Otitis Media

Introduction

When your baby is awake all night long - fussing, crying, and refusing all your efforts of comfort - you know something is wrong. Being alert to all the gestures and movements your child makes can give you important clues. If she repeatedly touches or tugs at her ear, she may have otitis media (ear infection), one of the most common infections in infants and young children. Your child will not have to suffer with the discomfort and pain of an ear infection for long. Treatment typically eases symptoms fairly quickly, and the infection sometimes even resolves with no treatment at all.

What is it?

Otitis media is an inflammation of the middle ear, which is located behind the eardrum and consists of three tiny bones that transmit sound from the eardrum to the inner ear. When bacteria or viruses get in the ear, they travel to the middle ear, where they can cause infection. An infection can lead to a build-up of fluid and pus behind the eardrum, which can cause ear pain and, occasionally, temporary hearing loss.

What causes it?

Scientists report that most cases of otitis media are caused by bacteria. A small percentage of otitis media cases are caused by a combination of both a virus and bacteria, and even fewer by a virus alone. Otitis media develops when there is a build-up of fluid in the middle ear cavity. The eustachian tube, a key element in the inner ear connects the middle ear to the back of the nose and normally balances pressure in the ear. It also pushes mucus and debris away from the middle ear. When the eustachian tube is blocked with mucus, air cannot flow through the ear, fluid accumulates and bacteria can grow.

An ear infection can also result from damage to the eustachian tube. If the tube is damaged and cannot effectively clear the mucus and debris, bacteria can travel to the middle ear and produce an infection. Infection causes the lining of the middle ear to swell, blocking the body's bacteria-fighting cells from traveling to the infected area to fight the infection.

Who has it?

One of the most common infections in infants and young children, otitis media is diagnosed more than 5 million times in the United States each year. The infection most often affects children age 6 months to 3 years. An estimated fifty percent of all children will develop otitis media by the age of one, and eighty percent will have had the condition by the age of three. If the child has not developed otitis media by the age of three, it is less likely they will ever develop severe or recurrent otitis media.

Otitis media can also occur in adults, but it is more common in children because their developing immune systems have more trouble fighting infections. In addition, a child's eustachian tube is shorter and straighter than that of an adult, which decreases air movement and fluid drainage in the ear allowing fluid to accumulate in the ear and cause infection.

How is otitis media diagnosed?
When attempting to diagnose otitis media, the doctor will obtain a detailed history of the patient's symptoms and look into the patient's ear using an instrument called an otoscope (an instrument that allows the doctor to see the eardrum). According to the American Academy of Pediatrics, a diagnosis of otitis media can be made based on the patient's symptoms (decreased appetite, fever, fluid draining from ear, loss of balance, unusual irritability), how quickly the symptoms developed, symptoms of middle ear irritation (tugging at the affected ear), and the presence of fluid in the middle ear.

In rare cases in both adults and children with recurrent otitis media that does not respond to antibiotics, a sample of the fluid from the middle ear is sometimes obtained by inserting a small needle into the eardrum. The sample is sent to a lab to determine the type of organism that is causing the infection and to identify which medications are most effective against it.

What are the risk factors?

Several factors can increase the likelihood of getting otitis media:

  • Winter season: Otitis media is more common in the winter months, when viral infections of the respiratory tract are more common. These infections can predispose an individual to bacterial infections like otitis media

  • Environmental factors: Second-hand smoke and high levels of air pollution can weaken a young child's immune system, increasing the chance of getting otitis media.

  • Attendance at a daycare center: Children who are around sick children, either siblings or playmates at a daycare center, are at increased risk of getting all types of infections, including otitis media.

  • Previous case: Individuals who have had otitis media are more likely to develop the infection than those who have never had it.

  • Age at first ear infection: The younger the child at the time of the first ear infection, the greater the child's risk of subsequent ear infections.

