Ear Infections

Introduction
Signs and Symptoms
Causes
Risk Factors
Screening and Diagnosis
Treatment
Outer Ear Infections

Ear infections are among the most common illnesses of early childhood. Three out of four children have had at least one ear infection by age 3, according to the National Institute on Deafness and Other Communication Disorders.

The medical term for middle ear infections is otitis media. Otitis refers to inflammation of the ear, and media means middle.

Although ear infections worry parents and make children uncomfortable, take heart. Most ear infections clear up on their own within a few days, and most children stop having ear infections once they reach school age.

Ear infections can be hard to detect, especially if your child is too young to say, "My ear hurts." Knowing what to look for can help. Children with ear infections may:

• Tug or pull at their ears
• Cry more than usual
• Have trouble sleeping
• Fail to respond to sounds
• Be unusually irritable
• Develop a fever
• Develop fluid that drains from the ears
• Have headaches

Ear infections usually start with a viral infection, such as a cold. The middle ear becomes inflamed from the infection, and fluid builds up behind the eardrum.

Ear infections also can be associated with dysfunction or swelling within the eustachian tubes - the narrow passageways that connect the middle ear to the nose. Normally these tubes equalize pressure inside and outside the ear. But a child's eustachian tubes are narrower and shorter than those of an adult. This makes it easier for fluid to get trapped in the middle ear when the eustachian tubes dysfunction or become blocked during a cold.

Another factor in ear infections is swelling of the adenoids. These are tissues located in the upper throat near the eustachian tubes. Adenoids contain lymphocytes - cells that normally fight infection. But sometimes the adenoids themselves get infected or enlarged, blocking the eustachian tubes. Infection in the adenoids can also spread to the eustachian tubes.

In addition, children don't have fully developed immune systems. So it's easier for them to develop many illnesses, including colds and ear infections.

Major risk factors for ear infections include:

• Age. Children between ages 6 and 18 months are the most susceptible to ear infections, although ear infections are common from ages 4 months to 4 years.

• Group child care. Children cared for in group settings are more likely to get colds and ear infections than are children who stay home.

• Reduced air quality. Children with exposure to tobacco smoke or higher levels of air pollution are at higher risk of ear infections.

• Family history. Your child's risk of ear infections increases if another member of the family has had such infections.

• Race. American Indians and Eskimos from Alaska or Canada tend to have more ear infections than do whites.

• Feeding position. Babies who drink from a bottle while lying down tend to have more ear infections than do babies who are held upright during feedings.

• Season. Ear infections are most common during the fall and winter.

There are two main types of ear infections:

• Acute otitis media (AOM). In AOM, parts of the ear are infected and swollen, and fluid and mucus are trapped inside the ear.

• Otitis media with effusion (OME). Effusion refers to fluid. In OME, fluid stays in the ear after the infection has cleared up. The presence of fluid increases the risk of a new infection.

Ear infections are diagnosed based on your child's medical history and a physical exam. During the exam, the doctor will look for inflammation in the middle ear with a lighted instrument known as an otoscope.

A related instrument is the pneumatic otoscope, which allows the doctor to gently puff air on the eardrum. Normally this causes the eardrum to move. Any fluid in the middle ear will prevent that movement.

Sometimes additional tests for ear infections are recommended - especially if your child has had fluid in the middle ear for some time:

• Tympanometry. This test also measures eardrum movement. A soft plug is inserted into the opening of the ear. The plug includes a device that changes air pressure inside the ear.

• Acoustic reflectometry. During this test, the doctor uses a hand-held instrument to project sounds of varying frequencies into the ear. How the sounds are reflected indicates differences between empty space and fluid.

Many ear infections clear on their own with no complications. However, long-lasting or recurrent infections can lead to:

• Short-term hearing loss. Fluid buildup can temporarily affect your child's hearing. That's because it's harder for the eardrum and the tiny bones in the middle ear to send sound vibrations through fluid. The average hearing loss is 25 decibels - about the same as putting plugs in your child's ears.

• Long-term hearing loss. Usually the fluid disappears on its own in a few weeks. But sometimes it remains in the middle ear for months, which can damage the eardrum and bones in the middle ear. Persistent middle ear fluid was once thought to contribute to speech or developmental delays, but researchers now say this isn't true.

