Otitis media - acute; Infection - inner ear; Middle ear infection - acute

In infants, the main sign is often irritability and inconsolable crying. Many infants and children with an acute ear infection have a fever or trouble sleeping. Tugging on the ear is not always a sign that the child has an ear infection.

Symptoms of an acute ear infection in older children or adults include:

• Ear pain or earache
• Fullness in the ear
• Feeling of general illness
• Vomiting
• Diarrhea
• Hearing loss in the affected ear

The ear infection may start shortly after having a cold. Sudden drainage of yellow or green fluid from the ear may mean a ruptured eardrum.

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, but you still need to see your doctor to confirm any possible ear infection.

The health care provider will look inside the ears using an instrument called an otoscope. This may show:

• Areas of dullness or redness
• Air bubbles or fluid behind the eardrum
• Bloody fluid or pus inside the middle ear
• A hole (perforation) in the eardrum

A hearing test may be recommended if the person has a history of ear infections.

Some 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 to the affected ear.
• Use over-the-counter pain relief drops for ears, or ask the doctor about prescription ear drops to relieve pain.
• Take over-the-counter medications for pain or fever, such as ibuprofen or acetaminophen. Do NOT give aspirin to children.

All children younger than 6 months with a fever or symptoms should see the doctor. Children who are older than 6 months may be watched at home if they do not have:

• A fever higher than 102 °F
• More severe pain or other symptoms
• Other medical problems

If there is no improvement or symptoms get worse, schedule an appointment with your health care provider to determine whether antibiotics are needed.

ANTIBIOTICS

A virus or bacteria can cause ear infections. Antibiotics will not help an infection caused by a virus. Many health care providers no longer prescribe antibiotics for every ear infection. However, all children younger than 6 months with an ear infection are treated with antibiotics.

Your health care provider is more likely to prescribe antibiotics if:

• Your child is under age 2
• Has a fever
• Appears sick
• Is not improving over 24 to 48 hours

Make sure you or your child takes the antibiotics every day and finishes all the medicine, rather than stopping when symptoms go away. If the antibiotics do not seem to be working within 48 to 72 hours, contact your doctor. You may need to switch to a different antibiotic.

Amoxicillin is commonly the first choice. Other antibiotics that may be given are azithromycin or clarithromycin, cefdinir, cefuroxime, cefpodoxime, amoxicillin clavulanate (Augmentin), clindamycin, or ceftriaxone.

Side effects of antibiotics include nausea, vomiting, and diarrhea. Although rare, serious allergic reactions may also occur.

Some children who have repeat infections that seem to go away in between may receive a smaller, daily dose of antibiotics to prevent new infections.

SURGERY

If an infection does not go away with the usual medical treatment, or if a child has many ear infections over a short period of time, the doctor may recommend 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. Tympanostomy tube insertion is done under general anesthesia.
• Usually the tubes fall out by themselves. Those that don't fall out may be removed in your doctor's office.

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

Ear infections can be treated but may occur again in the future. They can be quite painful. If you or your child are prescribed an antibiotic, it is important to finish all your medication as instructed.

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.
• If possible, choose a daycare that has a class with 6 or fewer children. This can reduce your child's chances of getting a cold or similar infection, and leads to fewer ear infections.
• Avoid pacifiers.
• Breastfeed -- this makes a child much less prone to ear infections. But, if bottle feeding, hold your infant in an upright, seated position.
• Do not expose your child to secondhand smoke.
• Make sure your child's immunizations are up-to-date. The pneumococcal vaccine prevents infections from the bacteria that most commonly causes acute ear infections and many respiratory infections.
• Avoid overusing antibiotics. Overusing antibiotics can lead to antibiotic resistance.

Tähtinen PA, Laine MK, Huovinen P, Jalava J, Ruuskanen O, Ruohola A. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med. 2011 Jan 13;364(2):116-26.

Hoberman A, Paradise JL, Rockette HE, Shaikh N, Wald ER, Kearney DH, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011 Jan 13;364(2):105-15.

Coker TR, Chan LS, Newberry SJ, Limbos MA, Suttorp MJ, Shekelle PG, et al. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis mediain children: a systematic review. JAMA. 2010 Nov 17;304(19):2161-9.

Koopman L, Hoes AW, Glasziou PP, Cees L, Appelman L, Burke P, et al. Antibiotic therapy to prevent the development of asymptomatic middle ear effusion in children with acute otitis media: a meta-analysis of individual patient data. Arch Otolaryngol Head Neck Surg. 2008;134:128-132.

Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0-18 years---United States, 2011. MMWR. 2011;60(5).