Middle Ear Infection In Infants, Toddlers, Children, and Adults

  • Medical Author:
    David Perlstein, MD, MBA, FAAP

    Dr. Perlstein received his Medical Degree from the University of Cincinnati and then completed his internship and residency in pediatrics at The New York Hospital, Cornell medical Center in New York City. After serving an additional year as Chief Pediatric Resident, he worked as a private practitioner and then was appointed Director of Ambulatory Pediatrics at St. Barnabas Hospital in the Bronx.

  • Medical Author: Charles Patrick Davis, MD, PhD
    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

Tips for Treating Ear Infections

Middle ear infection definition and facts

  • Middle ear infections or inflammation (otitis media) are inflammation, usually caused by infection, of ear tissue including the ear drum and tissues behind it, but not the ear canal.
  • It is the most common childhood condition for which antibiotics are prescribed.
  • Signs and symptoms include:
    • Fever
    • Ear pain
    • A feeling of fullness in the ear
  • Young children will have these symptoms and signs as well as fussiness and feeding problems.
  • The infection or inflammation causes fluid buildup in the middle ear.
  • A cold or other respiratory infection can lead to ear infections or inflammation.
  • Those at a higher risk for middle ear infections are children exposed to other children's colds (as often occurs in daycare centers), and babies who are bottlefed.
  • Middle ear pus causes pain and temporary hearing loss.
  • Rupture of the eardrum allows the pus and fluid to drain into the ear canal.
  • Ear infections are treated with observation, antibiotics, or ear tubes.
  • Routine childhood and yearly flu vaccinations may help prevent this type of infections

What is middle ear infection or inflammation?

Middle ear inflammation is also called otitis media. Otitis media is inflammation of the middle ear; however, many doctors consider otitis media to be either inflammation or infection of the middle ear, the area inside the ear drum (tympanic membrane - see illustration). "Otitis" means inflammation of the ear, and "media" means middle. This inflammation often begins with infections that cause sore throats, colds or other respiratory problems, and spreads to the middle ear. Infections can be caused by viruses or bacteria, and can be acute or chronic. Both ears can be infected at the same time (double ear infection). These infections are not "swimmers ear" (also termed otitis externa or outer ear infection because it occurs in the ear canal up to the ear drum), but not beyond. However, some people can have swimmer's ear and a middle ear infection at the same time.

Acute middle ear infections usually are of rapid onset and short duration. They typically are associated with fluid accumulation in the middle ear together with signs or symptoms of infections in the ear in addition to a bulging eardrum usually accompanied by pain or a perforated eardrum, often with drainage of purulent material (pus, also termed suppurative otitis media). The person also may have a fever.

Chronic middle ear infections are a persistent inflammation of the middle ear, typically for a minimum of three months. This is in distinction to an acute ear infection that usually lasts only several weeks. Following an acute infection, fluid (an effusion) may remain behind the ear drum (tympanic membrane) for up to three months before resolving. It may develop after a prolonged period of time with fluid (effusion) or negative pressure behind the eardrum (tympanic membrane). This type of infection can cause ongoing damage to the middle ear and eardrum, and there may be continuing drainage through a hole in the eardrum. Chronic middle ear infections often starts painlessly without fever. Ear pressure or popping can be persistent for months. Sometimes a subtle loss of hearing can be due to chronic middle ear infections.

Picture of the Ear Anatomy
Picture of the Ear Anatomy

Quick GuideEar Infection Symptoms, Causes, and Treatment

Ear Infection Symptoms, Causes, and Treatment

Is Your Infant or Child at Risk for Ear Infection?

Question: ______________ is a risk factor for ear infections in infants.

Answers:

  • A. Diarrhea
  • B. Bottlefeeding
  • C. Premature birth
  • C. Being first born

Signs and symptoms of acute middle ear infection in infants, toddlers, and children

Signs and symptoms of middle ear infections in babies, toddlers, and children may include:

  • Young non-verbal children may be irritable and pull or tug at their ear(s).
  • Young children with middle ear infections may be irritable, fussy, or have problems feeding or sleeping.
  • Older children may complain about pain and fullness in the ear (earache).
  • A child of any age may have a fever.
  • The buildup of pus within the middle ear causes pain and dampens the vibrations of the eardrum (so there is usually temporary hearing loss during the infection).
  • Severe ear infections may cause the eardrum to rupture. The pus then drains from the middle ear into the ear canal.
  • The hole in the eardrum from the rupture usually heals without medical treatment.

