Otitis media is an infection of the middle ear, which is located behind
the eardrum. There are two main types of otitis media. In the first,
called acute otitis media (AOM), parts of the ear are infected and
swollen, and fluid and mucus are trapped inside the ear. AOM can be quite
painful. In the second type, called otitis media with effusion (fluid), or
OME, fluid and mucus remain trapped within the ear after the infection is
over, making it more difficult for the ear to fight off new infections.
This fluid may adversely affect a child's hearing.
One of the most common childhood infections, Otitis media is the leading
cause of visits to the doctor by children. It is also the most frequent
reason children receive antibiotic prescriptions or undergo surgery.
In order to fully understand otitis media, it is helpful to have a basic
knowledge of ear anatomy. Deep within the outer ear canal is the eardrum,
which is a thin, transparent membrane that vibrates in response to sound.
Behind the eardrum is the space called the middle ear. When the eardrum
vibrates, three tiny bones within the middle ear, called ossicles,
transmit these sounds to the inner ear. Nerves are stimulated in the inner
ear, which then relay the sound signals to the brain. The eustachian tube,
which connects the middle ear to the nose, normally equalizes pressure in
the middle ear, allowing the eardrum and ossicles to vibrate correctly, so
that hearing is normal.
There are certain factors particular to children that make them more at
risk for otitis media. In children, the eustachian tube is shorter and
less slanted than in adults. Its size and position allow bacteria and
viruses to travel to the middle ear more easily. Children also have clumps
of infection fighting cells, commonly called adenoids, in the area of the
eustachian tube. These adenoids may enlarge with repeated respiratory
tract infections and ultimately block the eustachian tubes. When these
tubes are blocked, the middle ear is more likely to fill with fluid, which
in turn increases the risk for infection.
Otitis media is common. Fifty percent of children have an episode before
their first birthday, and 80 percent of children have an occurrence by
their third birthday. It is estimated that $3 to $4 billion are spent per
year on patients with a diagnosis of acute otitis media and related
complications. Ear infections are found in all age groups, but they are
considerably more common in children, especially those aged six months to
three years. Boys are affected more commonly than girls. Other children at
higher risk include those from poor families, Native Americans, children
or other defects of the facial structures, and children with
. Exposure to cigarette smoke and early entrance into daycare also
increase the risk. Otitis media occurs more frequently in winter and early
spring. It is less common among children who are breastfeeding. Some
studies show a genetic predisposition towards developing otitis media.
Causes and symptoms
The first precondition for the development of acute otitis media is
exposure to an organism capable of causing the infection. Otitis media may
be caused by either viruses or bacteria. Viral infections account for
approximately 15 percent of cases. The majority of other cases are caused
by a variety of bacteria. The three most common bacteria are
(responsible for 25–50% of cases),
Acute otitis media often occurs as an aftereffect of upper respiratory
infections, in which the eustachian tube and nasal membranes become
swollen and congested. This condition can lead to an impaired clearance
and pressure regulation in the middle ear, which, if sustained, may be
followed by viruses and bacteria traveling from the nasopharynx to the
Otitis media with effusion may develop within weeks of an acute episode of
middle ear infection, but in many cases the cause is unknown. It is often
associated with an abnormal or malfunctioning eustachian tube, which
causes negative pressure in the middle ear and leaking of fluid from tiny
blood vessels, or capillaries, into the middle ear.
The following are symptoms of acute otitis media:
Otitis media with effusion (OME) is the presence of middle ear fluid for
six weeks or longer after the initial episode of acute otitis media. The
hallmark of OME is the lack of obvious symptoms in those who most commonly
have the condition. Older children often complain of muffled hearing or a
sense of fullness in the ear. Younger children may turn up the television
volume. Most often OME is diagnosed when someone examines the ear for
another reason, such as a well-child physical. For this reason, OME is
often referred to as silent otitis media.
Unresolved episodes of otitis media may lead to a variety of
complications, including hearing loss and
. Any child who reports an earache or a sense of fullness in the ear,
especially if combined with a prior upper respiratory tract infection, or
fever, should be evaluated by a physician.
The physician will visualize the ear canal and ear drum by using a special
lighted instrument called an otoscope. Normally, the light from the
otoscope reflects off the eardrum in a characteristic fashion called the
"cone of light." In an infection, this reflection is often
shifted or absent. If fluid or pus is draining from the ear, it can be
collected and sent to a laboratory to determine if any specific infectious
organisms are present. Additionally, a tympanometry test will be
performed. Here, the doctor inserts a probe into the ear which emits a
tone with a certain amount of sound energy. The probe measures how much
sound energy bounces back off the eardrum, rather than being transmitted
to the middle ear. The more energy that is returned to the probe, the more
blocked the middle ear is.
