Middle ear infections

“Mommy, my ear hurts.” It’s a sentence no parent wants to hear, yet most of us will. Year after year, ear infections rank among the top reasons parents take their kids to the pediatrician.

There are different types of ear infections (such as the outer ear infection known as swimmer's ear), and they all can cause temporary hearing loss. Yet, in children, it's middle ear infections that are most associated with temporary hearing loss.

Also called acute otitis media, middle ear infections result in ear pain and inflammation. During or after the initial infection, fluid can build up in the air-filled space behind the eardrum, which is known as otitis media with effusion.

This build-up can reduce movement of the eardrum and middle ear bones, leading to trouble hearing. This can be alarming, but there is good news: If treated properly, the infection will clear, the ear pain will go away, and your child’s hearing ability will return to normal. Still, it's important to learn the causes, symptoms and risk factors so you know when to seek medical help for your child.

Causes of middle ear infections

In short, middle ear infections almost always develop during or after upper respiratory infections caused by viruses, especially the common cold. The respiratory infection causes inflammation and swelling at the back of the nose and throat, including the opening of the anatomic structure called the eustachian tube. This tube connects the throat to the middle ear, and when it’s swollen, it can no longer equalize the pressure in the middle ear space. This is a type of  eustachian tube dysfunction.

Subsequently, this pressure builds up in the tiny middle ear space and normal secretions can’t drain away as they normally would. The negative pressure and excess fluid can cause ear pain, pressure, dizziness and temporary hearing loss.

Why are children so prone to ear infections?

Middle ear infections can happen to anyone with a cold. However, younger children are far more prone to middle ear infections for two reasons. First, their immune systems are less developed, so it’s harder to fight off respiratory infections. Second, the eustachian tubes have a more horizontal orientation in young children, making it harder for fluid to drain.

Another risk factor for middle ear infection is a chronic infection or enlargement of the adenoids. Adenoid tissue is located at the back of the nose next to the eustachian tubes, so viral or bacterial invaders can easily spread to the middle ear. Additionally, when enlarged, the adenoid can block the eustachian tube openings, making it difficult for the tubes to function properly.

Symptoms of middle ear infections

For babies and toddlers who cannot verbally express they are experiencing pain or discomfort, it may be difficult to recognize the symptoms of an ear infection. If you're concerned a child that you take care of could have a middle ear infection, look for these tell-tale signs:

• Fever
• Constant or frequent scratching or pulling at the ears (indicating pain or discomfort)
• Slowed response to voices and other sounds (indicating trouble hearing)
• Irritability or difficulty sleeping
• Fluid drainage from the ear

For older children, adolescents and adults, these symptoms are also possible:

• A constant earache
• A feeling of pressure in the ears
• Difficulty understanding speech
• Feelings of dizziness or imbalance
• Vomiting or general nausea
• Rarely, a feeling of "double hearing" 

If you or your child has any of the symptoms above, call your pediatrician, family doctor or otolaryngologist, also known as an ear-nose-throat doctor (ENT). It is important to act quickly because a middle ear infection can easily be treated and the ear pain alleviated.

Here’s what to do if it’s the weekend or a holiday.

For children with autism, ear infection diagnosis may be delayed, due to communication difficulties. However, they are not more prone to infections than other children. More: Autism, auditory processing disorder and your child’s hearing health.

The link to hearing loss

Many different ear infections can affect hearing in one or both ears. This can be unsettling, but it's almost always temporary, mild, and doesn't result in any permanent hearing loss. Still, any hearing loss, especially in kids, should be evaluated by a healthcare professional.

Addressing hearing loss is important because infants and toddlers who suffer from recurrent ear infections or chronic fluid in the ear following infection experience stretches of hearing loss during a crucial learning period for speech and language.

Testing for an ear infection

As part of a medical exam, a doctor will use a lighted otoscope to look inside the ears, and in some cases, may perform a tympanometry test to measure the health of the eardrum and middle ear.

How are ear infections treated?

Treating a middle ear infection usually involves two steps: Treating the pain, and then, if symptoms don’t improve, prescribing antibiotic medication to fight the infection. Doctors sometimes wait to prescribe antibiotics because an otherwise healthy child may be able to fight the infection on their own, helping a child avoid side effects and other risks of antibiotics.

The American Academy of Pediatrics recommends focusing on pain management for the first 1 to 2 days before prescribing antibiotics. Over-the-counter ibuprofen and acetaminophen are recommended for pain relief, and occasionally ear drops that contain pain medicine.

Doctors sometimes wait to prescribe antibiotics, because the infection may clear up on its own.

If a doctor prescribes antibiotics to treat a middle ear infection, the first medication often prescribed is typically amoxicillin, as long as the child does not have a penicillin allergy. This oral antibiotic works to treat the infection. Over time, inflammation will get better, and the eustachian tubes can properly ventilate the middle ear.

Until the backed-up fluids have cleared and the eustachian tubes are functioning normally, your child is prone to recurrent infections and decreased hearing. It is important to take the entire course of prescribed antibiotics—even though the symptoms may have subsided. Older children may report being able to hear better several days after they have resumed normal activities. This is a sign that the fluid build-up has resolved.

Recurrent or chronic ear infections

For recurrent middle ear infections and lingering middle ear fluid that affects hearing, an otolaryngologist may recommend a minor surgical procedure known as ear tube surgery to insert tubes into the eardrums.

This is the most common outpatient procedure performed on children in the United States every year. During the procedure, an otolaryngologist will typically make a small incision (myringotomy) in the eardrum, remove any remaining fluid in the middle ear space, and insert a small tube (tympanostomy tube) into the eardrum.

The tube, also called a pressure equalization tube, aerates the middle ear space through the ear canal to allow any trapped fluids to dissipate and prevent recurrent infection. This procedure is reserved for children who have recurrent or ongoing infections despite the use of antibiotics (more than 3 in a 6-month period or 4 in a 12-month period with a recent infection) or who have persistent middle ear fluid for more than 3 months with an associated hearing loss. Your surgeon may also consider an adenoidectomy (removal of the adenoids) if there are symptoms of chronic stuffy nose or mouth breathing in addition to recurrent ear infections or persistent fluid in the middle ear space.

Can you prevent ear infections?

Because colds are very infectious and easily spread among children, it can be very hard to prevent your child from getting sick. However, there are risk factors you can control:

• Limit your child’s exposure to secondhand smoke
• Make sure your child—and you—are vaccinated against the flu every year
• Follow good hygiene habits, like frequent handwashing and using hand sanitizer
• Teach your child to cough into her elbow, not her hands

If hearing loss isn’t from an infection

If your child has sudden hearing loss but no signs of a middle ear or respiratory infection, be sure to check out our page on hearing loss in children. Acting quickly is important because children with hearing loss can have delayed language and speech development. Our directory can also help you find audiologists near you. 

^{This article has been medically reviewed by Gillian Diercks, MD, MPH, a fellowship-trained pediatric otolaryngologist at Mass Eye and Ear who sees pediatric patients at the Boston Main Campus and in our Newton and Wellesley practices. Dr. Diercks specializes in general pediatric ear, nose, and throat care, hearing loss, pediatric thyroid and endocrine disorders, treatment of sinus conditions and throat and voice care.}