These symptoms are often associated with signs of upper respiratory infection such as a runny or stuffy nose, or a cough.

Signs and symptoms of middle ear infections in adults

and symptoms in adults may have one or more of the following:

How common is acute middle ear infection or inflammation?

This type of infection is an extremely common diagnosis. In the U.S. it is estimated that 75% of all children experience at least one middle ear infection before the age of three.

Are ear infections contagious?

Ear infections are not contagious. However, many children develop infections following a cold or other viral infection, and those infections are contagious.

Why do infants and young children tend to have ear infections?

The Eustachian tube, a canal that runs from the middle ear to the back of the nose and throat, is shorter and more horizontal in infants and young children than in older children and adults. This allows easier entry into the middle ear for the microorganisms that cause infection and lead to otitis media. Young children also have more immature immune systems. The result is that infants and young children are at greater risk of acquiring ear infections than adults.

What are the risk factors for acute and middle ear infection?

  • Bottlefeeding: The position of the breastfeeding child is better than that of the bottlefeeding position in terms of the function of the Eustachian tube that leads into the middle ear. If an infant needs to be bottlfed, it's better to hold the the baby rather than allowing them to lie down with the bottle. Ideally, they should not take the bottle to bed. (In addition to increasing the chance for acute infection, falling asleep with milk in the mouth enhances the risk of tooth decay.)
  • Upper respiratory tract infection: Children often develop upper respiratory infections prior to developing this type of infection. Exposure to groups of children (as in child care centers) results in more frequent colds, and therefore more earaches.
  • Exposure to air with irritants, such as tobacco smoke
  • Birth defects: Children with cleft palate or Down syndrome are more prone to ear infections.
  • Eustachian tube problems: Any problems with the Eustachian tubes (for example, blockage, malformation, inflammation) will increase the risk of infection. If the individual has allergies he or she may have swelling and blockage of one or both Eustachian tubes.
  • Immunosuppressed: Individuals with suppressed immunosuppression are at increased risk for ear infections.
  • Ear infections later in childhood: Children who have episodes of acute infections before six months of age tend to have more later in childhood.

How do you get a middle ear infection?

Bacteria and viruses can cause middle ear infections. Bacteria such as Streptococcus pneumoniae (pneumococcus), Hemophilus influenzae, Pseudomonas, and Moraxella account for about 85% of cases of acute otitis media. Viruses account for the remaining 15%. Affected infants under six weeks of age tend to have infections from a variety of different bacteria in the middle ear.

How does the Eustachian tube change with age?

As a person ages, the Eustachian tube doubles in length and becomes more vertically positioned so that the nasopharyngeal orifice (opening) in the adult, is significantly below the tympanic orifice (the opening in the middle ear near the ear drum) than in a child. The greater length and particularly the slope of the tube as it grows serves more effectively to protect, aerate and drain the middle ear.

How is acute middle ear infection diagnosed?

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) have determined the criteria which are needed to diagnose acute otitis media (AOM); acute onset, middle ear effusion (MEE), and middle ear inflammation. The new guidelines describe this as "moderate to severe bulging of the tympanic membrane (ear drum) or new onset of otorrhea (ear drainage) not due to external otitis (inflammation of the ear canal) or mild bulging of the ear drum, and recent ear pain (holding, tugging, rubbing ear in a nonverbal child) or intense reddening of the ear drum." The guideline also strongly recommends that clinicians should not diagnose AOM without the presence of MEE. Recurrent acute otitis media is defined as at least three well-documented and separate acute otitis media episodes in 6 months or 4 well-documented and separate AOM episodes in the past 12 months with at least 1 in the past 6 months. There is no definitive lab test for acute otitis media.

Identification of the three criteria is dependent on clinical observation; middle ear effusion and middle ear inflammation are the most difficult to observe and as a consequence there are studies that suggest acute otitis media is over diagnosed. One method that helps determine acute otitis media versus otitis media with effusion is pneumatic otoscopy (the normal eardrum moves readily with pressure changes) and the appearance of the tympanic membrane (acute otitis media has abnormal appearance, otitis media with effusion does not). However, not everyone is skilled at this technique; Pediatricians, Family Practice, ENT specialists, and ER doctors that work in pediatric ER's are likely to be skilled in the diagnostic procedure.

