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Ear infection

Overview

An ear in need

Although ear infections strike people of all ages, children are particularly susceptible, especially between the ages of 6 months to 7 years.

Infections occur in several different parts of the ear:

Middle ear (otitis media) infection is the most common
External ear (otitis externa) infection is also known as swimmer's ear
Inner ear infections (otitis interna and labyrinthitis) are less common

Symptoms of an ear infection vary, and can include dull or sharp pain that is felt intermittently or constantly. You may also feel burning or throbbing in the ear. All earaches need prompt and careful attention.

Your physician can easily identify which part of your ear is infected and prescribe the appropriate treatment for you. Treatment usually takes from a few to several days. However it is possible, especially in cases involving children, that the condition will recur. Recurrence, especially in children, is difficult and frustrating. But it is essential to follow your physician's directions to prevent complications. In some cases, middle ear infections can cause a perforated eardrum, inflammation of the bone behind the ear (mastoiditis), or other complications.

Pain in the ear should never be ignored. In most cases, when treated properly, complications, if any, will be minimal.

Detailed Description

Infections and inflammation in the middle ear (otitis media) are most frequently caused by bacterial or viral infection and/or Eustachian tube obstruction. Less commonly, a ruptured eardrum may cause an infection. Middle ear infections are the most common and tend to recur, especially among children. The narrower tubes and sharper angles in a child's ear make them more prone to blockage and, therefore, infection.

Ear infections can also occur in your outer ear (otitis externa), the section that extends from the ear opening to the eardrum. This is often called swimmer's ear because it frequently develops when swimming in water that contains bacteria. When water is trapped in your ear canal, it creates a prime environment for a fungal or bacterial infection. Other causes of swimmer's ear include allergies, and either chemical irritants or foreign objects in the ear canal.

Inner ear infections (labyrinithitis) are rare but can be quite serious. An infection of the labyrinth (the semicircular canals of the inner ear) can cause total loss of hearing.

Characteristics of Ear Infections

Inflammation or infection of your middle ear (otitis media), which may be acute (short-term) or chronic, and accompanied by earache, irritability, fever, a feeling of fullness in the ear, and/or discharge from the ear. Trapped, infected "pus" creates pressure in the tubes.

Immersion in water can lead to infection in the outer ear canal (external otitis). You may feel ear pain and, less commonly, itching. You may also have a low fever or discharge a small amount of pus.

Pain in both types of ear infections may worsen when the ear is tugged. Symptoms may be accompanied by loss of hearing.

How Common Are Ear Infections?

Ear infections are most commonly diagnosed in children, accounting for over 50% of all visits to pediatricians. By age 6, 90% of all children have had at least one middle ear infection. Acute ear infections affect two-thirds of American children by age 2, and chronic ear infections affect two-thirds of children under age 6. Approximately $8 billion is spent annually on medical and surgical treatment of earaches in the United States.

Ear infections occur in all ages, but because their Eustachian tubes are smaller and angled more sharply than adults, making it easier for bacteria to get in, children and infants are particularly susceptible to otitis media, or middle ear infections. Children also get more colds than adults, making them more susceptible to ear infections. Senior citizens are more susceptible than younger adults, and may be more likely to experience some degree of hearing loss resulting from an infection. Studies show that males get ear infections slightly more often than females.

What You Can Expect

Sometimes ear infections resolve without use of antibiotics; your doctor may opt to watch and wait — at least at first. In most cases, when treated with antibiotics and/or surgery, treatment will be effective and complications, if any, will be minimal. Some patients will be prone to recurrence.

Conventional Treatment

Goals of Treatment

The immediate goals of treatment are to relieve pain, to clear up the infection, and to prevent possible complications such as loss of hearing.

Treatment Overview

Treatments for earaches and ear infections vary according to the cause and site of the infection. Antibiotics and ear drops are the two most commonly used therapies to treat ear infections in the United States. If antibiotics are not successful, a simple surgical procedure can also help clear up reoccurring ear infections.

Treatment for acute otitis media consists mainly of antibiotics (amoxicillin, ampicillin, etc). It is important that you take this medication exactly as directed and for as long as prescribed to prevent recurrence. (Treatment is usually seven to 10 days.) If antibiotics do not clear the infection or it does not resolve spontaneously, chronic otitis media may require surgery to place a drainage tube into your eardrum.

Treatment for otitis externa, or swimmer's ear, may include antibiotic, antifungal, or corticosteroid ear drops. Your doctor may place a wicking device into your ear canal to help keep the drops in contact with the canal for longer. Your doctor may prescribe oral antibiotics. Stay out of the water until your treatment is completed. If you suffer from pain, heat may offer some relief.