  • Bottle-feeding: A bottle-fed child is more likely to get otitis media than a child who is breast fed. That is because antibodies (proteins that defend the body from foreign substances) are passed from a mother to her breast-fed infant through her breast milk, speeding the development of the baby's immune system and increasing resistance to infection. The immune system is slower to develop in infants who are bottle fed.

  • Race: Otitis media is more prevalent among Native Americans and Eskimos from Alaska or Canada than among individuals of other races.

  • Weakened immune system: Children with immune systems that are not working as well as they should are at increased risk of many infections including otitis media.

  • Presence of physical abnormalities: Some physical conditions - for example, cleft palate, enlarged adenoids (glands near the ear), or Down's syndrome - increase an individual's chance of getting otitis media.

  • Other factors: Allergies, sinus infections, and gastroesophageal reflux disease all may put children at an increased risk for developing otitis media.

What are the symptoms?

Otitis media commonly occurs in infants who have not yet learned to talk, making it difficult for a parent to know when a child has an earache. The following are common signs of this infection:

  • Decreased appetite
  • Fever
  • Fluid draining from the ear
  • Increased fussiness
  • Loss of balance
  • Tugging at the affected ear
  • Unusual irritability

Older children can voice their symptoms but, like many adults, may not be able to pinpoint the cause of their discomfort. The following are some of the symptoms that an older child or an adult may experience:

  • Decreased hearing
  • Diarrhea
  • Dizziness
  • Fullness or pressure in the ear
  • Pain in the affected ear
  • Headache
  • Nausea
  • Sore throat
  • Vomiting

How is it treated?

Because otitis media can be due to a virus, bacteria, or both, it is often difficult to identify the exact cause and thus the most appropriate treatment. Treatment options include the following:

  • Pain Management

    Otitis media does not always cause pain. If pain is present, medications such as acetaminophen (Tylenol ?) or ibuprofen are typically effective.

  • Antibiotics

    In some patients, the doctor may decide to delay treatment with antibiotics (drugs that kill bacteria), giving the body a chance to fight the infection by itself. It has been reported by the American Academy of Pediatrics that around 61% of children have improved symptoms by 24 hours whether or not they were given antibiotics. Additionally, by 7 days, over 75% of all children were symptom-free, again regardless of treatment with an antibiotic. If there is no improvement in 24 hours in children 6-24 months or no improvement in 72 hours for children older than 24 months, antibiotics should be prescribed. Children younger than 6 months with signs and symptoms of otitis media should receive antibiotics.

    If the doctor decides to treat otitis media then an antibiotic will be prescribed. Some examples of the most common antibiotics used to treat otitis media include amoxicillin, amoxicillin and clavulanate acid, trimethoprim-sulfamethoxazole, cefuroxime, clarithromycin, and azithromycin.

    Because proven effective through clinical trials, some doctors are now choosing to treat uncomplicated cases of otitis media with a shorter course of antibiotic treatment. Antibiotics typically used for 5 days of treatment, but typically in higher doses, include amoxicillin, azithromycin, and cefuroxime.

    Although improvement is typically seen in 48 to 72 hours, the antibiotic should be taken as long as prescribed (typically for 5 to 14 days) to prevent a return of the infection.

    Furthermore, if the antibiotic is stopped early all of the bacteria causing the infection may not be eliminated. In fact, the ?weaker? bacteria die leaving behind the ?stronger? bacteria. These surviving bacteria begin to multiply and the resulting infection or ?return of the infection? is slightly harder to get rid of. Over time, when antibiotics are used improperly like this, bacteria that are no longer killed by the antibiotic develop, i.e., drug resistant bacteria. Many antibiotics are no longer useful due to the development of drug resistance

    Stomach upset and rash are common side effects of these antibiotics. To learn more about antibiotics used to treat otitis media, click on the Drug Class links at the bottom of the page.

