Ear Infections (Otitis Media) in Children
WHAT ARE MIDDLE EAR INFECTIONS (OTITIS
MEDIA) IN CHILDREN?
The Ear
The ear is the organ of hearing and balance and is organized into external, middle, and internal
areas.
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The outer ear collects sound waves that are conducted through a canal to the tympanic
membrane, commonly called the eardrum.
The tympanic membrane is a tissue that is lined on the inside with mucus. Like a drum, it
vibrates to the incoming sound waves, converting them into mechanical energy.
This energy resonates through the middle ear, a complex structure filled with air and
composed of tiny bones that vibrate to the rhythm of the eardrum and pass the sound
waves on to the inner ear.
The inner ear is filled with fluid. Here, hair-like structures stimulate nerves to convert the
mechanical waves to electrochemical impulses that are carried by a network of nerve
cells to the brain, which senses these impulses as sounds.
The inner ear also contains three semi-circular canals that function as the body's
gyroscope, regulating balance.
The Eustachian tube, an important structure in the ear, runs from the middle ear to the
passages behind the nose and the upper part of the throat. This tube ventilates the ear
and equalizes the air pressure in the middle ear to the outside air pressure. Problems
here are primary factors in most cases of ear infection.
Ear Infections (Otitis Media) in Children
Ear infections are often defined by whether they are acute (acute otitis media) or chronic (otitis
media with effusion).
Acute Otitis Media (AOM). Acute otitis media (AOM) is an infection in the middle ear that causes
an inflammation behind the tympanic membrane.
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Often it develops during or after a cold or a flu.
Middle ear infections are extremely common in children but are infrequent in adults.
In children, ear infections often recur, particularly if they first develop in early infancy.
Otitis Media with Effusion (OME) . Otitis media with effusion (OME) occurs when an effusion
(fluid) builds up in one or both middle ears. When this is chronic and severe the fluid is very sticky
and is commonly called "glue ear."
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It is not painful and the only clue that it is present is a feeling of stuffiness in the ears,
which can feel like "being under water."
Children who are susceptible to OME can have frequent episodes for more than half of
their first three years of life.
The episodes can last from weeks to months.
WHAT CAUSES MIDDLE EAR INFECTIONS IN
CHILDREN?
Overview of the Process Leading to the Infection
Otitis media (middle ear infection) is most often the result of a combination of factors that
increase susceptibility to infections by specific organisms in the middle ear. The infection typically
evolves as follows:
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The primary setting for ear infections is in a child's Eustachian tube, which runs from the
middle ear to the nose and upper throat. The Eustachian tubes in all children are shorter
and smaller than in adults and therefore more vulnerable to obstruction.
Changes in middle ear pressure occur in about two thirds of children with colds, which
are typically the first stage in ear infections. Colds are caused by viruses, such as the
rhinovirus. Viruses are increasingly viewed as important in many ear infections, although
they usually only set the scene for a bacterial infection.
Many bacteria normally thrive in the passages of the nose and throat. Most are benign
and some can even block harmful bacteria from getting out of control. In addition, a
defense system in the airways prevents the harmful bacteria from replicating and
infecting deeper passages, such as those in the ear. Such defenses include a mucus
layer that traps bacteria and cilia (hair-like structures) that move them out.
When a cold occurs, the virus can cause the membranes along the walls of the inner
passages to become inflamed, swell, and obstruct the airways. If this inflammation blocks
the narrow Eustachian tube so that it cannot drain the middle ear properly, fluid builds up.
The defense systems become inefficient, and the fluid becomes a reservoir and breeding
ground for bacteria and subsequent infection.
Of note: respiratory viruses may also contribute directly to the infection. Allergens can also
produce inflammation and blockage in the Eustachian tube, which creates an environment
favorable to bacteria.
Infecting Agents and Triggers
Bacteria. Certain bacteria are the primary causes of acute otitis media (AOM) and are detected in
about 60% of cases. The bacteria most commonly causing ear infections are:
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Streptococcus pneumoniae (also called S. pneumoniae or pneumococcus) is the most
common bacterial cause of acute otitis media, causing about 40% to 80% of cases in the
US.
Haemophilus influenzae is the next most common culprit and is responsible for 20% to
30% of acute infections.
Moraxella catarrhalis is also a common infectious agent, responsible for 10% to 20% of
infections.
Less common bacteria are Streptococcus pyogenes and Staphylococcus aureus.
Of note, about 15% of these bacteria are now believed to be resistant to the first-choice
antibiotics.
Viruses. Rhinovirus, a cause of the common cold, is commonly the first player in the process
leading to ear infection. It is not the direct infecting agent, however. However other viruses, such
as respiratory syncytial virus (RSV -- a common virus in children responsible for respiratory
infections) and influenza viruses ("Flu"), may be actual causes of some ear infections. Evidence
is increasing that such viruses may play a greater role than previously believed for either
predisposing or even causing ear infections. (Such evidence rests on the significantly lower rates
of ear infections in children who have been vaccinated against influenza.)
Allergies. Allergies can cause inflammation in the airways, and contribute to ear infections.
Inborn Conditions that Predispose a Child to Middle Ear Infections
Genetic Factors. Several studies suggest that multiple genetic factors may play a role in making a
child susceptible to otitis media.
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Genetic susceptibility to certain bacteria may result in development of persistent and
recurrent otitis media.
Abnormalities in genes that affect the defense systems (cilia and mucus production) and
the anatomy of the skull and passages would also increase the risk for ear infections.
Abnormalities in genes that regulate a powerful immune factor called interleukin 1 have
been identified in some patients with recurrent otitis media who did not have any allergic
disorders. Interleukin 1 plays a major role in producing inflammation in tissues and cells
during heightened immune activity. Abnormalities in interleukin production may possibly
result in a persistent inflammatory response.
Researchers are hoping that these findings may encourage primary care physicians to closely
monitor children who are offspring or siblings of individuals with a history of unusually frequent or
severe upper respiratory tract infections.
Medical or Physical Conditions that Affect the Middle Ear. Any medical or physical condition that
reduces the ear's defense system can increase the risk for ear infections. Children with shorterthan-normal and relatively horizontal Eustachian tubes are at particular risk for both initial and
recurrent infections. Other examples include inborn structural abnormalities, such as cleft palate,
or genetic conditions, such as Kartagener's syndrome, in which the cilia (hair-like structures) in
the ear are immobile and cause fluid build up.
Causes of Otitis Media with Effusion (OME)
Direct Causes of OME. In some cases, otitis media with effusion develops after an acute otitis
media attack, although often the direct cause of OME is unknown. The role of allergies, bacteria,
or other conditions may play some role in susceptible children, but their roles have not been
clearly defined:
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Allergies. In one study, 89% of patients with OME also had allergic rhinitis (e.g., hay
fever), suggesting a possible causal relationship in susceptible children. Some evidence
suggests that allergies produce high levels of white blood cells called neutrophils in the
ears of patients with OME.
Bacteria. It is not clear what role bacteria or other infectious agents play. Standard tests
do not detect bacteria in 40% to 60% of cultures taken from fluid in OME-affected ears.
(In one study, a sophisticated test found genetic evidence of Haemophilus influenza
bacteria in about a third of specimens in which no bacteria were detected by standard
culture techniques.)
Gastroesophageal Reflux Disorder. Gastroesophageal reflux disorder (GERD), in which
acid backs up into the esophagus, is a common cause of heartburn in adults. In infants,
GERD may occur when muscles in the upper part of the stomach are still immature and
force acid and other compounds to back up. GERD has become associated with many
upper airway problems, including ear infections and sinusitis, although some experts
argue that GERD is normal in children and the association is unfounded.
Conditions that Make Children Susceptible to OME. Even when the conditions discussed above
are present, however, most children do not develop OME. Susceptibility to OME is almost always
due to an abnormal or malfunctioning Eustachian tube that causes a negative pressure in the
middle ear, which, in turn, allows fluid to leak in through capillaries. Problems in the Eustachian
tube can be due to viral infections, second-hand smoke, injury, birth defects, such as cleft palate,
or genetic diseases that affect the defense systems, such as Kartagener's syndrome.
Causes of Increase in Incidence of Ear Infections and Other Airway
Infections and Disorders
Increased diagnosis of other disorders and infections of the upper and lower airways, such as
asthma, allergies, and sinusitis, have paralleled the rise in ear infections. For example, the same
bacteria are often responsible for both ear infections and sinusitis. In one study, 38% of children
with ear infections also had sinusitis, and other studies have reported that nearly half of children
with OME have concurrent sinusitis. These studies may have overestimated the extent of
clinically important sinus disease, but nonetheless, the association is significant but causal
relationships are unclear. Researchers are looking for common risk factors:
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Increase in Day Care Center Attendance. Although ear infections themselves are not
contagious, the respiratory infections that precipitate them can pose a risk for children
with close and frequent exposure to other children. Some experts believe, then, that the
increase in ear and other infections may be due to the higher attendance of very small
children, including infants, in day care centers beginning in the 1970s. For children who
had the condition for a long time, however, neither day care attendance nor any other risk
factor, including a history of upper respiratory tract infections or family history of OME,
appeared to be relevant. Attendance in day care centers, then, may explain part, but not
all, of the current increase in ear infections and other upper airway disorders.
Increase in Allergies. Some experts believe that the increase in allergies is also partially
responsible for the higher number of ear infections, which is unlikely to be related to day
care attendance. Studies indicate that 40% to 50% of children over three years old who
have chronic otitis media also have allergic rhinitis (hay fever). Allergies are also
associated with asthma and sinusitis.
The rise in the rate of otitis media, then, is probably due to a combination of factors that are also
responsible for the increase in these other airway problems.
WHO GETS EAR INFECTIONS?
Acute ear infections account for 15 to 30 million visits to the doctor each year in the US. In fact,
ear infections are the most common reason why an American child sees the doctor. Furthermore,
the incidence of AOM has been rising over the past decades.
Gender and Age
Acute Otitis Media. About two thirds of children will have a least one attack of acute otitis media
(AOM) by age three, and a third of these children will have at least three episodes. Boys are more
apt to have infections than girls are.
