Ear Infections

Ear infections are a common childhood ailment. Of course, adults get them too, but because the ear canals are smaller and straighter in children, they are more susceptible to infections. Most of the time, ear infections are not cause for too much alarm, but they still need to be properly treated.

Otitis Media

Middle ear infection (otitis media) often occurs after a cold or infection of the upper airways. There are tubes (Eustachian tubes) which drain fluid from the ears to the back of the throat, and these tubes can become swollen and blocked during a cold. The fluid that remains in the ear is susceptible to germs which can cause an infection.

The middle ear is a pocket of air behind the ear drum. The Eustachian tubes run from the inner ear to the back of the nose. When you need to equalize pressure on both sides of the ear drum (in an ascending airplane for example), you can swallow or yawn. During an ear infection, pressure from excess fluid builds up and presses on the ear drum causing pain.

The symptoms of otitis media are ear pain, fever, a decrease in hearing, and perhaps dizziness. If there is drainage from the ear, it could be caused by the ear drum bursting. Usually this will be accompanied by a decrease in pain because the pressure on the ear drum has been relieved. In this case, even though the child feels better, he should be seen by a doctor as soon as possible.

The usual treatment for otitis media is a course of antibiotics accompanied which can be accompanied by a pain reliever / fever reducer. Some times the antibiotics are oral, some times they are ear drops, on some occasions both may be used at the same time. The pain is usually alleviated quite quickly due to the action of the antibiotics, but it’s important to follow the full course of the medication or otherwise the infection may not clear up completely.

Glue Ear

This is another common condition that affects mainly children between the ages of two and five. It is characterized by a sticky glue-like substance that collects in the ear. It may cause a temporary loss of hearing, but if left un-treated it could cause permanent hearing loss.

The medical terms for glue ear are “otitis media with effusion”, “secretory otitis media” and “chronic secretory otitis media”. We can see from these terms that it is a condition of the middle ear, with a slightly different mechanism than otitis media.

The middle ear, as well as being attached to the Eustachian tubes, has a lining similar to that of your lungs. Air passes through this lining to the bloodstream, but if the Eustachian tubes become blocked, a vacuum is formed in the inner ear and the lining becomes inflamed. Once inflamed, the lining begins secreting a fluid which thickens and causes glue ear.

Just like otitis media, glue ear is a common side-effect of colds. It can also be aggravated by allergies or dust or cigarette smoke. It is quite often seen in children with cleft palates.

Glue ear affects hearing by creating either a temporary or sometimes permanent conductive hearing loss. In younger children, glue ear can delay language development. In older children, it can cause balance problems as well as a decrease in hearing ability. Turning the TV louder, asking for repetition, and unusual clumsiness may be indications of glue ear. Long-term presence of fluid can cause developmental issues leading to Central Auditory Processing Disorder (CAPD).

Glue ear can last a long time, but most children eventually recover from it naturally. A doctor may prescribe antibiotics or decongestants to alleviate the fluid build-up, and the condition will be followed for several months to see if any other complications develop.

Glue ear and recurring ear infections that don’t respond to antibiotics may be surgically treated. In a simple procedure, a tube (sometimes called a PE or “pressure equalization” tube) is inserted through the ear drum so that fluid can be sucked out. The tube also lets air into the inner ear allowing the ear drum to function normally. The procedure takes only a few minutes to perform but is usually done under general anesthesia in order to have a still ear during surgery for safety reasons.

Otitis Externa

Otitis externa (swimmers ear) is an infection of the external ear canal. Glands within the ear canal produce a layer of protective cerumen (ear wax). If too little ear wax is produced, the skin of the canal is less protected and hence more predisposed to infection. If too much ear wax is produced, the excessive wax may cause retention of water and debris, also leading to increase ear infections, especially if the water has a high bacteria content (pond, lake, ocean, hot tub). In some cases, normal ear canals can become infected with bacteria, fungus, or other infectious agents. In some instances, systemic disease can cause otitis externa.

Otitis externa is generally quite easy to treat, however it can lead to serious complications in individuals who are diabetic or immunocompromised. Otitis externa is defined as chronic when the duration of the infection exceeds four weeks or when more than four episodes occur in 1 year. Otitis externa occurs in 4 out of every 1000 individuals each year, with chronic cases representing about 5 percent of the overall population.

Acute infection can be very painful and needs immediate attention. A special stereoscopic microscope is necessary to inspect, clean, and apply medication. All rooms at CEI are equipped with these microscopes, allowing treatment generally not available in the average pediatrician or family practitioner’s office. Individuals who are prone to otitis externa are advised to either use ear plugs in association with all water exposure including baths/showers, or to use ear drying drops or an ear drying device after any exposure to water.

