EAR INFECTIONS
Ear infections are the single most common illness diagnosed by
pediatricians. Two thirds of all children have at least one ear
infection by three years of age, and one third of all children have
three or more ear infections by age three. The incidence of ear
infections peaks at seven to nine months of age and declines thereafter
except for a slight upswing at five to six years of age due to school
entry.
The medical term for ear infections is "otitis media", an inflammation
of the middle ear. This is different from swimmer's ear, or "otitis
externa", an inflammation of the ear canal. The middle ear is a small
space behind the eardrum that is normally filled with air and also
contains the tiny ear bones known as ossicles. The middle ear is
connected to the nose and throat by a narrow canal called the eustachian
tube. The eustachian tube keeps the pressure between the middle ear and
the ear canal equal, allowing the eardrum to vibrate in response to
soundwaves. This free vibration of the eardrum allows the transmission
of soundwaves to the ossicles inside the middle ear, and then through
nerves to the brain. This is how we hear.
Otitis media occurs when fluid builds up in the middle ear and then
becomes infected. The fluid buildup occurs because of poor drainage
through the eustachian tube. Eustachian tube drainage is most often
impaired because of swelling in the nose and throat because of a cold or
allergies. This is why most ear infections occur during or shortly
after colds or allergic episodes. Other causes of poor drainage of the
middle ear through the eustachian tube are enlarged adenoids and
exposure to cigarette smoke.
Since most ear infections occur with or after colds, efforts to reduce
the frequency of ear infections rely mostly on decreasing the frequency
of colds. Breast-feeding has been shown to reduce the occurrence of ear
infections, most likely by strengthening the infant's immune system.
Minimizing exposure to other young children also is helpful, as infants
and young children in day care have more ear infections. Other things
parents can do to reduce the likelihood of ear infections in their
children are not smoking cigarettes or exposing children to cigarette
smoke, and avoiding feeding an infant with a bottle while he or she is
lying down flat.
Ear pain is the most common symptom of otitis media. Because the pain
of otitis media is a result of increased pressure behind the eardrum due
to the presence of pus in the middle ear, pain will often be more severe
when the child is lying down. In infants, irritability or poor sleeping
may be the main symptoms of an ear infection. Fever occurs in many
children with ear infections, but is not always present. Its presence
is more common in younger patients. Other symptoms of ear infections
are hearing loss, loss of balance, and drainage from the ear canal. Not
all children who complain of earache have otitis media. Other causes of
ear pain are swimmer's ear, throat or tooth infections, and
temporomandibular joint (TMJ) disorders. Ear infections usually do not
cause the ear to hurt when touched or pulled; this is more commonly seen
in swimmer's ear.
Although most ear infections are caused by bacteria, about one third
are caused by viruses. This explains why some ear infections will
resolve on their own without treatment. Unfortunately, it is not
possible to tell by physical examination which ear infections are caused
by bacteria and which by viruses. For this reason, it has become
standard in this country to treat all diagnosed ear infections with
antibiotics. In some countries in Europe, pediatricians do not treat
all ear infections immediately with antibiotics, waiting instead to
treat only those that do not resolve on their own after a few days. It
is important to realize that other than the pain they cause, ear
infections are not dangerous or harmful, and there is no danger to
waiting even several days before antibiotic treatment. Pain relief can
usually be achieved with acetaminophen (Tylenol ®) or ibuprofen (Advil ®, Motrin ®)
Other helpful measures are keeping the head elevated with
extra pillows and applying a warm compress to the painful ear.
Amoxicillin is usually the antibiotic used to treat ear
infections. This is because it is effective in the great majority of
ear infections, it tastes good and is easy to use, and it has fewer side
effects and is far less expensive than many of the other medicines
available. As with all antibiotics, it is important that the medicine
be used in the way that it is prescribed. A small percentage of ear
infections will not respond to Amoxicillin. It is not unusual for the
antibiotic to take a few days to work, but if your child is not much
improved after two to three days it is probably time to speak again with
the doctor. If you feel that your child is not all better after
treatment, you should bring him or her back for a re-check. In certain
situations, such as when a child has had many ear infections or has not
responded well to an antibiotic in the past, your doctor will recommend
a follow-up visit.
Some children get lots of ear infections. A child is said to be
"otitis-prone" if she or he gets more than four ear infections in a year
or more than three in six months. These children may be candidates for
some type of intervention aimed at preventing more infections. One
reason for trying to reduce the number of ear infections in these
children is that children with an ear infection have a temporary
decrease in their hearing. Children who get many ear infections spend a
lot of time with decreased hearing during a crucial time in their
development of speech and language. There is some evidence that
reducing the number of ear infections in these children will make them
less likely to have long-term problems with speech and language. In
addition, reducing the pain, inconvenience and expense of recurrent ear
infections are also important goals.
There are two ways of preventing or minimizing ear infections in
"otitis-prone" children. Administration of daily low dose
"prophylactic" antibiotics is effective in reducing ear infections in
most children who are prone to otitis media. Amoxicillin is also the
antibiotic most often used for this purpose. The other option is
placement of tympanostomy tubes in the eardrums to allow for pressure
equalization behind the eardrum and the prevention of fluid buildup
behind the eardrum. Because this surgical procedure requires general
anesthesia, most parents and pediatricians opt to try prophylactic
antibiotics first. Tubes are used when there is a persistence of fluid
behind the eardrum that is affecting hearing, or when parents prefer not
to give children a daily antibiotic or the daily antibiotic is not
effective in preventing ear infections.
Ear infections are not contagious, although the colds that often
accompany them are. If your child has an ear infection but is in good
spirits and acting well, he or she is no more contagious than other
children with colds, and can return to day care or school. There is
also no restriction on swimming with an ear infection. There is no
relation between getting ears or hair wet and ear infections. However,
it can be harmful to the ear to dive into deep water with an ear
infection. The pressure of deep water can cause an infected ear to be
more painful or even perforate a hole in the eardrum. Flying with an
ear infection can be painful, and it is possible that changes in cabin
pressure can damage an infected ear. Although there is no unanimous
opinion among ear specialists, most pediatricians and ear specialists
agree that after several days of antibiotics, the risk of damage to the
ear from flying is very minimal.
If you think that your child might have an ear infection, give him or
her acetaminophen or ibuprofen, and try some of the other comfort
measures mentioned above. Pain medications generally take 30-45 minutes
before they work. If all else fails and you cannot get your child to
fall asleep, it is worth trying a dose of diphenhydramine (Benadryl ®) to see
if it will help her or him sleep. It is necessary for us to examine
your child in order to diagnose an ear infection, so we will need to see
the child in the office before prescribing an antibiotic if the child
does have otitis media. We all feel very strongly that it is not good
medical care to prescribe oral antibiotics over the telephone, and we
hope that you will understand this policy. It is very rare that the
above measures are not successful at keeping a child comfortable until
he or she can be seen in the office for a proper diagnosis.
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