| Ear infections are very common in children, especially those younger than two years of age, and are a common reason for visits to the Pediatrician.
There are two main types of ear infections in children, outer ear infections and middle ear infections. Risk factors for getting a lot of middle ear infections include being exposed to a lot of other children (like in a large day care), having a parent or other family member that smokes, having another family member that had a lot of ear infections and laying down while drinking a bottle. Ear infections are less common in children that breastfeed.
Outer ear infections (also called otitis externa or swimmers ear) usually occur when your child gets water in his ear, which may lead to inflammation and infection. Your child will have symptoms of an earache, that is worse when you move his outer earlobe. He may also have discharge from the ear and he should not have a fever. These infections are usually treated with antibiotic ear drops.
A middle ear infection (acute otitis media) typically occurs a week or two after your child has an upper respiratory tract infection, which can cause inflammation and fluid to build up behind his ear drum. This fluid can then become infected with bacteria and your child will likely develop ear pain, fever and irritability and he may be tugging at his ears. Your doctor can tell if your child has a middle ear infection by looking inside his ear at the ear drum. With an ear infection, the ear drum will look red and will usually be bulging because of pus building up behind it. The ear drum will also be immobile, meaning that your Pediatrician will not see the ear drum move when he squeezes the rubber insufflator bulb on the otoscope.
Since there are other conditions that can make an ear drum look red, including fever or just a crying child, it is important that your Pediatrician check the mobility of the ear drum when he evaluates your child for an ear infection. An ear drum that is red from crying or because of a fever will still be mobile when tested, and this is a good way to prevent misdiagnosis or over diagnosis of ear infections. A tympanogram can also be used to test for the mobility of the ear drum.
Ear infections are treated with antibiotics, although some may get better on their own. Unfortunately, ear infections are becoming more difficult to treat as the bacteria that cause ear infections are becoming resistant to antibiotics (meaning that the antibiotics don't work anymore). Resistance is most likely in younger children, especially if they have recently been on antibiotics, or they are in day care and have been exposed to other children that have been on antibiotics recently. The bacteria Streptococcus pneumoniae (Pneumococcus) is among the bacteria which have developed resistance to multiple antibiotics.
For children who are at risk of having an ear infection with a bacteria that has resistance to commonly used antibiotics, your Pediatrician may decide to prescribe a high dose (about twice the normal dosage) of Amoxicillin as treatment. Other strategies include prescribing a regular dose of Amoxicillin and also prescribing Augmentin, which is made up of Amoxicillin and Clavunatate (a medication that fights resistant bacteria). This combination gives your child the high dose of Amoxicillin and adds in another drug to fight resistance. Other antibiotics as recommended by the CDC for treatment of persistent ear infections include Ceftin (Cefuroxime axetil) or a shot of Ceftriaxone (Rocephin). Many other antibiotics do not work well against resistant bacteria and should be avoided. A longer course of therapy, such as ten days to two weeks, may also be required for resistant bacteria, especially in younger children.
Some children with persistent infections can benefit from tympmanocentesis, which is an office procedure that involves puncturing the ear drum with a needle, and draining some of the fluid and pus behind the ear drum. In addition to relieving pain that your child may be having, draining the fluid allows it to be tested to see what bacteria is causing the infection and which antibiotic the bacteria is sensitive to. This procedure is usually performed by a Pediatrician who has training in performing tympanocentesis or by an ENT specialist.
After a middle ear infection, your child's ear drum will typically have fluid behind it for one to three months (otitis media with effusion). This is normal and the fluid will usually clear up on its own, but it may normally take up to three months. It is not an infection and the fluid does not usually require antibiotics to clear up. In young children, your doctor will typically recheck your child's ears every 4-6 weeks until all of the fluid has cleared up.
