Otitis media

Introduction

Otitis media is an ear infection of the middle ear, the area just behind the eardrum. It happens when the eustachian tubes, which connect the middle ear to the nose, get blocked with fluid. Mucus, pus, and bacteria can also pool behind the eardrum, causing pressure and pain.

Ear infections usually start with a cold. Although adults can get ear infections, they are most common in infants and young children. That's because a child's eustachian tubes are narrower and shorter than an adults', and it's easier for fluid to get trapped in the middle ear. In fact, 75% of all children get ear infections. They happen most often between the ages of 6 - 11 months. By age 1, 60% of children will have had at least one ear infection and 17% will have 3 or more.

Ear infections usually clear up on their own. Although it used to be common for doctors to give antibiotics to children with ear infections, now guidelines from the American Academy of Pediatricians (AAP) suggest taking a wait and see approach for the first 72 hours.

With a severe ear infection, pressure may build up and cause the eardrum to rupture. Pus and blood may drain out. This usually relieves pain and pressure, and in most cases the eardrum heals on its own.

Signs and Symptoms

There are two main types of ear infections: acute otitis media (AOM), and otitis media with effusion (OME), where fluid remains trapped in the ear even after the infection is gone.

Acute otitis media causes pain, fever, and difficulty hearing. If a child is too young to talk, signs of an ear infection can include crying, irritability, trouble sleeping, and pulling on the ears.

Other symptoms that may be associated with an ear infection include sore throat (pharyngitis), neck pain, nasal congestion and discharge (rhinitis), headache, and ringing (tinnitus), buzzing, or other noise in the ear.

Causes

Ear infections happen when the eustachian tubes are blocked. Blockages can be caused by:

• A respiratory infection, such as cold or flu
• Allergies
• Exposure to cigarette smoke
• Infected or overgrown adenoids (tonsils)
• For infants, being fed lying down (drinking a bottle while lying on the back)

Ear infections happen most often in the winter. They are not contagious, but a cold may spread among a group of children and cause some of them to get ear infections.

Risk Factors

Risk factors for otitis media include:

• Age -- children between 6 - 36 months are most likely to get ear infections
• Attending daycare
• Recent illness, such as a cold or sinus infection
• History of allergies, like hay fever, also called allergic rhinitis, or sinusitis
• Exposure to secondhand smoke
• Having family members who are prone to ear infections; studies show a clear genetic component for bot hacute and recurrent otitis media 
• Using a pacifier
• Having a history of gastroesophageal reflux disease (GERD) 

Diagnosis

The doctor will ask questions about whether you (or your child) have had ear infections in the past and ask you to describe the current symptoms. He or she will use an otoscope to look inside the ear. If infected, there may be areas of dullness or redness or there may be air bubbles or fluid behind the eardrum. The fluid may be bloody or filled with pus. The doctor will also check for any sign of perforation -- a hole or holes -- in the eardrum.

Your doctor may also do other tests:

• Tympanometry, which uses a small handheld instrument to measure changes in air pressure in the ear. It can indicate if the eardrum is ruptured
• Reflectometry, in which a doctor places a small instrument near the ear that makes a sound. That allows the doctor to see if fluid is present behind the eardrum.
• A hearing test if your child has had persistent ear infections.

Preventive Care

You can reduce your child's risk of ear infection. Here are some tips:

• Don't expose your child to secondhand smoke.
• Keep your child away from other children who are sick.
• Always hold your infant in an upright, seated position during bottle feeding.
• Breastfeeding for at least 6 months can make a child less prone to ear infections.
• Don't use a pacifier.

The pneumococcal vaccine (Prevnar) prevents infections such as pneumonia and meningitis, and studies show it slightly reduces the risk of ear infections.

Treatment Approach

The goals for treating ear infections include curing the infection, relieving pain and other symptoms, and preventing future ear infections. If a bacterial infection is present, your doctor may prescribe antibiotics (see section titled Medications).

