MIDDLE EAR INFECTIONS or OTITIS MEDIA in children

Definition of middle ear infections

Otitis media is an inflammation of the middle part of the ear (ear is divided into outer, middle and inner ear). The middle ear is the region in which are located the small bones (incus, malleus, stapes) that transmit the sounds that hit the eardrum to the inner ear, allowing us to hear. While otitis media can happen in all age groups, it mainly affects children. It is called acute otitis media when a purulent fluid is present in the ear, as well as pain, redness of the eardrum and possibly fever. Its duration is generally from 7 to 14 days. It is called recurrent acute otitis media when the ear infection keeps coming back 3 or more times within a 6-month period. Chronic otitis media with effusion, or glue ear, is a condition in which sticky thick fluid accumulates in the middle ear (also called effusion). It may last for more than 6 weeks, with sticky secretions draining out of the ear, but it is not painful.

Frequency of middle ear infections

Next to the common cold, ear infections are the most commonly diagnosed childhood diagnosis. More than 3 out of 4 children have at least one ear infection by the age of 3 years. The earlier a child has a first ear infection, the more susceptible he/she will be to having others. Babies who are breastfed for more than 6 months have fewer ear infections than babies who begin bottle-feeding before they are one month old. Middle ear infections are more common in boys than in girls. Over the age of 5 years, nearly all children have outgrown their proneness to otitis.

Symptoms of middle ear infections

Earache (caused by the fluid in the middle ear pushing on the eardrum and the resulting inflammation) mentioned by the child or expressed by the younger ones by tugging at the ear, acting more irritable, or crying more than usual
Less appetite or less sleep as chewing, sucking or lying down can cause painful pressure changes in the middle ear
Clear, yellowish or blood-tinged fluid coming from the child’s ear or on the child’s pillow, could be a sign that the eardrum is ruptured as a result of the pressure from the fluid behind it. The rupture is painful, but after that the pain subsides with the release of fluid through the rupture
Fever
Nausea, vomiting
Dizziness
Temporary hearing difficulties (fluid build-up blocks the sounds).

Diagnosis of middle ear infections

If suspecting an ear infection, it is necessary to visit the doctor, who will make the diagnosis by taking the medical history and doing a physical examination and in particular examining the eardrums with an otoscope, a small instrument similar to a flashlight. In an infected ear, the eardrum usually appears red and swollen. If pus is draining from the ear, a sample can be sent for analysis to identify which type of bacteria is causing the infection.

Causes of middle ear infections

The middle ear is connected to the throat by a small tube called the eustachian tube which is protected from the outside by a thin membrane. When the throat becomes inflamed by an infection or an allergic reaction, it affects the Eustachian tube opening, allowing secretions to overflow into the tube and then into the middle ear, causing more inflammation, hearing loss and pain. Then bacteria and viruses that normally live in the throat can sometimes cross into the middle ear through the eustachian tube and cause infection. This often happens in the winter season, following a cold or after an allergic inflammation..
Children are particularly susceptible to otitis because of the shape and position of their eustachian tube, which is 2.5 narrower than that of adults and more horizontally situated, thus facilitating the migration of bacteria from the back of the nose and throat into the middle ear.
The adenoids, the gland-like structures located in the back of the upper throat near the eustachian tubes, are large in children and can thus interfere with the opening of the eustachian tubes when they become inflamed by infection.
Children’s immune system is not fully developed until the age of 7, thus it may not be able to fully fight bacterial and viral pathogens.

