All about ears

When babies and children have ear infections everyone in the house suffers because they cry all night and no one sleeps. They hurt. Especially at night. Parents don't want to see their children in pain and they don't want to see it happen again and again, so they often wonder if tubes are the answer.

Why do babies get so many ear infections?

The eustachian tube helps to equalize pressure in the middle ear. If it is swollen or blocked it does not allow the pus in the middle ear to drain (think of how the tissues in your nose swell with a cold or allergies). Infants and young children are more prone to ear infections than adults because their eustachian tube is flatter, which inhibits drainage (see picture below).

photo credit: MedlinePlus

Let's start with what an ear infection is and what it's not.

A healthy ear drum is grey and shiny and we can see the small ear bones behind it. (See eardrum on the right.)

photo source: Medscape

Correctly diagnosing an acute ear infection (otitis media, OM) can be more difficult than it seems. The child must have significant pus behind a red eardrum, making it appear to bulge out, as in the left image above, or pus draining out of the ear canal from pressure causing a hole in the eardrum allowing pus to drain (perforated eardrum) or ear tubes.

If there is pus behind the eardrum without redness or other symptoms, it is not an acute ear infection but rather otitis media with effusion (OME). This fluid can range from clear to white or yellow and may accumulate in the middle ear as a result of an upper respiratory infection or a resolving acute ear infection. Many kids have no symptoms, so is probably often never seen. OME is often found at "well" visits during the winter months. It typically self resolves within a month or two. If it persists beyond 3 months and causes hearing loss, tubes will drain the fluid (see below). Sometimes removing the tonsils or adenoids are recommended, since removal might help the eustachian tube drain the middle ear. Decongestants and other medicines have not been found to help OME. OME can get mistaken for an ear infection if the child is crying during an exam, which reddens the eardrum.

Many kids cry when being examined, and the eardrum can turn red just from crying (just like their face and ears turn red when they're mad). This is not an ear infection. It's just a crying kid. Yet many less experienced (or just busy) doctors and nurse practitioners call it an ear infection even if there's no pus so they can quickly write a prescription and move on to the next patient. Parents are happy with "knowing" and that they can do something about it. This is incorrect on several levels. There must be pus involved. It is easy to over diagnose an ear infection if you're just looking at the color of the eardrum.

Swimmer's ear is a different type of infection entirely and is covered in depth in Swimmer's Ear.

Are ear infections that rupture the eardrum more serious? 

I've had several parents worry that their child had a hole in the eardrum allowing pus to drain out. They automatically think this child is at higher risk of ear problems and should get tubes. This isn't exactly the case. Many factors can lead to ear drum perforation (or rupture). In general, when the eardrum perforates, a hole allows the pus to drain (much like tubes), which allows for faster healing of the infection and pain. This does not necessarily mean the child is prone to ear infections or needs tubes. In days before antibiotics, a treatment for ear infections was to put a needle into the ear drum to draw the pus out. This helped relieve pain and was very effective to clear the infection. I find that many kids who have eardrum ruptures feel better faster than those who don't. Occasionally the hole lasts for years and it becomes recommended to patch it closed, but typically the hole closes up very quickly -- sometimes too quickly before the infection is cleared and pus re-accumulates behind the eardrum.

How are ear infections treated?

First manage the pain.

Ear pain should be managed with pain relievers, whether it's a true infection or simply pain from the congestion that comes with a cold. You can begin pain relief at home whether or not the ear infection is confirmed with standard doses of either acetaminophen or ibuprofen.

Ear drops for pain work fast but the relief doesn't last long, so I recommend also giving acetaminophen or ibuprofen per standard dosing recommendations. Ear drops can include both over the counter options and prescription options as long as the eardrum doesn't have a hole or tube in it. Do not put anything in the ear if you suspect a hole or know your child has a tube unless your doctor recommends it. Olive oil works pretty well and most of us have that in our kitchen. Saturate a cotton ball with oil (not hot oil) and squeeze the cotton over the ear canal, putting 2-4 drops in the canal. There are many over the counter ear drops for pain, but I find that the oil you already own is not only cheaper, but works just as well. Prescription numbing drops are an option if your doctor thinks they are appropriate.

Safely elevating the head can help the pain associated with the increased pressure laying down. For young infants, elevate the head of the bed by putting risers under the legs of the bed or by wedging something under the mattress. Be sure it is stable, whichever you do. Never put an infant under 1 year of age on a pillow or other soft bedding. For older children, propping up on several pillows is often helpful. Many toddlers and young children will not stay on pillows, so this is less effective.

Treat associated issues.

When kids have ear pain, they often have a runny nose, cough, fever, and other symptoms. Each of these should be managed as discussed on previous blogs: green snot, cough, generally sick. How long symptoms will last are discussed here.

If there is a true ear infection, treatment varies by age of the child and severity of the infection:

• Pain relief for anyone with an ear infection is the first treatment. (See above.)
• Monitor for the first 2-3 days without antibiotics in many instances, since most ear infections will self-resolve.
• Antibiotics can be used if symptoms persist more than 2-3 days ~ earlier for children under 6 months of age, those with significant illness, those who had another ear infection within the past 30 days, or for those who have an increased risk of ear infection (such as immune deficiency or an atypical facial structure or chromosomal defect known to affect hearing or immune function).
• If a child has tubes and develops an ear infection, pus will drain out of the tube. Antibiotic ear drops are the first choice for this type of infection. Antibiotics by mouth are not typically needed.
• Prevent the next ear infection. See below.

