Acute otitis media
There are almost no children who have not been suspected (by the mother) or examined (by the doctor), for the question of acute otitis media. This is one of the most common reasons for visiting a pediatrician as well as giving antibiotics in childhood.
Unfortunately this is also a medical condition which is undiagnosed properly and not properly managed in quite a lot of cases. Sometimes diagnosed due to the difficulty in good observation of the eardrum and sometimes overdiagnosed in cases of fever without a good source.
But in this case it is all about anatomy, and in my opinion a parent who understands the structure of the ear will add to himself knowledge and understanding on the subject of the diversity of ear infections.
Remember, this chapter is about acute otitis media. Not for external ear infection and not for fluid in the ears.
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.
What is the immediate treatment method and when will the doctor offer it?
This method is intended for immediate use of oral antibiotics. The doctor will recommend this treatment in cases that do not meet the criteria of delayed treatment.
This method will always be chosen in small infants below the age of six months, in children with an abnormal medical background, in children with high fever attributed to the ear infection, in cases of impressive findings on ear examination (bulging or turbidity of the eardrum), or in bilateral otitis media.
Even if we have chosen to treat with antibiotics immediately, there is a room for aggressive treatment of pain, including oral treatment (acetaminophen or ibuprofen) and for your consideration also local treatment aimed at the pain.
What is the antibiotic of choice for treating Acute otitis media in children?
The antibiotic of choice for treating otitis media in children is Amoxicillin. You can read more, including dosages at the following link. Usually the treatment will be given for a full seven days (14 doses).
In cases where there is a sensitivity / allergy to antibiotics from the penicillin family, there is an indication for treatment with macrolides, Azithromycin for example for 3 days.
In cases of therapeutic failure, i.e. lack of improvement or exacerbation after appropriate treatment with Amoxicillin, a second-line antibiotic treatment, Amoxicillin-calvulanate for example. There are several formulations of this drug, so the choicee of the specifiec typw and dosage will be made by the pediatrician.
There is no need for a re-examination before stopping the treatment, unless the doctor for his reasons has requested it.
Is ear infection contagious and when can the child return to normal activity in kindergarten or school?
Bacterial otitis media is a non-contagious infection. The child can return to regular activity in the educational institution about 24 hours after the fever subsides and when he feels well, even if he is still being treated with antibiotics.
When is it right to consult a pediatric ENT specialist?
An available and good ENT doctor can be of great help in managing more complex cases of otitis media in children.
In cases where otitis media is suspected but it is not possible to clearly see the eardrum (usually due to wax blocking the canal), cleaning the ears by an ENT doctor is very usefull. But also in cases of therapeutic failure with the first or the second line treatments, there is room for referal.
Also, in cases where there are recurrent events of ear infections, when there is a need for further clarification including the possibility of a adenoid tonsil enlargement, there is room for an ENT check up as you will see below.
What to do in case of purulent otitis media and how does it happen?
A secretory ear infection (purulent otitis media) is an inflammation in which the eardrum is torn and pus spills into the ear canal and the eardrum area. You can read all about it in this post.
What are the dangers of ear infections? Will there be a hearing loss?
Improperly treated ear infection has many potential complications. From local to systemic infections. Therefore, it is imporatnt to get a pediatrician advice in any suspicion.
In terms of hearing, acute otitis media does not impair hearing. This is in contrast to serous otitis media (fluid in the ears) who will be detailed in another chapter.
Many recurrent infections, including those with a rupture of the eardrum, can have an effect on the structure of the eardrum and as a consequence on hearing. In these cases it is adviced to consulta pediatrician and a pediatric ENT specialist.
What to do in cases of recurrent ear infections?
Recurrent otitis media is a bundle that pediatricians deal with quite a bit.
Before talking about management and risk factors, try to answer the following two questions:
Is it really recurrent otitis media episodes? As I wrote at the beginning, otitis media is a disease that is sometimes overdiagnosed. For example, if the doctor saw a red eardrum, started amoxicillin but after 4 days of high fever, the fever went down and a typical rash came out – then most likely the child had roseola infantum (viral infection) and not a true ear infection. In short, if every time you go to the doctor you get out with antibiotics because of otitis media, there is a problem here …
Are these recurring events or alternatively an ongoing event? If two days after the end of the antibiotic there is re-inflammation, then it is a continuous event and not a recurring event and the management should be a little different.
If you have come to the conclusion that the child does indeed suffer from recurrent otitis media, then it is worth considering a number of points and risk factors, including:
A. Is the child vaccinated? Routine vaccines (Prevnar) and vaccines against respiratory viruses (flu) reduce the incidence of otitis media.
B. Does the child have a big adenoid tonsil and this is one of the risk factors for recurrent infections?
C. Is there environmental exposure to smoking? And save me the stories about parents who smoke only on the balcony, etc. Easy to say but hard to do, I know. But if your child has recurrent ear infections and you smoke, you are one of the risk factors.
D. Does the child drink a bottle while lying down? If so, change it.
E. Early weaning from a pacifier can reduce the number of events.
F. Taking the kid out of kindergarten also …
G. A state of immunosuppression should be considered with your physician.
At the end of the day, with proper management of your pediatrician and many times with the help of a pediatric specialist ENT, it is possible to get out of this endless cycle of recurrent ear infections.
I am aware of the approach of prolonged antibiotic treatment (for months) for children with recurrent ear infections. This is a very controversial approach. Personally, this is an approach I take in super-exceptional situations, about once a year.
Good luck!
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