It generally affects children between the ages of six and 18 months. The earlier a child has a first
ear infection the more susceptible he or she is to recurrent episodes (i.e., three or more episodes
within a six-month period).
As children grow, however, the structures in their ears enlarge and their immune systems
become stronger. By 16 months the risk for recurrent infections is rapidly declining. After age five,
most children have outgrown their susceptibility to any ear infections.
Otitis Media with Effusion. About 10% of children with AOM (who are usually between two and
four years old) develop persistent otitis media with effusion (OME). (Because OME has fewer
symptoms than acute otitis media, however, it is difficult to give an accurate estimate.)
Specific Risk Factors in Children
Ear infections are more likely to occur in the fall and winter. Some conditions, including the
following, also put children at higher risk for ear infection:
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Allergies.
Enrollment in day care.
Exposure to second-had cigarette smoke.
Being bottle-fed as infants.
Having siblings with recurrent ear infections.
Being in lower socioeconomic groups.
Being Native American.
Possibly having a higher number of cavities. (The study suggesting this was small. More
research is needed.)
Obesity. One 2001 study found a link between ear infections and childhood obesity.
Eardrum abnormalities increased the more the child weighed, which might explain the
association. The researchers also suggested that parents may be confusing their
children's fussiness due to the ear infection with hunger and, therefore, overfeeding
them.
Certain medical disorders, including Down's syndrome, cleft palate, Kartagener's
syndrome, and immunosuppressive disorders, such as HIV, increase the risk for ear
infections.
Parental Behavior
The behavior of parents can increase a child's risk for otitis media.
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Parents who smoke pose a significant risk for both otitis media with effusion (OME) and
recurrent acute otitis media (AOM) in their children. (Passive smoking does not appear to
be a cause of initial ear infections, however.)
Pregnant women who drink alcohol put their babies at risk for birth defects that can cause
a number of problems, among them hearing loss and OME.
Babies who are bottle-fed may have a higher risk for otitis media than do breastfed
babies.
Several studies have found that the use of pacifiers place children at even higher risk for
ear infections. Sucking increases production of saliva, which is a vehicle for bacteria that
can travel up the Eustachian tubes to the middle ear.
WHAT ARE THE SYMPTOMS OF EAR INFECTIONS IN
CHILDREN?
Symptoms of Acute Otitis Media
Symptoms of acute otitis media usually develop suddenly and can include:
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Pain or discomfort in the ear. (It is difficult to determine if a preverbal child or infant has
an ear infection. Some children may indicate pain if they have trouble swallowing food
and rejecting it. Some parents believe that tugging on the ear indicates an infection, but
this gesture is more likely to indicate pain from teething.)
Coughing.
Nasal congestion.
Fever.
Irritability.
Loss of appetite.
Vomiting.
Pus in the ear may cause hearing loss in some children.
If the ear infection is severe, the tympanic membrane may rupture causing the parent to
notice pus draining from the ear. (This usually brings relief from pain.)
Fevers and colds often make children irritable and fussy, so it is difficult to determine if otitis
media is present as well. In about a third of children with acute middle ear infection, symptoms
are not apparent.
Symptoms of Otitis Media with Effusion
Otitis media with effusion (OME) often has no symptoms at all. Some hearing loss may occur, but
it is often fluctuating and hard to detect even by observant parents. The only signal to a parent
that the condition exists may be when a child complains of "plugged up" hearing. Other symptoms
can include not responding to verbal commands, talking louder, and turning up the television or
radio.
Older children with OME may have difficulty targeting specific sounds in a noisy room. (In such
cases, some parents or teachers may attribute their behavior to lack of attention or even to an
attention deficit disorder.) OME is often diagnosed, however, only during a regular pediatric visit.
HOW SERIOUS ARE EAR INFECTIONS IN
CHILDREN?
Acute Otitis Media in Infancy
There has been some concern that ear infections in infants less than three months old may
indicate more serious infections, such as meningitis. A reassuring 2002 study reported, however,
that only 4% of infants with ear infections had any bacterial infections. Still, any indication of
infection in a baby warrants prompt medical attention.
Hearing Loss and Its Consequences
Evidence strongly suggests that severe cases of recurrent acute otitis media and persistent otitis
media with effusion (OME) impair hearing. The effect of long-term hearing problems may have
the following effects:
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Learning Delays. Hearing loss in children slows down language development and reading
skills. Children with even mild hearing loss may miss spoken words and have trouble
making sense out of a conversation or a lesson in school. It is not clear, however, even
after years of research, if OME and its attendant reduced hearing have any significant
and long-term effects on learning. Some research suggests that these effects may last
into the teens. Other studies, however, indicate that any effect on learning is temporary
and that children catch up later on. And some evidence suggests that lower learning
scores reported in children with OME may actually be due to the fact that such children
tend to be in lower socioeconomic groups and so have less home attention.
Behavioral and Social Problems. Children with impaired hearing may appear to be
distracted, inattentive, and unintelligent. Some have even been inaccurately diagnosed
as having attention deficit hyperactivity disorder. As with learning, however, studies have
been mixed on the significance of long-term effects of OME on behavior. Considering the
increased usage of medications for attention deficit disorder and the social burdens
carried by children diagnosed with emotional and learning disabilities, more research is
essential for clarifying this relationship.
Speech Problems. A few small studies have found speech problems in some young
children with OME.
Physical and Structural Injuries in the Face and Ears
Serious complications or permanent physical injuries from ear infections are very uncommon, but
may include the following:
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In severe or recurrent otitis media, certain children may be at risk for structural damage in
the ear.
Cysts in the ear known as cholesteatomas are an uncommon complication of recurrent or
severe ear infections.
In rare cases, even after a mild infection, certain children, possibly because of immune
abnormalities, develop calcification and hardening in the middle and, occasionally, in the
inner ear.
Mastoiditis
Before the introduction of antibiotics, mastoiditis, an infection in the bones located in the skull,
was a major and serious complication of otitis media. This condition is difficult to treat and
requires intravenous antibiotics and drainage procedures. Surgery may be required. If pain and
fever persist in spite of antibiotic treatment of otitis media, the physician should check for
mastoiditis. Even without antibiotics this is a rare complication. At present, cases of mastoiditis
are generally not associated with ear infections.
Other Possible Complications
Impaired Balance. Some studies have indicated that children with chronic OME have problems
with motor development and balance.
Facial Paralysis. Very rarely, a child may develop facial paralysis, which is temporary and
relieved by drainage surgery.
HOW ARE EAR INFECTIONS IN CHILDREN
DIAGNOSED?
Medical History
The physician should be sure to ask the parent for a history of any recent cold, flu, or other
respiratory infections. If the child complains of pain or has other symptoms of otitis media, such
as redness and inflammation, the physician should be sure to rule out any other causes of such
symptoms. They may include, but are not limited to the following:
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Otitis media with effusion. OME is commonly confused with acute otitis media. It must be
ruled out because it does not respond to antibiotics.
Dental problems (such as teething).
Infection in the outer ear. Symptoms include pain, redness, itching, and discharge.
Infection in the outer ear, however, can be confirmed by wiggling the ears, which will
produce pain. (This movement will have no significant effect if the infection is in the
middle ear.)
Foreign objects in the ear. This can be dangerous and a physician should always check
for this first when a small child indicates pain or problems in the ear.
Viral infection can produce redness and inflammation. Such infections, however, are not
treatable with antibiotics and resolve on their own.
A parent's or child's attempts to remove earwax.
Intense crying can cause redness and inflammation in the ear.
Physical Examination
Instruments Used for Examining the Ear. An ear examination should be part of any routine
physical examination in children, particularly because the problem is so common and many
children have no symptoms.
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The physician first removes any ear wax (called cerumen) in order to get a clear view of
the middle ear.
The physician employs a small flashlight-like instrument called an otoscope to view the
ear directly. This is the most important diagnostic step. This instrument will reveal signs
of acute otitis media, bulging eardrum, and blisters. The physician will also check color.
To determine ear infection the physician should always use a pneumatic otoscope. This
device detects any reduction in eardrum motion. It has a rubber bulb attachment that the
physician presses to push air into the ear. Pressing the bulb and observing the action of
the air against the eardrum allows the physician to gauge the eardrum's mobility.
Some physicians may use tympanometry to evaluate the ear. In this case a small probe
is held to the entrance of the ear canal and forms an airtight seal. While the air pressure
is varied, a sound with a fixed tone is directed at the eardrum and its energy is measured.
This device can detect fluid in the middle air and also obstruction in the Eustachian tube.
A procedure similar to tympanometry, called reflectometry, also measures reflected
sound to detect fluid and obstruction but does not require an airtight seal at the canal.
Neither tympanometry nor reflectometry are substitutes for the pneumatic otoscope, which allows
a direct view of the middle ear
Findings Indicating Ear Infection. The physician will then assess the results of this examination to
determine a diagnosis. There are two requirements for a diagnosis of ear infections: inflammation
and fluid in the middle ear. Certain findings indicate the following:
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The eardrum is grayish-pink and translucent and there is no fluid. No infection is present.
The eardrum is opaque and may be red, white, or yellowish. The child complains of pain.
If is also less mobile than usual, acute otitis media is likely. If the eardrum is bulging, then
bacterial infection is probably present.
The eardrum is red and inflamed but no fluid is present. The cause is more likely to be
irritation than a bacterial infection.
The eardrum is clear and translucent but is not mobile and if fluid is present. It is not
painful and the child has no other symptoms. Otitis media with effusion (OME) is likely to
be present.
A scarred, thick, or opaque eardrum may make it difficult for the physician to distinguish between
acute otitis media and OME.
Tympanocentesis
On rare occasions the physician may need to draw fluid from the ear using a needle for
identifying specific bacteria, a procedure called tympanocentesis. This procedure can also relieve
severe ear pain. This is most often performed by ear, nose, and throat (ENT) specialists, and
usually only in severe or recurrent cases. In most cases, tympanocentesis is not necessary in
order to obtain an accurate enough diagnosis for effective treatment.
Determining Hearing Problems
Hearing tests performed by an audiologist are usually recommended for children with persistent
