What happens with a middle ear infection ?
The middle ear is located on the other side of the eardrum. It has a tiny drainage tube called the eustachian tube connected to the back of the nose. This tube is used to equalise pressure, such as going up in an aeroplane or underwater. In children this tube is narrow. During a cold, the phlegm that is produced can track back through this tube to the middle ear space. This fluid will become inflamed, due the presence of bacteria and or viruses, which will build up pressure behind the ear drum. This becomes red, tender and inflamed. The diagrams show the progression of a middle ear infection.
By observing the appearance and movement of the eardrum through an otoscope your doctor is able to diagnose the presence of infection. Almost half of all children will have an ear infection during the first year of life. Many will be prone to recurrent ear infections.
The risk factors for middle ear disease includes: boys, the indigenous, those in day care, parents who smoke, those with allergies and those with a family history of ear problems. They are especially frequent during the winter months because of the number of colds.
What the child feels
Pain is the most common symptom of middle ear infections. In some cases it is very mild; in others it is severe enough to make the child cry. This will last for 6 – 12 hours and then it will ease to a dull ache. Older children usually complain of fullness, hearing loss or a sharp stabbing pain in the affected ear. Infants may be fussy or out of sorts, tug at their ear and sleep restlessly. The pain will often occur in the middle of the night as the pressure has built up behind the ear drum because of the sleeping position.
One-third to one-half of children with middle ear infection will develop fever, occasionally as high as 40 degrees. Elevated temperature is more common in infants and toddlers than in older children. Symptoms of a cold such as nasal congestion, cough, and conjunctivitis often accompany ear infections.
Sometimes the eardrum bursts when pressure from the infection stretches it to its maximum state. Although pus and blood may drain from the ear canal when this happens, there is no cause for alarm. The tear in the eardrum is usually quite small and seals off within 2 or 3 days. It is uncommon to have a lasting hole in the eardrum or prolonged hearing loss as a result of ear infection. When this happens it is necessary to move to ear drops as this is more effective than oral antibiotics.
The ear pain will resolve in most cases to a manageable level after a number of hours. Following this the child will be mildly deaf in that ear for between 2 weeks and 3 months. This is because the fluid in the middle ear space needs to slowly drain.
What do doctors do.
A painful middle ear infection is a common presentation for doctors, and middle of the night emergency departments. The doctor will assess the overall appearance of the child and examine the ear. Generally Pain relief involves keeping the child upright, some nurofen or panadol, and time. Antibiotics are sometimes used, particularly in the very young, those that appear particularly unwell, and those who are deemed to have risk factors for middle ear disease.
This is currently one of the most controversial areas in children‘s health. In most cases there is no need for antibiotics provided your child is older than 2 and the pain and temperature have settled after 24 hours. If the symptoms last longer then amoxil and sometimes augmentin is the antibiotic of choice. The side effect profile from antibiotics needs to be carefully considered before their use. It is my practice to treat the very young and those who have ongoing symptoms of acute otitis media. Be careful of ceclor which has little role in middle ear disease and has serious but uncommon side effects.
As mentioned if there is discharge from the ear then eardrops are appropriate and ideally this should contain and antibiotic called ciprofloxacin.
Since fluid can remain in the middle ear space for weeks or even months after an infection, your child may experience a temporary hearing problem. Isolated episodes of middle ear infections do not result in permanent hearing loss. The term glue ear describes this fluid which may become thick like ‘glue‘. This can take several months and sometimes longer to drain. It results in temporary mild deafness.
Treatment for Glue ear
In some cases watching and waiting maybe acceptable. Particularly if the child is functioning well, i.e. good speech language development and no other ENT issues. Sometimes however surgery is needed.
Small plastic cylinders are used by ENT surgeons to allow air to enter the middle ear cavity which helps with drainage of fluid. This is used in those with glue ear, recurrent infections, those with cranio-facial abnormalities, and those who have underlying risk factors for middle ear disease. They last from 6 months to a year.
Otovent – for those older than 3-4 years
The eustachian tube which drains the middle ear is blocked in those with glue ear. Increasing the pressure in this tube can be done by using a device called otovent – which involves blowing up a balloon with the nostril ! Studies have definitel
y shown that this is an effective treatment to help with glue ears. Unfortunately it requires some training, so is more effective for the older child. Otovent in Australia can be found at certain chemists or online – see otovent and costs about $30
Swimming and flying
Children with ear infection who do not have discharge from the ear canal can usually be permitted to go swimming. Diving or placing the head too deeply under water – below 2 feet – may cause pain. With flying the problem here is that the barometric pressure change will affect the already elevated pressure in the middle ear resulting in a risk of the ear drum bursting. This is the worst case scenario. As a general rule if this happens a child’s eardrum will heal within 2 to 3 days. If you are not prepared to take that risk then it is better not to fly.