How is acute middle ear infection or inflammation treated?

The treatment for acute otitis media varies depending upon the age and symptoms of the child. The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommend the following:

AAP and AAFP Recommendations 2013
AgeCertain Diagnosis
(Otorrhea with AOM or Unilateral or
Bilateral AOM with Severe Symptoms)
Certain Diagnosis
(Bilateral AOM without Otorrhea)
Uncertain Diagnosis
(Unilateral AOM without Otorrhea)
6 months-23 monthsAntibioticsAntibiotics if severe illness;
*Observation without antibiotics if non-severe illness
> 2 yearsAntibioticsAntibiotics if severe illness;
*Observation if non-severe illness
Antibiotics if severe illness;
*Observation without if non-severe illness

*Observation is an appropriate option only when follow-up can be ensured and antibacterial agents can be started if symptoms persist or worsen within 2-3 days. The guidelines also recommend "shared decision making" with the caregiver. Non-severe illness is represented by mild ear pain and fever <39 C (102.2 F) in the past 24 hours. Severe illness is defined as moderate to severe otalgia (ear pain) or any ear pain for at least 48 hours or fever 39 C. These 2013 guidelines are current.

If antibiotics are initiated, amoxicillin is usually recommended as the first line treatment. This is usually prescribed for 10 days. About 10% of children do not respond within the first 48-72 hours of treatment, and antibiotic therapy may have to be changed. Even after antibiotic treatment, some children are left with some fluid in the middle ear which can cause temporary hearing loss lasting for up to 3 to 6 weeks. In most children, this fluid eventually disappears spontaneously (on its own). Ceftriaxone (50mg/kg/d) injection is recommended for children that cannot take oral antibiotics; three days of this antibiotic is usually more effective than a single injection.

Children who have recurring bouts of otitis media may be referred to an otolaryngologist (ear nose and throat specialist or ENT). Some of these children may benefit from having an ear tube placed (tympanostomy tube) to permit fluid to drain from the middle ear. In addition, if a child has a bulging eardrum and is experiencing severe pain, a procedure to lance the eardrum (myringotomy) may be recommended to release the pus. The eardrum usually heals within a week. Prophylactic antibiotic therapy has not been shown to decrease the frequency of ear infections in those children with recurrent AOM.

Although treatment may cure an ear infection, it is possible for the ear to become re-infected.

Quick GuideEar Infection Symptoms, Causes, and Treatment

Ear Infection Symptoms, Causes, and Treatment

Are there any home remedies for acute middle ear infection?

Although there are a number of suggested home remedies for the treatment of ear infections, including humidified air, homeopathic treatments, naturopathic ear drops, decongestants, and antihistamines; there are limited studies suggesting the benefits of these measures over accepted and recommended treatments. Both oral and topical analgesics are effective in controlling the pain associated with ear infections, but the use of decongestants or antihistamines has not been demonstrated to improve symptoms or speed the resolution of acute otitis media.

What causes chronic middle ear infection or inflammation?

The Eustachian tube normally prevents the accumulation of fluid by allowing fluid to drain through the tube. Chronic otitis media develops over time, and often starts with a chronic middle ear effusion (fluid) that does not resolve. This persistent fluid will often become contaminated with bacteria, and the bacteria found in chronic otitis media are often different from those found in acute otitis media. Therefore, anything that disturbs the function of the Eustachian tube can lead to chronic otitis media.

In some individuals that are ill from other diseases, if there is pus draining from the ear, there is a danger that otitis media (especially bacterial-caused) may invade the mastoid bone and reach the brain. These individuals need to be seen urgently by a health-care professional. Do not delay treatment by trying home remedies.

What happens to the eardrum in chronic middle ear infection or inflammation?

The eardrum (tympanic membrane) has three delicate layers that help keep the eardrum thin, but strong. A chronic middle ear infection causes changes in the eardrum that weaken it, and often lead to a hole in the eardrum (tympanic membrane perforation). Eventually, the eardrum loses its strength and begins to collapse into the middle ear space.

When the eardrum collapses or retracts from negative pressure in the middle ear, it can attach to the other middle ear structures. It is frequently seen draped around the middle ear bones (ossicles) or the inner wall of the middle ear (promontory). This disrupts the conduction of sound through the middle ear, and may diminish hearing.

What happens to the eardrum if a hole develops in the eardrum?