otitis media with effusion. A hearing loss below 20 decibels usually indicates problems.
Determining Impaired Hearing in Infants and Small Children. Unfortunately, it is very difficult to
test children under two years old for hearing problems. One way to determine hearing problems
in infants is to gauge the baby's language development:
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At four to six weeks most babies with normal hearing are making cooing sounds.
By around five months the child should be laughing out loud and making one-syllable
sounds with both a vowel and consonant.
Between six and eight months, the infants should be able to make word-like sounds with
more than one syllable.
Usually starting around seven months the baby babbles (makes many word-like noises)
and should be doing this by 10 months.
Around 10 months, the baby is able to identify and use some term for the parent, dada,
baba, or mama.
The baby speaks his or her first word usually by the end of the first year.
If a child's progress is significantly delayed beyond these times, a parent should suspect possible
hearing problems.
Determining Impaired Hearing in Older Children. Hearing loss in older children may be detected
by the following behaviors:
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They may not respond to speech spoken beyond three feet away.
They may have difficulty following directions.
Their vocabulary may be limited.
They may have social and behavioral problems.
WHAT ARE THE MEASURES FOR PREVENTING EAR
INFECTIONS?
Avoiding Pacifier Use
There is some evidence to suggest that use of pacifiers may increase risk of otitis media in
children under three years old. Nevertheless, some physicians believe any association is
exaggerated and that the comfort a child derives from sucking (either thumb, breast, or pacifier) is
more important than any presumed increase risk for ear infection.
Breastfeeding
Breastfeeding offers protection against many early infections, including ear infections. For one,
the mother's milk provides immune factors that help protect the child from infections. Also, to be
breastfed, infants are held in a position that allows the Eustachian tubes to function well. If
possible, new mothers should breastfeed their infants for at least six months. For bottle-fed
babies, to improve protection mothers should not lay babies down with their bottle; they should
hold the infants in the same way they would to breastfeed them.
Preventing Colds and Flus
The best way to prevent ear infections is to prevent colds and flus in the first place.
Good Hygiene. Colds and flus are spread primarily when an infected person coughs or sneezes
near someone else. A very common method for transmitting a cold is by shaking hands.
Everyone should always wash his or her hands before eating and after going outside. Ordinary
soap is sufficient. Waterless hand cleaners that contain an alcohol-based gel are also effective for
every day use and may even kill cold viruses. (They are less effective, however, if extreme
hygiene is required. In such cases, alcohol-based rinses are needed.) Antibacterial soaps add
little protection, particularly against viruses. In fact, one study suggests that common liquid dish
washing soaps are up to 100 times more effective than antibacterial soaps in killing respiratory
syncytial virus (RSV), which is known to cause pneumonia and has been associated with ear
infections. Wiping surfaces with a solution that contains one part bleach to 10 parts water is very
effective in killing viruses.
Reducing Stress. Interestingly, giving children affection and helping them relax could help prevent
colds. More than one study has reported that people with low stress who also have an active
social life have fewer colds than people who have high stress levels or those who have low stress
and few social connections.
[For more information see Well-Connected Report #94, Colds and Influenza (the Flu).]
Dietary Factors and Supplements
Healthy Diet. Daily diets should include foods such as fresh, dark-colored fruits and vegetables,
which are rich in antioxidants and other important food chemicals that help boost the immune
system.
Foods Containing Lactobaccilli (Good Bacteria). Researchers are also studying the possible
protective value of certain strains of lactobacilli, bacteria found in the intestines. Some of these
strains, particularly acidophilus, are used to make yogurt. According to one Finnish study,
children attending day care who ate milk containing the strain lactobacilli GG could reduce
respiratory infections in these children by 10% to 20%. More research is warranted. (The strain
used was not the kind found in most commercial yogurt products,)
Xylitol. Xylitol, a sugar alcohol produced naturally in birch, strawberries, and raspberries, has
properties that fight Streptococcal pneumonia bacteria. Studies are reporting that children who
chew gum or swallow a syrup containing xylitol experience significantly fewer ear infections. It
also reduces cavities. Chewing gum (Clen Dent) may be more effective than the syrup. Although
in one study, xylitol did not reduce bacteria in the nose and throat, it did prevent ear infection. (It
does not appear to prevent ear infections in children who are having colds or flus.) Some health
providers report that even children one and a half years old can learn to chew and not swallow
gum. Studies have not been clinically tested children between six and 18 months, the highest-risk
age group for otitis media. This is an area for further research. The gum is not widely available in
the US although it can be purchased on the Internet (http://www.xylitolworks.com/) .
Avoiding Exposure to Cigarette Smoke
Parents or others should not smoke around children. Several studies have found that children
who live with smokers have a significant risk for ear infections. One study even suggested that
the more the mother smoked the higher the risk.
Preventing Viral Influenza
Preventing influenza (the "flu') may prove to be a more important protective measure against ear
infections than preventing bacterial infections. For example, studies report that children who were
vaccinated against influenza experienced 33% to 36% fewer ear infections during flu season than
unvaccinated children. (The vaccine provided no additional protection at other times.)
Viral Influenza (Flu) Vaccines. Vaccines against influenza (the "flu') currently employ inactivated
(not live) viruses to produce an immune response that will then attack the active virus. Vaccines
are now given by injection in the fall, usually between October and December. Antibodies to the
influenza virus usually develop within two weeks of vaccination, and immunity peaks within four to
six weeks, then gradually wanes. A live but weakened intranasal vaccine (FluMist) is proving to
be effective and safe in children and is awaiting approval by the FDA at the time of this report.
In general, experts recommend that the flu vaccine be given to all children over six months with a
condition that requires regular medical care. Children who are susceptible to recurrent ear
infections should probably be given vaccinations against influenza viruses. In fact, in 2003 the
American Academy of Pediatrics (AAP) and the CDC encourages vaccination in all children,
including healthy children, between six months and two years of age. This recommendation may
vary from year to year depending on the supply of the vaccine.
Possible negative side effects include the following:
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Allergic Reaction. Newer vaccines contain very little egg protein, but an allergic reaction
still may occur in people with strong allergies to eggs.
Soreness at the Injection Site. Up to two thirds of people who receive the influenza
vaccine develop redness or soreness at the injection site for one or two days afterward.
Flu-like Symptoms. Other side effects include mild fatigue and muscle aches and pains.
They tend to occur between six and 12 hours after the vaccination and last up to two
days. These symptoms are not influenza itself but an immune response to the virus
proteins in the vaccine. Anyone with a fever, however, should not be vaccinated until the
ailment has subsided.
Antiviral Drugs. Antiviral agents have now been developed to treat influenza. One such drug,
oseltamivir (Tamiflu), is approved for use in children age one and older. Studies report significant
reduction in symptoms and in the incidence of ear infections with this agent. In another study,
when the antiviral drug, zanamivir (Relenza), was administered in the nasal passages of adults
with influenza, middle ear abnormalities were reduced from 73% to 32%. This drug is available for
children greater than seven years old for treatment of influenza, but no research has determined
it value for preventing or treating otitis media in children.
Preventing Bacterial Infections
Preventive Antibiotics. Antibiotics have been used to prevent bacterial infections in children with
recurrent ear infections (four or more episodes a year). Studies suggest, however, that overall
they only prevent one episode a year, and are not generally recommended for prevention, except
for specific situations.
Pneumococcal Vaccine. The pneumococcal vaccine protects (Prevnar or PCV7) against S.
pneumoniae (also called pneumococcal) bacteria, the most common cause of middle ear
infections and other respiratory infections. It has now been added to the Recommended
Childhood Immunization Schedule and is also specifically approved for preventing otitis media.
An important 2003 study indicated that these vaccinations could result in 1.7 million fewer office
visits among four million children, 24% fewer procedures for tube implants, and significantly fewer
antibiotic prescriptions.
The recommended schedule of immunization is four doses, given at two, four, six, and 12 to 15
months of age. Infants starting immunization between seven and 11 months should have three
doses. (Parents should be sure their infants receive their second and third doses by six months in
order to achieve on-going protection from ear infections.) Children starting their vaccinations
between 12 and 23 months only need two doses. And those who are over two years old need
only one dose.
Experimental Agents
Researchers have observed that the noses and throats of children who are prone to ear
infections harbor smaller numbers of the "friendly" bacteria, notably alpha-streptococci. These
bacteria, normally found in the upper airways, compete for space with harmful bacteria. They
therefore help prevent overproduction of the harmful bacteria. Interesting research is underway
using a nasal spray containing alpha-streptococci. In early studies, the nasal spray has helped to
protect against recurrent otitis media in susceptible children.
WHAT ARE THE GENERAL GUIDELINES FOR
TREATING EAR INFECTIONS?
Overview
Although ear infections in children are extremely common, the research on this condition is oddly
unclear. Experts continue to argue about the best approach for treating ear infections. The major
debates rest on the use of antibiotics, surgery, and watchful waiting in both acute otitis media and
OME. Treatments for ear infections cost the country between three and four billion dollars each
year, and many of these treatments, particularly heavy antibiotic use and surgical procedures, are
often unnecessary in many children.
Treatment Guidelines for a Single-Episode of Acute Otitis Media
Antibiotics have been the mainstay treatments of acute otitis media. Major studies indicate,
however, that between 80% and 90% of all children with uncomplicated ear infections ear recover
within a week without antibiotics. (About 70% of even severe cases have been cured without
antibiotics.) Antibiotics do reduce symptoms more quickly, but only after a day, at which time the
pain is less in all children. In one study, compared to a group given no antibiotics, the treated
children experienced only 13% fewer persistent symptoms at day four and fever was only
reduced by a day. In terms of residual fluid, there was little difference at one month and no
difference at three months. [For warnings on overuse of antibiotics see What Are the Antibiotic
Choices for Treating Otitis Media?]
Unfortunately, there are no objective tests available to determine specifically the small
percentage of children with AOM that would actually benefit from antibiotics. An approach used in
the Netherlands has helped to produce a S. pneumoniae resistance rate to penicillin of only 1%.
An example of this method involves the following steps:




