Definition

Middle ear infection is a term for infection and inflammation of the middle ear. The middle ear is the part of the ear behind the eardrum.

	The Middle Ear
	© 2008 Nucleus Medical Art, Inc.

Causes

Middle ear infections are caused by bacteria and viruses. Common causative organisms include:

• Haemophilus influenzae
• Streptococcus pneumoniae
• Moraxella (or Branhamella) catarrhalis
• Streptococcus pyogenes (under 5% of cases)
• Staphylococcus aureus (3% or less of cases)

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

Risk factors include:

• Recent viral infection, such as a cold
• Recent sinusitis
• Age: babies and toddlers
• Attendance at day care
• Being bottle fed as an infant (especially while lying down) or using a pacifier
• Medical conditions that cause abnormalities of the eustachian tubes, such as:
  • Cleft palate
  • Down syndrome
• History of allergies—environmental allergies and food (milk) allergies have been shown to increase the risk of ear infections
• Gastroesophageal reflux disease (GERD)
• Babies whose mother drank alcohol while pregnant
• Exposure to second hand smoke, usually cigarette smoke, but also from cooking and wood-heating
• A variety of other conditions, both rare and common, can cause otitis media

Symptoms

Symptoms include:

• Ear pain (in babies too young to report pain, you may notice tugging or rubbing at the ear or face)
• Fever
• Irritability
• Hearing loss (may be only temporary, due to fluid accumulation interfering with hearing)
• Decreased appetite, difficulty feeding
• Disturbed sleep
• Drainage from ear
• Hearing loss (may be only temporary, due to fluid accumulation interfering with hearing)
• Difficulty with balance

Diagnosis

The doctor will ask about symptoms and medical history, and perform a physical exam. Most middle ear infections can be diagnosed by looking into the ear with an otoscope, a lighted instrument.

The doctor will look to see if there is fluid or pus behind the eardrum. A small tube and bulb (insufflator) may be attached to the otoscope so that a light puff of air can be blown into the ear. This helps the doctor see if the eardrum is moving normally.

Other tests may include:

• Tympanocentesis—withdrawal of fluid or pus from the middle ear using a needle to check for bacteria and to drain the pus or fluid
• Tympanometry—a test that measures pressure in the middle ear and responsiveness of the eardrum and to check on the presence of fluid or pus
• Hearing test—may be ordered for repeated ear infections

Treatment

Treatments include:

Antibiotics

Antibiotics are commonly given to treat ear infections. The most frequently recommended antibiotics are amoxicillin and clavulanate (augmentin). A number of other drugs including cephalosporins (cefprozil, cefdinir, cefpodoxime, and ceftriaxone) and sulfa drugs (septra, bactrim, pediazole) are sometimes used.

As it has come to light that antibiotic overuse causes bacteria to develop resistance to the antibiotic used. Many experts now believe that the risk of antibiotic treatment may be greater than its benefit for many children with an ear infection or suspected ear infection. In these children, symptoms of infection will often subside just as quickly without an antibiotic. Some doctors will even give parents a prescription for antibiotics but instruct them not to use the antibiotic unless pain or fever persists beyond an agreed-upon number of days.

Encouraging findings from a recent clinical trial (involving nearly 300 children aged 6 months to 12 years with severe otitis media seen in an emergency department) reveal that "wait-and-see" prescription of antibiotics—where parents are asked not to fill the prescription unless their child is either not better or is worse in 48 hours—is as effective as standard prescription. *

Some ear infections are not caused by bacteria, but instead by a virus. Antibiotics will not speed up the cure of a viral ear infection. These infections (and many bacterial infections) tend to improve on their own in 2-3 days without antibiotic treatment.

Over-the-Counter (OTC) Pain Relievers

OTC pain relievers can help reduce pain, fever, and irritability. These include acetaminophen or ibuprofen. Aspirin is not recommended for children with a current or recent viral infection. Check with your doctor before giving a child aspirin.

Ear Drops

Ear drops may help decrease pain. They cannot be used if there is any chance that the eardrum has ruptured.

Myringotomy

Myringotomy is a procedure during which a tiny incision is made in the eardrum to drain accumulated fluid.

Prevention

To reduce the chance of getting an ear infection:

• Avoid exposure to cigarette smoke and to smoke from wood-burning stoves.
• Breast-feed your baby for at least the first six months.
• Try to avoid using a pacifier.
• If you bottle-feed your baby, keep your baby's head propped up as much as possible. Don't leave a bottle in the crib with your baby.
• Some have also suggested that allergy to cow's milk may be the cause of otitis media. Allergy testing may be useful.
• Treat related conditions, such as gastroesophageal reflux.
• Practice good handwashing to avoid spreading germs.
• Make sure your child has all of his or her immunizations, especially the pneumococcal vaccine (Prevnar), which can reduce the risk of getting otitis media .
• Consider getting a yearly flu vaccine.
• Antibiotics may occasionally be used in a small dose, for long periods of time, in children with a history of repeated ear infections.
• Tympanostomy tubes can be inserted into the eardrum during a minor surgical procedure. These tiny tubes help equalize the pressure behind the eardrum, which can help prevent the accumulation of fluid and decrease the risk of ear infection.
• Sometimes a child's adenoids are so large that they interfere with the functioning of the eustachian tubes. Removing the adenoids (adenoidectomy) may help prevent future ear infections, though the benefit of surgery is small and may not last more than a year.

RESOURCES:

American Academy of Otolaryngology, Head and Neck Surgery
http://www.entnet.org

National Institute on Deafness and Other Communication Disorders
http://www.nidcd.nih.gov

CANADIAN RESOURCES:

Canadian Family Physician
http://www.cfpc.ca/cfp/

Caring for Kids, The Canadian Paediatric Society
http://www.caringforkids.cps.ca/

References:

Behrmann. Nelson Textbook of Pediatrics . 16th ed. WB Saunders; 2000.

Dambro. Griffith's 5-Minute Clinical Consult . 1999 ed. Lippincott Williams & Wilkins; 1999.

Hurst DS, Amin K, Seveus L, Venge P. Laryngoscope . 1999 Mar. 109(3):471-477.

National Institute on Deafness and Other Communication Disorders website. Available at: http://www.nidcd.nih.gov/ .

Phillips. Otitis media, milk allergy, and folk medicine. Pediatrics .1972. 50:346.

*Updated section on Antibiotics on 10/12/06 according to the following study, as cited by DynaMed's Systematic Literature Surveillance : Spiro DM, Tay KY, Arnold DH, Dziura JD, Baker MD, Shapiro ED. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled trial. JAMA . 2006;296(10):1235-41.

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