What is Acute Otitis Media (Ear Infection)?
Acute otitis media is a term used to describe an infection in the middle part of the ear. It comes in different forms, like acute otitis media (AOM), chronic suppurative otitis media (CSOM), and otitis media with effusion (OME). It is the second most common reason for children to visit the emergency department, following upper respiratory infections. Anyone can get otitis media, but it’s most common in children between 6 to 24 months old.
The infection in the middle part of the ear can be caused by a virus, bacteria, or both. The most common bacterial culprits are Streptococcus pneumoniae, non-typeable Haemophilus influenzae (NTHi), and Moraxella catarrhalis. Viruses that can cause otitis media include respiratory syncytial virus (RSV), coronaviruses, influenza viruses, adenoviruses, and more. Since the introduction of certain vaccines, the types of bacteria causing these infections have evolved.
Otitis media is diagnosed by a doctor based on the patient’s symptoms and a physical exam of the ear. Various tools like a pneumatic otoscope, which gives a detailed view of the ear, can help in this process. If a pneumatic otoscope isn’t available, other methods like tympanometry, which measures how the eardrum reacts to changes in air pressure, can be used instead.
Treatment for otitis media, particularly the use of antibiotics, is a matter of debate. It largely depends on the nature of the infection. If not treated properly, the infected fluid from the middle ear can spread to nearby areas and cause problems such as eardrum rupture, mastoiditis (infection in the bones behind the ear), and even meningitis or brain abscess. In the US, the preferred treatment for a confirmed diagnosis of AOM is a high dose of amoxicillin, especially useful in children under two. In countries like the Netherlands, a doctor might first observe the condition and prescribe antibiotics only if it doesn’t get better. However, this ‘watchful waiting’ approach isn’t widely adopted because of the risk of prolonged middle ear fluid affecting hearing and speech, along with the risk of other complications. Pain relievers such as ibuprofen can be used by patients with otitis media for relief from pain.
What Causes Acute Otitis Media (Ear Infection)?
- Having a weakened immune system – this is sometimes due to conditions like HIV or diabetes.
- Inherited factors – certain people might be genetically more likely to get ear infections.
- Abnormalities of the MUC5B gene – this gene affects mucus production and its dysfunction can make someone more susceptible to ear infections.
- Anatomic differences – some people have differently shaped mouths or throats that make them more likely to get ear infections.
- Dysfunction in tiny hair-like structures (cilia) that help to clear debris and mucus in the respiratory tract.
- Having a cochlear implant – this is an electronic medical device that replaces the function of the damaged inner ear.
- Lack of vitamin A.
- Certain bacteria, such as Streptococcus pneumoniae, Haemophilus influenza, and Moraxella (Branhamella) catarrhalis, which cause over 95% of bacterial ear infections.
- Certain viruses, like respiratory syncytial virus, flu virus, parainfluenza virus, rhinovirus, and adenovirus.
- Allergies – inflammation caused by allergic reactions can lead to ear infections.
- Not breastfeeding – breast milk provides essential antibodies that can prevent ear infections.
- Exposure to second-hand smoke.
- Attending daycare – kids in daycare are often in close contact with others who may have infections.
- Being in a lower socio-economic bracket.
Risk Factors and Frequency for Acute Otitis Media (Ear Infection)
Otitis media, or inflammation of the middle ear, is a worldwide issue that occurs slightly more in boys than girls. Pinpointing the exact number of cases each year is a challenge because not all cases are reported and rates differ across various regions. Otitis media primarily affects babies between six and twelve months, with the occurrence decreasing after they turn five years old.
- Around 4 out of 5 children will have some form of otitis media during their lifetime.
- 80% to 90% of children are likely to experience otitis media with fluid build-up in their ear before they start school.
- While otitis media is less common in adults, certain groups are at a higher risk, such as those who suffered recurrent ear infections in their childhood, have a cleft palate, compromised immune system, or other related conditions.
Signs and Symptoms of Acute Otitis Media (Ear Infection)
Otitis media, often known as a middle ear infection, can exhibit various symptoms that might make it challenging to diagnose. While ear pain is often considered a clear indicator, many children can display non-specific signs. These can include ear tugging, irritation, headaches, restless sleep, poor appetite, vomiting, or diarrhea. It’s worth noting that about two-thirds of patients might show low-grade fevers.
The diagnosis mainly depends on combining these signs and symptoms with clinical findings. According to the American Academy of Pediatrics, the condition may be confirmed if there’s a severe swelling of the eardrum or new outer ear discharge not caused by another ear condition. Alternatively, mild eardrum bulging along with recent ear pain or redness might also suggest acute otitis media. These factors are meant to help medical professionals make accurate diagnoses, but they aren’t intended to replace clinical judgment.