Children with bulging eardrum and evidence of pus or other indications of a severe
condition (i.e., high temperature and vomiting) should be immediately treated with
antibiotics.
Other children are monitored for two to three days (depending on the age of the child).
They are given full doses of acetaminophen (Tylenol) to relieve pain and reduce fever.
For children under two, if there is no improvement within one or two days, antibiotics are
started.
For children two and over, antibiotics are started if there is no improvement after three
days.
With this approach, only about 30% of children with ear infections require antibiotics (a far lower
rate than is common in the United States). It would also incur savings of about $185 million
dollars a year. Until recently, most US physicians and parents are very reluctant to abandon the
standard use of antibiotics. The greatest concern in not using antibiotics is a risk for mastoiditis--a
serious infection. However, evidence suggests that the risk for untreated children is only an
additional two cases each year for every 100,000 children. Fortunately, encouraging 2002 studies
have reported a significant decline in antibiotic prescriptions over the past few years.
The bottom line is that parents should question their physician closely if they recommend
antibiotics and feel comfortable waiting to see if they are truly necessary. They should not
pressure a physician into prescribing an antibiotic if it is clearly inappropriate. The physician very
often will give in.
[For specific information on antibiotics, see What Are the Antibiotic Choices for Treating Otitis
Media? below.]
Guidelines for Managing Persistent or Recurrent Acute Otitis Media
Persistent or recurrent acute otitis media is determined under the following circumstances:


