Otitis media is an infection or inflammation of the middle ear. This inflammation often begins when infections that cause sore throats, colds, or other respiratory or breathing problems spread to the middle ear. These can be viral or bacterial infections. Seventy-five percent of children experience at least one episode of otitis media by their third birthday. Almost half of these children will have three or more ear infections during their first 3 years. It is estimated that medical costs and lost wages because of otitis media amount to $5 billion a year in the United States. Although otitis media is primarily a disease of infants and young children, it can also affect adults.
The ear consists of three major parts: the outer ear, the middle ear, and the inner ear. The outer ear includes the pinna - the visible part of the ear - and the ear canal. The outer ear extends to the tympanic membrane or eardrum, which separates the outer ear from the middle ear. The middle ear is an air-filled space that is located behind the eardrum. The middle ear contains three tiny bones, the malleus, incus, and stapes, which transmit sound from the eardrum to the inner ear. The inner ear contains the hearing and balance organs. The cochlea contains the hearing organ which converts sound into electrical signals which are associated with the origin of impulses carried by nerves to the brain where their meanings are appreciated.
There are many reasons why children are more likely to suffer from otitis media than adults. First, children have more trouble fighting infections. This is because their immune systems are still developing. Another reason has to do with the child's eustachian tube. The eustachian tube is a small passageway that connects the upper part of the throat to the middle ear. It is shorter and straighter in the child than in the adult. It can contribute to otitis media in several ways.
The eustachian tube is usually closed but opens regularly to ventilate or replenish the air in the middle ear. This tube also equalizes middle ear air pressure in response to air pressure changes in the environment. However, a eustachian tube that is blocked by swelling of its lining or plugged with mucus from a cold or for some other reason cannot open to ventilate the middle ear. The lack of ventilation may allow fluid from the tissue that lines the middle ear to accumulate. If the eustachian tube remains plugged, the fluid cannot drain and begins to collect in the normally air-filled middle ear.
One more factor that makes children more susceptible to otitis media is that adenoids in children are larger than they are in adults. Adenoids are composed largely of cells (lymphocytes) that help fight infections. They are positioned in the back of the upper part of the throat near the eustachian tubes. Enlarged adenoids can, because of their size, interfere with the eustachian tube opening. In addition, adenoids may themselves become infected, and the infection may spread into the eustachian tubes.
Bacteria reach the middle ear through the lining or the passageway of the eustachian tube and can then produce infection, which causes swelling of the lining of the middle ear, blocking of the eustachian tube, and migration of white cells from the bloodstream to help fight the infection. In this process the white cells accumulate, often killing bacteria and dying themselves, leading to the formation of pus, a thick yellowish-white fluid in the middle ear. As the fluid increases, the child may have trouble hearing because the eardrum and middle ear bones are unable to move as freely as they should. As the infection worsens, many children also experience severe ear pain. Too much fluid in the ear can put pressure on the eardrum and eventually tear it.
There are several types of otitis media:
- Otitis media without effusion is an inflammation of the eardrum without fluid in the middle ear.
- Acute otitis media occurs when there is fluid in the middle ear accompanied by the rapid onset of signs and symptoms of middle ear infection.
- Otitis media with effusion is the presence of fluid in the middle ear without signs or symptoms of ear infection. It is also sometimes called serous otitis media.
- Chronic otitis media occurs when infection persists. This can cause ongoing damage to the middle ear and eardrum.
Several avenues of research are being explored to further improve the prevention, diagnosis, and treatment of otitis media. For example, research is better defining those children who are at high risk for developing otitis media and conditions that predispose certain individuals to middle ear infections. Emphasis is being placed on discovering the reasons why some children have more ear infections than other children. The effects of otitis media on children's speech and language development are important areas of study, as is research to develop more accurate methods to help physicians detect middle ear infections. How the defense molecules and cells involved with immunity respond to bacteria and viruses that often lead to otitis media is also under investigation. Scientists are evaluating the success of certain drugs currently being used for the treatment of otitis media and are examining new drugs that may be more effective, easier to administer, and better at preventing new infections. Most important, research is leading to the availability of vaccines that will prevent otitis media.
Serous otitis media may not cause any symptoms, however, fluid remaining in the middle ear for a long period of time may result in hearing loss. Although this condition can develop on its own, it most commonly occurs after being treated for acute otitis media.