An ear examination using an otoscope can help discern the condition. In cases of acute otitis media, the eardrum might appear reddened, normal, or there might be fluid in the middle ear. In more severe cases involving pus (suppurative otitis media), the eardrum might bulge and pus could be visible. If there’s excessive swelling in the ear canal, it might signal an outer ear infection, which needs different treatment.
It’s crucial to check the condition of the eardrum when there’s swelling in the ear canal. If the eardrum is intact and the ear canal is red and painful, additional ear drops might be needed to treat the outer ear infection. This can happen alongside or independently of otitis media, so checking the middle ear is vital. If the eardrum is ruptured, the swelling in the ear canal is likely a reactive condition. In such cases, appropriate ear drops should be used, specifically those safe for use in the middle ear, such as ofloxacin, since other medications can potentially harm the ear.
Testing for Acute Otitis Media (Ear Infection)
Otitis media, a medical term for an ear infection, is typically diagnosed using a physical examination and a special tool called an otoscope, preferably a pneumatic otoscope, which allows the doctor to check inside your ear.
Laboratory Tests
Usually, the doctor wouldn’t need to run lab tests. But in some cases, like when an infant younger than 12 weeks old has a fever without a known cause—aside from maybe acute otitis media—, the doctor may run a full sepsis workup. This is to make sure there are no other serious infections within the body. Lab tests could also be necessary if the doctor suspects that the ear infection could be linked to other body-wide or in-born diseases.
Imaging Studies
Your doctor wouldn’t usually order imaging tests like X-rays or MRIs unless they suspect complications beyond the middle ear, like inside the temporal bones of your skull or even within your brain.
In cases where complications from an ear infection are suspected, your doctor might order a type of X-ray called computed tomography (CT) of the temporal bones (bones in the skull surrounding the ears). This could help spot problems like mastoiditis (infection of the bone behind the ear), epidural abscess (infection near the spinal cord), sigmoid sinus thrombophlebitis (blood clot in the brain), meningitis (infection of the lining around the brain and spinal cord), brain abscess, subdural abscess (collection of pus between the brain and its outer coverings), ossicular disease (problems with the tiny bones in the middle ear), and cholesteatoma (skin growth in the middle ear).
Magnetic Resonance Imaging (MRI) might be used to look for any build-ups of fluid, especially in the middle ear.
Tympanocentesis
In some instances, your doctor might perform a medical procedure called tympanocentesis. This involves using a needle to take a small amount of fluid from the middle ear. The collected fluid can then be grown in a lab— a process called a culture— to determine if any harmful bacteria are present.
The procedure can help make the diagnosis more accurate and inform treatment options, but it’s only reserved for severe or stubborn cases that don’t respond to typical treatments.
Other Tests
To check for fluid build-up in the middle ear, doctors might also use tympanometry and acoustic reflectometry. These are non-invasive methods to determine if there is any fluid behind the eardrum, which could indicate an ear infection.
Treatment Options for Acute Otitis Media (Ear Infection)
If you’ve been diagnosed with acute otitis media, which is a type of ear infection, the main goals of treatment are to ease your pain and clear up the infection. Over-the-counter pain medications like non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen can help with the discomfort.
As for the infection, antibiotics can be very effective. However, there’s some debate over whether antibiotics should always be given right away for ear infections. In many European countries, for example, doctors will often wait to see if the infection clears up on its own before giving antibiotics. But in the United States, this “watchful waiting” approach isn’t as common.
If your ear infection is clearly caused by bacteria and is causing pus to form in your ear, oral antibiotics are commonly prescribed. The ones most often used are high-dose amoxicillin or a type of antibiotic called a second-generation cephalosporin. If your eardrum has a hole or tear in it—an issue known as a perforation—specific ear drops that contain antibiotics, like ofloxacin, are usually recommended. These drops provide a high dose of medication right where it’s needed, without causing any systemic side effects.
If you’re allergic to penicillin, alternatives recommended by the American Academy of Pediatrics (AAP) include the antibiotics azithromycin, clarithromycin, cefdinir, cefpodoxime, and cefuroxime. If your symptoms don’t improve after taking high-dose amoxicillin, your doctor might switch you to high-dose amoxicillin-clavulanate.
Patients with repeated ear infections—four or more within a year—might benefit from a procedure called a myringotomy with tube (grommet) placement. Here, a tiny tube is placed in your eardrum to help it stay open and properly ventilated. This reduces the risk of further ear infections and helps maintain normal hearing.