Labyrinthitis is an inner ear infection. The most common form of labyrinthitis is caused by a virus. In some cases, surgery may be necessary to remove infected tissue. The vast majority of cases — though they may involve vertigo (dizziness, imbalance) — resolve without intervention.

It is important that you treat your ear infections or be sure that they have resolved; untreated or unresolved middle ear infections can result in a ruptured eardrum. If fluid is present, otitis externa can also occur. Other possible complications include mastoiditis, meningitis, cholesteatomas, and permanent hearing loss. It's important to call your physician if, despite treatment, you have a fever above 102�F, if the signs of infection persist for more than 48 hours, or if you suffer from severe headaches, convulsions, or dizziness. In monitoring a child, you should also contact your physician if there is swelling around the child's ear or twitching of the child's face muscles.

Ear infections are curable. However, they may recur.

The success of treatment for clearing up the ear infection and reducing your pain varies. If antibiotics are not effective with middle ear infections, surgery may be necessary. However, note that the surgery itself may encourage additional infections at a later time.

Treatment Considerations

Heat can be applied to the area around your ears to alleviate pain.
Eardrops may also relieve pain.
Nonprescription nasal sprays or drops may help open the Eustachian tube and relieve pressure in the middle ear.
Humidifiers are popular adjucant treatments for ear infections and upper respiratory tract infections in children. Low humidity may be a contributing factor to middle ear infections by causing nasal swelling and reduced ventilation of the Eustachian tube. It may also reduce ventilation of the tube and dry the tube lining, which could lead to an increase in secretions and an inability to clear fluid. If you use a humidifier, it may help reverse these tendencies in otitis media with effusion (effusion refers to fluid in the Eustachian tube).

Most treatment for ear infections is performed on an outpatient basis, unless the condition is serious enough to require surgery.

Healthcare Professionals Who May Be Involved in Treatment

There are several health professionals who usually participate in diagnosing and/or treating ear infections:

Family physicians
General physicians
Pediatricians
Ear, nose, and throat specialists

Activity and Diet Restrictions

Ear infection symptoms usually improve in two to three days. To assure speedy recovery, follow some simple guidelines:

Rest or reduced activity until fever and pain subside.
Avoid participating in water sports and flying, if possible.
Food sensitivities contribute to many middle ear infections. Many children are sensitive to milk, dairy, wheat, and eggs. An elimination diet is a way of helping to pinpoint the food(s) causing the problem. For help conducting a formal elimination diet, consult a nutritionally oriented doctor or a naturopath.

Drug Therapy

Drugs most commonly prescribed
Antibiotics
Amoxil http://www.nmihi.com/a/amoxicillin.html
Augmentin http://www.nmihi.com/c/co-amoxiclav.html
Ceclor
Cipro http://www.nmihi.com/c/ciprofloxacin.html
Bactrim http://www.nmihi.com/t/co-trimoxazole.html
Keflex
Cleocin
Principen http://www.nmihi.com/a/ampicillin.html
Zithromax http://www.nmihi.com/a/azithromycin.html
Decongestants: oral or nasal to open nasal passages and Eustachian tube
Analgesics: for pain control and comfort such as acetaminophen and ibuprofen

Surgery

The standard medical approach to ear infections in children is antibiotics, analgesics, and/or antihistamines. However, if the ear infection is long-standing or unresponsive to the drugs, surgery is often performed.

The common, minor, same-day surgery involves placement of a tiny myringotomy tube through the eardrum to assist drainage of fluid. This is not a curative procedure and children with myringotomy tubes are more likely to have subsequent ear infections.

NOTE: Currently, myringotomies are being performed on close to one million American children each year. There is debate over the need for this procedure.

Managing Ear Infection Treatment

Managing therapy depends on which type of ear infection you or your child has.

Middle ear infection:

Administer antibiotics and ear drops, as instructed by your physician. Take all the prescribed antibiotics.
Avoid flying and water sports, if possible.
For infants, breastfeed when possible, and do not allow your child to take a bottle to bed.

Swimmer's ear:

Administer antibiotics and ear drops as instructed by the physician. Take all the prescribed antibiotics.
Do not swim until infection clears up.

Monitoring the Condition

After your physician's diagnosis and treatment, self care is usually adequate. However, your physician should monitor your general condition and medications, and you should contact your doctor if the pain persists despite treatment. Severe earaches and resistant infections may require treatment by an ear, nose, and throat specialist.

