Middle Ear Infections

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Otitis media is the inflammation of the space behind the eardrum called the middle ear. Bacteria or more commonly a virus may cause this infection. Otitis media may also be caused by the presence of uninfected fluid. If there is redness of the ear drum there may be an infection present – this is called acute otitis media. If you have an acute otitis media you may be given antibiotics to kill the bacteria. If there is fluid behind the drum without any redness or infection – this is called otitis media with effusion. Effusion is another word for fluid. In this case, the fluid does not cause ear pain and typically goes away on its own. Antibiotics are not effective for non-infected effusions.


The most common sign for acute otitis media is pain in the ear. In children, this may manifest as irritability or tugging of one or both ears. Other symptoms include fevers, pressure, ear fullness, ringing in the ears, or hearing loss. Otitis Media with Effusion (non-infected) typically does not present with pain or fevers but rather fullness, decreased hearing, and ringing in the ears.

Diagnosing otitis media requires the presence of fluid behind the eardrum and redness or inflammation of the eardrum. Otitis media with effusion has fluid but no inflammation. In the office, looking at the eardrum of a child may be difficult. The view may be obscured by earwax, the child may not allow the physician to get a good look, or the outer ear canal may be too small. Crying also causes the eardrum to turn red and make the diagnosis even more confusing. Some cases of ear fluid are difficult to diagnose because the fluid behind the eardrum is similar to the color of the drum itself.

In most instances, Dr. Pasha will order a tympanogram. A Tympanogram measures the pressure of the middle ear by placing a probe in the ear canal. This test will confirm if fluid is present. An audiogram or hearing test may also be ordered to evaluate for hearing loss.

The Eustachian tube is a small channel that goes from the middle ear space to the back of the nose. The Eustachian tube allows pressure or fluid to drain out of the middle ear and into the back of the nose. When you “pop” your ears by blowing gently while closing your nose and mouth you may force open this tube to relieve any pressure behind your eardrum. The Eustachian tube is lined with the same mucosa (lining) that lines the inside of your nose. Any condition that causes swelling of the inside of your nose (allergy, infection, etc…) may also cause swelling within this small tube causing the tube to close. If this tube does not open then fluid and pressure may build up behind the eardrum causing intermittent ear pain, popping sounds, ear fullness, or hearing loss. If the fluid persists, it may cause otitis media with effusion or if infected may cause acute otitis media. If the Eustachian tube continues to dysfunction, the pressure and fluid behind the eardrum may rupture allowing fluid to leak out of the ear canal.

Hearing loss in otitis media varies. Nonetheless, all children with otitis media or otitis media with effusion have some degree of hearing loss. The average hearing loss in children and adults with fluid is equivalent to placing your hands over your ears. Misunderstanding speech may become a problem in adults. In children, a rare potential adverse effect of such hearing loss is delayed speech and language skills. Draining the fluid (as with ear tubes) immediately restores the hearing.

There are several factors that increase the risk of otitis media:

Children: In general, children have more ear infections than adults. In children, the Eustachian tube is much smaller than adults and therefore may become more easily dysfunctional (“closes up”).

Exposure: The more a child is exposed to other children such as in a day care the bigger the risk of exposure to the bacteria that cause ear infections.

Smoking and Secondhand Smoke: Research has proven that even second-hand smoke results in an increase in otitis media in children of smoking parents.

Enlarged Adenoids: The adenoids are like tonsils that are located behind the nose where the opening of the Eustachian tube is located. If the adenoids become too large they may block the Eustachian tube or harbor infection. The adenoids are like tonsils that are located behind the nose where the opening of the Eustachian tube is located. If the adenoids become too large they may block the Eustachian tube or harbor infection.

Acute otitis media is caused by viral or bacteria most commonly Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis. There are many antibiotics that are used to kill these bacteria. The most common is amoxicillin. Amoxicillin has a long record of safety; however there has been an increase in resistance from some bacteria. To counter this resistance, amoxicillin is often prescribed in higher doses in an effort to combat these bacteria.

Many other antibiotics may also be prescribed – each has their benefits. Some common drugs include azithromycin (Zithromax), clarithromycin (Biaxin), and amoxicillin-clavulanate (Augmentin), or cefdinir (Omincef). Some bacteria may be resistant to one antibiotic and not another therefore you may have to change your antibiotics if the infection does not improve.

Otitis media with effusion may be present after a resolving ear infection. In this case, you may just observe until the fluid goes away. If the fluid is causing pain, pressure, fullness, hearing loss, or it does not go away you may be prescribed a decongestant or nasal spray to help open your Eustachian tube to “drain” the fluid more quickly. If fluid persists for more than 3 months, pressure equalization tubes are usually required.

A major concern in the world today is antibiotic resistance. If one uses antibiotics for a long period of time or if one takes several antibiotics and continues to have infections, the bacteria may have developed resistance to the most commonly prescribed antibiotics. The patient does not become “immune” to antibiotics but rather the bacteria “learn” to tolerate the antibiotics (especially amoxicillin).

Additionally, all medications have the potential for side effects (especially when taking for the long-term). Some patients are poorly tolerant of antibiotics, with gastrointestinal side effects or rashes.

Finally, antibiotics do not treat the underlying cause of otitis media and therefore it may result in repeated infections and discomfort for you or your child.

Allergies cause the mucous membranes of the nose to swell and enlarge. The Eustachian tube is also lined with the same membranes as the nose and therefore also may swell with allergy exposure. The swelling in the Eustachian tube may be significant enough to cause the tube to close and become dysfunctional resulting in pressure sensation, popping, or hearing loss of the ears.

By far, the majority of children with otitis media outgrow the problem by 3-5 years old. As the child grows older the Eustachian tube becomes more functional and patent allowing fluid and pressure to drain from the middle ear. Additionally, the immune system becomes more effective in fighting infection. Only a small percent of children continue to have problems into adolescence.


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