• Ruptured eardrum. During ear infections, fluid and pus may press against the eardrum. This can be painful. Rarely, the pressure ruptures the eardrum. If this happens, you may see a discharge of pus and blood from your child's ear. This can be alarming. But the rupture actually relieves your child's pain, and in most cases the eardrum heals on its own. If the eardrum ruptures repeatedly and doesn't heal, surgical repair may be needed.

Untreated ear infections also can lead to a type of sinusitis known as mastoiditis, which affects the mastoid bone of the skull. Rarely, infections can move from the ear to other parts of the head, including the brain.

Ear infections can be treated various ways. What's best for your child depends on many factors, including your child's age, medical history and the type of ear infection.

A wait-and-see approach
The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommend a wait-and-see approach for the first 72 hours for children who:

• Are older than age 6 months
• Are otherwise healthy
• Have mild signs and symptoms or an uncertain diagnosis

Most ear infections clear on their own in just a few days - and antibiotics won't help an infection caused by a virus. In fact, about 80 percent of children with acute otitis media recover without antibiotics, according to the AAP and AAFP.

If your child is uncomfortable, the doctor may recommend an over-the-counter pain reliever such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others). If your child doesn't have drainage from the ear or ear tubes, prescription eardrops containing a local anesthetic may be an option, too. The drops won't cure the infection, but they may relieve pain.

Warm the drops slightly by placing the bottle containing the drops in warm water. Then gently lay your child on a flat surface with his or her infected ear facing up. Don't insert the drops with your child in your arms or on your lap.

Antibiotic therapy
If your child is younger than age 6 months or has two or more ear infections within 30 days or chronic otitis media with effusion, the doctor may recommend an antibiotic. If the medication is effective, your child should start feeling better in a few days. Give your child the antibiotic for the full length of the prescription. Stopping medication too soon could allow the infection to come back.

Remember, antibiotics won't help an infection caused by a virus - and the overuse of antibiotics contributes to strains of the bacteria that resist these medications. Side effects - such as vomiting, diarrhea and allergic reactions - are possible as well.

Drainage tubes
If fluid in your child's ear is affecting his or her hearing or recurrent ear infections don't respond to antibiotics, your child's doctor may suggest surgery. The most common surgery for ear infections is a myringotomy. During this procedure, which requires general anesthesia, a surgeon inserts a small drainage tube through your child's eardrum. This helps drain the fluid and equalize the pressure between the middle ear and outer ear.

Your child's hearing should improve immediately. As your child grows, the tubes will come out on their own and the drainage holes will heal - often within a year. In the meantime, your child may need to wear special ear plugs in the pool and bathtub to keep water out of his or her ears.

Some children continue to have ear infections after surgery. Sometimes this leads to another set of tubes. If the ear infections continue after age 4, the surgeon may recommend removing your child's adenoids.

When your ear is exposed to excess moisture, however, water can remain trapped in your ear canal. The skin inside becomes soggy, diluting the acidity that normally prevents infection. A cut in the lining of the ear canal also can allow bacteria to penetrate your skin. When this happens, bacteria and fungi from contaminated water or from objects placed in your ear can grow and cause a condition called swimmer's ear (acute otitis externa, or external otitis).

Swimmer's ear is an infection of your outer ear and ear canal. It can be associated with a middle ear infection (otitis media) if the eardrum ruptures.

Usually, self-care steps can relieve the symptoms of swimmer's ear. However, a severe case of swimmer's ear will require a trip to your doctor.

Signs and symptoms of swimmer's ear usually appear within a few days of exposure to contaminated water, and may include:

• Severe pain on moving your outer ear (pinna, or auricle) or pushing on the little "bump" (tragus) in front of your ear.
• Pain or discomfort in or around your ear. Usually only one ear is involved.
• Itching of your outer ear.
• Swelling in your ear or lymph nodes in your neck.
• Feeling of fullness or stuffiness in your ear.
• Pus draining from your ear.
• Decreased or muffled hearing.

Swimmer's ear may also cause your outer ear to appear red with scaly or flaking skin.

