Introduction

Acute middle ear infections (acute otitis media, or AOM) are among the most common illnesses in babies and young children. Most children will have had at least one acute middle ear infection by the age of three. Parents often have sleepless nights when their child has a middle ear infection. The child may cry a lot, have an earache, run a fever and be unable to sleep. Parents might understandably be worried that it is something serious. But there is usually no cause for concern when it comes to acute middle ear infections. They generally clear up on their own within two to three days, and serious complications are rare.

Giving the child painkillers and fever-reducing treatment, as well as a lot of care and attention, is usually enough. But it is important to keep an eye on the child’s condition because further treatment may sometimes be necessary.

Symptoms

Acute middle ear infections in young children are typically associated with

• severe earache,
• a sudden onset,
• fever over 38°C (100.4°F),
• vomiting, and
• loss of hearing due to a build-up of fluid.

Young children are often not able to localize pain and may complain of a stomach ache although it is their ears that are hurting. It is also difficult for parents of babies or very young children to know how severe the pain is. Some children shake their heads a lot and hold or rub their ears when they have earache,

and most of them will have trouble hearing. In general, children who have this kind of infection are more restless, cry more, have a poor appetite and sleep badly. Some children may be weak and quieter than usual, though. It is very common for children who have an acute middle ear infection to wake up at night crying because the pain is so bad they can hardly sleep.

Causes and risk factors

Acute middle ear infections usually develop as part of a cold, flu, sore throat or a similar infection. Viruses or bacteria get into the throat and the mucous membranes become inflamed, increasing the production of fluid.

The membranes lining the ear and the Eustachian tube (the canal that connects the middle ear to the throat area) swell up too. As a result, the fluid secreted in the Eustachian tube and the middle ear can no longer drain out. It builds up in the middle ear and pushes on the eardrum. This can be painful and make your hearing worse.

The Eustachian tube is still very narrow and short in babies and toddlers, so germs in their upper throat can easily spread to their middle ear. Middle ear infections are less common after the age of seven because the Eustachian tube and the immune system are more developed.

Enlarged adenoids (“polyps”) can block the middle ear too, increasing the risk of an infection. Further risk factors include allergic reactions and sinusitis. These conditions can lead to swelling in the Eustachian tube, affecting the middle ear.

Children are more likely to get middle ear infections if they

• use a pacifier (a dummy),
• often have close contact with other children, for example at daycare or a nursery school,
• were bottle-fed from the start rather than being breastfed, or
• are often exposed to cigarette smoke.

Prevalence and outlook

Middle ear infections are among the most common reasons babies and toddlers are taken to the doctor. Each year about 30 out of 100 children under the age of three years are examined by a doctor for a middle ear infection. By the time they are three months old, 10 out of 100 babies will already have had a middle ear infection.

Middle ear infections usually clear up on their own within two to three days and generally do not lead to any complications. If the fluid that builds up in the middle ear pushes too hard on the eardrum, the eardrum can  burst. The thick, sticky fluid, sometimes also mixed with pus and blood, drains out into the ear canal and the pain gets better. The hole in the eardrum is usually only small and heals on its own within a few days or weeks. A small amount of fluid may continue to drain out of the ear until it heals. The medical term for secretion from the ear caused by an inflammation is otorrhea.

If the infection continues for several weeks, it is considered to be a chronic middle ear infection (chronic otitis media). The earache and fever will go away, but the built-up fluid will remain, with pus-containing discharge often leaking out through a small hole in the eardrum. There is a risk of permanent hearing loss and of the infection spreading to surrounding tissue and bones.

Effects

Sometimes fluid remains in the middle ear after the infection has disappeared and the eardrum has healed. This is called otitis media with effusion (OME), also known as glue ear. Children who have glue ear often feel pressure inside their ear, but rarely experience pain. Glue ear can cause hearing loss, which may delay speech and language development.

If a child has frequent middle ear infections and the eardrum ruptures again and again, the thin membrane may become scarred. This can make the eardrum harder, preventing it from moving freely. If this happens it can lead to hearing loss because incoming sound waves can no longer be fully passed on to the inner ear.

