| Home | Article Database | Resources | Tools & Just for Fun | Search HY |
Otitis Media (Ear Infection)
What is otitis media?
Otitis media is an infection or inflammation of the middle ear. This inflammation often begins when infections that cause sore throats, colds, or other respiratory or breathing problems spread to the middle ear. These can be viral or bacterial infections. Seventy-five percent of children
experience at least one episode of otitis media by their third birthday. Almost half of these children will have three or more ear infections during their first 3 years. It is estimated that medical costs and lost wages because of otitis media amount to $5 billion* a year in the United States. Although otitis media is primarily a disease of infants and young children, it can also affect adults.
*Gates GA. Cost-effectiveness considerations in otitis media treatment. Otolaryngol Head Neck Sur. April 1996. 114 (4): 525-530.
How do we hear?
The ear consists of three major parts: the outer ear, the middle ear, and the inner ear. The outer ear includes the pinna--the visible part of the ear--and the ear canal. The outer ear extends to the tympanic membrane or eardrum, which separates the outer ear from the middle ear. The middle ear is an air-filled space that is located behind the eardrum. The middle ear contains three tiny bones, the malleus, incus, and stapes, which transmit sound from the
eardrum to the inner ear. The inner ear contains the hearing and balance organs. The cochlea contains the hearing organ which converts sound into electrical signals which are associated with the origin of impulses carried by nerves to the brain where their meanings are appreciated.
Why are more children affected by otitis media than adults?
There are many reasons why children are more likely to suffer from otitis media than adults. First, children have more trouble fighting infections. This is because their immune systems are still developing. Another reason has to do with the child's eustachian tube. The eustachian tube is a small passageway that connects the upper part of the throat to the middle ear. It is shorter and straighter in the child than in the adult. It can contribute to otitis media in several ways.
The eustachian tube is usually closed but opens regularly to
ventilate or replenish the air in the middle ear. This tube also
equalizes middle ear air pressure in response to air pressure
changes in the environment. However, a eustachian tube that is
blocked by swelling of its lining or plugged with mucus from
a cold or for some other reason cannot open to ventilate the
middle ear. The lack of ventilation may allow fluid from the
tissue that lines the middle ear to accumulate. If the eustachian
tube remains plugged, the fluid cannot drain and begins to
collect in the normally air-filled middle ear.
One more factor that makes children more susceptible to
otitis media is that adenoids in children are larger than they
are in adults. Adenoids are composed largely of cells
(lymphocytes) that help fight infections. They are positioned
in the back of the upper part of the throat near the
eustachian tubes. Enlarged adenoids can, because of their
size, interfere with the eustachian tube opening. In addition,
adenoids may themselves become infected, and the
infection may spread into the eustachian tubes.
Bacteria reach the middle ear through the lining or the
passageway of the eustachian tube and can then produce
infection, which causes swelling of the lining of the middle
ear, blocking of the eustachian tube, and migration of
white cells from the bloodstream to help fight the infection.
In this process the white cells accumulate, often killing
bacteria and dying themselves, leading to the formation of
pus, a thick yellowish-white fluid in the middle ear. As the
fluid increases, the child may have trouble hearing because
the eardrum and middle ear bones are unable to move as
freely as they should. As the infection worsens, many
children also experience severe ear pain. Too much fluid in
the ear can put pressure on the eardrum and eventually tear
What are the effects of otitis media?
Otitis media not only causes severe pain but may result in
serious complications if it is not treated. An untreated
infection can travel from the middle ear to the nearby parts
of the head, including the brain. Although the hearing loss
caused by otitis media is usually temporary, untreated otitis
media may lead to permanent hearing impairment. Persistent
fluid in the middle ear and chronic otitis media can reduce a
child's hearing at a time that is critical for speech and
language development. Children who have early hearing
impairment from frequent ear infections are likely to have
speech and language disabilities.
How can someone tell if a child has otitis media?
Otitis media is often difficult to detect because most children
affected by this disorder do not yet have sufficient speech
and language skills to tell someone what is bothering them.
Common signs to look for are
- unusual irritability
- difficulty sleeping
- tugging or pulling at one or both ears
- fluid draining from the ear
- loss of balance
- unresponsiveness to quiet sounds or other signs of hearing difficulty such as sitting too close to the television or being inattentive
Can anything be done to prevent otitis media?