Causes of swimmer's ear may include:

• Persistent moisture in your ear from swimming, bathing or living in a humid environment
• Exposure to an infectious organism from swimming in polluted water
• Skin breakage caused by scratching or rubbing your ear with a foreign object (such as a cotton swab or pencil), or attempting to clean earwax (cerumen) from your ear canal
• Bacteria growth fostered by hair sprays or hair dyes in your ear

Swimmer's ear is common in children and in young adults. You may be at increased risk of infection if a skin condition, such as eczema, causes you to scratch your ears excessively. Earwax buildup or blockage also may increase your risk by trapping water in your ear and increasing the likelihood that you'll cut the skin while cleaning your ear.

Other ear problems also may increase your risk of swimmer's ear, including small ear canals that don't drain well and chronic middle ear infections that moisten and perforate the eardrum.

If you're an older adult or have an underlying medical condition, such as diabetes, your immune system may be impaired, increasing your risk of swimmer's ear. If you have poorly managed diabetes, you're at increased risk of developing severe, painful swimmer's ear that may be difficult to treat.

Swimmer's ear usually isn't serious, but complications can occur if it isn't treated. Complications may include:

• Temporary hearing loss. You may experience muffled hearing, but this usually goes away when the infection is gone.

• Recurrent outer ear infections (chronic otitis externa). Swimmer's ear may not respond to treatment or may keep coming back in some people. This can lead to infection in the surrounding skin (cellulitis).

• Bone and cartilage damage (necrotizing otitis externa). An outer ear infection that spreads can cause inflammation and damage to the bones and cartilage at the base of your skull, often causing increasingly severe pain. Older adults and people with diabetes are at increased risk. An older term for this is malignant otitis externa; however, this condition has nothing to do with cancer (malignancy).

• More widespread infection. If swimmer's ear develops into necrotizing otitis externa, the infection may spread and affect other parts of your body, such as the brain or cranial nerves. This severe infection can be life-threatening.

The goal of treating swimmer's ear is to clear up the infection. Treatment may include:

• Cleaning. Clearing your outer ear and ear canal of any drainage and flaky skin allows topical medications to work more effectively. Your doctor may perform this procedure with a suction device or a cotton-tipped probe. To prevent further irritation or injury, don't clean inside your own ear unless your doctor instructs you to do so.

• Topical medications. Your doctor may prescribe eardrops containing antibiotics to fight infection and corticosteroids to reduce itching and inflammation. Use eardrops liberally (four to five drops at a time) to penetrate the end of your ear canal. If your ear canal is swollen, your doctor may insert a special wick into your ear to allow the drops to reach the end of your ear canal.

• Oral medications. In some cases, doctors suggest using oral medications in addition to topical treatments. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil, Motrin, others), may help ease severe ear pain. Ask your doctor which over-the-counter pain medication is best for you. Always take NSAIDS with food.

• Lifestyle modifications. Don't swim, fly or scuba dive during treatment for swimmer's ear. For the most effective treatment results, water should be kept out of the ear. Talk to your doctor about your bathing habits.

Follow these tips to avoid swimmer's ear:

• Keep your ears dry. Dry your ears thoroughly after exposure to moisture from swimming or bathing. Dry only your outer ear slowly and gently with a soft towel or cloth. Never insert your finger or any other object into your ear.

• Swim wisely. Avoid swimming in polluted water.

• Use earplugs. Some earplugs are designed specifically to keep water out of your ears when swimming.

• Practice self-care. Mix 1 part white vinegar with 1 part alcohol to make an effective eardrop to use before and after swimming. Pour 1 teaspoon of the solution into each ear and let it drain back out. This mixture may help prevent the growth of bacteria and fungi that can cause swimmer's ear.

• Avoid putting foreign objects in your ear. Never attempt to dig out excess or hardened earwax with items such as a cotton swab, paper clip or hairpin. Using these items can pack material deeper into your ear canal and irritate the thin skin inside your ear.

• Protect your ears. Avoid substances that may irritate your ear, such as hair sprays and hair dyes. Or put cotton balls in your ears when applying these products.

• Use caution after ear infection or surgery. If you already have an ear infection or have recently had ear surgery, talk to your doctor before you swim.