Overview
The middle ear is the small air filled space behind the eardrum. It is joined to the back of the nose by a narrow passage, the eustachian tube, which keeps the pressure equal and lets fluid drain away.
During a cold the lining swells and the tube blocks. Fluid then collects behind the eardrum and can become infected, which is middle ear infection, or otitis media. Children get it far more often than adults because their eustachian tubes are shorter and more level, so fluid drains less easily. Sometimes fluid stays behind the eardrum for weeks after the infection has gone, dulling hearing.
Symptoms
- Pain inside the ear
- A blocked, full or pressured feeling
- Reduced hearing on that side
- Fever and feeling generally unwell
- Fluid, pus or blood stained discharge running from the ear
- Itching inside the ear
A young child who cannot describe earache may pull or rub the ear, cry more than usual, sleep badly, feed poorly, be off balance or seem not to hear well. Pain often eases suddenly if the eardrum bursts and the fluid escapes. Most infections settle within about three days, though symptoms sometimes last up to a week.
When to see a doctor
See a doctor within a few days for earache lasting more than three days, for any ear symptoms in a baby under a year old, for discharge from the ear, for hearing that has not come back after the pain settled, for infections that keep returning, and for ear symptoms in anyone whose immune system is weak.
Causes
Most middle ear infections begin with the viruses that cause colds and flu. The swelling they produce blocks the eustachian tube, fluid gathers behind the eardrum, and bacteria that live in the nose and throat can then multiply in it.
Large adenoids at the back of the nose can block the tube and harbour bacteria. Allergy, cigarette smoke and sudden pressure changes, as in a flight, also make the tube block more easily.
Risk factors
- Being a young child, particularly under three years
- Frequent colds, or going to a crowded creche or playschool
- Breathing other people's cigarette or bidi smoke, or cooking smoke
- Being bottle fed while lying flat
- Large adenoids
- Allergy and a persistently blocked nose
- A cleft palate or certain other conditions present from birth
- A weakened immune system
Complications
- A hole in the eardrum, with discharge, which usually heals but sometimes does not
- Fluid that stays behind the eardrum for weeks and dulls hearing
- Delayed speech and language in a young child whose hearing is affected
- Infections that keep coming back
- Infection of the bone behind the ear
- Long standing infection with a build up of skin inside the middle ear
- Rarely, spread of infection to the inner ear, the facial nerve or the covering of the brain
Prevention
- Keeping routine childhood immunisations up to date, including pneumococcal and flu vaccination
- Washing hands often, and keeping a child away from people with colds where possible
- Keeping the home free of cigarette, bidi and heavy cooking smoke
- Holding a baby fairly upright for bottle feeds rather than feeding lying flat
- Breastfeeding where possible
- Treating a persistently blocked nose and allergies
- Keeping the ear dry and out of dirty water while an infection is settling
Diagnosis
The doctor looks into the ear with a lighted instrument called an otoscope. An infected middle ear usually shows a red, bulging eardrum. A puff of air can be used to see whether the eardrum moves normally, since fluid behind it holds it still.
A simple test called tympanometry measures the movement of the eardrum and helps to show whether fluid is present. If hearing seems reduced, or infections keep returning, a hearing test is arranged, and a swab of discharge may be sent for testing.
Treatment
Pain relief comes first. Paracetamol or ibuprofen in the dose suited to age and weight settles most earache, and rest helps. Discharge can be wiped gently from the outer ear with cotton wool. Nothing is put inside the ear, and water and shampoo are kept out of it while it heals.
are not needed for everyone. Doctors often watch for a day or two before deciding, and are more likely to prescribe for babies, for a child who is very unwell, for infection in both ears, when there is discharge, or when symptoms are not improving. When antibiotics are prescribed, the whole course is finished. Antibiotic or steroid eardrops are sometimes used, particularly for infections of the ear canal.
For infections that keep returning, or fluid that stays behind the eardrum and affects hearing, an ENT doctor may suggest small ventilation tubes placed in the eardrum, sometimes with removal of the adenoids. Hearing is rechecked afterwards.
Myths and facts
Things people often say about this. Open each one to see what is true.
Myth“Warm oil, garlic juice or a few drops of breast milk will soothe an infected ear.”What is true?
Fact
None of these is a treatment for an ear infection, and health services advise against putting anything into the ear, including cotton buds and fingers. When there is discharge the eardrum may already have a small hole, so a liquid poured in does not stay in the ear canal. Pain relief such as paracetamol, and a doctor's opinion if it is not settling, are the safe steps.
Myth“Every earache needs antibiotics straight away.”What is true?
Fact
Most middle ear infections follow the viruses of colds and flu and clear within about three days. Guidelines often advise waiting and watching for a day or two with pain relief, keeping antibiotics for young babies, for confirmed infection and for symptoms that are not improving.
Myth“Cotton buds keep the ears clean and stop infections.”What is true?
Fact
Pushing cotton buds, fingers or cotton wool into the ear does not prevent infection. It tends to push wax deeper and can injure the ear canal or the eardrum. The outer ear can be wiped, and nothing should go inside it.
Myth“Fluid running from a child's ear is just wax coming out, and it will dry up on its own.”What is true?
Fact
Discharge from the ear usually means infected fluid is escaping through a hole in the eardrum, and it is a reason to see a doctor rather than wait. Repeated or long lasting discharge and fluid behind the eardrum can dull a child's hearing at the very age when speech is developing.
Questions to ask your doctor
Tick the ones you want answered and take them with you.
Common questions
Fluid is coming out of my child's ear. Is that dangerous?
It usually means the eardrum has developed a small hole and the infected fluid is draining out, which often eases the pain. The hole commonly heals by itself, but the child should be seen by a doctor. Wipe the outer ear gently, keep water out, and do not put anything into the ear.
Can my child swim or have a bath?
Keep water and shampoo out of the ear while an infection is settling, and avoid swimming until a doctor says it is fine, especially if there is discharge or a hole in the eardrum. Ordinary bathing is fine as long as the ear is kept dry.
Why does my child keep getting ear infections?
Young children have short, level eustachian tubes that block easily, and frequent colds, crowded childcare, smoke in the home and large adenoids all add to it. Most children grow out of it as the tubes mature. If infections keep coming back, an ENT opinion and a hearing test are worthwhile.
Will this affect my child's hearing permanently?
Usually not. Hearing often dips while fluid sits behind the eardrum and returns as it clears. Hearing that has not come back weeks after the infection, or repeated infections during the years when speech is developing, should be checked with a hearing test.