Possible Complications

Several complications may arise from untreated or poorly treated middle ear infections:

Middle ear effusions
Eardrum rupture
Hearing loss (usually temporary, but sometimes permanent)
Mastoiditis (inflammation of the mastoid bone behind the ear; rare)
Meningitis (rare)
Dural venous thrombophlebitis
Brain abscess
Facial nerve paralysis

Swimmer's ear (auditory ear canal infection) can also result in:

Complete closure of the ear canal (causing significant hearing loss)
Cellulitis (deep tissue infection)
Boils in the ear canal
Chronic inflammation that is difficult to cure

Quality of Life

If you or your child suffer repeatedly from swimmer's ear or middle ear infection, you may want to take the following precautions:

Try to avoid getting water up the nose when swimming and bathing.
Cut back on the amount of time spent in the water (limit children to no longer than one hour).
Allow your ears to dry for one and two hours before returning to the water.
After children bathe or shower, have them dry their ears with a small ball of cotton (not a cotton swab).
Dry your ears, or your child's ears, immediately after bathing, and use ear drops as directed.
If you or your child has persistent swimmer's ear, stay out of the water for at least one week (possibly longer if the pain and itching do not clear up).
Breastfeed whenever possible. Do not give your child a bottle to take to bed because fluid could flow from the throat to the Eustachian tube, increasing the chances of developing an ear infection.

Considerations for Children and Adolescents

The majority of patients diagnosed with middle ear infections are children.

Considerations for Older People

The immune system is somewhat less effective in aging people, opening the way for viral and other infections as well as immune disorders and allergies.

You can use ear drops to relieve pain, but remember that adverse reactions and side effects may be more frequent and/or severe in older people.

Moreover, older people may experience hearing loss or enlarged adenoids after an ear infection. If this happens to you, ask your doctor about using a steroid nasal spray, antihistamines, or decongestants during future respiratory infections.

Last updated 23 May 2012

Synonyms

Otitis externa or swimmer's ear
Otitis media (middle ear infection)
Otitis interna (inner ear infection)
Labyrinthitis (inflammation of the semicircular canals of the inner ear)

Causes

Established Causes

External ear infection is usually due to external factors, while middle ear infection is usually caused by upper respiratory infections or problems already present in the body.

Middle ear infection:

Upper respiratory infection (such as a cold or flu)
Bacterial and fungal infection
Allergies, especially food allergies and airborne allergies
Bottle or formula feeding, rather than breastfeeding
Tonsillitis or enlarged adenoids
A ruptured eardrum

External ear infection is caused by bacterial or fungal infection due to:

Swimming in dirty, polluted, or heavily chlorinated water
Humid weather or other causes of excessive moisture
Irritation from insertion of foreign objects
Wearing earplugs at work

Theoretical Causes

Recurrent ear infections are strongly associated with early bottle feeding, while breastfeeding (for a minimum of four months) has a protective effect
Studies show that the elimination of food allergens can positively effect the treatment of chronic otitis media in over 90% of children
Exposure to wood-burning stoves (or secondhand cigarette smoke) may also cause ear infections
Studies suggest daycare attendance can promote ear infections because it increases the risk of exposure to illness

Risk Factors

General risk factors include a history of recent upper respiratory tract infection. Another general risk factor is allergy. Additional risk factors for middle ear infections:

Exposure to smoke
Swimming and diving (can increase the risk of ascending bacterial infection)
Some Native Americans and Australian aborigines seem susceptible to ear infections
Sibling history of otitis media or family history of middle ear disease
High altitude
Infants taking a bottle to bed (fluid can pool in the child's throat near the Eustachian tube)
Unrepaired cleft palate, Down's syndrome, abnormalities in the structure of the head or face

Symptoms & Diagnosis

You may feel a dull or sharp pain that comes and goes or stays. You may also feel ringing, burning or throbbing in the ear.

Conditions That May Be Mistaken for an Ear Infection

Referred pain (from the nose, sinuses, teeth, gums, jaw joint, tongue, tonsils, throat, windpipe, voice box, esophagus, and salivary glands in the cheek)
Earwax blockage
Cranial nerve palsy
Eruption of wisdom teeth

How Ear Infections Are Diagnosed

Ear infection can often be diagnosed with a simple exam. The most common tool used in an ear exam is the otoscope, a lighted instrument used to inspect the auditory canal for earwax, obstructions, or changes in the ear canal or eardrum. Your doctor will also use an optical device to checks your nasal passage and pharynx.

Your doctor may use tympanometry, a probe that is inserted into the patient's ear to create an airtight seal, is a useful tool to help your doctor evaluate the condition of the middle ear and check for hearing loss. This instrument measures the middle ear's movement to air-pressure fluctuation and sound vibrations. Its principle purpose is to test how well the tympanic membrane conducts sound from the middle ear to the inner ear. If hearing loss is suspected, audiometry can confirm hearing loss and also measure its degree. If you are experiencing ear discharge, your doctor may take a swab sample to identify what is causing the infection.

