Otitis media is an infection of the middle ear (the space behind the eardrum), caused by bacteria or a virus. Middle ear infections often occur at the same time as a cold, allergies, nose and throat infection, or enlarged adenoids (glands at the top of the throat). Middle ear infections usually clear up without problems or long-term effects.
The ear structure and function
There are three main parts of the ear: outer, middle and inner:
- The outer ear is the opening outside of the body.
- The middle ear houses delicate bones that aid in hearing.
- The inner ear holds organs that control hearing and balance.
The Eustachian tube regulates air pressure within the middle ear, connecting it to the back of the nose and throat.
Middle ear infection is more common in children and is the most common childhood illness (other than a cold). Ear infections occur most often in children who are between age three months and three years, and are common until age eight. One-fourth of all children will have repeated ear infections; five to ten percent will develop a hole on the eardrum from fluid pressure. This hole usually heals in one week.
Children usually get more ear infections than adults. They usually get more colds and respiratory infections than adults, and the Eustachian tube is shorter and has less of a slope in children than in adults.
Other factors that can lead to middle ear infections include the following:
- Age: Infants and young children are at greater risk for ear infections.
- Sex: Boys tend to get ear infections more often than girls.
- Heredity: The tendency to get ear infections can be hereditary (runs in the family).
- Colds: Having colds often increases the chances of getting an ear infection.
- Allergies: Allergies cause inflammation (swelling) of the nasal passages and upper respiratory tract, which can cause blockage of the Eustachian tube or enlargement of the adenoids.
- Chronic illnesses: People with chronic (long-term) illnesses are more likely to develop ear infections, especially patients with immune deficiency and chronic respiratory disease, such as cystic fibrosis and asthma.
- Acute otitis media: Allergies, colds, respiratory infections, and inflamed or enlarged adenoids can block the bottom of the Eustachian tube, allowing normally produced fluids to build up in the middle ear. Trapped fluid can become infected by a virus or bacteria, causing pain and swelling of the eardrum.
- Otitis media with effusion: Symptoms of acute otitis media will disappear, but the fluid may remain. Trapped fluid may cause temporary and mild hearing loss. This is called otitis media with effusion and may last for up to three months.
Ear infections can be painful. Trapped fluid puts pressure on the eardrum, causing it to bulge. Other symptoms include:
- Ear pain: This symptom is obvious in older children and adults. In children who cannot yet speak, you should watch for other signs, like irritability or a great deal of crying.
- Loss of appetite: This may be most noticeable in young children, especially during bottle feedings. Pressure in the middle ear changes as the child swallows, causing more pain and less desire to eat.
- Irritability: Any kind of continuing pain may cause irritability in children and adults.
- Poor sleep: Pain may be worse when the child is lying down, as fluid is shifting.
- Fever: Ear infections can cause temperatures up to 104° F.
- Drainage from the ear: Yellow, brown, or white fluid that is not earwax may seep from the ear. This may mean that the eardrum has ruptured (broken).
- Difficulty hearing: Bones of the middle ear connect to the nerves that send electrical signals (as sound) to the brain. Fluid behind the eardrums slows down movement of these electrical signals through the inner ear bones.
Diagnosis and Tests
When an ear infection is suspected, the doctor or nurse will examine the ear using an instrument called an otoscope. A healthy eardrum will be pinkish gray in color and translucent (clear). If infection is present, the eardrum may be inflamed, swollen, or red.
The doctor may also check the fluid in the middle ear using a pneumatic otoscope, which blows a small amount of air at the eardrum. This should cause the eardrum to move back and forth. The eardrum will not move as easily if there is fluid inside the ear.
Another useful diagnostic tool is tympanometry, a test that uses sound and air pressure to check for fluid in the middle ear. (It cannot test hearing.) If needed, the doctor will order a hearing test (performed by an audiologist) for a patient who has persistent ear infections to help determine if there is any hearing loss, and how bad it is.
Management and Treatment
Many middle ear infections will get better on their own, while some need to be treated with an antibiotic. Your doctor will decide if your child needs to be treated with an antibiotic for an ear infection. Permanent damage to the ear or to the hearing is very rare.
Treatments include the following:
- Observation without antibiotics: Your doctor may determine that your child has a middle ear infection but does not need to be treated with antibiotics (depending on the age of your child and how severe the infection is). Many ear infections will get better on their own without antibiotic treatment. Your doctor will tell you how long the symptoms will last.