Acute otitis media causes sudden, severe earache, deafness, and tinnitus (ringing or buzzing in the ear), sense of fullness in the ear, irritability, tugging or rubbing the ear, an unwillingness to lie down, fever, headache, a change in appetite or sleeping patterns, fluid leaking from the ear, nausea and difficulty in speaking and hearing. Occasionally, the eardrum can burst, which causes a discharge of pus and relief of pain.
Complications of a single episode of otitis media are rare and include otitis externa (inflammation of the outer ear), and spread inward from the ear to the skull, causing, mastoiditis (inflammation of the mastoid bone cells), or into the brain, causing meningitis (inflammation of the membranes covering the brain and spinal cord) or a brain abscess.
Complications recurrent in otitis media include damage to the bones in the middle ear (sometimes causing total deafness) or a cholesteatoma (a matted ball of skin debris which can erode bone and cause further damage to the ear).
Causes and Risk factors:
Children are more commonly affected than adults because of the small size and horizontal position of their eustachian tube (the passage that connects the back of the nose to the middle ear). Otitis media affects about 2/3 of youngsters at least once before they reach their second birthday.
The four main causes of otitis media are allergy, infection, blockage of the eustachian tube and nutritional deficiency.
Allergy: Studies have shown that food and airborne allergies can cause otitis media. The most common offending foods are milk products (from cows), wheat, egg white, peanut products, soy, corn, oranges, tomatoes and chicken. The most common airborne allergens are cigarette smoke, pollen, animal dander, house dust, mold, fungi, sulfur dioxide, bacteria and volatile organic compounds such as formaldehyde, pesticides and herbicides.
Infection: Otitis media infections are caused by viruses or bacteria that infect the cells lining the eustachian tube, throat and middle ear. When infected, these cells become swollen and secrete a thick mucus that may clog the eustachian tube and cause fluid and pressure to build behind the eardrum. Some of the most common bacteria to cause this infection are Streptococcus pneumoniae, Haemophilus influenzae and moraxella catarrhalis.
Blockage of the eustachian tube: This obstruction can be a result of swollen tonsils or adenoids or problems involving the bones of the cranium, the temporomandibular joint (located at the jaw) or the cervical spine.
Nutritional deficiency: Researchers have found that children with vitamin A, zinc and iron deficiencies are more susceptible to upper respiratory and ear infections. Additionally, large amounts of prostaglandins (fatty acids found naturally in all people) and leukotrienes may also play a part.
Additionally, in infants, otitis media has been associated with bottle feeding. Breast feeding provides two protective mechanisms. One is the suction created by sucking on the breast helps close the ear canal and prevents reflux of particles and bacteria into the middle ear. Second is the general protection from infections provided by the mother's antibodies crossing over to the baby in the mother's milk.
Possible Complications: Cyst of the middle ear cyst (cholesteatoma) Facial paralysis Infection of one of the skull bones (mastoiditis) Inflammation around the brain (epidural abscess) Permanent damage to the ear with partial or complete deafness Most children will have temporary and minor hearing loss during and right after an ear infection, because fluid can linger in the ear. Although this fluid can go unnoticed, it can cause significant hearing problems in children. Any fluid in the ear that lasts longer than 8-12 weeks is cause for concern. In children, hearing problems may cause speech to develop slowly.
Permanent hearing loss is rare, but the risk increases with the number and length of infections.
The doctor should be sure to ask the parent if the child has had a recent cold, flu, or other respiratory infection. If the child complains of pain or has other symptoms of otitis media, such as redness and inflammation, the doctor should rule out any other causes. These may include, but are not limited to, the following:
Physical Examination: Instruments Used for Examining the Ear. An ear examination should be part of any routine physical examination in children, particularly because the problem is so common and may not cause symptoms.
The doctor first removes any ear wax (called cerumen) in order to get a clear view of the middle ear. The doctor uses a small flashlight-like instrument called an otoscope to view the ear directly. This is the most important diagnostic step. The otoscope can reveal signs of acute otitis media, bulging eardrum, and blisters. An otoscope is a tool that shines a beam of light to help visualize and examine the condition of the ear canal and eardrum. Examining the ear can reveal the cause of symptoms such as an earache, the ear feeling full, or hearing loss.
To determine an ear infection, the doctor should always use a pneumatic otoscope. This device detects any reduction in eardrum motion. It has a rubber bulb attachment that the doctor presses to push air into the ear. Pressing the bulb and observing the action of the air against the eardrum allows the doctor to gauge the eardrum's movement. Some doctors may use tympanometry to evaluate the ear. In this case, a small probe is held to the entrance of the ear canal and forms an airtight seal. While the air pressure is varied, a sound with a fixed tone is directed at the eardrum and its energy is measured. This device can detect fluid in the middle air and also obstruction in the Eustachian tube. A procedure similar to tympanometry, called reflectometry, also measures reflected sound. It can be used to detect fluid and obstruction, but does not require an airtight seal at the canal. Neither tympanometry nor reflectometry are substitutes for the pneumatic otoscope, which allows a direct view of the middle ear.
