Dr Andy Raffles
Acute Middle Ear Infections in Children
What is it: The middle ear is a closed space behind the eardrum that is filled with air as it is ventilated by the Eustachian tube connected to the back of the throat. An ear infection usually begins after a child has a sore throat or a cold and the Eustachian tube becomes swollen and blocked. The middle ear cannot ventilate and fluid builds up behind the eardrum. The fluid in the middle ear can then become infected with bacteria travelling up the Eustachian tube from the nose or throat. Pus builds up and causes pain and fever.
Who gets it: Acute middle ear infections (acute otitis media) are common in young children and most get an otitis media at least once before the age of two years. This is because the Eustachian tubes are still short and horizontal, so fluid can build up in the middle ear more easily. Other factors that increase the chance of a child getting an acute middle ear infection include using a dummy, bottle-feeding a child when lying down, breathing tobacco smoke. Boys tend to be affected more than girls. The condition is more common in the winter. Contact with other children also increases risks. Children who have a cleft lip or palate, or who have Down's Syndrome are also more likely to get middle ear infections.
Signs and diagnosis: Signs of ear infection include earache (young children may rub or tug at their ear), a raised temperature, irritability, crying, not sleeping well, not feeding well, being sick, concomitant cough or runny nose. They may not hear soft sounds well and older children may be able to describe hearing issues and feeling ‘blocked ears’. Some children may be clumsy or have problems with balance. The diagnosis is made by looking at the eardrum using an otoscope that has a magnifying glass and a light.
Complications: The majority of children with middle ear infections get better within days but some may have longer lasting problems. Recurrent middle ear infections can lead to glue ear. This is when fluid stays inside the middle ear after the infection clears up and causes hearing problems. Most often it actually does not need any specific treatment as it eventually goes away on its own within about three months. In some children, middle ear infections can cause the eardrum to burst (perforate) under the pressure of fluid building up. Than pus or fluid comes out from the child’s ear. Fortunately, the eardrum heals within weeks. However, sometimes the eardrum doesn’t heal and there is long-term infection of the ear. Children with such complications or with persistent glue ear are referred to an Ear, Nose and Throat (ENT) Specialist for treatment. Extremely rarely, infection can spread from the middle ear to surrounding tissues and infection in the bone behind the ear is called mastoiditis. This causes a soft, red painful lump behind the ear and a very high fever. It is an emergency and requires immediate hospitalisation.
Treatment: It is upsetting to see a child in pain with a middle ear infection. But most cases of middle ear infections clear up on their own within three days without any specific treatment. In the meantime, there are some things one can do to help - paracetamol is an efficient painkillers. A flannel wrung out in warm water and held gently over the ear may help reduce pain. Oils, eardrops or cotton buds must never be used. Antibiotics given initially have not been proven useful and it is important in general to use them cautiously and help prevent the development of bacteria that become resistant to antibiotics. But if the infection lasts longer than 3 days, it is then appropriate to start antibiotics. Sometimes antibiotics are given straight away: If a child is seen when he/she has already had symptoms for three days and is not showing signs of getting better or if a child is under two years old and both ears are infected. They are also given if there is a perforated eardrum with fluid coming out of the ear. If a child is very young (under three months) and has a raised temperature, it is likely that he/she will be sent to hospital for further tests to identify the source of fever. Indeed, such small babies do not get acute otitis media on their own and generally there is a more serious medical issue associated.
Progress: If a child is given antibiotics, it is important to complete the course even if symptoms get better. Once the infection clears, fluid may still remain in the middle ear but usually disappears within three to six weeks and the child who may have some hearing loss which generally gets better within this time.
Surgery: There are some occasions, when surgery may be recommended. If a child keeps having middle ear infections or if a child develops ‘glue ear’. The most usual surgical procedure is called myringotomy: A specialist ENT surgeon makes a small cut in the eardrum and puts in small ventilation tubes called grommets to help drain the fluid. The hole in the eardrum heals naturally within a few days or weeks. Generally, after a number of months or a few years, the grommets fall off within 6-9 months. There will be follow-up visits with the specialist until then. In the rare cases of mastoiditis and if the antibiotics do not control the infection, surgery is done to remove the infected cells from the bone behind the ear. This is known as a mastoidectomy