke and
attendance in day care centers are common predisposing factors for the development of otitis
media.
If your child complains of an earache or tugs at the ear, see your doctor promptly.
Otitis media may initially be treated with an antibiotic. Be sure to follow the treatment plan and
see your physician until the condition is fully cured.
Fluid in the ears affects hearing and must be watched closely. If it persists, the fluid can be
drained and tubes can be placed in the ears to keep the middle ear clear.
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Otitis media is generally not serious if properly and promptly treated. Complications and
permanent deafness resulting from ear infections are now fortunately rare. Neglecting ear
problems, however, can lead to permanent damage including hearing loss.
With the help of your physician, you can help your child to feel and hear better.
This newsletter is provided in the interest of general medical education and is not intended as specific medical advice. For specific
advice, please consult your physician.
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