Acute otitis media
There are almost no children who have not been suspected (by the mother) or examined (by the doctor) on the question of acute otitis media. This is one of the most common reasons for visiting a pediatrician as well as giving antibiotics in childhood.
Unfortunately this is also a medical condition which is undiagnosed and properly managed in quite a few cases. Sometimes streaked due to difficulty in good observation of the eardrum and sometimes overdiagnosed.
But in this case it is all about anatomy, and in my opinion a parent who understands the structure of the ear will add to himself knowledge and understanding on the subject of ear infections, on its various issue.
How is the ear built and what is meant by otitis media?
See the following drawing for the structure of the ear. The ear has three parts, an outer ear, a middle ear and an inner ear.
We are all familiar with the auricle which is the outer cartilaginous part of the ear. In the center of the auricle there is a hole that finds the auditory canal. At the end of the same ear canal, after a few inches lies the eardrum and this is the boundary between the outer and middle ear.
Begins in the eardrum which is a membrane that moves gently according to the sound waves and vibrates three delicate auditory bones that are behind the eardrum. Eventually the third bone is attached to another small membrane called the oval window and this is the boundary between the middle ear and the inner ear.
A more internal space that contains additional auditory organs (labyrinth and cochlea) and eventually turns the air vibrations into electrical stimuli that are absorbed by the brain.
The middle area, the same middle ear, is the area that causes us a lot of trouble and this is the area where the middle ear infection occurs. It is important to also understand the connection between that middle ear cavity and the nose. There is a canal that goes forward and connects the same cavity in the ear to the area behind the nose. It is therefore easy to understand that when the canal is blocked (in the case of a cold for example or a large adenoid tonsil) then there is no proper ventilation of the middle ear cavity.
What is the prevalence of acute otitis media in children?
Since textbooks put different types of ear conditions into the definition of inflammation, including ear fluids, there is no exact prevalence. There is no doubt that otitis media is a disease of small children or babies, especially in the first and second year of life. But ear infections can of course happen at any age including old age.
Lots of factors affect the incidence of ear infections – some are changeable and some are not. For example:
Age – Otitis media is a disease, as we have written, of children up to two years of age. Later in life the incidence decreases but is still higher in children of early school age.
Sex – Boys get sick more than girls.
Genetics – There is a higher prevalence running in families. The specific cause was not found.
Breastfeeding – Breastfeeding has a protective effect.
Exposure to tobacco – Passive smoking is a very significant risk factor.
Exposure to other children – Significant exposure to other children (family or kindergarten) is a risk factor.
Seasonality – Since a lot of bacterial ear infections are a complication of a mild viral infection in the upper airways it is easy to understand that winter is the season when there are more ear infections in children.
Other anecdotes linked to a higher incidence of ear infections in children – using a pacifier or drinking a bottle while lying down.
What are the common bacteria that cause ear infections in children and is there a vaccine against them?
The three most common bacteria that cause ear infections are:
Streptococcus pneumoniae – a vaccine against it (called Prevnar) is given in Israel at the age of 2 months, 4 month and one year. Even if this vaccine has reduced the incidence of ear infections from this bacterium in children, it has not eliminated the disease.
Unclassified Hemophilus influenza – no vaccine (this is not the same type b Hemophilus against which our children do get vaccinated).
Group A streptococcus – yes, the same one that also causes a sore throat. No vaccine.
Getting to know and understanding who the various bacteria are has a direct impact on choosing the right antibiotic treatment, see below.
What are the symptoms of acute otitis media in children?
The symptoms vary and are age dependent. The most common sign is pain that can manifest in young babies in increasing restlessness at night. Sometimes with high temperature and sometimes without.
Remember that many cases happen after the child has a cold for several days.
Tugs and ear touches in children, who do not suffer from anything else, are usually a sign of fatigue and frustration rather than for otitis media.
What does the doctor assess when he examines the ear in children?