If the child has had three or more separate ear infections every six months.
If the child has had four or more ear infections within a year.
In children with this condition, the following treatment options are available:



Watchful waiting. This is especially appropriate for children with a history of ear infections
that resolve without antibiotics.
Second-line and other powerful antibiotics. Powerful antibiotics are used to treat severe
infections and are stopped when they clears. (Less potent antibiotics have also been
used an on-going basis for prevention recurring infection, but they offer little benefits and
almost all physicians are moving away from this practice because of concerns about
resistance.) [For specific antibiotics in these cases, see What Are the Antibiotic Choices
for Treating Otitis Media?]
Tympanostomy. This is a surgical procedure that implants tubes to drain fluid and prevent
build-up and infection. [ See What Are the Surgical Procedures for Ear Infections?]
Treatment Guidelines for Otitis Media with Effusion (OME)
Watchful Waiting. The child is typically monitored for the first three months. Antibiotics are not
helpful for most patients with OME. For one, the condition resolves without treatment in nearly all
children, especially those whose OME followed an acute ear infection.
The Role of Antibiotics. Antibiotics tend to be used only if the condition persists after three
months or one or both of the following has occurred within the three months period:


The child is suffering.
Hearing loss occurs. (A hearing test should be conducted if the condition persists for over
three months, in any case, whether antibiotics have been given or not.)
In cases when they are prescribed for OME, antibiotics are typically given for 14 days. [ See What
Are the Antibiotic Choices for Treating Otitis Media?]
Treatment Failure at Six Weeks. If OME persists for six weeks in spite of antibiotic therapies, the
following two options are generally considered:


