Otitis Media

Otitis media is an infection or inflammation of the middle ear, the space behind your eardrum. It’s the most common childhood illness after colds, affecting up to 80% of children before they reach school age. While it can be painful and worrying for parents, most ear infections clear up on their own, though some cases may need antibiotics or other treatments.

Table of contents

• What is otitis media?
• Types of otitis media
• Signs and symptoms
• What causes ear infections?
• Risk factors
• How is it diagnosed?
• Treatment options
• Possible complications
• How to prevent ear infections

What is otitis media?

Otitis media is a sudden infection in your middle ear, which is the air-filled space between your eardrum and inner ear. This part of your ear houses delicate bones that transmit sound vibrations so you can hear.^[1]

Your middle ear connects to the back of your throat through tubes called eustachian tubes. These tubes regulate air pressure in your ear and prevent fluid from building up. When a eustachian tube doesn’t work properly, fluid has difficulty draining from your middle ear. This trapped fluid can become infected by viruses or bacteria, causing pain and other symptoms.^[1]

Middle ear infections occur most often in children between 6 months and 2 years of age. They’re common until age 8.^[1] Approximately 80% of all children will experience a case of otitis media during their lifetime, and between 80% and 90% will have at least one episode before school age.^[2][8]

Types of otitis media

There are several different types of otitis media, each with its own characteristics:^[6]

• Acute otitis media (AOM) is an infection that starts quickly and usually presents with ear pain. This is the most common type of middle ear infection.
• Otitis media with effusion (OME) occurs when fluid builds up in the middle ear without causing an infection. It typically doesn’t cause fever, ear pain, or pus buildup. This often follows an episode of acute otitis media.^[8]
• Chronic suppurative otitis media (CSOM) is a persistent ear infection lasting more than six weeks that results in a torn or perforated eardrum with discharge from the ear.^[7]
• Adhesive otitis media occurs when a thin, pulled-back eardrum becomes stuck to the middle ear space.^[6]

Signs and symptoms

Symptoms of an ear infection often begin after a cold. Common symptoms include:^[1][3]

• Ear pain
• Loss of appetite
• Trouble sleeping
• Trouble hearing in the blocked ear
• A feeling of fullness or pressure in your ear
• Yellow, brown, or white drainage from your ear (this may mean that your eardrum has broken)
• Fever ranging from 100.5 to 104 degrees Fahrenheit (38 to 40 degrees Celsius)
• Headache

Important: Do not place anything in your ear canal if you have drainage from your ear. An item touching a torn eardrum can cause more damage.^[1]

Since small children and infants can’t always communicate their symptoms, it’s important to recognize the signs. A child with an ear infection may:^[1][3]

• Rub or tug on their ears
• Cry more than usual or act fussy
• Have trouble sleeping
• Start mouth breathing or have increased snoring
• Refuse to eat during feedings (pressure in the middle ear changes as your child swallows, causing more pain)
• Lose their balance

What causes ear infections?

Bacteria and viruses cause ear infections. Often, ear infections begin after a cold or another upper respiratory infection. The germs travel into your middle ear through the eustachian tube. Once inside, the virus or bacteria can cause your eustachian tubes to swell. The swelling can cause the tube to become blocked, leading to poor drainage and infected fluid in your middle ear.^[1]

The most common bacterial organisms causing otitis media are Streptococcus pneumoniae, followed by Haemophilus influenzae (nontypeable), and Moraxella catarrhalis.^[2][8] After the introduction of pneumococcal vaccines, the types of bacteria causing infections have changed somewhat.^[8]

Common viral causes include respiratory syncytial virus (RSV), coronaviruses, influenza viruses, adenoviruses, human metapneumovirus, and picornaviruses.^[2]

Otitis media usually happens as a complication of eustachian tube dysfunction that occurs during a viral upper respiratory infection.^[8] When your child catches a cold, mucus can block the small passage connecting the ear and throat. This trapped fluid allows bacteria or viruses to multiply, leading to infection.^[4]

Risk factors

Children are more likely than adults to get ear infections because:^[1]

• Their eustachian tubes don’t function as well as adults, which encourages fluid to gather behind the eardrum
• Their immune system (the body’s infection-fighting system) is still developing
• They’re more likely to catch illnesses from other children

Other risk factors that increase the likelihood of developing otitis media include:^[4][8]

• Young age (especially between 6 months and 2 years)
• Exposure to cigarette smoke or other respiratory irritants
• Attending day care
• Using a pacifier
• Not being breastfed
• Having allergies
• Family history of recurring ear infections
• Having conditions like cleft lip and palate or Down syndrome

How is it diagnosed?

