Acute otitis media

How is the ear built and what is meant by otitis media?

See the following drawing for the structure of the ear. The ear has three parts, an outer ear, a middle ear and an inner ear.

Outer ear

We are all familiar with the auricle which is the outer cartilaginous part of the ear. In the center of the auricle there is a hole that is the entry to the auditory canal. At the end of the same ear canal, after a few inches lies the eardrum and this is the boundary between the outer and middle ear.

Middle ear

Begins in the eardrum which is a membrane that moves gently according to the sound waves and vibrates three delicate auditory bones connected behind the eardrum. Eventually the third bone is attached to another small membrane called the oval window and this is the boundary between the middle ear and the inner ear.

Inner ear

A more internal space that contains additional auditory organs (labyrinth and cochlea) and eventually turns the air vibrations of the sound waves into electrical stimuli decoded by the brain.

The middle ear is the area that causes us a lot of trouble and this is the area where “acute otitis media” occurs. It is important to recoginze that there is a connection between that middle ear cavity and the posterior part of the nose. There is a canal that goes forward and connects the same cavity in the ear to the area behind the nose. It is therefore easy to understand that when the canal is blocked (in the case of a cold for example or a large adenoid tonsil) , there is no proper ventilation of the middle ear cavity and infections occur.

What is the prevalence of Acute otitis media in children?

Since textbooks put different types of ear conditions into the definition of inflammation, including ear fluids, there is no exact prevalence. There is no doubt that otitis media is a disease of small children or babies, especially in the first and second year of life. But ear infections can, of course, happen at any age including at old age.

Lots of factors affect the incidence of ear infections – some are changeable and some are not. For example:

Age – Otitis media is a disease, as we have written, of children up to two years of age. Later in life the incidence decreases but is still higher in children of early school age. This is because the anatomy of that canal connecting the middle ear and nose is more susceptible to blockage in small children. As the child head grows, the canal changes its angle and tends to stay open.

Sex – Boys get sick more than girls.

Genetics – There is a higher prevalence running in families. The specific cause was not found.

Breastfeeding – Breastfeeding has a protective effect.

Exposure to tobacco – Passive smoking is a very significant risk factor.

Exposure to other children – Significant exposure to other children (family or kindergarten) is a risk factor because the risk of contracting viral and bacterial infection increases.

Seasonality – Since a lot of bacterial ear infections are a complication of a mild viral infection in the upper airways it is easy to understand that winter is the season when there are more ear infections in children.

Other anecdotes linked to a higher incidence of ear infections in children – using a pacifier or drinking a bottle while lying down.

What are the common bacteria that cause ear infections in children and is there a vaccine against them?

The three most common bacteria that cause ear infections are:

Streptococcus pneumoniae – There is a vaccine against it (called Prevnar) which is usually given during the first year of life. Even if this vaccine has reduced the incidence of ear infections from this bacterium in children, it has not eliminated the disease.

Unclassified Hemophilus influenza – no vaccine (this is not the same type b Hemophilus which we are vaccinate our chidren against).

Moraxella catarrhalis – another “friend”. No vaccine.

Group A streptococcus – yes, the same one that also causes a sore throat. No vaccine.

Getting to know and understanding who the various bacteria are has a direct impact on choosing the right antibiotic treatment, see below…

What are the symptoms of Acute otitis media in children?

The symptoms vary and are age dependent. The most common sign is pain that can manifest in young babies with increasing restlessness at night. Sometimes it comes with high temperature and sometimes without.

Remember that many cases happen after the child has a cold for several days.

Tugs and ear touches in children, who do not suffer from anything else, are usually a sign of fatigue and frustration rather than for otitis media.

What does the doctor assess when he examines the ear in children?

On otoscopy (looking inside the ear canal) the doctor looks directly at the eardrum and evaluates a number of parameters including: turbidity, bulging, redness, blurring of the normal shape of the eardrum and lack of light reflex. The most important and significant signs are the bulging and turbidity of the eardrum.

Remember that an ear examination is not a painful test, even in cases where there is indeed otitis media. The holding of the child and the situation may not be pleasant for the child but the test itself is uninjured and painless.

Both ears will always be examined, and usually in the case of reporting a particular side of ear pain the doctor will first examine the pain-free ear.

What are the two approaches of treating otitis media and when will he choose each approach?

The approach methods are the delayed treatment method or the immediate treatment method.

What is the delayed treatment method and when will the doctor offer it?

Following a number of studies that have demonstrated low, if any, efficacy in the treatment of ear infections in children, an approach has been developed around the world that states that in some situations it is possible to wait without an antibiotic treatment.

The advantage of the delayed treatment method is the saving of the antibiotic course. I remind you all that antibiotic treatment can not only be aimed at the “criminal” bacterium that causes inflammation in the ear but also kills other “good” bacteria, some of which are mainly intestinal friendly ones. In addition, many repeated antibiotic treatments contribute to increasing rates of resistant bacteria for antibiotics.

The delayed treatment approach method will be usually offered to parents of children who are previously healthy, aged over six months, without significant bulging of the eardrum, without fever above 39 degrees, without considerable restlessness and who have unilateral inflammation. Parental consent is required.

The attending physician should ensure adequate follow-up, including clinical or daily telephone calls during the first few days following the decision to suspend treatment.

We have to remember that not giving antibiotics doesn’t mean the child has no pain or discomfort. So this approach includes pain treatment (acetaminophen or ibuprofen), ear drops that relieve the pain locally and a waiting period of 24 to 48 hours. Pain treatment is an important part of this approach, since the persistence of pain is the main reason for the failure of this method.

From my experience, the delayed treatment method is a very successful method if the doctor wisely selects the children, and parents, who are suitable for this approach. In young children, with fever and impressive findings on ear examination, the delayed treatment method will probably fail.

In my estimation, with the right choice of candidates, over 50% of antibiotic treatments for otitis media can be avoided.