A hole that forms in the eardrum (tympanic membrane perforation) usually causes a chronic draining ear, or a condition called chronic otitis media with perforation. Often the drainage (otorrhea) will have a foul odor and can be seen draining from the ear. Hearing can improve after the middle ear fluid is released, or it may worsen secondary to the inflammation in the middle ear.

How is chronic middle ear infection or inflammation treated?

Initially, antibiotics may resolve the ear infection. If a tympanic membrane perforation also is present, topical antibiotic drops may be used. If eardrum or ossicle scarring has occurred, that will not be reversed with antibiotics alone. Surgery often is indicated to repair the tympanic membrane (eardrum), remove the infected tissue and scar from the middle ear and the mastoid bone. Long-term prophylactic antibiotics are not recommended.

What are the goals of chronic otitis media surgery?

The goals of surgery are to first remove all of the infected tissue so that it can be "safe" from recurrent infections. The second goal is to recreate a middle ear space with an intact eardrum. Finally, hearing is to be restored. This may seem strange that hearing is the last priority, but if the first two priorities are not met, anything that is done to improve hearing will ultimately fail. If hearing is restored, but the infection returns, the hearing will be lost again. Likewise, if hearing is restored, but the middle ear space is not recreated, the eardrum will re-stick to the middle ear or the ossicles.

What is serious middle ear infection or inflammation?

Serous otitis media is inflammation in the middle ear without infection. Typically, the Eustachian tube is not functioning and cannot ventilate the ear normally. As a result, fluid accumulates in the middle-ear. This can lead to a dullness or fullness within the ear along with diminished hearing.

Which specialties of doctors treat middle ear infections?

The majority of children and adults are diagnosed and treated by either pediatricians, primary health care doctors, emergency or urgent care medical providers, or other health care professionals. ENT specialists may be consulted for some individuals. Rarely, a neurologist or neurosurgeon may be needed if a severe infection that may extend to other organ systems occur.

What limitations are there on a child with middle ear infection or inflammation?

Otitis media is not contagious (although the initial cold that caused it may be). A child with otitis media can travel by airplane but, if the Eustachian tube is not working well, the pressure change as the plane descends may cause the child pain. It is best not to fly (or swim) with a draining ear. You should always consult your physician if you have specific concerns.

Can otitis media (middle ear infection or inflammation) be prevented?

Currently the best way to prevent acute otitis media is to assure a child is vaccinated. Ensuring that your child receives an annual flu vaccine and is up to date with his/her pneumococcal vaccine is the best way to prevent the most common causes of middle ear infections (otitis media). In addition both early and sustained breastfeeding (for at least 6 months) and avoidance of tobacco spoke exposure have been shown to be related to fewer ear infections. Recent studies suggest that Xylitol based gum or lozenges may have a preventive impact on acute otitis media. Unfortunately it cannot be used in young children, and must be used 3-5 times a day during the cold and flu season to be effective.

REFERENCES:

Coleman et al. Cochrane Database Syst Rev 2008 July 16;(3)

Donaldson, J.D., MD. "Acute Otitis Media." Medscape. Updated: May 26, 2016.
<http://emedicine.medscape.com/article/859316-overview>

Lieberthal A et al. Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media. Pediatrics. March 2013. 131:3.e964-e999.

Natal, B.L., MD. "Emergent Management of Acute Otitis Media." Medscape. Updated: Aug 31, 2015.
<http://emedicine.medscape.com/article/764006-overview>

Rennie, C.E. "Pneumatic Otoscope Examination." Medscape. Updated: Feb 05, 2016.<http://emedicine.medscape.com/article/1348950-overview>

Last Editorial Review: 3/16/2017

Reviewed on 3/16/2017
References
REFERENCES:

Coleman et al. Cochrane Database Syst Rev 2008 July 16;(3)

Donaldson, J.D., MD. "Acute Otitis Media." Medscape. Updated: May 26, 2016.
<http://emedicine.medscape.com/article/859316-overview>

Lieberthal A et al. Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media. Pediatrics. March 2013. 131:3.e964-e999.

Natal, B.L., MD. "Emergent Management of Acute Otitis Media." Medscape. Updated: Aug 31, 2015.
<http://emedicine.medscape.com/article/764006-overview>

Rennie, C.E. "Pneumatic Otoscope Examination." Medscape. Updated: Feb 05, 2016.<http://emedicine.medscape.com/article/1348950-overview>

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