While an effusion does not cause any symptoms, such as pain or fever, it can cause a temporary hearing loss, until the fluid goes away. Effusions are often mistaken for ear infections. If your child has a persistent ear infection, but does not have any symptoms, such as ear pain, irritability or fever, then you may want to ask your Pediatrician about the possibility that it is just an effusion and not a true ear infection.
The difficulty occurs when a child with otitis media with effusion gets an upper respiratory tract infection and develops signs and symptoms, including fever and irritability. It can sometimes be very difficult to tell if the child's symptoms are just from the upper respiratory tract infection and he continues to just have an effusion in his ear (which wouldn't require an antibiotic prescription), or if the child has now developed a true ear infection.
In addition to observation and tympanostomy tube placement for persistent effusions in both ears that is lasting more than 3-6 months and causing a hearing loss, other more controversial treatments include antibiotics and steroids. It can be more difficult to decide what to do with a child that only has hearing loss in one ear, or who has a persistent effusion, but no hearing loss.
For some children, if their ear infection does not clear up with repeated courses of antibiotics, if they have fluid in both ears for more than 3-6 months and it is affecting their hearing, or if they have recurrent ear infections, then they may require a referral to an ENT specialist (otolaryngologist) and the placement of tympanostomy tubes.
Tubes are usually placed as an outpatient surgical procedure with a brief general anesthetic. They usually stay in the ear for about a year and then come out (or extrude) by themselves. Complications can include otorrhea (drainage from the ear), having a tube that doesn't come out and needs to be surgically removed, cholesteatomas and a persistent perforation of the ear drum.
The usual guidelines for referral to an ENT specialist include having more than 4-6 ear infections in one year or having more than 3-4 ear infections in a six month period. These are just general guidelines though. Reasons to get a referral earlier include beginning to get recurrent ear infections at a young age (such as less than 4-6 months old), having a hearing loss, getting a lot of ear infections in the summer months (when you would expect less), or having complicated ear infections that are very painful and require multiple courses of antibiotics to clear up. Some reasons to wait longer include it being the late Winter or Spring (after which you would expect less ear infections), having uncomplicated ear infections that quickly clear up with single course of antibiotics, or recurrent ear infections in an older child.
Ear tubes are not a magic cure for ear infections. Although they do help most children, some continue to get ear infections, even with the tubes. A child with an ear infection who has an open or patent tympanostomy tube should have purulent drainage from his ear, which makes it easy to know when he has an ear infection. Also, because the infected fluid is able to drain out, pressure does not build up behind the ear drum, so there is usually no ear pain. And antibiotic ear (otic) drops are usually prescribed for ear infections with an open tube, allowing the antibiotic to get right at the sight of the infection (vs. using an oral antibiotic which has to get absorbed in the stomach and get into the blood stream first).
Children with tympanostomy tubes who continue to get recurrent ear infections may benefit from an adenoidectomy, which is surgery to remove the adenoids, which is especially helpful if they are enlarged.
Ear infections, especially if they are chronic, can rarely lead to serious complications, including meningitis, epidural abscesses, brain abscesses, mastoiditis (an infection of the bones behind the ear), facial nerve paralysis and hearing loss with or without speech delays. Another complication is chronic suppurative otitis media, which is an ear infection that chronically drains. It is to prevent these complications that many Pediatricians and ENT specialists are against just observing ear infections and not using antibiotics.
Ear infections are less common as your child gets older. They are also less common in children who are not in day care.
A new immunization called Prevnar protects against infection with the Pneumococcus bacteria, which is a common cause of ear infections. Although not specifically approved as a therapy to reduce ear infections, this vaccine may reduce the number of ear infections in children prone to getting ear infections. It is currently recommended that all children under age two years get this vaccine and you should especially consider it if your child is prone to ear infections or other family members get recurrent ear infections.
Ear Infections Internet Resources:
- Chronic Ear Infections: American Academy of Pediatrics guide to chronic ear infections in children
- Ear Infections: American Academy of Pediatrics guide to ear infections in children, including treatments and risk factors.
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