However, most ear infections clear up on their own. One review of the scientific literature found that the symptoms of otitis media got better in two-thirds of children by 24 hours and in 80% of children at 2 - 7 days. Because antibiotics tend to be overused for treating ear infections, and because childdren may become resistant to antibiotics most commonly used to treat otitis media, the AAP and the American Academy of Family Physicians guidelines suggest taking a wait and see approach for 72 hours if:

• The child is older than 6 months
• The child is otherwise healthy
• The child has mild symptoms or an unclear diagnosis.

Your doctor may suggest using an over-the-counter pain reliever (see Medications). There are also alternative ways to treat the symptoms of ear infections and to prevent persistent and recurrent ear infections. For example, herbal ear drops and homeopathic remedies may help treat or prevent ear infections.

Before giving any medication to a child -- whether over the counter, an herbal remedy, or a dietary supplement -- you should talk to your pediatrician.

Lifestyle

Applying a warm, moist cloth over the affected ear may help relieve pain.

Medications

• Antibiotics -- If your doctor prescribes antibiotics, be sure to give your child all the doses. The antibiotic most often prescribed for an ear infection is amoxicillin, unless your child is allergic to penicillin. If that's the case, there are several options. Children who are treated with antibiotics are more likely to develop vomiting, diarrhea, or a rash.
• Ear drops -- If your child has recurring ear infections, a perforated eardrum, or develops infection after ear tubes have been placed (see Surgery and Other Procedures), your doctor may prescribe antibiotic ear drops instead of oral antibiotics, to be used over a period of time, such as a few months. If your child doesn't have ear tubes in place and doesn't have any drainage from the ear, your doctor may also prescribe anesthetic ear drops to relieve pain.
• Ibuprofen, acetaminophen -- Ask your doctor about using over-the-counter oral medications for pain or fever, such as ibuprofen (Advil, Motrin) or acetaminophen (Tylenol). Children under 19 should not take aspirin, due to the risk of developing a rare but serious illness called Reye's syndrome.

Surgery and Other Procedures

Drainage tubes (myringotomy) -- If your child has recurring ear infections that don't respond to antibiotics or if the fluid in the ear affects his hearing, your doctor may suggest putting in drainage tubes. During this surgery, which requires general anesthesia, the surgeon inserts a small drainage tube through the eardrum. Fluid behind the eardrum can drain out, equalizing the pressure between the middle and outer ear, which should improve your child's hearing. The tubes usually come out on their own as your child grows and the drainage holes heal.

If ear infections persist after age 4, your doctor may suggest having your child's adenoids (tonsils) removed.

Nutrition and Dietary Supplements

Because supplements (like those described below) may have side effects or interact with medications, you should take them only under the supervision of a knowledgeable health care provider. If you think your child has an ear infection, you should always talk to your doctor -- don't try to treat the child yourself.

• Probiotics (Lactobacillus) -- So-called “good” bacteria or probiotics help prevent infections in the intestines, and there is preliminary evidence that they might help prevent colds, too. One study found that children in daycare centers who drank milk fortified with Lactobacillus had fewer and less severe colds. However, it's not clear whether that would help reduce ear infections. A study found that children who took probiotics did not get any fewer ear infections than those who took placebo -- although they did get fewer colds. People with weakened immune systems or who take drugs to suppress the immune system should not take probiotics without their doctor's supervision.
• Xylitol -- A sugar alcohol produced naturally in birch, strawberries, and raspberries, it may help fight a type of bacteria that's associated with ear infections. In one study, children who chewed sugarless gum sweetened with xylitol reduced their risk of developing an ear infection by more than a third. However, children in the study were given the gum 5 times a day, which makes it hard to keep up with the regimen. Another study found that taking xylitol only when a child showed symptoms of a cold or respiratory infection didn't prevent the child from developing an ear infection. More research is needed.
• Elimination diet -- Some doctors believe food allergies contribute to chronic ear infections. Your doctor may ask you to try an elimination diet, which cuts out common food allergens such as wheat or dairy. If symptoms get better, you gradually add back the foods until symptoms return. Then you are able to identify the problem food.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care practitioner. Before giving any herbs to a child to treat an ear infection, talk to your pediatrician.