A healthcare provider can diagnose a middle ear infection by asking about symptoms and examining your child. They will look inside your child’s ear with a lighted instrument called an otoscope to examine the eardrum and look for pus or fluid in the middle ear.^[12]

An accurate diagnosis of acute otitis media requires moderate to severe bulging of the eardrum, new onset of discharge from the ear not caused by external ear infection, or mild bulging of the eardrum with recent ear pain (less than 48 hours) or redness.^[8]

Several diagnostic tools can help with the examination:^[2]

• Pneumatic otoscopy is the most reliable method. It uses a puff of air to see if the eardrum moves normally. Impaired movement suggests fluid behind the eardrum.^[8]
• Tympanometry measures changes in how the eardrum responds to air pressure changes
• Acoustic reflectometry measures reflected sound from the eardrum

It’s critical for doctors to distinguish between different types of otitis media to avoid unnecessary antibiotic use, which can lead to increased side effects and development of antibiotic resistance.^[8]

Treatment options

Many children’s ear infections clear up without antibiotics. The body’s immune system can often fight off middle ear infection on its own.^[19] Treatment depends on the person’s age and how severe the symptoms are.^[12]

Pain management

Managing pain from an ear infection is important and should be the first step in treatment.^[8] Pain relief options include:^[12]

• Pain medicines you can get without a prescription, such as acetaminophen (Tylenol) and ibuprofen (Advil, Motrin)
• Benzocaine ear drops
• A warm, moist face cloth on the ear may help relieve pain^[13]

Plan to take a full dose of pain reliever before bedtime, as getting enough sleep will help recovery.^[13]

Watchful waiting

Healthcare providers may recommend a wait-and-see approach for certain children:^[12][19]

• Children 6 to 23 months with mild pain in one ear for less than 48 hours and a temperature less than 102.2°F (39°C)
• Children 24 months and older with mild pain in one or both ears for less than 48 hours and a temperature less than 102.2°F (39°C)

This approach gives the immune system time to fight off the infection. If symptoms don’t improve after 2-3 days, antibiotics may then be prescribed.^[19]

Antibiotics

Severe middle ear infections or infections that last longer than 2-3 days need antibiotics right away.^[19] High-dose amoxicillin (80 to 90 mg per kg per day) is the antibiotic of choice for treating acute otitis media in patients who are not allergic to penicillin.^[8][11]

If your doctor prescribed antibiotics, take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.^[13]

Children with symptoms that continue despite 48 to 72 hours of antibiotic therapy should be reexamined, and a second-line medication, such as amoxicillin/clavulanate, should be used if appropriate.^[8]

Surgical treatment

If ear pain is severe or infections keep recurring, doctors may need to drain fluid from your middle ear. They may make a small hole in the eardrum to drain the fluid or place tubes in the eardrum to keep fluid draining properly.^[5]

Treatment for otitis media with effusion

Antibiotics, decongestants, or nasal steroids do not speed up the clearance of middle ear fluid in otitis media with effusion and are not recommended.^[8] Children with evidence of structural damage to the ear, hearing loss, or language delay should be referred to an ear, nose, and throat specialist.^[8]

Possible complications

Most people don’t have complications from ear infections. However, without proper treatment, infected fluid from the middle ear can spread to nearby structures.^[2] Possible complications include:^[2][5]

• Eardrum perforation (a hole in the eardrum)
• Mastoiditis (infection of the bone behind the ear)
• Labyrinthitis (infection of the inner ear)
• Meningitis (infection of the membranes covering the brain and spinal cord)
• Brain abscess
• Hearing loss, which may be temporary or long-term

Children who get frequent ear infections may experience long-term hearing loss. If children with hearing loss due to otitis media with effusion do not learn sign language, it may affect their ability to learn.^[7]

How to prevent ear infections

While you can’t prevent every ear infection, several steps can lower the risk:^[1][4][19]

• Make sure your children receive recommended vaccines, including pneumococcal and influenza vaccines
• Breastfeed your baby, ideally exclusively until 6 months and continuing for at least 12 months
• Wash hands frequently to reduce the spread of germs
• Don’t smoke and avoid exposure to secondhand smoke
• Don’t let infants drink from a bottle while lying down or take a bottle to bed
• Limit pacifier use
• Dry your child’s ears thoroughly after swimming

When to seek medical care

You should see your doctor if you or your child experience:^[3][4][13]

• Symptoms lasting more than 2-3 days
• Symptoms in a child younger than 6 months old
• Worsening symptoms
• A fever of 102.2°F (39°C) or higher
• Pus, discharge, or fluid coming from the ear
• Hearing loss
• Frequent ear infections

Seek urgent medical attention if you notice redness, pain, or swelling of the bone behind your ear, or if your ear is pushed forward. This may indicate mastoiditis, a serious complication.^[4]

If your child is under 3 months old with a fever of 100.4°F (38°C) or higher, talk to a healthcare provider right away.^[19]