  • Observation

    If the cause of the otitis media is viral, antibiotics will not help - observation and pain control is the recommended course of action. Viral otitis media should resolve on its own within 7-14 days with no treatment. Observation may also be recommended for many cases of bacterial otitis media. It has been reported that around 80% of otitis media cases (whether viral or bacterial) resolve within 2-14 days without treatment of antibiotics.

  • Ear Tubes

    If middle ear fluid has accumulated in the ear for longer than 3 months and the patient is experiencing hearing loss, a doctor may recommend inserting a tympanostomy tube into the patient's ear. This will allow air to move through the middle ear and balance the pressure between the outer and middle ear. Ear tubes may also be recommended for children who have repeated ear infections.

    During myringotomy, the operation performed to insert the tubes, a small incision is made in the opening of the child's eardrum to allow placement of a metal or plastic tube. The tube typically stays in the eardrum for 6 to 12 months, during which time water should be kept out of the ears. Once the tubes are inserted and fluid is drained from the middle ear, any hearing loss should be reversed and any pain should disappear.

  • Can otitis media be prevented?

    There is no way to completely eliminate the risk factors associated with otitis media, but certain steps may be taken to lower the chance of developing this condition. Some of these include:

    • Avoid feeding the child while he or she is laying flat
    • Try to reduce the use of a pacifier
    • Avoid utilizing daycare (or moving the child from a large daycare center to a smaller home based place of care)
    • Avoid smoking around children

Helping Yourself

The following are steps you can take to reduce your child's risk of getting otitis media:

  • Keep children away from sick playmates
  • Do not expose children to second-hand smoke
  • Breast-feed infants to give their immune systems a "jump start"
  • Give children all medications exactly as directed and for the entire course that the doctor has recommended
  • Ensure that children eat a healthy diet, including lots of fresh fruits and vegetables for energy and to support the immune system

What is on the horizon?

Because otitis media is so common in infants and children, ongoing research is directed at finding ways to prevent, diagnose, and better treat the infection. Efforts are also under way to identify better ways to determine which children are at high risk for developing otitis media and why certain individuals are more susceptible to ear infections than others. Scientists also are evaluating the success of antibiotics currently used to treat otitis media and examining new drugs that may prove more effective. Vaccines that show promise in preventing otitis media also are in development.

References

American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis meds. Pediatrics 2004; 113: 1451-65.

Berman S. Otitis media in children. New England Journal of Medicine. 1995; 332:1560-65.

Hendley JO. Otitis media. New England Journal of Medicine. 2002; 347:1169-74.

Kenna M. Otitis Media and the New Guidelines. The Journal of Otolaryngology. Volume 34, Supplement 1, June 2005.

Kozyrsky AL, Hildes-Ripstein GE, Longstaffe SE, et al. Treatment of acute otitis media with a shortened course of antibiotics. JAMA. 1998; 279:1736-42.

Mayo Clinic website. Diseases and Conditions. Available at: http://www.mayoclinic.com/health/ear-infections/DS00303/DSECTION=1. Accessed December 20, 2006.

National Institute on Deafness and Other Communication Disorders website. Available at: http://www.nidcd.nih.gov/health/hearing/otitism.asp. Accessed February 17, 2004.

Oszko MA, Leff RD. Common ear diseases. In: Herfindal ET, Gourley DR (eds.). Textbook of therapeutics, drug and disease management. 6th ed. Baltimore, Md.: Williams & Wilkins; 1996:951-59.

Pichichero M, et al. Acute Otitis Media: Making sense of recent guidelines on antimicrobial treatment. www.jfponline.com; Vol 54 No. 4; April 2005.

Richer M. Upper respiratory tract infections. In: Dipiro JT, Talbert RL, Yee GC, et al. (eds.). Pharmacotherapy: a pathophysiological approach. 6th ed. New York: The McGraw-Hill Companies, Inc.; 2005:1963-67.

Rovers MM, Schilder AG, Zielhuis GA, et al. Otitis media. The Lancet. 2004; 363:465-73.

Otitis Media Health Condition Last Updated: September 2007

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

Back