Findings Indicating AOM or OME. A diagnosis of AOM requires all three of the following criteria:
History of recent sudden symptoms: Symptoms may include fever, pulling on the ear, pain, irritability, or discharge (otorrhea) from the ear. Presence of fluid in the middle ear. This may be indicated by fullness or bulging of the eardrum or limited mobility. Signs and symptoms of inflammation. These may include redness of the eardrum as well as assessment of the child's discomfort. Ear pain that is severe enough to interfere with sleep may indicate inflammation. AOM (fluid and infection) is often difficult to differentiate from OME (fluid without infection). It is important for a doctor to make this distinction as OME does not require antibiotic treatment. In patients with OME, an air bubble may be visible and the eardrum is often cloudy and very immobile. A scarred, thick, or opaque eardrum may make it difficult for the doctor to distinguish between acute otitis media and OME.
Severity of AOM: Acute otitis media is characterized as severe or non-severe.
Non-severe AOM: Mild-to-moderate pain, temperature less than 102.2° F (39° C). Severe AOM: Moderate-to-severe pain, temperature of 102.2° F (39° C) or higher.
Home Diagnosis: Parents can also use a sonar-like device, such as the EarCheck Monitor, to determine if there is fluid in their child's middle ear. EarCheck employs acoustic reflectometry technology which bounces sound waves off the eardrum to assess mobility. When fluid is present behind the middle ear (a symptom of AOM and OME), the eardrum will not be as mobile. The device works like an ear thermometer and is painless. Results indicate the likelihood of the presence of fluid and may help patients decide whether they need to contact their child's doctor.
Tympanocentesis: On rare occasions the doctor may need to draw fluid from the ear using a needle for identifying specific bacteria, a procedure called tympanocentesis. This procedure can also relieve severe ear pain. This is most often performed by an ear, nose, and throat (ENT) specialist, and usually only in severe or recurrent cases. In most cases, tympanocentesis is not necessary in order to obtain an accurate enough diagnosis for effective treatment.
Determining Hearing Problems: Hearing tests performed by an audiologist are usually recommended for children with persistent otitis media with effusion. A hearing loss below 20 decibels usually indicates problems.
Determining Impaired Hearing in Infants and Small Children. Unfortunately, it is very difficult to test children under 2 years old for hearing problems. One way to determine hearing problems in infants is to gauge the baby's language development:
At 4 - 6 weeks most babies with normal hearing are making cooing sounds. By around 5 months the child should be laughing out loud and making one-syllable sounds with both a vowel and consonant. Between 6 - 8 months, the infants should be able to make word-like sounds with more than one syllable. Usually starting around 7 months the baby babbles (makes many word-like noises) and should be doing this by 10 months. Around 10 months, the baby is able to identify and use some term for the parent. The baby speaks his or her first word usually by the end of the first year. If a child's progress is significantly delayed beyond these times, a parent should suspect possible hearing problems.
Determining Impaired Hearing in Older Children. Hearing loss in older children may be detected by the following behaviors:
They may not respond to speech spoken beyond 3 feet away. They may have difficulty following directions. Their vocabulary may be limited. They may have social and behavioral problems.
- Otitis media with effusion. OME is commonly confused with acute otitis media. It must be ruled out because it does not respond to antibiotics.
- Dental problems (such as teething).
- Infection in the outer ear. Symptoms include pain, redness, itching, and discharge. Infection in the outer ear, however, can be confirmed by wiggling the ears, which will produce pain. (This movement will have no significant effect if the infection is in the middle ear.)
- Foreign objects in the ear. This can be dangerous. A doctor should always check for this first when a small child indicates pain or problems in the ear.
- Viral infection can produce redness and inflammation. Such infections, however, are not treatable with antibiotics and resolve on their own.
- A parent's or child's attempts to remove earwax.
- Intense crying can cause redness and inflammation in the ear.
Treatments for ear infections cost the U.S. between 3 - 4 billion dollars each year, and many of these treatments, particularly heavy antibiotic use and surgical procedures, are often unnecessary in many children.
Experts continue to argue about the best approach for treating ear infections. The major debates rest on the use of antibiotics, surgery, and watchful waiting in both acute otitis media (AOM) and otitis media with effusion (OME).
