Ear infections are very common in children and are normally caused by bacteria or viruses. The most common ear infections are middle ear infections also referred to as acute otitis media.

ear infections, ear drops

DEFINITION:

An ear infection, or acute otitis media, is defined as the presence of fluid in the middle ear along with symptoms of an acute illness

SYMPTOMS:

  • Ear pain
  • Fever
  • Throat pain
  • Fussiness
  • Irritability
  • Pulling at the ears
  • No symptoms at all (sometimes)

DIAGNOSIS:

A physician will look into the ear using an otoscope with an insufflator. If the eardrum is not moving well with insufflation and the color of the eardrum is red instead of its normal white, a diagnosis of acute otitis media can be made.

TREATMENT:

Close observation with good follow-up:

  • Antibiotics
  • Pain medications
  • Tonsillectomy
  • Adenoidectomy
  • Tympanocentesis- taking the fluid out of the middle ear through a needle
  • Tympanostomy tubes

CAUSES:

Most ear infections are caused by bacteria, some are caused by viruses, and some have no identifiable cause. The most common bacteria are called Streptococcus pneumoniae at 50%, then Haemophilus influenzae at 30%, Moraxella catarrhalis at 15%, and Streptococcus pyogenes at 5%. Ear infections occur most commonly in children from 6 months to 6 years of age. Risk factors which increase the chances of getting an ear infection include:

  • Daycare attendance
  • Exposure to cigarette smoke
  • Winter months
  • Family history of ear infections
  • Lack of breast feeding
  • Maxillofacial abnormalities such as cleft palate
  • Bottle propping
  • Prior history of ear infections

OUTCOME:

Overall, ear infections clear with no problems. There is a concern about permanent hearing loss with multiple ear infections or an ear infection that won’t go away with proper treatment. Complications can include mastoiditis, which is an infection of the bone behind the ear, and meningitis, which is the infection entering the intracranial space, or the brain and spinal cord.

DISCUSSION:

Ear infections are one of the most common reasons for a child to visit his or her pediatrician. Most children with an ear infection experience a lot of pain and discomfort, and parents want to do anything to make their child feel better. Once the physician diagnoses an ear infection, a decision can be made about treatment. Most doctors prefer to treat ear infections with antibiotics and, if an antibiotic is used, amoxicillin is the drug of choice.

The reason for this is that amoxicillin will cause the least amount of bacterial resistance, has few side effects, is inexpensive, and works as well as any of the more expensive medicines. If amoxicillin fails, then there are multiple choices for a second antibiotic.

In addition, acetaminophen (Tylenol, Tempra), ibuprofen (Motrin, Advil), numbing eardrops, and warm compresses can be used. Another valid option is to avoid antibiotics and let the infection run its course. Most ear infections will go away without treatment. This option has both advantages and potential drawbacks. One advantage is that by avoiding antibiotics you avoid their potential complications, such as upset stomach, allergic reactions, yeast infections, trying to force a medication into an unwilling child’s mouth, and creating resistance in your child.

Every time a child takes an antibiotic, all susceptible organisms are destroyed, giving resistant organisms a chance to grow. As whole communities use antibiotics, pressure is put on the organism to mutate, and then it becomes resistant in order to survive. So, being on an antibiotic may be harmful not only to a child, but also an entire community by effecting then perpetuating a resistant organism. Before the days of antibiotics, children got ear infections and generally did well.

The potential drawbacks come from possible complications of an untreated ear infection. These include:

Mastoiditis (an infection of the bone behind the ear), and rarely meningitis where the bacteria invade the intracranial area and the brain

In order for antibiotics to be withheld, the child should be older than two years, have no underlying immunodeficiencies, have had no ear infections in the last three months, and have parents willing to watch and wait. In addition, these children should be rechecked in 48 to 72 hours, and acetaminophen, ibuprofen, ear drops, and compresses may be used to help with the symptoms.

The use of steroids is controversial in the treatment of acute otitis media. Some physicians feel that they lessen the inflammation associated with ear infections, thereby allowing easier clearing of the middle ear; others feel that steroids do nothing. Cold medicines including antihistamines, decongestants and cough suppressants seem to be no help in preventing ear infections. If ear infections persist despite antibiotic treatment, the next step may be taken.

If fluid persists behind the eardrum, there is the potential for hearing loss. To prevent this, the fluid can be removed. This can be done by tympanocentesis, where a needle is put through the eardrum and fluid is pulled out. The fluid can then be sent for culture to determine the exact cause of infection. Also, tympanostomy tubes can be placed in the eardrum. This is the most common surgical treatment for children. According to the Agency for Health Care Policy and Research, tubes should be placed in children who have persistent fluid with hearing loss from four to six months. Again, the removed fluid can then be cultured.

The tube allows fluid to flow out of the ear canal, decreasing pain and the potential for hearing loss. In many cases, children will not get another ear infection after tube placement. In some children, removal of the adenoids may allow for fluid drainage from behind the ear, and down the Eustachian tube to the throat. In rare instances, removal of the tonsils along with the adenoids may be of some benefit. Vaccinations show some promise in preventing acute otitis media or ear infections. The new pneumococcal vaccine is estimated to lessen the incidence of ear infections by 10% to 20% by making children immune to the most common bacterial cause of ear infections: Streptococcus pneumoniae.

ONE DOCTOR’S OPINION:

With the exception of colds, I see ear infections more than anything else. I still use antibiotics, and I try to use amoxicillin whenever possible. I explain to parents that this is still the best medicine to use first because it causes the least amount of resistance. Also, higher doses are used now, i.e., 80 mg. per kg. of body weight, instead of 40 mg. per kg. of body weight as this seems to work for some of those resistant bugs.

Something I never do, and which I believe should never be done, is to have an antibiotic called in over the telephone. Antibiotics are not over-the-counter medications, nor should they be. They can be dangerous if used improperly. I can’t tell you how many times a parent wanted an antibiotic called in, and on examination I find a pebble in the ear, a perforated ear drum or hole in the ear drum, a more complicated infection for which oral antibiotics don’t work, or a swimmer’s ear requiring ear drops instead of an antibiotic. The best thing to do when you think your child has an ear infection is to see your physician and, until then, use acetaminophen, ibuprofen, numbing ear drops and warm compresses.

Written by Dr. Michael Bornstein, who has over 28 years of experience as a pediatrician. 

Disclaimer: The contents of this article, including text and images, are for informational purposes only and do not constitute a medical service. Always seek the advice of a physician or other qualified health professional for medical advice, diagnosis, and treatment.