General ENT

Ear Infections


Acute Otitis Media

Introduction

Acute otitis media is an ear infection of the middle ear. It can effect children and adults and happens when the eustachian tubes get blocked by swelling. Mucus, pus, and bacteria build up behind the eardrum, causing pressure, pain and hearing loss and can lead to eardrum rupture. Ear infections usually start with a cold or sinus infection, but can occur on their own. Although adults can get ear infections, they are most common young children. A child's eustachian tubes are narrower, shorter and more horizontally placed than an adults’.  This makes it easier for fluid to get trapped in the middle ear.  In studies, 75% of children get at least one ear infection. They happen most often in the first year of life. By age 1, 60% of children will have had at least one ear infection and 17% will have had 3 or more.

Ear infections usually resolve on their own. Current guidelines from the American Academy of Pediatricians (AAP) suggests taking a wait-and-see approach for the first 72 hours of an acute infection. With a severe ear infection, pressure may build up and cause the eardrum to rupture. Pus and blood may drain out. This usually decreases pain and pressure, and in most cases the eardrum heals on its own.

Symptoms of Acute Otitis Media

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 after the infection resolves.  This leaves clear fluid behind and frequently is associated with a sense of ear plugging and decreased hearing, but rarely pain.

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.

Risk Factors

Risk factors for otitis media include:

  • Young children between are more likely to get ear infections.
  • Daycare
  • Cold, flu or sinus infection.
  • Allergies, also called allergic rhinitis.
  • Exposure to cigarette smoke
  • Family members with ear infections.
  • Using a pacifier.
  • Gastroesophageal reflux disease (GERD).
Treatment

The first step in treating acute otitis media is a thorough evaluation by your primary care physician or Comprehensive ENT physician This will include listening to the patient’s story and examination of the ear, nose, and throat. Depending on the individuals unique situation, further testing may include a hearing test, tympanometry (a pressure test of the middle ear) and uncommonly CT or MRI scan.

Treatment depends upon the severity of the disease. Goals include clearing the infection, relieving pain and hearing and other symptoms, and preventing future ear infections. If a bacterial infection is present, your doctor may prescribe oral and topical antibiotics.

However, most ear infections resolve on their own. Antibiotics tend to be overused for treating ear infections. For this reason children may develop  bacteria resistant to antibiotics most commonly used to treat otitis media.  The AAP and the American Academy of Family Physicians guidelines recommend taking a wait and see approach for 72 hours if:

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

Your Comprehensive ENT physician may recommend using over-the-counter pain relievers. Before giving any medication to a child you should talk to your pediatrician.

Prevention is very important.

You can reduce you or your child's risk of ear infections by:

  • NOT exposing your child to secondhand smoke.
  • 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.
  • Avoid use of a pacifier.

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

Medications
  • Antibiotics. If your doctor prescribes antibiotics, be sure to give your child all the doses as prescribed. The antibiotic most often prescribed for an ear infection is amoxicillin, unless the patient is allergic to penicillin. Patients treated with antibiotics can develop vomiting, diarrhea, or a rash.  You should contact your prescribing physician for these symptoms.
  • Ear drops. If the eardrum is ruptured (has a hole in it) your doctor may prescribe antibiotic ear drops instead of oral antibiotics. Current recommendations for patients with ear tubes or perforations present are to use antibiotic drops before oral antibiotics.
  • Ibuprofen, acetaminophen. Ask your doctor about using over-the-counter oral medications for pain or fever, such as ibuprofen (Advil, Motrin) or acetaminophen (Tylenol).
Surgery (Myringotomy and PE Tube Placement)

If the patient has recurring ear infections that do not respond to antibiotics, or if the fluid in the ear affects hearing, your Comprehensive ENT physician may suggest putting in PE tubes. This surgery requires general anesthesia for children but can often be done in the office under local anesthesia for adults. The surgeon inserts a small drainage tube through the eardrum. Fluid behind the eardrum can drain out, equalizing the pressure between the middle and environment. The eardrum usually pushes the tubes out on their own over the ensuing 6-18 months.

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

Other Considerations

Precautions

Swimming and diving underwater may make an ear infection worse. If you or your child has a ruptured eardrum, they should avoid diving completely under the water. “Dry ear precautions” are no longer required, but sometimes are recommended.  Swimming is still OK in most situations.  Your Comprehensive ENT physician will advise you.

Outcomes

Usually, an ear infection is a simple condition without complications. Most patients will have temporary hearing loss during and soon after ear infections. Permanent hearing loss is rare, however the risk increases with recurrent ear infections. Other potential complications include:

  • Ruptured or perforated eardrum
  • Chronic otitis media
  • Recurrent ear infections
  • Mastoiditis, an infection of the bones around the skull
  • Speech or language delay in a child with lasting hearing loss from multiple ear infections or persistent fluid

Chronic Otitis Media

What is Chronic Otitis Media?