Why not use antibiotics for every ear infection?

The large majority of ear infections are caused by a virus, for which antibiotics are ineffective. About 80% of ear infections self resolve without antibiotics. Not only are antibiotics not needed, but they also carry risks. About 15% of kids who take antibiotics develop diarrhea or vomiting. Nearly 5% of children have an allergic reaction to antibiotics -- this can be life threatening. So when you look at the benefits vs risks, you can see that most of the time antibiotics should not be used as a first treatment.

When bacteria are exposed to an antibiotic but don't get completely killed, they learn to avoid not being killed the next time they see that same antibiotic. This is called bacterial resistance, also known as "superbugs". Superbugs can be shared from one child to another, which explains why some children who have never had antibiotics before have an infection that is not easily taken care of with the first (or second) round of antibiotics and why if a child needed several different antibiotics to clear an ear infection might get better with generic amoxicillin with the next. It's the bacteria in the ear that become resistant, not the child. The more we use antibiotics, the more resistance builds up and the less likely antibiotics will work for serious infections.

What are tubes and how do they work?

Tympanostomy tubes are small plastic tubes that are placed in a surgically made hole in the eardrum (tympanic membrane). They keep the hole in the eardrum open so that if pus develops in the middle ear it can drain out through the tube. This helps prevent the pain caused by the pus filling the middle ear area and pushing out on the eardrum. It also helps prevent the hearing loss that happens when the eardrum can't move due to pus behind it.

photo from USAToday (Rosenfeld RM. A Parent's Guide to Ear Tubes. Hamilton: BC Decker Inc., 2005)

Pus behind the eardrum causes many symptoms, which may include balance problems, poor school performance, hearing difficulties, behavioral problems, ear discomfort, sleep disturbance, and/or decreased appetite with poor weight gain. The benefits of tube placement for these children must be compared to the cost and risks of anesthesia and having an opening in the eardrum.

The majority of ear infections resolve completely without complication. The longer the pus remains behind the eardrum the less likely it will go away. If the pus is there longer than 3 months, it is less likely to resolve without treatment.

When are tubes recommended?

Since placing tubes does involve risks, they are not recommended for everyone. Guidelines recommend the following evaluation for tubes:

• If pus or fluid has been in the middle ear for over 3 months (OME or OM that never clears), a hearing test should be done.
• If the hearing test is failed, tubes should be considered.
• If fluid has been there longer than 3 months but hearing is normal, recheck the hearing every 3-6 months until the fluid clears. If the hearing test is failed on rechecks, then tubes are warranted.
• Children with higher risk of speech issues or hearing loss may be considered for tubes earlier. This would include children with abnormal facial structures, such as cleft palate, or certain genetic conditions that predispose to developmental delays, hearing concerns, or immune problems. 

What about recurrent ear infections?

I know parents get frustrated with recurrent ear infections, and I've seen many families who are happy that they got tubes for their child after recurrent ear infections, but studies show they aren't really necessary. If each ear infection clears, that shows that the eustachian tube (the tube that drains the middle ear into the throat) can do its job. As long as the pus is there less than 3 months with each infection, the risk of tubes does not usually outweigh the benefits.

Are there kids who should be considered tube candidates earlier?

Some kids are more sensitive to the problems associated with OME. These kids might have sensory, physical, cognitive, or behavioral issues that increase his or her risk of speech, language, or learning problems from pus in the middle ear. Children with known craniofacial abnormalities or chromosomal abnormalities who are at higher risk for speech and hearing impairment will also be considered for tubes more liberally. These kids might benefit from tubes even if they don't have pus for 3 months in the middle ear or hearing loss.

What are complications and risks of tubes?

Tube placement requires anesthesia, which is overall safe, but not without risk. 

Tubes keep a hole in the eardrum, which can allow water and bacteria to get into the middle ear, leading to infection. This leads to pus draining out of the ear canal, called otorrhea. This pus can be treated with antibiotic ear drops initially, and oral antibiotics if it last more than a month.

Some ENTs recommend earplugs when kids with tubes swim, but studies do not show that they are needed in most cases. If kids get recurrent otorrhea, they might be candidates for earplugs when swimming. Kids who swim in lake water or do deep water diving might also benefit from earplugs.

What can be done to prevent ear infections?

• Avoid all smoke exposure. Tobacco smoke is known to predispose children to ear infections, upper respiratory infections and wheezing.
• Do not bottle prop. Keeping a baby's head elevated a bit while bottle feeding can help prevent ear infections.
• Breastfeed. Breast milk is protective against many types of infection, including ear infections.
• General infection prevention. Avoid taking your infant to places where there are a lot of people. Wash hands often. Attempt to limit sharing of toys that young children mouth, and wash them between children. If your child attends daycare, try to find one where there are fewer children per room.
• Vaccinate. One of the biggest causes of bacterial ear infections is pneumococcus. Your child will be vaccinated against this as part of the standard vaccine schedule.
• Keep the pacifier in the crib. When kids play, they often drop their pacifier, which can encourage germs to accumulate on it before they put it back in their mouth.
• Xylitol. There are several studies that suggest chewing gum with xylitol as its sweetener helps prevent ear infections in children who can chew gum. For younger infants, there are nose sprays with xylitol. Xylitol is a naturally occurring substance that is used as a sweetener is many products, many of which are reviewed here. I do not endorse any of these, but do find this a helpful resource. 

For More Information:

Middle Ear Infections: Summary of the AAP ear infection guidelines
Xylitol sugar supplement for preventing middle ear infection in children up to 12 years of age