Specific prevention strategies applicable to all infants and
children such as immunization against viral respiratory
infections or specifically against the bacteria that cause otitis
media are not currently available. Nevertheless, it is known
that children who are cared for in group settings, as
well as children who live with adults who smoke cigarettes,
have more ear infections. Therefore, a child who is prone to
otitis media should avoid contact with sick playmates and
environmental tobacco smoke. Infants who nurse from a
bottle while lying down also appear to develop otitis media
more frequently. Children who have been breast-fed often
have fewer episodes of otitis media. Research has shown
that cold and allergy medications such as antihistamines and
decongestants are not helpful in preventing ear infections. The best hope for avoiding ear infections is the development
of vaccines against the bacteria that most often cause otitis
media. Scientists are currently developing vaccines that
show promise in preventing otitis media. Additional clinical
research must be completed to ensure their effectiveness
How does a child's physician diagnose otitis media?
The simplest way to detect an active infection in the middle
ear is to look in the child's ear with an otoscope, a light
instrument that allows the physician to examine the outer ear
and the eardrum. Inflammation of the eardrum indicates an
infection. There are several ways that a physician checks for
middle ear fluid. The use of a special type of otoscope
called a pneumatic otoscope allows the physician to blow a
puff of air onto the eardrum to test eardrum movement. (An
eardrum with fluid behind it does not move as well as an
eardrum with air behind it.)
A useful test of middle ear function is called tympanometry.
This test requires insertion of a small soft plug into the
opening of the child's ear canal. The plug contains a
speaker, a microphone, and a device that is able to change the
air pressure in the ear canal, allowing for several measures
of the middle ear. The child feels air pressure changes in the
ear or hears a few brief tones. While this test provides
information on the condition of the middle ear, it does not
determine how well the child hears. A physician may
suggest a hearing test for a child who has frequent ear
infections to determine the extent of hearing loss. The
hearing test is usually performed by an audiologist, a person
who is specially trained to measure hearing.
How is otitis media treated?
Many physicians recommend the use of an antibiotic (a drug
that kills bacteria) when there is an active middle ear infection.
If a child is experiencing pain, the physician may also recommend
a pain reliever. Following the physician's instructions is very
important. Once started, the antibiotic should be taken until it is
finished. Most physicians will have the child return for a followup
examination to see if the infection has cleared.
Unfortunately, there are many bacteria that can cause otitis media,
and some have become resistant to some antibiotics. This happens
when antibiotics are given for coughs, colds, flu, or viral infections
where antibiotic treatment is not useful. When bacteria become resistant
to antibiotics, those treatments are then less effective against infections.
This means that several different antibiotics may have to be tried
before an ear infection clears. Antibiotics may also produce unwanted side
effects such as nausea, diarrhea, and rashes.**
Once the infection clears, fluid may remain in the middle
ear for several months. Middle ear fluid that is not infected
often disappears after 3 to 6 weeks. Neither
antihistamines nor decongestants are recommended as
helpful in the treatment of otitis media at any stage in the
disease process. Sometimes physicians will treat the child
with an antibiotic to hasten the elimination of the fluid. If the
fluid persists for more than 3 months and is associated
with a loss of hearing, many physicians suggest the insertion
of "tubes" in the affected ears. This operation, called a
myringotomy, can usually be done on an outpatient basis by
a surgeon, who is usually an otolaryngologist (a physician
who specializes in the ears, nose, and throat). While the
child is asleep under general anesthesia, the surgeon makes
a small opening in the child's eardrum. A small metal or
plastic tube is placed into the opening in the eardrum. The
tube ventilates the middle ear and helps keep the air
pressure in the middle ear equal to the air pressure in the
environment. The tube normally stays in the eardrum for 6
to 12 months, after which time it usually comes out
spontaneously. If a child has enlarged or infected adenoids,
the surgeon may recommend removal of the adenoids at the
same time the ear tubes are inserted. Removal of the
adenoids has been shown to reduce episodes of otitis media
in some children, but not those who are under 4 years of
age. Research, however, has shown that removal of a
child's tonsils does not reduce occurrences of otitis media.
Tonsillotomy and adenoidectomy may be appropriate for
reasons other than middle ear fluid.
Hearing should be fully restored once the fluid is removed.
Some children may need to have the operation again if the
otitis media returns after the tubes come out. While the
tubes are in place, water should be kept out of the ears.
Many physicians recommend that a child with tubes wear
special ear plugs while swimming or bathing so that water
does not enter the middle ear.
What research is being done on otitis media?
Several avenues of research are being explored to further
improve the prevention, diagnosis, and treatment of otitis
media. For example, research is better defining those
children who are at high risk for developing otitis media and
conditions that predispose certain individuals to middle ear
infections. Emphasis is being placed on discovering the
reasons why some children have more ear infections than
other children. The effects of otitis media on children's
speech and language development are important areas of
study, as is research to develop more accurate
methods to help physicians detect middle ear infections.