Finally, it’s worth noting that while it might be tempting to try steroids or antihistamines to help with your ear infection symptoms, research shows these treatments aren’t particularly effective.
What else can Acute Otitis Media (Ear Infection) be?
When a doctor is trying to diagnose an ear infection (otitis media), they have to rule out a variety of conditions that show similar symptoms. These can include:
- Cholesteatoma (a skin growth in the middle ear)
- High temperature in infants and toddlers
- Unexplained fever
- Hearing loss
- Nasal polyps in children
- Nasopharyngeal cancer (a type of head and neck cancer)
- Otitis externa (an inflammation of the ear canal)
- Infections caused by human parainfluenza viruses and other similar viruses
- Health issues triggered by secondhand smoke
- Allergic rhinitis in children (a type of inflammation in the nose)
- Bacterial meningitis in children (an infection of the membranes surrounding the brain and spinal cord)
- Acid reflux in children
- The bacteria known as Haemophilus influenzae causing illness in children
- HIV infection in children
- Mastoiditis in children (an infection in the mastoid bone of the skull)
- Streptococcus pneumoniae infections in children
- Primary ciliary dyskinesia (a disorder that affects the cilia, tiny hair-like structures that move mucus and fluids through the body)
- Respiratory syncytial virus infection (a common virus that affects the respiratory tract)
- Rhinovirus infection (common cold)
- Teething
It’s important for the doctor to consider all these conditions and conduct the necessary tests to reach the correct diagnosis.
What to expect with Acute Otitis Media (Ear Infection)
The outlook is generally good for most patients with otitis media (a type of ear infection). Deaths from this condition are very rare these days, especially in developed countries. This is because of better access to healthcare, which means the condition can be diagnosed and treated early. Antibiotics are usually quite effective in treating this.
Several factors can influence how this condition progresses. For instance, if a child has had less than three episodes of otitis media, they’re three times more likely to get better with just one course of antibiotics than those who catch this condition in seasons other than winter.
However, children who develop complications from this condition can be harder to treat and may experience the condition more frequently. Although it’s rare, complications that affect the areas inside the ear and brain can be quite serious and carry significant risk.
Also, children who’ve had otitis media before they learned to speak are at risk for mild to moderate hearing loss which affects their ability to carry sounds. Children who had otitis media in the first two years of their life often struggle to hear sharp or high-pitched sounds, like the ‘s’ sound.
Possible Complications When Diagnosed with Acute Otitis Media (Ear Infection)
Because the middle ear area is intricate and intricate, complications that occur can be difficult to manage. These complications can be broadly categorized into two types: intratemporal (inside the ear) and intracranial (inside the head).
Intratemporal complications can include:
- Hearing loss (either due to damage to the structures that conduct sound, or the nerve that senses it)
- Tympanic membrane perforation (rupture of the eardrum, can be sudden or long-term)
- Chronic suppurative otitis media (long term infection with pus in the middle ear, can be with or without bony growth, or cholesteatoma)
- Cholesteatoma (abnormal skin growth in the middle ear)
- Tympanosclerosis (hardening of the eardrum)
- Mastoiditis (infection of the hollow spaces in the skull behind the ear, called mastoid)
- Petrositis (infection of temporal bone)
- Labyrinthitis (inflammation of the inner ear)
- Facial paralysis
- Cholesterol granuloma (cysts filled with cholesterol crystals)
- Infectious eczematoid dermatitis (itchy skin condition cause by infection)
Ear infections can also impact hearing, notably in the critical 6 to 24-month age range – a key time for language development. Chronic ear infections can lead to conductive hearing loss and delay language development. This may impact speech and require speech therapy. That’s why aggressive early treatment of recurring ear infections is recommended by pediatric and ear specialists.
Intracranial complications can occur when the infection spreads beyond the ear:
- Meningitis (infection of the membranes covering brain and spinal cord)
- Subdural empyema (pus filled infection between the brain surface and its outer covering)
- Brain abscess (brain infection pocket)
- Extradural abscess (pus-filled infection outside the brain covering)
- Lateral sinus thrombosis (clot formation in the vein draining brain)
- Otitic hydrocephalus (increased spinal fluid pressure due to ear infection)
Preventing Acute Otitis Media (Ear Infection)
Vaccines for pneumonia and the flu can help prevent upper respiratory infections in children. Additionally, keeping youngsters away from tobacco smoke can lower their chances of developing these infections. This is because tobacco smoke can irritate the respiratory system and raise the risk of pneumonia in children. For babies suffering from ear infections, breastfeeding is highly recommended; this is because breast milk has special proteins known as immunoglobulins that can shield babies from harmful germs during their early stages of life outside the womb.