On otoscopy (looking inside the ear canal) the doctor looks directly at the eardrum and evaluates a number of parameters including: turbidity, bulging, redness, blurring of the normal shape of the eardrum and lack of light reflex. The most important and significant signs are the bulging and turbidity of the eardrum.
Remember that an ear examination is not a painful test, even in cases where there is indeed otitis media. The holding of the child and the situation may not be pleasant for the child but the test itself is uninjured and painless.
Both ears will always be examined, and usually in the case of reporting a particular ear pain the doctor will first examine the pain-free ear.
What two approaches to treating otitis media can the pediatrician offer and when will he choose each approach?
The approach methods are the delayed treatment method or the immediate treatment method.
What is the delayed treatment method and when will the doctor offer it?
Following a number of studies that have demonstrated low, if any, efficacy in the treatment of ear infections in children, an approach has been developed around the world that states that in some situations it is possible to wait without antibiotic treatment.
The advantage of the delayed treatment method is the savings of the antibiotic course. I remind you all that antibiotic treatment can not only be aimed at the criminal bacterium that causes inflammation in the ear but also kills other bacteria, some of which are mainly intestinal friendly. In addition, many repeated antibiotic treatments contribute to increasing the formation of resistant bacteria for antibiotics.
In Israel, the delayed treatment method will be offered to parents of children who are previously healthy, aged over six months, without significant bulging of the eardrum, without fever above 39 degrees, without considerable restlessness and who have unilateral inflammation.
The attending physician should ensure adequate follow-up, including clinical or daily telephone calls during the first few days following the decision to suspend treatment.
In addition, parental consent is required for delayed treatment.
Practical the delayed treatment method includes pain treatment (acetaminophen or ibuprofen), ear drops that relieve the pain locally (Otidin or Anesthetic) and waiting for 24 to 48 hours.
From my experience, the delayed treatment method is a very successful method if the doctor wisely selects the children (and parents) who are suitable for this approach. In young children, with fever and impressive findings on the ear test, the delayed treatment method will fail.
In addition, if this method is chosen, one should remind the parents to treat the pain as well. Since the persistence of the pain is the main reason for the failure of this method.
In my estimation, with the right choice of candidates, over 50% of antibiotic treatments for otitis media can be taken down.
What is the immediate treatment method and when will the doctor offer it?
Intended for immediate use of oral antibiotics. The doctor will recommend this treatment in cases that do not meet the criteria of delayed treatment.
This method will always be chosen in small infants below the age of six months, in children with an abnormal medical background, in children with high fever attributed to the ear infection, in cases of impressive findings on ear examination (bulging or turbidity of the eardrum) or in bilateral otitis media.
Even if we have chosen to treat antibiotics immediately, there is room for aggressive treatment of pain, including oral treatment (acetaminophen or ibuprofen) and for your consideration also local treatment aimed at the pain.
What is the antibiotic of choice for treating acute otitis media in children?
The antibiotic of choice for treating otitis media in children is Amoxicillin. You can read more, including dosages at the following link. Usually the treatment will be given for a full seven days (14 doses).
In cases where there is a sensitivity / allergy to antibiotics from the penicillin family, there is room for treatment with macrolides, Azenil for example for 3 days.
In cases of therapeutic failure, i.e. lack of improvement or exacerbation after appropriate treatment with Amoxicillin, there is room for second-line antibiotic treatment including Augmentin. There are two types of Augmentin in children (Augmentin 400 and Augmentin 600), as can be seenat the following link, And the choice of type and dosage will be made by the pediatrician.
There is no need for a re-examination before stopping the treatment, unless the doctor for his reasons has requested it.
Is ear infection contagious and when can the child return to normal activity in kindergarten or school?
Bacterial otitis media is a non-contagious infection. The child can return to regular activity in the educational institution where he is about 24 hours after the fever decreased and when he feels well, even if he is still being treated with antibiotics.
When is it right to consult a pediatric ENT specialist?
