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1.MIDDLE EAR INFECTIONS
Factors involved in the cause (etiology) and mechanisms (pathogenesis) of middle-ear disease. Middle-ear disease (otitis media) can be caused by one or more of the following factors: Infection from a cold that spreads the virus (& bacteria) from the back of the nose through the Eustachian tube (tube connects back of the nose to middle ear) to the middle ear. Eustachian tube dysfunction (poor function), such as the impaired opening of the tube during swallowing, usually in babies, but especially those infants with an unrepaired cleft palate, is the main problem. Host factors which include impaired immunity, familial disposition (ear disease running in families), lack of breastfeeding, male sex, race, such as certain Native Americans (Inuits), nasal allergy, daycare, and smoking. Also, sinusitis, adenoid enlargement, and infection, tumors of the back of the nose have
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2. What are the signs and symptoms of the middle-ear disease?
Acute Middle-Ear Infection (Acute Otitis Media)
Acute middle-ear infection is the rapid onset of an earache (otalgia) usually with fever and often with hearing loss. In young babies who are not verbal, the earache may show as tugging at the ear, crying and fever is usually present. Also, there may be systemic signs and symptoms associated with the above, such as irritability, sleepiness (lethargy), not wanting to eat (anorexia), vomiting, and diarrhea. In some attacks, the eardrum may rupture which results in drainage from the ear canal that looks like pus that comes out of the nose during a cold. There may be blood in the discharge.Middle-Ear Effusion (Otitis Media with Effusion)
Otitis media with effusion is the occurrence of fluid in the middle ear that is not infected and typically without symptoms. It can occur following an attack of acute middle-ear infection in which the signs and symptoms of acute infection have resolved, with or without antibiotic treatment, in which case it is called persistent middle-ear effusion (fluid). Or it may occur without any previous episode of acute otitis media. The child may complain of fullness (mild pain) in the ear and hearing loss, which may be only evident to parents and teachers, or suspected when the television is very loud. Some children will constantly ask to have words repeated with “what?” The hearing loss may be identified by a routine school screening hearing test or tests performed during visits to the primary care physician. Some children complain of hearing noises (tinnitus) in their ears, which may be noted as ringing, buzzing, snapping or popping. Although somewhat uncommon, a middle-ear disease may cause balance problems (vertigo) in children and adults. Adults and older children will be very specific about imbalance, but in infants, the parents will relate the child has become “clumsy,” such as falling while attempting to walk despite successfully walking in the past.Eustachian Tube Dysfunction
The Eustachian tube connects the back of the nose (nasopharynx) to the middle ear which equalizes air pressure between the outside pressure and the pressure in the middle ear. (Figure 4-2 from Targeted Therapies. A caption should be: “Eustachian tube connects the nasopharynx with the middle ear.”) Some older children and adults who have problems in opening their Eustachian tube during periods of colds or allergy, during descent in airplanes, or even on a chronic basis will complain of mild ear pain or fullness and tinnitus. This disorder may occur in girls in puberty. -
3. How is the middle ear examined and what does the eardrum look like when diseased
Pneumatic Otoscopy
The most important diagnostic method, in addition to the medical history, is the assessment of the appearance and mobility of the eardrum, which includes pneumatic otoscopy. This figure shows the examiner performing pneumatic otoscopy by depressing the rubber bulb that is attached to the otoscope with the thumb to see the movement of the eardrum. Middle ears filled with fluid move poorly when compared to the normal eardrum which moves briskly.- Normal eardrum
- Acute middle-ear infection, aka, acute otitis media
- Middle-ear effusion (fluid), aka otitis media with effusion
- antibiotics ending in “mycin,” such as erythromycin and gentamycin
- Tympanostomy tube in the eardrum
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4. When should antibiotics be given to my child for an acute middle-ear infection?
Antibiotics are effective in treating acute otitis media, but not all children require them as many kids, especially older ones with mild symptoms, can improve without antibiotics. Note: Decisions related to giving antibiotics, or not, and which antibiotics for acute middle-ear infection should be between the physician and the parent, i.e., shared decision making.
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5. How can I prevent ear infections?
Non-medical Methods
Breastfeeding your infant is associated with less middle-ear infections than bottle-feeding. No smoking in the household as passive smoke is associated with increased risk of middle-ear infections. Pacifier use is associated with ear infections and is discouraged after the age of one year. Daycare is a risk factor for middle-ear infections, as the babies pass colds around to the other children and colds are associated with the middle-ear disease.Medical Methods
Vaccines are effective in preventing most but not all, middle-ear infections, such as the ones against the bacterium pneumococci. Influenza virus vaccines are an option in an effort to prevent recurrent episodes. Antibiotic Prophylaxis (prevention), such as a low dose of amoxicillin given at bedtime, is effective. But this method when given long-term has been associated with drug-resistant bacteria. Note: Decisions related to administering vaccines and antibiotics for prevention, should be between the physician and the parent, i.e., shared decision making.Surgical Methods
Myringotomy and tympanostomy tube is a surgical option for prevention of middle-ear infections. The operation requires a very short general anesthetic as an outpatient procedure. The otolaryngologist will insert a tiny plastic tube in the eardrum which aerates the middle ear to relieve fluid in the middle ear and prevent further middle-ear disease. (See above FAQ (Frequently Asked Questions): “How is the middle ear examined, and what does the eardrum look like when diseased?” for a photograph of a tube in the eardrum.) Note: Decisions related to recommending this surgical procedure for prevention of otitis media should be between the physician and the patient or parents of children, i.e., shared decision making. -
6. How should Otitis Media with Effusion (“Secretory Otitis) be Treated?
Otitis media with effusion is relatively asymptomatic fluid in the middle ear. The fluid usually resolves without treatment in time, such as weeks to a couple of months, but when chronic treatment may be required. When the effusion does not come after an episode of acute middle-ear infection, which is common, the underlying cause may not be obvious but has been associated with conditions listed above in Frequently Asked Questions: “What Causes Middle-Ear Disease?” Note: Decisions related to treating or not treating, and which treatments, either medical or surgical, for otitis media with effusion should be between the physician and the patient or parents of children, i.e., shared decision making.