Antibiotics are continued and stopped when the condition has cleared, usually in 14 days.
(Although some physicians continue to prescribe antibiotics even after the condition has
cleared to prevent recurrence, this practice is generally not recommended. First,
extended treatment does not appear to add any benefits, and second, it increases the
risk for emerging bacteria strains resistant to antibiotics.)
Surgery (tube insertion) is usually recommended if OME is still present for more than
three months, there is evidence of hearing loss of over 20 decibels, and the child has
been effectively treated with antibiotics. As with antibiotics, however, some experts
believe surgery, too, is overused for otitis media. [ See What Are the Surgical Procedures
for Ear Infections?]
Inappropriate Treatments. The following treatments are not recommended for otitis media with
effusion:



Corticosteroids (Steroids). Corticosteroids reduce inflammation and have been
investigated for OME. When used in combination with antibiotics, they clear OME more
rapidly than antibiotics alone, but two weeks after treatment there are no differences.
Steroids are, therefore, not recommended.
Antihistamines, Decongestants, or Both. These agents are not effective for OME, either
used alone or in combination. Antihistamines are useful for controlling seasonal allergies,
which might contribute to ear infections, but it is not clear if they have any effect on OME.
Adenoidectomy or Tonsillectomy. These are invasive surgeries that are not
recommended to treat OME. They may be used in combination with ear tube insertion for
children who have accompanying complications in the adenoids or tonsils.
Investigative Treatments for OME. Preliminary research suggests that glutathione, an antioxidant,
may be an effective treatment for OME. More research is needed.
WHAT ARE THE HOME REMEDIES USED FOR EAR
INFECTIONS IN CHILDREN?
Watchful Waiting
Careful monitoring of the child's condition (watchful waiting) along with home remedies and
common over the counter cold medicines may be a viable alternative to antibiotic treatment for
many children with a first episode of acute otitis media.




In one 2000 study, 240 children under age two who were diagnosed with acute otitis
media were treated with watchful waiting. After four days, only 3% of the children
required treatment with antibiotics, while the infection cleared in the other 97%.
Children, however, must be monitored carefully.
High fever, severe pain, or other signs of complications should warrant immediate
attention by a medical professional.
Parents of infants should contact their doctor immediately if they have any fever,
regardless other symptoms.
Natural Remedies for Ear Aches
Before antibiotics, parents used home remedies to treat the pain of ear infections. Now, with
current concern over antibiotic overuse, many of these remedies are back in favor.



Depending on regional cultures, parents may have pressed a warm water bottle or warm
bag of salt against the ear. Such old-fashioned remedies may still help to ease ear pain.
Drops of tea tree oil may be beneficial. This herbal treatment has mild anti-bacterial
properties, but it may irritate the skin.
Studies have reported that Otikon, an extract made of various plants, including garlic and
St. John's Wort, is an effective anesthetic in treating the pain associated with ear
infections. Plants contained in Otikon may have side effects.
Herbal remedies are not standardized or regulated, and their quality and safety are largely
unknown. Parents should never give their child herbal remedies, including oral remedies, without
approval from a physician.
Valsalva's Maneuver. A simple technique called the Valsalva's maneuver is useful in opening the
Eustachian tubes and providing occasional relief from the chronic stuffy feeling accompanying
otitis media with effusion. It may also be useful for unplugging ears during air travel descent as
well. It works as follows:



The child takes a deep breath and closes the mouth.
He or she then blows the nose gently while, at the same time, pinching it firmly shut.
The parent should be sure to instruct the child not to blow too hard or the eardrum could
be harmed.
This technique should not be used if an infection is present.
Pain-Relievers
A number of pain relievers are available to help relieve symptoms.



Either acetaminophen (e.g., Tylenol) or ibuprofen (e.g., Advil) is the pain-reliever of
choice in children.
Older children may be able to take prescription pain relievers that contain codeine if the
pain is severe.
Eardrops containing anesthetics (Auralgan) are also available by prescription. In one
study Auralgan provides effective short-acting pain relief and helps children endure ear
discomfort until an oral pain reliever takes effect. In one study, 89% of children who took
eardrops were able to avoid antibiotics. Parents should check with a physician before
using them. Eardrops could cause damage in children who have a ruptured eardrum.
This might be indicated by fluid drainage from the ear canal.
Note: Aspirin and aspirin-containing products are not recommended for children or adolescents.
Reports of Reye's Syndrome, a very serious condition, have been associated with aspirin use in
children who have chicken pox or flu.
Cold and Allergy Remedies
Many non-prescription products are available that combine antihistamines, decongestants, and
other ingredients, and some are advertised as cold remedies for children. Researchers have
found little or no benefits for acute otitis media or for otitis media with effusion using
decongestants (either oral or nasal sprays or drops), antihistamines, or combination product.
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WHAT ARE THE ANTIBIOTIC CHOICES FOR
TREATING OTITIS MEDIA?
Overview on Antibiotics and Their Overuse for Otitis Media
Antibiotics have been the mainstay treatments of acute otitis media. Until recently nearly every
American child who visits a doctor with an ear infection receives antibiotics. In one region of the
US more than 70% of children received antibiotics before they were seven months old, and the
most common reason for these medications was otitis media.
Major studies indicate, however, that in most cases of acute otitis media antibiotics are
unnecessary. Between 80% and 90% of all children with uncomplicated ear infections ear recover
within a week without antibiotics. (About 70% of even severe cases have been cured without
antibiotics.) Antibiotics are rarely needed for otitis media with effusion.
The intense and widespread use of antibiotics is leading to a serious global problem--which is
bacterial resistance to common antibiotics. For example, according to reports in 2002 and 2001,
in Canada 15% of S. pneumoniae strains are resistant to penicillin, in the US between 30% and
40% are resistant, and in Hong Kong between 70% and 80% of strains no longer respond to
penicillin. Furthermore, in the US about 23% of S. pneumoniae are currently resistant to at least
three antibiotics. High rates of resistance strains are even being observed in infants. In general,
regions and institutions with the highest rate of resistance are those in which antibiotics are
heavily prescribed.
According to one study, children at highest risk for both ear infections and harboring bacterial
strains resistant to antibiotics are boys who attend day care, who are exposed to cigarette smoke,
who were bottle-fed, and who have siblings with recurrent ear infections.
Encouraging studies are now reporting that inappropriate antibiotic prescriptions are on the
decline. In one study, there was a 47% reduction in prescriptions for otitis media since 1989.
(Prescriptions for other common respiratory infections also decreased--by 47% for sore throat, by
61% for acute bronchitis, and 45% for colds and flus. Rates for sinusitis were unchanged.)
Antibiotic Regimens for Single-Episodes of AOM
When antibiotics are needed, a number of different classes are available for treating acute ear
infections. Amoxicillin is a penicillin antibiotic and the drug of first choice. Other antibiotics are
available for children who are allergic to penicillin or who do not respond within three to five days.
Duration. If a child needs antibiotics for acute otitis media, the following are some
recommendations for duration of regimens.


