Ear infections are one of the most common reasons parents take their children to the doctor. While there are different types of ear infections, the most common is called otitis media, which means an inflammation and infection of the middle ear. The middle ear is located just behind the eardrum.

The term "acute" refers to a short and painful episode. An ear infection that lasts a long time or comes and goes is called chronic otitis media.

For links to other types of ear infections, see otitis.

Ear infections are common in infants and children in part because their eustachian tubes become clogged easily. For each ear, a eustachian tube runs from the middle ear to the back of the throat. Its purpose is to drain fluid and bacteria that normally occurs in the middle ear. If the eustachian tube becomes blocked, fluid can build up and become infected.

Anything that causes the eustachian tubes and upper airways to become inflamed or irritated, or cause more fluids to be produced, can lead to a blocked eustachian tube. These include:

• Colds and sinus infections
• Allergies
• Tobacco smoke or other irritants
• Infected or overgrown adenoids
• Excess mucus and saliva produced during teething

Ear infections are also more likely if a child spends a lot of time drinking from a sippy cup or bottle while lying on his or her back. Contrary to popular opinion, getting water in the ears will not cause an acute ear infection, unless the eardrum has a hole from a previous episode.

Ear infections occur most frequently in the winter. An ear infection is not itself contagious, but a cold may spread among children and cause some of them to get ear infections.

Risk factors include the following:

• Not being breast-fed
• Recent ear infection
• Recent illness of any type (lowers resistance of the body to infection)
• Day care (especially with more than 6 children)
• Pacifier use
• Genetic factors (susceptibility to infection may run in families)
• Changes in altitude or climate
• Cold climate

An acute ear infection causes pain (earache). In infants, the clearest sign is often irritability and inconsolable crying. Many infants and children develop a fever or have trouble sleeping. Parents often think that tugging on the ear is a symptom of an ear infection, but studies have shown that the same number of children going to the doctor tug on the ear whether or not the ear is infected.

Other possible symptoms include:

• Fullness in the ear
• Feeling of general illness
• Vomiting
• Diarrhea
• Hearing loss in the affected ear

The child may have symptoms of a cold, or the ear infection may start shortly after having a cold.

All acute ear infections include fluid behind the eardrum. You can use an electronic ear monitor, such as EarCheck, to detect this fluid at home. The device is available at pharmacies.

The doctor will ask questions about whether your child (or you) have had ear infections in the past and will want you to describe the current symptoms, including whether your child has had any symptoms of a cold or allergies recently. Your doctor will examine your child's throat, sinuses, head, neck, and lungs.

Using an instrument called an otoscope, the doctor will look inside your child's ears. If infected, there may be areas of dullness or redness or there may be air bubbles or fluid behind the eardrum. The fluid may be bloody or purulent (filled with pus). The physician will also check for any sign of perforation (hole or holes) in the eardrum.

A hearing test may be recommended if your child has had persistent (chronic and recurrent) ear infections.

The goals for treating ear infections include relieving pain, curing the infection, preventing complications, and preventing recurrent ear infections. Most ear infections will safely clear up on their own without antibiotics. Often, treating the pain and allowing the body time to heal itself is all that is needed:

• Apply a warm cloth or warm water bottle.
• Use over-the-counter pain relief drops for ears.
• Take over-the counter medications for pain or fever, like ibuprofen or acetaminophen. DO NOT give aspirin to children.
• Use prescription ear drops to relieve pain.

ANTIBIOTICS

Some ear infections require antibiotics to clear the infection and to prevent them from becoming worse. This is more likely if the child is under age 2, has a fever, is acting sick (beyond just the ear), or is not improving over 24 to 48 hours.

However, for several years there was a tendency to over-prescribe antibiotics, leading to the increasing numbers of bacteria that are resistant to these drugs. Joint guidelines from the American Academy of Pediatrics and the American Academy of Family Physicians are aimed at using antibiotics for ear infections when they are most needed. If the antibiotics do not seem to be working within 48 to 72 hours, contact your doctor to consider switching to a stronger antibiotic. Usually there is no benefit to more than two, or at the most three, rounds of appropriate antibiotics.

SURGERY

If there is fluid in the middle ear and the condition persists, even with antibiotic treatment, a healthcare provider may recommend myringotomy (surgical opening of the eardrum) to relieve pressure and allow drainage of the fluid. This may or may not involve the insertion of tympanostomy tubes (often referred to as ear tubes). In this procedure, a tiny tube is inserted into the eardrum, keeping open a small hole that allows air to get in so fluids can drain more easily down the eustachian tube. Tympanostomy tube insertion is done under general anesthesia. Usually the tubes fall out by themselves. Those that don't may be removed in your doctor's office.

If the adenoids are enlarged, surgical removal may be considered, especially if you have chronic, recurrent ear infections. Removing tonsils does not seem to help with ear infections.

Ear infections are curable with treatment but may recur. They are not life threatening but may be quite painful.

Generally, an ear infection is a simple, non-serious condition without complications. Most children will have minor, temporary hearing loss during and right after an ear infection. This is due to fluid lingering in the ear.

Although this fluid can go unnoticed, any fluid that lasts longer than 8-12 weeks is cause for concern. In children, hearing problems may cause speech to develop slowly. Permanent hearing loss is extremely rare, but the risk increases if the child has a lot of ear infections.

Other potential complications from otitis media include:

• Ruptured or perforated eardrum
• Chronic, recurrent ear infections
• Enlarged adenoids or tonsils
• Mastoiditis (an infection of the bones around the skull)
• Meningitis (an infection of the brain)
• Formation of an abscess or a cyst (called cholesteatoma) from chronic, recurrent ear infections
• Speech or language delay in a child who suffers lasting hearing loss from multiple, recurrent ear infections

Call your child's doctor if:

• Pain, fever, or irritability do not improve within 24 to 48 hours
• At the start, the child seems sicker than just an ear infection
• Your child has a high fever or severe pain
• Severe pain suddenly stops hurting -- this may indicate a ruptured eardrum
• Symptoms worsen
• New symptoms appear, especially severe headache, dizziness, swelling around the ear, or twitching of the face muscles

For a child younger than 6 months, let the doctor know right away if the child has a fever, even if no other symptoms are present.

You can reduce your child's risk of ear infections with the following practices:

• Wash hands and toys frequently. Also, day care with 6 or fewer children can lessen your child's chances of getting a cold or similar infection. This leads to fewer ear infections.
• Avoid pacifiers, especially at daycare.
• Breastfeed -- this makes a child much less prone to ear infections. But, if bottle feeding, hold your infant in an upright, seated position.
• Don't expose your child to secondhand smoke.
• The pneumococcal vaccine prevents infections from the organism that most commonly causes acute ear infections and many respiratory infections.
• Some evidence suggests that xylitol, a natural sweetener, may reduce ear infections.
• Avoid overusing antibiotics.

American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004 May;113(5):1451-65. Review.

Noble J. Textbook of Primary Care Medicine. 3rd ed. St. Louis, Mo: Mosby; 2001.

Gershon, AA, Hotez, PJ, and Katz, SL, eds. Krugman’s Infectious Diseases of Children. 11th ed. St. Louis, Mo: Mosby; 2004.

Long, SS, Pickering, LK, and Prober, CG, eds. Principles and Practice of Pediatric Infectious Diseases. 2nd ed. New York, NY: Churchill Livingstone, 2003.