• Herbal ear drops (Calendula officinalis, Hypericum perfoliatum, Verbascum thapsus, Allium sativum) -- A few studies suggest that ear drops containing calendula, mullein, St. John's wort, and garlic were as effective at relieving pain as prescription ear drops. However, using oily ear drops can make it hard for the doctor to examine your child's middle ear, so always talk to your doctor before using them. If you have a ruptured ear drum, do not use herbal ear drops.
• Belladonna, as a homeopathic medicine -- In one study, children who took a homeopathic preparation of belladonna had fewer ear infections, and the ones they got didn't last as long as children who took antibiotics. (See Homeopathy section.)
• Echinacea (Echinacea purpurea) -- Although it has not been studied for ear infections, some doctors may suggest echinacea to help prevent recurring ear infections. Only give echinacea to a child under your doctor's supervision. Women who are pregnant or breastfeeding should not take echinacea. If you are allergic to ragweed, you may be allergic to echinacea.

Homeopathy

Although not many studies have examined the effectiveness of specific homeopathic therapies in general, there have been several studies evaluating homeopathy for ear infections. Some of the homeopathic remedies included in such studies or that a professional homeopath might consider for the treatment of ear infections are listed below. Before prescribing a remedy, homeopaths take into account a person's constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Aconitum -- for throbbing ear pain that comes on suddenly after exposure to cold or wind; and in children with high fever and whose ears have a bright red coloring
• Belladonna -- for sudden onset of infection with piercing pain that often spreads to the neck, flushed face including reddened ears, agitation (even impaired consciousness and nightmares), wide-eyed stare, high fever, and swollen glands; this remedy is most appropriate for children who feel relief when sitting upright and from warm compresses to the ear; this remedy should not be used in children whose symptoms have persisted for more than 3 days
• Chamomilla -- for intense ear pain and extreme irritability and anger (including screaming); this remedy is most appropriate for children who are difficult to comfort unless being rocked or carried by a person who is walking back and forth
• Hepar Sulphuricum -- for sharp pains and a smelly, yellowish-green discharge that occur in the middle and late stages of an ear infection, particularly when the child is extremely moody and clearly angry; this remedy is most appropriate for individuals whose symptoms are worsened by cold air and improved by warmth
• Lycopedium -- for right side ear pain that is worse in the late afternoon and early evening; the child will generally say that his ears feel stuffed up and he may hear a ringing or buzzing sound; the appropriate individual tends to be insecure and need others around, although the personality type may act like a bully as a defense mechanism
• Mercurius -- good for chronic ear infections; for acute or chronic pain that is worse at night and may extend down into the throat; relief comes from nose blowing; and the appropriate child may sweat or drool a lot and have bad breath
• Pulsatilla -- for infection following exposure to cold or damp weather; the ear is often red and may have a yellowish/greenish discharge; ear pain worsens when sleeping in a warm bed and is relieved somewhat by cool compresses; this remedy is most appropriate for children who tend to be gentle, weepy, and mildly whiny, and who are easily soothed by affection
• Silica -- for chronic or late stage infection when the child feels chilly, weak, and tired; sweating may also be present.

Other Considerations

Warnings and Precautions

If you think your child has an ear infection, especially if your child is under 2, call your pediatrician.

Let your doctor know if your child's symptoms such as pain, fever, or irritability do not get better within 24 - 48 hours.

If severe pain suddenly stops, it may indicate a ruptured eardrum.

Swimming and diving underwater may make an ear infection worse. If your child has a ruptured eardrum, he should avoid swimming or diving completely. If your child has ear tubes, use earplugs or cotton balls coated with petroleum jelly when swimming to prevent infection.

Prognosis and Complications

Usually, an ear infection is a simple condition without complications. Most children will have minor, temporary hearing loss during and right after an ear infection. Permanent hearing loss is very rare, but the risk increases if the child has a lot of ear infections. Other potential complications include:

• Ruptured or perforated eardrum, which usually heals on its own
• Chronic, recurrent ear infections
• Enlarged adenoids or tonsils
• Mastoiditis, an infection of the bones around the skull
• Speech or language delay in a child who suffers lasting hearing loss from multiple, recurrent ear infections; very rare