So what is a middle ear infection?

The middle section of the ear, the same section that causes us lots of trouble, is the area where the “regular” infections of the ear occur.
It is important to recognize that there is a connection between the middle ear and the nose. There is a canal that goes forward and connects the middle ear cavity to an area found at the back of the nose. Therefore, it is easy to understand why the middle ear does not get any ventilation when this canal is congested or blocked (for example when a child with a third tonsil has a runny nose).

How prevalent is otitis media in children?

Since the medical textbooks include different conditions when talking about ear infections, including ear fluids, it is difficult to estimate the true prevalence. There is no doubt that otitis media is a childhood or infant illness and is particularly common in the first and second year of life. But ear infections can, of course, occur at any age.
There are many different factors that play a role in the prevalence of ear infections – some can be altered, while others cannot. For example:
Age – otitis media is a condition that is prevalent in children under the age of 2, as mentioned above. After this age the prevalence decreases but it is still higher in early school-aged children.
Gender – boys tend to get it more than girls
Genetics – it has higher prevalence in certain families. The exact cause is unknown
Breastfeeding – breastfeeding has a protective effect as you can see in the link here.
Exposure to tobacco – passive smoking is a significant risk factor.
Exposure to other children – being exposed to other children (in daycare) is a significant risk factor.
Seasonality – since lots of bacterial ear infections are a complication of a mild upper respiratory viral infection, it is easy to understand why most ear infections in children occur during the winter season.

Other anecdotes that are associated with high prevalence of ear infections in children – the use of soothers or feeding from a bottle while laying down.

What are the most common bacteria to cause ear infections in children and do we have vaccines for them?

The three most common bacterial causes of ear infections are:
Streptococcus pneumonia – the vaccine for it (Prevnar 20) is given at the age of 2 months, 4 months and 1 year in most places around the world. Even if this vaccine has reduced the prevalence of ear infections caused by this bacteria in children, it certainly has not eradicated it.
Hemophilus influenza nontypeable – there is no vaccine for this (it is not the same as hemophilus influenza type b for which is there is a vaccine available).
Streptococcus group A – yes, that same one that causes throat infections. There is no vaccine for it.
Getting familiar with, and understanding what the different bacteria are, has a direct effect on the choice of antibiotic treatment, as you will see below.

What are the signs and symptoms of ear infections in children?

The symptoms vary and are age dependent. The most common sign is pain that can manifest with irritability in children that increases during the night time, with or without fever.
Keep in mind that this often occurs after an upper respiratory tract infection lasting several days.
Pulling or tugging at the ear, without any other symptoms, is often a sign of fatigue and frustration rather than an ear infection.

What is the doctor looking for when examining your child’s ear?

When the doctor looks through an otoscope, he or she directly examines the ear drum, and looks at certain parameters, including: turbidity, bulging, redness, blurring of the normal shape of the eardrum and lack of light reflex. The most important and meaningful signs are bulging and turbidity of the eardrum.
Keep in mind that an ear examination is not painful, even if the child has an ear infection. Holding the child in place and the entire situation is probably unpleasant for them, but the actual examination is not painful and does not injure the child.
Let me clarify, often parents tell me that they think the child may have otitis media because he or she had presented with pain when they touched the outer ear or while they were checking their temperature. Well, that is certainly not a sign of otitis media.
The doctor will always assess both ears and will often start with the one that is not painful, if pain is reported in one of them.

What are the two different approaches to treatment of otitis media and when will the doctor choose one over the other?

The two different approaches are the watchful waiting approach and the immediate treatment approach.

What is the watchful waiting approach when it comes to otitis media and when will the doctor offer it?

