Ear Infections
One of the most common reasons parents seek health care for their children is ear infections. About 75% of children have at least one ear infection by age three. Acute otitis media, the medical term for ear infections, is the most common condition for which children receive antibiotics. Despite the high prevalence of ear infections, there is still some debate about the best way to manage ear infections.
Acute otitis media (AOM) is an infection of the middle part of the ear. The three main parts of the ear are the outer ear, the middle ear, and the inner ear. The middle ear is the area affected by AOM. Both the outer ear and the inner ear can become infected, but have different symptoms and treatment. The middle ear is the space behind the ear drum. There is a small tube called the Eustachian tube, which empties into the back of the throat, allowing for drainage of fluid and equalization of air pressure from the air space in the middle ear. Ear infections occur when a virus or bacteria causes a simultaneous buildup of infection and fluid in the middle ear, and an inflammatory narrowing or blockage of the Eustachian tube. This causes a build up of fluid and pressure in the middle ear resulting in infection, pain, and fever. There is some evidence that environmental factors such as allergies and second hand tobacco smoke play a role in the development of AOM. While AOM is common, fortunately the complications, which include partial hearing loss, are uncommon.
Historically, most physicians and nurse practitioners have treated AOM with antibiotics. Antibiotics are medications that are prescribed to treat bacterial infections. Antibiotics cannot treat viral infections. The high use of antibiotics for treating AOM is contributing to antibiotic resistance. Antibiotic resistance occurs as a result of overuse of antibiotics, and can cause some serious bacterial infections to be difficult to treat. Recent research has suggested that AOM does not always require treatment with antibiotics. With low incidence of complications, and high rates of spontaneous recovery, the value of antibiotic treatment for AOM is being reviewed. Sometimes aggressively treating the child with pain medication, such as Tylenol or Advil, combined with close follow-up is all that may be required. Practice guidelines in the United States now officially allow for the option of treating pain and observation for children over age 2. While practice guidelines for Canada are presently under review, some physicians and nurse practitioners here are currently offering this option.
The decision to treat or to observe is complicated and depends on the severity of symptoms, including pain and fever, age of the child, past medical and immunization history, the number of ear infections a child has experienced, and parental preference for treatment. Accurate diagnosis is also crucial. Symptoms include pain (often severe), irritability, and fever. Studies have shown, surprisingly, that pulling or tugging at the ear is not a very common or accurate symptom. AOM is diagnosed clinically by the presence of middle ear fluid, bulging of the ear drum, and redness of the ear drum. A tool called an otoscope is used to visualize the middle ear structures.
If antibiotic treatment is chosen, amoxicillin remains the drug of choice. Patients allergic to penicillin or amoxicillin need a different class of drug. Pain medication such as acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) should also be given. While length of treatment varies from three to ten days depending on the antibiotic used, children that do not improve within 48 hours of starting treatment should be re-assessed. If the option to observe and treat only with pain medication is chosen, follow-up should occur within 48 hours, either in person, or by phone.
Children with frequent AOM may require referral to a specialist called an otolaryngologist (ear, nose and throat specialist). There is little consensus on how many ear infections actually necessitate a referral. If a child is referred, the specialist has the option of offering a surgical procedure called tympanostomy tube insertion. This procedure involves inserting tubes in the ear drum to allow for drainage of fluids and prevention of infection. The decision to offer this procedure is also complicated. These specialists can also offer hearing testing. If a parent is concerned about the number of ear infections in a child, or about hearing loss, they should speak with a physician or nurse practitioner.
Preventing ear infections is difficult but avoiding exposure to second hand smoke and environmental allergies can help. Ensuring your child is fully immunized is also very important. Two of the bacteria that commonly cause ear infections can be prevented through immunization.
If you are concerned your child may have an ear infection, he or she should be assessed by a physician or nurse practitioner. The decision to treat, or observe, should be made in consultation with the parent. Close follow-up is important with either option. For further information speak to your family practitioner or call Telehealth Ontario, a telephone health advice line at 1-866-797-0000.