Acute otitis media (middle ear infection)
What is acute otitis media?
Otitis media is an infection in the middle ear (otitis means "ear infection", media means "middle"). This is different from an outer ear infection, such as otitis externa (swimmer’s ear; externa means external or outer), which is an infection of the ear canal. There are different types of otitis media. Acute otitis media typically causes pain, redness of the eardrum and possible fever.
What causes acute otitis media?
Children are prone to developing ear infections in the first 2 to 4 years of life for several reasons. The Eustachian tubes in children are shorter and more horizontal than those of adults (see the diagram below), which lets bacteria and viruses find their way into the middle ear more easily, where they can cause inflammation, which may lead to infection. Also, the adenoids which are gland-like structures located in the back of the nose near the Eustachian tubes, are large in children and can interfere with the opening of the Eustachian tubes. The adenoids can also act as a reservoir for infection.
Several other factors can contribute to children getting ear infections, such as bottle feeding, secondhand exposure to cigarette smoke (this causes inflammation and blockage of the Eustachian tubes) and childcare attendance (where children are more exposed to the bugs that cause otitis media from other children). Otitis media is more common in boys and in children with a family history of ear infections. They are also more common during the winter season, when lots of people get upper respiratory tract infections or colds.
Most cases of otitis media are caused by viruses and not bacteria, which is why in many cases antibiotics (which are effective against bacteria only) are not required.
Are certain children more prone than others to developing acute otitis media?
Yes, children with Down syndrome and cleft palate are more prone to developing both acute otitis media and otitis media with effusion (glue ear) due to an abnormality in the structure and function of their Eustachian tubes. Children with immune system disorders are also more prone.
What are the symptoms of acute otitis media?
The signs and symptoms of acute otitis media may range from very mild to severe. Infection in the middle ear may form pus, which may push on the eardrum, causing ear pain. Older children may complain of an earache, but a younger child might just tug at the ear or simply become irritable and cry more than usual. Lying down, chewing, and sucking also can cause painful pressure changes in the middle ear, so a child may eat less than normal or have trouble sleeping. There may be a fever.
If the pressure from the pus gets high enough, it can rupture through the eardrum and drain from the ear. Blood can sometimes be seen mixed in with the pus. This is the ear’s way of naturally ridding itself from the infection and releases the pressure behind the eardrum, usually bringing relief from the pain. At this point, the fever often settles as well. In most cases, the eardrum heals up once the infection has resolved.
Is acute otitis media contagious?
Acute otitis media is not contagious, though the colds that sometimes cause them can be.
How long does it last?
An episode of acute otitis media often resolves on its own within 2 or 3 days, even without any specific treatment.
How is it diagnosed?
Your GP should usually be able to make a diagnosis based on the symptoms and by examining the ear and looking at the ear drum.
What is the treatment?
There's no single best approach for treating all middle ear infections. In deciding how to manage your child's ear infection, your doctor will consider the following questions:
Is this a true acute otitis media or another type of ear infection?
How often is the child getting infections?
How long do the infections last?
How old is the child?
Does the child have any risk factors that make him or her more prone to developing otitis media?
Is the child having ongoing problems with hearing in between episodes of acute otitis media?
As most episodes of acute otitis media will resolve on their own, a "wait-and-see" approach can be undertaken, which involves giving the child pain relief (such as paracetamol and ibuprofen) without antibiotics for a few days and monitoring their progress.
When should I take my child to the doctor?
If there is no improvement in symptoms after a period of “wait and see” (usually 2 to 3 days), take your child to see your doctor for further assessment. Your doctor may decide to prescribe antibiotics, in which case a 10-day course is usually recommended. For children 6 years of age and older with a mild to moderate infection, a shortened course of antibiotics (5 to 7 days) may be appropriate. The most commonly used antibiotic is amoxicillin (Amoxil), which is a penicillin-based antibiotic. But even after antibiotic treatment for an episode of acute otitis media, fluid may remain in the middle ear for up to several months, resulting in an otitis media with effusion (glue ear).
Bear in mind that antibiotics have their limitations. They will not help an infection caused by a virus (the majority of cases) and will not get rid of middle ear fluid (glue). They typically do not relieve pain in the first 24 hours and have only a minimal effect after that. They can also cause side effects and an overuse of antibiotics can lead to the development of antibiotic-resistant bacteria, which can be much more difficult to treat.
If your child shows unusual or worrisome symptoms such as increased drowsiness, vomiting or fits and/or develops a tender swelling behind the ear, they may have developed a mastoiditis and should be seen by an ENT surgeon for further management. Read more about mastoiditis here.
Are there other treatment options for acute otitis media?
Some children will require ventilation tubes (grommets) for their otitis media. These include:
Children suffering from recurrent episodes of acute otitis media
Children who have developed glue ear as a result of acute otitis media, resulting in hearing difficulty and/or delayed speech
Both of the above
These tubes allow ventilation of the middle ear by bypassing the dysfunctional Eustachian tube, and prevent the build up of fluid or pus behind the ear drum. Sometimes, removal of the adenoids (an adenoidectomy) may also be indicated. Mr Trinidade can discuss in more detail whether grommet insertion and adenoidectomy is right for your child.
Can acute otitis media be prevented?
Some of the risk factors for acute otitis media cannot be changed, such as a family history of frequent ear infections or the child’s gender, but certain lifestyle choices can help protect children:
Breastfeeding infants for at least 6 months provides them with natural immunity and helps to prevent the development of early episodes of ear infections. If a baby is bottle-fed, hold the baby at an angle instead of lying the child down with the bottle to prevent regurgitation of feed into the Eustachian tubes.
Second-hand smoke has been shown to greatly increase the frequency and severity of ear infections. Even if the smoker in the home smokes outside, smoke particles inhaled from their clothes can have the same effect.
While not always possible, minimizing exposure to large groups of children (such as in childcare centres) can protect your child from some of the upper respiratory infections that can lead to ear infections.
Parents and children should wash their hands well and often. This is one of the most important ways to stop the spread of germs that can cause colds that could result in acute otitis media.
Keeping your child's immunizations up to date can help prevent ear infections.
Acute otitis media with pus bulging behind the ear drum
A normal ear drum