For swimmer's ear, your doctor may perform a Gram's stain, a method of staining cells for easy identification under the microscope. A cell culture of the ear discharge may also be helpful.

Alternative care

Herbs

Garlic: helps kill the germs that cause external ear infections and swimmer's ear. Try crushing a few cloves of garlic and adding them to warm olive oil. Gently apply a small amount of the garlic oil.
Eating garlic may also provide antibiotic action against middle ear infections. Add lightly sauteed garlic to foods your children eat.
Echinacea: can stimulate immune response to help heal middle ear infections. Estimate children's doses based on their weight. An adult dose is about two eyedroppers of tincture three times a day. If a child weighs one-quarter as much as you do, administer half an eyedropper of tincture in juice three times a day.

Self care & Prevention

Preventing Ear Infections

To help prevent middle ear infections in children, breastfeed them. Several studies show that children who are breastfed develop fewer ear infections. In addition, exposure to secondhand smoke increases risk of middle ear infections. Keep your children away from smoke.

To help prevent swimmer's ear, or to prevent re-infection, you can do the following:

Use water-repellent earplugs while swimming, showering, or bathing.
Swim with your head above the water.
Put one or two drops of a drying solution such as vinegar into each ear after swimming.

Self-Care Measures

Outer ear infections: These usually develop behind the ear. Wash the area with soap and water and treat it with hydrogen peroxide and an over-the-counter antibiotic ointment.

Ear canal infections (swimmer's ear):

Use an eyedropper to insert white vinegar several times day. Take aspirin or ibuprofen for the pain and inflammation. Acetaminophen relieves pain but has no anti-inflammatory effect.
After swimming, place in each ear canal a few drops of a solution made from half white vinegar (acetic acid) and half rubbing (isopropyl) alcohol.
After swimming or bathing, dry the ears thoroughly, but don't use cotton-tipped swabs, which can traumatize water-irritated ear canals and contribute to infection. Instead, twist the end of a disposable facial tissue and use that.

Bacterial or viral middle ear infection:

Treating this common complication of childhood colds is easier if you have a system in place:

First, get to know what your children's eardrums look like when they are healthy. Buy an otoscope, the device physicians use to examine ears. Relatively inexpensive models are available for parents. Ask your child's physician or local parents' resources center if there's a "Pediatrics for Parents" class in your area. If so, try to go; they always devote a good deal of attention to ear infections. If not, you can still learn to examine your children's ears. Before you attempt to use your otoscope, however, it's crucial to understand that children's ear canals are quite narrow, and that anything inserted in them is likely to cause flinching, squirming, and possibly pain. To keep things as mellow as possible, make a game of ear examinations. Show your children the otoscope. Let them play with it. Let them look in your ears before you look in theirs. When you examine them, pull the outer ear down and back to straighten the ear canal and give you the best view. You need not insert the otoscope tip very far, or for very long. Practice taking quick looks.
- The healthy eardrum looks translucent pink or gray with a bright triangular "light reflex" area at the bottom.
- Pending ear infections change eardrum appearance to red with distortion of the light reflex.
- Full-blown ear infections make the eardrum look brighter red with outward bulging.
Now that you've read how eardrums are supposed to look under various circumstances, don't be surprised if you feel totally at sea and unable to distinguish any landmarks in your children's ears. Inexperienced physicians have the same problem. Ear exams are quite challenging. Just be patient, and keep trying. As you practice, you're not only becoming more skilled at ear exams, but also your children are getting more used to being examined. This mutual familiarity definitely helps when a child has ear pain.
Studies show that parents who practice home ear examination wind up spending fewer nights in emergency rooms with screaming children. They don't panic over ear pain. They can assess their children's ears throughout colds, and if the ears start to redden, they can simply consult the child's physician by phone, or in the office if necessary.
A middle ear infection actually involves two issues: the pain and the infection. The former is what makes children howl. To deal with it, give the child a pain reliever containing acetaminophen (not aspirin, because in rare cases, it may cause Reye's syndrome, a potentially fatal condition). Then have the child lie down on a heating pad, and for additional comfort, place a few drops of warm vegetable oil in the affected ear. If necessary, give the child more acetaminophen.
The next morning, call the child's pediatrician and discuss the need for antibiotics.

Some parents become concerned that repeated or chronic ear infections may impair the child's hearing and become a learning disability. Permanent hearing impairment is possible, but not all that common. If you become concerned, have your child's hearing checked professionally.