Five days of antibiotic therapy appears to be sufficient for most children with
uncomplicated AOM. Such children are typically those over two years old, those who
start to improve within 72 hours, and those who have no risk factors for complications.
A full ten to fourteen day course of antibiotics (usually amoxicillin) is typically used for
younger children and for those with complications such as a perforated ear drum, facial
abnormalities, or impaired immune systems.
Parents should be sure their child completes the drug regimen. Not completing it is a major factor
in the growth of bacterial strains that are resistant to antibiotics.
What to Expect. Earaches usually resolve within eight to 24 hours after taking an antibiotic,
although about 10% of children who are treated do not respond. Failure may be due to the
following or other causes:


In many cases in which the response to an antibiotic is incomplete, a virus is often
present.
In other cases, the bacteria causing ear infection may be resistant to the antibiotic and a
different antibiotic may be needed.
Note: In some children whose treatment is successful, fluid will still remain in the middle ear for
weeks or months, even after the infection has resolved. During that period, children may have
some hearing problems, but eventually the fluid almost always drains away. Antibiotics should not
be used to treat residual fluid.
Follow-Up. Follow-up may involve the following steps:



If the infection clears up with a single regimen in children less than 15 months old or in
children with risk factors for reinfection, an examination should be scheduled two to three
weeks after therapy.
If the infection clears up with a single regimen in older children with no specific risk
factors, they should be reexamined three to six weeks after treatment.
If signs of infection are still present (e.g., pus is still present in the ear) within 48 hours of
taking the last antibiotic dose, the child should be re-examined. (Parents are excellent
judges of whether their child's condition has cleared up.)
In cases where complications are suspected, consultation with an ear, nose, and throat specialist
(called an otolaryngologist) should be strongly considered. This specialist may perform a
tympanocentesis or myringotomy, procedures in which fluid is drawn from the ear and examined
for specific organisms. But this is reserved for severe cases.
Specific Antibiotics Used for Acute Otitis Media (AOM)
While many different antibiotics may be used to effectively treat otitis media, the physician needs
to balance effectiveness, safety, and convenience, as well as try to minimize the emergence of
bacterial resistant to antibiotics. The prevalence of such antibiotic-resistant bacteria has
dramatically increased worldwide, but regions vary widely. To this end, the Centers for Disease
Control and Prevention (CDC) has made very clear recommendations about first and second line
treatments for otitis media.
First Line of Antibiotics for AOM. The following are the standard antibiotics used for an initial
infection.


Amoxicillin (Amoxil, Polymox, Trimox, Wymox, or any generic formulation) is the most
widely prescribed oral antibiotic for acute otitis media. This is a penicillin antibiotic and is
both inexpensive and highly effective against the S. pneumoniae bacteria. Unfortunately,
bacterial resistance to amoxicillin has increased significantly, so the CDC has advised
doubling the standard dose. Amoxicillin is also not as effective against H. influenzae. In
areas where bacterial-resistance to antibiotics is high, some physicians recommend highdose amoxicillin.
Ofloxacin (Floxin) is an antibiotic known as a fluoroquinolone (also simply called
quinolone). It is available in eardrops and is now recommended as first-line therapy for
children with AOM who also have perforated eardrums or infection after implanted
tympanostomy tubes. Ofloxacin is proving to be very effective and safe for these children.
(Drops are effective only in these cases.) Another quinolone, ciprofloxacin, is also
available in eardrop form outside the US.
Second-Line Antibiotics for AOM. Second-line antibiotics are used under the following
circumstances:



If the condition persists after using first-line agents.
If the ear infection is recurrent.
If the patient has had other antibiotics within the past month.
Second-line antibiotics include the following:

Amoxicillin/clavulanate combination (Augmentin). This agent is known as an augmented
penicillin, and it works against a wide spectrum of bacteria. A new extra-strength
formulation (Augmentin ES-600) has been approved. It is proving to be highly beneficial
for recurrent or persistent AOM. It is effective against some amoxicillin- and penicillin-

resistant bacteria. It also works well against other common bacteria that cause AOM,
notably H. influenza and M. catarrhalis, including resistant strains.
Cephalosporins. Cephalosporins belong to the same class as penicillins (those called
beta lactam antibiotics). Certain second- or third-generation oral cephalosporin antibiotics
may be good second-line options. Of these cefuroxime (Ceftin) and cefpodoxime (Vantin)
have the best record to date among the cephalosporins for coverage against bacteria that
infect the upper respiratory tract. (Their safety and effectiveness in infants under six
months old are not proven.) Ceftriaxone (Rocephin), an injectable cephalosporin, is also
an option. Administering it in a single injection may be sufficient for some children,
although a 2001 study reported that a three-day regimen was more effective for children
with non-responsive otitis media. A person who is allergic to penicillin has a 5% to 14%
chance of being allergic to a cephalosporin.
Antibiotics for Other Circumstances. More powerful and expensive antibiotics are available for
children under other circumstances, including the following:


For children who are allergic to penicillin, cephalosporins, of both.
For children with persistent or recurrent episodes of acute otitis media who do not
respond to first- or second line agent (and who then probably have bacterial strains
resistant to those antibiotics).
These antibiotics are usually very expensive, however, and are not commonly used. They include
the following:



Macrolides include erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), and
roxithromycin (Rulid). Azithromycin is generally equivalent to Augmentin in effectiveness
and needs to be taken for only five days. In fact, both a one-dose and three-dose
regimen of Zithromax is approved for treatment of AOM. These antibiotics are effective
against S. pneumoniae and M catarrhalis, but macrolide-resistance rates doubled
between 1995 and 1999 as more and more children were being treated with these
antibiotics. They are not effective against H. influenzae.
Trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra) or a combination of
erythromycin and sulfisoxazole (Eryzole, Pediazole) are useful for people allergic to
penicillin. It should not be used in patients whose infections occurred after dental work or
in patients allergic to sulfa drugs. Allergic reactions can be very serious. Bacterial
resistance to these agents has increased dramatically, however, and failure rates are
high in certain regions. An oral solution (Primsol) uses trimethoprim alone. It poses less
risk for an allergic reaction than the combination and yet is still effective.
Clindamycin (Cleocin). This antibiotic is known as a lincosamide and is useful against
many S. pneumoniae bacteria but not against H. influenzae.
Side Effects of Antibiotics