An available and good ENT doctor can be of great help in managing more complex cases of otitis media in children.
Even in cases where otitis media is suspected but it is not possible to see the eardrum (usually due to wax blocking the canal) but also in cases of therapeutic failure on the first or second line of treatment, there is room to refer for an ENT examination.
Also, in cases where there are recurrent events of ear infections, when there is place for further clarification including the possibility of a adenoid tonsil, there is room for an ENT check up as you will see below.
What to do in case of purulent otitis media and how does it happen?
A secretory ear infection (purulent otitis media) is an inflammation in which the eardrum is torn and pus spills into the ear canal and the eardrum area. A reading on purulent otitis media can be extended at the following link .
What are the harms of ear infections? Will there be hearing loss?
Improperly treated ear infection has many potential complications. From local to systemic infections. Therefore, there is room for pediatrician advice in any suspicion.
In terms of hearing, acute otitis media does not impair hearing. This is in contrast to serous otitis media (fluid in the ears) who will be detailed in another chapter.
Many recurrent infections, including those with a rupture of the eardrum, can have an effect on the structure of the eardrum and hearing. In these cases there is room for advice from a pediatrician and a pediatric ENT specialist.
What to do in cases of recurrent ear infections?
Recurrent otitis media is a bundle that pediatricians deal with quite a bit.
Before talking about management and risk factors, try to answer the following two questions:
Is it really recurrent otitis media episodes? As I wrote at the beginning, otitis media is a disease that is sometimes overdiagnosed. For example, if the doctor saw red eardrum, started Moxypen (oral antibiotic) but after 4 days of high fever, the fever went down and a typical rash came out – then most likely the child had roseola infantum and not a true ear infection. In short, if every time you go to the doctor you go out with antibiotics because of otitis media, there is a problem here …
Are these recurring events or alternatively an ongoing event? If two days after the end of the antibiotic there is re-inflammation, then it is a continuous event and not a recurring event and the management should be a little different.
If you have come to the conclusion that the child does indeed suffer from recurrent otitis media, then it is worth considering a number of points and risk factors, including:
A. Is the child vaccinated? Routine vaccines (Prevnar) and vaccines against respiratory viruses (flu) reduce the incidence of otitis media.
B. Does the child have a big adenoid tonsil and this is one of the risk factors for recurrent infections?
C. Is there environmental exposure to smoking? I do not buy stories about parents who smoke only on the balcony, etc. Easy to say but hard to do, I know, but if your child has recurrent ear infections and you smoke, you are one of the risk factors.
D. Does the child drink a bottle while lying down? If so, change it.
E. Early weaning from a pacifier can reduce the number of events.
F. Taking the kid out of kindergarten also …
G. A brief immunosuppression including immunoglobulin deficiency (IgA and IgG subgroups) should be considered with the attending physician.
At the end of the day, with proper management of a pediatrician and many times a pediatric specialist ENT, it is possible to get out of this endless cycle of recurrent ear infections.
I am aware of the approach of prolonged antibiotic treatment (for months) for children with recurrent ear infections. This is a very controversial approach. Personally, this is an approach I take in super-exceptional situations, about once a year.
Summary of acute otitis media in children
Inflammation / infection in the space behind the eardrum. Can occur at any age but is more common in infants and young children.
Pain and restlessness, mostly with fever.
Usually not. Pulling in the ears usually expresses fatigue and frustration, not necessarily an ear infection.
Treatment is derived from the symptoms and appearance of the eardrum.
There are cases where the doctor will recommend the delayed treatment method and there are cases where the doctor will recommend starting antibiotics.
No, sensitivity to pressure in the outer ear is most often a manifestation of external ear infection (swimmer’s inflammation). Treatment in this case is completely different.
Stop to think together with your pediatrician. Is the diagnosis really correct? Can risk factors for recurrent ear infections be identified and reduced? Is there a adenoid tonsil or fluid in the ears that justifies surgical treatment?