Treatment Guidelines for Acute Otis Media (AOM): In 2004, the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) released updated guidelines for the management and diagnosis of acute otitis media.
These guidelines include the following recommendations: Accurate diagnosis of AOM including differentiation from OME. Children less than 6 months of age should receive immediate antibiotic treatment. Children 6 months or older should be treated for pain within the first 24 hours with either acetaminophen or ibuprofen. An initial observation period of 48 - 72 hours is recommended for select children to determine if the infection will resolve on its own without antibiotic treatment. (Most children do improve within 72 hours.) For children aged 6 months - 2 years, criteria for recommending an observation period are an uncertain diagnosis of AOM and a determination that the AOM is not severe. For children older than 2 years, the observation period criteria are non-severe symptoms or uncertain diagnosis. Severe AOM symptoms include moderate to severe pain and a fever of at least 102.2° Fahrenheit (39° Celsius). (A 2006 Lancet study suggested that antibiotics are only useful in this age group when both ears are affected.) If antibiotics are needed, amoxicillin is recommended as first-line treatment (except in children who are allergic to penicillins).
Treatment Guidelines for Otitis Media with Effusion (OME): The American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) released updated clinical practice guidelines for OME in 2004. These guidelines include the following treatment recommendations:
Watchful Waiting for OME: The child is typically monitored for the first 3 months. Antibiotics are not helpful for most patients with OME. For one, the condition resolves without treatment in nearly all children, especially those whose OME followed an acute ear infection. Approximately 75 - 90% of OME cases that result from AOM resolve within 3 months. If OME last longer than 3 months, a hearing test should be conducted. Even if OME lasts for longer than 3 months, the condition may resolve on its own and intervention may not be necessary. The doctor will re-evaluate the child at periodic intervals to determine if there is risk for hearing loss.
Drug Treatment: Antibiotics and corticosteroids do not help and are not recommended for routine management of OME. These drugs are not effective for OME, either when used alone or in combination. In fact, a 2006 study suggested that antihistamines and decongestants may cause more harm than good by provoking side effects such as stomach upset and drowsiness. At present, there is no compelling evidence to indicate that allergy treatment can assist with OME management nor has a causal relationship between allergies and OME been established.
Surgery: Children may be considered candidates for surgery if they have if they have OME lasting longer than 4 months that is accompanied by hearing loss. OME that is persistent or recurrent (even if there is no hearing loss) and may put the child at risk for developmental delays or structural damage to the ear. OME and structural damage to the eardrum or middle ear. The decision to pursue surgery must be determined on an individual basis.
Tympanostomy tube insertion is the first choice for surgical intervention. Approximately 20 - 50% of children who undergo this procedure may have OME relapse and require additional surgery. Adenoidectomy plus myringotomy, with or without tube insertion, is recommended as a repeat surgical procedure. Tube insertion may be advised for children younger than 4 years of age. Adenoidectomy is not recommended as an initial procedure unless some other condition (chronic sinusitis, nasal obstruction, adenoiditis) is present. Neither myringotomy alone or tonsillectomy is recommended for OME treatment.
Medicine and medications:
Until recently, nearly every American child with an ear infection who visited a doctor received antibiotics. In one region of the U.S., more than 70% of children received antibiotics before they were 7 months old, and the most common reason for these medications was acute otitis media.
Major studies now indicate that antibiotics are unnecessary in most cases of acute otitis media. Between 80 - 90% of all children with uncomplicated ear infections recover within a week without antibiotics. Antibiotics are rarely recommended for otitis media with effusion.
Antibiotic Resistance. The intense and widespread use of antibiotics is leading to a serious global problem of bacterial resistance to common antibiotics. In the U.S., nearly a quarter of S. pneumoniae are currently resistant to at least three antibiotics. High rates of resistance strains are even being observed in infants. In general, regions and institutions with the highest rate of resistance are those in which antibiotics are the most heavily prescribed.
Because of the high rate of antibiotic resistance, and the fact that non-severe AOM usually resolves without antibiotics, many pediatric guidelines recommend a “watchful waiting” period before antibiotics are prescribed. (See "Watchful Waiting" in the Treatment section of this report.) Current guidelines released by the American Academy of Pediatrics and the American Academy of Family Physicians recommend an initial observation period of 48 - 72 hours for select children. Pain relief can initially be given with acetaminophen (Tylenol), ibuprofen (Advil), or topical benzocaine drops.