- Antibiotics: Antibiotics, prescribed by your doctor, may be needed to kill the bacteria that are causing the ear infection. Do not forget to take or give it in regular doses until the bottle is empty, even if the pain and fever are gone. Finishing the medicine will keep the ear infection from flaring up again. Follow the instructions on the prescription about proper storage and the proper dose. Use a measuring spoon for liquid antibiotics to be sure that you give the right amount. Call the doctor if fever and pain are not gone within two days of starting the antibiotics. Antibiotics may cause nausea, diarrhea, rashes, or yeast infections, and may also interact with other medications. Rarely, allergic reactions can occur. There is the potential that bacteria will, over time, develop a resistance to frequently used antibiotics. Be sure to tell your doctor about your medical history and any over-the-counter and prescription medications that you are currently taking.
- Pain relief: Acetaminophen or ibuprofen can help relieve earache or fever until the antibiotic takes effect. These medications usually control the pain within one to two hours. Earaches tend to hurt more at bedtime. Using a warm compress on the outside of the ear may also help relieve pain. (This is not recommended for infants.)
- Restrictions: The ears do not need to be covered when going outside. Swimming is okay as long as there is no perforation (tear) in the eardrum or drainage from the ear. Air travel or a trip to the mountains is safe, although temporary pain is possible during takeoff and landing. Swallowing fluids, chewing on gum during descent, or having a child suck on a pacifier will help relieve discomfort during air travel. Children can return to school or day care as soon as the fever is gone. Ear infections are not contagious.
- Myringotomy: If fluid remains in the ear for more than three months, your doctor may want to insert small metal or plastic tubes through the eardrum to equalize pressure between the middle and outer ear. This outpatient procedure (myringotomy) is usually performed on children and can be done under general anesthesia. The tubes will remain in from 6 to 12 months and normally fall out on their own. The outer ear will need to be kept dry and free of water until the holes have closed completely.
There are ways to help prevent ear infections in children and adults. Often, changing the environment at home is all that is necessary, but sometimes surgery is needed, too.
If any of the following precautions apply to you or your child, follow them or talk to your doctor about them:
- Avoid contact with second-hand tobacco smoke, also known as passive smoking. Passive smoking brings about more infections, and can cause more severe infections. Be sure no one smokes in your home or at a day care. No one should smoke in the house or car, especially when children are present.
- Control allergies. Inflammation caused by allergies can cause ear infection, especially if you or your child have other allergies, such as eczema.
- Reduce your child's exposure to colds during the first year of life. Most ear infections start with a cold. If possible, try to delay the use of large day care centers during the first year.
- Breastfeed your baby during the first 6 to 12 months of life. Antibodies in breast milk reduce the rate of ear infections.
- Avoid bottle propping. If you bottle feed, hold your baby at a 45-degree angle. Feeding in the horizontal position can cause formula and other fluids to flow back into the Eustachian tubes. Allowing an infant to hold his or her own bottle also can cause milk to drain into the middle ear. Weaning your baby from a bottle between 9 and 12 months of age will help stop this problem.
- Watch for mouth breathing or snoring. Constant snoring or breathing through the mouth may be caused by large adenoids. These may contribute to ear infections. An exam by an otolaryngologist, and even surgery to remove the adenoids (adenoidectomy), may be necessary.
- Immunizations: Make sure your child’s immunizations are up to date, including yearly influenza vaccine (flu shot) for those six months and older. Preventing viral infections and other infections help prevent ear infections.
Outlook / Prognosis
Children should be scheduled for a return appointment three to four weeks after an ear infection. At that visit, the doctor will examine the eardrum to be certain that the infection is going away. Your doctor may also want to test the child's hearing. Follow-up exams are very important, especially if the infection has caused a hole in the eardrum.
Middle ear infections have few complications or long-term effects. It is especially important that children with middle ear infection have appropriate follow-up with their doctors.
Possible long-term effects of middle ear infection include:
- Inner ear infection
- Scarring of the eardrum
- Hearing loss
- Mastoiditis (infection of the skull behind the ear)
- Meningitis (infection in the tissues around the brain and spinal cord)
- Speech development problems in children
- Facial paralysis
Call your child's doctor immediately if:
- Your child develops a stiff neck.
- You child acts very lethargic (sluggish), responds poorly, or is inconsolable.
Call your child's doctor during office hours if:
- The fever or pain is not gone after your child is diagnosed with an ear infection.
- You have any questions or concerns.
Questions to ask your doctor or your child's doctor:
- Should I give my child or myself medication? If so, for how long and at what times of the day?
- How should I store the medication? Does it need to be refrigerated?
- When will my child (or I) start to feel better?
- Do I need to make a follow-up visit?
- Should I keep my child home from school or daycare? If so, when can she or he return?
- Should the child be restricted from any activities? If so, which ones?
- Are there certain foods or liquids to avoid?
- Which over-the-counter medications, such as pain relievers, do you recommend?
- Which symptoms should I report?
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or healthcare provider. Please consult your healthcare provider for advice about a specific medical condition.
This document was last reviewed on: 03/08/2019