Disease: Middle Ear Infection or Inflammation
(Otitis Media)

    Ear infection or inflammation (otitis media) facts

    • Otitis media (ear infection or inflammation) is the most common childhood condition for which antibiotics are prescribed.
    • Otitis media features fever, ear pain, and a feeling of fullness in the ear; as well as fussiness and feeding problems in young children.
    • Otitis media is usually an infection and/or inflammation of the middle ear.
    • Ear infection or inflammation causes fluid buildup in the middle ear.
    • A cold or other respiratory infection can lead to ear infections or inflammation.
    • Exposure to other children's colds as often occurs in daycare centers, raises the risk of contracting otitis media (ear infection or inflammation).
    • Bottlefeeding increases the risk of ear infection or inflammation in babies.
    • Middle ear pus causes pain and temporary hearing loss.
    • Rupture of the eardrum allows the pus to drain into the ear canal.
    • Otitis media (ear infection or inflammation) is treated with observation, antibiotics, or ear tubes.

    What is otitis media (middle ear infection or inflammation)?

    Otitis media is inflammation of the middle ear; however, many doctors consider otitis media to be either inflammation or infection of the middle ear. "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.

    Acute otitis media is usually of rapid onset and short duration. Acute otitis media is typically associated with fluid accumulation in the middle ear together with signs or symptoms of ear infection; a bulging eardrum usually accompanied by pain, or a perforated eardrum, often with drainage of purulent material (pus, also termed suppurative otitis media). Fever can be present.

    Chronic otitis media is a persistent inflammation of the middle ear, typically for a minimum of a month. This is in distinction to an acute ear infection (acute otitis media) 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. Chronic otitis media may develop after a prolonged period of time with fluid (effusion) or negative pressure behind the eardrum (tympanic membrane). Chronic otitis media can cause ongoing damage to the middle ear and eardrum, and there may be continuing drainage through a hole in the eardrum. Chronic otitis media 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 otitis media.

    Picture of the Ear Anatomy

    What are the symptoms of acute middle ear infection?

    Young children with otitis media may be irritable, fussy, or have problems feeding or sleeping. Older children may complain about pain and fullness in the ear (earache). Fever may be present in a child of any age. These symptoms are often associated with signs of upper respiratory infection such as a runny or stuffy nose, or a cough.

    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 with medical treatment.

    How common is acute middle ear infection or inflammation?

    Otitis media is an extremely common diagnosis. In the U.S. it is estimated that 75% of all children experience at least one episode before the age of three.

    "Are ear infections contagious?

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

    Why do 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 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. The result is that children are at greater risk of acquiring ear infections than adults.

    How does the Eustachian tube change as a child gets older?

    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.

    What microorganisms cause middle ear infection or inflammation?

    Bacteria and viruses can cause otitis media. Bacteria such as Streptococcus pneumoniae (pneumococcus), nontypable 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.

    What is the relationship between bottlefeeding and middle ear infection or inflammation?

    Bottlefeeding is a risk factor for developing otitis media. 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 a child needs to be bottlefed, it is best to hold the infant rather than allow the child to lie down with the bottle. Ideally, the child should not take the bottle to bed. (In addition to increasing the chance for acute otitis media, falling asleep with milk in the mouth enhances the risk of tooth decay.)

    What are the risk factors for acute middle ear infection or inflammation?

    Children often develop upper respiratory infections prior to developing acute otitis media. 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, also increases the chance of otitis media. Children with cleft palate or Down syndrome are more prone to ear infections. Any problems with the Eustachian tubes (for example, blockage, malformation, inflammation) will increase the risk of otitis media.

    Children who have episodes of acute otitis media before six months of age tend to have more ear infections later in childhood.

    How is acute otitis media 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 three acute otitis media episodes in 6 months or 4 acute otitis media episodes in a year. 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
    Age
    Certain 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 months

    Antibiotics
    Antibiotics if severe illness; *Observation without antibiotics if non-severe illness
    ≥2 years Antibiotics Antibiotics 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 new 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.

    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.

    Are there any home remedies for acute ear infection (otitis media)?

    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.

    In some patients that are ill from other diseases, have pus draining from the ear, or are immunocompromised, there is a danger that otitis media, especially bacterial-caused, may invade the mastoid bone and reach the brain. These patients need to be seen urgently by a medical caregiver; do not delay their treatment by trying home remedies.

    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.

    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 looses its strength and begins to collapse into the middle ear space.

    When the eardrum collapses, 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 infection. If a tympanic membrane perforation is also present, topical antibiotic drops may be used. If eardrum or ossicle scarring has occurred, that will not be reversed with antibiotics alone. Surgery is often 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.

    What are the symptoms of acute middle ear infection?

    Young children with otitis media may be irritable, fussy, or have problems feeding or sleeping. Older children may complain about pain and fullness in the ear (earache). Fever may be present in a child of any age. These symptoms are often associated with signs of upper respiratory infection such as a runny or stuffy nose, or a cough.

    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 with medical treatment.

    How common is acute middle ear infection or inflammation?

    Otitis media is an extremely common diagnosis. In the U.S. it is estimated that 75% of all children experience at least one episode before the age of three.

    "Are ear infections contagious?

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

    Why do 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 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. The result is that children are at greater risk of acquiring ear infections than adults.

    How does the Eustachian tube change as a child gets older?

    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.

    What microorganisms cause middle ear infection or inflammation?

    Bacteria and viruses can cause otitis media. Bacteria such as Streptococcus pneumoniae (pneumococcus), nontypable 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.

    What is the relationship between bottlefeeding and middle ear infection or inflammation?

    Bottlefeeding is a risk factor for developing otitis media. 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 a child needs to be bottlefed, it is best to hold the infant rather than allow the child to lie down with the bottle. Ideally, the child should not take the bottle to bed. (In addition to increasing the chance for acute otitis media, falling asleep with milk in the mouth enhances the risk of tooth decay.)

    What are the risk factors for acute middle ear infection or inflammation?

    Children often develop upper respiratory infections prior to developing acute otitis media. 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, also increases the chance of otitis media. Children with cleft palate or Down syndrome are more prone to ear infections. Any problems with the Eustachian tubes (for example, blockage, malformation, inflammation) will increase the risk of otitis media.

    Children who have episodes of acute otitis media before six months of age tend to have more ear infections later in childhood.

    How is acute otitis media 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 three acute otitis media episodes in 6 months or 4 acute otitis media episodes in a year. 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
    Age
    Certain 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 months

    Antibiotics
    Antibiotics if severe illness; *Observation without antibiotics if non-severe illness
    ≥2 years Antibiotics Antibiotics 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 new 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.

    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.

    Are there any home remedies for acute ear infection (otitis media)?

    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.

    In some patients that are ill from other diseases, have pus draining from the ear, or are immunocompromised, there is a danger that otitis media, especially bacterial-caused, may invade the mastoid bone and reach the brain. These patients need to be seen urgently by a medical caregiver; do not delay their treatment by trying home remedies.

    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.

    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 looses its strength and begins to collapse into the middle ear space.

    When the eardrum collapses, 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 infection. If a tympanic membrane perforation is also present, topical antibiotic drops may be used. If eardrum or ossicle scarring has occurred, that will not be reversed with antibiotics alone. Surgery is often 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.

    Source: http://www.rxlist.com

    Otitis media is an extremely common diagnosis. In the U.S. it is estimated that 75% of all children experience at least one episode before the age of three.

    Source: http://www.rxlist.com

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