A diagnosis of acute otitis media is based on the following:
Otitis media with effusion can be more difficult to detect, since it is
not painful and the child usually does not appear ill. The physician may
rely on one or several tests to determine the diagnosis.
Treatment of AOM is focused on relieving any pain that may be present and
addressing the infection itself. Usually,
or ibuprofen prove adequate in
Otitis media is an ear infection in which fluid accumulates within
the middle ear. A common condition occurring in childhood, it is
estimated that 85 percent of all American children will develop
otitis media at least once.
(Illustration by Electronic Illustrators Group.)
relieving the pain. In cases of severe pain, narcotics may occasionally
Occasionally, an "observation option" will be used in a
child who has uncomplicated acute otitis media. This refers to delaying
antibacterial treatment of certain children for 48 to 72 hours and
limiting management to symptomatic relief. The decision to observe or
treat is based on the child's age, the certainty of the diagnosis,
and the severity of the illness. To observe a child without initial
antibacterial therapy, it is important that the parent or caregiver has a
ready means of communicating with the doctor. There also must be a system
in place that permits a prompt reevaluation of the child if symptoms
persist or worsen. If the decision is made to use an antibiotic, the usual
recommendation is for amoxicillin, preferably at a dose of 80 to
90mg/kg/day. If the initial treatment plan fails to work within 48 to 72
hours, the physician may reconsider the diagnosis of AOM. Further
treatment may involve changing
For young children ages one to three years, most physicians prefer a
conservative, or wait-and-see, approach, using antibiotics if the
infection is persistent, the child is in pain, or there is evidence of
hearing loss. Most cases of otitis media with effusion get better within
three months without any treatment. If the child continues to have
repeated episodes of OME, despite taking antibiotics, the physician may
decide to try long-term, low-dose treatment with antibiotics, even after
the condition has cleared. If OME persists for over three months, despite
antibiotic treatment, the doctor may suggest a hearing test. If OME
persists for more than four to six months, even if hearing tests are
normal, the doctor may
suggest surgery to drain the eardrum and implant
for continuous drainage.
In some cases, a surgical perforation to drain pus from the middle ear may
be performed. This procedure is called a
. The hole created by the myringotomy generally heals itself in about a
week. In 2002 a new minimally invasive procedure was introduced that uses
a laser to perform the myringotomy. It can be performed in the
doctor's office and heals more rapidly than the standard
myringotomy. In some cases, the physician may decide that the placement of
tubes during the myringotomy is recommended. These small tubes are placed
to aid in draining the fluid from the middle ear. They fall out on their
own after a few months. The decision to place these tubes is based on the
Another type of surgery, called an adenoidectomy, removes the adenoids.
Removing the adenoids has been shown to help some children with otitis
media between the ages of four to eight. It is a procedure generally
reserved for those children who have recurrent otitis media after
myringotomy tubes are extruded.
Treatment guidelines from the American Academy of Pediatrics and the
American Academy of Family Physicians in the early 2000s state that there
is insufficient evidence to either support or discourage the use of
alternative medicines for acute otitis media. Increasing numbers of
parents and caregivers are using various forms of nonconventional
treatment for their children. Treatments that have been used for AOM
include homeopathy, acupuncture, herbal remedies, chiropractic treatments,
and nutritional supplements. Although most treatments are harmless, some
are not. Some can have a direct and dangerous effect, whereas others may
interfere with the effects of conventional treatments. Parent should
inform their doctor if they are using any alternative or unconventional
methods to treat their child's otitis media.
The prognosis of acute otitis media is excellent. The duration is
variable. There may be improvement within 48 hours even without any
treatment. Treatment with antibiotics for a week to 10 days is usually
—Common name for the pharyngeal tonsils, which are lymph masses
in the wall of the air passageway (pharynx) just behind the nose.
—The escape of fluid from blood vessels or the lymphatic system
and its collection in a cavity.
—A thin tube between the middle ear and the pharnyx. Its purpose
is to equalize pressure on either side of the ear drum.
—A surgical procedure in which an incision is made in the ear
drum to allow fluid or pus to escape from the middle ear.
—One of the three regions of the pharynx, the nasopharynx is the
region behind the nasal cavity.
—The three small bones of the middle ear: the malleus (hammer),
the incus (anvil) and the stapes (stirrup). These bones help carry sound
from the eardrum to the inner ear.
A common concern among parents has been whether recurring episodes of
otitis media will cause impairments in their child's development.
Research indicates that
persistent otitis media in the first three years of life does not have an
adverse effect on development.
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One Prince Street, Alexandria, VA 22314. Web site:
American Academy of Pediatrics.
141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098.
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