How the defense molecules and cells involved with
immunity respond to bacteria and viruses that often lead to
otitis media is also under investigation. Scientists are
evaluating the success of certain drugs currently being used
for the treatment of otitis media and are examining new
drugs that may be more effective, easier to administer, and
better at preventing new infections. Most important,
research is leading to the availability of vaccines that will
prevent otitis media.
**There is ongoing scientific discussion about the use and potential overuse of antibiotic therapy for otitis media.
For further information, please note the following publications.
Berman S, Byrns PJ, Bondy J, Smith PJ, Lezotte D. Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric Medicaid population. Pediatrics. 4 Oct 1997. 100(4): 585-592.
Culpepper L, Froom J. Routine antimicrobial treatment of acute otitis media: is it necessary? JAMA. 26 Nov 1997. 278(20): 1643-1645.
Dagan R, Leibovitz E, Leiberman A, Yagupsky P.Clinical significance of antibiotic resistance in acute otitis media and implication of antibiotic treatment on carriage and spread of resistant organisms. Pediatr Infect Dis J. 19 May 2000. 19(5 Suppl): S57-S65.
Dowell SF, Butler JC, Giebink GS, Jacobs MR, Jernigan D, Musher DM, Rakowsky A, Schwartz B. Acute otitis media: management and surveillance in an era of pneumococcal resistance-a report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J. Jan 1999. 18(1): 1-9.
Ehrlich GD, Veeh R, Wang X, Costerton JW, Hayes JD, Hu FZ,
Daigle BJ, Ehrich MD, Post JC. Mucosal biofilm formation on middle-ear mucosa in the chinchilla model of otitis media. JAMA. April 2002.
Glasziou PP, Hayem M, Del Mar CB. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2000. 2: CD000219.
Kozyrskyj AL, Hildes-Ripstein GE, Longstaffe SE, Wincott JL, Sitar DS, Klassen TP, Moffatt ME. Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis. JAMA. 3 Jun 1998. 279(21): 1736-1742.
Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I.
Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ. #6 July 2002. 325(7354): 22-24.
Maw R, Wilks J, Harvey I, Peters TJ, Golding J. Early surgery compared with watchful waiting for glue ear and effect on language development in preschool children: a randomised trial. Lancet. 20 Mar 1999. 353 (9157): 960-963.
McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA. 19 June 2002. 287(23): 3096-3102.
Otitis Media with Effusion in Young Children, Clinical Practice Guideline No. 12, AHCPR Publication No. 94-0622. Agency for Healthcare Research and Quality, Rockville, MD. July 1994.
Perz JF, Craig AS, Coffey CS, Jorgensen DM, Mitchel E, Hall S, Schaffner W, Griffin MR. Changes in antibiotic prescribing for children after a community-wide campaign. JAMA. 19 June 2002. 287(23): 3103-3109.
Pichichero ME. Acute otitis media: part II. Treatment in an era of increasing antibiotic resistance. Am Fam Physician. 15 April 2000. 61(8): 2410-2416.
Rosenfeld RM, Vertrees JE, Carr J, Cipolle RJ, Uden DL, Giebink GS, Canafax DM. Clinical efficacy of antimicrobial drugs for acute otitis media: metaanalysis of 5400 children from thirty-three randomized trials. J Pediatrics. Mar 1994. 124(3): 355-367.
Stine AR. Is amoxicillin more effective than placebo in treating acute otitis media in children younger than 2 years? J Fam Pract. May 2000. 49(5): 465-466.
Where can I get additional information?
Agency for Healthcare Research and Quality
2101 E. Jefferson Street, Suite 501
Rockville, MD 20852
Voice: (301) 594-1346
Toll-Free: (800) 358-9295
American Academy of Otolaryngology-Head and Neck Surgery
One Prince Street
Alexandria, VA 22314
Voice: (703) 519-1589
TTY: (703) 519-1585
Fax: (703) 299-1125
American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1098
Voice: (847) 434-4000
Fax: (847) 434-8000
American Speech-Language-Hearing Association
10801 Rockville Pike
Rockville, MD 20852
Voice: (301) 897-3279
TTY: (301) 897-0157
Toll-Free Voice: (800) 638-8255
Fax: (301) 897-7355
NIH Pub. No. 97-4216
Reviewed: July 2002
For more information, contact the NIDCD Information Clearinghouse.
National Institute on Deafness and Other Communication Disorders
National Institutes of Health
31 Center Drive, MSC 2320
Bethesda, MD USA 20892-2320