Risk factors for middle ear infections

Having a cold
Allergic rhinitis, rhinosinusitis, rhinopharygitis or infectious adenoitis
Acute otitis media in the first year of life is a risk factor for recurrent acute otitis media
Children whose brothers or sisters have had recurrent middle ear infections
Family or personal history of allergies that cause congestion on a chronic basis
Having a cleft palate
Down’s syndrome
Premature birth
Impaired immune defences
Boys are more prone to middle ear infections than girls
Increased exposure to respiratory pathogens by siblings and in childcare, as crowded conditions favour colonization and spread of pathogens causing respiratory tract infections which often occur before the ear infection
Exposure to passive smoking
Bottle feeding instead of breast feeding because the formula milk lacks the immune defences provided in the mother’s milk
Frequent use of a dummy or pacifier because sucking may increase production of saliva, which can contain bacteria and be transported through the eustachian tube to the middle ear
Barometric trauma as the pressure in the middle ear rises for instance when travelling by plane. If the eustachian tube is not open, the pressure in the middle ear cannot be equalized and may thus cause injury and acute otitis media
During recent investigations, the bacterium Helicobacter pylori (normally found in the gastrointestinal system) has been identified in the middle ear as well as in tonsillar and adenoid tissues in patients with otitis media, indicating its possible role in the pathogenesis of this disease
Other factors identified as risk factors include genetic predisposition and gastro-oesophageal reflux.

Complications of middle ear infections

In some children, recurrent middle ear infections or chronic ear infections with effusion may cause hearing problems and thus delay speech development, contributing to learning and behavioural problems.Although very rare, severe or recurrent middle ear infections may cause serious complications such as

Ruptured eardrums which may necessitate surgery if they do not heal on their own
Mastoiditis : infection of the mastoid bone situated behind the ear
Meningitis : infection of the brain and spinal cord
Hardening and calcification of the middle or inner ear.

Prevention and treatment of middle ear infections

Preventive measures

Several different approaches are available.

Non specific preventive measures

Immunostimulants of bacterial origin or other sources (synthetic, thymic extracts) to reinforce the body’s immune defence mechanisms against infections
Nutritional supplements such as vitamin A and C, as well as trace elements.

Specific preventive measures

Influenza vaccination
Pneumococcal vaccination
Correction of cleft palate
Appropriate treatment of acute adenoiditis, allergies or gastro-oesophageal reflux.

General preventive measures

Breast-feeding for at least 6 months
Plenty of fruit and vegetables
Wash hands frequently
Avoid exposure to smoking
Avoid pacifiers and exposure to crowded environments.

Medical treatment measures

Antibiotics are not advised in certain cases because the infection may clear on its own within 2-3 days. If that is not the case or if the child is less than 2 years old or if the infection is severe or if a complication develops, antibiotics may be given to treat the ear infection caused by bacteria but they won’t help to fight an infection caused by a virus
Pain relievers such as paracetamol, acetaminophen or ibuprofen are also indicated
Decongestants, but only after having checked with the doctor, may be useful for keeping the eustachian tubes to become blocked
Ear drops if the doctor approves, but not if fluid has leaked from the ear as this may be a sign of a ruptured eardrum.

Interventional procedures

If the middle ear infection fails to respond to the above measures, the doctor may suggest one of the following procedures.

Tympanocentesis: fluid is gently drawn from the ear with a needle and sent for analysis to identify the specific bacterium causing the infection and to decide upon the appropriate antibiotic treatment. This procedure may also relieve severe ear pain by draining the fluid
Tympanostomy tubes: under short general anaesthesia a small hole is made in the eardrum and a tiny silicon or teflon tube is inserted into the hole to allow the remaining fluid and bacteria to drain through the ear canal. After insertion of the ear tubes, hearing generally returns to normal and the likelihood for further ear infections is greatly reduced. The tubes stay in the ears for about 6 to 12 months, then mostly fall out on their own and the eardrums close.
Myringotomy: a small cut is made in the eardrum to allow fluid to drain and keep the eardrum for rupturing. The eardrum heals in generally one week. Recently a laser-assisted myringotomy has been developed and its role in the treatment of otitis media is still being investigated.
Adenoidectomy: it may be performed if the adenoids (small organs located in the back of the throat, behind the nose) are enlarged enough to interfere with the function of the eustachian tubes. However, as the adenoids do also actively participate in the body’s immune defences system, their removal has to be carefully evaluated with respect to the real benefit to the child.

Any medical information on this website is not intended as a substitute for informed medical advice. No action should be taken before consulting with a healthcare professional.