If there is no improvement or symptoms worsen, parents can schedule an appointment with the child's doctor to determine if antibiotics are needed. (Parents should contact the doctor within the first 24 hours if their child is 6 months or younger and has fever or other severe symptoms.) Another option is to ask the doctor for a Safety Net Antibiotic Prescription (SNAP) that can be filled if symptoms do not improve within 48 - 72 hours.
Antibiotic Regimens for Acute Otitis Media (AOM): When antibiotics are needed, a number of different classes are available for treating acute ear infections. Amoxicillin is a penicillin antibiotic and the drug of first choice. Other antibiotics are available for children who are allergic to penicillin or who do not respond within 2 - 3 days.
Duration. If a child needs antibiotics for acute otitis media, experts recommend they be taken for the following periods of time:
A 10-day course of antibiotics is usually recommended for children younger than 6 years of age, and for those with severe AOM. Antibiotic therapy for 5 - 7 days is recommended for children 6 years of age or older with mild-to-moderate symptoms. Parents should be sure their child finishes the entire course of therapy. Failure to finish is a major factor in the growth of bacterial strains that are resistant to antibiotics.
What to Expect. Earaches usually resolve within 8 - 24 hours after taking an antibiotic, although about 10% of children who are treated do not respond. This may occur when a virus is present or if the bacteria causing the ear infection is resistant to the prescribed antibiotic. A different antibiotic may be needed.
In some children whose treatment is successful, fluid will still remain in the middle ear for weeks or months, even after the infection has resolved. During that period, children may have some hearing problems, but eventually the fluid almost always drains away. Antibiotics should not be used to treat residual fluid.
Specific Antibiotics Used for Acute Otitis Media (AOM): The selection of an antibiotic is determined in part by the severity of the child's condition as well as a history of response/non-response to antibiotic therapy. Treatment decisions take into account whether the child's condition is severe or non-severe.
Amoxicillin is generally recommended for first-line treatment of AOM. The combination drug amoxicillin-clavunate is prescribed for patients who have severe pain or a fever higher than 102.2° (39° Celsius). Other drug classes may be prescribed if a child is allergic to penicillins or does not respond to the initial therapy.
The following treatment guidelines provide general recommendations based on the severity of a child's AOM.
First-line treatment for non-severe AOM:
Amoxicillin 80-90 mg/kg per day orally. Amoxicillin is a penicillin antibiotic. If the patient has an allergy or a history of non-response to penicillin drugs, one of the following antibiotics may be prescribed:
Azithromycin or clarithromycin. These drugs are in the macrolide class and are administered orally. Cefdinir, cefuroxime, or cefpodoxime. These drugs are classified as cephalosporins and are taken by mouth. They may cause reactions in penicillin-allergic patients. If the patient does not respond to amoxicillin or alternative antibiotic drugs after 48 - 72 hours, one of the following drugs may be prescribed:
Amoxicillin-clavulanate, clindamycin, or ceftriaxone. Ceftriaxone is injected intramuscularly. The other two drugs are administered orally. Each of these drugs is a different type of antibiotic. Amoxicillin-clavulanate (Augmentin) is classified as a penicillin; ceftriaxone (Rocephin) is a cephalosporin; clindamycin (Cleocin) is a lincosamide. First-line treatment for severe AOM:
Amoxicillin-clavulanate (Augmentin). This antibiotic is known as an augmented penicillin. It works against a wide spectrum of bacteria and is administered orally. Second-line treatment for severe AOM:
Ceftriaxone. Ceftriaxone (Rocephin) is an injectable cephalosporin that may be prescribed as an alternative to amoxicillin-clavulanate, especially for children who have vomiting or other conditions that hamper oral administration. Tympanocentesis or clindamycin. Patients with severe AOM who have failed to respond to amoxicillin-clavulanate after 48 - 72 hours may require the withdrawal of fluid from the ear (tympanocentesis) in order to identify the bacterial strain causing the infection. If tympanocentesis cannot be performed, clindamycin may be prescribed orally to treat penicillin-resistant pathogens that have not responded to prior drug therapy.
Side Effects of Antibiotics: The most common side effects of nearly all antibiotics are gastrointestinal problems, including cramps, nausea, vomiting, and diarrhea. This can be a significant problem in infants and small children. One study reported that giving such children a soy-based formula that contained fiber (Isomil DF) was helpful in reducing these side effects. Amoxicillin use during infancy may lead to enamel defects and discolorations of permanent teeth Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening anaphylactic shock. Some drugs, including certain over-the-counter medications, interact with antibiotics. Parents should tell the doctor about all medications their children are taking.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.