What is the leading cause of sick visits to the doctor and the most common reason for children to get antibiotics? You guessed it—which probably wasn’t too hard since it’s the title of this post, but I’ll cut you some slack—ear infections, or acute otitis media, are truly what we see most as pediatricians.

So, what should you do if your child gets one? And how should you navigate doctor’s visits if your child keeps getting them? I know there isn’t a parent in the world who hasn’t thought, “If I just had one of those little lights with the black plastic piece, I could look in their ear myself and life would be so much easier”. More on that later I promise but for now, let’s get a grasp on the anatomy of your child’s ear so we can better understand how and why an ear infection starts. Don’t panic, there won’t be a test!

So to put it in very simple terms, there are two type of ear infections. 1). Otitis Externa (or swimmer’s ear) and 2.) Otitis Media (or middle/inner ear infection). Today we’re limiting our discussion to the middle/inner ear or, again, what is mostly commonly referred to as the classic “ear infection”.

Below is a picture! Now for a quick game…

1. Find the tympanic membrane (also called the ear drum)
2. Find the Eustachian tube
3. Notice that the Eustachian tube leads to that pretentious word for “nose” – nasopharynx.
4. Forget everything else (well maybe not the middle ear space, that’s important too)

Ok, excellent. Now think of the ear canal as a tunnel that lets doctors see the tympanic membrane. The tympanic membrane is sort of like a translucent window into the middle ear. However, the real purpose of the tympanic membrane is to serve as membrane that vibrates in response to sound waves and ultimately translates those sounds waves into language, music, etc (or at my house, children continually asking for a snack…I’m really not sure why, we just ate dinner but I digress…).

Anyway, back to ear infections. Often the child will have a preceding illness, such as a cold or upper respiratory tract infection that causes some inflammation in the nasal passages and the eustachian tube. This, in turn, leads to fluid accumulation within that middle ear that serves as a perfect breeding ground for opportunistic bacteria and this proliferation of growth and suppuration cause the dreaded ear infection.

“Now, hold on!” You might be saying, “Last time I checked, I’m pretty sure I still have all those body parts referenced above but you don’t see me complaining of ear pain or needing to be held constantly whenever I get a cold!”. Good point – I’m glad you brought it up.

So there are some key differences between children and older adolescents/adults that make infants and children particularly susceptible to ear infections. For one, the Eustachian tube is shorter, more floppy, and more horizontally positioned than in adults, permitting nasal secretions to enter the middle ear more easily. Also, children tend to get more colds and upper respiratory tract infections because they continue to build their immune symptoms through exposure, and this will increase the chances for ear infections to occur.

I can hear your next thought coming, “I’ll buy that, but it seems that not all children suffer from ear infections the same way my child does”. Yeah, it’s true, there are several other factors that can play a role…

Why Does it Feel Like Your Child Gets More Ear Infections than Other Children?

1. Studies have shown that family history and genetics play a big part in your child’s probability of getting ear infections. Unfortunately, ear infections really can “run in the famly”.
2. Daycare exposure at a young age may also contribute to more ear infections. The likely-hood of children in daycare getting colds and viruses is high which as stated before, can promote ear infections—especially at a young age.
3. Tobacco smoke exposure can also enhance the chance of your child getting an ear infection more often.

So hopefully the above information explains a little bit of the “where” and “why” for ear infections. But what does it look like clinically for children to have an ear infection? In short, it’s complicated. Some children experience no tangible symptoms with an ear infection, while others can show signs through ailments that you would never think to be associated with an ear infection at all (ie diarrhea and vomiting). With that caveat, here’s list of typical symptoms…

Common Symptoms of an Ear Infection

1. Ear pain
2. Ear rubbing
3. Ear drainage
4. Hearing loss
5. Fever (although temperature > 104°F is unusual)
6. Restless sleep
7. Fussiness

“Ok, so based on that, you’re saying my young infant with fussiness and restless sleep (isn’t that all infants?!) probably has an ear infection?” . Yes – and we need you to come into the office immediately. No, I’m kidding. But, at Parkside, we understand how vulnerable families can feel when they are concerned that their child may have an ear infection. There just isn’t a lot of hard, objective information to go with.

I say this a lot in the office during visits, but as simple as it sounds, sometimes the only way to know if your child has developed an ear infection, is to have a pediatrician look in the ears. And, we believe that parents know their child best. So, if you feel like your child is acting “off” and has had symptoms of a cold, then it is very reasonable to let us look in their ears.

So what exactly are we looking for when we use an otoscope? Basically, we are looking down at the translucent ear drum and interpreting the degree of inflammation present as well as the presence and/ or amount of purulent fluid.

And I will make the disclaimer that this is easier said than done depending on the age of child, size and shape of ear canal, amount of ear wax present and cooperation of the child. And as I alluded to previously, it might seem that any person with the equipment and good eye sight could diagnose an ear infection, but you have to remember that identifying an ear infection is a skill that is learned.

Most pediatricians have looked in thousands of ears. Long story short, resist that urge to order an otoscope on Amazon.

If the ears look great, then no need for apologies or embarrassment. Again, we understand, young infants are not the most reliable historians.

However, if we find that the child’s history, clinical symptoms, and their ear exam, all line up and point to a present ear infection, then we can discuss treatment options.

Ear Infection Treatment Options

1. Watch and Wait. There are some instances where observation is possible. Many health guidelines suggest initial observation (with pain control) as an option for healthy children (ie without conditions that predispose to ear infections) between 6 to 24 months of age. Ok, but some real talk, observation is reasonable but often requires an extra follow-up visit if there is no improvement. Also, ear infections can progress quickly. I’ve seen ears go from relatively normal to quite infected in < 24 hours.
2. Of course, more often than not, your Parkside provider will recommend antibiotics to help treat your child’s ear infection. The type of antibiotic will be dependent on whether there are other symptoms (ie concomitant eye infection), any recent antibiotic exposure and, of course, medication allergies. Most antibiotics will need to be administered for 10 days and some require refrigeration. It’s worth noting that many simple infections are responsive to Amoxicillin. It is true that a percentage of all infections requires escalation of therapy to a stronger antibiotic (think Cefdinir or Augmentin). However, the point I want to stress is that when this happens, it does not mean that the child is now unresponsive to Amoxicillin. Rather, the particular bacteria that caused that unique infection has some resistance. Therefore, there is good evidence and thought that if that child were to get another ear infection in 3-4 months, Amoxicillin would be a reasonable choice because the assumption is the new infection could be slightly different bacterial make up with good chance of susceptibility. Clear as mud? Perfect!
3. Ear Tubes are a last resort option for treatment of children with consistent ear infections. Ear tubes function by providing an artificial conduit through the ear drum. This serves two purposes – the first being that they provide trapped fluid with an escape route when it can’t make its way down the Eustachian tube. This relieves pressure (pain!) and reduces chances of “stagnant” fluid from getting infected. The second benefit of tubes is that they can allow for treatment of an ear infection to be done with drops. We now have a means to get medicine to the middle ear rather than treating systemically. Here at Parkside, we take recommending ear tubes seriously, but the tubes can be a game changer for the right candidate. So if you have questions talk your provider. Every child’s situation is different and I’m sure you will not find it shocking that there can be some gray area in medicine!

Alright, if you’re still reading along then I am impressed! That’s probably more information than you ever wanted to know about an ear.

Until next time,

Dr. Jeff Broome

Parkside Provider, National Park persuer, and proud Tennessee native