(OTITIS MEDIA)

Otitis media mean inflammation of the middle ear. The middle ear is a small space located behind the eardrum. An acute otitis media may be caused by a bacterial infection behind the eardrum. It usually comes as a complication of a cold. Some are caused by viruses. It is not possible to tell which ear infections are bacterial or viral simply by the physician looking at the eardrum. The reason ear infections are common in children is because the eustachian tube, which is the tube between the middle ear and the back of the nasal passage, is short and straight compared to adults. This tube becomes blocked and does not function well in the presence of congestion. Fluid then builds up in the middle ear and may become infected.

Most common in children 6 months till 2 or three years, but can occur at any age, even newborns.

Signs of an acute ear infection may include:

• Fussy babies who don't eat well or pull off the bottle or breast
• Not sleeping well
• Usually with a cold, but occasionally without signs of a cold
• May or may not have a fever
• Pulling on the ear (pullling on the ear in a happy, non-sick child may be a sign of teething)
• Not hearing well, talking loudly, ignoring normal voice tones, television volume increased
• Older child complaining of pain

Situations that will increase risk of ear infection include:

• Daycare
• Smoking environment
• Taking a botttle or nursing with the baby lying flat
• Family history of lots of ear infections, allergies (from foods, animals, dust, mold or pollens)
• Flying (especially with a cold)
• Swimming underwater and diving into the water
• Enlarged adenoids (see adenoids in the treatment section below).

Any of these risk factors may need to be addressed with your physician to see if there is something that may be done preventatively. Sometimes a trial off dairy products may be helpful if allergies are playing a role for ear infections.

• 5 to 10% of children may rupture the eardrum with an acute ear infection and yellow, thin possibly bloody fluid may be noted coming from the ear. These will usually heal within a couple weeks.
• When seen in the office, some children may have serous otitis, fluid in the middle ear that is not infected and usually without symptoms of pain. This may accompany a cold or may be present after an acute infection has already been treated with antibiotics. Your doctor may elect not to treat this with antibiotics depending on the situation.
• Serious complications of a middle ear infection can include meningitis (an infection of the fluid surrounding the brain and spinal cord) and mastoiditis (an infection of the mastoid bone that is around the middle ear).
• Another concern about ear infections involves hearing loss and language development. Fluid that stays in the middle air space for a long period of time may eventually cause hearing loss and may impair language development and behavior.
• Many young children (4 months to 18 months) may pull on their ears with teething. These children usually do not have a cold and sleep fine.
• Swimmer’s ear (otitis externa) is an infection of the skin of the ear canal. There is usually a history of swimming and pain with movement of the earlobe.
• Myths about ear infections: Getting water splashed in the ear, earwax, wind or being cold do not cause a middle ear infections.
• Ear infections are not contagious, but the viruses that cause a cold which leads to an ear infection is contagious.
• Home otoscopes to visualize the ear allow parents to diagnose ear infections are not very useful. The lights on these are not adequate and it takes a lot of training to see the eardrum and understand what it all means.
• At times a child is brought to the office with a cold for a day or two and the physician does not find an ear infection. If the cold continues, an ear infection may still develop and the child may return in 2 or 3 days with an obvious ear infection. Be alert to worsening of symptoms or if the cold does not seem to run its course in a week.

Earache/otitis media continued:

For the majority of simple earaches the doctor does not need to be contacted in the middle of the night, unless the home remedies have not worked and the child is in extreme pain. In that situation, the doctor may prescribe some ear drops for the pain and possibly some antibiotics until the child can be seen in the office. Note that even if your physician prescribes some antibiotics in the middle of the night, your child may still have pain for 24 to 48 hours after starting the antibiotics. Ibuprofen or acetaminophen are more helpful in relieving pain initially with the majority of ear infections. Also see associated protocols such as fever, congestion, cough for other concerns that may need immediate attention.

• Severe pain that has not responded to any home remedies
• History of any penetrating ear trauma
• Stiff neck
• Redness, swelling and tenderness over the bone behind the ear
• Acting sick

• Earache especially when accompanied by: fever, loss of sleep, fussiness, ear discharge, poor appetite, pulling off the bottle or breast,
• History of swimming and pain with movement of the earlobe (swimmer’s ear)
• Child on antibiotics for an ear infection that is still having pain symptoms after 48 hours

Pain. Controlling the pain until the patient can be seen is the primary problem. The most severe pain occurs when an infection comes on rapidly, because of rapid stretching of the eardrum. The pain usually resolves if an eardrum perforates and you will see fluid coming out of the ear. Some very mild earaches may be due to temporary blockage of the eustachian tube and if not accompanied by any other symptoms, the child may be watched at home. Give appropriate dosages of acetaminophen or ibuprofen (see fever protocol for dosages). If you have prescription ear drops in the house for pain, these may be used as long as there is no discharge from the ear (an indication of a perforated eardrum). Your physician may prescribe these in the middle of the night if pain is severe. You may want to ask for a prescription at the office visit to have on hand if your child is prone to frequent ear infections. A warm compress over the ear may be helpful. Slightly warmed up cooking oil, garlic or mullein oil may also be helpful.

Antibiotics. Your physician will probably prescribe antibiotics when your child is diagnosed with an acute ear infection. However, some ear infections may not need antibiotics depending on the situation. There is more concern about overuse of antibiotics, so please discuss these issues with your physician at the office visit. Make sure you keep the medicine refrigerated if instructed by the pharmacy. Some antibiotics are taken with food and others must be taken on a empty stomach and some can be taken either way. Antibiotics that may be taken with food, may be mixed with food or drink. However, you must make sure the child will take the full amount. Symptoms of the earache should improve within 48 hours of starting the antibiotic. However, if cold symptoms such as congestion and cough are present, these do not necessarily improve with antibiotics. Antibiotics do have an expiration date, so be sure to discard after that date. Complete the entire course of antibiotics as directed, usually ten days, but some newer antibiotics only need to be taken for five days.

Over-the-counter medications. Antihistamine and decongestant combinations have not been proven to prevent ear infections when used to treat cold symptoms. They may be helpful in relieving the cold symptoms only.

Adenoids. Adenoids are lymph tissue (related to the tonsillar lymph tissue) located behind the nasal passage and is not visible by physical exam to the physician. Because of their proximity to the eustachian tube, they may affect eustachian tube function and contribute to frequent ear infections when enlarged. Signs of large adenoids include snoring and open mouth breathing. If your physician suspects large adenoids may be contributing to frequent ear infections, they may recommend surgery to have them removed.

Flying with an ear infection. It is generally not recommended to fly with a sick child with an acute painful ear. There is a small chance of triggering a perforation, although perforation may occur without flying. Many parents have inadvertently flown with children with an ear infection without any apparent problems. Discuss with your physician if you have any travel plans at the office visit. The decision may need to be based on the appearance of the eardrum and how sick the child is acting.

Ear wax. Ear wax production is normal and healthy, with some people producing more wax than others. Color can vary from whitish to dark brown. It acts as protection for the ear canal. It naturally becomes pushed out, but occasionally some people produce so much that it may become impacted in the ear canal. If you see wax around the edge, you may remove it with a washcloth or cotton swab. However, never insert cotton swabs into an ear canal to clean the wax. This only packs the wax in deeper. If your physician does note excess ear wax production, they may ask you to use an over-the-counter cerumen-softening agent and then some gentle irrigation with warm water.

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