Tympanograms

Tympanograms are used to evaluate the ear drum and middle ear. A tympanometer consists of three parts – a tiny loudspeaker to emit sound waves, a microphone to pick up the response and an air pump. All three are contained in a metal probe which is inserted into the ear canal where it forms a seal. Air is then pumped into the ear canal which causes the ear drum to move to various positions and then sound response is recorded by the microphone.

The results can tell the doctor if there is something behind the eardrum preventing its movement. Typically this would be a build up of fluid or pus as in the case of an ear infection. If there are PE tubes inserted, the tympanogram can show whether the tubes are blocked or not.

FIVE STEPS TO PREVENTING EAR INFECTIONS

If your child has had several ear infections already, or you simple wish to lower her risk of getting them in the first place, here are some ways to prevent or at least lessen the frequency and severity of ear infections:

In infants:

1. Breastfeed. This is the number one way to reduce ear infections in infants. It eliminates many potential allergy issues, and the position that you must hold your child in also eliminates the positioning problem described in #2

2. Feed your child upright. Many babies are prone to reflux, where stomach contents can regurgitate up into the throat, and also the Eustachian tubes. Always feed your child upright (at no less than 30 degrees), and keep them upright for at least thirty minutes after a feeding, to allow the stomach contents to empty.

For children of all ages:

3. Reduce exposure to group settings. Continuous exposure to other children in daycares and schools increases the risk that your child will catch more colds, and consequently more ear infections. Crowded daycare settings are guaranteed colds just waiting to happen. Small, home daycare settings or smaller class sizes will lower the risk. If the child has siblings, or there are frequently extended family members in the home, they could be carrying infections that the susceptible child is picking up. Requiring siblings to wash their hands frequently might help reduce ear infections in the susceptible child.

4. Control allergies. If you think allergies are contributing to your child's runny nose and, consequently, ear infections, get allergy testing to identify and eliminate allergenic triggers. The most common food allergens implicated in ear infections are cow’s milk and dairy products, wheat, eggs, chocolate, citrus, corn, soy, peanuts or other nuts, shellfish, sugar, and yeast. Non food allergens include dust, mold, and pet dander.

5. Cigarette smoke. There is strong evidence that smoking irritates children's nasal passages, which leads to Eustachian tube dysfunction.

MEDICAL PREVENTION FOR CHRONIC OR FREQUENT EAR INFECTIONS

More than two ear infections in a six month period, or three over a year means a child likely needs more aggressive medical intervention. Ear infections can cause a temporary 40 decibel hearing loss, and children’s speech and language can be adversely impacted by prolonged bouts with ear infections and fluid. The four different forms of medical intervention that are available include:

1. Prophylactic antibiotics. This consists of a once-a-day low dose of amoxicillin or similar antibiotic. This can be done during the cold season, or can be started at the first sign of cold symptoms. While this can result in your child receiving antibiotic more often, leading to antibiotic resistance, it can also avoid full dose courses of possibly stronger antibiotics.

2. Use of Antibiotic ear drops in addition to oral antibiotics. This is only indicated when the eardrum or outer ear is also involved with infection.

3. Immunization. There is a newer vaccine called Prevnar that came out in 2000. For children over 15 months, one dose is sufficient. This vaccine helps prevent infections from a bacterium called pneumococcus. This bug causes pneumonia, blood infections, meningitis and ear infections. This vaccination can prevent ear infections in two ways:

• Decreased total number of ear infections – Studies have shown that this shot decreases overall ear infections by 10 – 20%.
  
• Decreased ear infections from resistant pneumococcus – The vaccine has been shown to significantly decrease the number of ear infections caused by pneumococcus that are resistant to standard antibiotics.

4. Myringotomy / Pressure Equalization (PE) tubes. A myringotomy is a hole that is deliberately placed in the ear drum to allow the fluid trapped behind the middle ear to discharge. Frequently, at the same time a myringotomy is performed, small plastic tubes (PE tubes) are placed in that hole to keep that hole open. With younger children this procedure must be done under general anesthesia, but as children get older, the procedure can actually be done in the office by a skilled Otologist. The procedure stops infections completely in over 90% of children with recurrent infection that do not respond to other less invasive treatments. Surgery is recommended for fluid present for over 2-3 months, a high number of recurrent infections, a complication from an infection and other more specialized reasons.

CONCLUSION:

It can be difficult to break the cycle of chronic ear infections without a comprehensive medical examination and specialty care from an Otologist, who is an otolaryngologist (ENT) who has undergone two additional years of training and specializes in hearing only. With appropriate medical treatment and therapy, children with chronic ear infections can fully function in a hearing world.

Click here to make an appointment with the California Ear Institute to consult with one of our board certified Otologists regarding your child’s ear-related condition.