Rare complications

Complications following an acute middle ear infection are very rare. But it is still important to carefully monitor the child’s symptoms and hearing, and get further treatment if needed.

Rare complications include the following:

• Mastoiditis (bacterial infection of the membranes lining the mastoid bone in the skull, found behind the ear),
• Meningitis (infection of the membranes covering the brain and spinal cord)
• Damage to the inner ear (e.g. damage to the nerves, which can lead to hearing loss)

The main symptom of mastoiditis is pain behind the ear, sometimes accompanied by swelling and fever too. Mastoiditis must be treated with antibiotics to prevent the infection from spreading to the bone.

If the bacteria spread, they can cause meningitis. Typical symptoms of meningitis include a high fever, severe headache, nausea, a stiff neck, sleepiness and confusion. This complication is life-threatening and must be treated immediately.

Diagnosis

Normally the doctor first asks the parents and, if possible, the child about acute symptoms as well as the history of the illness. This is followed by examinations of both ears, the neck and the throat. The doctor also takes the child's temperature.

The eardrum is examined with an instrument called an otoscope. This is a device with a magnifying glass and a small lamp that allows the doctor to look into the ear canal. The doctor can check the child’s hearing with a “tympanometer.” This instrument can generate and pick up noises. It can also change the air pressure to see whether the eardrum is able to move freely.

Three main signs of an acute middle ear infection include

• sudden onset of the illness with severe earache, possibly fever, hearing problems and general weakness,
• a red eardrum, and
• an eardrum that bulges outward, does not move freely and is not transparent, which suggests there might be fluid trapped behind the eardrum.

Sometimes it is even difficult for doctors to say for sure whether or not it is an acute middle ear infection.

Prevention

Middle ear infections cannot usually be prevented. There are some things you can do that might lower the risk a little. One is to give children a pacifier (dummy) less often. It is particularly important to make sure that children grow up in as smoke-free an environment as possible. Passive smoking increases the risk of infections in the airways, as well as in the upper throat. It also weakens the child's immune system.

Treatment

Acute middle ear infections can be very painful, so treatment focuses mainly on providing fast pain relief. Medicines that relieve pain and lower fever, such as acetaminophen (paracetamol) or ibuprofen, can be used for this purpose.

Antibiotics often aren't much help – because they only work if the infection is caused by bacteria and not a virus. And the symptoms frequently go away quickly on their own anyway. If a child has fluid coming out of their ear, or if a child under the age of two has an infection in both ears, it is probably bacterial. In that case antibiotics can be useful.

People are often advised to use decongestant nose drops to reduce the swelling and help open up the passages leading to the middle ear. Decongestants probably do not influence the course of the infection or the symptoms, though. If the child’s nose is blocked, nose drops can make it easier for them to breathe through their nose for a few hours. Decongestants should not be used for more than a few days.

There is no scientific proof that home remedies like cooling leg wraps, onion packs and herbal or homeopathic products are effective in the treatment of earache and fever.

Sources

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• Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM). Ohrenschmerzen. S2k-Leitlinie. November 2014. (AWMF-Leitlinien; Volume 053 - 009).
• Nelson AM. A comprehensive review of evidence and current recommendations related to pacifier usage. J Pediatr Nurs 2012; 27(6): 690-699. [PubMed: 22342261]
• Russel D, Luthra M, Wright J, Golby M, Plastow L, Marshall MN. A qualitative investigation of parents' concerns, experiences and expectations in managing otitis media in children: implications for general practitioners. Primary Health Care Research and Development 2003; 4: 85-93.
• Strachan DP, Cook DG. Health effects of passive smoking. 4. Parental smoking, middle ear disease and adenotonsillectomy in children. Thorax 1998; 53(1): 50-56. [PMC free article: PMC1758689] [PubMed: 9577522]
• Venekamp RP, Damoiseaux RA, Schilder AG. Acute otitis media in children. BMJ Clin Evid 2014. [PMC free article: PMC4166866] [PubMed: 25229555]
• Venekamp RP, Sanders SL, Glasziou PP, Del Mar CB, Rovers MM. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev 2015; (6): CD000219. [PubMed: 26099233]

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