Due to a number of studies that demonstrated low efficacy of antibiotics in treating otitis media in children, the world has developed an approach that says that in certain situations, we can wait before starting antibiotic treatment.
The advantage of this approach is avoiding a course of antibiotics. Keep in mind that antibiotics can also destroy other bacteria, not only the ones causing the infection, some of which are friendly (especially the ones in our intestines). In addition, recurrent courses of antibiotics contribute to the formation of resistant bacteria.
The watchful waiting approach will be typically offered to parents of children who are previously healthy, older than 6 months of age, not presenting with severe bulging of the eardrum, do not have fever over 39 degrees Celsius, and are not presenting with irritability or bilateral otitis media.
The physician must offer adequate follow up, either clinical or by phone, on the first few days of the illness while the decision for treatment is being made.
In addition, the parents must agree to the plan.
Practically speaking, the watchful waiting approach includes treatment of the pain (acetaminophen or ibuprofen), ear drops to relieve local pain (anesthetic) and waiting 24-48 hours.
From my own experience, the watchful waiting approach is very successful when the doctor chooses the right children (and parents) to offer it to.
In younger children, with fever and prominent findings on physical examination, the watchful waiting approach will fail.
In addition, when this approach is chosen, it is important to tell the parents to treat the pain well because persistence of the pain is the main reason behind failure of this approach. In my opinion, when choosing the right candidates, you can reduce the use of antibiotics for ear infections by about 50%.

What is the immediate treatment approach and when will the doctor offer it?

This refers to the recommendation to start antibiotics by mouth immediately. The doctor will suggest this in cases that do not fulfil criteria for watchful waiting.
This approach will always be the one offered to children under the age of 6 months, children with underlying medical history, children with high fever or significant findings on physical examination (bulging or turbidity) or children with bilateral ear infections.
Even if we choose to treat with antibiotics right away, it is still important to aggressively treat the pain, by mouth with acetaminophen or ibuprofen and locally, with topical ear drops.

What is the antibiotic of choice when it comes to treatment of acute otitis media in children?

The antibiotic of choice for the treatment of acute otitis media in children is Amoxicillin. Most of the time the treatment will be given for 7-10 days (14-20 doses).
If the patient is sensitive or allergic to Amoxicillin or drugs from the penicillin family, we treat with a macrolide, mostly Azithromycin, for a period of 3-5 days.
When the treatment fails, or in other words, there is lack of improvement or worsening of the infection despite adequate treatment with Amoxicillin, we refer to the second line of treatment which is Amoxicillin-Clavulanic. There are two types of Amoxicillin-Clavulanic in children (400 and 600), as you can see in the link here, the type of Amoxicillin-Clavulanic and dose choice will be determined by the pediatrician.
There is no need for a re-assessment prior to stopping the treatment, unless your pediatrician has specifically requested that.

Are ear infections infectious and when can the child return to their daily activities at daycare/school?

Acute bacterial otitis media is not infectious. The child can return to their daily activities 24 hours after the fever has resolved and when they are feeling well, even if they are being treated with antibiotics.

When should we refer to a pediatric ENT specialist?

A good and accessible ENT specialist can help manage complex scenarios of acute otitis media in children.
Especially in children where there is a concern for otitis media but it is difficult to visualize the eardrum (usually because of ear wax obstructing the canal) but also when treatment has failed following both first line and second line treatment.
In situations of recurrent otitis media, further workup and investigations should be performed (for example, to look for a third tonsil), and it is also a good idea to see an ENT specialist then, as you will see below.

How should discharge from the ear be managed and why does it happen?

An ear infection leading to discharge is often because of a tear in the eardrum causing mucous to spill into the ear canal and auricle. You can find out more about purulent ear infections here.

What are potential harms of ear infections? Can it cause hearing loss?

Untreated ear infections can have potential complications, from local infection to systemic infections. It is therefore important to consult with your pediatrician whenever there is a concern for ear infections.
In terms of hearing, acute otitis media does not affect hearing. In contrast to ear infections with effusion (fluids in the ear) which we will discuss in a different chapter.
Recurrent ear infection, including those causing a tear in the ear drum, may have an effect on the structure of the eardrum and hearing. In these situations, it is best to consult with a pediatric ENT specialist.

What needs to be done when there are recurrent ear infections?

Because of the importance of this topic and its prevalence, I have decided to dedicate a chapter to the management of recurrent ear infections, and you can find it in the following link.

In summary, this is one of the most important topics in pediatrics. I hope this chapter will help you and give you the right tools to diagnose and manage acute otitis media in your children properly.
We will now move on to brief questions to make sure we know this topic perfectly!