The most common side effects of nearly all antibiotics are gastrointestinal problems,
including cramps, nausea, vomiting, and diarrhea. This can be a significant problem in
infants and small children. One study reported that giving such children a soy-based
formula that contained fiber (Isomil DF) was helpful in reducing these side effects.
Allergic reactions can also occur with all antibiotics but are most common with
medications derived from penicillin or sulfa. These reactions can range from mild skin
rashes to rare but severe, even life-threatening anaphylactic shock.
Some drugs, including certain over-the-counter medications, interact with antibiotics;
patients should report to the physician all medications they are taking.
WHAT ARE THE SURGICAL PROCEDURES FOR EAR
INFECTIONS?
General Guidelines for Surgery
Surgery to drain the ear drum ( myringotomy) with or without implanted ventilation tubes to drain
the fluid ( tympanostomy) is the basic surgical procedure for otitis media. It is the second most
frequently performed procedure for children under two (circumcision is first).
Surgery is usually recommend for the following:


Children with persistent otitis media with effusion (OME) for more than three months and
hearing loss in spite of aggressive antibiotic treatment.
Children with more than four episodes of acute otitis media per year. (Evidence suggests
that tubes are helpful only for recurrent AOM with bulging eardrums. It did not appear to
prevent recurrence in children without bulging eardrums.)
Hearing is almost always restored following tympanostomy.
Debate on its Widespread Use. There is still some debate, however about the wide-spread use of
surgery for ear infections. In 1996 tubes were placed in the ears of an estimated 280,000 children
younger than three years of age underwent the operation.


Arguments Against its Use. A number of studies have suggested, however, that the
procedures in children who are between one and two years old make no difference in
language development--one of the primary reasons for the procedure--by the time the
child reaches three. The procedure, although extremely safe, is not risk-free.
Arguments for Its Use. Still, a number of studies on this patient population report
immediate improvement in ear problems and in the quality of both the child's life and that
of the parents. In one study, for example, 84% of parents said they would make the same
decision. (Some experts, in fact, prefer surgery over antibiotics initially for children with
persistent OME and hearing loss because of the risk for drug-resistant strains of bacteria
with antibiotic overuse.)
With increasing health care costs, research will be important to pin down the short- and long-term
benefits of the procedure.
Myringotomy
Myringotomy is used to drain the fluid and may be used as a single procedure in unresponsive
acute otitis media. It involves the following steps.




The surgeon makes a very small incision in the eardrum.
Fluid is sucked out using a vacuum-like device.
The fluid is usually examined for identifying specific bacteria.
The eardrum heals in about a week.
Tympanostomy (with Myringotomy)
A tympanostomy involves the insertion of tube to allow fluid to drain from the middle ear. It is
performed in otitis media with effusion persists in spite of drug therapy or if it is caused by
structural or inborn problems. It involves the following:



A general anesthetic is required, but children typically recover completely within a few
hours.
Myringotomy is first performed [see above].
After myringotomy, the physician inserts a tube to allow continuous drainage of the fluid
from the middle ear.
Postoperative Effects. It is a simple procedure, and the child almost never has to spend the night
in the hospital. Acetaminophen (Tylenol) or ibuprofen (Advil) is sufficient for any postoperative
pain in most children. Some, however, may require codeine or other powerful pain relievers. One
study found that lidocaine eardrops were effective in relieving pain and stress after the procedure.
Complications. Otorrhea, which is drainage of secretion from the ear, is the most common
complication after surgery and can be persistent in some children. It is usually treated with
antibiotic eardrops, such as ofloxacin (Floxin). One study suggests that wearing earplugs may
alleviate the problem.
More serious complications from the operation are very uncommon:





General anesthetic poses risks, although rare, for allergic reactions or other
complications, such as throat spasm or obstruction, which are nearly always easily
treated. According to one 2002 study, such complications occur in less than 2% of the
patients. The risk is highest in children who have other medical conditions, most
commonly upper respiratory infections, lung disease, or GERD.
Sometimes the tubes become blocked from sticky secretions or clotted blood after the
operation.
Persistent eardrum perforation is the most common serious complication, but it too is
rare.
Scarring can also occur, particularly in children who require more than one procedure,
but it almost never affects hearing.
Small keratin (skin cell) containing cysts called cholesteatomas develop around the tube
site in over 1% of patients. This raises some concern about the long-term safety of the
procedure, although other studies have indicated that this complication is rare. More
studies are needed.
Success Rates. Hearing is almost always restored following tympanostomy. Failure to achieve
normal or near-normal hearing is usually due to complicated conditions, such as preexisting ear
problems or persistent OME in children who have had previous multiple tympanostomies. In one
10 year study, hearing loss was still present in 12.5% of people who had had surgery, although in
half of these individuals, hearing loss was very mild (loss was below 20 decibels). Persistent fluid
was the main reason for continued impaired hearing. Only 1.9% of hearing loss cases could be
attributed to complications of the operation itself.
Precautions. While the tubes are in place, children may take the following precautions:
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Many doctors feel that children should use earplugs when swimming as long as the tubes
are in place in order to prevent infection. (Cotton balls coated with petroleum jelly are
effective alternatives to ear plugs.)
Children may shower without earplugs.
Some physicians feel that as long as the child does not dive or swim underwater, earplugs may
not be necessary, but parents should consult their own child's doctor on this subject.
Follow-Up. After surgery, the children may experience the following course.
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Eventually, the tubes fall out as the hole in the eardrum closes. This may happen
between several months to over a year. This is painless and the patient and parents may
not even be aware that the tubes are out.
The operation may need to be repeated, occasionally several times, if, after the tubes fall
out, the effusion and hearing loss still persist.
Antibiotics are often prescribed after surgery to prevent such recurrence.
Adenoid and Tonsil Removal
Adenoids are collections of spongy lymph tissue in the back of the throat. Removal of the
adenoids, called adenoidectomy, is sometimes considered if they are overly enlarged and
interfere with Eustachian tube function. In such cases, the procedure might follow myringotomy
and tympanostomy.
Removing tonsils along with adenoids ( adenotonsillectomy) may improve the results of
tympanostomy, particularly if the two procedures are performed at the same time. It is commonly
held, however, that, except for special circumstances, adenoidectomy should not be conducted
on children under four.
Studies suggest that adenoidectomy on its own has no effect on recurring ear infections. The
combined approach reduces recurrence only very slightly, and has a high (15%) complication
rate.
Laser-Assisted Tympanic Membrane Fenestration
A technique called laser-assisted tympanic membrane fenestration (LTMF) uses a laser to create
a tiny hole and allow the fluid to drain immediately. No tubes are inserted and the child does not
need general anesthesia. It is best suited for alleviating symptoms rapidly in children with very
severe acute otitis media and in older children with OME, although the procedure itself can cause
discomfort. The laser equipment is also extremely expensive and so the procedure is unlikely to
be widespread in the near future.