Chronic Otitis Media (COM) is the term used to describe a number of problems that result from the long-term damage to the middle ear by infection and/or inflammation. These include the following:

  • Severe retraction or perforation of the eardrum (a hole in the eardrum)
  • Scarring or erosion of the sound conducting bones of the middle ear
  • Chronic or recurring drainage from the ear
  • Inflammation causing erosion of the bony cover or the facial nerve, balance canals, or cochlea (hearing organ)
  • Erosion of the bony borders of the middle ear or mastoid, which, in severe infections can result in infection spreading to the the lining of the brain or the brain itself
  • Presence of cholesteatoma, a skin cyst that grows within the middle ear or mastoid space
  • Persistence of fluid behind an intact eardrum
How Does Chronic Otitis Media Occur?

If the eustachian tube becomes blocked due to swelling or congestion in the nose, by swelling of the lining of the middle ear, or by swelling of the mucous membrane of the eustachian tube itself, the air pressure in the middle ear cannot equalize properly. Negative pressure develops, and if the obstruction is prolonged, fluid may be drawn into the air space of the middle ear from the middle ear lining. This may occur with a cold or flu virus or a sinus infection or allergies and is a common cause of ear infections in children (serous otitis media). Serous otitis media usually resolves without treatment, but may require a course of antibiotics or steroids. It is a common reason for placement of tubes in children and adults if the fluid persists for a long time or repeated infections occur.

If the eustachian tube blockage persists, chronic changes in the tissue of the middle ear begin to occur. First, the mucous become thicker, and less likely to drain. Then the lining itself can begin to thicken and become inflamed. The defense mechanisms of the eustachian tube and middle ear become compromised and bacteria normally present in the nose can the middle ear and cause a painful condition called acute otitis media. This responds to antibiotic treatment, but may require placement of tubes.

The negative pressure in the middle ear or alternating periods of negative, normal and positive pressure may deform the eardrum. Over time, the eardrum may become severely distorted, thinned, or even perforated. These changes may cause hearing loss and a sensation of pressure. When there is a hole in the eardrum, the natural protection of the middle ear from the environment is lost. Water and bacteria entering the middle ear from the ear canal can cause repeated inflammation and infection. Drainage from the ear is a common sign of a perforation.

Inflammation and infection in time can cause erosion of the middle ear ossicles and the walls of the middle and inner ear. This can lead to hearing loss, imbalance, or weakness of facial movement. In rare cases, the infection may extend deeper into the head, causing meningitis or brain abscess.

A cholesteatoma, or skin cyst, is essentially skin from the ear canal trapped under the eardrum. Skin from the ear canal or outside surface of the eardrum, is the as skin on the rest of our bodies and does not belong in the middle ear. If it becomes trapped or grows through a perforation, it can build up and can cause damage to the structures of the middle ear, inner ear and/or mastoid.

How Do I Know If I Or My Child Have Chronic Otitis Media?

Warning signs of chronic otitis media include:

  • Persistent blockage of fullness of the ear
  • Hearing loss
  • Persistent ear drainage
  • Development of balance problems
  • Facial weakness
  • Persistent deep ear pain or headache
  • Fever

Chronic otitis media can occasionally develop over several months in a patient with no previous history of ear disease. Any of the above symptoms should prompt an evaluation by an ENT.

How is Chronic Otitis Media Treated?

The first step in treating chronic otitis media is a thorough evaluation by an ENT physician. This will include a history and examination of the ear, nose, and throat. Depending on the individuals unique situation, further testing may include a hearing test, tympanometry (a pressure test of the middle ear) and CT or MRI scan.

Treatment depends upon the severity of the disease. In the beginning, efforts to control the causes of eustachian tube obstruction, such as allergies or other infectious problems, may prevent progression of chronic otitis media. Uncomplicated chronic ear fluid is treated with antibiotics, steroids, and/or placement of ventilation tubes. Many children and adults with chronic or recurrent ear infections have ventilation tubes inserted in their eardrums to allow normal air exchange in the middle ear until the eustachian tube matures or underlying causes of the eustachian tube dysfunction can be treated.

If the disease has progressed enough to cause damage to the eardrum or ossicles, more intensive treatment is usually needed. If active infection is present in the form of ear drainage, antibiotic eardrops or oral antibiotics are prescribed. Once the active infection is controlled, surgery is usually recommended. There are three objectives of surgery for COM:

  • First, creation of a safe dry ear which depends upon eradication of the disease
  • Repair of the middle ear and mastoid bone to prevent recurrence
  • Preservation or improvement in hearing

Surgeries to achieve these objectives include tympanoplasty, mastoidectomy, or typanomastoidectomy. Your Comprehensive ENT doctor will know what treatments you or your child needs.

No matter what treatments for Chronic otitis media are needed, Routine Checkups by your ENT are recommended at least yearly until resolution of the ear problems is confirmed.

Acute Otitis Externa or Swimmer’s Ear

Acute otitis externa or swimmer’s ear is an infection of the external ear. and/or ear canal. It can effect children and adults. These infections usually result from the ear canal being exposed to water repeatedly or remaining wet after showers, swimming or being irrigated to remove wax.  They also can be caused by ear trauma from Q tips or other objects being inserted into the ear canals. These infections are usually painful and symptoms can include ear drainage and decreased hearing. They are frequently treated with antibiotic ear drops and may require the ear canal to be cleaned first. If persistent or severe, oral antibiotics may be prescribed. Your Comprehensive ENT physician will advise you on what treatments are needed. These infections can be recurrent, but frequently can be prevented with good ear hygiene.

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